Garden I femoral neck fractures in patients 65 years old and older: Is conservative functional treatment a viable option? - 14/04/10

Doi : 10.1016/j.otsr.2009.11.012

J.-M. Buord ^a,^⁎ , X. Flecher ^a, S. Parratte ^a, L. Boyer ^b, J.-M. Aubaniac ^a, J.-N. Argenson ^a
^a University Hospital Musculo-Skeletal Institute, Sainte-Marguerite Hospital, Orthopaedics surgery and Traumatology Department, Marseille, France
^b Public Health Division, Public Health and Medical Information Department, La Timone Hospital, Marseille, France

Corresponding author at: Hôpital Sainte-Marguerite, BP 29, 13274 Marseille cedex 09, France. Tel.: +33 6 30 54 40 19; fax: +33 4 91 74 56 25.

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Summary

Introduction

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.

Patients and methods

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 82years. 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 12months. 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.

Results

The observed displacement rate was 33.3% (19 patients) within an average period of 10days. 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.

Discussion

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.

Conclusions

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.