Injury, Int. J. Care Injured 46 (2015) 507–514
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Young femoral neck fractures: Are we measuring outcomes that matter? Sheila Sprague a,b, Gerard P. Slobogean a,c, Taryn Scott b, Manraj Chahal a, Mohit Bhandari a,b,* a b c
Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada Department of Clinical Epidemiology and Biostatics, McMaster University, Hamilton, ON, Canada Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 July 2014 Accepted 17 November 2014
Introduction: Femoral neck fractures in younger aged patients are particularly devastating injuries with profound impairments of quality of life and function. As there are multiple differences in patient and injury characteristics between young and elderly femoral neck fracture patients, the geriatric hip fracture literature is unlikely to be generalisable to patients under age 60. We conducted a systematic review to determine if clinically relevant outcome measures have been used in previously published clinical studies of internal fixation in young adults with femoral neck fractures. Methods: We conducted a comprehensive literature search using multiple electronic databases and conference proceedings to identify studies which used internal fixation for the management of femoral neck fractures in patients between the ages of 15 to 60. Eligibility screening and data abstraction were performed in duplicate. We classified the reported outcomes into the following categories: operative and hospital outcomes, radiographic outcomes, clinical outcomes, and functional outcomes and healthrelated quality of life. We calculated the frequencies of reported outcomes. Results: Fort-two studies met our inclusion criteria. Operative and hospital outcomes were poorly reported with less than one-quarter of studies reporting relevant data. Important radiographic outcomes were also inadequately reported with only one-third of studies reporting the quality of the fracture reduction, and methods for assessment were highly variable. The assessment of avascular necrosis was reported in almost all the included studies (95.2%); however, the assessment of nonunion was only reported in three-quarters of the studies. Re-operations were reported in 73.8% of the included studies and the assessment of fracture healing was only reported in two-thirds of the studies. Less than half of the studies reported functional outcomes or health-related quality of life (overall patient evaluation scales and systems (45.2%), patient functional outcomes (30.9%), and health-related quality of life (4.8%). Discussion: Our systematic review found that the assessment of clinically relevant outcomes in the young femoral neck fracture literature is lacking, which makes utilising the literature to guide clinical practice challenging. Future studies should aim to include important radiographic measures, fracturehealing complications, functional outcomes, and health-related quality of life during any assessment of young femoral neck fracture treatment. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Femoral neck fracture Hip fracture Outcomes Non-geriatric
Introduction Internal fixation of femoral neck fractures is frequently associated with high complication rates and poor functional
* Corresponding author at: Division of Orthopaedic Surgery, 293 Wellington St. No. 110, Hamilton, Canada L8L 8E7. Tel.: +1 905 527 4322x44490; fax: +1 905 523 8781. E-mail address: [email protected] (M. Bhandari). http://dx.doi.org/10.1016/j.injury.2014.11.020 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
outcomes. For elderly patients, displaced fractures are typically treated with arthroplasty to avoid these major fracture healing complications; however, in younger adults internal fixation is performed for nearly all femoral neck fractures to preserve the native hip joint, to facilitate increased functional demands, and to avoid concerns of arthroplasty longevity. As a result, young femoral neck fracture patients are particularly at risk for experiencing significant fracture healing complications, re-operations, and lifelong morbidity.
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While there is large body of literature pertaining to the treatment of femoral neck fractures in geriatric populations, the generalisability of these findings to younger adults may be limited due to key differences in terms of the physiological condition of patients, the injury mechanism, the goal of treatment, and the method of treatment [1–4]. These differences demonstrate the importance of identifying separate and distinct clinical guidance for treating femoral neck fractures in young adults. Reporting outcome measures that are relevant to the younger population is crucial to facilitate comparisons of treatment efficacy, to identify the incidence of complications, and to properly inform patients of their expected outcomes. The objective of this systematic review is to describe the characteristics of the young femoral neck fracture literature and to determine if clinically relevant outcome measures have been used when reporting the results of internal fixation in younger hip fracture patients. Specifically, we aimed to determine how previous authors have quantified the following outcomes in our target population: operative and hospital outcomes, radiographic outcomes, clinical outcomes, and functional outcomes and healthrelated quality of life.
screening the article titles identified in the literature searches to determine whether the articles should be considered for inclusion. Since the screening process needed to distinguish between elderly and young femoral neck fractures, any title that mentioned fixation of femoral neck fractures or hip fractures was selected for further review. The titles identified as potentially eligible were then screened at the abstract level. Again, the authors erred on the side of inclusivity. Any conflicts identified at the title and abstract screening stages were discussed, and if consensus was not reached, the reference proceeded to the next level of screening. The full-text of all articles identified as potentially eligible at the abstract screening level were then reviewed. Any disagreements at the full-text stage were resolved with input from a third author. Articles that met the inclusion criteria were selected for data abstraction. We used the Distiller Systematic Review software (http:// systematic-review.net/) to facilitate our article selection process. Level of agreement between the two authors was assessed with the kappa statistic. We adopted an a priori criterion of k 0.65 for adequate agreement. Data abstraction
Methods Literature search We conducted a systematic review of the published literature to identify clinical studies that used internal fixation for the management of femoral neck fractures in patients age 60 years. In consultation with a research librarian, we conducted systematic literature searches of the Medline, Embase, CINAHL, and Cochrane databases using the search terms contained in Appendix A. We hand searched the abstracts from the past five annual meetings (2008 to 2012) from the Orthopaedic Trauma Association (OTA), the Canadian Orthopaedic Association (COA), and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT). In addition, we hand searched abstracts from the past two annual meetings (2011 and 2012) of the American Academy of Orthopaedic Surgeons (AAOS). Following the literature searches, two of the authors independently reviewed the reference lists of all included articles for further eligible articles. Eligibility criteria We included published studies that met the following eligibility criteria: (1) the population was comprised of young adults (ages 15 to 60 years) with a femoral neck fracture, (2) patients were treated with internal fixation, (3) the study type was ‘‘therapeutic’’ or ‘‘prognostic’’ and falls within evidence levels I, II, III, or IV (case series with more than 10 patients), and (4) the study reported any outcome measure following fracture fixation. Studies that included patients with femoral neck fractures and ipsilateral femoral shaft injuries, and/or femoral neck fracturedislocations were also eligible. We excluded studies that focused on: (1) stress fractures; (2) treatment of delayed fractures (greater than 14 days from injury); (3) management of femoral neck fracture nonunions; and (4) management of osteonecrosis following femoral neck fractures. We also excluded studies that were published in languages other than English, review articles, and meta-analyses. Article selection Two authors independently reviewed the titles, abstracts, and full-text articles for inclusion. The authors began by
Two authors independently abstracted all relevant information from each included article on study specific case report forms. Briefly, we abstracted study characteristics, patient demographics, fracture characteristics, surgical details, and the outcomes reported from each included study. Any disagreements between the two authors were reconciled through a consensus meeting; if agreement could not be reached, a third author resolved the disagreement. Reported outcomes were then classified into themes, including: operative and hospital outcomes, radiographic outcomes, clinical outcomes (i.e. re-operations, fracture healing, fracture-related complications, general medical complications), functional outcomes, and health-related quality of life. Data analysis Descriptive statistics were used to summarise the study and patient characteristics. Frequency data (proportions and percentages) describe the use of reported outcomes, and qualitative descriptions characterise the outcomes used in each of the included studies.
