Fixation of femoral neck fracture. A randomized 2-year follow-up study of hook pins and sliding screw plate in 222 patients. Three cancellous bone screws versus a screw-angle plate in the treatment of Garden I and II fractures of the femoral neck. Fixation of displaced femoral neck fractures with a sliding screw plate and a cancellous screw or two Olmed screws. A prospective, randomized study of 225 elderly patients with a 3-year follow-up. Fixation of fractures of the femoral neck. A prospective, randomised trial of three Ullevaal hip screws versus two Hansson hook-pins. [Fixation of fractures of the femoral neck using screws or hook-pins. Radionuclide study and short-term results]. Nail versus screw fixation of femoral neck fractures. A 2-year radiological and clinical prospective study. Cannulated screws for fixation of femoral neck fractures. No difference between Uppsala screws and Richards screws in a randomized prospective study of 268 cases. Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures. Internal fixation of femoral neck fractures. Dynamic Hip and Gouffon screws compared in 73 patients. Fixation of femoral neck fracture. Prospective comparison of von Bahr screws, Gouffon screws, and Hessel pins. Internal fixation of femoral neck fractures. Compression screw compared with nail plate fixation. Fixation of 220 femoral neck fractures. A prospective comparison of the Rydell nail and the LIH hook pins. Uppsala screws or Hansson pins for internal fixation of femoral neck fractures? A prospective study of 180 cases. Treatment of displaced fractures of the femoral neck. Smith-Petersen osteosynthesis versus sliding-nail-plate osteosynthesis. Fixation of displaced subcapital femoral fractures. Compression screw fixation versus double divergent pins. Internal fixation of femoral neck fracture. No difference between the Rydell four-flanged nail and Gouffon's pins. Two-year follow-up of femoral neck fractures. Comparison of osteosynthesis methods. Fixation of displaced femoral neck fractures. A comparison between sliding screw plate and four cancellous bone screws. Internal fixation of 410 cervical hip fractures. A randomized comparison of a single nail versus two hook-pins. A randomised study in all cervical hip fractures osteosynthesis with Hansson hook-pins versus AO-screws in 199 consecutive patients followed for two years. Factors influencing the incidence of reoperation after femoral neck fractures. Fixation of femoral neck fractures. A four-flanged nail versus threaded pins in 200 cases. Internal fixation of femoral neck fractures. Two methods compared. Short versus long thread cannulated cancellous screws for intracapsular hip fractures: a randomised trial of 432 patients. Femoral neck fracture: sliding screw plate versus sliding nail plate--a randomized trial. Dislocated fractures of the femoral neck treated with von Bahr screws or hip compression screw. Results of a prospective, randomized study.
We compared fixation with hook pins or sliding screw plate in a prospective randomized study of 222 patients with a cervical hip fracture. Radiographic evidence of early redisplacement, nonunion, or late segmental collapse was found in 43 of 122 patients operated on with two hook pins and in 40 of 100 patients operated on with the sliding screw plate. According to the actuarial method, the failure rate after 2 years was 38% with hook pins and 46% with screw plates, which not is a significant difference. Due to early redisplacement, reoperation with an endoprosthesis was performed within 0.5 (2) years in 11 (22) patients in the hook-pin group and in 4 (17) patients in the sliding-screw plate group. A consecutive clinical series of 33 patients with either an undisplaced (Garden I) or minimally displaced (Garden II) femoral neck fracture was randomly divided into two operative protocols. Half of the fractures were treated with three cannulated cancellous bone screws, while the other half were treated with a standard screw-angle plate device. After a mean follow-up of 2 years, 4 patients had died, while 20 of the remaining 29 hips showed excellent or good, 3 fair and 6 poor functional results. The three-screw fixation seemed to yield more technical complications as compared to the screw-angle plate fixation. However, the differences in functional end-results were of no clear statistical significance. We conclude that the screw-angle plate device gives acceptable results in this group of fractures. The use of cannulated hip screws may be more advantageous in the treatment of dislocated femoral neck fractures, where the torsional strength of fracture fixation and femoral head viability are more critical. To analyse the importance of fixation method in displaced femoral neck fractures and to identify factors predictive of failure of the fixation.
                Two hundred and twenty-five patients were included in a prospective, randomised study and operated on for a displaced, subcapital fracture of the femoral neck with either a sliding screw plate and a parallel cancellous screw (SSP), or two Olmed screws. The median follow-up time was 39 (22-51) months, excluding reoperated and dead patients.
