Long Term Outcome of Treatment of Subaxial Cervical Spine Fractures

              Long Term Outcome of Treatment of Subaxial Cervical Spine Fractures

                                                          Dr KS Dhillon

Classification of subaxial cervical spine fractures

The widely used classification for lower cervical spine injuries is the one by the AO group. It divides lower cervical spine injuries into 3 types i.e type A, B, C based on the trauma mechanism.

A: compression
B: distraction
C: rotation

Type A compression injuries are further subdivided into type:
 A.1  =  impaction
 A.2  =  split
 A.3  =  burst.

Type B distraction injuries are further subdivided into:
 B.1  =  posterior distraction with vertebral body intact
 B.2  =  posterior distraction + fracture of the vertebral body
 B.3  =  anterior distraction + hyperextension.

Type C rotation injuries are subdivided into:
C.1  =  unilateral facet fracture-dislocation
C.2  =  unilateral facet dislocation
C.3  =  rotational shear injury of the joint mass.

To remedy a lack of consensus on the classification of lower cervical spine injuries the Subaxial Injury Classification (SLIC) Scale was created [1]. This classification takes into account morphology; status of the disco-ligamentous complex and neurological assessment.



Table 1. Subaxial Injury Classification (SLIC) scale.
   
Morphology                                                                                                  Points
No abnormality                                                                                               0
Compression + burst                                                                                1 + 1  =  2
Distraction (e.g., facet perch or hyperextension)                                            3
Rotation or translation (e.g., facet dislocation, unstable teardrop,
or advanced-stage flexion-compression injury)                                              4

Disc-ligamentous complex
Intact                                                                                                               0
Indeterminate (e.g., isolated interspinous widening or MRI signal
change only)                                                                                                    1
Disrupted (e.g., widening of the anterior disk space or facet perch
or dislocation)                                                                                                  2

Neurological status
Intact                                                                                                              0
Root injury                                                                                                      1
Complete cord injury                                                                                      2
Incomplete cord injury                                                                                    3
Continuous cord compression (neuro-modifier in the setting of a
neurological deficit)                                                                                     + 1

Based on the above parameters, scores are assigned to each injury. Patients with a score lower than 4 will need nonsurgical treatment and patients with scores higher than 4 will require surgical treatment. Patients with a score of 4 can be treated surgically or nonsurgically depending on the experience of the surgeon.

Treatment of subaxial cervical spine fractures

Unfortunately, there is insufficient evidence to recommend treatment standards and there is also insufficient evidence to recommend treatment guidelines for subaxial cervical spine injuries [2]. The main principles of treatment include decompression of compressed neurological structures, restoration of vertebral column integrity, prevention and management of complications, and facilitation of rehabilitation [3].

Subaxial Injury Classification (SLIC) Scale has been introduced to help in decision making for treatment of subaxial injuries [1]. Generally, patients with a score lower than 4 are treated nonsurgically while patients with scores higher than 4 are treated with surgery. Patients with a score of 4 can be treated surgically or nonsurgically depending on the experience of the surgeon.
Many patients with cervical spine injuries can be treated nonoperatively. Options for conservative treatment include the use of a cervical orthosis or rigid stabilization with a halo jacket.

In patients with displaced cervical spine injury, a closed reduction can be carried out. It is safe to treat displaced subaxial fracture and subaxial subluxations and dislocations, by traction [3].

Lee et al [4] carried out a study involving 210 patients with unilateral and bilateral facet dislocations. They found that rapid traction under sedation using weights up to 150 pounds was safer than carrying out manipulation under anesthesia. They also found that early reduction of the dislocation in patients with neurological deficit gave them the best chance of neurological recovery.

Surgery is usually indicated in patients when a close reduction has failed, in patients with unstable injuries and when there is bilateral facet dislocation of more than 25% or 11°. Progressive neurological deterioration would be another indication for surgery. Kyphosis of 30° or more or loss of vertebral height of more than 50% is often associated with a high incidence of late complications, and this situation may warrant surgical intervention. Late instability and severe post-traumatic kyphosis may warrant surgical intervention [3].

In patients with partial neurological injury, early surgical intervention is usually recommended. There is some evidence that early surgical intervention (less than 24 hours) is safe and effective. Neurological recovery can also occur in some patients who have delayed decompression [4,5].
Some have claimed that 70% of patients with partial spinal cord injury improve one grade or more (American Spinal Injuries Association, International Medical Society of Paraplegia grades) if the surgery is carried within 6 hours after the injury [7]. When surgery is carried out after 6 hours only 12% of the patients show improvement. In patients with a complete spinal cord injury, the chances of neurological recovery is poor.

Decompression and/or stabilized of the cervical spine can be carried out via the anterior, posterior or a combination of both approaches, depending on the type of injury. The clinical success rates are higher with the anterior approach through the anterior approach is biomechanically inferior to the posterior approach [3].

Long term outcome of cervical spine injury treatment

There is a dearth of literature on the long term outcome of management of cervical spine injuries. The largest study with a long term follow up is the one by Fredø et al [8]. They followed up 256 patients with subaxial cervical spine injuries who were treated surgically. The surgical approach was anterior in 69% of the patients, posterior in 22% and combined in 9 % of the patients.
The mean follow-up period was 3.1 years with a range of 0.5–9.0 years. None of their patients had neurological deterioration after the surgery.

In patients who were operated within 24 hours, 48.8% showed improvement of their neurological grades, whereas in patients operated after 24 hours 53.1% showed improvement in their neurological grades. The improvement in AIS (American Spinal Injury Association impairment scale) grades between the two groups were not significantly different (p = 0.442). Of the patients with preoperative radiculopathy, 11 % of the patients continued to have radicular symptoms. There were four patients who developed radiculopathy after surgery, three of these patients were asymptomatic at follow-up.
Neck pain was assessed using the Visual Analog Scale (VAS). They found that the median VAS score for neck pain was 1 (range 0–10). Eighty percent of the patients had VAS scores ≤3, 15 % had VAS scores 4–6, and 5 % had VAS scores ≥7. There was no significant association between the surgical approach and neck pain [8].

They found that 26% of the patients had no neck stiffness, 63% had mild neck stiffness and 11% had severe neck stiffness. Neck stiffness was more common in patients who had fusion with posterior screw fixation.

Six percent of patients sustained hoarseness and 9% developed dysphagia after surgery. Of the 256 patients who were followed up with cervical CT scans, 98.4 % had a stable fusion, 0.4 % had a secondary loss of alignment, and in 1.2 % of the patients, there was loosening or fracture of their fixation device[8]. In this study, the surgical mortality(death within 30 days after surgery) was 2.3 %.
Koller et al. [9] carried out a retrospective review of 28 patients who had anterior cervical decompression, fusion, and plating (ACDFP) for unstable subaxial injuries without neurological deficit, to assess the mid- to long-term outcome. The mean follow up period was 5.5 years (range16–128 months). The self-rated clinical outcome was excellent or good in 81% of patients and moderate or poor in 19% of the patients.

Construct failure was seen in 31% of cases.  The fusion rate was 88.5%.  Adjacent-level degeneration progression was significantly influenced by a decreased plate-to-disc-distance. The motion of adjacent level intervertebral space was not altered due to the adjacent fusion, but it was reduced in the presence of advanced adjacent level degeneration.

Conclusion

There is a dearth of literature on the long term outcome of management of cervical spine injuries. The largest study with a long term follow up is the one by Fredø et al [8]. They followed up 256 patients with subaxial cervical spine injuries who were treated surgically. The mean follow-up period was 3.1 years with a range of 0.5–9.0 years. They obtained stable fusion in 98.4% of the patients, 0.4 % had a secondary loss of alignment, and in 1.2 % of the patients, there was implant failure. The surgical mortality (death within 30 days after surgery) was 2.3 %.