Results Literature search results The electronic database search identified 1182 articles that were potentially eligible for inclusion in this review (Fig. 1). Of these studies, 1012 were excluded after review of titles, 30 after reviewing the abstracts, and 107 after full-text review. Therefore, 33 articles were identified for inclusion in this review. A search of the meeting abstracts identified 3804 titles, with 3513 excluded after review of titles and 286 after review of abstracts. One additional abstract was excluded as it had duplicate data to a full publication that had been identified in the literature search. This left four abstracts for inclusion in the review. The hand search of the reference lists of the included articles identified five additional studies that met the eligibility criteria for this review. In summary, 42 articles are included in this review [5–46]. The two authors had acceptable agreement regarding which studies should be included or excluded (percent of overall agreement = 86.90; unweighted kappa = 0.68).
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Fig. 1. Literature search results.
Study and patient characteristics The majority of the included studies were conducted in Asia (40.5%), North America (21.4%), and Continental Europe (21.4%) (Table 1). Most of the studies were single-centre initiatives (81.0%), and the majority of the studies were retrospective case series (59.5%) or retrospective comparative studies (21.4%). Only
2 studies (4.8%) were randomised controlled trials. The mean sample size of the included studies was 39.4 33.8 with sample sizes ranging from 11 to 146 patients. The mean length of patient follow-up within the included studies was 35.8 16.3 months with a range of 12 to 78 months. Twenty-seven studies (64.3%) included patients with isolated femoral neck fractures; 14 studies (33.3%) included only patients with ipsilateral femoral neck and shaft
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510 Table 1 Study characteristics. Characteristic
Frequency N (%) N = 42
Location of research Asia North America Continental Europe United Kingdom New Zealand Not mentioned
17 9 9 5 1 1
Funding source No statement of funding provided Non-funded Government grant
35 (83.3%) 6 (14.3%) 1 (2.4%)
Year of publication 1961 to 1970 1971 to 1980 1981 to 1990 1991 to 2000 2001 to 2010 2011 to 2012
1 1 5 10 18 7
(2.4%) (2.4%) (11.9%) (23.8%) (42.9%) (16.7%)
Study design Randomised controlled trial Prospective comparative study Retrospective comparative study Retrospective prognostic study Prospective case series Retrospective case series
2 1 9 1 2 25
(4.8%) (2.4%) (21.4%) (2.4%) (4.8%) (59.5%)
Number of clinical sites One Two Three Mean sample size (standard deviation) Mean length of follow-up, months (standard deviation) Mean follow-up, percent (standard deviation) Fractures included Femoral neck fractures only Ipsilateral femoral neck and shaft fractures Both isolated femoral neck fracture and ipsilateral Femoral neck and shaft fractures
(40.5%) (21.4%) (21.4%) (11.9%) (2.4%) (2.4%)
34 (81.0%) 4 (9.5%) 4 (9.5%) 39.43 33.8 35.75 16.3 91.5 8.4 27 (64.3%) 14 (33.3%) 1 (2.4%)
fractures, and one study (2.4%) included patients with both isolated femoral neck fractures and ipsilateral femoral neck and shaft fractures. There were 1655 patients with 1664 fractures included in the 42 studies (Table 2). The mean age of the patients was 39.2 5.6 years, and the majority of the patients had isolated femoral neck fractures (81.3%). Thirty-five studies (83.3%) reported fracture displacement with 1293 (77.7%) patients having displaced fractures. Twenty-nine studies reported the method of reduction used; in these Table 2 Patient and fracture characteristics (N = 42). Characteristic
Number of studies reporting (%)
Total patients (%)
Sample size Mean age (standard deviation) Fracture location Femoral neck only Ipsilateral FN and shaft fracture Not specified Fracture displacement Displaced Undisplaced Not specified Method of reduction Open reduction Closed reduction Not specified
42 (100%) 30 (71.4%) 42 (100%)
1655 39.2 5.6
FN—femoral neck.
1353 (81.3%) 266 (16.0%) 45 (2.7%)
studies, 158 patients underwent open reduction and 1089 patients had closed reduction. Over 20 different methods of internal fixation were used across the 42 studies. Reported operative and hospital outcomes Few studies reported operative and hospital outcomes (Table 3). Briefly, 10 studies (23.8%) reported the length of surgery, and 5 studies (11.9%) studies reported patient blood loss during surgery. Nine studies (21.4%) commented on technical problems during surgery, and two studies (4.8%) reported intra-operative complications during surgery. The length of hospital stay was stated in only six studies (14.3%). Reported radiographic outcomes Important radiographic outcomes were poorly reported across the included studies (Table 4). Only one-third of the studies assessed the quality of the fracture reduction, which is important information since malreduction is known to be associated with healing complications. These studies used a variety of different criteria to assess quality of reduction including the method described by Haidukewych [47] (1 study, 2.4%), Garden’s angle or scale [48] (7 studies, 16.7%), and a variety of different criteria specified by the authors (7 studies, 16.7%). Only six studies (14.3%) reported loss of reduction, and seven studies (16.7%) assessed the adequacy of implant placement, which is also a potentially important predictor of complications. Surprisingly, radiographic shortening was only reported in two studies (4.8%) which also may have significant implications on clinical outcome. Reported clinical outcomes Re-operations, including the type of procedure and indication, were reported in 31 studies (73.8%) (Table 5). The assessment of fracture healing was only explicitly reported in two-thirds of the studies (28 studies, 66.7%). When it was reported, union was described as either the proportion of fractures healed at a specified time point, the time to fracture union, or a combination of both measures. The assessment of avascular necrosis was reported in almost all the included studies (40 studies, 95.2%); however, the assessment of fracture nonunion, another common fracturerelated complication, was only reported in three-quarters of the studies (32 studies (76.2%). Other fracture-related complications were reported less frequently including: infection (24 studies, 57.1%), symptomatic hardware (21 studies, 50.0%), malunion (16 studies, 38.1%), delayed union (11 studies, 26.2%), leg length discrepancy or shortening of the limb (4 studies, 9.5%), loss of fixation (4 studies, 9.5%), and arthritis (3 studies, 7.1%). As expected, general medical complications were assessed in just over half of the studies (22 studies, 52.4%) with 14 studies (33.3%) assessing deep vein thrombosis, pulmonary embolism, or fat embolism, and 8 studies (19.0%) reporting patient deaths. Table 3 Reported operative and hospital outcomes (N = 42). Reported outcome
Number of studies reporting (%)
References
Length of surgery Technical problems during surgery Blood loss & transfusion requirements Length of hospital stay intra-operative complications
10 (23.8%) 9 (21.4%)
[6,14,17,18,20,26,30,31,39,40] [13,14,17,20,22,24,26,32,35]
35 (83.3%) 1293 (77.7%) 238 (14.3%) 133 (8.0%) 29 (69.0%) 158 (9.5%) 1089 (65.4%) 417 (25.1%)
5 (11.9%)
[17,20,21,26,40]
6 (14.3%) 2 (4.8%)
[15,17,18,32,35,39] [27,29]
S. Sprague et al. / Injury, Int. J. Care Injured 46 (2015) 507–514 Table 4 Reported radiographic outcomes (N = 42). Reported outcome
Number of studies reporting (%)
References
Quality of reduction Loss of reduction Assessment of implant placement Radiographic FN shortening Bone quality
15 (35.7%) 6 (14.3%) 7 (16.7%)
[5–12,18,20,22,24,26,34,44] [9,10,14,20,37,39 [5,6,8,9,24,35,44]
2 (4.8%)
[5,10]
1 (2.4%)
[10]
FN—femoral neck.