                Operation and anaesthesia time was considerably longer for the SSP system. The risk of failure was significantly increased (odds ratio 6.6) for patients operated with SSP outside ordinary working time. Poor reduction was recognized as a risk factor of failure for both types of fixation (odds ratio 3.1). The rate of reoperation within 3 months was 18.5% in the SSP group and 9.4% in the Olmed screw group. The rates of nonunion were 6.2% and 8.5%, respectively. The rates of late segmental collapse, 18.0% and 19.5% of all united fractures, respectively, decreased with increasing age (odds ratio 0.88). Salvage operations (replacement with bipolar or total hip prosthesis) were made in 30.6% and 26.5% of the cases, and the total rates of reoperation were 37.0% and 29.1%, respectively. We conclude that both treatment methods result in an unacceptably high rate of failures and reoperations, and that alternative treatment, prosthesis replacement, should be considered in selected cases. In a prospective, randomised trial, we compared the use of three Ullevaal hip screws with that of two Hansson hook-pins in 278 patients with fractures of the femoral neck. Background factors were similar in both groups. Follow-up was for two years. There were no significant differences between the groups in length of time of surgery, hospital stay, general complications, mortality, pain or walking ability. Likewise, the rates of early failure of fixation, nonunion, and the need for reoperation did not differ significantly between the groups. The use of hook-pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6, p = 0.05) and a lower incidence of necrosis of the femoral head (odds ratio 3.5, p = 0.04). There was a strong relationship between poor reduction and fixation of the fracture and subsequent reoperation (p = 0.0005 and p = 0.0001, respectively). Likewise, peroperative drill penetration of the femoral head was associated with a greater risk of reoperation (p = 0.038). Both methods gave favourable results. In total, 22% of the patients needed a major reoperation (usually hemiarthroplasty), while in 7% of the cases the fixation device needed to be removed. Osteosynthesis as the sole method for operation of all fractures of the femoral neck was thus successful in 78% of patients. With selective treatment most of the remaining patients would have benefited if treated by a primary arthroplasty. Accurate selection requires the development of better prognostic methods. In a prospective randomized investigation, AO screws (53 cases) and hook-pins (57 cases) were used for femoral neck fracture fixation in 110 cases. The results of the one-week postoperative scintimetry and a four-month radiographic follow-up were analysed. The femoral head vitality according to scintimetry was similar in the two groups, whether undisplaced or displaced fractures. Within four months from the operation, six cases with screw fixation had been subjected to total hip arthroplasty while only one with hook-pins, all because of fracture redisplacement. However, at the four-month control, another more fracture operated on with screws and five more operated on with hook-pins were scheduled for hip arthroplasty. Thus, no difference between the two methods regarding postoperative femoral head vitality or complications in short term follow-up, was noted. 137 recent femoral neck fractures were randomly allocated in a prospective study to internal fixation with either Nyström nails or Scand screws. A radiological and clinical follow-up was conducted of all survivors one and two years postoperatively. Reduction was unsatisfactory in 15 of 87 patients included in the two-year follow-up study. 13 of them developed complications. The 44 Nyström-nailed fractures included in the two-year follow-up showed sliding of the nail in 22 cases, redisplacement/nonunion in 14, and late segmental collapse in 5. The results of clinical examination were excellent or good in 30 patients and fair or poor in 14. Among the 43 Scand-screwed fractures sliding of the screw occurred in 1 case, redisplacement/nonunion in 14, and late segmental collapse in 4. In 35 patients the result was graded as excellent or good and in 8 as fair or poor. No statistical difference between the groups was found with respect to the incidence of redisplacement, nonunion and late segmental collapse, nor with respect to the results of the clinical assessment at the one-year and two-year follow-up. There was a considerably higher incidence of extrusion of the internal fixation device among the nailed fractures than those treated with screws. The results indicate that Scand screws are a better alternative to Nyström nails in the treatment of femoral neck fractures. If an adequate reduction cannot be achieved, primary hip replacement is recommended. We compared 2 types of cannulated hip screws in a randomized prospective study of 268 femoral neck fractures. Complications were defined as penetration of the screw into the joint, early redisplacement, nonunion or segmental collapse. During the first year, complications were noted in 31 of 130 patients treated with 3 Richards screws and in 34 