Some of the patients who underwent internal fixation of the fracture may have non-union or ischemic necrosis of the femoral head after healing, resulting in about 20%-36% of the patients with femoral neck fracture requiring reoperation, at which time artificial hip replacement is considered to be the best treatment option to solve the problem. 33 such patients were treated in our hospital from January 1997 to June 2008, and total hip replacement was performed with satisfactory clinical results. The clinical results were satisfactory. The clinical results are reported below.
1. Clinical data and methods
1.1 General data
From January 1997 to June 2008, 33 cases of non-union (13 cases) and ischemic necrosis of the femoral head (20 cases) after internal fixation of femoral neck fracture were admitted to our hospital. Among them, 24 cases were male and 9 cases were female. The age ranged from 35 to 59 years, with a mean of 51.1 years (we advised patients under 34 years to undergo hip fusion). Thirteen patients had non-healing femoral neck fractures after internal fixation for 1 to 3 years after surgery, with the original fracture type: 9 cases of subhead type and 4 cases of head and neck type; 20 patients had ischemic necrosis of the femoral head after healing for 2 to 8 years after surgery, with the original fracture type: 8 cases of subhead type, 9 cases of head and neck type, 2 cases of transcervical type, and 1 case of basal type. The Harris hip efficacy scoring system (1969) was used to score 27-59 points, with a mean score of 42.
1.2 Treatment method
Five patients with non-healing femoral neck fractures underwent internal fixation removal and total hip replacement with a modified Gibson approach 3 months later; eight patients underwent internal fixation removal and total hip replacement in one stage through the original lateral hip incision; all 20 patients with ischemic necrosis of the femoral head after healing underwent total hip replacement with a modified Gibson approach. The greater trochanter and the gluteus medius and minimus stops attached to it were exposed, and the lateral bursa of the greater trochanter was removed; the internal fixation was exposed and removed in patients whose internal fixation was not removed; the short external rotation muscle group was cut against the bone, and the traction mark was closed with a No. 7 silk suture, and the posterior joint capsule was exposed by pulling backward together with the blood vessels and nerves through the upper and lower foramina of the pyriform muscle.
The posterior capsule was cut into a tongue-shaped flap using the posterior acetabular rim as the base, and the femoral head and neck were retracted posteriorly and medially with a No. 7 silk suture to reveal the traction mark. The femoral head was detached and the femoral neck was osteotomized, with approximately 1.0 cm of the femoral spur preserved medially and a small portion of the medial aspect of the greater trochanter excised laterally. The acetabulum was exposed, cleaned and filed, and then the acetabulum was abducted about 35° to 45° and tilted forward about 10° to 20° to implant the acetabular prosthesis. The cemented prosthesis was fixed with bone cement, and the non-cemented prosthesis was pressed into place and then reinforced with 2 to 3 screws, and a polyethylene liner was installed.
The osteotomy surface of the femoral neck was exposed, the proximal medullary cavity was cleaned and filed, and the femoral prosthesis was implanted at an anterior tilt of about 15°, which was fixed with bone cement if it was cemented. The hip joint was repositioned and checked for joint stability, mobility, lower limb length and impingement at the limit of movement. Three to four small bone holes were drilled in the inter-rotor crest, and the posterior joint capsule tongue flap and short external rotator muscle group, pre-marked with No. 7 silk, were sutured sequentially to the inter-rotor crest. One plasma drainage tube was placed deep in the incision and one under the skin, and the incision was closed in layers.
There were 4 cases of all-cemented type, 7 cases of cemented femoral prosthesis type, and 22 cases of uncemented type.
1.3 Postoperative treatment
Postoperative antibacterial agents were given for 7-10 d to prevent infection, and low-molecular heparin sodium was given for 7-10 d to prevent deep vein thrombosis, together with mechanical massage of both lower limbs. The plasma drainage tube was removed 2-3 d after surgery according to the plasma drainage flow. Postoperatively, the lower limbs of the operated side were kept in abduction and rotation neutral position and prevented from excessive hip flexion, especially during recovery from anesthesia to prevent posterior dislocation of the femoral prosthesis. Active flexion and extension of the ankle joint and isometric contraction exercises of the quadriceps muscle were started the next day.
4 to 14 d after surgery, the patient was instructed to gradually practice turning, getting out of bed, standing, walking and sitting activities, and to perform hip flexion, extension and abduction exercises to prevent excessive flexion, inversion and internal rotation. After discharge from the hospital, patients were instructed to avoid heavy physical activities and high-intensity physical exercise as much as possible, not to sit on a low stool, not to stretch their legs, not to flex the hip more than 90° within 6 weeks, not to flex the hip more than 120° after 6 weeks, to walk upstairs on the healthy side first and downstairs on the operated side first, to walk with a double crutch within 6 weeks, to walk with a single crutch from 7 to 12 weeks, and to abandon the crutch after 12 weeks. After the operation, the patient was followed up at 3 months, 6 months, 1 year and every year thereafter and X-ray was taken to understand the condition of the prosthesis.
