case study fracture neck of femur

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Bilateral femoral neck fractures in an adult male following minimal trauma after a simple mechanical fall: a case report

• Asheesh Sood 1 ,
• Christopher Rao 2 &
• Ian Holloway 1  

Cases Journal volume  2 , Article number:  92 ( 2009 ) Cite this article

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Despite being rare there are several reports in the medical literature of bilateral femoral neck fractures in adult patients. They have been reported to have occurred following major trauma, or as a result of primary or secondary bone disease. In this case report we describe for the first time in the literature bilateral femoral neck fractures in a patient following minimal trauma after a simple mechanical fall.

Case presentation

We describe the case of an 84-year-old gentleman who sustained bilateral intracapsular fractures following a simple mechanical fall. Prompt diagnosis and early surgical intervention resulted in a satisfactory outcome.

This case highlights that in the elderly, even in the absence of primary and secondary bone disease, bilateral neck of femur fractures can occur following relatively minor trauma. Consequently, the orthopaedic surgeon, emergency physician and general practitioner should be aware of this injury, particularly when managing traumatic injuries in confused patients.

Bilateral fractures of the Neck of the Femur (NOF) have been reported to have occurred following major trauma, or as a result of primary or secondary bone disease. We describe the case of an 84-year-old gentleman who sustained bilateral intracapsular fractured NOF following a simple mechanical fall. Early diagnosis, resuscitation, surgical intervention, post-operative mobilisation and discharge; according to best practice guidelines [ 1 ]; resulted in a satisfactory outcome.

Following a review of the published literature we undertake to discuss the importance of prompt diagnosis and early surgical treatment in achieving a satisfactory outcome following this injury. Finally, we aim to discuss the implications of this case on our routine orthopaedic practice.

An 84-year-old gentleman presented to the Accident and Emergency Department in the early hours of the morning after a mechanical fall down three stairs. He was an active, independent gentleman with no significant co-morbidities. He was also the full time carer for his wife who suffered from multiple sclerosis. His pre-morbid mobility was good and he did not require any walking aids.

He was immediately resuscitated in the Accident and Emergency Department. Clinical examination revealed external rotation of both legs and pain on passive movement of both hips. X-ray of his pelvis showed completely displaced intracapsular hip fractures on both sides [Figure 1 ].

Anterioposterior radiograph of the pelvis showing bilateral completely displaced intracapsular fractures of the neck of femur .

The fractures were treated by cemented hemiarthroplasty using Thompson prostheses. This was undertaken with the patient in the supine position within 24 hours of admission using an antero-lateral approach by two senior Orthopaedic surgeons [Figure 2 ]. He had a satisfactory post-operative recovery and was able to mobilise and fully weight-bear within 2 days of the surgery.

Anterioposterior radiograph of the pelvis showing bilateral fractures of the neck of femur treated by cemented Thompson hemiarthroplasties .

Simultaneous bilateral NOF fractures are rare. They are however, several reports in the medical literature of bilateral NOF fractures occurring as a result of primary or secondary bone disease. For example, hypocalcemia [ 2 ], osteomalacia [ 3 ], osteoporosis, renal osteodystrophy [ 4 ], radiotherapy [ 5 ] and multiple myeloma. Bilateral NOF fractures have also been reported to have occurred following persistent, sustained stress [ 5 ].

Uncomplicated trauma is a rare cause of bilateral fractured NOF [ 6 ]. There have been reports of bilateral NOF fractures after seizures secondary to epilepsy, drugs, and electrocution [ 6 ]. Intracapsular fractures of the NOF prior to the fifth decade of life usually result from severe injury [ 5 ]. Konforti et al [ 7 ] described bilateral NOF fractures in a 37-year-old gentleman crushed during a mining accident. Carrell et al [ 8 ] described the case of an 8 year old boy who sustained a bilateral neck fractures following a 25 foot fall. More recently Gunal et al [ 9 ] describe bilateral traumatic NOF fractures.

In the case we describe an otherwise fit and well gentleman who sustained bilateral NOF fractures following a low energy injury fall down three stairs. This is a common mechanism of injury which often leads to a unilateral NOF fracture. It is important to note that this patient gave a definite history of a fall which led to the injury in contrast to fatigue fractures [ 5 ] where patients describe their leg giving way followed by pain. Bilateral fractured NOF have been reported in the literature in the elderly following minimal trauma [ 10 ]. However, in this case described the patient had a background of corticosteroid induced osteoporosis, gross obesity and rheumatoid arthritis.

Guidelines for the management of hip fractures recommend that surgical intervention should be carried out within 48 hours of the fracture occurring [ 1 ]. As well as causing distress to the patient, delay in surgery is associated with increased morbidity and mortality, and a reduced chance of success and rehabilitation [ 11 ]. Surgery should be performed as soon as the medical condition of the patient allows, provided that appropriate staffing and facilities are available [ 11 ]. However, it has also been demonstrated that surgical treatment conducted as night-time emergency cases are associated with increases mortality [ 11 ].

Our management of this patient was entirely consistent with these guidelines. The fractures were diagnosed early and the patient was resuscitated appropriately. The patient was reviewed by the physicians and anaesthetists on the day of admission and optimized medically. Both hip fractures were managed by simultaneous cemented hemiarthroplasty within 24 hours of admission on a day-time trauma list. McBryde et al [ 12 ] have demonstrated the safety of simultaneous hip arthroplasties, albeit in the context of elective surgery. The operation was performed in the supine position, to avoid repositioning the patient, in order to shorten the total operating time. There is however, no evidence to support the superior efficacy of any position and we feel the surgeon should use the position with which he is most comfortable.

All hip injuries presenting to the Accident and Emergency Department in our hospital have an anterioposterior radiograph of the pelvis with both hips included as part of initial assessment. This is an important precaution as there may be an injury of the opposite hip which could easily be missed. As a result of this case, our junior surgical staff have been trained to be particularly vigilant to the possibility of bilateral NOF fractures, particularly in the very elderly, in cases where there may be primary or secondary bone disease, when the mechanism of injury is high-impact or unknown, and when patients are confused and unable to localize pain.

In this case report we present a rare combination of injuries occurring simultaneously in an elderly gentleman. While a unilateral hip fracture is a very common injury managed appropriately on a regular basis by Orthopaedic surgeons, bilateral injuries of this nature presenting simultaneously can prove to be a diagnostic and therapeutic challenge. Early recognition and prompt surgical intervention can lead to good outcomes despite the severity of this injury. Bilateral anterioposterior radiographs should be taken as a matter of routine in patients presenting with suspected fractured NOF and orthopedic staff should be vigilant to the possibility of bilateral NOF fractures.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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Northwick Park Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, UK

Asheesh Sood & Ian Holloway

Department of Biosurgery and Surgical Technology, Imperial College London, 5 Cheerytree House, Droop Street, London, W10 4EL, UK

Christopher Rao

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Authors' contributions

AS and CR were responsible for drafting the case study. IH was responsible for revising it critically for important intellectual content and was the consultant ultimately responsible for managing this patient. All authors have made substantial contribution to the conception of this case report, read and approved the final version to be submitted.

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Sood, A., Rao, C. & Holloway, I. Bilateral femoral neck fractures in an adult male following minimal trauma after a simple mechanical fall: a case report. Cases Journal 2 , 92 (2009). https://doi.org/10.1186/1757-1626-2-92

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Published : 28 January 2009

DOI : https://doi.org/10.1186/1757-1626-2-92

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• Renal Osteodystrophy
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• Intracapsular Fracture
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• Cement Hemiarthroplasty

Cases Journal

ISSN: 1757-1626

• Open access
• Published: 02 January 2024

Fixation of femoral neck fracture with femoral neck system: a retrospective cohort study of 43 patients

• Jae Youn Yoon 1 ,
• Seong-Eun Byun 2 &
• Young-Ho Cho 3  

BMC Musculoskeletal Disorders volume  25 , Article number:  8 ( 2024 ) Cite this article

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Backgrounds

This study aimed to analyze the clinical outcomes of femoral neck fractures (FNF) in patients treated with a femoral neck system (FNS, DePuy Synthes), which is a recently introduced device.

This retrospective cohort study of 43 patients who underwent osteosynthesis using FNS for FNF between July 2019 and June 2021 with a minimum follow-up of 6 months. The researchers examined the patients’ demographic factors and radiologically evaluated the fracture type and fixation status, bone union, and postoperative complications.

Of 43 patients, 25 were female, and the patients’ mean age and body mass index were 62.1 years and 22.5 kg/m 2 , respectively. According to the Association of Osteosynthesis/Orthopaedic Trauma Association (AO/OTA) classification, the most common fracture types were 31B1.1 and B1.2 (13 cases each), followed by B2.3, B2.1, and B2.2 (seven, five, and four cases, respectively). Radiological bone union was confirmed in 39 patients (90.7%), and the mean time to union was 3.6 months. Two cases of nonunion, one case of lag screw cut-out, and one case of osteonecrosis were confirmed; all four cases later underwent arthroplasty. The mean time to reoperation was 4.5 months. Meanwhile, five patients underwent implant removal after the bone union, and distal locking screw stripping was noted in three patients. All three patients required metal plate cutting to remove the implants.

Conclusions

Osteosynthesis of FNF using the newly introduced FNS showed favorable clinical outcomes and no specific hardware-related complications were reported during the follow-up. However, attention must be paid to the issue regarding distal locking screw failure during hardware removal.

Peer Review reports

Femoral neck fracture (FNF) is the most common type of hip fracture in elderly patients; however, it also occurs in young patients as a result of high-energy trauma [ 1 , 2 ]. The number of patients with FNF continues to increase, and the number of patients with disabilities due to FNF is expected to increase to 21 million in the near future [ 3 ]. Owing to the high morbidity and mortality of FNF, providing appropriate treatment and rehabilitation to these patients is a significant issue in reducing the physical and economic burden of patients and society [ 4 , 5 ].

Surgical treatment is indicated in most FNFs, and the treatment method (osteosynthesis or replacement arthroplasty) is determined according to the anatomical location and angle of the fracture line, degree of displacement, surgeon’s preference, and general condition of the patient. Arthroplasty is usually preferred in elderly patients with displaced FNFs (Garden stage 3 and 4) to reduce the possibility of reoperation and to promote rapid functional recovery. In younger patients, however, functional requirements are relatively high, and they might experience various complications related to arthroplasty in the future. Therefore, joint preservation surgery is usually considered in young patients [ 6 ].

Currently, multiple cannulated screws (MCS) or dynamic hip screws (DHS) are the most commonly used fixation devices for the osteosynthesis of FNFs. Fixation using MCS is less invasive, with less bone removal, less disruption of the blood supply, and good torsional stability [ 7 ]. However, limb shortening and implant protrusion are often reported, and due to weak resistance to shear force, its use in Pauwels type 3 fractures is limited. Fixation with DHS has advantages in terms of rigid fixation and higher resistance to bending and shear forces. However, DHS fixation requires extensive surgical exposure, including greater bone stock removal and soft tissue damage. Despite the distinct differences in characteristics between the two instruments, both instruments showed good clinical results [ 8 , 9 ]. No significant difference in clinical outcomes between the two devices was reported in a recent large-scale multicenter randomized clinical study [ 3 ].

A new fixation device, the femoral neck system (FNS; DePuy Synthes, MA, USA), has the combined advantages of the former two devices. Fixation with FNS is minimally invasive similar to MCS fixation because of its small implant footprint and can shorten the operation time and reduce the risk of radiation exposure owing to its simple surgical method [ 10 , 11 ]. According to biomechanical studies, the overall construct stability of FNS is similar to that of DHS and superior to that of MCS [ 12 ]. These biomechanical advantages provide a theoretical basis for using FNF in Pauwels type 3 (vertical shear) FNF [ 13 ].

Despite these theoretical and biomechanical advantages, only a few studies report the clinical outcomes of osteosynthesis using FNS, and the results are inconsistent among the studies. Therefore, we aimed to share our experience of using FNS in patients with FNF and perform a failure analysis in several cases. We also discussed the potential problems regarding implant removal, which have never been addressed in previous studies.