Koller et al. [9] carried out a small retrospective review of 28 patients who had anterior cervical decompression, fusion, and plating (ACDFP) for unstable subaxial injuries without neurological deficit, to assess the mid- to long-term outcome. The mean follow up period was 5.5 years (range16–128 months). Their results were not as good as the ones reported by Fredø et al [8]. Construct failure rates were very high with an incidence of 31%. Their fusion rates were lower at 88.5%.

To date, no other studies on the long term outcome of management of subaxial cervical spine injuries, have been published.

References

1. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, et al. The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system. Spine (Phila Pa 1976) 2007;32(23):2620–9.
2. Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC. Treatment of subaxial cervical spinal injuries. Neurosurgery. 2002 Mar;50(3 Suppl): S156-65.
3. O'Dowd JK. Basic principles of management for cervical spine trauma. Eur Spine J. 2010 Mar; 19(Suppl 1): 18–22.
4. Lee AS, MacLean JC, Newton DA. Rapid traction for reduction of cervical spine dislocations. J Bone Joint Surg Br. 1994 May;76(3):352-6.
5. La Rosa G, Conti A, Cardali S, Cacciola F, Tomasello F. Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach. Spinal Cord 2004;42:503-12.
6. Fehlings MG, Perrin RG. The role and timing of early decompression for cervical spinal cord injury: Update with a review of recent clinical evidence. Injury 2005;36 Suppl 2:B13-26.
7. Fehlings M, Aarabi B, Dvorak M, et al. (2008) A prospective multicenter trial to evaluate the role and timing of decompression in patients with cervical spinal cord injury: initial one-year results of the STASCIS study. Paper presented at the AANS meeting in Chicago.
8. Fredø HL, Rizvi SAM, Rezai M, Rønning P, Lied B and Helseth E. Complications and long-term outcomes after open surgery for traumatic subaxial cervical spine fractures: a consecutive series of 303 patients. BMC Surg. 2016 Aug 15;16(1):56.
9. Koller H, Reynolds J, Zenner J, Forstner R, Hempfing A, Maislinger I, Kolb K, Tauber M, Resch H, Mayer M, Hitzl W. Mid- to long-term outcome of instrumented anterior cervical fusion for subaxial injuries. Eur Spine J. 2009 May;18(5):630-53. 

Neurological complications of lumbar epidural anesthesia and analgesia.

      Neurological complications of lumbar epidural anesthesia and analgesia.

                                     Dr KS Dhillon

Introduction

Epidural anesthesia and analgesia (EAA) are widely used in clinical practice for surgery and postoperative analgesia. Epidural anesthesia and analgesia reduces or eliminates perioperative physiological stress responses to surgery and this inturn decreases surgical complications and improve clinical outcomes[1-3].

Studies have shown a significant reduction in perioperative cardiac morbidity, pulmonary infections, deep vein thrombosis, pulmonary embolism, ileus, acute renal failure, blood loss and need for transfusion. The length of hospital stay and the 30 day mortality is also reduced with EAA [4]. EAA is also believed to preserve postoperative immune function by attenuating the stress response of surgery. Studies have shown significant reductions in the incidence of postoperative infections in patients treated with EAA [5,6].

EAA is generally regarded as safe and effective but EAA can be associated with serious complications. Though the complications are rare they can sometimes be devastating.

Neurological complications of lumbar epidural anesthesia and analgesia.

Studies show that the frequency of severe, permanent neurological complications related to epidural catheterisation is low at about  0.1–1/10,000 procedures [7-12]. Epidural anesthesia can be associated with radiculopathy, cauda equina syndrome and myelopathy leading to permanent neurological disability [13]. Compression of the spinal cord or nerve roots can occur from extradural abscesses or haematomas. Arterial and venous infarction of the spinal cord and nerve root trauma can occur during catheter placement. Chemically induced arachnoiditis by the drugs used for the epidural has also been implicated in causing permanent neurological disability [14-18].

Lumbar epidural injections in patients with pre-existing spinal stenosis can  precipitate severe and widespread lumbosacral polyradiculopathy [13,19].

Neurotoxicity from local anesthetics is a well known phenomenon and is related to the type and concentration of anesthetic and its systemic absorption. Intrathecal lignocaine at high doses has been associated with neurologic side effects [20,21].

Epidural catheters can inadvertently penetrate the dural space, cause damage to neurovascular structures and also can lead to infection. The incidence of accidental dural puncture during needle insertion is about 0.16–1.3% and the incidence of postdural headache in these patients is about 16–86% [22-25].

Nerve root irritation by the catheter and intrathecal injection of local anesthesia can produce transient neurologic symptoms (TNS) such as  sharp radicular back pain and paresthesias [26].

Risk factors for TNS include the use of lidocaine as the local anesthetic, lithotomy position, obesity, and performance of the procedure in the outpatient department [27].The TNS usually usually resolve once the catheter is removed. Epidural abscesses and meningitis following epidural and spinal anesthesia is rare [28].

Risk factors for meningitis include dural puncture, non sterile technique, prolonged indwelling catheter and septicemia [29,30]. Paraplegia, the most serious complication of epidural anesthesia can be caused by an epidural hematoma which forms during catheter placement or removal. The secondary cause of this complication is the concomitant pre-, intra-, or postoperative administration of drugs that affect blood coagulation (anticoagulants) [31].  Spinal abscesses and anterior spinal artery syndrome are also known to cause paraplegia. Epidural haematoma formation is a rare complication with an incidence of less than 1 in 150,000 [32].

Injury to the spinal vasculature during catheter placement has been described and the incidence is about 3–12%. Despite injury to spinal vasculature symptomatic epidural hematomas are rare [33,34]. Early recognition of symptomatic epidural haematomas and decompressive laminectomy within 8 hours have been shown to improve clinical outcomes [35].

Epidural abscess and meningitis

The reported incidence of epidural abscess after epidural catheterisation is about 1 : 1000 and for meningitis is about 1 : 50 000 [36].

There are several ways in which bacteria may enter the epidural space. One of the sources of infection is needle or catheter contamination and lack of barrier precautions, such as the use of chlorhexidine 0.5% in 70% alcohol for skin disinfection [37-39]. Contamination of the needle or catheter by oropharyngeal and nasal flora of the anesthetist has been proven by cultures obtained from the epidural abscess and from the anaesthetist [40,41].

Epidural solution can be a source of epidural infection despite the use of bacterial filter. There is some evidence to suggest that frequent syringe changes could be associated with a higher rate of epidural infection  [42-44]. The 500-ml bags of epidural infusion fluid has not been found to be  associated with epidural abscesses or meningitis [45].

Infection of the insertion site of the catheter with migration of the bacteria along the catheter tract is a common mechanism of epidural infections. A haematogenous source of epidural infection after epidural catheterisation is uncommon [46-48].

There are several predisposing factors for epidural infection. Patients who are immunocompromised are more likely to develop infection [49-51]. Difficulty in insertion of epidural catheter is also a known risk factor for infection. Difficulty in insertion is associated with the formation of asymptomatic epidural haematoma [49,52,53] or subcutaneous haematoma which can act as a nidus for infection [54]. Epidural analgesia of more then 3 days is associated with higher infection rates [51].

Staphylococcus is the most common organism cultured from epidural abscesses [49,50,51,55]. Methicillin resistant staphylococcus has also been cultured in some of these abscesses.

Patients with an epidural abscess usually presents with midline back pain and fever about 5 days after epidural insertion [49-51]. If untreated neurological deficit with paraplegia usually develops within a week [49]. The prognosis for recovery is poor once paraplegia develops [49,56].
Meningitis usually results from dural puncture and patients present with headache and fever, with some patients developing neck rigidity [50]. In some patients who developed meningitis there were no reports of dural puncture [45].

In patients suspected to have an epidural abscess, an MRI scan is the investigation of choice [58]. Sometimes back pain is ascribed to musculoskeletal pain and a delay in diagnosis can result. Therefore a high index of suspicion is necessary to prevent delays in diagnosis.

