na

Injury, Int. J. Care Injured 46 (2015) 484491

Contents lists available at ScienceDirect

Inju

jo ur n al ho m epag e: ww w.elIntroduction

Femoral neck fractures in patients 60 years of age or youngerrepresent challenging injuries to treat because of the high-energytrauma mechanisms and the displaced fracture patterns typicallyfound in this patient population [1]. The younger patient age andincreased functional demands for work and recreational activitiesmandate a surgical treatment that preserves the native hip [2].Although controversy exists surrounding methods of reductionand internal xation, an understanding of the burden of disease isrequired.

The purpose of the current study is to quantitatively pool theincidence of patient important complications following internalxation of young femoral neck fractures. This study aims to updatethe existing meta-analysis literature, expand previous reviews byincluding ipsilateral femoral neck and shaft fractures, and focus onmultiple complications that impact quality of life and functionaloutcome.

Methods

Study eligibility

Only studies that met the following criteria were consideredeligible: [1] the population was comprised of non-geriatric adultpatients (ages 1660 years) with a femoral neck fracture [2], thepatients were treated with any type of internal xation [3], theauthors reported original research, and [4] the study reported at

Article history:

Received 23 July 2014

Accepted 6 October 2014

Keywords:

Non-geriatiric hip fracture

Femoral neck fracture

Background: Femoral neck fractures in patients 60 years of age or younger are challenging injuries to

treat because of the high-energy trauma mechanisms and the displaced fracture patterns typically found

in this patient population. Understanding the burden of disease is an important rst step in addressing

treatment controversies in this population. The purpose of the current study is to quantitatively pool the

incidence of patient important complications following internal xation of young femoral neck fractures.

Methods: A comprehensive search of the Medline, Embase, CINAHL, Cochrane Database of Systematic

Reviews, and Central databases was completed under the direction of a biomedical librarian. Multiple

outcomes of interest (complications) were collected and included: reoperation, femoral head avascular

necrosis, fracture non-union, infection, implant failure, and malunion.

Results: 1558 fractures from 41 studies were included in the meta-analysis. An18.0% pooled reoperation

incidence was observed for isolated femoral neck fractures. The total pooled incidence of avascular

necrosis (AVN) was 14.3%, and the total incidence of nonunion was 9.3%. When stratied for fracture

displacement displaced fractures were more likely to undergo reoperation and to result in AVN or non-

union. The total incidence of malunion was 7.1%, implant failure was 9.7%, and surgical site infection was

5.1%. Complications associated with a femoral neck fracture treated in conjunction with an ipsilateral

femoral shaft fracture were lower overall than the pooled estimates for isolated neck fractures.

Conclusions: The results of our analysis demonstrate that the incidence of complications experienced by

young femoral neck fracture patients is relatively high. Reoperation following internal xation of

isolated femoral neck fractures occurred in nearly 20% of cases, and AVN and nonunion were the most

common complications that likely contributed to repeat surgeries. These results highlight the importance

of further efforts to improve the clinical outcomes in this population.

2014 Elsevier Ltd. All rights reserved.

* Corresponding author at: Division of Orthopaedic Trauma, Department of

Orthopaedics, University of British Columbia, Centre for Hip Health & Mobility,

771 2635 Laurel Street, Vancouver, BC V5Z 1M9, Canada. Tel.: +1 604 875 5809.

E-mail address: gsloboge@gmail.com (G.P. Slobogean).

http://dx.doi.org/10.1016/j.injury.2014.10.010

00201383/ 2014 Elsevier Ltd. All rights reserved.Complications following young femoral

G.P. Slobogean a,b,*, S.A. Sprague b,c, T. Scott c, M. BhaDepartment of Orthopaedic Surgery, University of British Columbia, CanadabDivision of Orthopaedic Surgery, Department of Surgery, McMaster University, CanadacDepartment of Clinical Epidemiology and Biostatics, McMaster University, Canada

A R T I C L E I N F O A B S T R A C Teck fractures

ndari b,c

ry

s evier . c om / lo cat e/ in ju r y

G.P. Slobogean et al. / Injury, Int. J. Care Injured 46 (2015) 484491 485least one complication outcome measure following fracturexation. Only English language articles were included. Potentiallyeligible studies were also excluded if they focused on [1] stressfractures; [2] treatment of delayed fractures (greater than 14 daysfrom injury) [3], management of femoral neck non-unions, or [4]management of osteonecrosis following femoral neck fractures.Studies involving combined femoral neck and femoral shaftfractures were also included based on a priori planned subgroupanalyses.