Study design and patient selection

This retrospective cohort study was conducted at three different institutions, and the respective institutional review boards approved this study. The requirement for formal informed consent was waived because of the retrospective nature of the study. We reviewed the medical records of 49 patients who underwent osteosynthesis using FNS for mono-traumatic FNF between July 2019 and June 2021, and those who satisfied the minimum follow-up period of 6 months were enrolled in the study. In agreement, osteosynthesis was performed in patients aged < 65 years, even with Garden stage 3 and 4 fractures, unless there were no particular limitations. In patients over 65 years of age, the surgical method was decided considering the patient’s medical condition, fracture displacement, and presence of arthritic changes.

Data collection

Clinically, we collected patients’ demographic factors, including age, sex, body mass index (BMI), medical history (including a history of diabetes mellitus, hypertension, deep vein thrombosis, pulmonary embolism, stroke, chronic kidney disease, and liver cirrhosis), and medications (including anticoagulants or antiplatelet agents). The Koval’s grade and Charlson comorbidity index (CCI) were used to assess the individual preoperative ambulation state and medical comorbidities. The operation time, type of anesthesia, length of hospital stay, and complications during admission were also reviewed.

Radiologically, the initial fracture pattern, reduction status, implant position, tip-apex distance (TAD), bolt sliding length, time to union, and any other complications (such as osteonecrosis, nonunion, infection, and post-traumatic arthritis) were also reviewed. The Garden, Pauwels, and AO/OTA classifications were used to distinguish the fracture types, and the Cleveland index was used to analyze the location of the bolt [ 14 , 15 ]. TAD and bolt sliding length were calculated using the ratio of the radiographic measurements [ 16 ]. Delayed union (4 months after fixation) and nonunion (6 months after fixation) were determined when the patient complained of persistent pain that did not improve gradually, and radiological improvement (callus formation and cortical bone bridging in three different directions on both anteroposterior and translateral views) was not observed. In these patients, three-dimensional computed tomography was performed to evaluate surgical failure and plan for revision surgery.

Surgical procedures and postoperative rehabilitation

Each surgeon at a different institution performed the surgeries. The patients were placed in a supine position on a fracture table with a conventional traction device, and fluoroscopy was used to aid the operation. A closed reduction technique with minimal skin incision (4–5 cm) was routinely performed; however, mini-open reduction with Hoffman retractor or Kelly forceps was necessary in several cases, which required accurate fracture reduction. Patients were trained to start protected weight bearing (30–50% of the individual body weight) using an assistive device (walker or double crutches) 1 or 2 days after the surgery. Patients were discharged from the hospital when independent ambulation with an orthosis was possible and the pain was controlled.

After discharge, the patients were regularly followed up at the outpatient clinic at 6, 12, and 36 weeks postoperatively. The outpatient schedule was adjusted according to the situation if any changes in the patient’s medical condition or surgery-related complications were observed or suspected. Patients were educated on partial weight bearing using an assistive device (walker or double crutches) starting 1 or 2 days postoperatively for up to 6 weeks. Following that, tolerable weight bearing was recommended for an additional 6 weeks when the clinical bone union was mainly observed.

Statistical analyses

Metric data are presented as the mean values with a 95% confidence interval (CI), and categorical variables are presented as absolute frequencies and percentage distributions. Student’s t-test or Mann–Whitney test was used for metric data, and chi-square test or Fisher’s exact test was used for categorical data. Univariate logistic regression analysis was used to assess the risk factors associated with revision surgery. All statistical analyses were performed using SPSS statistical software version 21 (IBM Co., Armonk, NY, USA), and a statistical significance was set at p  < 0.05.

Demographics of the patient

A total of 49 patients underwent surgical treatment using FNS during the study period; among them, 43 patients satisfied the inclusion criteria and were included in the analysis. The mean age of the patients was 62.1 (range: 57.7–66.5) years, and 25 (56%) patients were female. The mean follow-up duration of the enrolled patients was 12.5 months (range: 11.1–14.0). Additional patient demographic factors and detailed fracture classifications are presented in Table  1 . According to the Garden classification, 31 (72.1%) patients had stable fractures and 12 (27.9%) had unstable fractures. According to the Pauwels classification, 33 (46.7%) patients had a fracture angle of less than 50 degrees (Pauwels type 1 and 2), and 10 (23.3%) patients had a vertical shear fracture (Pauwels type 3).

Surgical factors

The mean duration from the time of injury to surgery was 1.6 (range: 1.1–2.1) days, and the mean operation time (incision to closure) was 47.9 (range: 43.8–51.9) minutes. Thirty-six (84%) patients underwent general anesthesia and seven (16%) underwent spinal anesthesia. We used a one-hole plate for all patients, except one. Bolt and anti-rotation screws were fixed at the same length in 32 (74.4%) patients, as initially recommended by the manufacturer. An anti-rotation screw 5 mm longer than the bolt was used in 11 (25.6%) patients to obtain stronger rotation resistance. When the bolt position was measured radiographically, the average TAD was 21.1 (range: 18.5–23.8) mm, and 39 (88.6%) patients satisfied the TAD of a bolt within 25 mm. The insertion position of the bolt in the femoral head was diagrammed using the Cleveland index (Fig.  1 ). The center-center and center-inferior positions were used in 19 (44.2%) and eight (23.3%) cases, respectively. Insertion of bolts in the anterior and superior positions was avoided.

Illustration showing the location of the bolt in the femoral head using a femoral neck system (Cleveland index)

No acute perioperative complications were observed during admission, except in two cases that showed short-term postoperative delirium. However, the delirium subsided within 3 days, and both patients were successfully discharged from the hospital after rehabilitation. No postoperative infections were noted during the follow-up period.

Complications

Four (9.1%) patients complained of residual pain in the affected hip at the final follow-up, and six (13.6%) presented with limping gaits. Regarding serious complications during follow-up, two cases of nonunion, one case of screw cut-out, and one case of post-traumatic osteoarthritis (due to osteonecrosis) were observed. All four patients later underwent arthroplasty due to complications (Fig.  2 ). The detailed data of the patients who experienced surgical failure are presented in Table  2 . When univariate regression analysis was performed to determine the risk factors for revision surgery, prior stroke history ( p  = 0.018, odds ratio [OR] = 18.5), longer TAD ( p  = 0.016, OR = 1.24), and longer bolt sliding length ( p  = 0.015, OR = 2.02) showed statistically significant results (Table  3 ). However, the multivariate analysis failed to derive statistically significant results for these variables.

Case of a 48-year-old female femoral neck fracture (FNF) patient with underlying moderate-grade Intellectual disability. ( A, E ) The patient was diagnosed with Garden type 4 FNF, and the bone quality was poor due to general medical conditions. ( B, F ) In Immediate postoperative x-rays, the position of the bolt was not central, and posterior angulation of the femoral head was noted. We inserted an additional screw to maintain the reduction status and to compensate for the rotation instability. ( C, G ) Fixation failure occurred 1.5 months after the operation. The bolt slid laterally to a maximum degree (20 mm), and the additional screw was also pulled out. ( D ) We performed hemiarthroplasty after implant removal at 1.6 months after the initial surgery

After the complete bone union was confirmed, five patients (mean age, 43.8 years; mean BMI, 23.1 kg/m 2 ; female:male ratio = 2:3) underwent additional surgery for implant removal, and the mean duration between initial surgery and implant removal was 17.6 (range: 14.7–18.9) months. During the implant removal procedure, distal locking screw stripping occurred in three patients. The implant could only be removed after forced metal plate cutting with a Hercules plate cutter or saw due to screw breakage, but implants were successfully removed from all the patients (Fig.  3 ).

Case of failure in implant removal of a 61-year-old female patient. ( A ) Due to a jammed locking screw, the plate had to be cut in half using a metal cutting saw (arrowheads) to get it removed from the patient. ( B ) Stripping of the internal hexagon in the head of a locking screw (arrow) occurred easily. ( C ) A gross photo was taken after complete implant removal. The screw and the remaining plate were easily pulled out together, and no screw shank fracture occurred

The overall failure rate of FNS in our study, with a mean follow-up of 12.5 months, was 9.3% (4/43 patients), and the results were similar or superior to those reported in previous studies (8.8–21%) [ 3 , 17 , 18 ]. Even in patients with Pauwels type 3 fracture, which is a relative contraindication to MCS fixation, complete bone union was achieved without major complications such as nonunion or angular deformation in most patients (Table  1 ). With regard to the favorable clinical outcome of FNS, Stoffel et al. [ 12 ] demonstrated the biomechanical strength of FNS compared to the existing MCS and DHS through a biomechanical study conducted in 2017. According to their study, it was confirmed that the FNS had a higher axial stiffness and better resistance to varus tilting and construct failure compared to MCS and DHS. A lower incidence of femoral neck and leg shortening was observed with FNS than that observed with MCS. Despite the minimally invasive mechanical properties, the biomechanical stiffness was similar to that of DHS. Recently, Moon et al. [ 13 ] reported that FNS can provide stronger structural stability than DHS in displaced basicervical neck fractures, which are considered rotationally unstable. Since our study included data on patients with all types of FNFs within a certain period for which osteosynthesis was planned, our data would be insufficient to statistically prove the clinical superiority of FNS in certain criteria or specific fracture patterns. However, based on the favorable clinical results, although limited, we believe that FNS can be used easily and safely for various types of FNFs.

The major postoperative complications included fracture nonunion, osteonecrosis, and screw cut-out. The nonunion rate reported in previous studies varied from 6 to 33%, and the rate in our study was much lower (4.7%, 2/44 patients) [ 19 , 20 , 21 ]. Similarly, post-traumatic osteonecrosis was reported in only one case (2.3%) during the follow-up period, and the result was also significantly lower than that reported in previous studies (4.5–11%) [ 3 , 22 ]. Most cases of fracture nonunion are diagnosed within 10–12 months, and given our mean follow-up period was 12.5 months, the favorable outcome might be attributable to the superior biomechanical stability of the FNS. In contrast, osteonecrosis may be detected even 2 years or more after trauma. Since we did not routinely use more invasive imaging modalities (such as magnetic resonance imaging and computed tomography) in addition to simple radiographs, the actual incidence of osteonecrosis might have been overlooked.

Although the clinical significance of surgical timing is controversial, multiple factors such as patients’ sex, BMI, age, fracture type, time elapsed from injury to surgery, and the quality of reduction are known to affect the outcomes and risk of reoperation [ 3 , 18 , 20 , 23 ]. Stassen et al. [ 18 ] reported that the patient’s age and presence of chronic lung disease were closely related to reoperation. Meanwhile, Davidson et al. [ 17 ] revealed that the patient’s age, surgeons’ seniority, and proper placement of FNS were closely associated with reoperation. Or results (Table  3 ) found that prior stroke history, TAD, and bolt sliding length were related to reoperation. It was confirmed that both case identification numbers 13 and 14, presented in Table  2 , had a prior history of stroke. Despite the history of stroke, the pre-injury ambulatory function of the patients was not severely limited (Koval’s grade 1 and 3), and the CCI score, which indicates the degree of patients’ morbidity, showed no difference compared to the group of patients that did not undergo revision surgery. Therefore, clinical significance of patients’ stroke history should be validated through further detailed analysis.

Radiologically measured TAD and bolt sliding length were also the major risk factors for reoperations. First, the TAD exceeded 25 mm in three out of four patients who underwent reoperation, and the TAD in the other case was 24.9 mm, which was also near the 25 mm value. Only a few studies have studied the relationship between FNS and TAD, and the results have been inconsistent. Jung et al. [ 24 ] reported that the length and position of the bolts play an important role in obtaining biomechanical stability in Pauwels type 3 fractures. However, Stassen et al. and Davidson et al. [ 17 , 18 ] did not observe a statistically significant association between TAD and revision surgery. Nevertheless, both authors emphasized that the precise central location of the bolt is of substantial importance in surgical prognosis. The bolt length is provided in 5 mm increments; therefore, some difficulties in finely adjusting the TAD exist. However, it is advisable to keep the TAD of the bolt within 25 mm and insert it in a position as central as possible. Meanwhile, bolt sliding is a process that occurs acutely during intraoperative inter-device compression and gradually during the natural healing process. The bolt allowed for sliding on the angular plate up to a maximum length of 20 mm. In our study, in the patients that underwent revision surgery, however, the degree of sliding was longer than the mean value and occurred very rapidly, especially in patients with bolt cut-out and nonunion due to reduction failure. Therefore, verifying the causal relationship may be limited despite a statistically significant correlation.

