Translate this page into:
Non-cannulated versus cannulated cancellous screws for the internal fixation of femoral neck fractures in osteoporotic patients: A single-blind randomized clinical trial
∗Corresponding author: Shahab Mahdipour. shahab5mph@gmail.com
-
Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
The incidence of femoral neck fractures in osteoporotic patients is rising worldwide and is associated with significant increases in healthcare and social costs, as well as dependency. Improving minimally invasive treatment strategies, including internal fixation with screws, can result in favorable clinical outcomes and lesser incidence of complications, while preserving the hip. This study compared the outcomes of using non-cannulated cancellous screws (NCS) and cannulated cancellous screws (CS) in the internal fixation of undisplaced intracapsular femoral neck fractures (UIFNF) of osteoporotic patients of Iranian descent.
This randomized clinical trial was conducted on the patients referring to an institutional tertiary hospital in northwestern Iran between March 2020 and June 2021. The patients' preoperative, perioperative, and postoperative characteristics were evaluated for at least two years. Primary endpoints were defined as the incidence of hip-related complications, while secondary endpoints were assessed based on the patients’ hip function using Harris Hip Score (HHS).
Fifty-seven patients with osteoporosis and UIFNF were included in the final analysis, with 27 patients in the NCS group and 30 patients in the CS group. The surgical duration, the amount of intraoperative blood loss, and the frequency of C-arm were considerably lower in the CS group (p < 0.05). The incidence of implant failure was higher in the NCS group (p = 0.04). Screw migration occurred more frequently in the CS group (p = 0.03). The HHS values were significantly higher for the NCS group than those of the CS group at both the 1-year and 2-years of follow-up assessments (1 year, p = 0.007; 2 years, p = 0.001).
Fixation using CS was accompanied by enhanced perioperative outcomes and lower implant failure rates compared to the NCS group. However, patients in the NCS group posed a reduced risk of complications, including screw migration, and experienced a long-term improvement in HHS scores.
Keywords
Femoral neck fractures
Complications
Bone screws
Cannulated cancellous screws
Harris hip score
CS
CONSORT
HHS
NCS
SPMSQ
SD
UIFNF
1 Introduction
Hip fractures are healthcare issues increasingly affecting elderly patients and lead to substantial social and healthcare costs.1,2 Osteoporosis is an important risk factor for femoral neck fractures in elderly patients. Osteoporotic fractures are defined as those occurring in low-density regions of the bone, and have an increased incidence over the age of 50.3–5 The treatment of osteoporotic hip fractures is often complicated by decreased implant anchorage to the weakened bone due to the reduced holding strength of the implants in the cancellous osteoporotic bones. Fixation failure might subsequently occur.3,6 Moreover, Osteoporosis highly limits the strength of fixation in osteoporotic bones as a result of cortical thinning and hence, loss of fixation and implant failure.7
The most effective treatment approach for geriatric osteoporotic patients with fractures of femoral neck is still controversial. Internal fixation using the multiple cannulated cancellous screws (CS) inserted in an inverted triangular manner is the preferred approach for the treatment of undisplaced intracapsular femoral neck fractures (UIFNF). This approach offers several benefits, such as minimal invasiveness, as well as improved tensile and torsional stability.8–11 Moreover, fixation using CSs is a more precise method of stabilization due to the use of a guidewire.12 However, complications such as screw exit, fixation failure, osteonecrosis, persistent pain, and nonunion have limited the application of this procedure, particularly in elderly patients with osteoporosis.3,11,13,14 These screws may also result in dynamic compression at the fracture site during axial loading, leading to femoral neck shortening.15
Cannulation of screws decreases thread depth, which can compromise the holding strength of the CSs, especially in osteoporotic patients.6,16 Moreover, a reduction in the minor diameter of screws intended for insertion into low-density cancellous bone materials leads to an increase in holding power of screws, while the opposite effect is observed in high-density bone materials.17 Since osteoporotic bones demand higher bone purchase of the implants compared to normal bones,7 we postulated that utilizing non-cannulated cancellous screws (NCSs) with a smaller minor diameter for internal fixation of UINFNs in osteoporotic patients could enhance their bone purchase, pullout strength, and resistance against shearing and rotational forces, in contrast to CSs with a comparable thread diameter but larger minor diameter. Moreover, the rate of the above-mentioned complications might be reduced by utilizing NCSs. Due to the rising incidence of osteoporotic fractures worldwide, novel fixation strategies ought to be sought and concisely evaluated. Hence, we aimed to compare pre, peri, and postoperative outcomes of internal fixation with NCS versus CS in osteoporotic patients with UIFNF, particularly in terms of fixation failure. Our main hypothesis was that the clinical outcomes of internal fixation with NCSs is superior to CSs in the UIFNF of elderly osteoporotic patients. To the best of our knowledge, no other clinical trial has addressed this question.