Functional outcomes and health-related quality of life Only 19 studies (45.2%) included an overall patient evaluation scale system as part of their reported outcomes (Table 6). In six of these studies (14.3%), the authors used a patient evaluation rating system that they developed. In the other 13 studies (30.9%), the authors used a previously developed scale or system that they may have modified. Systems utilised included the Friedman and Wyman Scale [49] (5 studies, 11.9%), the Harris Hip Score [50] (4 studies, 9.5%), the Judet scale [51] (2 studies, 4.8%), the Arnold Evaluation Guide [52] (1 study, 2.4%), and the Merle D’AubingnePostel Scoring System [53] (1 study, 2.4%). Thirteen studies (30.9%) reported patient functional outcomes that were not included as a component of an overall patient score (Table 6). These outcomes included pain (6 studies, 14.3%), range of motion (5 studies, 11.9%), return to work (4 studies, 9.5%), activities of daily living (4 studies, 9.5%), assessment of gait or walking ability (2 studies, 4.8%), and return to sporting activities (1 study, 2.4%). Health-related quality of life outcome measures were administered in 2 studies (4.8%) (Table 6). A recently published abstract [46] administered the Short Form-36 (SF-36) [54] to participants. The second study [11] used the SF-36 and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) (Table 6) [55]. Discussion This systematic review summarises the outcome measures used in clinical studies evaluating femoral neck fracture fixation in
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patients 60 years old. Although multiple outcomes were identified across the 42 included studies, there are significant gaps in the assessment and reporting of outcomes necessary to guide clinical practice. Specifically, key aspects of fracture displacement, quality of reduction and implant placement, and numerous patient important outcomes are routinely not reported in the existing literature. Without these data, surgeons are unable to compare treatment efficacy, identify the incidence of complications, or properly inform their patients of expected outcomes. We found that many of the outcomes reported in the young femoral neck studies are similar to those used in studies of femoral neck fractures in elderly populations. While this is appropriate for radiographic complications such as avascular necrosis, the increased functional demands of younger patients require that researchers measure outcomes that will be both sensitive and important to these younger individuals with highly active lifestyles. For example, many of the included studies used hip outcome questionnaires designed for osteoarthritic patients to measure quality of life and function; these instruments lack content validity for use in younger active patients (e.g. WOMAC and the Harris Hip Score). Furthermore, femoral neck fracture shortening is known to decrease hip abductor function and is associated with poorer physical function [56,57]. For younger patients this may lead to a lifetime of hip weakness, gait abnormalities, and poor functional outcomes. Within the past decade there has been a shift in orthopaedic surgery research from solely reporting fixation success or failure towards measurement of patient reported functional outcomes and health-related quality of life [58,59]. The increasing emphasis on these outcomes reflects a global shift towards patient centred medicine, and despite the historical importance of many surgeonbased assessments, patient reported outcomes must be at focal point of any clinical evaluation. This belief has also been adopted by the research community, and several authors have recommend the use of standardised, validated tools to assess function and health-related quality of life in clinical trials [60–64]. Within the elderly hip fracture literature multiple studies use patient reported functional outcomes, and we suspect this reflects the higher quality of research found in this population [65–71]. In contrast, the majority of the studies included in the current review were of a lower level of evidence and were retrospective in nature. Regardless of the combination of outcome measures used in a study population, we believe a minimum set of outcomes
Table 5 Reported clinical outcomes (N = 42). Reported outcome
Number of studies reporting (%)
References for studies that reported the outcome
Re-operations Revision surgery and indication for revision surgery
31 (73.8%)
[5,7–12,14–22,24,26,27,29–31,33,34,36,37,39,40–42,44]
Fracture union Proportion healed Nonunion Time to union
26 (61.9%) 32 (76.2%) 17 (40.5%)
[5,7,9–11,14,16–24,26,27,29–33,35,38,41,42] [5–12,14–19,22–27,29,30–32,34,37,38,40,41,43,45,46] [5,7,8,14,17,19,20–22,26–27,29,30,31,33,40,41]
Fracture-related complications Avascular necrosis Infection Symptomatic hardware Malunion or malalignment Delayed union Leg length discrepancy or shortening of the limb Loss of fixation Arthritis
40 (95.2%) 24 (57.1%) 21 (50.0%) 16 (38.1%) 11 (26.2%) 4 (9.5%) 4 (9.5%) 3 (7.1%)
[5–39,41–45] [5–7,11,12,15,17–22,26,29–36,39,41,43] [5,6,8,9,15–18,20,23,26,28,29,31–33,36,37,39–41] [5,9,14,16,17,21,26–28,30,31,33,40,41,43,46] [8,11,14,16–18,26–28,31,39] [28,29,33,37] [7,22,25,44] [9,35,37]
22 (52.4%) 14 (33.3%)
[5,6,11,13,15–17,20,21,26,30–33,35–39,42–44] [6,11,13,15–17,21,26,30,31,33,36,42,43]
8 (19.0%)
[5,11,15,35–38,42]
General medical complications General medical complications Deep vein thrombosis Pulmonary embolism, or fat embolism Death
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Table 6 Functional outcomes and health-related quality of life. Reported outcome
Number of studies reporting (%)
References for studies that reported the outcome
Patient evaluation scales and systems Overall patient evaluation/rating system developed by authors Friedman and Wyman scale Harris hip score Judet scale Arnold evaluation guide Merle D’Aubingne-Postel scoring system
6 5 4 2 1 1
(14.3%) (11.9%) (9.5%) (4.8%) (2.4%) (2.4%)
[14,18,27,28,35,39] [17,30–32,41] [8,9,34,45] [5,19] [20] [37]
Functional outcomes* Pain Range of motion Return to work Activities of daily living Assessment of gait/walking Ability Return to sporting activities
6 5 4 4 2 1
(14.3%) (11.9%) (9.5%) (9.5%) (4.8%) (2.4%)
[20,24,26,31,39,46] [8,26,29,33,37] [19,26,32,39] [26,32,39,42] [24,29] [39]
Health-related quality of life Short form-36 The western Ontario and McMaster Universities Arthritis index (WOMAC)
2 (4.8%) 1 (2.4%)
*
[11,46] [11]
Studies that measured these outcomes that were not presented as a component of a patient evaluation score.
Table 7 Recommended study measures associated with patient important outcomes. Study Measure
Rationale
Radiographic Reduction quality Implant placement Fracture shortening
Malreduction associated with fracture healing complications Incorrect placement associated with increased fixation failure Decreased abductor muscle tension and potential limb length discrepancy associated with poor function
Clinical Reoperation Avascular necrosis Fracture nonunion
Unplanned surgery causes increased morbidity and prolonged recovery Significant cause of hip pain, decreased function, and often leads to early hip arthroplasty Significant cause of hip pain, decreased function, and reoperation
Functional outcomes Hip Specific functional outcome
Young hip fracture patients have increased functional demands not reported in physician-centred instruments
associated with patient important events should be reported (Table 7). Overall, the results of this study must be interpreted in the context of the study design. This review only included studies that were published in English language journals, and as a result, may be limited by language publication bias. In addition, we suspect some authors may have collected more complication data than what is tabulated in our data synthesis; however, we are only able to report complications that were explicitly described in the publications. To minimise under-reporting of these outcomes, we also included any data that indicated when a specified complication did not occur. Finally, our systematic review only included studies in which the study population age was 60 years, or studies in which data could be abstracted for a subgroup of patients ages 60 years. In our literature search, we did locate several studies that included patients of all ages without stratification of their results for our younger target population; as a result, these studies were excluded. Despite these limitations, our study is strengthened by its systematic approach, pre-defined and broad eligibility criteria, and our duplicated screening and data abstraction methods. Our systematic review of the young femoral neck fracture literature provides a comprehensive overview of the study characteristics and outcomes reported in previous research. We found strikingly few studies reported clinically relevant outcomes necessary to appropriately guide surgical practice, and many
outcomes were more appropriate for lower demand elderly patient populations. As future clinical research seeks to improve the outcomes of young femoral neck fracture treatment, we recommend authors consider measuring and reporting key outcomes related to radiographic measures, fracture healing events, and patient reported function.