Finally, locking screw stripping occurred in 60% of the cases (3/5 cases) during implant removal after the complete bone union. With regard to the reason for hardware removal, three out of five patients complained of postoperative pain at the surgical site. When a physical examination was performed at an outpatient clinic, positive direct tenderness was confirmed by the physicians. In the remaining two cases, surgery was performed due to the patient’s personal request. One young business worker had a foreign body sensation and had inconvenience related to security check-out screening at overseas airports. The other was a professional bicyclist with concerns about future periprosthetic fractures. This has not been reported in previous studies and various mechanisms have been considered to explain this phenomenon.

The footprint of the plate in contact with the lateral femoral cortex, which secures angular stability, is small, and only one or two 5.0 titanium locking screws support the load. The excessive stress applied to the thread between the plate and screw head may result in mechanical locking or jamming of the threaded head of the screw, which may cause shear failure of the screw head. Another hypothesis is that the location of the locking screw insertion may also be related to this phenomenon. The distal locking screw secured the plate by obtaining a bicortical fixation at the level of the lesser trochanter of the proximal femur. In this area, the cortical bone is very thick, and the calcar femorale is located at the posteromedial junction of the femoral neck and diaphysis, making the actual working length of the thread much longer. Therefore, the torque used for screw removal exceeded the strength of the thread, and the thread pattern was destroyed during the removal process, making it impossible to release the thread.

Since implant removal is primarily considered in active young patients, the good bone quality and thick cortical bone in these patients may act as obstacles to implant removal. To avoid such unexpected difficulties during surgery, it is necessary to prepare any available devices, such as a reverse-threaded screw extractor set, diamond burr, or trephine drill. In some cases, a plate cutting tool may be helpful (Fig.  3 ). Meticulous attention must be paid not to spread metal debris that is inevitably generated during this undesired procedure. Moreover, notifying the patients before the surgery is critically important.

Our study is limited by its non-randomized design, lack of patient-reported outcome measures, and a relatively small number of participants. However, this study is significant because the main purpose of this study was to discuss the initial experience of using a new fixation device (FNS) and evaluate the radiological complications, such as nonunion, osteonecrosis, and screw cut-out. Furthermore, despite the small number of study participants, we identified several statistically significant factors related to surgical failure.

Based on our clinical experience with a mean follow-up of 12.5 months and other recent studies, we believe that the FNS can be safely and easily used for various types of FNFs. However, future large-scale randomized controlled studies are required to validate mid- to long-term clinical outcomes between DHS and/or MCS with FNS, as well as post-market surveillance regarding implant failure and screw stripping.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author, as a supplementary file, on reasonable request.

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Department of Orthopaedic Surgery, Dongguk University Ilsan Hospital, Goyang-si, Republic of Korea

Jae Youn Yoon

Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam-si, Republic of Korea

Seong-Eun Byun

Department of Orthopaedic Surgery, Daegu Fatima Hospital, 99, Ayang-ro, Dong-gu, Daegu, Republic of Korea

Young-Ho Cho

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JYY is responsible for writing the entire manuscript, organizing the data, and statistical analysis. SEB is also responsible for collecting patients’ data and preparing figures and tables. YHC is responsible for designing the concept of the study and investigating references as the corresponding author. All authors read and approved the final manuscript.

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This retrospective study was conducted under the approval of the Institutional Review Board of the Dongguk University Ilsan Hospital (IRB No.: DUIH 2022-10-004), and all methods were performed in accordance with the relevant guidelines and regulations. Due the retrospective study design, the need for individual informed consent was waived by the institutional review board from the Dongguk University Ilsan Hospital.

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Yoon, J.Y., Byun, SE. & Cho, YH. Fixation of femoral neck fracture with femoral neck system: a retrospective cohort study of 43 patients. BMC Musculoskelet Disord 25 , 8 (2024). https://doi.org/10.1186/s12891-023-07113-2

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DOI : https://doi.org/10.1186/s12891-023-07113-2

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• Hip fracture
• Femur neck fracture
• Femoral neck system
• Internal fixation
• Complication

BMC Musculoskeletal Disorders

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Citation, DOI, disclosures and case data

At the time the case was submitted for publication Calum Worsley had no financial relationships to ineligible companies to disclose.

Presentation

Right hip pain

Patient Data

On the frontal projection there is subtle cortical irregularity at the junction of the right femoral head and neck.

On the lateral projection, the head is off center in relation to the neck , confirming the presence of a fracture.

Case Discussion

The patient underwent successful right hip hemiarthroplasty.

If frontal imaging of the hip is equivocal for the presence of a fracture, lateral imaging can be useful, looking in particular for the head to be centered on the neck.

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The impact of COVID-19 on morbidity and mortality in neck of femur fracture patients

A prospective case-control cohort study.

• Alex E. Ward
• Daniel Tadross
• Fiona Wells
• Lawrence Majkowski
• Umna Naveed
• Rathan Jeyapalan
• David G. Partridge
• Suvira Madan
• Chris M. Blundell

Within the UK, around 70,000 patients suffer neck of femur (NOF) fractures annually. Patients presenting with this injury are often frail, leading to increased morbidity and a 30-day mortality rate of 6.1%. COVID-19 infection has a broad spectrum of clinical presentations with the elderly, and those with pre-existing comorbidities are at a higher risk of severe respiratory compromise and death. Further increased risk has been observed in the postoperative period. The aim of this study was to assess the impact of COVID-19 infection on the complication and mortality rates of NOF fracture patients.

All NOF fracture patients presenting between March 2020 and May 2020 were included. Patients were divided into two subgroup: those with or without clinical and/or laboratory diagnosis of COVID-19. Data were collected on patient demographics, pattern of injury, complications, length of stay, and mortality.

Overall, 132 patients were included. Of these, 34.8% (n = 46) were diagnosed with COVID-19. Bacterial pneumonia was observed at a significantly higher rate in those patients with COVID-19 (56.5% vs 15.1%; p =< 0.000). Non respiratory complications such as acute kidney injury (30.4% vs 9.3%; p =0.002) and urinary tract infection (10.9% vs 3.5%; p =0.126) were also more common in those patients with COVID-19. Length of stay was increased by a median of 21.5 days in patients diagnosed with COVID-19 (p < 0.000). 30-day mortality was significantly higher in patients with COVID-19 (37.0%) when compared to those without (10.5%; p <0.000).

This study has shown that patients with a neck of femur fracture have a high rate of mortality and complications such as bacterial pneumonia and acute kidney injury when diagnosed with COVID-19 within the perioperative period. We have demonstrated the high risk of in hospital transmission of COVID-19 and the association between the infection and an increased length of stay for the patients affected.

Cite this article: Bone Joint Open 2020;1-11:669–675.

Take home message

COVID-19-positive hip fracture patients have a significantly higher risk of mortality than their negative counterparts.

The incidence of superadded bacterial pneumonia and acute kidney injury is high in hip fracture patients diagnosed with COVID-19.

There is a potentially high risk of in hospital transmission of COVID-19.

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as COVID-19, is a novel coronavirus first identified in December 2019 and has a broad spectrum of clinical presentations. 1 Patients who are elderly, immunocompromised and those with pre-existing comorbidities are at a higher risk of severe complications and death from COVID-19 particularly in the postoperative period. 2

Hip fractures are often a manifestation of increasing frailty and patients usually have multiple medical conditions. They have a significant 30 day mortality of around 10% and a mortality at one year at around 33%. 3 Due to the complex needs of these patients and the significant associated mortality and morbidity, innovations have been devised to care for hip fracture patients. This includes multidisciplinary pathways and the best practice tariff that describe best standards of care. These include; surgery within 36 hours, joint orthopaedic/geriatric care, as well as bone protection and falls assessments. 4

As a result of their frailty, hip fracture patients are at particularly high risk of severe complications if they contract COVID-19. The majority of patients admitted with hip fractures are not considered candidates for level two or three care due to frailty, and so for many of these patients the scope for intervention where there is respiratory compromise is more limited. Therefore, when exposed to a virus that can cause severe hypoxaemia there is a very real anticipated risk to life. 5

This study collates is the largest dataset of hip fracture patients in one centre during the COVID-19 pandemic in the UK; collating perioperative clinical information on hip fracture patients and comparing postoperative outcomes and complications in those with and without COVID-19. The primary aim of the study was to identify the effect of COVID-19 on postoperative mortality. Further to this, the study sought to quantify the rates of complications, in particular those causing respiratory compromise.

Case identification

Cases were identified by contacting the hospital information services team who provided retrospective lists of patients under the care of the orthopaedic team who had tested positive by polymerase chain reaction (PCR) for COVID-19 on a rolling weekly basis. The data were collected in a period between 1 March 2020 and 31 May 2020. This was then cross-referenced with departmental lists of patients with a diagnosis of neck of femur fracture. Patients were separated into two groups: proven positive COVID-19 swabs or clinically suspected COVID-19, and patients with a negative swab and no clinical suspicion of COVID-19. Patients were included as positive if they were diagnosed between seven days pre-admission and 30 days post-admission. Patients who were negative on PCR testing but had clinical and radiological features of COVID-19 were identified by the orthogeriatric team. Definitions of hospital versus community transmitted infection are seen in Figure 1 . 6

Definitions of community versus hospital-acquired infection. 6

The study data were collected following approval from the clinical effectiveness unit based within Sheffield Teaching Hospitals (References STH21372 and 9921).

The primary outcome for this study was mortality at 30 days post-admission. Secondary outcomes to be assessed include rates of respiratory complications, including bacterial pneumonia, other complications, reintervention, and also the impact of infection on patient length of stay.

Data collection

Data were collected on patient demographics, comorbidities and social history. Further information was collected about any recent admissions, timing of symptoms and management of fracture.

Statistical analysis

Patient demographics were compared using simple statistical analysis. The incidence of outcomes such as mortality and complications were compared using chi squared or Fisher’s exact test where appropriate. Continuous data was compared using Mann-Whitney U test to be resilient to outliers. Significance was set at p < 0.05.

Patient demographics

Over the study period, 132 patients with neck of femur fracture were admitted. In all, 46 patients (34.8%) had a clinical diagnosis of COVID-19, with the majority being confirmed on laboratory testing (n = 41, 89.1%). The mean age of patients identified was 82.1 years (49 to 100), and 27.3% (n = 36) of patients were male ( Table I ).

Patient demographics.

Mann-Whitney U test.

Chi squared.

Patient comorbidities and social history

The most common comorbidity overall was ischaemic heart disease which was present in 64.4% of all patients and was observed at a significantly higher rate in the COVID-19 positive subgroup (p= 0.0003) ( Table I ). Similar rates of diabetes and chronic kidney disease were observed between the two groups with non-significantly higher rates of diagnoses of pulmonary disease and active cancer being observed in the COVID-19 group. The majority of patients were from their own home (75%). For those patients admitted from care there was no significant difference between the two groups, with 28% of COVID-19-positive patients coming from care/nursing homes in comparison to 21% of COVID-19-negative patients (p = 0.267).

On admission to hospital, the patient’s Clinical Frailty score (CFS) and Nottingham Hip Fracture score (NHFS) scores were calculated. Of the COVID-19-positive patients, a significantly higher proportion of patients had higher CFS than their negative COVID-19 counterparts (p= 0.009). The range of NHFS were similar between the two groups (p = 0.957).