2 Materials and methods
2.1 Patients and study design
The present research was conducted in accordance with the Helsinki Declaration, and the internal review board approved the methodology of our research. We followed the Consolidated Standards of Reporting Trials (CONSORT) statement for performing our single-blind randomized clinical trial. All patients who experienced femoral neck fractures and were referred to an institutional tertiary hospital in northwestern Iran between March 2020 and June 2021 were assessed for eligibility to participate in our study. The CONSORT 2010 flow diagram representing the enrollment, allocation, follow-up and analysis of patients is demonstrated in Fig. 1. The study was conducted according to the Declaration of Helsinki and was approved by the internal review board of our institution (Ethics code: IRCT20221113056482N1). Both oral and written informed consent was obtained to represent patients’ willingness to participate in our study.
The inclusion criteria consisted of osteoporotic individuals who had undisplaced intracapsular fractures of the femoral neck with a Garden index of I or II within the past three days due to low-energy trauma and were aged over 45 years. The patients ought to have comorbidities that are risk factor of osteoporosis including renal diseases, chronic liver diseases, cerebrovascular and cardiovascular diseases, the history of long-term corticosteroids administration, hypogonadism, hyperparathyroidism, inflammatory diseases such as rheumatoid arthritis, and diabetes mellitus.18 Osteoporosis was diagnosed via Singh index of less than three according to the plain radiographs of the contralateral femoral neck and head.19,20 Moreover, the patients must have been capable of living independently at home and walking with or without walking aids.
The exclusion criteria for this study were as follows: pathological fractures of the femoral neck, patients with severe comorbidities deemed inappropriate for surgery by an anesthesiologist, severe multiple traumas, follow-up time less than 2 years, patients taking prescribed medications for the treatment of osteoporosis except for vitamin D and calcium, and significant cognitive impairment (measured by three or more correct answers to the Short Portable Mental Status Questionnaire (SPMSQ)21). Patients who experienced each of the assessed clinical outcomes, including wound infections, failure of fixation, nonunion, implant failure, screw migration, reoperation, and avascular necrosis of the femoral head, were included in the study, even if they did not complete their follow-up visits by the end of 2 years.
Osteoporosis was diagnosed via Singh index of less than three according to the plain radiographs of the contralateral femoral neck and head.19,22 Block randomization was performed using blocks of size 4, in a 1:1 ratio. Additionally, randomization was stratified by gender and the Garden classification of the fracture. The participants were blinded to their assigned treatment. The allocation of patients to their assigned treatments was conducted consecutively using a computer-generated random list of blocks. The patients underwent internal fixation treatment performed by a skilled orthopedic surgeon (A. S.). The surgeon, staff, and outcome assessors were not blinded during the study.
