In the fixation of adult femoral neck fractures, does percutaneous hematoma drainage have an effect on bone union?
Keywords:Femoral neck fracture, Intracapsular fracture, Cannulated screw, Fracture hematoma, Hematoma punction
Background/Aim: Major blood circulation of the femur head is provided by retrograde flow from the medial femoral circumflex artery. The biggest problem here is uncertainty that the fracture hematoma disrupts the feeding of the femoral head. The aim of this study was to evaluate the effect on bone union of percutaneous hematoma punction in femoral neck fractures in patients aged <60 years and in patients with similar fracture types operated on in similar periods and to compare the outcomes in respect of complications. Methods: In this retrospective cohort study, from a total of 58 patients who presented at the Orthopedics and Traumatology Clinic of a tertiary level training and research hospital between January 2014 and December 2018 and were diagnosed with intracapsular femoral neck fracture, the study included 49 patients who met the inclusion criteria and had follow-up of at least 1 year. In the treatment of all the fractures, 3 cannulated spongious screws were used. Percutaneous hematoma drainage was applied to 25 patients [Hem (+)=Group 1], and was not applied to 24 patients [Hem (-)=Group 2]. The patients were separated into two groups as those with and without fracture hematoma. The demographic data, time to union and femoral neck anatomic parameters were statistically compared between the two groups. Clinical and radiographic evaluations were made at the end of postoperative 1 month, 3 months, 6 months and 1 year. The Harris Hip Score was used in the clinical evaluation. Results: The mean follow-up period was 21 months (range, 12-36 months). Group 1 comprised 18 (72%) females and 7 (28%) males with a mean age of 38 years (range, 19-53 years), and Group 2 comprised 16 (66%) females and 8 (34%) males with a mean age of 40 years (range, 19-58 years) (age: P=0.483). In Group 1, the right side was affected in 14 patients (56%) and the left side in 11 (44%). In Group 2, the right side was affected in 14 patients (58%) and the left side in 10 (42%) (P=0.869). A mean of 28 cc hematoma was drained from Group 1. In 47 patients, the operation was performed within the first 24 hours. The fractures were determined as Garden type 3 in 52% (n=13) of Group 1 and in 54% (n=13) of Group 2 (P=0.940). Full bone union was obtained in 80% (n=20) of Group 1 and in 79% (n=19) of Group 2 (P=0.728). Revision surgery was required in 7 patients in Group 1 and in 3 patients in Group 2. At the final follow-up examination, the difference between the healthy side and the fractured side femoral neck offset values were calculated. The difference in femoral offset compared with the healthy non-operated side was -3.48 (9.44) mm in Group 1, and -2.25 (7.97) mm in Group 2 (P=0.625). No significant difference was determined between the groups in respect of the anatomic parameters after union. The Harris Hip Scores were determined as mean 89 (range, 63-98) in Group 1 and 91 (range, 64-98) in Group 2 (P=0.616). No statistically significant difference was determined between the groups in respect of the clinical evaluation. Avascular necrosis developed in the femoral head in 4 (16%) patients in Group 1 and in 1 (4.17%) in Group 2 (P=0.349). Conclusion: From the results of this study it was seen that unlike hematoma formed in extremity fractures, hematoma in femoral neck fractures has an effect that makes union difficult rather than facilitating callus formation. Hematoma punction led to an increased risk of avascular necrosis with impaired intraosseous circulation flowing in reverse to the femoral head due to negative pressure formed in the fracture line.
Askin SR, Bryan RS. Femoral neck fractures in young adults. Clin Orthop Relat Res. 1976 Jan-Feb;(114):259-64. PMID: 1261119.
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 Mar;(312):238-46. PMID: 7634609.
Damany DS, Parker MJ, Chojnowski A. Complications after intracapsular hip fractures in young adults. A meta-analysis of 18 published studies involving 564 fractures. Injury. 2005 Jan;36(1):131-41. doi: 10.1016/j.injury.2004.05.023.
Kregor PJ. The effect of femoral neck fractures on femoral head blood flow. Orthopedics. 1996 Dec;19(12):1031-6; quiz 1037-8. PMID: 8972521.
Koval KJ, Zuckerman JD. Femoral Neck Fractures. In: Koval KJ, Zuckerman JD, eds. Hip Fractures. A Practical Guide to Management. New York: Springer; 2000. pp. 49–127.
Soto-Hall R, Johnson LH, Johnson RA. Varıatıons In The Intra-Artıcular Pressure Of The Hıp Joınt In Injury And Dısease. A Probable Factor In: Avascular Necrosis. J Bone Joint Surg Am. 1964 Apr;46:509-16. PMID: 14131429.
Flynn M. A new method of reduction of fractures of the neck of the femur based on anatomical studies of the hip joint. Injury. 1974 May;5(4):309-17. PMID: 4426685.
Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg (Br). 1961; 43:647-63. doi: 10.1302/0301-620X.43B4.647.
Pauwels F. Der Schenkelhalsbruch, ein mechanisches problem. Grundlagen des Heilungsvorganges, Prognose und Kausale Therapie. Stuttgart, Germany: Beilagenheft zur Zeitschrift fur Orthop Chirurgie.1935. pp. 64.
Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969 Jun;51(4):737-55. PMID: 5783851.
Rodríguez-Merchán EC. In situ fixation of nondisplaced intracapsular fractures of the proximal femur. Clin Orthop Relat Res. 2002 Jun;(399):42-51. PMID: 12011693.
Slobogean GP, Sprague SA, Scott T, McKee M, Bhandari M. Management of young femoral neck fractures: is there a consensus? Injury. 2015 Mar;46(3):435-40. doi: 10.1016/j.injury.2014.11.028.
Tükenmez M, Çekin T, Perçin S, Tezeren G. Femur Boyun Kırıklarında İnternal Fiksasyon. CÜ Tıp Fakültesi Dergisi. 2004;26(3):131-5.
Bulut O, Tükenmez M, Demirel H, Çekin T. Erişkin femur boyun kırıklarında multipl kansellöz vida fiksasyonu. Eklem Hastalıkları ve Cerrahisi. 2004;15(4):183-7.
Bonnaire F, Schaefer DJ, Kuner EH. Hemarthrosis and hip joint pressure in femoral neck fractures. Clin Orthop Relat Res. 1998 Aug;(353):148-55. doi: 10.1097/00003086-199808000-00017.
Harper WM, Barnes MR, Gregg PJ. Femoral head blood flow in femoral neck fractures. An analysis using intra-osseous pressure measurement. J Bone Joint Surg Br. 1991 Jan;73(1):73-5. doi: 10.1302/0301-620X.73B1.1991780.
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 Jan;132(1):73-9. doi: 10.1007/s00402-011-1395-1.
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 Sep;84(9):1605-12. doi: 10.2106/00004623-200209000-00013.
Maruenda JI, Barrios C, Gomar-Sancho F. Intracapsular hip pressure after femoral neck fracture. Clin Orthop Relat Res. 1997 Jul;(340):172-80. doi: 10.1097/00003086-199707000-00022.
Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck fracture in young adults. J Trauma. 1986 Oct;26(10):932-7. doi: 10.1097/00005373-198610000-00013.
Kinik H, Polat O, Mergen E. Femoral neck fractures treated with cannulated screw. Acta Orthopaedica et Traumatologica Turcica. 2006; 33(1):13-17.
Zetterberg CH, Irstam L, Andersson GB. Femoral neck fractures in young adults. Acta Orthop Scand. 1982 Jun;53(3):427-35. doi: 10.3109/17453678208992237.
How to Cite
Copyright (c) 2022 Recep Dinçer, Anıl Gülcü
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.