of 138 patients treated with 2 Uppsala screws. Secondary arthroplasty was performed in 17 cases in the Richards group and in 16 cases in the Uppsala group. Clinical outcome did not differ between the groups. We studied fixation of displaced femoral neck fractures prospectively in a randomized multicenter study, comparing 2 Olmed screws, 2 Tronzo screws and 3 Ullevaal hip screws. The study population consisted of 482 women and 125 men, of whom 432 women and 100 men were older than 65 years of age. Their median age was 80 (54-97) years. Despite agreement on criteria, the rates of reoperations for pain and failure--salvage (prosthesis replacement) and other reoperations (removal of implant)--differed significantly between the 3 hospitals regardless of type of fixation. In total, the percentages of salvage operations were: Olmed screw 17/175, Tronzo 17/130 and Ullevaal screw 11/302 (n.s.); the percentages of other reoperations were 11, 6 and 13, respectively (n.s.). In the whole series, the 2-year rate of salvage operations was 14%. No differences between the implants were found in patients older than 65 years of age. We conclude that an agreed, common definition of a hard end-point (reoperation) does not ensure comparability of results, because of differences in clinical decision making. A prospective, randomized study comparing the Dynamic Hip screws and the Gouffon screws in the treatment of femoral neck fractures was terminated before the planned number of patients had been admitted, owing to a preponderance of early failure of the Gouffon screws (P 0.014); thus only 73 patients entered the study. After three years' follow-up, 25/38 Gouffon screws and 12/35 Dynamic Hip screws had failed. Six patients treated with Gouffon screws and 14 treated with Dynamic Hip screws had died. The outcome still favoured the use of Dynamic Hip screws (P 0.02). We report a prospective study of 214 patients with femoral neck fractures operated on with multiple pinning. The fractures were randomly allocated to fixation with either von Bahr screws or Hessel pins in 1983 and 1984 or von Bahr or Gouffon screws in 1984 and 1985. After 2 years, the failure rate was one third in the von Bahr and the Gouffon screw groups and one half in the Hessel pin group. We conclude that the nonthreaded Hessel pin is inferior to the von Bahr and Gouffon screws for fixation of femoral neck fractures. In a prospective, randomized study of femoral neck fracture operations, a newly developed compression-screw device was compared with the McLaughlin nail-plate. One hundred and twenty-eight fractures were treated with the compression screw and 127 with a nail plate. The patients were followed up for 3 years. All undisplaced fractures healed in both groups. Eleven per cent of displaced Garden 3 and 4 fractures did not heal in the compression-screw group compared to 25 per cent in the nail-plate group. Late segmental collapse occurred in 15 per cent of the healed displaced fractures in the compression-screw group, compared to 21 per cent in the nail-plate group. Fixation of femoral neck fractures using the new compression-screw device gave fewer failures without concomitant disadvantages compared to nail plate fixation. 220 patients with femoral neck fractures were randomly treated with either a Rydell nail (n 110) or two LIH hook pins (n 110). The age, sex, and displacement patterns were similar in both group. All the patients were operated on by orthopedic specialists and followed clinically and radiographically for 2 years or until death. The mortality at 2 years was similar (28 percent) in both groups. Among 154 survivors, early redisplacement or nonunion was recorded in 19 percent of the Rydell-nailed fractures and 32 percent of the LIH-pinned fractures. In nondisplaced fractures, complications occurred in 8/30 Rydell cases compared with 3/16 in the LIH group. In displaced fractures, complications occurred in 21/48 Rydell cases compared with 28/60 in the LIH group. In a prospective randomized trial, two methods of internal fixation of femoral neck fractures were compared. Totally, 179 patients with 180 fractures were treated with either two Uppsala screws (n 96) or two Hansson pins (n 84). In all, 130 fractures were primarily displaced (Garden stages III and IV), whereas 88 percent of the fractures in both groups were well reduced. The patients were followed clinically and radiographically for 1 year. Thirty-six patients died within 12 months after the operation. The functional results and the incidence of segmental collapse and nonunion did not differ between the groups. However, at the 4-month follow-up, 2 of 59 of the Garden's stages III and IV in the Uppsala-screw group were found displaced, whereas the corresponding result in the Hansson-pin group was 9 of 52 (P = 0.03). In a prospectively planned follow-up study 383 cases of displaced medial fractures of the femoral neck were allocated either to Smith-Petersen osteosynthesis or to sliding-nail-plate osteosynthesis. Two hundred and forty-nine cases were followed for more than 2 years. The two differently treated groups were alike. The results showed that sliding-nail-plate osteosynthesis