2.2 Surgical interventions
Internal fixation of patients with UIFNF was performed using either NCSs or CSs (Arad Teb Toos Corporation, Iran) (Fig. 2, Table 1), depending on their assigned groups. The participants in both groups were positioned supine on the fracture table and received regional or general anesthesia. Femoral neck radiographs were taken with a C-arm X-ray machine immediately before the operation to confirm the satisfactory reduction of the fracture. The sterilization procedure was then carried out. Both groups received prophylactic injections of cefazolin23. Patients received postoperative low-molecular-weight heparin for at least ten days. Additionally, they were instructed to practice toe touches and partial weight-bearing, during the first and second six weeks, respectively, and progress to full weight-bearing during the following three months after the operation.
| Minor diameter (mm) | Major diameter (mm) | Shaft diameter (mm) | Cannulation (mm) | |
| 6.5 mm NCS | 3.3 | 6.5 | 4.5 | – |
| 6.5 mm CS | 4.6 | 6.5 | 4.9 | 2.1 mm |
For the fixation group using NCS (Fig. 3), a longitudinal incision with a length of 3–5 cm was made below the greater trochanter. Three Kirschner 2 mm guidewires were then placed in an inverted triangular configuration under the guidance of a C-arm X-ray machine. After inserting the guidewires into the correct location, their position was confirmed by image intensification (Fig. 3-A). Then, drilling was conducted into the 30–40 mm length using a cannulated reamer. Next, the cannulated drill and its associated guidewire were pulled out and a 6.5 mm NCS with an appropriate length was fixated, the position of which was determined by C-arm (Fig. 3-B). If the screw had been secured in a correct position, it was then fully inserted with an appropriate length. After insertion, its position and length were re-evaluated (Fig. 3-C). The other two screws were inserted similarly and tightened until the depth of the NCSs was under 5 mm of the femoral head cartilage (Fig. 3 (C-E)). The process was repeated if the screws were inserted in the wrong position. At the end, the surgical incision was closed (Fig. S1). In the group undergoing CS fixation (Fig. S2), a 3–5 cm incision was made below the greater trochanter. An inverted triangular configuration was then pre-drilled using three Kirschner guidewires under the guidance of C-arm. After ensuring the correct location of the guide pins, a 4 mm cannulated drill bit was used to drill through a 2 mm guidewire. Then, three 6.5 mm CSs with the appropriate length were installed and tightened.
2.3 Outcome evaluation
The demographic variables, as well as preoperative, perioperative, and postoperative clinical characteristics, were accurately recorded using physical examination techniques and radiographs using a checklist completed by a medical student and an orthopedic surgery resident, supervised by experienced orthopedic surgeons. The primary endpoints consisted of complications related to the hip, including fixation failure, nonunion, implant failure, screw migration, the need for reoperation, superficial or deep surgical site infections, and avascular necrosis of the femoral head.24 Nonunion was described as a fracture line that did not heal after at least six months. Implant failure was defined as either implant breakage or implant bending. The secondary endpoint consisted of evaluating hip function using HHS values at six different time points during the follow-up period (two weeks, one month, three months, six months, one year, and two years after the surgery). These scores were precisely calculated and documented by an orthopedic surgery resident, and then were compared between the two groups.15,25,26
2.4 Statistical analysis
Statistical analyses were conducted using SPSS 26.0 software (IBM Corporation, Chicago, IL, USA). The chi-squared test and Fisher's exact test were utilized to compare categorical variables between the two groups. Quantitative variables were expressed as mean ± standard deviation (SD) and compared using Student's t-test. A p-value below 0.05 was considered statistically significant.