Conflict of interest statement This study was coordinated at the Centre for Evidence Based Orthopaedics, McMaster University. Dr. Gerard Slobogean is funded, in part, by the Canadian Institute of Health Research and the Vancouver Coastal Health Research Institute. Dr. Bhandari is funded, in part, by a Canada Research Chair. No additional funding was received for the completion of this manuscript and there are no possible conflicts of interest associated with this manuscript.
Acknowledgements Dr. Mohit Bhandari is funded, in part, by a Canada Research Chair. Dr. Gerard Slobogean is funded, in part, by the Canadian Institutes of Health Research 201303MTP-303853-MTP-CAAA224988 and Vancouver Coastal Health Research Institute.
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Appendix A. Search terms for electronic databases MEDLINE (25-Nov-2012)
EMBASE (26-Nov-2012)
CINAHL (28-Nov-2012)
CDSR & CENTRAL (28-Nov-2012)
(1) Exp hip fractures/(16,794) (2) Femoral neck fractures/(7276) (3) 1 and 2 (4) (Young: adj15 adult).mp. (284,142) (5) Middle aged/(3096,173) (6) Young adult/(258,304) (7) Or/4-6 (3226,501) (8) Exp fracture fixation/(45,128) (9) Surgical fixation.mp (591) (10) Internal fixation.mp (10,535) (11) Or/8–10 (49,682) (12) Exp aged/(2179,035) (13) Exp arthroplasty/(35,027) (14) 12 or 13 (2196,611) (15) 3 and 7 and 11 (2033) (16) 15 not 14 (359)
(1) Exp hip fractures/(27,044) (2) Exp femur neck fracture/(8513) (3) 1 or 2 (27,044) (4) (Young: adj15 adult).mp. (34,200) (5) Exp adolescent/(1221,703) (6) Exp middle age/(1091,830) (7) Exp young adult/(4300,466) (8) 4 or 5 or 6 or 7 (5104,469) (9) Exp fracture fixation/(63,235) (10) Surgical fixation.mp. (602) (11) Internal fixation.mp. (12,895) (12) 9 or 10 or 11 (66,753) (13) Exp arthroplasty/(68,724) (14) Exp aged/(2083,704) (15) 13 or 14 (2127,492) (16) 3 and 8 and 12 (2582) (17) 16 not 15 (851)
(1) (2) (3) (4) (5)
(1) (2) (3) (4) (5) (6) (7) (8) (9)
Appendix B. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.injury.2014.11.020. References [1] Bhandari M, Tornetta 3rd P, Hanson B, Swiontkowski MF. Optimal internal fixation for femoral neck fractures. J Orthop Trauma 2009;23:403–7. [2] Bhandari M, Devereaux PJ, Swiontkowski M, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. J Bone Joint Surg Am 2003;85A:1673–81. [3] Forsh DA, Ferguson TA. Contemporary management of femoral neck fractures: the young and the old. Curr Rev Musculoskelet Med 2012;5:214–21. [4] Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am 2008;90:2254–66. [5] Srivastava KP, Chandra H, Gupta R. Assessment of comparative results of methods of compression fixation of femoral neck fractures—a preliminary report. Indian J Orthop 1989;23:141–4. [6] Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br 2004;86:1035–40. [7] Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br 2011;93:811–6. [8] Vidyadhara S, Rao SK. Cephalomedullary nails in the management of ipsilateral neck and shaft fractures of the femur—one or two femoral neck screws. Injury 2009;40:296–303. [9] Farooq MA, Orkazai SH, Okusanya O, Devitt AT. Intracapsular fractures of the femoral neck in younger patients. Ir J Med Sci 2005;174:42–5. [10] Huang TW, Hsu WH, Peng KT, Lee CY. Effect of integrity of the posterior cortex in displaced femoral neck fractures on outcome after surgical fixation in young adults. Injury 2011;42:217–22. [11] Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR, Mahomed NN. Comparison of early and delayed fixation of subcapital hip fractures in patients sixty years of age or less. J Bone Joint Surg Am 2002;84-A:1605–12. [12] Liporace F, Gaines R, Collinge Haidukewych GJ. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg Am 2008;90:1654–9. [13] Razik F, Alexopoulos AS, El-Osta B, Connolly MJ, Brown A, Hassan S, Ravikumar K. Time to internal fixation of femoral neck fractures in patients under sixty years: does this matter in the development of osteonecrosis of femoral head. Int Orthop 2012;36:2127–32. [14] Singh R, Rohilla R, Magu NK, Siwach R, Kadian V, Sangwan SS. Ipsilateral femoral neck and shaft fractures: a retrospective analysis of two treatment methods. J Orthop Traumatol 2008;9:141–7. [15] Stearns AT, Jaberoo MC, Ashraf R, Wheelwright EF, Maclean AD. Displaced intracapuslar hip fractures in the working age alcohol-abusing patient. Scott Med J 2009;54:16–20. [16] Verettas DA, Galanis B, Kazakos K, Hatziyiannakis A, Kotsios E. Fractures of the proximal part of the femur in patients under 50 years of age. Injury 2002;33:41–5. [17] Wang WY, Liu L, Wang GL, Fang Y, Yang TF. Ipsilateral basicervical femoral neck and shaft fractures treated with long proximal femoral nail antirotation or various plate combinations: comparative study. J Orthop Sci 2010;15:323–30.