was significantly superior to Smith-Petersen osteosynthesis. We recommend that Smith-Petersen osteosynthesis be abandoned. One hundred and twenty-seven consecutive patients with displaced subcapital fractures of the femoral neck (Garden Grade III or IV) all under 80 years of age and independently mobile, were randomly allocated to fixation with either double divergent pins or a single sliding screw-plate device. The incidence of non-union and infection in the sliding screw-plate group was significantly higher, and we believe that when internal fixation is considered appropriate multiple pinning should be used. Mobility after treatment was disappointing in about half of the patients, and we feel that internal fixation can only be justified in patients who are physiologically well preserved and who maintain a high level of activity. Two methods of internal fixation of femoral neck fractures were compared in a prospective randomized study of 223 patients. Radiographic evidence of early redisplacement, nonunion, or late segmental collapse occurred in 45 of 122 patients operated on with the Rydell four-flanged hook nail and in 33 of 101 patients operated on with Gouffon pins. According to the actuarial method of follow-up, the failure rates after 2 years were respectively 41 and 35 percent in the nail and pin groups, which is a nonsignificant difference. For 14 consecutive months, all 152 femoral neck fracture patients greater than or equal to 50 years of age admitted to the Lund University Hospital were operated on with two hook-pins if born on an uneven date and a four-flanged nail if born on an even date. A clinical 2-year follow-up revealed a 35 per cent mortality. Among survivors, radiographic healing complications were seen in undisplaced fractures in 1/13 pinned and 5/14 nailed (p greater than 0.05) and in displaced fractures in 12/36 pinned and 23/32 nailed (p less than 0.01). This outcome correlated well with the early postoperative scintimetry. Reoperation within 2 years had been performed for seven pinned and 19 nailed fractures. In hook-pinning, thus, less than one patient out of 12 needed a reoperation with THR within 2 years. This figure is interpreted as strongly favouring hook-pinning before arthroplasty as the primary procedure in femoral neck fracture. In a prospective, randomized trial, 104 consecutive patients with displaced femoral neck fractures were allocated either to fixation with a sliding screw plate or 4 ASIF cancellous bone screws. The patients were reexamined at fixed intervals to determine the time of union. The 2-year-cumulated rate of union was 64 per cent in the plate group and 84 per cent in the screw group. Totally, 410 patients with a cervical hip fracture were randomized between two methods of osteosynthesis: a single nail (Rydell) and two hook-pins (LIH). Seventy-five percent of the patients were women. Sixty-nine percent were alive after 2 years. The patients were followed up with clinical and radiographic examinations for 2 years postoperatively. No difference between the two groups were found regarding quality of reduction, early displacement within 3 months, extraction after healing, nonunion, late segmental collapse, or reoperation with a total hip arthroplasty. Nor did we find any differences between the two groups when selecting those alive after 2 years or when dividing the fractures in displaced and nondisplaced fractures. A consecutive series of patients with all types of cervical hip fracture (both undisplaced and displaced) were randomised to osteosynthesis with Hansson hook-pins (n = 98) or AO-screws (n = 101). Background parameters, fracture type and reduction of the fracture did not differ significantly between the groups. Fifty-seven percent of the patients were operated on within 6 h of admission to hospital, 74% within 12 h and 92% within 24 h. The mean (median) time for operation was 36 (30) min for the hook-pins and 40 (35) min for the AO-screws. The devices were significantly better positioned in the hook-pin group (81% of cases good) compared to the AO-screws (66% good) (p = 0.04). In all, 72% of the patients had no deficiency either in reduction of the fracture, positioning of the implants or had drill penetration of the femoral head. Direct unrestricted weight bearing was encouraged in 92% of the hook-pin and 90% of the AO-screws group. The mean (median) hospital time was 13 (10) days with no significant difference between the groups. Following treatment, 5% walked without aids, 76% of the patients walked with some aids, and 16% could not walk. The walking ability was not known for 4%. At four months, 59% of the patients were living in their own home (64% before fracture), 18% (25% before) in a nursing home, 5% (11% before) in other accommodation and 18% were dead. After two years, 77% of the hook-pin patients had not needed any re-operation compared to 73% in the AO-screw group. In total a secondary hemi-arthroplasty had been performed in 7% and total hip arthroplasty in 12% of the patients. Extraction only of osteosynthesis material had been performed in 5%. The difference in the reoperation rates between the two methods was not