femoral neck fracture speaker : 骨科林愈鈞 modular : 簡松雄主任

$: Femoral neck fracture Speaker : 骨科林愈鈞 Modular : 簡松雄主任$
Femoral neck fracture Femoral neck fracture

Speaker : Speaker : 骨科林愈鈞骨科林愈鈞Modular : Modular : 簡松雄主任簡松雄主任

Patient profilePatient profile

NameName ：游：游 XX XX 菊菊 GenderGender ：： FemaleFemale AgeAge ：： 59 years old59 years old Chart numberChart number ：： 0276666302766663

Chief complaintChief complaint

Right hip painful deformityRight hip painful deformity

Present illnessPresent illness

The 59 year-old female was a victim of hypertension The 59 year-old female was a victim of hypertension before.before.

On 95.3.7, she suffered from slipped down and felt On 95.3.7, she suffered from slipped down and felt right hip pain and can’t walk. right hip pain and can’t walk.

She was brought to our OPD for help. She was brought to our OPD for help. Severe pain with limited ROM was noted.Severe pain with limited ROM was noted.

Physical examination Physical examination

Tenderness, swelling of the right hipTenderness, swelling of the right hip ROM limitation (+), severe pain when movingROM limitation (+), severe pain when moving

Past historyPast history

Diabetes mellitusDiabetes mellitus ：： (-)(-) HypertensionHypertension ：： (+)(+) Drug allergyDrug allergy ：： denieddenied Medication historyMedication history ：： (-)(-) Operation historyOperation history ：： (-)(-) Admission historyAdmission history ：： (-)(-)

Tentative diagnosisTentative diagnosis

Right femoral neck fracture, Garden type IIIRight femoral neck fracture, Garden type III

PlanPlan

Arrange open reduction and internal fixation wArrange open reduction and internal fixation with three cannulated screwsith three cannulated screws

EBM DiscussionEBM Discussion

Evidence-Based MedicineEvidence-Based Medicine

Patient Patient :: A 59 y/o female was a case of femoral neck displaced A 59 y/o female was a case of femoral neck displaced fracture, right hipfracture, right hip

Intervention :Intervention : Open reduction and internal fixationOpen reduction and internal fixation

Comparison :Comparison :Arrangement of arthroplasty Arrangement of arthroplasty

Outcome :Outcome :Open reduction and internal fixationOpen reduction and internal fixation was better than awas better than arthroplasty of the outcomerthroplasty of the outcome

Evidence-Based MedicineEvidence-Based Medicine One Question Sentence:One Question Sentence:

Can open reduction and internal fixationCan open reduction and internal fixation be better than arthropbe better than arthroplasty for the patient with femoral neck displaced fracture?lasty for the patient with femoral neck displaced fracture?

Type of Question:Type of Question: TherapyTherapy

Ideal Study type:Ideal Study type: SR of RCT or High-Quality RCTSR of RCT or High-Quality RCT

Feasible Study type:Feasible Study type:SR of RCT or High-Quality RCTSR of RCT or High-Quality RCT

Search Strategy Design :Search Strategy Design :Database : PubMedDatabase : PubMedKey words and search tactics: PCL + Avulsion fracture Key words and search tactics: PCL + Avulsion fracture

JAAOS 2005;13P 220-229

Search Strategy DesignSearch Strategy Design

Abstract 1Abstract 1

Internal fixation versus arthroplasty foInternal fixation versus arthroplasty for intracapsular proximal femoral fractr intracapsular proximal femoral fractures in adults.ures in adults. [Systematic Review] [Systematic Review]

Cochrane Database of Systematic Reviews. 1, Cochrane Database of Systematic Reviews. 1, 2006.2006.

This version 1st published online: 22 April 2003 in Issue 2, 2003.


Search strategy:Search strategy: MEDLINE (1966 to January 2002), MEDLINE (1966 to January 2002), EMBASE (1988 to 2002, Week 2), Current Contents EMBASE (1988 to 2002, Week 2), Current Contents (1993 to 2002, Week 4), PREMEDLINE (January 20(1993 to 2002, Week 4), PREMEDLINE (January 2002) and selected orthopaedic journals and conference 02) and selected orthopaedic journals and conference proceedings, and reference lists of relevant articles. proceedings, and reference lists of relevant articles.

Selection criteria:Selection criteria: All randomised and quasi-random All randomised and quasi-randomised trials comparing internal fixation with arthroplastised trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adultsy for intracapsular hip fractures in adults

Abstract 1Abstract 1 Thirteen trials involving 2091 patients were includedThirteen trials involving 2091 patients were included Main results :Main results :

★ ★ Internal fixation had a reduced length of surgery, Internal fixation had a reduced length of surgery, operative blood loss, need for blood transfusion operative blood loss, need for blood transfusion and risk of deep wound infection. and risk of deep wound infection. ★★ Arthroplasty had a lower re-operation rate and Arthroplasty had a lower re-operation rate and total cost in comparison with fixation. total cost in comparison with fixation. ★★ No definite differences for hospital stay, mortality, No definite differences for hospital stay, mortality,

degree of residual pain, regain of mobility or degree of residual pain, regain of mobility or regain of same residential state were found regain of same residential state were found ★★ Hip and other composite scores :Hip and other composite scores : ORIF v.s Hemiarthroplasty ORIF v.s Hemiarthroplasty No difference No difference ORIF v.s THR ORIF v.s THR Better in the THR group Better in the THR group


Conclusions:Conclusions: ★★ Internal fixation is associated with less Internal fixation is associated with less initial operative trauma but has an increased initial operative trauma but has an increased risk of re-operation on the hip risk of re-operation on the hip ★★ Definite conclusions cannot be made for Definite conclusions cannot be made for differences in pain and residual disability differences in pain and residual disability between the two groups. between the two groups. ★★ The attending physician should choose the The attending physician should choose the method which they feel is most appropriate method which they feel is most appropriate for each individual patient. for each individual patient.