Femoral neck fracture Elderly Geriatric Arthroplasty 1 not 2 or 3 or 4 (101)
Hip fractures.mp (812) Femoral neck fractures.mp (318) 1 or 2 (1079) Aged.mp (251,158) Elderly.mp (12,271) Geriatric.mp (2849) Arthroplasty.mp (3231) or/4–7 (255,498) 3 not 8 (163)
[18] Broos PL, Vercruysse R, Fourneau I, Driesen R, Stappaerts KH. Unstable femoral neck fractures in young adults: treatment with the AO 130-degree blade plate. J Orthop Trauma 1998;12:235–9. [19] Butt MF, Dhar SA, Gani NU, Farooq M, Mir MR, Halwai MA, et al. Delayed fixation of displaced femoral neck fractures in younger adults. Injury 2008;39:238–43. [20] Chang MC, Lo WH, Chen TH. Vascularized iliac bone graft for displaced femoral neck fractures in young adults. Orthopedics 1999;22:493–9. [21] Chaturvedi S, Sahu SC. Ipsilateral concomitant fractures of the femoral neck and shaft. Injury 1993;24:243–6. [22] Gautam VK, Anand S, Dhaon BK. Management of displaced femoral neck fractures in young adults (a group at risk). Injury 1998;29:215–8. [23] He XJ, Wang KZ, Mao LZ, Chen JC, Li H, Lu AP. Treatment of intracapsular displaced fracture of femoral neck by vascularized fibular graft and compression screw internal fixation. J Ortho Technol 1995;3:116–9. [24] Henari S, Leonard M, Hamadto M, Cogley D. Review of a single contemporary femoral neck fracture fixation method in young patients. Orthopedics 2011;34:171. [25] Huang HK, Su YP, Chen CM, Chiu FY, Liu CL. Displaced femoral neck fractures in young adults treated with closed reduction and internal fixation. Orthopedics 2010;33:873. [26] Jain P, Maini L, Mishra P, Upadhyay A, Agarwal A. Cephalomedullary interlocked nail for ipsilateral hip and femoral shaft fractures. Injury 2004;35:1031–8. [27] Koldenhoven GA, Burke JS, Pierron R. Ipsilateral femoral neck and shaft fractures. South Med J 1997;90:288–93. [28] Masetti G, Bungaro P, Beltrandi S, Montanari G, Lucaccini C. Osteosynthesis in fractures of the femoral neck in the young adult. Chir Organ Mov 1990;75:231–8. [29] Morwessel R, Evarts CM. The use of quadratus femoris muscle pedicle bone graft for the treatment of displaced femoral neck fractures. Orthopedics 1985;8:972–6. [30] Oh CW, Oh JK, Park BC, Jeon IH, Kyung HS, Kim Y, et al. Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures. Arch Orthop Trauma Surg 2006;126:448–53. [31] Okcu G, Aktuglu K. Antegrade nailing of femoral shaft fractures combined with neck or distal femur fractures. A retrospective review of 25 cases, with a follow-up of 36–150 months. Arch Orthop Trauma Surg 2003;123:544–50. [32] Parfenchuck TA, Carter LW, Young TR. Ipsilateral fractures of the femoral neck and shaft. Orthop Rev 1993;22:356–63. [33] Randelli P, Landi S, Fanton F, Hoover GK, Morandi M. Treatment of ipsilateral femoral neck and shaft fractures with the Russell–Taylor reconstructive nail. Orthopedics 1999;22:673–6. [34] Rawall S, Bali K, Upendra B, Garg B, Yadav CS, Jayaswal A. Displaced femoral neck fractures in the young: significance of posterior comminution and raised intracapsular pressure. Arch Orthop Trauma Surg 2012;132:73–9. [35] Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O, Paavilainen T. Subcapital fractures of the femur treated with two thin Smith–Petersen nails. Acta Orthop Scand 1977;48:494–8. [36] Robinson CM, Court-Brown CM, McQueen MM, Christie J. Hip fractures in adults younger than 50 years of age. Epidemiology and results. Clin Orthop Relat Res 1995;312:238–46. [37] Tooke SM, Favero KJ. Femoral neck fractures in skeletally mature patients, fifty years old or less. J Bone Joint Surg Am 1985;67:1255–60. [38] Brown JT, Abrimi G. Transcervical femoral fracture. A review of 195 patients treated by sliding nail-plate fixation. J Bone Joint Surg 1964;46B:648–63. [39] Driesen R, Niks S, Broos PL, Fabry G. Unstable femoral neck fractures treated with a 130 degree blade plate. Acta Orthop Belg 1994;60:322–7. [40] Kao HK, Wu CC, Lee PC, Su CY, Fan KF, Tseng IC. Ipsilateral femoral neck and shaft fractures treated with russell-taylor reconstruction intramedullary nails. Chang Gung Med J 2006;29:79–85.
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[41] Khallaf F, Al-Mosalamy M, Al-Akkad M, Hantira H. Surgical treatment for the ipsilateral fractures of femoral neck and shaft. Med Princ Pract 2005;14: 318–24. [42] Swiontkowski M, Hansen ST, Kellam J. Ipsilateral fractures of the femoral neck and shaft. J Bone Joint Surg 1984;66:260–8. [43] Tzachev N, Baltov A, Ivanov V, Zlatev B, Lotov A. Cefalomedullary nails in the treatment of ipsilateral femoral neck and shaft fractures. In: Presented at the European Federation of National Associations of Orthopaedics and Traumatology 2009 Congress; 2009 [Abstract]. [44] Gardner ST, Weaver MJ, Jerabek SA, Vrahas MS, Appleton PT. Displaced femoral neck fracture sin patients
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Young femoral neck fractures: Are we measuring outcomes that matter? Sheila Sprague a,b, Gerard P. Slobogean a,c, Taryn Scott b, Manraj Chahal a, Mohit Bhandari a,b,* a b c
Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada Department of Clinical Epidemiology and Biostatics, McMaster University, Hamilton, ON, Canada Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 July 2014 Accepted 17 November 2014
Introduction: Femoral neck fractures in younger aged patients are particularly devastating injuries with profound impairments of quality of life and function. As there are multiple differences in patient and injury characteristics between young and elderly femoral neck fracture patients, the geriatric hip fracture literature is unlikely to be generalisable to patients under age 60. We conducted a systematic review to determine if clinically relevant outcome measures have been used in previously published clinical studies of internal fixation in young adults with femoral neck fractures. Methods: We conducted a comprehensive literature search using multiple electronic databases and conference proceedings to identify studies which used internal fixation for the management of femoral neck fractures in patients between the ages of 15 to 60. Eligibility screening and data abstraction were performed in duplicate. We classified the reported outcomes into the following categories: operative and hospital outcomes, radiographic outcomes, clinical outcomes, and functional outcomes and healthrelated quality of life. We calculated the frequencies of reported outcomes. Results: Fort-two studies met our inclusion criteria. Operative and hospital outcomes were poorly reported with less than one-quarter of studies reporting relevant data. Important radiographic outcomes were also inadequately reported with only one-third of studies reporting the quality of the fracture reduction, and methods for assessment were highly variable. The assessment of avascular necrosis was reported in almost all the included studies (95.2%); however, the assessment of nonunion was only reported in three-quarters of the studies. Re-operations were reported in 73.8% of the included studies and the assessment of fracture healing was only reported in two-thirds of the studies. Less than half of the studies reported functional outcomes or health-related quality of life (overall patient evaluation scales and systems (45.2%), patient functional outcomes (30.9%), and health-related quality of life (4.8%). Discussion: Our systematic review found that the assessment of clinically relevant outcomes in the young femoral neck fracture literature is lacking, which makes utilising the literature to guide clinical practice challenging. Future studies should aim to include important radiographic measures, fracturehealing complications, functional outcomes, and health-related quality of life during any assessment of young femoral neck fracture treatment. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Femoral neck fracture Hip fracture Outcomes Non-geriatric
Introduction Internal fixation of femoral neck fractures is frequently associated with high complication rates and poor functional
* Corresponding author at: Division of Orthopaedic Surgery, 293 Wellington St. No. 110, Hamilton, Canada L8L 8E7. Tel.: +1 905 527 4322x44490; fax: +1 905 523 8781. E-mail address: [email protected] (M. Bhandari). http://dx.doi.org/10.1016/j.injury.2014.11.020 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
outcomes. For elderly patients, displaced fractures are typically treated with arthroplasty to avoid these major fracture healing complications; however, in younger adults internal fixation is performed for nearly all femoral neck fractures to preserve the native hip joint, to facilitate increased functional demands, and to avoid concerns of arthroplasty longevity. As a result, young femoral neck fracture patients are particularly at risk for experiencing significant fracture healing complications, re-operations, and lifelong morbidity.