Identication of studies

In November 2012, a comprehensive literature search wasperformed to identify studies involving the management offemoral neck fractures in patients age 60 years. Using the OVIDinterface, electronic searches of the following databases wereperformed: Medline, Embase, CINAHL, Cochrane Database ofSystematic Reviews, and Central. Keywords and MeSH headingsrelated to femoral neck fractures and surgical xation were utilizedunder the direction of a biomedical librarian. A full description ofthe search strategy is found in Appendix A.

Following the literature searches, two investigators reviewedthe references lists of all key articles for further eligible articles.Frequently cited articles were identied and a separate ScienceCitation Index search (SciSearch) was performed to locatepotentially relevant studies. We also conducted a related articlessearch on PubMed.

Title review

Two reviewers independently screened the titles identied inthe literature searches. Titles that clearly did not meet theeligibility criteria were excluded; in all situations, the reviewerserred on the side of inclusivity and selected the abstract to bereviewed. Since the search strategy attempts to lter out elderlyfractures, any paper that mentions xation of femoral neckfractures was selected for further review. The abstract and full-textreview was performed in a similar independent and duplicatefashion with two reviewers. When consensus could not be reachedon study eligibility, a third reviewer was consulted.

Data extraction

Two reviewers independently performed the data extraction.Study characteristics, patient demographics, fracture patterns, andsurgical details were recorded for each included study. Multipleoutcomes of interest (complications) were collected and included:femoral head avascular necrosis, fracture non-union, reoperation,infection, implant failure, and malunion. The malunion outcomeincluded any case described as malaligned, malreduced, mal-rotated, or malunited.

Data analysis

A random-effects model of DerSimonian and Laird was used toprovide pooled estimates of the incidence of complications withinthe young femoral neck fracture literature [3]. This model assumesthat the studies included in this review represent a random sampleof all of the potentially available studies. While we are condentthat our search strategy identied all relevant studies in thispopulation, it remains plausible that not every study everconducted was identied. The random-effects model accountsfor this fact and assumes that we have a representative sample ofall existing studies (published, non-published, and in progress). Foreach complication of interest we calculated the pooled incidenceand 95% condence interval (CI). The I2 statistic was reported foreach pooled estimate as a measure of study heterogeneity; valuesgreater than 50% represent substantial study heterogeneity [4].Subgroup analyses were performed based on fracture displace-ment as well as the presence of an ipsilateral femoral shaft fracture.

Results

Fig. 1 outlines the search results and selection of eligiblestudies. 41 articles were included in our analysis: 27 studiesinvolved patients with femoral neck fractures only and 14publications included femoral neck fractures associated withipsilateral femoral shaft fractures [546]. Table 1 summarizes theoutcomes reported by the included studies. Briey, 1558 fractureswere included. The mean sample size of included studies was39.43 33.8 patients. The mean of the average age and duration offollow-up reported in each study was 39.4 5.6 years and35.2 16.6 months, respectively. All research was publishedbetween 1964 and 2012. 60% of included studies were retrospectivecase series; only two studies were prospective randomised controltrials. Table 2 presents the pooled results of isolated femoral neckfractures, combined neckshaft fractures, and the overall incidence ofcomplications when all results are combined.

Reoperation

28 studies reported reoperation events within their studypopulation. A total of 181 event in 1061 included patients. Therewas an overall 18.0% reoperation incidence for isolated femoralneck fractures (95% CI 13.124.2%, I2 = 19.8%; Fig. 2). When thepooled results were stratied for fracture displacement, similarreoperation estimates were obtained for displaced fractures(17.8%, 95% CI 12.424.9) and much lower estimates wereobserved for undisplaced fractures (6.9%, 95% CI 2.617.1%).Although a large difference in the point estimates between thesubgroups is reported, the condence intervals overlap and fail todemonstrate statistical signicance.

Femoral head avascular necrosis

39 studies reported femoral head avascular necrosis occurringin their study population. A total of 184 events in 1552 patientswere included. The total pooled incidence of avascular necrosis forisolated femoral neck fractures was 14.3% (95% CI, 12.524.2%,I2 = 0%; Fig. 3). Similar to reoperation events, displaced fractureswere associated with a statistically higher incidence of avascularnecrosis than undisplaced fractures (14.7%, 95% CI 12.317.5%versus 6.4%, 95% CI 3.411.8%).