Injury pattern and fracture management

Within both subgroups there were a similar proportion of patients with intertrochanteric fractures with more variation in the fracture anatomy seen in extracapsular injuries ( Table II ). The majority of patients were managed operatively with five patients (3.8%) being treated conservatively due to being unfit for surgery, one due to severity of COVID-19 infection on admission. Full details of operation types are seen in Table III . Of the patients fit enough for operative management, 81.1% had their operation within 36 hours of admission (n = 103). Of the remaining 24 patients, ten required medical optimization/reversal of anticoagulants, nine needed to wait for theatre space, three required further imaging/investigations and two waited for an appropriate surgeon to undergo a total hip arthroplasty. Of the patients who were COVID-19-negative, 22% (n = 18) had a delay to theatre in comparison to 13.3% (n = 6) of those who were positive (p = 0.263).

Fracture pattern (p = 0.208).

Fracture management (p = 0.114).

In the postoperative period, one COVID-19-negative patient had a planned admission to the high dependency unit (1.2%). They had a CFS of 7 and an ASA of 4, with increasing oxygen demands due to pre-existing lung disease. This decision was made proactively via multi-disciplinary discussion involving the orthopaedic, orthogeriatric and anaesthetic teams.

Timing of diagnosis of COVID-19

Nine patients had symptoms of COVID-19 upon admission to hospital (19.6%). The timing of diagnosis for the majority of patients (n = 28; 60.8%) suggested in hospital transmission due to current length of stay or recent prior admission ( Figure 1 and Table IV ).

Hospital versus community transmission.

30-day mortality

In all, 37% (n = 17) of COVID-19 positive patients died within 30 days of sustaining a hip fracture compared to 10.5% (n = 9) of COVID-19 negative patients (chi squared; p <0.000). Of the COVID-19-positive patients who passed away, all but three of the patients had COVID-19 listed on their death certificate as a contributing factor (n = 14; 30.4%). Overall, 26 out of 132 patients (19.7%) died within 30 days of their injury.

Pulmonary complications

Within 30 days after operation, five patients developed pulmonary embolism (3.8%). Two of these patients had a diagnosis of COVID-19 as opposed to three who did not (chi squared p = 1.000). COVID-19 patients, however, demonstrated significantly increased rates of bacterial pneumonia treated with antibiotics according to trust protocol (56.5% vs 15.1%; chi squared p = < 0.00001) and acute respiratory distress syndrome (8.7% vs 0%; Fishers exact test p = 0.014) compared to patients who did not have COVID-19.

Other complications

Overall, 16.7% of patients with a hip fracture developed an acute kidney injury (AKI). 30.4% of CV19 patients developed an AKI, as opposed to 9.3% of non-COVID-19 patients who developed an AKI (chi squared p = 0.002). A single patient had a cerebrovascular accident and another required surgical reintervention in the COVID-19 group. No non-COVID-19 patients experienced these complications ( Table V ). Overall, COVID-19 patients had a rate of 87% for developing any complication, compared to 33.7% in non-COVID-19 patients (chi squared p < 0.01).

Complication and mortality rates.

Fishers exact test.

Length of stay

Patients with a diagnosis of COVID-19 had an extended median length of stay of 21.5 days (1 to 75) compared to a median of ten days (2 to 67) in patients who were not diagnosed with COVID-19 (Mann-Whitney U test, p < 0.000).

COVID-19 infection in hip fracture patients is associated with a higher 30-day mortality compared to COVID-19-negative counterparts. Our study has shown that over a third of patients (37%, n = 17) with a COVID-19-positive diagnosis died within 30 days of their admission to hospital. Our findings of increased 30-day mortality in COVID-19-positive hip fracture patients are consistent with other studies in the UK and USA showing early mortality rates between 30% to 56%. 7 - 9 Within this study, however, high rates of diagnosis of IHD were observed in the COVID-19-positive subgroup (p= 0.0003). This has not been observed in previously published studies and may have contributed to the higher rate of mortality in those infected with COVID-19. 10

For the COVID-19-positive patients included in this study, there was a significantly higher rate of bacterial pneumonia and/or respiratory distress in comparison to their COVID-19-negative counterparts (p= 0.0004). The 56.5% rate seen within this cohort is similar to what has been observed within an international pan-surgical study, where 512.% (n = 577) of patients suffered with bacterial pneumonia (diagnosed clinically and treated according to local microbiology protocols) and/or acute respiratory distress within the perioperative period. 2 However, within the hip fracture specific literature, these high rates have not been previously observed with studies demonstrating comparable rates to 2019 11 and much lower rates of 13.4%. 7

With regards to non-pulmonary complications, there was a significantly increased rate of perioperative AKI for patients who were diagnosed as COVID-19-positive (p = 0.002). It has been documented within the literature that the infection has an impact on renal function with more than 40% of patients having abnormal proteinuria at the time of being diagnosed as COVID-19 positive. This condition has been associated with increased risk of inpatient mortality with more elderly, male and those patients with comorbidities being at a higher risk of death. 11 Careful fluid input and output monitoring has been advocated within guidance produced by the National Institute of Clinical Excellence (NICE) 12 to reduce the risk of this complication; however, the pathophysiology is not yet fully understood. 13

The extended patient length of stay within this study may be due to the increased morbidity associated with the complications of COVID-19. This seems to be in concordance with current literature; a study by Kayani et al 7 demonstrated an extended length of stay in COVID-19 patients, with inpatient admissions being double that of COVID-19-negative patients. In this study, another factor affecting the length of stay for care and nursing home patients were ever-evolving changes in criteria for patient flow to intermediate community rehabilitation services. Due to the emerging evidence on COVID-19 infection, the criteria for patients to successfully step down to a community rehabilitation bed kept constantly changing, including the introduction of criteria including a wait of 14 days in hospital. As well as the change in guidelines, the increased incidence of co-morbidities like IHD and increased frailty (CFS) within the COVID-19-positive subgroup may have led patients to require a longer length of stay and therefore predisposed them to nosocomial COVID-19. This is an area which requires further research.

Within this study, 17.4% (n = 8) of hip fracture patients were admitted with symptoms of COVID-19 and became symptomatic within two days with no prior hospital admission. This rate is lower than what has been previously observed, with 26% of patients having been symptomatic in a national multicentre study. 14 One challenge of COVID-19, is the long incubation periods which some patients experience, being much longer than that of influenza (1.4 days). 15 Typically, the incubation period of COVID-19 is five to six days but has been reported to be as long as 14 to 19 days. 16 , 17 This has the potential to lead to some patients becoming symptomatic during their inpatient stay, despite being infected prior to admission. This long incubation period, in combination with the potential for spread from asymptomatic or paucisymptomatic patients, also makes COVID-19 a potent nosocomial threat, especially in an environment containing a large proportion of elderly or comorbid individuals. In this study, many patients appear to have contracted COVID-19 within the hospital environment, despite adoption of cohort bays and wards 18 and staff personal protective equipment being used in line with UK government guidance. 19 The multidisciplinary team (consisting of orthopaedics, orthogeriatrics, microbiology, infection control, and senior nursing staff) also proactively identified the risks of nosocomial transmission, reporting weekly figures and adjusting cohort ward and bay use accordingly.

Within our cohort of patients, 80.3% (n = 103) of patients were operated on within 36 hours who were treated operatively which is comparable to other studies. 14 , 20 Five patients in our cohort were treated non-operatively; four patients were not fit for an anaesthetic secondary to respiratory compromise (one patient was COVID-19-positive) and one patient being bed bound and comfortable. During COVID-19, the theatre capacity within our establishment changed significantly with initially only having one theatre list per day but demand resulted in increasing this capacity during the latter stages of COVID-19 to a maximum of three trauma lists on some days due to hip fracture care and other general orthopaedic trauma. There were 24 patients who did not receive operative intervention within 36 hours (nine due to lack of time; four patients required 48 hours following anticoagulation; two patients awaiting MRI; two patients awaiting surgery for total hip arthroplasty; six patients required further optimization medically; one awaiting COVID-19 swab preoperatively). Our COVID-19 swab precautions changed throughout, with patients initially having to wait for COVID-19 swab results prior to operative treatment, but this was only during the early stages of COVID-19. Swab results did not result in delays in the latter stages of COVID-19 due to increased access to testing.

It should be considered when analyzing the data that it was collected from clinical notes and electronic patient systems. The accuracy of data collected was based on what had been documented by the medical team, but as they are used to direct clinical practice it can be expected that they are at an established standard. COVID-19 PCR sensitivity can vary based on specimen quality and test performed. 21 During the study period, a dual target assay with high sensitivity and specificity was used at Sheffield Teaching Hospitals. 22 Due to an international shortage of extraction reagents, extraction-free PCR was run on a large proportion of samples from mid-April, with an approximate 5% reduction in diagnostic sensitivity as a consequence.

This study has shown that patients with a neck of femur fracture have a high rate of mortality and complications such as bacterial pneumonia and AKI when diagnosed with COVID- 19 within the perioperative period. We have demonstrated the high risk of in hospital transmission of COVID-19 and the association between the infection and an increased length of stay for the patients affected.

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Author contributions

A. E. Ward: Undertook statistical analysis, Wrote and reviewed the manuscript.

D. Tadross: Carried out statistical analysis, Wrote and reviewed the manuscript.

F. Wells: Carried out statistical analysis, Wrote and reviewed the manuscript.

L. Majkowski: Wrote and reviewed the manuscript.

U. Naveed: Wrote and reviewed the manuscript.

R. Jeyapalan: Wrote and reviewed the manuscript.

D. G. Partridge: Wrote and reviewed the manuscript.

S. Madan: Wrote and reviewed the manuscript.

C. M. Blundell: Wrote and reviewed the manuscript.

Funding statement

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.

Acknowledgements

The authors would like to thank Cristina Lagaron-Manso for her assistance with data collection.

Follow A. E. Ward @Ward89A

© 2020 Author(s) et al . This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/ .

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1 No.11 | Pages 669 - 675

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https://doi.org/10.1302/2633-1462.111.BJO-2020-0141.R1

Orthopaedic Registrar

Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

[email protected]

Foundation Doctor

Core Surgical Trainee

Consultant Microbiologist

Consultant Orthogeriatrician

Consultant Orthopaedic Surgeon

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Prehabilitation in a Periprosthetic Fracture of the Femur: A Case Report

Affiliation.

• 1 Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND.
• PMID: 38595905
• PMCID: PMC11002703
• DOI: 10.7759/cureus.55872

Periprosthetic fractures (PPF) are related to orthopaedic implants like internal fixators, replacement devices, etc. In this case report, we discussed a 55-year-old male patient who came to our tertiary care hospital with complaints of pain and swelling over the left hip for six months. After radiological investigations, he was diagnosed with a left PPF of the femur with posterior dislocation. He was referred to the musculoskeletal physiotherapy department for in-patient rehabilitation before surgery. He received strengthening exercises for lower limb, back, and abdominal muscles, pain management, gait training, etc. for two weeks before his decided surgery date. The patient showed improved strength and maintained his range. There were an improved Visual Analogue Scale (VAS) score and a Lower Extremity Functional Scale (LEFS) score, which signified a reduction in pain and improved functional independence due to enhanced lower limb function, respectively.

Keywords: case report; periprosthetic fracture; physiotherapy; pre-operative physiotherapy; pre-operative rehabilitation; prehabilitation; rehabilitation; treatment.

Copyright © 2024, Bhoge et al.

Publication types

• Case Reports

• Research article
• Open access
• Published: 10 April 2024

Application direct anterior approach in pediatric femoral head and neck lesions

• Jian Zheng 1 , 2 , 5 ,
• Yanting Zhang 2 , 5 &
• Guoxin Nan 1 , 3 , 4  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  233 ( 2024 ) Cite this article

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Metrics details

Femoral neck is one of the high-risk areas for benign tumors and tumor-like lesions. Small range of lesions may also lead to pathological fracture, femoral head necrosis and other serious problems.

To investigate a new minimally invasive surgical approach to resect femoral head and neck lesions in children.

