In the fixation of adult femoral neck fractures, does percutaneous hematoma drainage have an effect on bone union?

Abstract

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.