A lumbar puncture with csf microscopy is necessary for the diagnosis of meningitis [45].
Epidural abscesses are treated with a combination of early surgical decompression and prolonged antibiotic therapy [53]. Patients with minimal or no neurological deficit can be managed with antibiotics alone [55].

Epidural haematoma

Coagulopathies predispose patients to epidural haematomas following epidural catheter insertion [56]. Hence the timing of anticoagulant administration is important in reducing the risk of epidural haematomas [59,60]. The newer recommendations, recommend that low molecular weight heparin administration for prevention of deep vein thrombosis (DVT) be delayed for 24 h in case of a bloody tap [60]. Another risk factor for the development of epidural haematoma is difficulty in identifying the epidural space [61].

Difficulty in identification of the epidural space can often be encountered in patients who are obese. Other risk factors include advanced age, female gender and bony spinal pathology [50].
The usual clinical presentation of an epidural haematoma is radicular back pain with rapidly progressive neurological (motor and sensory) deficit and sphincter dysfunction [56]. The symptoms usually develop within 24 hours of either epidural insertion or removal, but sometimes the onset of symptoms may be delayed [50].

An MRI scan of the spine is the investigation of choice in patients suspected of having an epidural haematoma. Often the neurological deficit is attributed to the epidural infusion and the back pain to a musculoskeletal cause and this leads to a delay in diagnosis [62]. Early diagnosis is of paramount importance since a favourable outcome is dependent on early spinal decompression within 8 hours of the onset of symptoms [56]. Neurological outcome depends on the extent of the neurological deficit, the size of the haematoma and the time between haematoma formation and surgical decompression [56].

Leg strength monitoring is essential in assessment of spinal cord health
in patients receiving epidural analgesia [41]. The Bromage scale is commonly used to measure motor block [63].

Grade Criteria                                                                  Degree of block

I          Free movement of legs and feet                            Nil (0%)

II        Just able to flex knees with free movement
           of feet                                                                   Partial (33%)

III       Unable to flex knees, but with free movement     Almost complete
          of feet                                                                    (66%)

IV        Unable to move legs and feet                             Complete (100%)   


Table 1. Bromage scale

The perfect analgesic technique would provide complete pain relief with no motor block. Leg weakness during epidural analgesia must be treated with suspicion until proven to be reversible. [42].  Patients who have significant weakness of the leg should have epidural infusion stopped and if no motor recovery occurs within 4 hours, an urgent MRI scan should be performed [45] .

Direct penetration of the spinal cord during epidural catheterisation and subsequent injection of fluid into the substance of the cord, leading to localised hydromyelia has been proposed as one of the mechanisms for severe neurological complications resulting from epidural anaesthesia and analgesia [64]. Examination shows segmental levels of motor and sensory impairment which corresponds to the level of spinal cord injury. MRI shows tubular, clearly demarcated lesions which are hyperintense on T2 weighted images and hypointense on T1.

Air bubbles in the cord has been identified in patients who have become paraplegic after epidural anesthesia [65].

Local anesthetic drugs have been found to be potentially neurotoxic in experimental studies [66]. Polyethylene glycol found in methylprednisolone acetate is known to cause necrosis of neuronal tissue [67]. Injection of these neurotoxic drugs into the cord can cause damage to the cord.
Intravenous high dose methylprednisolone may be of value in these patients with cord damage.

Arachnoiditis and subarachnoid cyst

Arachnoiditis as a complication of epidural anesthesia has been reported.  Torres et al [68] reported 7 cases where patients developed arachnoiditis following epidural anesthesia. Subarachnoid cysts developed in all patients and in 5 cord cavitation developed. MRI was found to be useful in the detection of the arachnoiditis and the intramedullary cysts, as well as to monitor the extent of the lesion and progression of the lesions. In one case a tethered cord was present and in another there was spinal cord atrophy.

Possible etiology of these complications include scars from meningeal inflammation which induce ischemia leading to cavitation. CSF circulation blockade can also cause dilation of the central spinal canal which results in ischemia from compression followed by myelomalacia and cavitation.
Although progressive inflammation of the arachnoid due to trauma, infection, or hydrocortisone has been reported since the early 1970s,  coexistence of extensive syringomyelia (ES) and a giant anterior arachnoid spinal cyst (AASC) had not been reported until 2012. In 2012 Hirai et al [69] reported a case of adhesive arachnoiditis with extensive syringomyelia and a giant arachnoid cyst after spinal and epidural anesthesia. They had a  29 years old woman who presented with sudden anuresis 5 months after spinal/epidural anesthesia for cesarean section. She subsequently developed paraplegia with numbness below the chest. An MRI showed a giant AASC compressing the spinal cord at T1-T6 and there was an adhesive lesion at T7. Slight improvement in motor function occurred after
posterior laminectomy at T6-T7 and adhesiolysis at T7. Three years after the surgery motor function deteriorated further and posterior laminectomy at T5-T6 with insertion of a cyst-peritoneal shunt into the AASC was carried out.

Nogués et al [70] published a report where 3 women who had epidural anesthesia for gynecological surgery developed spinal arachnoiditis which led to subarachnoid cysts and cord cavitation. They found that MRI is useful for making a diagnosis and monitoring the extent and progress of the lesion.

Conclusion

Epidural anesthesia and analgesia (EAA) are extensively used in clinical practice for surgery and postoperative analgesia. Epidural anesthesia and analgesia reduces surgical complications and improve clinical outcomes.

Studies show a significant reduction in perioperative cardiac morbidity, pulmonary infections, deep vein thrombosis, pulmonary embolism, ileus, acute renal failure, blood loss and need for transfusion with EAA. The length of hospital stay and the 30 day mortality is also reduced with EAA. The incidence of postoperative infections is significantly reduced in patients treated with EAA. Though EAA is generally regarded as safe and effective, serious devastating neurological complications can occur following EAA.

Epidural abscess, meningitis, epidural haematomas, hydromyelia, cord cavitation, arachnoiditis and arachnoid spinal cysts are known complications of EAA which can produce serious and sometimes permanent neurological deficit including paraplegia. Prompt diagnosis and early aggressive treatment is essential for a good clinical outcome.

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Anterior dislocation of the shoulder

                  Anterior dislocation of the shoulder     

                                          Dr KS Dhillon

Anatomy of the shoulder Joint

Glenohumeral joint 

The shoulder joint also known as the glenohumeral joint is formed by the articulation of the head of the humerus with the glenoid cavity of the scapula. The head of the humerus is much larger than the glenoid fossa (only 25–30% of the humeral head is covered by the glenoid surface). To reduce the disproportion in the size of the surfaces, the glenoid fossa is deepened by a fibrocartilage rim, called the glenoid labrum. The articular margins are covered with hyaline cartilage. The joint capsule extends from the anatomical neck of the humerus to the rim of the glenoid. The shoulder capsule is large, loose and redundant to allow greater mobility at the joint. The inner surface of the capsule is lined with synovial membrane.

Ligaments of the joint

At the anterior portion of the capsule is reinforced by the glenohumeral ligaments including the superior, medial and inferior glenohumeral ligaments. These ligaments provide anterior stability to the shoulder. Superior stability is provided by the coracohumeral ligament which extends from the base of the coracoid process to the greater tubercle of the humerus. A transverse humeral ligament which spans the distance between the two tubercles of the humerus holds the tendon of the long head of the biceps in the intertubercular groove. Another ligament, the coracoacromial ligament runs between the acromion and coracoid process of the scapula and it forms the coracoacromial arch.  This ligament lies superior to the shoulder joint and prevents superior displacement of the humeral head.

Muscles and tendons

The clinically important contractile structures of the shoulder joint are the supraspinatus, infraspinatus, subscapularis and, of less importance, the teres minor. They form the rotator cuff and these muscles arise from the scapula and attach to the tuberosities of the humerus. Superficially these muscles are separate but in the deeper region they merge with each other as well as with the capsule and the tendon of the long head of the biceps.

