Avascular necrosis after internal fixation of intracapsular hip fractures; a study of the outcome for 1023 patients
Introduction
Hip fractures are a major public health issue and a major economic burden in healthcare. This is reflected in the UK by the recent publication of an evidence-based recommendation, “The Care of Patients with Fragility Fracture”, by the British Orthopaedic Accsociation,22 in combination with the launch of the National Hip Fracture Audit. It is predicted that the number of hip fractures worldwide could be as high as 8.2 million by 2050,15 with worldwide costs in 1997 of $131.5 billion.9 Eighty per cent of hip fractures occur in women who have an 11.4% lifetime risk at age 50 years, comparable to that of breast cancer.21
Approximately half of hip fractures are intracapsular. There is continuing debate regarding the merits of internal fixation versus arthroplasty for this fracture. Much of this centres about the risk of the fracture healing complications of non-union and later avascular necrosis (AVN). An estimation of the risk of these complications occurring is essential before a surgeon and patient can make an informed decision of internal fixation versus arthroplasty. There is a general consensus for undisplaced intracapsular fractures to be treated with internal fixation to allow early mobilisation and reduce the risk of them becoming displaced at a later date.4, 22 For displaced fractures there is a higher risk of fracture healing complications but many of the studies reporting on this are now from some years ago using surgical methods that are now outdated. The aim of our study was to determine the incidence of AVN related to age, gender, degree of displacement and operation delay for a large series of patients with intracapsular fractures treated with internal fixation using contemporary methods.
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Materials and methods
Between January 1989 and August 2006, 2938 patients with an intracapsular fracture of the hip were treated at our unit. 1289 of these were treated with internal fixation. Twenty of these patients had pathological fractures from bone tumours and were excluded from the study. A further four patients with an additional femoral shaft fracture for which both fractures were treated with an intramedullary nail were excluded as was one complex fracture treated with a blade plate. Two hundred and forty
Results
The mean age of the patients was 75.4 years (range 16–100); 243 (23.8%) were male. 777 lived in their own home, 148 lived in residential homes, 50 lived in nursing homes and 48 sustained the injury while a hospital inpatient. Fractures classified as either undisplaced or displaced were related to the patient's age (Fig. 1).
The overall incidence of AVN for all patients was 6.6%. AVN was less common for undisplaced fractures than for displaced fractures (21 of 528 [4.0%] vs 47 of 495 [9.5%], p =
Discussion
The operative management of displaced intracapsular fractures has stimulated debate for decades. A survey of the members of the Orthopaedic Trauma Association and the European-AO International-affiliated trauma centres showed that internal fixation was the operation of choice for intracapsular displaced hip fractures in patients younger than 60 years versus arthroplasty for patients over 80 years.3 There was great variation in the treatment preferences for patients who were between 60 and 80
Conflict of interest statement
The authors declare that they have no conflict of interest in connection with this paper. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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