Internal fixation compared with arthroplastInternal fixation compared with arthroplasty for displaced fractures of the femoral necy for displaced fractures of the femoral neck: a meta-analysis (Structured abstract)k: a meta-analysis (Structured abstract)

Centre for Reviews and Dissemination UniversUniversity of York, York, U.K.ity of York, York, U.K.

This version 1st published online: Journal of Bone and Joint Surgery. American volume, 2003;85-A(9):1673-1681.


Outcomes assessment :Outcomes assessment :Mortality, revision surgery, pain, function, coMortality, revision surgery, pain, function, complications (wound infection, hip dislocation, mplications (wound infection, hip dislocation, nonunion, avascular necrosis and post-operativnonunion, avascular necrosis and post-operative confusion), blood loss and surgical time takee confusion), blood loss and surgical time taken n


Search strategy:Search strategy: MEDLINE (1969 to June 2002); Sc MEDLINE (1969 to June 2002); Science Citation Index and the Cochrane Controlled Triience Citation Index and the Cochrane Controlled Trials Register; Four orthopaedic journals were handsearals Register; Four orthopaedic journals were handsearched (1998 to June 2002); bibliographies of two orthoched (1998 to June 2002); bibliographies of two orthopaedic textbooks, and poster presentations of three ortpaedic textbooks, and poster presentations of three orthopaedic societies (1996 to 2002).hopaedic societies (1996 to 2002).

Selection criteria: Selection criteria: Randomised or quasi-randomised Randomised or quasi-randomised trials study; Patients aged 65 years or older who had a trials study; Patients aged 65 years or older who had a displaced femoral neck fracture displaced femoral neck fracture

Abstract 2Abstract 2 Twelve studies and two abstracts were eligible for inclusiTwelve studies and two abstracts were eligible for inclusi

on (n=1,933)on (n=1,933) Result :Result :

★★ Mortality Mortality No significant difference No significant difference

★★ Revision surgery Revision surgery Arthroplasty significantly Arthroplasty significantly reduced the risk reduced the risk

★★ Pain & function Pain & function No significant difference No significant difference

★★ Infection Infection Arthroplasty was significantly increased Arthroplasty was significantly increased

★★ Blood loss & surgical time Blood loss & surgical time Arthroplasty was Arthroplasty was significantly increased significantly increased


Conclusions :Conclusions :Arthroplasty significantly reduces the risk of rArthroplasty significantly reduces the risk of revision surgery at the cost of greater infection evision surgery at the cost of greater infection rates, blood loss and operative time. rates, blood loss and operative time.


Comparison of internal fixation witComparison of internal fixation with total hip replacement for displaceh total hip replacement for displaced femoral neck fractures: randomid femoral neck fractures: randomized, controlled trial performed at fzed, controlled trial performed at four yearsour years

The Journal of Bone and Joint Surgery, The Journal of Bone and Joint Surgery, American volume

Volume 87-A(8), August 2005, p 1680–1688Volume 87-A(8), August 2005, p 1680–1688


Methods : 102 patients (mean age, eighty years) were 102 patients (mean age, eighty years) were randomly allocated to be treated with total hip replacerandomly allocated to be treated with total hip replacement or internal fixation.ment or internal fixation.

Inclusion criteria : an age of at least seventy years, abInclusion criteria : an age of at least seventy years, absence of severe cognitive dysfunction, an independent sence of severe cognitive dysfunction, an independent living status, and the ability to walk independently. living status, and the ability to walk independently.

The main outcome measurements were hip complicatiThe main outcome measurements were hip complications, reoperations, hip function, and health-related quaons, reoperations, hip function, and health-related quality of life. lity of life.

Forty-eight-month follow-up evaluation Forty-eight-month follow-up evaluation


Results:Results: THA : ORIF at the forty-eight-month follow -up evaluation Mortality rate 25% in both groups. – No significant dif

ference Rate of hip complications 4% : 42% (p < 0.001) Reoperation rates 4% and 47%, respectively (p < 0.00

1) The arthroplasty group had no additional hip complicatio

ns or reoperations between the 24 ~48 month follow-up visits. In the fixation group, the percentage of hip complications increased from 36% to 42% and the percentage of reoperations increased from 42% to 47% during the same period.


The hip function was significantly better and the decline in health-related quality of life was less pronounced in the arthroplasty group than it was in the fixation group at the 4, 12, and 24-month follow-up evaluations.

97% of the patients in the arthroplasty group and 57% of the patients in the fixation group who were available for follow-up at forty-eight months had no hip complications (p < 0.001).


Conclusions:Conclusions: Compared with internal fixation, primary total Compared with internal fixation, primary total

hip replacement provides a better outcome for hip replacement provides a better outcome for mentally competent elderly patients with a dismentally competent elderly patients with a displaced femoral neck fracture. placed femoral neck fracture.

The complication and reoperation rates were siThe complication and reoperation rates were significantly lower and hip function and health-rgnificantly lower and hip function and health-related quality of life were at least as good at foelated quality of life were at least as good at four years after the surgery.ur years after the surgery.

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