Femoral neck fracture Speaker : 骨科 林愈鈞 Modular : 簡松雄 主任

Patient profile Name ：游 XX 菊 Name ：游 XX 菊 Gender ： Female Gender ： Female Age ： 59 years old Age ： 59 years old Chart number ： Chart number ：

Chief complaint Right hip painful deformity Right hip painful deformity

Present illness The 59 year-old female was a victim of hypertension before. The 59 year-old female was a victim of hypertension before. On , she suffered from slipped down and felt right hip pain and can ’ t walk. On , she suffered from slipped down and felt right hip pain and can ’ t walk. She was brought to our OPD for help. She was brought to our OPD for help. Severe pain with limited ROM was noted. Severe pain with limited ROM was noted.

Physical examination Tenderness, swelling of the right hip Tenderness, swelling of the right hip ROM limitation (+), severe pain when moving ROM limitation (+), severe pain when moving

Past history Diabetes mellitus ： (-) Diabetes mellitus ： (-) Hypertension ： (+) Hypertension ： (+) Drug allergy ： denied Drug allergy ： denied Medication history ： (-) Medication history ： (-) Operation history ： (-) Operation history ： (-) Admission history ： (-) Admission history ： (-)

Tentative diagnosis Right femoral neck fracture, Garden type III Right femoral neck fracture, Garden type III

Plan Arrange open reduction and internal fixation with three cannulated screws Arrange open reduction and internal fixation with three cannulated screws

EBM Discussion

Evidence-Based Medicine Patient : A 59 y/o female was a case of femoral neck displaced fracture, right hip Patient : A 59 y/o female was a case of femoral neck displaced fracture, right hip Intervention : Open reduction and internal fixation Intervention : Open reduction and internal fixation Comparison : Arrangement of arthroplasty Comparison : Arrangement of arthroplasty Outcome : Open reduction and internal fixation was better than arthroplasty of the outcome Outcome : Open reduction and internal fixation was better than arthroplasty of the outcome

Evidence-Based Medicine One Question Sentence: Can open reduction and internal fixation be better than arthroplasty for the patient with femoral neck displaced fracture? One Question Sentence: Can open reduction and internal fixation be better than arthroplasty for the patient with femoral neck displaced fracture? Type of Question: Therapy Type of Question: Therapy Ideal Study type: SR of RCT or High-Quality RCT Ideal Study type: SR of RCT or High-Quality RCT Feasible Study type: SR of RCT or High-Quality RCT Feasible Study type: SR of RCT or High-Quality RCT Search Strategy Design : Database : PubMed Key words and search tactics: PCL + Avulsion fracture Search Strategy Design : Database : PubMed Key words and search tactics: PCL + Avulsion fracture

JAAOS 2005;13 P

Search Strategy Design

Abstract 1 Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. [Systematic Review] Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. [Systematic Review] Cochrane Database of Systematic Reviews. 1, Cochrane Database of Systematic Reviews. 1, This version 1st published online: 22 April 2003 in Issue 2, 2003.

Abstract 1 Search strategy: MEDLINE (1966 to January 2002), EMBASE (1988 to 2002, Week 2), Current Contents (1993 to 2002, Week 4), PREMEDLINE (January 2002) and selected orthopaedic journals and conference proceedings, and reference lists of relevant articles. Search strategy: MEDLINE (1966 to January 2002), EMBASE (1988 to 2002, Week 2), Current Contents (1993 to 2002, Week 4), PREMEDLINE (January 2002) and selected orthopaedic journals and conference proceedings, and reference lists of relevant articles. Selection criteria: All randomised and quasi- randomised trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults Selection criteria: All randomised and quasi- randomised trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults

Abstract 1 Thirteen trials involving 2091 patients were included Thirteen trials involving 2091 patients were included Main results : ★ Internal fixation had a reduced length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection. ★ Arthroplasty had a lower re-operation rate and total cost in comparison with fixation. ★ No definite differences for hospital stay, mortality, degree of residual pain, regain of mobility or regain of same residential state were found ★ Hip and other composite scores : ORIF v.s Hemiarthroplasty  No difference ORIF v.s THR  Better in the THR group Main results : ★ Internal fixation had a reduced length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection. ★ Arthroplasty had a lower re-operation rate and total cost in comparison with fixation. ★ No definite differences for hospital stay, mortality, degree of residual pain, regain of mobility or regain of same residential state were found ★ Hip and other composite scores : ORIF v.s Hemiarthroplasty  No difference ORIF v.s THR  Better in the THR group

Abstract 1 Conclusions: ★ Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip ★ Definite conclusions cannot be made for differences in pain and residual disability between the two groups. ★ The attending physician should choose the method which they feel is most appropriate for each individual patient. Conclusions: ★ Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip ★ Definite conclusions cannot be made for differences in pain and residual disability between the two groups. ★ The attending physician should choose the method which they feel is most appropriate for each individual patient.