Nonunion

Fracture nonunion events were pooled from 35 studies. A totalof 109 events in 1328 patients were included. The pooled incidenceof nonunion after internal xation for isolated fractures was 9.3%(95% CI 6.613.0%; Fig. 4). The point estimate for displacedfractures (10.0%) was nearly double the incidence of undisplacedfractures (5.2%), however, the condence intervals were too wideto demonstrate signicance (displaced 95% CI 6.914.3%; undis-placed 95% CI 2.013.1%).

Malunion, implant failure, and infection

Malunion, implant failure, and infection outcomes were lesscommonly reported by the included studies (Table 1). The pooledincidence of reported femoral neck malunion was 7.1% (95% CI 2.717.5%). The incidence of implant failure was 9.7% (95% CI 5.416.7%),and the incidence of surgical site infection was 5.1% (95% CI 3.28.0%). Pooled analyses comparing these outcomes for displaced and

Fig. 1. Study ow and selection of included studies.

G.P. Slobogean et al. / Injury, Int. J. Care Injured 46 (2015) 484491486

Table 1Summary of included studies.

Name Shaft fractures included Sample size Complicatio

Reoperation

Brown 1964 N 14

Swiontkowski 1984 Y 13 U

Morwessel 1985 N 13 U

Tooke 1985 N 27 U

Srivastava 1989 N 30 U

Masetti 1990 N 21

G.P. Slobogean et al. / Injury, Int. J. Care Injured 46 (2015) 484491 487Chaturvedi 1993 Y 16

Parfenchuck 1993 Y 11 U

Driesen 1984 N 26 U

He 1995 N 25

Robinson 1995 N 45 U

Koldenhoven 1997 Y 11 U

Broos 1998 N 30 U

Gautam 1998 N 25 U

Chang 1999 N 26 U

Randelli 1999 Y 27 U

Jain 2002 N 38 U

Verettas 2002 N 12 U

Okcu 2003 Y 15 U

Upadhyay 2004 N 27

Jain 2004 Y 19

Farooq 2005 N 23 U

Khallaf 2005 Y 17 U undisplaced fractures were not performed due to the small amountof data available.

Femoral neck outcomes associated with ipsilateral shaft fractures

Complications associated with a femoral neck fracture treatedin conjunction with an ipsilateral femoral shaft fracture wereoverall lower than the pooled estimates for isolated neck fractures(Table 2). Specically, the incidence of AVN and nonunionfollowing a combined neckshaft fracture pattern most closelymirrored the isolated, undisplaced femoral neck fracture subgroup.Both complications were relatively uncommon, with pointestimates 23 times lower than the isolated femoral neckfractures. The remaining malunion, implant failure, and infection

Oh 2006 Y 17 U

Kao 2006 Y 12 U

Liporace 2008 N 62

Singh 2008 Y 27 U

Butt 2008 N 52 U

Vidyadhara 2009 Y 43 U

Yildirim 2009 N 55

Stearns 2009 N 59

Tzachev 2009 Y 18

Huang 2010 N 122

Wang 2010 Y 21 U

Duckworth 2011 N 122 U

Huang 2011 N 146 U

Henari 2011 N 12 U

Pollack 2012 N 91

Razik 2012 N 92

Gardner 2012 N 69 U

Rawall 2012 N 27 U

Total 27 1558 28

Table 2Pooled complications of isolated femoral neck fractures.

Outcome Incidence (%) 95% CI I2 statistic (%)

Reoperation 18.0 13.124.2 19.8

AVN 14.3 12.516.4 0

Nonunion 9.3 6.613.0 0

Malunion 7.1 2.717.5 0

Implant failure 9.7 5.416.7 12.3

Infection 5.1 3.28.0 0ns reported

AVN Non-union Malunion Infection Implant failure

U U

U U

U U U

U U

U U U U

U U U

U U U

U U

U U U

U U

U U U

U U U

U U

U U U

U U

U U U U U

U U U U

U U

U U U U

U U U

U U U

U U

U U U U Ucomplications also displayed lower point estimates than theisolated neck fracture group (Table 3).