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While there is large body of literature pertaining to the treatment of femoral neck fractures in geriatric populations, the generalisability of these findings to younger adults may be limited due to key differences in terms of the physiological condition of patients, the injury mechanism, the goal of treatment, and the method of treatment [1–4]. These differences demonstrate the importance of identifying separate and distinct clinical guidance for treating femoral neck fractures in young adults. Reporting outcome measures that are relevant to the younger population is crucial to facilitate comparisons of treatment efficacy, to identify the incidence of complications, and to properly inform patients of their expected outcomes. The objective of this systematic review is to describe the characteristics of the young femoral neck fracture literature and to determine if clinically relevant outcome measures have been used when reporting the results of internal fixation in younger hip fracture patients. Specifically, we aimed to determine how previous authors have quantified the following outcomes in our target population: operative and hospital outcomes, radiographic outcomes, clinical outcomes, and functional outcomes and healthrelated quality of life.
screening the article titles identified in the literature searches to determine whether the articles should be considered for inclusion. Since the screening process needed to distinguish between elderly and young femoral neck fractures, any title that mentioned fixation of femoral neck fractures or hip fractures was selected for further review. The titles identified as potentially eligible were then screened at the abstract level. Again, the authors erred on the side of inclusivity. Any conflicts identified at the title and abstract screening stages were discussed, and if consensus was not reached, the reference proceeded to the next level of screening. The full-text of all articles identified as potentially eligible at the abstract screening level were then reviewed. Any disagreements at the full-text stage were resolved with input from a third author. Articles that met the inclusion criteria were selected for data abstraction. We used the Distiller Systematic Review software (http:// systematic-review.net/) to facilitate our article selection process. Level of agreement between the two authors was assessed with the kappa statistic. We adopted an a priori criterion of k 0.65 for adequate agreement. Data abstraction
Methods Literature search We conducted a systematic review of the published literature to identify clinical studies that used internal fixation for the management of femoral neck fractures in patients age 60 years. In consultation with a research librarian, we conducted systematic literature searches of the Medline, Embase, CINAHL, and Cochrane databases using the search terms contained in Appendix A. We hand searched the abstracts from the past five annual meetings (2008 to 2012) from the Orthopaedic Trauma Association (OTA), the Canadian Orthopaedic Association (COA), and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT). In addition, we hand searched abstracts from the past two annual meetings (2011 and 2012) of the American Academy of Orthopaedic Surgeons (AAOS). Following the literature searches, two of the authors independently reviewed the reference lists of all included articles for further eligible articles. Eligibility criteria We included published studies that met the following eligibility criteria: (1) the population was comprised of young adults (ages 15 to 60 years) with a femoral neck fracture, (2) patients were treated with internal fixation, (3) the study type was ‘‘therapeutic’’ or ‘‘prognostic’’ and falls within evidence levels I, II, III, or IV (case series with more than 10 patients), and (4) the study reported any outcome measure following fracture fixation. Studies that included patients with femoral neck fractures and ipsilateral femoral shaft injuries, and/or femoral neck fracturedislocations were also eligible. We excluded studies that focused on: (1) stress fractures; (2) treatment of delayed fractures (greater than 14 days from injury); (3) management of femoral neck fracture nonunions; and (4) management of osteonecrosis following femoral neck fractures. We also excluded studies that were published in languages other than English, review articles, and meta-analyses. Article selection Two authors independently reviewed the titles, abstracts, and full-text articles for inclusion. The authors began by
Two authors independently abstracted all relevant information from each included article on study specific case report forms. Briefly, we abstracted study characteristics, patient demographics, fracture characteristics, surgical details, and the outcomes reported from each included study. Any disagreements between the two authors were reconciled through a consensus meeting; if agreement could not be reached, a third author resolved the disagreement. Reported outcomes were then classified into themes, including: operative and hospital outcomes, radiographic outcomes, clinical outcomes (i.e. re-operations, fracture healing, fracture-related complications, general medical complications), functional outcomes, and health-related quality of life. Data analysis Descriptive statistics were used to summarise the study and patient characteristics. Frequency data (proportions and percentages) describe the use of reported outcomes, and qualitative descriptions characterise the outcomes used in each of the included studies.
Results Literature search results The electronic database search identified 1182 articles that were potentially eligible for inclusion in this review (Fig. 1). Of these studies, 1012 were excluded after review of titles, 30 after reviewing the abstracts, and 107 after full-text review. Therefore, 33 articles were identified for inclusion in this review. A search of the meeting abstracts identified 3804 titles, with 3513 excluded after review of titles and 286 after review of abstracts. One additional abstract was excluded as it had duplicate data to a full publication that had been identified in the literature search. This left four abstracts for inclusion in the review. The hand search of the reference lists of the included articles identified five additional studies that met the eligibility criteria for this review. In summary, 42 articles are included in this review [5–46]. The two authors had acceptable agreement regarding which studies should be included or excluded (percent of overall agreement = 86.90; unweighted kappa = 0.68).
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Fig. 1. Literature search results.
Study and patient characteristics The majority of the included studies were conducted in Asia (40.5%), North America (21.4%), and Continental Europe (21.4%) (Table 1). Most of the studies were single-centre initiatives (81.0%), and the majority of the studies were retrospective case series (59.5%) or retrospective comparative studies (21.4%). Only
2 studies (4.8%) were randomised controlled trials. The mean sample size of the included studies was 39.4 33.8 with sample sizes ranging from 11 to 146 patients. The mean length of patient follow-up within the included studies was 35.8 16.3 months with a range of 12 to 78 months. Twenty-seven studies (64.3%) included patients with isolated femoral neck fractures; 14 studies (33.3%) included only patients with ipsilateral femoral neck and shaft
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510 Table 1 Study characteristics. Characteristic
Frequency N (%) N = 42
Location of research Asia North America Continental Europe United Kingdom New Zealand Not mentioned
17 9 9 5 1 1
Funding source No statement of funding provided Non-funded Government grant
35 (83.3%) 6 (14.3%) 1 (2.4%)
Year of publication 1961 to 1970 1971 to 1980 1981 to 1990 1991 to 2000 2001 to 2010 2011 to 2012
1 1 5 10 18 7
(2.4%) (2.4%) (11.9%) (23.8%) (42.9%) (16.7%)
Study design Randomised controlled trial Prospective comparative study Retrospective comparative study Retrospective prognostic study Prospective case series Retrospective case series
2 1 9 1 2 25
(4.8%) (2.4%) (21.4%) (2.4%) (4.8%) (59.5%)
Number of clinical sites One Two Three Mean sample size (standard deviation) Mean length of follow-up, months (standard deviation) Mean follow-up, percent (standard deviation) Fractures included Femoral neck fractures only Ipsilateral femoral neck and shaft fractures Both isolated femoral neck fracture and ipsilateral Femoral neck and shaft fractures
(40.5%) (21.4%) (21.4%) (11.9%) (2.4%) (2.4%)
34 (81.0%) 4 (9.5%) 4 (9.5%) 39.43 33.8 35.75 16.3 91.5 8.4 27 (64.3%) 14 (33.3%) 1 (2.4%)
fractures, and one study (2.4%) included patients with both isolated femoral neck fractures and ipsilateral femoral neck and shaft fractures. There were 1655 patients with 1664 fractures included in the 42 studies (Table 2). The mean age of the patients was 39.2 5.6 years, and the majority of the patients had isolated femoral neck fractures (81.3%). Thirty-five studies (83.3%) reported fracture displacement with 1293 (77.7%) patients having displaced fractures. Twenty-nine studies reported the method of reduction used; in these Table 2 Patient and fracture characteristics (N = 42). Characteristic
Number of studies reporting (%)
Total patients (%)
Sample size Mean age (standard deviation) Fracture location Femoral neck only Ipsilateral FN and shaft fracture Not specified Fracture displacement Displaced Undisplaced Not specified Method of reduction Open reduction Closed reduction Not specified
42 (100%) 30 (71.4%) 42 (100%)
1655 39.2 5.6
FN—femoral neck.