Patients and methods

Retrospective study of 20 patients with femoral neck and femoral head lesions from February 2019 to March 2023 in our hospital. Among them, 14 were boys and 6 were girls, 17 were femoral neck lesions and 3 were femoral head lesions. The age of the patients ranged from 3.2 to 12.6 years, with a mean of 7.1 years. The patients were divided into group A and group B according to different surgical approaches; group A used the Smith-Peterson approach, Watson-Jones approach or surgical dislocation approach and group B used the DAA. Intra-operatively, incision length, operative time and blood loss were recorded in both groups. Group A consisted of 1 femoral head lesion and 8 femoral neck lesions, including 5 cases of bone cyst and 4 cases of eosinophilic granuloma. Group B consisted of 2 femoral head lesion and 9 femoral neck lesions. A total of 11 patients with different types of disease were included in group B, including bone cysts (3 cases), aneurysmal bone cysts (1 case), eosinophilic granulomas (6 cases), Kaposi's sarcoma (1 case).

The two groups of patients differed in terms of incision length ( P  < 0.05), operative blood loss ( P  < 0.05) and operative time ( P  < 0.05). At 6–48 months post-operatively, there were no significant differences in function and all patients had good hip function.

The direct anterior approach is effective for resection of paediatric femoral head and neck lesions. It provides clear exposure of the surgical site, minimal trauma and does not compromise the integrity of the anterior musculature.

Level of evidence : III.

Introduction

The femoral neck is one of the high-risk areas for benign tumors and tumor-like lesions. Due to its anatomical and biomechanical characteristics, even small-scale lesions can lead to pathological fractures, aseptic necrosis of the femoral head, and other serious problems [ 1 ]. Localized lesions commonly found in the femoral neck include eosinophilic granuloma, bone cysts, fibrous dysplasia, osteoid osteoma, herniation pits of the femoral neck, and chronic osteomyelitis [ 2 ]. For most of the benign lesions, conservative treatment can be adopted. However, for actively growing lesions that have the potential to erode adjacent bone and cause pathological fractures, surgical treatment is necessary [ 3 ].

For different lesions, there are different approaches, such as the Smith-Peterson approach and the Watson-Jones approach, and each approach has disadvantages and advantages [ 4 ]. If it is a lesion of the femoral head, the hip capsule should be opened, and the Smith-Peterson approach is preferred. This approach should expose a large incision and needs to cut the rectus femoris muscle, resulting in greater trauma, but the advantage is that the surgical field is widely exposed [ 5 , 6 ]. If the lesion is in the femoral neck, the traditional approach is adopted by anterolateral Watson-Jones approach, but this approach is hard to expose the medial part of the femoral neck. If the lesion is in the medial part of the femoral neck, surgical hip dislocation is required, and the greater trochanter needs osteotomy. After the lesion is removed, the greater trochanter is reduced and fixed by screws. A secondary operation was required to remove the screw [ 7 , 8 ]. Additionally, another known disadvantage of the Watson-Jones approach is the potential for superior gluteal nerve injury, abductor muscle injury, and subsequent Trendelenburg gait [ 9 ].

The direct anterior approach (DAA) was described by Carl Hunter in 1871 [ 10 ]. Thus reducing the risk of hip dislocation postoperatively [ 11 ]. The DAA does not require the severing of any muscles and tendons, preserves muscle and bone attachment, avoids tearing of muscle tissue, and still exposes the femoral neck and femoral head [ 12 ]. The DAA is similar to the Smith-Peterson approach in that it allows for a supine surgical position, which improves anesthesia and lung ventilation for the patient [ 13 ]. In recent years, with the popularity of minimal invasive technology concept, the DAA has been widely used in total hip arthroplasty (THA) [ 14 ]. However, there are not many applications in the field of pediatric orthopedics. The purpose of this study was to report our experience with the DAA in the removal of lesions in the femoral head and femoral neck in children and to evaluate the effectiveness of this approach.

A retrospective study of relevant treatments performed between March 2019 and March 2023 at our hospital. The inclusion criteria: (1) the age of onset was not more than 14 years old; (2) no pathological fracture; (3) The lesions were located between the base of the femoral neck and the head. Finally, 20 children met these criteria, and their data were screened for inclusion in this study. Among these children, there were 14 male children and 6 female children, femoral neck lesions appeared in 17 children, and femoral head lesions appeared in 3 children. The children ranged in age from 3.2 to 12.6 years, with an average age of 6.7 years. Before surgery, the patient was examined and diagnosed in detail using multiple imaging techniques such as X-ray, CT and MRI (Fig.  1 ). The surgical approach is divided into two groups, A and B. Group A includes the Smith-Peterson approach, the Watson-Jones approach, or the surgical hip dislocation approach. Group B includes direct anterior approach (DAA). A comparison was made between the two groups in terms of incision length, surgical time, blood loss, and post-operative functional differences. In order to ensure the rigour and reliability of the research, our research has been strictly approved by the Ethics Committee of our Institute.

Imaging findings of femoral neck lesions: CT ( A ) and X-ray ( B ) findings of eosinophilic granuloma

Surgical technique

All operations were performed by the same experienced surgeon. The surgeries were conducted under general anesthesia, and the children were positioned in a supine position. The DAA follows the neurovascular and muscular plane, especially the anatomical gap between the tensor fascia lata and the sartorius muscles [ 15 ]. It provides access to the hip joint by entering the superficial interval between the sartorius muscle (innervated by the femoral nerve) and the tensor fasciae latae (innervated by the superior gluteal nerve), and the deep interval between the rectus femoris (innervated by the femoral nerve) and gluteus medius (innervated by the superior gluteal nerve) [ 16 ]. However, the DAA does not require widening the interneural plane by removing the origin of the tensor fascia lata muscle on the iliac bone.

The grid localization method (as described in a previously published article [ 17 ]) was used to position and visualize the lesion through fluoroscopy with a C-arm, and the location of the lesion was described (Fig.  2 ). The surgical approach to DAA is described as follows. The skin and subcutaneous tissue were cut longitude-wise with the focal point as the centre. The incision length was about 3–4 cm, and then the sartorial muscle and the tensor fascia lata were bluntly separated to expose the interval. Entering along the interval reveals the deep muscles of the rectus femoris and gluteus medius. If it is necessary to further expose the femoral head, the hip joint capsule should be opened, the proximal end of the blunt free femoris rectus muscle should be lateral, and the proximal end of the femoris rectus muscle should be pulled inward to reveal the anterior part of the hip capsule, separate the fat pad in front of the joint capsule, and finally cut the joint capsule to expose the femoral head. If the femoral neck position needs to be exposed, opening the joint capsule is generally unnecessary. Patients treated through the surgical hip dislocation approach require intraoperative osteotomy at the greater trochanter. Following removal of the lesion, fixation with screws is necessary.

The grid localization method was used to locate the lesions: Grid positioning under X-ray ( A ) and body surface marking ( B ）

During the surgery, variables such as incision length, time from incision to lesion exposure, time for lesion removal, total operative time after lesion removal, and estimated blood loss until exposure completion were recorded. After the lesion was completely removed, thorough irrigation with normal saline was performed, followed by routine bone grafting. All pathological tissues were sent for diagnostic examination only. In order to prevent fracture, the hip was routinely immobilized with hip spica casting or orthotic devices for 6 weeks.

All cases in groups A and B were discharged from the hospital after recovery from surgery and all patients were followed up for a period of 6–48 months. All patients were assessed for hip function using the Harris Hip Score.

Statistical analysis

All data are presented in box and violin plots and all data points and interquartile intervals are shown. The whiskers indicated the minimum and maximum values.Statistical significance was determined using unpaired Student’s t-test performed with Prism 8 software (GraphPad Software, San Diego, California, USA). A value of P  < 0.05 was considered statistically significant. Harris Hip Score were normally distributed, and homogeneity of variance is expressed as mean ± standard deviation (SD).

Group A had 9 cases, and Group B had 10 cases (Table  1 ). There was no significant difference in age between the two groups ( P  = 0.6614). In Group A, there was 1 case of femoral head lesion and 8 cases of femoral neck lesions, including 5 cases of bone cyst and 4 cases of eosinophilic granuloma. In Group B, there was 2 case of femoral head lesion and 8 cases of femoral neck lesions. In group B,10 patients with different types of disease, including bone cysts (3 patients), aneurysmal bone cyst (1 case), eosinophilic granuloma (6 patients) were included in this study. The aneurysmal bone cyst cases in Group B had excessive differences in haemorrhage compared to the whole and have been removed from the comparison of haemorrhage. It can be seen that patients with different types of diseases.There were differences between the two groups in terms of incision length ( P  < 0.05) (Fig.  3 ), surgical blood loss ( P  < 0.05), and surgical time ( P  < 0.05) (Fig.  4 ). Patients in both groups A and B were followed up for 6–48 months. Patients were evaluated for Harris hip function and compared 6 months after surgery. Following surgical debridement of the lesion, both group A (84.889 ± 3.689) and group B (84.5 ± 3.596) demonstrated good recovery of hip function despite utilizing different surgical approaches. However, the difference in functional scores between the two groups did not reach statistical significance ( P  > 0.05). There was no significant difference in the Harris Hip Scores of the children in groups A and B, which indicates that the children had good hip function, freedom of movement and normal gait (Table  2 ).

Exposure of the lesion through the DAA ( A ) and the length of the incision ( B )

Comparison of age of patients, length of incision,amount of bleeding and time of operation between Group A and Group B

The femoral head is located in the hip joint, and the hip capsule must be opened intraoperatively to remove the femoral head lesion [ 13 ]. For most pediatric surgeons, they usually choose the Simith-Peterson approach, which allows clear exposure of the surgical area [ 18 ], but the approach involves a larger incision and often requires severing the rectus femoris muscle, which takes a longer time to suture. In addition, due to postoperative damage to the rectus femoris muscle, the patient needs to wait for the muscle to fully heal before appropriate joint activity can be initiated. If a femoral neck fracture or lesion is encountered, the Watson-Jones approach is usually used. This approach, which is entered from the lateral side of the hip, can easily treat the basal lesions of the femoral neck with relatively good results [ 8 ]. However, if there is a lesion on the inner side of the femoral neck, a major trochanteric osteotomy is required. After lesion removal, the major trochanter needs to be fixed with screws, which involves a larger trauma and may require secondary surgery for removal of the internal fixation.

The DAA isfirst described by German surgeon Carl Hueter in the nineteenth century and published in Der Grundriss der Chirurgie (The Compendium of Surgery). This surgical approach is also known as the "Hueter approach" [ 4 ]. It was not until 1917, after a report by Smith-Peterson, that the surgical approach became widely known. In 1950, French doctor Judet also reported hip replacement by anterior approach [ 19 ], but with the emergence of new artificial joints, this approach gradually decreases and was only occasionally used in the treatment of hip infection in children [ 4 ]. In 1980, Light and Keggi reported the experience of 104 patients of modern total hip arthroplasty using the anterior approach. This surgical approach has the advantages of the short operation time, less bleeding, no intraoperative complications, short hospitalization time, fast functional recovery, etc., which has aroused the attention of the medical community again. Become one of the surgical approaches for Total Hip Arthroplasty (THA) [ 20 ]. But what really brought it to the forefront of clinicians' discussions was the popularity of minimally invasive surgery in recent decades.

Compared with Simth-Peterson and Watson-Jones, the DAA is not familiar to pediatric surgeons and has been rarely reported in the field of pediatric orthopedics. In fact, this approach has the advantages of less trauma, easy exposure and shorter operation time, which is more suitable for children. In addition, the DAA also relatively "protects" the vessels where the base of the femoral neck is located, which can effectively avoid vascular damage [ 21 , 22 ]. If the lesion removal in this area causes excessive trauma and disrupts the blood supply, it may increase the risk of complications such as avascular necrosis of the femoral head. Therefore, minimally invasive surgery is the key to avoiding this serious complication. In contrast, the Watson-Jones or Simith-Peterson approaches often result in large surgical trauma and a relatively higher risk of complications. Surgical dislocation approaches involve even greater trauma and may require secondary surgeries.