3 Results
3.1 Baseline preoperative data
Between March 2020 and June 2021, a total of 211 patients with UIFNF were referred to an institutional tertiary hospital in northwestern Iran. However, 90 patients did not fulfill the inclusion criteria, and 27 patients declined to participate. We included 94 patients who met the inclusion criteria, with 47 patients allocated to each treatment group (Fig. 1). A total of 27 patients from the NCS and 30 patients from the CS groups completed the two-year follow-up visits or reached at least one of the primary endpoints, and were included in the final analysis. The average age of the patients was 71.0 years, and 54.4% of them were female (Table 2). There was no significant difference in gender (male/female, 12/15 vs 14/16, p = 0.53), age (71.18 ± 7.30 vs 70.96 ± 6.26, p = 0.90), fracture location (right/left, 13/14 vs 16/14, p = 0.45), and duration until surgery (32.07 ± 30.43 vs 34.56 ± 14.89, p = 0.69) between the both groups. A total of 27 (47.4%) and 30 (52.6%) patients were classified as having a Garden fracture type of I and II, respectively. There was no significant difference in Garden classification between the two groups (I/II: 13/14 vs 14/16, p = 0.56) (Table 2). The bending resistance of the screw pitches for NCSs and CSs was estimated using the formula below, where ‘I’ represents the bending resistance, ‘D’ represents the minor diameter, and ‘d’ represents the cannulation diameter (Table 1). Considering the similarity of the materials used in both types of screws, the bending stiffness = E × I, where E represents modulus of elasticity, can also be estimated.6 The bending stiffness of CSs in our study was approximately 4 times higher than NCSs.INCS = π × D4 / 64 → INCS = 5.8 mm4ICS = π × (D4 – d4) / 64 → ICS = 21.1 mm4
| Total | NCS | CS | P value | ||
| Age (years, mean ± SD) | 71.0 ± 6.7 | 71.1 ± 7.3 | 70.9 ± 6.2 | 0.90 | |
| Gender (n (%)) | Male | 26 (45.6) | 12 (44.4) | 14 (46.7) | 0.53 |
| Female | 31 (54.4) | 15 (55.6) | 16 (53.3) | ||
| Garden class (n (%)) | I | 27 (47.4) | 13 (48.1) | 14 (46.7) | 0.56 |
| II | 30 (52.6) | 14 (51.9) | 16 (53.3) | ||
| Time to surgery (hours, mean ± SD) | 33.3 ± 23.3 | 32.0 ± 30.4 | 34.5 ± 14.8 | 0.69 | |
| Fracture side (n (%)) | right | 29 (50.9) | 13 (48.1) | 16 (53.3) | 0.45 |
| left | 28 (49.1) | 14 (51.9) | 14 (46.7) | ||
| Duration of hospitalization (days, mean ± SD) | 3.2 ± 0.4 | 3.2 ± 0.4 | 3.3 ± 0.4 | 0.36 | |
| Surgical duration (minutes, mean ± SD) | 43.9 ± 5.1 | 46.2 ± 4.2 | 41.8 ± 4.9 | 0.001 | |
| Length of the surgical incision (mm, mean ± SD) | 40.7 ± 3.8 | 40.7 ± 4.2 | 40.8 ± 3.5 | 0.98 | |
| Intraoperative blood loss (mL, mean ± SD) | 54.0 ± 11.1 | 58.8 ± 7.6 | 49.6 ± 12.1 | 0.001 | |
| Radiation exposure frequency (times, mean ± SD) | 10.3 ± 3.3 | 13.4 ± 1.8 | 7.5 ± 1.2 | 0.000 | |
3.2 Perioperative data
The average length of hospital stay was 3.2 ± 0.4 days for the NCS group and 3.3 ± 0.4 days for the CS group. No significant difference between the two treatment groups was detected (p = 0.36). The average duration of surgery was 46.2 ± 4.2 min in the NCS group and 41.8 ± 4.9 min in the CS group, revealing a statistically significant difference between the two groups (p = 0.001). The average length of the surgical incision was 40.7 ± 4.2 and 40.8 ± 3.5 in the NCS and CS groups, respectively. There was no statistically significant difference in the length of the surgical incision between the two groups (p = 0.98). Intraoperative blood loss was 58.8 ± 7.6 mL and 49.6 ± 12.1 mL in the NCS and CS groups, respectively. The NCS group experienced a significantly higher blood loss (p = 0.001). Obtaining radiographs via C-arm X-ray machine was conducted 13.4 ± 1.8 times in the NCS group, which was significantly greater than the CS group (7.5 ± 1.2 times) (p = 0.001) (Table 2).
