Mir, Hassan Riaz

OBJECTIVES: The objective of this study was to determine the difference in failure rates of surgical repair for displaced femoral neck fractures in patients younger than 60 years of age according to fixation strategy. METHODS: Design: This is a retrospective, comparative cohort study. Setting: Twenty-six Level 1 North American trauma centers. Patient Selection Criteria: Patients younger than 60 years of age with a displaced femoral neck fracture (OTA 31-B2, B3) undergoing surgical repair from 2005 to 2017. Outcome Measures and Comparisons: Patient demographics, injury characteristics, repair methods used, and treatment failure (nonunion/failed fixation, avascular necrosis, and need for secondary surgery) were compared according to fixation strategy. RESULTS: Five hundred and sixty-five patients met inclusion criteria and were studied. The mean age was 42 years, 36% were female, and the average Pauwels' angle of fractures was 55 degrees. There were 305 patients treated with multiple cannulated screws (MCS) and 260 treated with a fixed-angle (FA) construct. Treatment failures were 46% overall, but was more likely to occur in MCS constructs versus FA devices (55% vs. 36%, P < 0.001). When FA constructs were substratified, the use of a sliding hip screw with addition of a medial femoral neck buttress plate (FNBP) and “antirotation” (AR) screw demonstrated better results than either FNBP or AR screw alone or neither with the lowest overall construct failure rate of 11% (P < 0.036). CONCLUSIONS: Historically used fixation constructs for femoral neck fractures (eg, multiple cannulated screws and sliding hip screw) in young and middle-aged adults performed poorly compared with more recently proposed constructs, including those using a medial femoral neck buttress plate and an antirotation screw. Fixed-angle constructs outperformed multiple cannulated screws overall, and augmentation of fixed-angle constructs with a medial femoral neck buttress plate and antirotation screw improved the likelihood of successful treatment. Surgeons should prioritize fixation decisions when repairing displaced femoral neck fractures in patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: To study the results of displaced femoral neck fractures (FNFs) in adults less than 60 years of age by comparing patients, injury, treatment, and the characteristics of treatment failure specifically according to patients' age at injury, that is, by their “decade of life” [ie, “under 30” (29 years and younger), “the 30s” (30–39 years), “the 40s” (40–49 years), and “the 50s” (50–59 years)]. METHODS: Design: Multicenter retrospective comparative cohort series. Setting: Twenty-six North American Level 1 Trauma Centers. Patient Selection Criteria: Skeletally mature patients aged 18–59 years with operative repair of displaced FNFs. Outcome Measures and Comparisons: Main outcome measures were treatment failures (fixation failure and/or nonunion, osteonecrosis, malunion, and the need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). These were compared across decades of adult life through middle age (<30 years, 30–39 years, 40–49 years, and 50–59 years). RESULTS: Overall, treatment failure was observed in 264 of 565 (47%) of all hips. The mean age was 42.2 years, 35.8% of patients were women, and the mean Pauwels angle was 53.8 degrees. Complications and the need for major secondary surgeries increased with each increasing decade of life assessed: 36% of failure occurred in patients <30 years of age, 40% in their 30s, 48% in their 40s, and 57% in their 50s ( P < 0.001). Rates of osteonecrosis increased with decades of life (under 30s and 30s vs. 40s vs. 50s developed osteonecrosis in 10%, 10%, 20%, and 27% of hips, P < 0.001), while fixation failure and/or nonunion only increased by decade of life to a level of trend ( P = 0.06). Reparative methods varied widely between decade-long age groups, including reduction type (open vs. closed, P < 0.001), reduction quality ( P = 0.030), and construct type (cannulated screws vs. fixed angle devices, P = 0.024), while some variables evaluated did not change with age group. CONCLUSIONS: Displaced FNFs in young and middle-aged adults are a challenging clinical problem with a high rate of treatment failure. Major complications and the need for complex reconstructive surgery increased greatly by decade of life with the patients in their sixth decade experiencing osteonecrosis at the highest rate seen among patients in the decades studied. Interestingly, treatments provided to patients in their 50s were notably different than those provided to younger patient groups. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives:To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample.Design:Consecutive retrospective cohort review.Setting:Eighteen academic orthopedic trauma centers.Patients/Participants:Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery.Intervention:Humeral shaft nonunion repair and assessment of postoperative radial nerve function.Main Outcome:Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery.Results:Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18–93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P= 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved.Conclusion:In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.