The DAA involves dissecting through the superficial interval between the sartorius muscle and the tensor fasciae latae, as well as the deep interval between the rectus femoris and gluteus medius muscles. This approach allows for good exposure of the hip joint while avoiding the “extensive dissection” required by other approaches (15). Thus, there is minimal bleeding during hip joint exposure, with an average blood loss of only 23.9 mL in our case series. In addition, the DAA can expose the femoral neck and femoral head without cutting any muscles and tendons and is a scheme to expose the surgical field solely through the space between muscles, basically without damaging or affecting the muscles of the lower extremities. In rare patients, during the final articulation of the hip joint, it is necessary to cut off part of the inverted head of the rectus femoris in order to facilitate the articulation of the hip joint (in most patients, it is not necessary to cut off). The anatomical advantages of this surgical approach allow for rapid recovery of muscle and joint function after surgery. In our case series,unless there were a concern about the fracture, it would be rare for patients to need to remain in bed for rest. Because this approach can directly expose the hip joint, the exposed incision is small and there is no muscle disconnection, so the incision suture is fast. The average suture time in this group is 40.3 min, which relatively shortens the entire operation time. However, the amount of bleeding can vary significantly among different diseases, and therefore the bleeding volume between patients may not be directly comparable. For example, aneurysmal bone cyst bleeding is more, and Kapo's sarcoma bleeding is also a lot, but simple bone cyst bleeding will be less. Therefore, the characteristics of different diseases need to be taken into account when assessing and comparing the amount of blood loss.

This retrospective study has limitations due to its limited sample size. Specifically, the low incidence of femoral head ischaemic necrosis does not completely demonstrate the benefits of the access route, which requires verification in a larger study. Additionally, alternative approaches to removing femoral neck lesions exist, but we have focused solely on the method used in this study.

The DDA approach has a broad application in the treatment of childhood diseases. It is favored for its advantages of less trauma, quick recovery, short hospital stay, short operation time, and low complications, following the patient to start moving early.

Availability of data and materials

All data in the study were obtained in good faith and the datasets used and analysed during the current study are available from the corresponding author upon reasonable request.

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Jian Zheng & Yanting Zhang

Dongguan Eighth People’s Hospital, Dongguan, China

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Authors’ roles: GN conceived and designed the study. GN and JZ drafted the manuscript. JZ and YZ analyzed the data. All the authors read and approved the final manuscript.

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Zheng, J., Zhang, Y. & Nan, G. Application direct anterior approach in pediatric femoral head and neck lesions. J Orthop Surg Res 19 , 233 (2024). https://doi.org/10.1186/s13018-024-04721-z

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• 2 Department of Sports Medicine, The Affiliated Hospital of Qingdao University, Shandong, China
• 3 Department of Operation Room, The Affiliated Hospital of Qingdao University, Shandong, China

Phosphaturic mesenchymal tumors (PMT) are rare and distinctive tumors that typically result in paraneoplastic syndrome known as tumor-induced osteomalacia (TIO). We report a case of bilateral osteoporotic femoral neck fracture caused by PMT. PMT was surgically resected, followed by sequential treatment of bilateral femoral neck fractures with total hip arthroplasty (THA). A 49-year-old perimenopausal woman experienced consistent bone pain with limb weakness persisting for over 2 years. Initially, she was diagnosed with early osteonecrosis of the femoral head and received nonsurgical treatment. However, from 2020 to 2022, her pain extended to the bilateral shoulders and knees with increased intensity. She had no positive family history or any other genetic diseases, and her menstrual cycles were regular. Physical examination revealed tenderness at the midpoints of the bilateral groin and restricted bilateral hip range of motion, with grade 3/5 muscle strength in both lower extremities. Laboratory findings revealed moderate anemia (hemoglobin 66 g/L), leukopenia (2.70 × 10 9 /L), neutropenia (1.28 × 10 9 /L), hypophosphatemia (0.36 mmol/L), high alkaline phosphatase activity (308.00 U/L), and normal serum calcium (2.22 mmol/L). After surgery, additional examinations were performed to explore the cause of hypophosphatemic osteomalacia. After definitive diagnosis, the patient underwent tumor resection via T11 laminectomy on August 6, 2022. Six months after the second THA, the patient regained normal gait with satisfactory hip movement function without recurrence of PMT-associated osteomalacia or prosthesis loosening. By providing detailed clinical data and a diagnostic and treatment approach, we aimed to improve the clinical understanding of femoral neck fractures caused by TIO.

1 Introduction

Phosphaturic mesenchymal tumors (PMT) are extremely rare, with only approximately 450 cases being reported to date in the literature, the vast majority of which are benign ( 1 ). PMT is often diagnosed in middle-aged adults; however, it has also been observed in children and in older patients. PMT is characterized by elevated levels of fibroblast growth factor‐23 (FGF23), which is a phosphaturic hormone produced by the bone that reduces serum phosphate levels by suppressing proximal tubular phosphate re-absorption ( 2 ). FGF23 can also influence systemic vitamin D activity by suppressing the renal expression of 1α-hydroxylase, resulting in a decrease in calcitriol production ( 3 ). Hypophosphatemia and tumor-induced osteomalacia (TIO) are the main consequences of these processes. Recently, PMT has been recognized as one of the leading causes of TIO ( 1 ). A study by Lee et al. ( 4 ) showed that the fusion of FN1 (which encodes fibronectin 1) and FGFR1 (which encodes the fibroblast growth factor receptor 1) genes is expressed in half of PMT (41%) cases. This result suggests that the FN1-FGFR1 fusion gene plays a critical role in FGFR1 signaling pathways, leading to overexpression of FGF23 and tumor growth.

Here, we present a case of a woman with bilateral osteoporotic femoral neck fractures. PMT was discovered during the treatment of the fractures. The patient underwent PMT resection and total hip arthroplasty (THA) sequentially. Here, we describe the clinical manifestations, diagnostic process, treatment and prognosis of this case to aid in the clinical diagnosis and treatment of femoral neck fractures caused by TIO.

2 Case description

A 49-year-old perimenopausal woman presented with consistent bone pain with limb weakness persisting for > 2 years. She first sought treatment at our hospital because of bilateral hip pain in June 2020, with normal hip radiograph findings ( Figure 1A ), although low signal intensity were noted in the bilateral femoral heads on magnetic resonance imaging ( Figure 1B ). She was initially diagnosed with early osteonecrosis of the femoral head and underwent nonsurgical treatment. Two years later, from 2020 to 2022, pain extended to the bilateral shoulders and knees with increased intensity; muscle strength of the extremities gradually decreased. The patient was admitted to our hospital for a comprehensive evaluation on 24 June 2022. She had no positive family history or other genetic diseases and her menstrual cycles were regular. Physical examination revealed tenderness of the midpoints of the bilateral groin and restricted bilateral hip range of motion, with grade 3/5 muscle strength in both lower extremities.

Figure 1 A 49-year-old woman presented consistent bone pain with limb weakness for more than 2 years. (A) The pelvic AP radiograph presented grossly normal hips in June 2020. (B) Magnetic resonance imaging revealed low-signal intensity bands in the bilateral femoral head. (C, D) Images presented blurred bilateral hips with insufficiency femoral neck fracture in June 2022 (indicated by white arrow). (E) Severe osteomalacia was found in the femoral head sample. (F, G) A well-circumscribed lesion of about 13×18-mm in size was observed in the T11 by PET/CT( white arrow in F) and MRI with long T1 and T2 signals (white arrow in G) in August 2022. (H) Radiographs obtained in September 2022 demonstrated the narrow space and coxa vara of the left hip, and proper prosthetic placement without loosening in the right hip. (I) Radiographs obtained in March 2023 showed proper bilateral prosthetic positions without signs of loosening.

All procedures performed in this study adhered to the ethical standards of the institutional and/or national research committee. Written informed consent was obtained from the patient for the publication of this case report.

The results at admission included moderate anemia (hemoglobin 66 g/L), leukopenia (2.70 10 9 /L), neutropenia (1.28 10 9 /L), hypophosphatemia (0.36 mmol/L), high alkaline phosphatase activity (308.00 U/L), and normal serum calcium (2.22 mmol/L). Regarding the evaluation of anemia, low levels of ferritin (4.68 μg/L) were observed, indicating iron deficiency anemia (IDA). Urine phosphorus at 24 h was 0.34 g/24 h (reference range: 0.7–1.7 g/24 h). In terms of bone metabolism markers, the parathyroid hormone levels were 55.90 pg/mL (reference range: 15–65 pg/mL), 25-dihydroxyvitamin D levels (25-OH Vit D) was 11.20 ng/mL (deficiency: < 20 ng/mL), total N terminal procollagen I peptide was 113.00 ng/mL (reference range, premenopausal: 8.53–64.32  ng/mL, postmenopausal: 21.32–112.80 ng/mL), β-Cross Laps was 0.72 ng/mL (reference range: premenopausal 0.068–0.680 ng/mL, postmenopausal 0.131–0.900 ng/mL), and osteocalcin was 22.40 ng/mL (reference range, premenopausal: 4.11–21.87 ng/mL, postmenopausal 8.87–29.05 ng/mL) ( Table 1 ). No obvious abnormalities in terms of lung cancer or tumor markers were found. Plain pelvic radiograph obtained in June 2022 showed bilateral hip blur with insufficient femoral neck fractures ( Figure 1C ), and bilateral hip transverse computed tomography (CT) confirmed bilateral femoral neck fractures ( Figure 1D ). Whole-body bone scintigraphy showed radionuclide concentration in the joints without any significantly apparent hot spots in the extremities and spine. Bone mass density (BMD) demonstrated severe osteoporosis in the lumbar spine (0.654 g/cm 2 , T-score -3.8) and the left femur (0.223 g/cm 2 , T-score -5.9).

Table 1 Reference ranges for all biochemical data.

Based on these characteristics, the patient was diagnosed with bilateral osteoporotic femoral neck fractures secondary to hypophosphatemia. To alleviate the symptoms of severe pain, the patient was treated with a right THA in July 2022. Severe osteomalacia of the acetabulum and femoral head was observed intraoperatively, with a variation in the shape of the cortical bone as the external force was applied, whereas a nearly normal trabecular appearance was observed despite the lack of rigidity ( Figure 1E ).

During the week following the surgery, additional examinations were performed to explore the cause of hypophosphatemic osteomalacia. Based on the patient’s hematological changes and clinical presentation, we first considered myeloma and examined biochemical markers, including serum immunoglobulin, β2-microglobulin, immunoglobulin light chain, and immunoglobulin electrophoresis. However, all these laboratory findings were within normal ranges and therefore, the suspected diagnosis of multiple myeloma was excluded. Moreover, 18 F-FDG PET/CT was conducted as a supplementary search, and an osteolytic bone lesion with increased radioactivity in the right side of the T11 vertebral body and adnexa was found, which proved to be a well-circumscribed lesion of approximately 13×18 mm in the T11 with long T1 and T2 signals and an SUVmax of 5.5. on MRI ( Figures 1F, G ).

Subsequently, the patient underwent a CT-guided core biopsy of the lesion, which showed short spindle cells arranged in a hemangiopericytoma-like pattern with no significant cytologic atypia or increased mitotic activity. A panel of immunohistochemistry markers was tested, including CD56, CD34, ERG, SATB2, SSTR2, β-Catenin, S-100, STAT6, SMA, and Ki67. Tumor cells showed positive immunoreactivity to ERG, CD56, SATB2, SSTR2, and β-catenin, but were negative for CD34, S-100, STAT6, and SMA. Furthermore, the Ki67 test showed a very low proliferative index (3%). Based on the morphological characteristics and the immunoprofile described above, the patient was definitively diagnosed with phosphaturic mesenchymal TIO.