2.Results
All cases were followed up from 1 to 12 years, with an average of 5.3 years. Follow-up scoring criteria: Harris hip efficacy scoring system (1969) was used, which was divided into four aspects: pain (44 points), function (47 points), deformity (4 points) and joint mobility (5 points), with a total score of 100 points, and scores of 90-100 were considered excellent, 80-89 were considered good, 70-79 were considered moderate and below 70 were considered poor [1]. In this group of cases, the scores ranged from 76 to 97, with an average of 91.3 (49.3 points more than the preoperative score), including 24 cases of excellent, 6 cases of good, 3 cases of moderate, and 0 cases of poor, with an excellent rate of 90.9%. (With 2 cases of typical case x-ray films)
3. Discussion
3.1 Decision of treatment plan for femoral neck fracture
We believe that the treatment plan for femoral neck fracture should be considered based on the patient’s age, fracture type, bone condition, underlying disease and general condition. Generally speaking, experts and scholars agree that artificial joint (total or hemi hip) replacement should be chosen for elderly patients over 60 years of age, but we believe that internal fixation can still be considered for basal femoral neck fractures with good physical condition and bone quality, especially for fractures that can be repositioned by traction or can be fixed by percutaneous nailing (e.g. hollow nail, fracture thread nail, etc.) if they are not significantly displaced. Patients.
Patients aged 50-59 years should be offered a choice between internal fixation and arthroplasty depending on the patient’s condition. Arthroplasty is recommended for old fractures over 55 years of age regardless of the type.
For young adults under 50 years of age, we recommend internal fixation of the fracture regardless of the type of fracture, except for patients over 35 years of age with pre-injury rheumatoid arthritis and other diseases who insist on arthroplasty. However, we cannot deprive patients of their right to know, and must explain the advantages and disadvantages of the two treatment options to each patient and family for their choice, especially that the fracture may not heal with internal fixation or may occur ischemic necrosis of the femoral head after healing, and that joint fusion or artificial joint replacement is needed again, in order to gain the understanding of patients and families and voluntarily assume the treatment risks.
3.2 Selection of the incisional approach for total hip replacement
In patients with ischemic necrosis of the femoral head after internal fixation of the femoral neck fracture, there are two types of incisions for total hip replacement: the original lateral incision of the hip and the alternative incision. For cases in which internal fixation removal and total hip replacement are performed in one phase, there is no controversy, and the original lateral hip incision should be used as much as possible, rather than making another incision to minimize trauma and bleeding.
For cases in which internal fixation removal and total hip replacement are performed in stages and ischemic necrosis of the femoral head occurs after healing, some patients often ask the physician to take the original incisional approach, which can indeed reduce a surgical scar and make it more beautiful. The physician cannot listen to the patient’s opinion unilaterally and should choose the incisional approach based on the patient’s specific situation and his or her own experience. Our experience is that the modified Gibson approach, which we are most familiar with, has clear anatomy, easy exposure, convenient operation and less bleeding, which also reduces the difficulty of surgery.
3.3 Surgical timing of total hip replacement
There is a controversy about whether to perform total hip replacement in one phase or in stages, and how long the staging interval should be for patients whose internal fixation has not been removed. The reasons for staging are to increase the bone volume of the proximal femur, to reduce the incidence of complications such as intraoperative splintering and infection of the proximal femur, and to prevent the cement from spilling out of the screw holes during intraoperative cement injection (especially for larger internal fixations such as power hip screws (DHS) and intramedullary nails of the proximal femur), which cannot effectively inject cement under pressure and reduce the fixation effect, and to allow free choice of surgical access and reduce the difficulty of surgery. However, staging increases the patient’s pain (one more surgery and prolonged duration of illness) and medical costs.
The longer the time interval, the longer the patient’s pain will be, and the more serious the contracture of soft tissues and muscle atrophy around the hip joint will be, which is not conducive to postoperative rehabilitation. On the contrary, completing two surgeries in one phase reduces patients’ pain and medical costs, but requiring two surgeries to be completed in the same incision increases the difficulty of surgery to a certain extent and increases the incidence of intraoperative and postoperative complications such as splitting of the proximal femur and infection.
3.4 Clinical efficacy of total hip replacement
It is common sense that if a total hip replacement is performed after a femoral neck fracture is not healed or ischemic necrosis of the femoral head occurs after healing, the recovery effect should be slightly worse than that of a total hip replacement directly after the fracture due to factors such as multiple surgical scar formation, soft tissue contracture and muscle atrophy. However, in fact, the satisfaction rate of our group of patients was higher than that of patients who underwent total hip replacement directly after fracture.
The reason for this may be that our patients suffered from pain and urgently needed to be relieved of their pain before and after the surgery, and the latter had a significantly better outcome than the patients who underwent total hip replacement directly after fracture. In addition, the subjective evaluation component (pain) of the Harris hip efficacy scoring system we used had a greater proportion, and the former gave a higher pain score due to lower efficacy expectations, while the latter gave a lower pain score due to high efficacy expectations, resulting in the illusion that the former had better clinical efficacy than the latter.