1353 (81.3%) 266 (16.0%) 45 (2.7%)
studies, 158 patients underwent open reduction and 1089 patients had closed reduction. Over 20 different methods of internal fixation were used across the 42 studies. Reported operative and hospital outcomes Few studies reported operative and hospital outcomes (Table 3). Briefly, 10 studies (23.8%) reported the length of surgery, and 5 studies (11.9%) studies reported patient blood loss during surgery. Nine studies (21.4%) commented on technical problems during surgery, and two studies (4.8%) reported intra-operative complications during surgery. The length of hospital stay was stated in only six studies (14.3%). Reported radiographic outcomes Important radiographic outcomes were poorly reported across the included studies (Table 4). Only one-third of the studies assessed the quality of the fracture reduction, which is important information since malreduction is known to be associated with healing complications. These studies used a variety of different criteria to assess quality of reduction including the method described by Haidukewych [47] (1 study, 2.4%), Garden’s angle or scale [48] (7 studies, 16.7%), and a variety of different criteria specified by the authors (7 studies, 16.7%). Only six studies (14.3%) reported loss of reduction, and seven studies (16.7%) assessed the adequacy of implant placement, which is also a potentially important predictor of complications. Surprisingly, radiographic shortening was only reported in two studies (4.8%) which also may have significant implications on clinical outcome. Reported clinical outcomes Re-operations, including the type of procedure and indication, were reported in 31 studies (73.8%) (Table 5). The assessment of fracture healing was only explicitly reported in two-thirds of the studies (28 studies, 66.7%). When it was reported, union was described as either the proportion of fractures healed at a specified time point, the time to fracture union, or a combination of both measures. The assessment of avascular necrosis was reported in almost all the included studies (40 studies, 95.2%); however, the assessment of fracture nonunion, another common fracturerelated complication, was only reported in three-quarters of the studies (32 studies (76.2%). Other fracture-related complications were reported less frequently including: infection (24 studies, 57.1%), symptomatic hardware (21 studies, 50.0%), malunion (16 studies, 38.1%), delayed union (11 studies, 26.2%), leg length discrepancy or shortening of the limb (4 studies, 9.5%), loss of fixation (4 studies, 9.5%), and arthritis (3 studies, 7.1%). As expected, general medical complications were assessed in just over half of the studies (22 studies, 52.4%) with 14 studies (33.3%) assessing deep vein thrombosis, pulmonary embolism, or fat embolism, and 8 studies (19.0%) reporting patient deaths. Table 3 Reported operative and hospital outcomes (N = 42). Reported outcome
Number of studies reporting (%)
References
Length of surgery Technical problems during surgery Blood loss & transfusion requirements Length of hospital stay intra-operative complications
10 (23.8%) 9 (21.4%)
[6,14,17,18,20,26,30,31,39,40] [13,14,17,20,22,24,26,32,35]
35 (83.3%) 1293 (77.7%) 238 (14.3%) 133 (8.0%) 29 (69.0%) 158 (9.5%) 1089 (65.4%) 417 (25.1%)
5 (11.9%)
[17,20,21,26,40]
6 (14.3%) 2 (4.8%)
[15,17,18,32,35,39] [27,29]
S. Sprague et al. / Injury, Int. J. Care Injured 46 (2015) 507–514 Table 4 Reported radiographic outcomes (N = 42). Reported outcome
Number of studies reporting (%)
References
Quality of reduction Loss of reduction Assessment of implant placement Radiographic FN shortening Bone quality
15 (35.7%) 6 (14.3%) 7 (16.7%)
[5–12,18,20,22,24,26,34,44] [9,10,14,20,37,39 [5,6,8,9,24,35,44]
2 (4.8%)
[5,10]
1 (2.4%)
[10]
FN—femoral neck.
Functional outcomes and health-related quality of life Only 19 studies (45.2%) included an overall patient evaluation scale system as part of their reported outcomes (Table 6). In six of these studies (14.3%), the authors used a patient evaluation rating system that they developed. In the other 13 studies (30.9%), the authors used a previously developed scale or system that they may have modified. Systems utilised included the Friedman and Wyman Scale [49] (5 studies, 11.9%), the Harris Hip Score [50] (4 studies, 9.5%), the Judet scale [51] (2 studies, 4.8%), the Arnold Evaluation Guide [52] (1 study, 2.4%), and the Merle D’AubingnePostel Scoring System [53] (1 study, 2.4%). Thirteen studies (30.9%) reported patient functional outcomes that were not included as a component of an overall patient score (Table 6). These outcomes included pain (6 studies, 14.3%), range of motion (5 studies, 11.9%), return to work (4 studies, 9.5%), activities of daily living (4 studies, 9.5%), assessment of gait or walking ability (2 studies, 4.8%), and return to sporting activities (1 study, 2.4%). Health-related quality of life outcome measures were administered in 2 studies (4.8%) (Table 6). A recently published abstract [46] administered the Short Form-36 (SF-36) [54] to participants. The second study [11] used the SF-36 and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) (Table 6) [55]. Discussion This systematic review summarises the outcome measures used in clinical studies evaluating femoral neck fracture fixation in
511
patients 60 years old. Although multiple outcomes were identified across the 42 included studies, there are significant gaps in the assessment and reporting of outcomes necessary to guide clinical practice. Specifically, key aspects of fracture displacement, quality of reduction and implant placement, and numerous patient important outcomes are routinely not reported in the existing literature. Without these data, surgeons are unable to compare treatment efficacy, identify the incidence of complications, or properly inform their patients of expected outcomes. We found that many of the outcomes reported in the young femoral neck studies are similar to those used in studies of femoral neck fractures in elderly populations. While this is appropriate for radiographic complications such as avascular necrosis, the increased functional demands of younger patients require that researchers measure outcomes that will be both sensitive and important to these younger individuals with highly active lifestyles. For example, many of the included studies used hip outcome questionnaires designed for osteoarthritic patients to measure quality of life and function; these instruments lack content validity for use in younger active patients (e.g. WOMAC and the Harris Hip Score). Furthermore, femoral neck fracture shortening is known to decrease hip abductor function and is associated with poorer physical function [56,57]. For younger patients this may lead to a lifetime of hip weakness, gait abnormalities, and poor functional outcomes. Within the past decade there has been a shift in orthopaedic surgery research from solely reporting fixation success or failure towards measurement of patient reported functional outcomes and health-related quality of life [58,59]. The increasing emphasis on these outcomes reflects a global shift towards patient centred medicine, and despite the historical importance of many surgeonbased assessments, patient reported outcomes must be at focal point of any clinical evaluation. This belief has also been adopted by the research community, and several authors have recommend the use of standardised, validated tools to assess function and health-related quality of life in clinical trials [60–64]. Within the elderly hip fracture literature multiple studies use patient reported functional outcomes, and we suspect this reflects the higher quality of research found in this population [65–71]. In contrast, the majority of the studies included in the current review were of a lower level of evidence and were retrospective in nature. Regardless of the combination of outcome measures used in a study population, we believe a minimum set of outcomes