After the definitive diagnosis, the patient underwent tumor resection via T11 laminectomy on 6 August 2022. The pathology and immunohistochemistry of the resected tumor were consistent with the findings of the needle biopsy. Bone metabolic markers improved significantly, including serum phosphorus levels increasing from 0.42 mmol/L at 3 days preoperatively to 0.94 mmol/L at the first postoperative evaluation, and alkaline phosphatase decreased from 321.00 U/L to 229.00 U/L, accordingly. Furthermore, the patient experienced large-scale relief from symptoms of bone pain and weakness 3 months after tumor resection. However, she continued to experience persistent pain and limited mobility of the left hip, with a narrow space and coxa vara deformity of the left hip was revealed on radiography ( Figure 1H ). The patient underwent a left-sided THA to restore original function and to reduce physical discomfort and pain. Intraoperatively, we found that bone quality had improved considerably compared to the right side in primary THA, which was consistent with the findings of the preoperative laboratory tests, including hemoglobin 89 g/L, white blood cell counts 3.06 10 9 cells/L, neutrophil counts 1.66 10 9 cells/L, ferritin 14.80 μg/L, serum phosphorus 1.29 mmol/L, alkaline phosphatase 168.00 U/L, parathyroid hormone 63.90 pg/mL, 25-OH vitamin D 9.70 ng/mL, total procollagen I N terminal peptide 372.00 ng/mL, β-CrossLaps 3.25 ng/mL, and N-MID osteocalcin of 99.00 ng/mL. The patient’s bone density was reassessed in November 2023. The results showed a lumbar BMD of -1.3 in T score, and with other parts within the normal range of T scores. A six-month follow-up was performed after the second THA. By May 2023, the patient returned to normal gait with satisfactory hip movement function without recurrence of PMT-associated osteomalacia or loosening of the prosthesis ( Figure 1I ).

3 Discussion

We report a case of bilateral osteoporotic femoral neck fractures secondary to a PMT at the T11 level, with the following main characteristics: (1) hypophosphatemia and hypophosphaturia, (2) significant anemia and neutropenia, (3) combined bone pain and muscle weakness, (4) marked relief of the aforementioned clinical presentations was achieved after a PMT was detected in the thoracic spine and fully resected, and (5) bilateral osteoporotic femoral neck fractures were successfully treated by THA sequentially.

PMT can occur in almost any soft or osseous tissue. In soft tissues, PMT most often involves the extremities, while bone tumors usually involve the appendicular bones, skull, and sinuses ( 1 ). Cases of PMT were reviewed and summarized in 2020 by Garg et al. ( 5 ). Since its discovery in 1947, only 21 cases of PMT have been reported involving the spinal column, of which only six were PMT involving the thoracic spine. An analysis of 144 cases of PMT revealed that the most common signs and symptoms of the disease, such as bone pain, difficulty walking, muscle weakness, pathological fractures, and height loss ( 6 ), were usually the result of chronic hypophosphatemia rather than a direct consequence of the tumor itself. Our patient had a hip deformity caused by repeated stress fractures in the femoral neck, which left her with symptoms of hip pain even after the complete removal of the primary tumor.

The diagnosis of PMT may be challenging because these tumors are usually small, and it is difficult to identify lesions using imaging technology. The average time from the onset to a correct diagnosis was 2.9 ± 2.3 years ( 6 ). In our case, bone scintigraphy revealed active joint inflammation without tumor localization. PMTs commonly express somatostatin receptors (SSTR), as determined by somatostatin receptor scintigraphy using a radiolabeled somatostatin analogue, octreotide ( 7 ). However, based on a study by Jadhav ( 8 ), 99 Tc-HYNIC-TOC SPECT/CT and 68 Ga-DOTA-TATE PET/CT performed equally well and were superior to 18 F-FDG PET/CT in tumor localization among somatostatin receptor-based scans. 99 Tc-HYNIC-TOC SPECT/CT or 68 Ga-DOTA-TATE PET/CT were not performed in this case due to equipment limitations.

Biochemical findings play a crucial role in diagnosis. Patients with PMTs usually demonstrate low serum phosphate, normal serum calcium, elevated alkaline phosphatase, normal or elevated PTH and high serum FGF-23 concentrations. Furthermore, urine phosphate level is an important reference indicator for the diagnosis of TIO. Interestingly, it is high in normal subjects, whereas it was low in this case. Folpe et al. ( 9 ) advanced the novel concept of histologically identical tumors not accompanied by phosphaturia or TIO, which they called non-phosphaturic variants. They suggested that these variants may be tumors that secrete inactive or insufficient FGF23. In some reported cases of non-phosphaturic variants ( 10 – 12 ), the patients did not show clinical signs of TIO. In this case, the patient presents only non-phosphaturia, but with clinical and laboratory evidence of TIO. Therefore, we believe that this case was not a non-phosphaturic variant. Nonetheless, the reason for non-phosphaturia-associated TIO is not well understood. The physiological balance of phosphate is maintained by coordinated interactions between the small intestine, bone, parathyroid gland, and kidneys ( 3 ). We believe that the most likely reason is that the patient’s phosphaturia level was high at the early stage of the disease and that FGF23 inhibited 25-OH vitamin D synthesis, which in turn affected the intestinal absorption of phosphorus. The prolonged imbalance in phosphorus metabolism resulted in low phosphorus levels in the patient’s body, and although FGF23 inhibited renal tubular reabsorption of phosphorus, the amount of phosphorus that could be filtered by the kidneys was limited, resulting in low urinary phosphorus levels. In addition, patients may suffer from certain asymptomatic digestive disorders, which can also interfere with phosphorus absorption. However, our patient did not undergo endoscopic biopsy. Furthermore, the spine may contain fewer cells that release FGF23; however, serum FGF23 levels were not measured. There was no evidence that PMT caused IDA or leukopenia and we did not find any other comorbidities that contributed to the changes in the hemogram. The diagnosis of multiple myeloma was excluded based on the evaluation of immunoglobulins. The patient’s hematological parameters improved significantly and ferritin levels returned to normal after surgery. Clinicians should pay attention to hypophosphaturia and anemia to avoid misdiagnosis.

A recent study by Chatterjee et al. ( 13 ) demonstrated that PMT presents a unique immunophenotype (SATB2+/ERG+/CD56+/S-100-/STAT6-), that corresponded to our case.

Complete resection is the best treatment for PMT ( 14 ). Radial resection of the tumor leads to the rapid normalization of biochemical parameters. After surgery, hypophosphatemia and serum alkaline phosphatase levels were significantly ameliorated. However, at 3-month follow-up after tumor resection, the patient still had persistent pain with limited mobility in the left hip. X-rays ( Figure 1H ) showed femoral head collapse and joint space narrowing. The deformity of the femoral head was unchanged compared to the radiographs before the first THA ( Figure 1C ), although a significant increase in bone density was observed. This may be related to osteonecrosis of the femoral head caused by the long-term fracture on it. Therefore, the patient underwent contralateral hip arthroplasty. A recent retrospective study ( 15 ) showed that female sex, spine tumors, bone tissue involvement, malignancy, and low preoperative serum phosphorus levels were risk factors for refractory outcomes. Although this patient had more than one identifiable risk factor, she remained disease-free with no evidence of recurrence.

The limitation of this case lies in the absence of FGF23. Although we considered assessing FGF23 for the diagnosis of TIO, the patient chose not to perform this test owing to financial reasons. Consequently, we were unable to observe the dynamic changes in FGF23 throughout the various disease stages. Moreover, we could not offer a conclusive explanation regarding the potential connection between the hypophosphaturia, anemia and neutropenia with FGF23 level.

In conclusion, our report provides detailed clinical data and a diagnostic and treatment approach for the diagnosis of femoral neck fractures caused by TIO. This report should improve the clinical understanding of these rare PMTs and improve patient management. Clinicians should be aware that the long-term prognosis of these patients requires close monitoring.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

Ethics statement

Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

YZ: Writing – original draft. MH: Writing – original draft. CG: Data curation, Writing – review & editing. XY: Data curation, Writing – review & editing. SX: Methodology, Writing – review & editing. HX: Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study was funded by the China Postdoctoral Science Foundation (2022M721751) and the Youth Program of Natural Science Foundation of Shandong Province (ZR2020QH079).

Acknowledgments

We are grateful to the patient who kindly consented to the publication of this paper.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: phosphaturic mesenchymal tumor, tumor-induced osteomalacia, femoral neck fracture, thoracic spine, hypophosphoruria, total hip arthroplasty

Citation: Zhang Y, Hu M, Guo C, Yang X, Xiang S and Xu H (2024) Phosphaturic mesenchymal tumor-induced bilateral osteomalacia femoral neck fractures: a case report. Front. Endocrinol. 15:1373794. doi: 10.3389/fendo.2024.1373794

Received: 20 January 2024; Accepted: 01 April 2024; Published: 16 April 2024.

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Copyright © 2024 Zhang, Hu, Guo, Yang, Xiang and Xu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Hao Xu, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

The association between prealbumin concentration at admission and mortality in elderly patients with hip fractures: a cohort study

• Original Article
• Published: 11 April 2024
• Volume 19 , article number  27 , ( 2024 )

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• Shao-Hua Chen 1 ,
• Bin-Fei Zhang 1 &
• Yu-Min Zhang 1  

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Malnutrition is associated with complications and mortality in patients of hip fracture. Prealbumin may be more suitable than albumin to accurately predict the prognosis of hip fracture in elderly patients. We found that prealbumin concentration was nonlinearly associated with mortality in elderly patients with hip fracture, and an inflection point effect was observed.

To evaluate the association between prealbumin concentration at admission and mortality in elderly patients with hip fractures.

Elderly patients with hip fractures were screened between Jan 2015 and Sep 2019. Demographic and clinical characteristics of the patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between prealbumin concentration at admission and mortality. All analyses were performed using EmpowerStats and the R software.

This cohort study included 2387 patients who met the study criteria. The mean follow-up was 37.64 months. The prealbumin concentration was 162.67 ± 43.2 mg/L. Multivariate Cox regression showed that prealbumin concentration was associated with mortality in geriatric patients with hip fracture (hazard ratio [HR] = 0.95, 95% confidence intervals [CI]: 0.93–0.97, P  < 0.0001). In addition, an inflection point effect was observed in the nonlinear association. The inflection point was 162.2 mg/L. If it is less than this inflection point, then every 10 mg/L increase in prealbumin was associated with a 7% reduction in the risk of death (HR = 0.93, 95%CI: 0.90–0.96, P  < 0.0001). When greater than the inflection point, there was no difference in the risk of death (HR = 0.99, 95%CI: 0.95–1.03, P  = 0.5127).

The prealbumin concentrations at admission were nonlinearly associated with long-term mortality in geriatric hip fractures, and 162.2 mg/L could be considered a prognostic factor of mortality risk.

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The data was implemented by Xi’an Honghui Hospital. According to relevant regulations, the data could not be shared, but could be requested from correspondence author.

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Shao-Hua Chen, Bin-Fei Zhang & Yu-Min Zhang

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Chen, SH., Zhang, BF. & Zhang, YM. The association between prealbumin concentration at admission and mortality in elderly patients with hip fractures: a cohort study. Arch Osteoporos 19 , 27 (2024). https://doi.org/10.1007/s11657-024-01384-5

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Combined acetabular and femoral neck fractures with intrapelvic femoral head dislocation: Successful staged management of a rare injury in two cases

Mohamed abo-elsoud.

1 Department of Orthopedics, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt

Mohamed El-Gebeily

2 Department of Orthopedics, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Ihab El-Desouky

Combined central acetabular and femoral neck fractures with intrapelvic femoral head dislocation is an infrequent situation that provides a problematic condition for surgeons attempting to reconstruct the hip joint. Herein, we report two cases involving central acetabular fracture-dislocation combined with intrapelvic dislocation of a fractured femoral neck. Each case involved associated injuries that made primary total hip arthroplasty (THA) impossible and necessitated using the fewest skin incisions possible. As a result, we first attempted a posterior acetabular fixation of both the anterior and posterior columns with intra-articular plating of the anterior column. Finally, a cementless acetabular cup was implanted. There were no complications identified during the stages of reconstruction up to and including THA. The two patients̓ final Harris Hip scores were 98 for the first patient (at five years), and 91 for the second patient (at 1 ½ years). In conclusion, staged reconstruction of the hip joint with intra-articular acetabular plating does not weaken the acetabular bone that can accept insertion of THA with cementless biological acetabular fixation without complications and with an acceptable clinical outcome up to five years.