3.3 Postoperative data
After a two-year follow-up, successful fracture fixation was achieved in 100% of the patients in the NCS group (Fig. S1) and in 83.3% of patients in the CS group (Fig. S2, Table 3). Four patients in the NCS group and no patients in the CS group experienced implant failure. The frequency of implant failure was significantly greater in the NCS group in comparison to the CS group (p = 0.04) (Fig. 2). None of the patients from the NCS group experienced screw migration, while 5 patients from the CS group did. The incidence of screw migration was significantly higher in the CS group (p = 0.03). The fixation failure was more common in the CS group (3 patients (10.0%)) in comparison with the NCS group (none of the patients), however, it was not statistically significant (p = 0.13) (Fig. 3). The HHS values of the NCS group were significantly higher than the CS group at one year and two years of follow-up (one year, p = 0.007; two years, p = 0.001) (Table 3).
| Total | NCS | CS | P value | |
| Union time (months, mean ± SD) | 3.4 ± 0.7 | 3.3 ± 0.6 | 3.6 ± 0.8 | 0.15 |
| Wound Infection (n (%)) | 3 (5.2) | 1 (3.7) | 2 (6.6) | 0.54 |
| Implant failure (n (%)) | 4 (7.0) | 4 (14.8) | 0 (0.0) | 0.04 |
| Fixation failure (n (%)) | 3 (5.3) | 0 (0.0) | 3 (10.0) | 0.13 |
| Screw migration (n (%)) | 5 (8.8) | 0 (0.0) | 5 (16.7) | 0.03 |
| Reoperation (n (%)) | 6 (10.5) | 1 (3.7) | 5 (16.7) | 0.12 |
| Avascular necrosis of femoral head (n (%)) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1.0 |
| HHS (mean ± SD) | ||||
| 2 weeks | 27.9 ± 6.6 | 27.5 ± 6.9 | 28.3 ± 6.4 | 0.67 |
| 1 month | 38.2 ± 7.6 | 38.9 ± 8.0 | 37.5 ± 7.4 | 0.50 |
| 3 months | 62.1 ± 5.6 | 60.8 ± 6.5 | 63.2 ± 4.5 | 0.11 |
| 6 months | 71.7 ± 5.5 | 72.6 ± 5.8 | 70.9 ± 5.1 | 0.24 |
| 1 year | 77.6 ± 7.8 | 80.4 ± 7.3 | 75.0 ± 7.4 | 0.007 |
| 2 years | 86.3 ± 6.1 | 89.1 ± 5.7 | 83.9 ± 5.5 | 0.001 |
Furthermore, we detected no statistically significant difference in the duration of union (NCS/CS: 3.3 ± 0.6/3.6 ± 0.8) (p = 0.15), superficial or deep surgical site infections (NCS/CS: 3.7%/6.6%) (p = 0.54), the rates of reoperation (NCS/CS: 3.7%/16.7%) (p = 0.12), and avascular necrosis of the femoral head (NCS/CS: 0%/0%) (p = 1.0) between the two groups (Table 3).
4 Discussion
A total of 27 patients from the NCS and 30 patients from the CS groups were included in the final analysis. In terms of perioperative findings, the average duration of surgery, the frequency of C-arm X-ray, and the amount of intraoperative blood loss were significantly higher in the NCS group in comparison to the CS group. However, no statistically significant difference was detected among the two groups in the average length of hospital stay or the mean length of the surgical incision. After a two-year follow-up, successful fracture fixation was achieved in all patients of the NCS group and in 83.3% of patients in the CS group. The incidence of implant failure and screw migration were significantly higher in the NCS group compared to the CS group. The HHS values of the NCS group were significantly higher than the CS group at one year and two years of follow-up. The fixation failure was more common in the CS group in comparison with the NCS group, however, it was not statistically significant. Moreover, we detected no statistically significant difference in the duration of union, superficial or deep surgical site infections, the rates of reoperation, and avascular necrosis of the femoral head between the two groups.
