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Journal of Peking University (Health Sciences) ›› 2020, Vol. 52 ›› Issue (2): 290-297. doi: 10.19723/j.issn.1671-167X.2020.02.016

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Analysis of risk factors for necrosis of femoral head after internal fixation surgery in young and mid-aged patients with femoral neck fracture

Bing-chuan LIU,Chuan SUN,Yong XING,Fang ZHOU,Yun TIAN(),Hong-quan JI,Zhi-shan ZHANG,Yan GUO,Yang LV,Zhong-wei YANG,Guo-jin HOU,Shan GAO   

  1. Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
  • Received:2019-01-06 Online:2020-04-18 Published:2020-04-18
  • Contact: Yun TIAN E-mail:tiany@bjmu.edu.cn

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Abstract:

Objective: To retrospectively analyze the risk factors of avascular necrosis of femoral head (ANFH) after internal fixation in young and mid-aged adults.Methods: From January 2007 to December 2017, femoral neck fracture patients (18-60 years old) treated by reduction and internal fixation were retrospectively studied in Peking University Third Hospital. We recorded their gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) grade, reason of injury, fracture side, interval between injury and surgery, location of fracture line, Garden classification, Pauwels classification, reduction method (open or closed), internal fixation and reduction quality. The diagnosis of ANFH was confirmed based on X-ray and MRI images during the follow-up. The internal fixation method inclu-ded cannulated compression screw (CCS) or dynamic hip screw (DHS, with or without anti-rotation screw). χ 2 test and Logistic regression analysis were used to analyze the relationship between the various factors and postoperative ANFH. Results: A total of 113 patients were included in this study, including 63 males and 50 females with an average age of (43.17 ± 12.34) years. They were followed up by (25.08 ± 16.17) months. ASA grade included grade Ⅰ (21 cases), grade Ⅱ (55 cases) and grade Ⅲ (37 cases). The reasons of injury included low-energy trauma (76 cases) and high-energy (37 cases). The fracture line included subcapital type (37 cases), transverse type (74 cases) and basal type (2 cases). Garden classification included type Ⅰ (3 cases), type Ⅱ (46 cases), type Ⅲ (39 cases) and type Ⅳ (25 cases). Pauwels classification included type Ⅰ (21 cases), type Ⅱ (55 cases) and type Ⅲ (37 cases). Interval between injury and surgery was (3.88 ± 3.66) days, 108 patients and 5 patients performed closed and open reduction respectively. 63 patients performed CCS, and 50 patients performed DHS. The reduction quality included grade A (91 cases), grade B (18 cases) and grade C (4 cases). 18 patients developed ANFH after surgery, the incidence rate was 15.93%(18/113). The result of χ 2 test showed the reason of injury (OR=0.19, P < 0.01), Garden classification (OR=0.13, P < 0.01), Pauwels classification (OR=0.12, P = 0.02), internal fixation method (OR=3.29, P = 0.04) and reduction quality (OR=0.33, P < 0.01) were significantly associated with ANFH. These five factors were further included into the Logistic regression analysis, and its results showed that the reason of injury (OR=4.11, P = 0.03) and Garden classification (OR=4.85, P = 0.04) were statistically significant. Conclusion: The reason of injury, Garden classification, Pauwels classification, internal fixation and reduction quality may increase the risk of ANFH after surgery, and the reason of injury and Garden classification were much more significant.

Key words: Femoral neck fracture, Necrosis of femoral head, Risk factors

CLC Number: 

  • R683.4

Table 1

Reduction quality classification of femoral neck fracture"

Classification Angle of deviationa Neck-shaft angle
A < 15° 125° - 140°
B 15° - 30° 120° - 140° or 140° -150°
C > 30° <125° or >150°

Table 2

χ2 test for necrosis of femoral head after internal fixation"

Parameter Total(n=113) Necrosis(n=18) Non-necrosis(n=95) OR P value 95%CI
Gender 1.29 0.62 0.46, 3.64
Male 63 11 52
Female 50 7 43
Age/years 0.91 0.86 0.33, 2.57
< 40 46 7 39
40-60 67 11 56
BMI/(kg/m2) 0.69 0.53 0.22, 2.18
≤25 88 13 75
>25 25 5 20
ASA gradea 0.24
Ⅰ 21 1 20 0.16 0.06 0.02, 1.37
Ⅱ 55 9 46 0.71 0.52 0.25, 2.05
Ⅲ 37 8 29
Reason of fracture 0.19 <0.01 0.06, 0.55
Low-energy trauma 75 6 69
High-energy trauma 38 12 26
Interval between injury and surgery 1.09 0.86 0.39, 3.07
≤ 3 d 67 11 56
>3 d 46 7 39
Side of fracture 0.63 0.38 0.23, 1.75
Left 61 8 53
Right 52 10 42
Location of fracture lineb 0.71
Subcapital 37 7 30 1.07 0.50 0.98, 1.17
Transverse 74 11 63 1.03 0.56 0.99, 1.08
Basal 2 0 2
Garden classification 0.13 <0.01 0.03, 0.59
Ⅰ and Ⅱ 49 2 47
Ⅲ and Ⅳ 64 16 48
Pauwels classificationc 0.02
Ⅰ 21 1 20 0.12 0.02 0.01, 0.99
Ⅱ 55 6 49 0.29 0.02 0.10, 0.87
Ⅲ 37 11 26
Reduction method 0.75 0.80 0.08, 7.10
Closed 108 17 91
Open 5 1 4
Internal fixation 3.29 0.04 1.01, 10.71
CCS 63 14 49
DHS 50 4 46
Reduction qualityd <0.01
A 91 9 82 0.33 0.34 0.03, 3.51
B 18 8 10 2.40 0.47 0.21, 27.72
C 4 1 3

Table 3

Multivariate Logistic regression analysis of risk factors for necrosis of femoral head after internal fixation"

Parameter OR P value 95%CI
Reason of fracture 4.11 0.03 1.19, 14.24
Garden classification 4.85 0.04 1.08, 21.75
Pauwels classificationa
Ⅰ vs. Ⅲ 1.95 0.57 0.19, 20.05
Ⅱ vs. Ⅲ 1.65 0.45 0.45, 6.08
Internal fixation 0.28 0.06 0.07, 1.06
Reduction qualityb
A vs. C 2.13 0.56 0.16, 27.59
B vs. C 0.29 0.37 0.02, 4.54

Figure 1

Typical case, 55 years old, male, left femoral neck fractureA, X-ray image before surgery; B1,B2, CT images before surgery; C,D, X-ray images at 1 day after surgery; E,F, X-ray images at 6 and 12 months after surgery; G, X-ray image at 18 months after surgery; H, MRI image at 18 months after surgery (the yellow circle shows obvious subchondral low signal line; I, X-ray image at 39 months after surgery; J1,J2, range of hip motion at 39 months after surgery."

Figure 2

Typical case, 50 years old, male, right femoral neck fracture A, X-ray image before surgery; B1,B2, CT images before surgery; C,D, X-ray images at 1 day after surgery; E,F,G,H,I, X-ray images at 6, 12, 23, 40, 48 months after surgery; J,K,L, range of hip motion at 48 months after surgery."

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