Abstract 2 Internal fixation compared with arthroplasty for displaced fractures of the femoral neck: a meta-analysis (Structured abstract) Internal fixation compared with arthroplasty for displaced fractures of the femoral neck: a meta-analysis (Structured abstract) University of York, York, U.K. Centre for Reviews and Dissemination University of York, York, U.K. This version 1st published online: Journal of Bone and Joint Surgery. American volume, 2003;85-A(9):

Abstract 2 Outcomes assessment : Mortality, revision surgery, pain, function, complications (wound infection, hip dislocation, nonunion, avascular necrosis and post-operative confusion), blood loss and surgical time taken Outcomes assessment : Mortality, revision surgery, pain, function, complications (wound infection, hip dislocation, nonunion, avascular necrosis and post-operative confusion), blood loss and surgical time taken

Abstract 2 Search strategy: MEDLINE (1969 to June 2002); Science Citation Index and the Cochrane Controlled Trials Register; Four orthopaedic journals were handsearched (1998 to June 2002); bibliographies of two orthopaedic textbooks, and poster presentations of three orthopaedic societies (1996 to 2002). Search strategy: MEDLINE (1969 to June 2002); Science Citation Index and the Cochrane Controlled Trials Register; Four orthopaedic journals were handsearched (1998 to June 2002); bibliographies of two orthopaedic textbooks, and poster presentations of three orthopaedic societies (1996 to 2002). Selection criteria: Randomised or quasi-randomised trials study; Patients aged 65 years or older who had a displaced femoral neck fracture Selection criteria: Randomised or quasi-randomised trials study; Patients aged 65 years or older who had a displaced femoral neck fracture

Abstract 2 Twelve studies and two abstracts were eligible for inclusion (n=1,933) Twelve studies and two abstracts were eligible for inclusion (n=1,933) Result : ★ Mortality  No significant difference ★ Revision surgery  Arthroplasty significantly reduced the risk ★ Pain & function  No significant difference ★ Infection  Arthroplasty was significantly increased ★ Blood loss & surgical time  Arthroplasty was significantly increased Result : ★ Mortality  No significant difference ★ Revision surgery  Arthroplasty significantly reduced the risk ★ Pain & function  No significant difference ★ Infection  Arthroplasty was significantly increased ★ Blood loss & surgical time  Arthroplasty was significantly increased

Abstract 2 Conclusions : Arthroplasty significantly reduces the risk of revision surgery at the cost of greater infection rates, blood loss and operative time. Conclusions : Arthroplasty significantly reduces the risk of revision surgery at the cost of greater infection rates, blood loss and operative time.

Abstract 3 Comparison of internal fixation with total hip replacement for displaced femoral neck fractures: randomized, controlled trial performed at four years Comparison of internal fixation with total hip replacement for displaced femoral neck fractures: randomized, controlled trial performed at four years The Journal of Bone and Joint Surgery, Volume 87-A(8), August 2005, p 1680 – 1688 The Journal of Bone and Joint Surgery, American volume Volume 87-A(8), August 2005, p 1680 – 1688

Abstract patients (mean age, eighty years) were randomly allocated to be treated with total hip replacement or internal fixation. Methods : 102 patients (mean age, eighty years) were randomly allocated to be treated with total hip replacement or internal fixation. Inclusion criteria : an age of at least seventy years, absence of severe cognitive dysfunction, an independent living status, and the ability to walk independently. Inclusion criteria : an age of at least seventy years, absence of severe cognitive dysfunction, an independent living status, and the ability to walk independently. The main outcome measurements were hip complications, reoperations, hip function, and health- related quality of life. The main outcome measurements were hip complications, reoperations, hip function, and health- related quality of life. Forty-eight-month follow-up evaluation Forty-eight-month follow-up evaluation

Abstract 3 Results: THA : ORIF at the forty-eight-month follow -up evaluation Mortality rate  25% in both groups. – No significant difference Rate of hip complications  4% : 42% (p < 0.001) Reoperation rates  4% and 47%, respectively (p < 0.001) The arthroplasty group had no additional hip complications or reoperations between the 24 ~48 month follow-up visits. In the fixation group, the percentage of hip complications increased from 36% to 42% and the percentage of reoperations increased from 42% to 47% during the same period.

Abstract 3 The hip function was significantly better and the decline in health-related quality of life was less pronounced in the arthroplasty group than it was in the fixation group at the 4, 12, and 24-month follow-up evaluations. 97% of the patients in the arthroplasty group and 57% of the patients in the fixation group who were available for follow-up at forty-eight months had no hip complications (p < 0.001).

Abstract 3 Conclusions: Conclusions: Compared with internal fixation, primary total hip replacement provides a better outcome for mentally competent elderly patients with a displaced femoral neck fracture. Compared with internal fixation, primary total hip replacement provides a better outcome for mentally competent elderly patients with a displaced femoral neck fracture. The complication and reoperation rates were significantly lower and hip function and health-related quality of life were at least as good at four years after the surgery. The complication and reoperation rates were significantly lower and hip function and health-related quality of life were at least as good at four years after the surgery.

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