Cortical thickness and cancellous bone density are crucial factors linked to the strength of fixation. These factors are reduced in osteoporosis, leading to insufficient anchoring of the implant to the osteoporotic bones. This, in turn, leads to an increased incidence of fixation failure in geriatric patients.27–29 Identifying minimally invasive internal fixation techniques to augment the stable anchorage of implants to osteoporotic bone can significantly reduce the incidence of fixation failure. A study conducted by Gardner et al., compared utilizing NCSs with CSs in the internal fixation of femoral neck fractures in synthetic bone models, and revealed higher compressive strength and load to failure of the NCSs compared to the CSs.30 Nevertheless, this study was conducted in a controlled laboratory environment using synthetic bone models. This prompted us to evaluate the effectiveness of internal fixation with NCSs in osteoporotic patients in whom higher compression strength and a lower risk of fixation failure is demanded.
According to our results, screw migration occurred significantly lower in the NCS group compared to the CS group. Cannulation of screws in CSs results in a wider core diameter and decreased thread depth compared to NCSs. This results in an increased surface area of the screw threads and improved screw purchase on the bone in NCSs, which consequently leads to an increased holding strength of NCSs in low-density cancellous bones.31 As mentioned earlier, stable fixation of osteoporotic fractures is highly dependent on the holding strength of the screws. Since NCSs are more capable of being firmly anchored to the cancellous osteoporotic bones than CSs, utilizing NCSs might lead to an enhanced mechanical fixation. This may potentially result in a reduced risk of screw migration and fixation failure.
Another crucial element that could enhance the fixation efficacy is the existence of compression at the fracture site. This can be attained by an improved bone purchase of the screws, which is primarily linked to the properties of the material into which the screw is inserted. The other potential contributor is the higher ratio of outer diameter to core diameter.32 Research has shown that reducing the minor diameter of cannulated screws intended for insertion into low-density cancellous bone materials leads to an increase in the holding power of screws. Conversely, the opposite effect is observed in high-density bone materials.31,33 Therefore, the bone purchase of NCSs with smaller minor diameters in osteoporotic bones may be more advantageous than CSs with comparable major diameters, but larger minor diameter. Moreover, increased surface area and lack of self-drilling in NCSs contributes to bone compression rather than cutting and are among other factors augmenting the compressive strength of NCSs.16,30,34 As mentioned earlier, Gardner et al.30 found that NCSs exhibited higher load to failure and compressive strength compared to CSs. However, internal fixation of UIFNFs in osteoporotic patients in our study was not associated with a significant improvement in the rates of fixation failure.
According to our results, implant failure occurred more frequently in the NCS group compared to the CS group. This might be attributable to the lower bending stiffness in the NCSs compared to the CSs. This arises from the widened core diameter (4.6 mm) of the CSs following their cannulation, compared to the solid cylindric implants such as NCSs (3.3 mm) with a similar major diameter. This leads to a higher incidence of implant failure in the NCS group. However, implant failure in the NCS group did not lead to fixation failure in any of the cases. The probable underlying mechanism for the observed phenomenon might be the increased anchorage of the NCSs to the cancellous bone. This could have reduced the implant migration and cut-out as a result of increased compression at the fracture site. This consequently might have given rise to a reduced rate of screw migration in the NCS group. Our finding is in line with previous studies indicating the higher impact of the loss of fixation, rather than implant breakage, in fixation failure of osteoporotic bones.6,7
Our research improved the previous literature in the following ways. Our study was the first study to compare the application of NCSs and CSs for the internal fixation of femoral neck fractures in osteoporotic patients. We also introduced a novel surgical approach for effective insertion of NCSs, which was not accompanied by fixation failure in any of the cases. We gathered further information on the intraoperative differences of the two fixation techniques. Moreover, we followed the patients for two years and recorded any incidences of post-surgical adverse events and the HHS values pertaining to our novel surgical technique compared to the standard method. Our results shed light on the major advantages and limitations of fixation of UIFNF in osteoporotic patients using CSs and NCSs and provided researchers with clues to develop more effective fixation techniques in these patients.