Movements of the shoulder joint

The glenohumeral joint is the most mobile joint in the human body. The movements at the shoulder joint include abduction, adduction, flexion, extension, internal and external rotation.

Abduction

The supraspinatus muscle and the deltoid muscle are responsible for this movement. The muscle plays an important role in initiation of abduction. When this tendon is completely torn the patient can no longer lift the arm actively and must make a swinging movement of the whole body in order
to start the movement. Once the arm has moved through 30° of abduction, the deltoid takes over to complete abduction. During full elevation of the limb to 180 degrees only 90 degrees takes place at the glenohumeral joint and the rest occurs at the scapulothoracic region. The deltoid is the prime mover and the supraspinatus is the accessory muscle.

Adduction

Adduction of the arm is performed by the teres minor and major, pectoralis major, latissimus dorsi and the long head of the triceps brachii. The pectoralis major and latissimus dorsi are the prime movers while the
teres major and long head of triceps brachii are the accessory muscles.

Flexion

Flexion of the arm is carried out by the pectoralis major, deltoid, coracobrachialis and the biceps brachii. The pectoralis major and deltoid are the prime movers while coracobrachialis and the biceps brachii are the accessory muscles.

Extension

Extension of the arm is performed by the deltoid, teres major, latissimus dorsi and the long head of the biceps brachii. The deltoid is the prime mover and the teres major, latissimus dorsi and the long head of biceps brachii are the accessory muscles.

Medial Rotation

Medial or internal rotation is carried out by the subscapularis, pectoralis major, deltoid, latissimus dorsi and teres major. The subscapularis is the prime mover and the pectoralis major, deltoid, latissimus dorsi and teres major are the accessory muscles.

Lateral Rotation

Lateral or external rotation is performed by the infraspinatus, teres major and the deltoid. The infraspinatus is the prime mover and teres major and deltoid are the accessory muscles.

Dislocation of the Shoulder Joint

Dislocations of the shoulder are described by the position of the humeral head in relation to the glenoid fossa after a dislocation has occurred. Anterior dislocations are the most common with prevalence rate of 95%. The prevalence rate for posterior is 4% and for inferior dislocations is 1%. The presence of the coraco-acromial arch superiorly prevents superior dislocation of the femoral head.

Anterior shoulder dislocation

Anterior shoulder dislocation has a bimodal age distribution. The first and the largest group are young adult men who sustained high-energy injuries to the shoulder. The second peak occurs in patients over the age of 60 years. This older group of patients are those who have a dislocation from a much lower level of violence. In the older group of patients early reduction and early mobilization to prevent joint stiffness is the management priority.

In the younger group of patients the risk of recurrent dislocation strongly correlates with the severity of initial injury the age of the patient. The risk is particularly high in the 16–30 year old group.
In anterior dislocation of the shoulder, violent external rotation in abduction  causes the humeral head to lever out of the glenoid socket. This is sometimes associated with avulsion of anterior bony and soft tissue structures. When a portion of the anterior labrum is detached from the glenoid and the anterior glenoid periosteum is torn, the lesion is referred to as a Bankart's lesion. Magnetic resonance arthrography shows that the prevalence of these lesions after first time anterior dislocation is about 23% [1]. When the posterior part of the humeral head exits the joint, the head collides with the anterior rim of the glenoid, creating a bony indentation at the back of the humeral head. This bony defect are known as a Hill Sachs lesions, the prevalence of which is as high as 71% after an anterior dislocation [1].

Clinical presentation

Following an anterior dislocation of the shoulder, the patient presents with severe pain and the arm is held in an abducted and externally rotated position. The normal counter of the shoulder is lost and a defect is palpable anterior, lateral and inferior to the acromion. The humeral head is usually palpable anteriorly in the region of the coracoid process.

Bony injury

Carrying out X rays of the shoulder including an AP and axillary view is mandatory for the diagnose an anterior dislocation of the shoulder as well as to exclude associated fractures. Hill Sachs lesions can be seen in 54% of the patients[2]. In older patients an associated greater tuberosity fracture is quite common.

Vascular injury

Stayner et al [3] reported two cases of axillary artery injury in 95 cases of shoulder dislocation which amounts to a prevalence rate of about 2%. This injury occurs more frequently in the elderly whose arteries are artherosclerotic.

In patients with axillary artery injury the pathognomonic triad consisting of anterior shoulder dislocation, absent or diminished distal pulses and protruding axillary haematoma is present [4]. Since the upper limb has an excellent collateral circulation, the radial pulse can be palpable and good capillary filling present despite the presence of major arterial injury [4]. The presence of reduced pulse pressure and coolness in the hand warrants an urgent angiography. Upper limb ischemia may be due to arterial spasm which does not need surgery. An angiogram can distinguish transient spasm from a tear which requires surgery.

Nerve injury

Nerve injuries are common after anterior dislocation of the shoulder. Visser et al [5] carried out a prospective clinical and electrophysiological examination in 77 patients with anterior dislocation of the shoulder. They found axonal loss in 48% of the patients. The axillary nerve was most frequently involved (42%). Function of the shoulder was significantly impaired in patients with axillary and suprascapular nerves injuries. They found that increasing age and presence of haematoma are unfavourable prognostic factors.

Te Slaa et al [6] reported a 21% incidence of nerve injuries in patients with primary glenohumeral dislocation. Atef et al [7] reported a much lower incidence of nerve injury in patients with anterior dislocation of the shoulder. They report isolated axillary nerve injury in 3.33% of the patients and combined nerve injuries in 12.5% of the patients. Most of the nerve injuries recover fully without intervention. There are some more severe injuries which do not recovery.
Brachial plexus injury can be associated with shoulder dislocation. These injuries are usually postganglionic, infraclavicular and in continuity. Hence the prognosis for recovery is excellent [8,9].

Rotator cuff tears

As with nerve injuries, the incidence of rotator cuff tears also vary widely. The incidence of rotator cuff tears in patients with anterior dislocation varies between 14%–65%.  The incidence of this complication increases with increasing age [10].

Treatment of anterior dislocation shoulder

There is no consensus in the literature on the best technique for reduction of a dislocated shoulder. Success of any technique would depend on the surgeon's familiarity and analgesia used [11].
The easiest way to reduce the dislocation is by manipulation under general anesthesia. However most of the dislocation are usually reduced in the emergency department.

Chitgopkar and Khan  [12] were able to reduce 10 out of 12 anterior dislocation of the shoulder by using the original Kocher's technique without any sedation or anesthesia. The original Kocher’s method is apparently gentle and  painless. The patient initiates the movements, the surgeon just guides the patient through the manoeuvre. In 2 patients the humeral head had to be guided proximally and laterally using an index finger in the axilla. The patients can  go home immediately after the procedure.

Uglow [13] carried out a prospective randomised trial involving 45 patients with an anterior dislocation of the shoulder who were randomised into one of two treatment groups and manipulation was performed using Kocher's  method. In one group entonox was used and in the other intravenous sedation was used. A successful reduction was achieved in 80.9% of Entonox group and in 100% of intravenous sedation group.

Kosnik et al [14] carried out a prospective, randomized, non blinded clinical trial involving 49 patients who had anterior dislocation of the shoulder to evaluate whether local intraarticular lidocaine injection is as effective as effective as intravenous analgesia/sedation in facilitating shoulder dislocation. They found that intravenous analgesia/sedation had a higher success rate (100%) as compared to intraarticular lidocaine injection (86%), the differences, however, were not statistically significant (P = 0.16).

Wakai et al [15] carried out a Cochrane systematic review to compare the clinical efficacy and safety of intra-articular lignocaine (IAL) and intravenous analgesia (with or without sedation) (IVAS) for reduction of acute anterior shoulder dislocation. They found no significant difference between IAL and IVAS with regard to the success rate of reduction, pain during reduction, post-reduction pain relief. IAL is apparently less expensive and associated with fewer adverse effects and the recovery time is also shorter with IAL.