Discussion

The current meta-analysis has pooled the results of 42 studiesinvolving internal xation of femoral neck fractures. The results ofour analysis demonstrate that the incidence of complicationsexperienced by young femoral neck fracture patients is relativelyhigh. Nearly 20% of patients with an isolated femoral neck fracturehad a reoperation related to their hip fracture. The incidence ofother patient important complications is also relatively common.

To the best of our knowledge, there has been one previousmeta-analysis that has pooled the outcomes of young femoral neckfracture xation. Damany and colleagues reviewed the incidence ofavascular necrosis and nonunion in patients ages 50 years [1].Their analysis included 564 patients in 18 studies publishedbetween 1976 and 2003. The authors reported a 23.0% overallincidence of AVN and an 8.9% incidence of nonunion. Their analysisalso examined associations of reduction method (open versusclosed) and timing ( 12 h) on the incidence ofcomplications. Similar to our results, a much higher incidence ofcomplications following displaced fractures was observed.

U U U U U

U U

U U

U U U

U U U

U U U

U U

U U U

U U U U

U U U

U U U U U

U U U

U U

U U

U U U

U

U U

39 35 16 15 10

G.P. Slobogean et al. / Injury, Int. J. Care Injured 46 (2015) 484491488Our study extends the previous work of Damany et al. in severalaspects. Our review updates the literature by including nine yearsof more recent publications. The updated search years, theinclusion of ipsilateral femoral neck and shaft fractures, and ourother methods for ensuring a sensitive search strategy allowed usto include an additional 1000 fractures and 24 studies in ourpooled analysis. Furthermore, we used a random-effects model topool the results, rather than the simple weighted-averages methodemployed by Damany; this allowed us to provide a moreconservative estimate of each outcome that accounts for samplingerror of the true incidence of complications.

In addition to the benets of our larger sample size andimproved statistical pooling methods, our meta-analysis includeda subgroup of patients with ipsilateral femoral neck and shaftfractures. Clinically, treating this population of femoral neckfractures can be technically challenging due to signicantdisplacement in the setting of an unstable shaft fracture, usingmultiple implants for adjacent fractures, and the potential ofinitially missing occult femoral neck fractures. When consideringthe incidence of complications in this subgroup, the pointestimates were uniformly lower than the isolated neck fracturepopulation and many of the pooled estimates were similar to theundisplaced subgroup. This suggests the outcomes of femoral neckfractures in a combined neckshaft fracture pattern might be lesssevere than the displaced femoral neck group; this mirrors clinicalobservations in which 10% of these fractures are initially occult orminimally displaced [47].

When considering isolated femoral neck fractures only,displaced fractures were associated with a substantially higherincidence of reoperation, AVN, and nonunion. Although not

Fig. 2. Forest plot and pooled ansurprising, this observation underscores the challenging natureof treating the young femoral neck fracture population; themajority of young femoral neck fractures occur from high-energytrauma and are signicantly displaced. The frequency of displacedfractures within the overall distribution of fracture patterns alsoexplains why the estimates for the displaced subgroup closelymirrors the complication estimates for the entire isolated femoralneck fracture population. In addition, the pooled estimate of an18.0% incidence of femoral neck reoperation is a compellingreminder that these injuries often cause signicant patient

alysis of reoperation events.

Table 4Pooled complications of all femoral neck fractures combined.

Outcome Incidence (%) 95% CI I2 statistic (%)

Reoperation 15.9 12.220.6 6.7

AVN 13.3 11.615.5 6.4

Nonunion 8.3 6.211.1 0

Malunion 6.4 3.810.5 0

Implant failure 9.2 6.413.2 0

Infection 4.8 3.17.2 0

Table 3Pooled complications of combined femoral neck and shaft fractures.

Outcome Incidence (%) 95% CI I2 statistic (%)

Reoperation 12.5 8.019.1 0

AVN 4.6 2.58.3 0

Nonunion 5.1 2.89.3 0

Malunion 5.6 3.19.9 0

Implant failure 6.3 3.012.7 0

Infection 3.6 1.49.3 0

Fig. 3. Forest plot and pooled analysis of AVN events.

Fig. 4. Forest plot and pooled analysis of nonunion events.