The primary constraint of our research was the limited number of participants, which resulted from the rigorous inclusion and exclusion criteria aimed at isolating a homogeneous population of middle-aged and elderly osteoporotic patients. Additionally, the study was conducted at a single center and may not represent the whole population. While the patients were blinded, the surgeons and staff were not. We also did not assess or compare patient-reported outcomes, such as quality-of-life measures such as EuroQol five dimensions questionnaire and mental health evaluations. Moreover, the presence of chronic arthritis or other hip diseases, as well as a history of ipsilateral hip or femoral surgery, which can significantly affect fracture fixation, were not among our exclusion criteria. In addition, the length of our follow-up period was relatively narrow, which might have resulted in under-estimating some of the outcomes.
5 Conclusion
Based on our research, fixation of UIFNF fractures using CSs resulted in improved perioperative outcomes compared to fixation using NCSs. However, the incidence of certain postoperative complications, such as screw migration, was significantly greater in the CS group compared to the NCS group, while implant failure occurred more commonly in the NCS group compared to the CS group. According to our findings, when performing UIFNF fixation at setting with limited resources, application of CS is preferred due to better perioperative outcomes. Though, at settings with access to more advanced life-support facilities, patients are more likely to benefit from NCS due to the relatively lower likelihood of implant failure, conferring better long-term outcomes.
Ethical statement
The study was conducted according to the Declaration of Helsinki and was approved by the Ethical Committee of Tabriz University of Medical Sciences (Ethics code: IRCT20221113056482N1). Both oral and written informed consent was obtained to represent patients’ willingness to participate in our study.
Author statement
Alireza Sadeghpour: Conceptualization; Funding acquisition; Methodology; Supervision; Investigation; Shahab Mahdipour: Conceptualization; Data curation; Methodology; Project administration; Resources; Hadi Alizadeh: Data curation; Formal analysis; Writing – original draft; Writing – review & editing; Software; Jafar Ganjpour-Sales: Conceptualization; Validation; Investigation; Hossein Aslani: Conceptualization; Validation; Investigation; Mohammad Reza Moharrami: Conceptualization; Validation; Investigation.
Funding
This study was funded by Shohada Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
Patient consent
Both oral and written informed consent was obtained to represent patients’ willingness to participate in our study.
References
- Intracapsular hip fractures in the elderly. Do we know what is important? Injury. 2017;48(3):695-700.
- [Google Scholar]
- Closed reduction and internal fixation versus total hip arthroplasty for displaced femoral neck fracture. Chin J Traumatol. 2014;17(2):63-68.
- [Google Scholar]
- The global burden of surgical management of osteoporotic fractures. World J Surg. 2020;44:1009-1019.
- [Google Scholar]
- Biomechanics of implant fixation in osteoporotic bone. Curr Osteoporos Rep. 2020;18(5):577-586.
- [Google Scholar]
- Fixation using alternative implants for the treatment of hip fractures (FAITH): design and rationale for a multi-centre randomized trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures. BMC Muscoskel Disord. 2014;15(1):219.
- [Google Scholar]
- Biomechanical rationale for implant choices in femoral neck fracture fixation in the non-elderly. Injury. 2015;46(3):445-452.
- [Google Scholar]
- Outcomes of elderly patients with nondisplaced or minimally displaced femoral neck fractures treated with internal fixation: a systematic review and meta-analysis. Injury. 2019;50(12):2158-2166.