Taylor et al [16] carried out a multicenter, randomized, clinical trial to compare propofol and midazolam/fentanyl for reduction of anterior shoulder dislocations using the modified Kocher's maneuver. They found propofol to be as effective as midazolam/fentanyl for reduction of anterior shoulder dislocation. They cautioned that the advantage of shorter wakening times with propofol should be weighed against possible adverse events such as respiratory depression and vomiting.
Gleeson et al [17] carried out a study to compare the use of supra-scapular nerve block with intra-articular lignocaine for reduction of anterior dislocation of the shoulder. They found that intra-articular lidocaine injection was easier to perform and also was more effective for pain relief.
Gleeson et al [18] in another study compared the effectiveness of Entonox to intra-articular local anaesthetic for shoulder reduction and found that Entonox was more effective then intraarticular local anesthetic for pain relief.

Management post reduction

Traditionally after the shoulder has been relocated it is immobilised in an arm sling in a position of internal rotation for about 3 weeks. Some have, however, challenged this tradition.

Hoveliu et al [19] carried out a study involving 245 patients with 247 primary anterior dislocations of the shoulder who were followed up for 10 years after the dislocation had been reduced. Post reduction patients were assigned to one of three treatment groups: immobilization with arm sling which was discontinued once the patient was comfortable, immobilization with arm tied to torso with a bandage for 3 to 4 weeks or immobilization for various duration. They found that the type and duration of the initial treatment had no effect on the shoulder dislocation recurrence rates.

Itoi et al [20] carried out a magnetic resonance imaging (MRI) study in patients who had had a dislocation of the shoulder to assess the degree of coaptation of the Bankart lesion with the arm in internal rotation and  external rotation. They found that the degree of separation of the torn labrum was significantly less in external rotation than in internal rotation. This would mean that immobilisation in a sling with the arm in an external rotation position would reduce the incidence of recurrent dislocation.

In 2003, Itoi et al [21] published the outcome of a prospective study involving 40 patients with anterior dislocation, where post reduction, 20 patients had conventional immobilization in internal rotation and the other 20 patients had their arm immobilized in external rotation. They found that the dislocation recurrence rate was 0% in the external rotation group and the recurrence rate was 30% in the internal rotation group at a mean follow up of 15.5 months. The difference in recurrence rate was even greater in patients less than 30 years of age, with a recurrence rate of 45% in the internal rotation group and 0% in the external rotation group.

Whelan et al [22] carried out a meta-analysis of randomized controlled trials to assess the effectiveness of internal rotation versus external rotation immobilization on the rate of recurrence after primary anterior dislocation of the shoulder. They found that immobilization in external rotation was not significantly more effective in reducing the recurrence rate.

Hanchard et al [23] carried out a Chochrane systematic review to assess the effects of conservative treatment after closed reduction of anterior dislocation of the shoulder. Their review showed that evidence from randomised controlled trials existed only for a single approach i.e immobilisation in external rotation versus immobilisation in internal rotation. The evidence available was insufficient to demonstrate whether immobilisation in external rotation was any better then immobilisation in internal rotation.

Paterson et al [24] carried out a systematic review and meta-analysis of the literature to determine the optimum duration and position of immobilization of the shoulder after anterior dislocation to prevent recurrent dislocation.

They found that there is no benefit of conventional sling immobilization for
longer than one week for the treatment of primary anterior shoulder dislocation in younger patients. They also found that an age of less than
thirty years at the time of injury was significantly predictive of recurrence.

Recurrent dislocation

The risk factors for recurrent dislocation of the shoulder are young age, participation in contact sporting activities, presence of Hill-Sachs or osseous Bankart lesion, ipsilateral rotator cuff or deltoid muscle insufficiency, and underlying ligamentous laxity.

Hoveliu et al [19] carried out a study involving 245 patients with 247 primary anterior dislocations of the shoulder who were followed up for 10 years after the dislocation had been reduced.They found a recurrence rate of 48%. The recurrence rate in the 12 to 22 year age group was 34%, 28% in the 23 to 29 year age group and 9% in the 30 to 40 year age group. Twenty three percent of the patients with recurrent dislocation needed surgery.

Twenty-two per cent of the shoulders that had at least two recurrences in the first two to five years stabilized spontaneously without operative intervention at ten years follow up.
Simonet and Cofield [25] carried out a study involving 116 patients with anterior dislocation of the shoulder. Their study showed a 33% recurrence rate. The incidence of recurrent dislocation was 66% in those less then 20 years old and 40% in those between 20 and 40 years of age. There were no recurrent dislocations in those who were older than 40 years of age. The recurrence rate was 82% in young athletes and 30% in non athletes of the same age.

Some patients do not experience repeat dislocation but may suffer from recurrent subluxation of the joint which limits their overall activity levels.

Treatment of recurrent anterior dislocation

There are numerous surgical procedures available for treatment of recurrent shoulder dislocation. These include open Bankart, arthroscopic Bankart, Latarjet, Bristow, and older techniques, such as Putti-Platt and Magnuson-Stack. Arthroscopic and open Bankart operations to repair the labral tear are usually performed on patients with glenoid labral tears. In patients with glenoid bone loss the Latarjet or Bristow procedure is usually carried out. In both the Latarjet and Bristow procedures the coracoid process is osteotomized and transferred with the conjoined tendons through a horizontal split in the subscapularis tendon and fixed to the scapular neck near the glenoid with a screw. The Putti-Platt and Magnuson-Stack procedures are nonanatomic historical procedures where shortening and tightening of the subscapularis tendon is carried out.

Glazebrook et al [26] carried out a systematic review of the literature to assess the quantity and quality of scientific evidence available for surgical procedures used in the treatment of anterior shoulder dislocations.

They allocated a grade of recommendation for each surgical procedure based on the quality of the studies. Grade A recommendations were based  on consistent level 1 studies, grade B recommendations on level 2 or 3  studies and grade C recommendations were based on level 4 or 5 evidence. Grade I articles have insufficient evidence to recommend a treatment.

They found evidence for grade A recommendation for four surgical procedures. The arthroscopic Bankart, open Bankart, and Latarjet procedures were given grade A for recommendation and the Putti-Platt procedure was given a grade A against recommendation.

Six surgical procedures were given a grade B recommendation. Arthroscopic remplissage, remplissage, and arthroscopic lavage were given grade B in favour of recommendation. Bristow, open capsular shift and thermal capsulorrhaphy were given a grade B against recommendation.

There were 11 grade C surgical procedures with 7 against and 4 in favour of recommendation. The 7 against recommendation procedures included Magnuson-Stack, Bankart and remplissage, Boytchev, Eden-Hybbinette, arthroscopic staple capsulorrhaphy, stapling operation, and Caspari technique. The 4 in favour of grade C recommendation included J graft, arthroscopic Latarjet, Latarjet-Patte, and iliac crest bone graft.

The Putti-Platt procedure is not recommended any more. It is an old procedure and the literature on the subject is outdated. Limitation of range of motion is common and the redislocation rates are very high. The most extensively studied procedure is the Bankart’s procedure. Most published studies report superior outcome with open Bankart as compared to arthroscopic Bankart, with a lower recurrence rate and no significant difference in complication rate [27,28]. There are also studies which suggest that the arthroscopic Bankart and open Bankart show comparable postoperative results in terms of stability, range of motion, and complications [29,30]. There are other level 1 studies which suggest that both surgical procedures are adequate but arthroscopic Bankart offers better postoperative results with greater stability, fewer complications, and better range of motion [31]. The Latarjet procedure has been reported to give promising results with low recurrence rates, high graft union rates, satisfactory clinical outcome scores, and few complications [32-34].

Historically, open repair remains the gold standard treatment against which other treatment options are compared. The open repair is associated with a 95% reduction in re-dislocation[2].