G.P. Slobogean et al. / Injury, Int. J. Care Injured 46 (2015) 484491 489

tic

G.P. Slobogean et al. / Injury, Int. J. Care Injured 46 (2015) 484491490morbidity. Additionally, although reoperation represents a seriouscomplication, it is important to recognize that many of the othercomplications of interest also lead to profound impacts on patientquality of life (Tables 4 and 5).

Deep infection, implant failure, and nonunion are all seriousevents that will often lead to a repeat surgical procedure; however,the other complications of interest such as signicant malunion orlate onset AVN may not lead to an early reoperation during thefollow-up periods of the included studies. This observationunderscores the importance of measuring health related qualityof life and other patient reported functional outcomes to ensurethe true impact of these injuries; only 45% of the included studiesreported any patient reported functional measures. Finally, it isimportant to recognize that our study estimates are limited by theavailable data; longer-term follow-up and increased availability ofpatient-reported outcomes would improve future meta-analyses.

In conclusion, this meta-analysis provides pooled estimates forseveral patient important complications following femoral neckfracture xation in patients ages

[28] Masetti G, Bungaro P, Beltrandi S, Montanari G, Lucaccini C. Osteosynthesis infractures of the femoral neck in the young adult. Chir Org Mov 1990;75:2318.

[29] Morwessel R, Evarts CM. The use of quadratus femoris muscle pedicle bonegraft for the treatment of displaced femoral neck fractures. Orthopedics1985;8:9726.

[30] Oh CW, Oh JK, Park BC, Jeon IH, Kyung HS, Kim Y, et al. Retrograde nailing withsubsequent screw xation for ipsilateral femoral shaft and neck fractures. ArchOrthop Trauma Surg 2006;126:44853.

[31] Okcu G, Aktuglu K. Antegrade nailing of femoral shaft fractures combined withneck or distal femur fractures. A retrospective review of 25 cases, with afollow-up of 36150 months. Arch Orthop Trauma Surg 2003;123:54450.

[32] Parfenchuck TA, Carter LW, Young TR. Ipsilateral fractures of the femoral neckand shaft. Orthop Rev 1993;22:35663.

[33] Randelli P, Landi S, Fanton F, Hoover GK, Morandi M. Treatment of ipsilateralfemoral neck and shaft fractures with the RussellTaylor reconstructive nail.Orthopedics 1999;22:6736.

[34] Rawall S, Bali K, Upendra B, Garg B, Yadav CS, Jayaswal A. Displaced femoralneck fractures in the young: signicance of posterior comminution and raisedintracapsular pressure. Arch Orthop Trauma Surg 2012;132:739.

[35] Robinson CM, Court-Brown CM, McQueen MM, Christie J. Hip fractures inadults younger than 50 years of age. Epidemiology and results. Clin OrthopRelat Res 1995;312:23846.

[36] Tooke SM, Favero KJ. Femoral neck fractures in skeletally mature patients, ftyyears old or less. J Bone Jt Surg Am 1985;67:125560.

[37] Brown JT, Abrimi G. Transcervical femoral fracture. A review of 195 patientstreated by sliding nail-plate xation. J Bone Jt Surg 1964;46B:64863.

[38] Driesen R, Niks S, Broos PL, Fabry G. Unstable femoral neck fractures treatedwith a 130 degree blade plate. Acta Orthop Belg 1994;60:3227.

[39] Kao HK, Wu CC, Lee PC, Su CY, Fan KF, Tseng IC. Ipsilateral femoral neck andshaft fractures treated with RussellTaylor reconstruction intramedullarynails. Chang Gung Med J 2006;29:7985.

[40] Khallaf F, Al-Mosalamy M, Al-Akkad M, Hantira H. Surgical treatment for theipsilateral fractures of femoral neck and shaft. Med Princ Pract 2005;14:31824.

[41] Swiontkowski M, Hansen ST, Kellam J. Ipsilateral fractures of the femoral neckand shaft. J Bone Jt Surg 1984;66:2608.

[42] Tzachev N, Baltov A, Ivanov V, Zlatev B, Lotov A. Cefalomedullary nails in thetreatment of ipsilateral femoral neck and shaft fractures. Presented at theEuropean Federation of National Associations of Orthopaedics and Trauma-tology 2009 Congress; 2009 [Abstract].

[43] Gardner ST, Weaver MJ, Jerabek SA, Vrahas MS, Appleton PT. Displaced femoralneck fracture sin patients