- [Google Scholar]
- Hemiarthroplasty vs total hip arthroplasty for the management of displaced neck of femur fractures: a systematic review and meta-analysis. J Arthroplasty. 2019;34(8):1837-1843. e2.
- [Google Scholar]
- Accurate placement of cannulated screws in femoral neck fractures: screw and guide wire combined technique. Orthop Surg. 2021;13(8):2472-2476.
- [Google Scholar]
- Fractured neck of femur—internal fixation versus arthroplasty. Deutsch Aerzteblatt Int. 2010;107(23):401.
- [Google Scholar]
- Revision surgery occurs frequently after percutaneous fixation of stable femoral neck fractures in elderly patients. Clin Orthop Relat Res. 2014;472(12):4010-4014.
- [Google Scholar]
- Factors associated with femoral neck shortening after closed or open reduction and screw fixation. Indian J Orthop. 2022;56(2):303-311.
- [Google Scholar]
- Pullout force testing of cortical and cancellous screws in whole bone. 2017:117-132.
- [Google Scholar]
- Development and initial validation of a novel thread design for nonlocking cancellous screws. J Orthop Res. 2022;40(12):2813-2821.
- [Google Scholar]
- A comprehensive overview on osteoporosis and its risk factors. Therapeut Clin Risk Manag 2018:2029-2049.
- [Google Scholar]
- Evaluation of Singh Index and Osteoporosis Self-Assessment Tool for Asians as risk assessment tools of hip fracture in patients with type 2 diabetes mellitus. J Orthop Surg Res. 2017;12(1):37.
- [Google Scholar]
- Concordance between the mini-mental state examination, short portable mental status questionnaire and montreal cognitive assessment tests for screening for cognitive impairment in older adults. Adv Gerontol. 2021;11:312-316.
- [Google Scholar]
- Antibiotic prophylaxis in orthopaedic surgery: difficult decisions in an era of evolving antibiotic resistance. Bone Joint J. 2016;98(8):1014-1019.
- [Google Scholar]
- What makes fixation of femoral neck fractures fail? A systematic review and meta-analysis of risk factors. Injury 2022
- [Google Scholar]
- Pulsed electromagnetic fields for the treatment of tibial delayed unions and nonunions. A prospective clinical study and review of the literature. J Orthop Surg Res. 2012;7:24.
- [Google Scholar]
- Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence. Injury. 2015;46:S8-S19.
- [Google Scholar]
- Clinical results of treatment of garden type 1 and 2 femoral neck fractures in patients over 70-year old. Eur J Trauma Emerg Surg. 2016;42(2):191-196.
- [Google Scholar]
- Bone mineral content and fixation strength of femoral neck fractures: a cadaver study. Acta Orthop Scand. 1994;65(2):161-165.
- [Google Scholar]
- Analysis of surgical delay and its influence on morbimortality in patients with hip fracture. Rev Española Cirugía Ortopédica Traumatol. 2019;63(3):246-251.
- [Google Scholar]
- Cannulated versus non-cannulated cancellous screw fixation for femoral neck fractures: a synthetic bone biomechanical study. J Orthop Surg. 2015;23(1):41-46.
- [Google Scholar]
- Cancellous bone screw thread design and holding power. J Orthop Trauma. 1996;10(7):462-469.
- [Google Scholar]
- Torsion and bending analysis of internal fixation techniques for femoral neck fractures: the role of implant design and bone density. J Orthop Res. 1987;5(3):433-444.
- [Google Scholar]
- Designs and techniques that improve the pullout strength of pedicle screws in osteoporotic vertebrae: current status. BioMed Res Int. 2014;2014
- [Google Scholar]
- Recent studies on the pullout strength behavior of spinal fixation. J Dev Biol Tissue Eng. 2011;3(4):48-54.
- [Google Scholar]