Long-term prognosis

Hovelius et al [2] reported an 8.7% incidence of moderate to severe osteoarthritis in patients who had their first dislocation when they were below the age of 40 years.

Ogawa et al [35] reported a higher incidence of osteoarthritis in patients with traumatic anterior shoulder instability who were due for surgery. Plain X-rays showed osteoarthritis in 11.3% of cases whereas CT scans showed osteoarthritis in 31.2% of the cases.
It would appear that osteoarthritis is not an uncommon complication of  anterior dislocation of the shoulder.

Conclusion

Anterior dislocation of the shoulder is the most common dislocation in the human body. There is a bimodal age distribution in patients with anterior dislocation. The first and the largest group are young adult men who sustained high-energy injuries to the shoulder. The second peak occurs in patients over the age of 60 where the level of violence is low. In the younger age group the incidence of recurrent dislocation can be very high. Anterior dislocation of the shoulder can be associated with rotator cuff tears, vascular injury, nerve injury and bony injury.

There is no consensus in the literature on the best technique for reduction of a dislocated shoulder. Several techniques have been described and there is no one technique which is more superior to another. There is also no consensus in the literature as to the method and duration of shoulder  immobilization after the dislocation has been reduced.

The incidence of recurrent dislocation varies between 9% to 82%. It is the highest (82%) in young athletes. The incidence of recurrent dislocation reduces as we age.

There are a large number of procedures which can be used to treat recurrent dislocation. The most commonly used techniques include Bankart’s repair and the Latarjet procedure. Not all patients with recurrent dislocation would require surgery. Some stabilize spontaneously with time.

Osteoarthritis is not an uncommon long term complication of shoulder dislocation.

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27. An, VVG, Sivakumar, BS, Phan, K, Trantalis, J. A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs Bankart repair. J Shoulder Elbow Surg. 2016;25(5):853–863.
28. Freedman, KB, Smith, AP, Romeo, AA, Cole, BJ, Bach, BR. Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for recurrent anterior instability of the shoulder. Am J Sports Med. 2004;32(6):1520–1527. 
29. Bottoni, CR, Smith, EL, Berkowitz, MJ, Towle, RB, Moore, JH. Arthroscopic versus open shoulder stabilization for recurrent anterior instability. Am J Sports Med. 2006;34(11):1730–1737.
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Management of Intracapsular Neck of Femur Fractures

     Management of Intracapsular Neck of Femur Fractures

                                            Dr KS Dhillon

Anatomy of the proximal femur

The proximal femur consists of the head, neck, lesser trochanter and the greater trochanter. The head is approximately two-thirds of a sphere and its surface is articular except for fovea capitis femoris where ligament of head is attached. The greater trochanter is large prominence which projects upward from shaft on lateral aspect of junction of neck and the shaft of the femur and the lesser trochanter is protuberance on posteromedial side. The  intertrochanteric crest, extends between two trochanters on the posterior aspect and on the anterior aspect a wide, rough intertrochanteric line stretches from greater to lesser trochanter.

The neck extents from the head to the intertrochanteric region and it forms an angle of 125 degrees with the femoral shaft. The angle can vary between 120 to 135 degrees. The angle is less in adults, females and in short people. When the angle is more then 135 degrees, it is referred to as coxa valga and when less then 120 degrees it is referred to as coxa vara.

The head is anteverted between 5-15 degrees and when the anteversion is less then 15 degrees it is referred as increased femoral anteversion. When the the anteversion is less then 5 degrees, the condition is termed femoral retroversion.

The neck shaft angle is 140 degrees and the anteversion is 40 degrees at birth, both of which decreases as we become adults.

The blood supply to the head comes from three blood vessels. The foveal artery which is a branch of the obturator artery supplies the foveal region. The profunda femoris gives out two branches, the medial and lateral femoral circumflex. The ascending branch of the lateral femoral circumflex anteriorly and medial femoral circumflex posteriorly form an extracapsular arterial ring. This ring gives rise to ascending cervical arteries which form a subsynovial intracapsular arterial ring at the base of the head.

Classification of Intracapsular neck fractures 

Depending on the location, the fracture can be subcapital, transcervical or basicervical. Gardens classification is commonly used of intracapsular neck fractures [1].

Type                     Description                                  Undisplaced/Displaced
 I               Valgus impacted incomplete fracture                Nondisplaced
                 Lateral cortex fractured, medial intact 
II               Complete fracture                                              Nondisplaced
III              Complete fracture with partial displacement      Displaced
IV              Complete fracture with complete displacement  Displaced

Table I. Garden's classification

The Pauwel classification divides the fractures three groups based on the inclination of the fracture line relative to the horizontal. In Type I the inclination is less than 30°; in Type II, 30° to 50°; and in Type III it is greater than 50°. As the angle of inclination increases, the transition of forces from being compressive to shearing occurs [2]. The AO classification for intracapsular fractures is too complicated and its use is not recommended [3].

The  reliability of the Garden classification is poor with interobserver Kappa values of between 0.03 and 0.56 [4-7]. Despite the poor reliability of the Garden’s classification it is still the most commonly used classification.

The interobserver reliability of the Pauwels classification is also poor with overall kappa values around 0.31[8].

In order to improve reliability of the Garden classification, some have recommended simplifying the classification by having only 2 groups i.e displaced versus nondisplaced fractures [9,10]. Better Kappa values of between 0.67 and 0.77 have been reported with this simplified classification [9,11].

Treatment of intra-articular femoral neck fractures

Globally with the increasing mean age of the population, the incidence of hip fractures is bound to increase in years to come. These fractures are a common source of morbidity and mortality.

Management of these fractures depends on several factors such as preinjury ambulatory status, age of patient, cognitive function, and comorbidities as well as on fracture factors, such as age of the fracture, displacement of the fracture and the degree of osteoporosis.

The treatment options available include nonoperative and operative treatment for these fractures. Operative options include, percutaneous fixation, closed reduction with internal fixation, open reduction with internal fixation and arthroplasty. With several treatment options available, what then is the best treatment option?

Nondisplaced femoral neck fracture

The premorbid condition of the patient is important in determining whether to treat nondisplaced femoral neck fractures conservatively or surgically. Patients who are elderly and at high risk of anesthesia and surgery-related complications are ideally treated conservatively. Elderly patients who are nonambulatory and those who are severly demented can be treated conservatively. Surgical fixation for nondisplaced will prevent displacement of undisplaced fractures and allow for early mobilization of thr patient.

Nondisplaced fractures can be treated by percutaneous pinning or screw fixation. Zu et al [12] in 2017 carried out a systematic review of the treatment of undisplaced femoral neck fractures in the elderly. Their review included 29 studies involving 5071 patients. One thousand one hundred twenty patients were treated conservatively and 3951 had surgical treatment. The union rates were 68.8% in patients treated conservatively and 92.6% in patients treated surgically. The incidence of avascular necrosis was 10.3% in patients treated conservatively and 7.7% in those treated surgically. Fixation failure rate was low at 3.3%.

Surgical treatment is the treatment of choice for undisplaced fractures of the femoral neck in younger patients (less then 65 years). Conservative treatment is reserved for patients whose surgical risks outweigh any benefits from the surgery. Union rates are higher with operative treatment [13-15].

Oñativia et al [16] carried out a systematic review to study the outcome of treatment of undisplaced femoral neck fractures with screw fixation in the elderly (more then 60 years) patients. Three studies reported mortality rates of 18.8%; 22%, and 19% at one year follow up. One study reported mortality rate of  42% at 5 years. The overall reoperation rate ranged from 8%-19%, with conversion to hip arthroplasty in 8% and16% of the patients.

The authors concluded that internal fixation with cannulated screws for undisplaced fractures of the femoral neck in the elderly is a valuable option despite the substantial reoperation and mortality rates.

Displaced femoral neck fractures

Treatment options for displaced femoral neck fractures include closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty and total hip replacement.