Table 5 Reported clinical outcomes (N = 42). Reported outcome
Number of studies reporting (%)
References for studies that reported the outcome
Re-operations Revision surgery and indication for revision surgery
31 (73.8%)
[5,7–12,14–22,24,26,27,29–31,33,34,36,37,39,40–42,44]
Fracture union Proportion healed Nonunion Time to union
26 (61.9%) 32 (76.2%) 17 (40.5%)
[5,7,9–11,14,16–24,26,27,29–33,35,38,41,42] [5–12,14–19,22–27,29,30–32,34,37,38,40,41,43,45,46] [5,7,8,14,17,19,20–22,26–27,29,30,31,33,40,41]
Fracture-related complications Avascular necrosis Infection Symptomatic hardware Malunion or malalignment Delayed union Leg length discrepancy or shortening of the limb Loss of fixation Arthritis
40 (95.2%) 24 (57.1%) 21 (50.0%) 16 (38.1%) 11 (26.2%) 4 (9.5%) 4 (9.5%) 3 (7.1%)
[5–39,41–45] [5–7,11,12,15,17–22,26,29–36,39,41,43] [5,6,8,9,15–18,20,23,26,28,29,31–33,36,37,39–41] [5,9,14,16,17,21,26–28,30,31,33,40,41,43,46] [8,11,14,16–18,26–28,31,39] [28,29,33,37] [7,22,25,44] [9,35,37]
22 (52.4%) 14 (33.3%)
[5,6,11,13,15–17,20,21,26,30–33,35–39,42–44] [6,11,13,15–17,21,26,30,31,33,36,42,43]
8 (19.0%)
[5,11,15,35–38,42]
General medical complications General medical complications Deep vein thrombosis Pulmonary embolism, or fat embolism Death
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Table 6 Functional outcomes and health-related quality of life. Reported outcome
Number of studies reporting (%)
References for studies that reported the outcome
Patient evaluation scales and systems Overall patient evaluation/rating system developed by authors Friedman and Wyman scale Harris hip score Judet scale Arnold evaluation guide Merle D’Aubingne-Postel scoring system
6 5 4 2 1 1
(14.3%) (11.9%) (9.5%) (4.8%) (2.4%) (2.4%)
[14,18,27,28,35,39] [17,30–32,41] [8,9,34,45] [5,19] [20] [37]
Functional outcomes* Pain Range of motion Return to work Activities of daily living Assessment of gait/walking Ability Return to sporting activities
6 5 4 4 2 1
(14.3%) (11.9%) (9.5%) (9.5%) (4.8%) (2.4%)
[20,24,26,31,39,46] [8,26,29,33,37] [19,26,32,39] [26,32,39,42] [24,29] [39]
Health-related quality of life Short form-36 The western Ontario and McMaster Universities Arthritis index (WOMAC)
2 (4.8%) 1 (2.4%)
*
[11,46] [11]
Studies that measured these outcomes that were not presented as a component of a patient evaluation score.
Table 7 Recommended study measures associated with patient important outcomes. Study Measure
Rationale
Radiographic Reduction quality Implant placement Fracture shortening
Malreduction associated with fracture healing complications Incorrect placement associated with increased fixation failure Decreased abductor muscle tension and potential limb length discrepancy associated with poor function
Clinical Reoperation Avascular necrosis Fracture nonunion
Unplanned surgery causes increased morbidity and prolonged recovery Significant cause of hip pain, decreased function, and often leads to early hip arthroplasty Significant cause of hip pain, decreased function, and reoperation
Functional outcomes Hip Specific functional outcome
Young hip fracture patients have increased functional demands not reported in physician-centred instruments
associated with patient important events should be reported (Table 7). Overall, the results of this study must be interpreted in the context of the study design. This review only included studies that were published in English language journals, and as a result, may be limited by language publication bias. In addition, we suspect some authors may have collected more complication data than what is tabulated in our data synthesis; however, we are only able to report complications that were explicitly described in the publications. To minimise under-reporting of these outcomes, we also included any data that indicated when a specified complication did not occur. Finally, our systematic review only included studies in which the study population age was 60 years, or studies in which data could be abstracted for a subgroup of patients ages 60 years. In our literature search, we did locate several studies that included patients of all ages without stratification of their results for our younger target population; as a result, these studies were excluded. Despite these limitations, our study is strengthened by its systematic approach, pre-defined and broad eligibility criteria, and our duplicated screening and data abstraction methods. Our systematic review of the young femoral neck fracture literature provides a comprehensive overview of the study characteristics and outcomes reported in previous research. We found strikingly few studies reported clinically relevant outcomes necessary to appropriately guide surgical practice, and many
outcomes were more appropriate for lower demand elderly patient populations. As future clinical research seeks to improve the outcomes of young femoral neck fracture treatment, we recommend authors consider measuring and reporting key outcomes related to radiographic measures, fracture healing events, and patient reported function.
Conflict of interest statement This study was coordinated at the Centre for Evidence Based Orthopaedics, McMaster University. Dr. Gerard Slobogean is funded, in part, by the Canadian Institute of Health Research and the Vancouver Coastal Health Research Institute. Dr. Bhandari is funded, in part, by a Canada Research Chair. No additional funding was received for the completion of this manuscript and there are no possible conflicts of interest associated with this manuscript.
Acknowledgements Dr. Mohit Bhandari is funded, in part, by a Canada Research Chair. Dr. Gerard Slobogean is funded, in part, by the Canadian Institutes of Health Research 201303MTP-303853-MTP-CAAA224988 and Vancouver Coastal Health Research Institute.
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Appendix A. Search terms for electronic databases MEDLINE (25-Nov-2012)
EMBASE (26-Nov-2012)
CINAHL (28-Nov-2012)
CDSR & CENTRAL (28-Nov-2012)
(1) Exp hip fractures/(16,794) (2) Femoral neck fractures/(7276) (3) 1 and 2 (4) (Young: adj15 adult).mp. (284,142) (5) Middle aged/(3096,173) (6) Young adult/(258,304) (7) Or/4-6 (3226,501) (8) Exp fracture fixation/(45,128) (9) Surgical fixation.mp (591) (10) Internal fixation.mp (10,535) (11) Or/8–10 (49,682) (12) Exp aged/(2179,035) (13) Exp arthroplasty/(35,027) (14) 12 or 13 (2196,611) (15) 3 and 7 and 11 (2033) (16) 15 not 14 (359)
(1) Exp hip fractures/(27,044) (2) Exp femur neck fracture/(8513) (3) 1 or 2 (27,044) (4) (Young: adj15 adult).mp. (34,200) (5) Exp adolescent/(1221,703) (6) Exp middle age/(1091,830) (7) Exp young adult/(4300,466) (8) 4 or 5 or 6 or 7 (5104,469) (9) Exp fracture fixation/(63,235) (10) Surgical fixation.mp. (602) (11) Internal fixation.mp. (12,895) (12) 9 or 10 or 11 (66,753) (13) Exp arthroplasty/(68,724) (14) Exp aged/(2083,704) (15) 13 or 14 (2127,492) (16) 3 and 8 and 12 (2582) (17) 16 not 15 (851)
(1) (2) (3) (4) (5)
(1) (2) (3) (4) (5) (6) (7) (8) (9)
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Femoral neck fracture Elderly Geriatric Arthroplasty 1 not 2 or 3 or 4 (101)
Hip fractures.mp (812) Femoral neck fractures.mp (318) 1 or 2 (1079) Aged.mp (251,158) Elderly.mp (12,271) Geriatric.mp (2849) Arthroplasty.mp (3231) or/4–7 (255,498) 3 not 8 (163)
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