University Hospital Musculo-Skeletal Institute, Sainte-Marguerite Hospital, Orthopaedics surgery and Traumatology Department, Marseille, France.
Orthop Traumatol Surg Res. 2010 May;96(3):228-34. doi: 10.1016/j.otsr.2009.11.012. Epub 2010 Apr 14.
Internal fixation is the preferred treatment of Garden I femoral neck fractures in the elderly. High re-operation rates have however been reported, and the results of arthroplasty performed following internal fixation failure are not as good as those of primary arthroplasty. This is why we are advocating functional treatment. Our hypothesis is that this treatment leads to fewer decubitus complications than strict orthopaedic treatment and no more mechanical complications than internal fixation in a selected population sample. Therefore, the objective of our prospective work was: (1) to assess the results of functional treatment of Garden I femoral neck fractures in elderly subjects, and (2) to investigate predictive factors of secondary displacement.
All patients over age 65 years, admitted for a Garden I femoral neck fracture between January 2006 and May 2008, were included in this prospective study representing 56 cases (57 fractures) with an average age of 82 years. Functional treatment was performed, including early weight-bearing mobilisation, followed by radiographic evaluation at days 2, 7, 21 and 45, then at 3, 6 and 12 months. In the absence of displacement, discharge was planned at day 5 (Non-Displaced [ND] group). Otherwise, arthroplasty was performed (Displaced [D] group). Parker score and Harris Hip Score (HHS) were used for functional evaluation.
The observed displacement rate was 33.3% (19 patients) within an average period of 10 days. In the ND group, one case of osteonecrosis was observed and treated by arthroplasty. The average Parker score was 6.9 and the HHS 82 in the ND group, and 7 and 85, respectively, in the D group. None of the factors studied (age, gender, side, fracture type, inclination angle, degree of outward displacement, sagittal displacement, general status) was statistically predictive of final displacement.
The medical complication rate was only 7% in our series, which seems to be lower than that resulting from orthopaedic treatment. The observed secondary displacement rate seemed to be higher than the rate found in the literature on surgical treatment (5.4 to 20%), but the osteonecrosis rate appeared to be lower (11 to 25%). In addition, surgical treatment was the purveyor of specific complications in over 10% of cases.
The present prospective study with minimum 1-year follow-up shows that functional treatment results in fewer decubitus complications than orthopaedic treatment and a rate of revision surgery comparable to internal fixation since 70% of included patients could have been successfully treated without surgical intervention. However, the investigation of a larger cohort would be necessary to identify predictive factors for the treatment's failure.
Level III prospective non-comparative cohort study.
对于老年Garden I 型股骨颈骨折，内固定是首选的治疗方法。然而，已有报道称该方法的再手术率较高，且内固定失败后行关节置换术的效果不如初次关节置换术。这就是我们提倡功能治疗的原因。我们的假设是，与严格的骨科治疗相比，这种治疗方法导致压疮并发症更少，与选择的人群样本中的内固定相比，机械并发症也不会更多。因此，我们前瞻性工作的目的是：（1）评估老年Garden I 型股骨颈骨折功能治疗的结果，（2）探讨继发性移位的预测因素。
2006 年 1 月至 2008 年 5 月期间，所有 65 岁以上因 Garden I 型股骨颈骨折入院的患者均纳入本前瞻性研究，共 56 例（57 处骨折），平均年龄为 82 岁。进行功能治疗，包括早期负重活动，然后在第 2、7、21 和 45 天以及第 3、6 和 12 个月进行影像学评估。如果没有移位，则计划在第 5 天出院（无移位 [ND] 组）。否则，行关节置换术（移位 [D] 组）。使用 Parker 评分和 Harris 髋关节评分（HHS）进行功能评估。
平均 10 天内出现 33.3%（19 例）的观察性移位率。在 ND 组中，1 例发生骨坏死，行关节置换治疗。ND 组的平均 Parker 评分为 6.9，HHS 为 82，D 组分别为 7 和 85。研究中没有一个因素（年龄、性别、侧别、骨折类型、倾斜角度、向外移位程度、矢状位移位、总体状况）具有统计学意义的预测最终移位的能力。
在我们的研究中，医疗并发症发生率仅为 7%，似乎低于骨科治疗的发生率。观察到的继发性移位率似乎高于文献中报道的手术治疗（5.4%至 20%），但骨坏死率似乎较低（11%至 25%）。此外，手术治疗导致超过 10%的病例出现特定并发症。
本前瞻性研究随访时间至少 1 年，结果表明，与骨科治疗相比，功能治疗导致压疮并发症更少，且由于 70%的纳入患者无需手术干预即可成功治疗，因此手术翻修率与内固定相当。然而，需要进行更大的队列研究以确定治疗失败的预测因素。
III 级非对照前瞻性队列研究。