Parker and Stockton [17] carried out a Cochrane database systematic  review to determine which implant is superior for the internal fixation of intracapsular proximal femoral fractures. The review included 28 randomized or quasi randomized trials of 5,547 patients with femoral neck fractures who were treated with 19 different pin and/or screw constructs. They found that no one implant was superior to another when it came to outcomes such as fracture healing, AVN, infection, pain scores, reoperation rate, use of walking aids, periprosthetic fracture, or mortality. The sliding hip screw took longer to insert and was associated with an increased blood loss as compared to other modes of fixation.

Parker and Blundell [18] carried out a meta-analysis of 25 randomized controlled clinical trials (RCTs) involving 4,925 patients with intracapsular femoral neck fractures who were treated with various implants. They also found that no one implant was superior to another with regards to nonunion and fracture displacement rates. There was limited evidence of superiority of screw fixation over smooth pins. There was no advantage in using a side
plate for fixation.

Internal Fixation Versus Hemiarthroplasty

Masson et al [19] carried out Cochrane Database systematic review to compare internal fixation with hemiarthroplasty for treatment of displaced femoral neck fractures. The review included 13 trials involving 2091 patients. They found that with internal fixation the duration of surgery was shorter, operative blood loss was less, less blood transfusion were needed and the infection rates were lower when compared to hemiarthroplasty surgery. Arthroplasty on the other hand had a lower re-operation rate as compared to fixation (8% vs 31%). There was no difference in the length of hospital stay, mortality, degree of residual pain and postoperative mobility.

Parker et al [20] carried out a prospective randomised study to compare the outcome of internal fixation as compared to hemiarthroplasty in patients over the age of 70 years with displaced fracture of the femoral neck. The study included 455 patients. They found no differences in the outcomes for
pain, mobility, or mortality at 3-year follow-up. The revision rate was 5% for the hemiarthroplasty group and 40% in the internal fixation group.

Rödén et al [21] carried out RCT of 100 patients with displaced femoral neck fracture who were treated either with screw fixation or a bipolar prosthesis. The patients were more then 70 years old and were ambulatory before the injury. The duration of surgery was shorter and the blood loss was less in the internal fixation group. The revision rates were very high (34 of 53 patients) in the internal fixation group. Seven out of 47 patients with hemiarthroplasty had a postoperative dislocation. The mortality rates were similar at  2- or 5-year follow-up.

Rogmark et al [22]  carried out an RCT comparing internal fixation with hemiarthroplasty. At 2-year follow-up, those patients who hemiarthroplasty had improved walking and stair climbing ability, and less pain as compared to those who had internal fixation.

Lu-Yao et al [23] carried out a meta-analysis of 106 reports on the treatment of displaced fractures of the femoral neck. They found that within the first 2 years of follow up, 33% of patients who had internal fixation of a displaced fracture of the femoral neck, developed a non-union and 16% developed avascular necrosis. The reoperation rates were 20% to 30% in patients who had internal fixation as compared to 6% to 18% after hemiarthroplasty. They found that the mortality rate at thirty days was higher in patients who had a hemiarthroplasty as compared to patients who had internal fixation. The difference, however, was not significant (p = 0.22) and the difference did not persist beyond three months. The mortality rates at 2 months were lower in patients who had an anterior operative approach for the arthroplasty as compared to a posterior approach.

Fracture of the neck are common in the elderly and hence most of these studies were carried out in elderly patients. There is a paucity of literature on the outcome of treatment in the younger population.Though the outcome in patients with hip arthroplasty appear to be better then internal fixation in most of the studies, the goal of treatment in the younger population would be preservation of the hip by internal fixation of the fracture and dealing with complications as they arise.

Cemented or Cementless Hemiarthroplasty

The earlier hemiarthroplasty prosthesis known as the Austin Moore prosthesis were uncemented prosthesis. Then came the Thomson prosthesis which were cemented. These are still in use today. The outcome with cemented prosthesis is better then non-cemented prosthesis.

Parker et al [24] carried out a Cochrane systematic review to assess the outcome of cemented and uncemented hip arthroplasties for the treatment of femoral neck fractures. They found that there is good evidence which shows that cementing the prosthesis in place reduces postoperative pain and leads to better mobility.

Emery et al [25] carried out RCT of 53 hemiarthroplasties. Twenty seven patients had a cemented hemiarthroplasty, and 26 patients had a cementless hemiarthroplasty. At 17 month follow up they found no statistically significant difference between the groups as far as  postoperative complications such as surgical time, estimated blood loss, or mortality, were concerned. Patients with cementless stems, however,  experienced a much higher level of hip pain and were more dependent on walking aids.

Lo et al [26] also found less thigh pain in patients with cemented stem and their Harris Hip Score was higher then those with uncemented stems. There was no significant difference in complication and mortality rates.

Foster et al [27] found that 7% of the patients with cementless prosthesis had periprosthetic fracture while none of the patients cemented hemiarthroplasty had periprosthetic fracture. This study involved 244 patients, Austin Moore prosthesis were used in 70 patients and cemented Thompson prosthesis was used in 174 patients.

There is overwhelming evidence in the literature to support the use of a cemented prosthesis in the treatment of displaced femoral neck fractures in the elderly.

Unipolar or Bipolar Hemiarthroplasty

The bipolar prosthesis was introduced to reduce acetabular wear and revisions after a hemiarthroplasty by having prosthesis to prosthesis interface in a bipolar prosthesis. Many studies have tried to document superior results with a bipolar prosthesis.

A Cochrane systematic review by Parker et al [24], involving 7 trials with 857 participants and 863 fractures of the neck of the femur, comparing  unipolar hemiarthroplasty with bipolar  hemiarthroplasty showed no significant differences between the two types of implants.

There is level II evidence in the SIGN database which compares unipolar with bipolar prostheses. One of the studies by Eiskjaer et al [28] showed that there was radiological evidence that majority of motion in bipolar prosthesis occurred at the outer articulation (acetabulum-prosthesis interface). There was little or no motion at the motion at the bipolar interface. Hence the bipolar prosthesis are no different from unipolar prosthesis. The SIGN recommendations state that bipolar hemiarthroplasty should not be used in preference to unipolar hemiarthroplasty since there is limited evidence of clinical benefit of bipolar prosthesis.

Kanto et al [29] carried out a prospective, randomized controlled trial of 175 displaced intracapsular femoral neck fractures in patients over 65 years. Eighty eight had patients were treated with unipolar and 87 with bipolar prosthesis. They found no difference in revision rates between the two groups at 8 years follow up.

Ng and Lee [30] carried out a study involving 193 patients who had displaced femoral neck fractures. One hundred and eighteen of the patients were treated with unipolar prosthesis and 75 were treated with a bipolar prosthesis. At an average follow up of 4 years there was no difference between the two groups with regard to hip pain, functional hip scores, rates of acetabular erosion, component migration, revision surgery and complications rates. The authors concluded that the use of more expensive bipolar prosthesis in elderly patients is not justified.

Calder et al [31] performed a randomised prospective trial to compare a unipolar prosthesis with a bipolar prosthesis in the treatment of hip fractures in patients over the age of 80 years. At 2 years follow up they found no statistical difference between the rate of complications in the two groups. The degree of return to the preinjury state was significantly greater (p = 0.04) in patients with unipolar prosthesis. The cost of a unipolar prosthesis, according to the authors, is one quarter that of a bipolar.  The authors concluded that there can be no justification for the use of an expensive bipolar prosthesis in patients over 80 years of age.

The above studies provided level I evidence in support of unipolar prosthesis. There are several studies which favour the use of bipolar prosthesis and these include studies by Eiskjaer and Ostgård [32] (level II evidence), Yamagata et al [33] (level III evidence) and Haidukewych et al [34] (level IV evidence).

Internal Fixation or Total Hip Arthroplasty (THA)

There are several studies which provide level I and II evidence that THA
leads to better outcomes than internal fixation in patients with displaced femoral neck fractures. The function scores are higher and revision surgery rates are lower in patients treated with THA, as compared to those treated with internal fixation [35-42]. This can be an option in patients who are elderly, healthy and cognitively intact.