Introduction

In the orthopedic literature, combined acetabular and femoral neck fractures with intrapelvic femoral head dislocation are rare. A 2014 study found minimal occurrences.[ 1 ] Moore[ 2 ] was the first to describe this injury configuration after post-mortem examination of a patient with a pelvic injury in 1851. Stewart and Milford[ 3 ] described only one intrapelvic femoral head dislocation case in their large series. Judet et al.[ 4 ] reported only two cases, whereas the other authors did not encounter this injury pattern in their case studies.[ 5 , 6 ]

This complex injury has only been managed in four cases in the English literature.[ 7 - 10 ] Two more cases were described in two more Spanish publications.[ 11 , 12 ] Meinhard et al.[ 7 ] were the first to describe the management and follow-up of a single case treated with open reduction and internal fixation with screws and developed hip arthritis within two years. More cases followed, with different procedures to replace the damaged joint over a stable acetabular bearing bone.[ 8 - 12 ]

In this article, we report two cases of central hip fracture-dislocation with femoral head intrusion into the pelvis. A single posterior approach was used to fixate both the anterior and posterior columns, with intra-articular plating of the anterior column. The final stage of management involved total hip arthroplasty (THA) with a cementless cup. The staged management with intra-articular acetabular plating did not compromise the acetabular ability to receive a cementless cup with no complications and an excellent clinical outcome.

Case Report

Case 1- A 27-year-old man was crushed between the train and the platform seven years ago. A general assessment and resuscitation were performed at a local hospital with the insertion of a urinary catheter, which revealed frank hematuria. After transfer to our emergency department and a thorough examination, the extremities’ neurovascular status was intact. However, a Moral-Lavallee lesion over the right hip was noted. Additionally, the left arm was broken. Pelvic X-rays, computed tomography (CT) scan and an ascending urethrogram revealed the followings: (i) fracture of the femoral neck, right hip; (ii) anterior with posterior hemi-transverse acetabular fractures according to Judet and Letournel,[ 4 ] with the femoral head completely dislocated inside the lesser pelvis; (iii) right sacroiliac joint disruption; (iv) Denis type 2 left sacral fracture; (v) tetra-rami fracture of the anterior pelvic ring (Figure 1); (vi) fracture of the left humerus (AO/ASIF; 12-A2).[ 7 ] Ascending urethrogram showed extra-peritoneal rupture of the bladder.

Urology surgeons performed a vertical midline laparotomy and discovered the femoral head embedded in the bladder tear without any soft tissue attachment and contaminated by urine and the femoral head was discarded. We stabilized the pelvic injury with a supra-acetabular external fixator and bilateral iliosacral screws following bladder repair over a suprapubic catheter. After 10 days, the patient’s general condition was stabilized with corrected anemia and improved contusion around the hip. The extra-peritoneal drain was removed with non-infected healing of the laparotomy wounds allowing for fracture fixation. The external fixator rod was temporarily removed, while the patient was under general anesthesia to facilitate positioning. After stabilizing the posterior column fracture with a 4.5-mm reconstruction plate using the KocherLangenbeck approach, a significant central defect in the acetabular floor was noticed. With the possibility of the contaminated abdominal cavity, that was against another anterior approach, the anterior wall fracture was fixed with a 3.5-mm reconstruction plate from within the acetabular inner surface (intra-articular fixation) using two screws into the anterior wall and two screws into the acetabular dome. A static cement spacer loaded with antibiotics (2 g gentamicin + 2 g vancomycin/40 g bone cement) was inserted inside the acetabulum (Figure 2).

Eight months later, the patient was prepared for the third stage: i.e., THA, after complete healing of fractures (assessed by X-rays and CT scan films) and exclusion of infection (average values of white blood cell [WBC], erythrocyte sedimentation rate [ESR], and C-reactive protein [CRP]). A limb length discrepancy of 2 cm was evident. Under spinal anesthesia, the spacer and the intra-articular anterior plate were removed. The anterior and posterior fractures were completely healed with no areas of non-union; however, the acetabulum showed a defect in the medial wall. The acetabulum was slightly over-reamed, and a cancellous bone graft obtained from the proximal femoral canal was used as a plug for the defect. A 62-mm Ringloc-X cementless multi-hole acetabular shell (Zimmer-Biomet, Warsaw, IN, USA) was used to achieve a perfect fit. A standard offset, size 5, cementless Exception® (Zimmer-Biomet, Warsaw, IN, USA) stem was used for the femur with a 36-mm ceramic head articulating with E1 crosslinked polyethylene liner (Zimmer-Biomet, Warsaw, IN, USA). Limb length was equalized. The wound was closed in layers over a drain.

Toe-touch weight-bearing with a frame was allowed immediately, and full weight-bearing started at six weeks. The patient returned to his pre-injury job as a civil engineer three months after the THA. At five-year follow-up, functional Harris Hip Score (HHS) was 98 at the final follow-up. No signs of loosening were observed (Figure 3). A written informed consent was obtained from the patient.

Case 2- A 54-year-old man was admitted to our emergency department after a motor car accident two years ago. After initial resuscitation, orthopedic examination revealed tenderness over the left hip region with externally rotated limb position. The left knee region showed contusions with an open wound over the lateral side (Gustilo-Anderson type 2). In addition, the left ankle was swollen and deformed with skin bullae. Pelvic, left knee, and left ankle X-rays were done, CT scans of the pelvis, with 3-mm acetabular cuts, the left knee and left ankle revealed the followings: (i) T-shaped comminuted fracture of the left acetabulum; (ii) femoral neck fracture of the left hip with an intra-pelvic position of the head through central dislocation (Figure 4); (iii) tibial plateau fracture (AO/ASIF; 41-B3); and (iv) Pilon fracture of the left ankle (AO/ASIF;43-C3).

Thorough debridement of the knee wounds with the application of a bridging external fixator was performed together with an under-image reduction of the ankle joint, followed by applying a Delta-frame external fixator.

Within seven days, the local condition of the knee joint improved, allowing for the fixation stage. Through the Kocher-Langenbeck's posterior approach, the posterior column fracture component was distracted, allowing delivery of the femoral head through the floor defect. The femoral neck stump appeared end-on, facilitating the extraction of the head using bone rongeurs. Then, fixation of the posterior column was done using two 4.5-mm reconstruction plates. The floor fragment was reduced with fixation of the anterior column with a 3.5-mm intra-articular reconstruction plate. A cement spacer loaded with antibiotics was inserted inside the acetabulum (Figure 5). Fixation of knee fracture was done in the same session. The ankle joint needed two more weeks for the skin condition to improve to allow for internal fixation.

Nine months after the fixation stage, total healing of the acetabular fractures was confirmed by CT and X-ray films permitting the THA stage. Through the posterior approach, removing the anterior plate and the spacer was done, followed by the insertion of a cementless Trilogy® multi-hole cup with a Longevity® polyethylene insert (Zimmer-Biomet, Warsaw, IN, USA). A 36-mm head was used over a cemented Exception® stem of standard offset (Zimmer-Biomet, Warsaw, IN, USA) (Figure 6). The postoperative period passed uneventfully. Toe-touch weight-bearing with a frame was allowed immediately, and full weight-bearing started at six weeks. At the latest follow-up, 18 months after THA, there was a limb length discrepancy of 1.5-cm; however, the HHS was 91. A written informed consent was obtained from the patient.

This report presents staged management of two cases with intrapelvic femoral head dislocation following the acetabulum and femoral neck fractures. Intra-articular fixation of the anterior column through the posterior acetabular approach was challenged to produce the best possible results that enabled successful implantation of the delayed THA using cementless biological acetabular fixation without complications and with an acceptable clinical outcome up to five years of follow-up.

Central acetabular dislocation results either from a direct blow to the greater trochanter with the hip in 30 to 50º of internal rotation or an axially directed blow to the flexed knee with the hip flexed to 90º with abducted to 40 to 50º.[ 4 ] Experimentally, it could be produced by an impact on the trochanteric region.[ 13 ]

Meinhard et al.[ 7 ] believed that the proximal femur in one moment of impact (in internal rotation) could transmit most of the force to the central portion of the acetabular fracturing it. Then, some abduction degrees occurred in a second moment, concentrating the forces on the weakest element: i.e., the incarcerated femoral neck causing its fracture.

Moya Aparicio and de la Torre García[ 11 ] described the second step of the abduction of the femur that placed the femoral neck under the solid upper lip of the acetabulum, similar to a guillotine for the femoral neck.

The highly severe combination that intrudes the femoral head into an utterly intrapelvic position to float freely inside the pelvis is a scarce situation. Based on our literature search, such injuries were reported only in four cases in the English literature.[ 7 - 10 ] In Spanish literature, two more reports were published that described two cases.[ 11 , 12 ]

The management of these cases varied. Meinhard et al.[ 7 ] fixed the head using 4 'Kadar’ type screws with a vascularized graft. After two years, the patient had symptomatic post-traumatic hip arthritis. Mestdagh et al.[ 8 ] performed cementless total hip replacement three months after skeletal traction to integrate the acetabular fracture. Mesa et al.[ 10 ] described the management of a patient with delayed cementless THA six months after injury. The result was satisfying, and the patient walked without aids. The follow-up included only the first six months after surgery. Dusak et al.[ 9 ] reported a managed case three weeks after injury by primary cemented THA after femoral head autograft of the defect and insertion of acetabular cage fixed with multiple screws. However, the follow-up period of this case was not mentioned. Hidalgo-Péreza et al.[ 12 ] also used a single-stage reconstruction, presuming the primary THA would provide greater benefits and prevent complications, if there was no technical contraindication due to associated pelvic or sacrum fractures.

Delayed THA after more than three months was successful in two studies.[ 8 , 10 ] This load-deprivation period allowed for proper healing of the acetabulum, and insertion of cementless acetabular cups were feasible afterward. Moya Aparicio and de la Torre García[ 11 ] proposed a two-stage reconstruction with the femoral head extraction and the fractured greater trochanter fixation as the first stage. The second stage was aborted as the patient was content at that management level. Table I shows the overview of the cases of combined central acetabular and femoral neck fractures with intra-pelvic head dislocation and their management.

The situation in our cases was more cumbersome. In the first case, pelvic injuries with acetabular comminution were associated with urological injuries necessitating staged reconstruction. The potentially contaminated anterior field, due to urological intervention, prevented an anterior approaching of the acetabulum and provided a chance to fix the anterior column with an intra-articular plating through the posterior approach. Afterward, the acetabular column healing allowed delayed THA with cementless acetabular cup implantation. In the second case, in the presence of potentially infected distal injuries to the acetabular fracture, we decided against primary THA and fixed both acetabular columns through a single posterior approach. Delayed THA was done with an excellent score.

Intra-articular fixation of the anterior acetabular column was not described before in the literature. This method was attempted to help stabilize the acetabulum through one approach, thereby reducing the complication rates, including infection and wound problems. In both cases, non-infected healing was achieved without weakening of the acetabular bone that could accept the insertion of stable cementless acetabular cups, and a five-year follow-up of the first case showed no signs of loosening.

Both of our cases were treated with cementless acetabular cups. While certain arguments concerning the best cup attachment method exist,[ 14 , 15 ] this is not the case with acetabular reconstruction following a fracture. Initially, acetabular components, both cemented and uncemented, were used to treat postacetabular fracture arthritis.[ 16 , 17 ] Subsequent research indicated that a sclerotic acetabular bone bed following fractures is inappropriate for cement fixation. Recent developments in cementless acetabular fixation have improved the radiological and functional characteristics of THA following acetabular fractures; as a result, this technique of fixation is used for cup placement in these situations.[ 18 , 19 ]

Although this study includes the most extended follow-up of a case suffering this form of injury, a primary conclusion can only be taken about the effectiveness of the intra-articular acetabular fixation method due to the limited number of cases and the need for it due to circumstances. It cannot be concluded whether this procedure can be performed in all similar cases. However, due to the scarcity of this fracture pattern, this method may serve as an aiding tool under certain situations.

In conclusion, staged reconstruction of the hip joint with intra-articular acetabular plating enabled successful implantation of the total hip prosthesis without complications and with an acceptable clinical outcome in this complex situation. Intra-articular acetabular fixation method did not weaken the acetabular bone and allowed for a delayed cementless cup insertion.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Financial Disclosure: The authors received no financial support for the research and/or authorship of this article.