significant. In the undisplaced fractures, 84% of the patients had not needed any reoperation after two years compared to 70% among the displaced fractures. Major reoperation had been performed in 10% (1% hemi and 9% total hip arthroplasty) in the patients with undisplaced fractures compared to 26% in those with displaced fractures (10% hemi, 16% total hip arthroplasty and 1% Girdlestone operation). The remaining patients had only undergone removal of metalwork. Osteosynthesis thus proved to be a successful operation in many of the patients with displaced fractures. A preoperative, prognostic-based selection between osteosynthesis and arthroplasty is the future goal for optimised femoral neck fracture treatment. This investigation compares two groups of patients with fractures of the femoral neck: 22 required a further operation and 72 did not. Special attention was paid to osteoporosis, the displacement of the fracture, viability of the femoral head, operative impaction and osteosynthesis with a Thornton nail or three Scand hip pins. There was a significant (p less than 0.01) difference between the two groups with regard to osteoporosis, fracture displacement and viability of the femoral head. Scand hip pins, as compared to Thornton nails, showed a tendency (p less than 0.1) to need a smaller number of reoperations. Operative impaction compared with no impaction showed no difference. Two methods of internal fixation for cervical hip fractures were compared in a "randomized to surgeons" type of study. One hundred patients were treated with the Rydell four-flanged nail and 100 with the Gouffon pins. Redisplacement, nonunion, or segmental collapse occurred in 27 patients operated on with the Rydell nail and in 29 patients operated on with the Gouffon pins. According to the actuarial method of follow-up, the failure rates after 2 years were 31 and 33 percent in the two groups. In a prospective randomised study, the Hansson pin technique for internal fixation of fractures of the femoral neck was compared with the Uppsala screw technique. The series consisted of 115 consecutive patients, 97 women and 18 men, with a mean age of 80 years. There were 56 patients treated with Hansson pins and 59 with Uppsala screws. After one year 22 patients had died, eight in the Hansson pin group and 14 in the Uppsala screw group (p = 0.28). Twenty-four complications had occurred, 18 in the Hansson pin group and six in the Uppsala screw group (p = 0.008). After exclusion of those with complications, the patients in the Hansson pin group had significantly more pain, less mobility, and a smaller proportion were living in their own homes. It is unclear which length of thread may be most advantageous for the internal fixation of an intracapsular fracture with cancellous screws. We have compared the 16 mm versus the 32 mm threads on cancellous screws within a randomised trial for 432 patients. All fractures were fixed with three screws and patients followed-up for a minimum of one year from injury. The characteristics of the patients in the two groups were similar with a mean age of 76 years. 23% were male. The most common complication encountered was non-union of the fracture which for undisplaced fractures occurred in 7/107 (6.5%) of short threaded screws versus 11/133 (8.3%) of long threaded screws. For displaced fractures the figures were 29/104 (27.9%) versus 24/89 (27.0%). Other complications for the short versus long threaded group were avascular necrosis (two cases versus five cases) and fracture below the implant (two cases in each group). Elective removal of the screws for discomfort was undertaken in five and three cases, respectively. None of these differences between groups was statistically significant. In summary there is no difference in fracture healing complications related to the length of the screw threads.
                Copyright (c) 2009 Elsevier Ltd. All rights reserved. In a randomized trial 49 patients with fracture of the neck of the femur and an age of less than 70 years or a high level of physical activity were allocated to treatment with a sliding screw plate or a sliding nail plate fixation. The patients were followed for 2-5 years. At follow-up the union rate was found to be 86.2 per cent of the fractures in the screw plate group and 73.7 per cent in the nail plate group (P less than 0.3). Necrosis of the femoral head was encountered in respectively 10 and 21 per cent. Hip replacement was necessary in respectively 23.3 and 31.6 per cent. The nail slid out of the femoral head, resulting in recurrence of the fracture's displacement in three fractures with a sliding nail plate, and in none with a sliding screw plate (P = 0.053). Secondary loss of the femoral neck's angle was more frequently seen in the sliding nail plate group (P less than 0.01). In conclusion, the sliding screw plate gives better fixation of fractures of the neck of the femur and was followed by a lower frequency of reoperation than after an unthreaded device. nan
No clear conclusions can be made on the choice of implant for internal fixation of intracapsular fractures from the available evidence within randomised trials.