Complications of fracture neck femur

High mortality rates in patients with femoral neck are seen in the elderly population and not in the younger population. The young patients, however, suffer great morbidity due to high rates of osteonecrosis and non-unions.

Femoral head osteonecrosis 

The overall incidence of AVN of the femoral head in patients with femoral neck fractures has been reported to be as high as 25%. In young patients the average incidence AVN after femoral neck fractures is about 45% [43].

Several factors influence the development of osteonecrosis including age at the time of injury (AVN is less in older patients) the degree of displacement, posterior comminution, fracture line verticality and the quality of fracture reduction [44]. Most cases of AVN present within 2 years but it can manifest anytime between 6 months and 6 years [43].

Patients usually complain of groin, gluteal, or proximal thigh and or ipsilateral knee pain.The pain is usually deep seated, throbbing in nature and weight-bearing activities aggravate the pain. The pain can also be present at night.

In the early stages an MRI is the most useful imaging tool and in the later stages, x rays can demonstrate the presence of AVN. The Ficat and Arlet classification is commonly used for classifying the stages of AVN. They use a combination of plain x rays, MRI, and clinical features to stage avascular necrosis of the femoral head.

Ficat and Arlet Classification [45]

Stage 0

• Plain x rays: normal
• MRI: normal
• Clinical symptoms: nil

Stage I

• Plain x rays: normal or minor osteopenia
• MRI: edema
• Bone scan: increased uptake
• Clinical symptoms: pain usually in the groin

Stage II

• Plain x rays: mixed osteopenia and/or sclerosis and/or subchondral cysts, without subchondral lucency 
• MRI: geographic defect
• Bone scan: increased uptake
• Clinical symptoms: pain and stiffness

Stage III

• Plain x rays: crescent sign with/without cortical collapse
• MRI: same as plain radiograph
• Clinical symptoms: pain and stiffness hip with pain radiating to knee and limp
• Stage IV
• Plain x rays: end-stage with evidence of secondary osteoarthritis 
• MRI: same as plain radiograph
• Clinical symptoms: pain and limp

Haidukewych et al [46]  reported an overall AVN rate of 23% in 82 patients aged between 15 and 50 years, with 83 femoral neck fractures. Sixty five percent of the patients with AVN required total hip arthroplasty. Twenty nine percent of the patients with AVN did not have significant symptoms and did not require additional surgery. Jain et al [47] in a retrospective review of 38 patients with subcapital fractures of the femoral neck treated with internal fixation reported that the occurrence of AVN did not significantly affect patient functioning at the 2.5-year follow-up. Overall the rate of femoral head retention at 6 years is about 82% which would mean that about 18% of patients younger than age 50 years would require a total hip replacement [43].

Management of osteonecrosis of the femoral head

The definitive treatment of symptomatic AVN is total hip arthroplasty. However in young active patients this is not a suitable option. Several joint preservation options are available such as core decompression, bone grafting and femoral osteotomy.

Core decompression

Core decompression has been used in the treatment of idiopathic AVN. The procedure involves drilling a 10mm channel from the lateral femoral cortex to the center of the necrosis area to improve venous flow and improve perfusion of the femoral head. Its efficacy in post traumatic AVN has not been tested. This technique can only be used for Ficat grades I and II for pain relief. It however cannot prevent progression of the lesion [48]. Buckley et al [49] achieved a 90% success rate with core decompression combined with curettage of the necrotic area and insertion of autograft, in the treatment of atraumatic AVN. This technique will be more useful than core decompression alone in the treatment of traumatic AVN.

Bone grafting

Vascularised and non vascularised bone grafting has been used in the treatment of AVN. Various methods of bone grafting have also been used. Bone grafting is usually recommended in patients who have less than 2 mm of subchondral bone depression and when the femoral head involvement is less than 30% and also in patients when core decompression has failed [50].
Both vascularised and non vascularised fibular grafts have been used to treat non traumatic AVN.

Plakseychuk et al [51] compared the outcome of vascularized and nonvascularized fibular grafts for Ficat stages I to III AVN. At 7 years follow-up, the authors reported an 80% femoral head survival for stage I and II hips in the vascularized fibula group compared with 30% in the nonvascularized group. The results for stage III hips were poor in both  groups.

Rotational Osteotomy

The anterior-superior part of the femoral head is typically involved in  advanced osteonecrosis (stages III and IV). In such patients a rotational proximal femoral osteotomy can be carried out to shift the collapsed portion away from the weight bearing zone of the femoral head. This operation can only be carried out when at least 66% of the femoral head cartilage is intact [52]. Sugioka et al [53] have reported excellent results with rotational osteotomies of the proximal femur in patients with stage III and IV.  They reported a 73% success rate in stage III and a 70% success rate in stage IV disease at 3-year to 6-year follow-up. Gallinaro and Masse [54] obtained satisfactory outcome in 62.5% of their patients with stage II and stage III disease with a flexion osteotomy of the proximal femur.

Mont et al [54] were able to obtain good or excellent results in 76% of their patients who had osteotomies for stage II and stage III disease. Twenty four percent of their patients had a fair or poor result.

Total Hip Arthroplasty

The last option for the treatment of AVN is a total hip replacement. The earlier reports of total hip arthroplasty (THA) in patients with AVN showed poor survivorship and outcomes [56-60]. More recent reports, however, suggests that the survivorship or outcomes of THA for AVN are improving [61-64]. With better outcome of THA in patients with AVN, more patients are now offered a THA instead of joint salvage procedure.

Non-union

The incidence of non-union after femoral neck fractures varies between 10% to 33% [65]. The degree of initial fracture displacement, the quality of reduction and increasing age of the patient correlates with a higher risk of a non-union[66-69].

The patient typically presents with pain in the groin. X rays will show the presence of nonunion. When any doubt exists then a CT scan will help confirm the diagnosis.
The options available for treatment of a nonunion include, fixation with new implant, valgus osteotomy, prosthetic replacement and arthrodesis. In  young patients, salvage of the femoral head with preservation of the hip joint is desirable. This can be achieved by a valgus osteotomy or bone grafting [70].

A valgus osteotomy converts a vertical fracture line into a horizontal fracture line thereby converting the shearing forces parallel to the nonunion to compressive forces which promote healing.
Marti et al [71] published a large series of 50 patients with femoral neck nonunion who were treated with a Pauwel abduction osteotomy. The average age of the patients was 53 years and the average follow-up was  7.1 years. Forty-three of the 50 femoral neck nonunions healed (86% union rate). The seven femoral neck nonunions which did not heal were treated with prosthetic replacement. Other authors have reported union rates of between 85% to 100% [72].

Bone grafting is rarely used for treatment of femoral neck nonunions. Bone grafting is usually carried out when there is considerable loss of bone stock and in non-unions with well-aligned fractures where the shear angles are low [44].

Conclusion

Nearly half of the hip fractures involve the femoral neck and these fractures are seen in the elderly who sustain these fractures from simple falls. Femoral neck fractures are rare in young adults. Displaced femoral neck fractures in the elderly patients are treated with a hemiarthroplasty or a hip replacement. Non-displaced and valgus impacted femoral neck fractures are treated with internal fixation. Nonelderly patients are not suitable for hip arthroplasty and they are treated by hip preservation surgical procedures such as close or open reduction with internal fixation of the fracture.
Non surgical treatment is reserved for patients who are not fit to undergo a surgical procedure.
The outcome of surgical fixation of nondisplaced fracture is good but the treatment of displaced fractures is fraught with major complications such as nonunions and or AVN. Nonunions of femoral neck fractures can be treated with valgus osteotomy with very high success rate. Treatment of AVN can be a problem in young active patients. The treatment options for AVN are not so reliable and often a total hip arthroplasty is required which has a limited lifespan and is not suitable for young patients.

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