Rehabilitation after a hip fracture in Moscow - terms and methods of recovery in the center

A hip fracture is one of the most difficult injuries to treat and rehabilitate. Most often occurs in older people over 60 years of age. This is facilitated by age-related changes: a lack of calcium and phosphorus in bone tissue, a decrease in muscle tone due to a decrease in motor activity. The femur breaks at its thinnest part, at the junction of the bone and the head. The peculiarity of the injury is that a person becomes bedridden for a long time. Modern surgery offers surgical treatment using osteosynthesis and endoprosthetics.

What is the danger of a hip fracture?

Doctors believe that a hip fracture is not so dangerous as the complications it leads to. In older people, after injury, a number of concomitant diseases begin to appear.

A hip fracture disrupts the integrity of the muscles and vessels through which blood circulates, delivering nutrients and oxygen to cells. Due to injury, blood circulation in the injured limb is disrupted. Necrosis of the head of the bone occurs due to lack of nutrition. This situation leads to its decomposition and complete disappearance - aseptic necrosis.

Not every elderly patient can be cured surgically. If surgery for an injury is contraindicated for medical reasons, the person is treated with immobilization. A pensioner with a hip fracture remains in a supine position for about 6-8 months. He must not roll over on his side or stand up.

Being immobile increases the risk of developing pressure sores on protruding bones: the sacrum and heels. Mucus accumulates in the lungs, which can lead to pneumonia. A sedentary lifestyle causes intestinal atony. This is fraught with constipation and general intoxication of the body. Inflammatory processes may begin in the stomach, intestines, and bile ducts.

A recumbent lifestyle provokes the development of thromboembolism - the formation of blood clots on the walls of the main arteries. At any moment, a blood clot can break away from the walls, rush through the bloodstream to the heart and lead to death.

Mental complications are observed. Limited movements and space, pain, and one’s own powerlessness to change the situation negatively affect a person’s emotional state. Against this background, psychosis and depression develop. Some patients with a hip fracture cannot withstand conservative treatment and die.

Department of Traumatology and Orthopedics

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A. Y. ZAROV, V. R. GUDKOV

GBOU HPE First Moscow State Medical University named after. THEM. Sechenov, Moscow

ANO Central Clinical Hospital of St. Alexis of the Moscow Patriarchate, Moscow

Information about the authors:

Zarov Alexey Yuryevich – GBOU HPE First Moscow State Medical University named after I.M. Sechenov. Department of Traumatology, Orthopedics and Disaster Surgery, assistant department of the Central Clinical Hospital of St. Alexius of the Moscow Patriarchate

Gudkov Vitaly Robertovich – Central Clinical Hospital of St. Alexius of the Moscow Patriarchate

Currently, the opinion about the advisability of organ-preserving operations for fractures of the femoral neck is becoming increasingly widespread. Features of the anatomical structure and blood supply of this area lead to special tactics for treating intra-articular fractures of the femoral neck. This article provides an overview of modern osteosynthesis options, including osteosynthesis with cancellous screws, dynamic hip screws, and the Targon FN system.

Key words: cancellous screws, dynamic hip screw, osteosynthesis, femoral neck fracture.

Introduction

The incidence of fractures of the proximal femur, according to various estimates, ranges from 27 to 80 cases per 100 thousand population, with about 50% being intra-articular fractures of the femoral neck (Parker MJ, white A., Boyle A. 2008). In Russia, this figure is 61 cases per 100 thousand people and increases with the age of patients. Thus, 230 out of 100 thousand people over 75 years old experience fractures in this area (Shersternya N.A. 2005). An increase in the risk of hip fracture with age is associated with a progressive decrease in bone density - osteopenia (Babhulkar S., Tanna DD 2013). Osteopenic processes under the age of 60 are more pronounced in women, which is associated with hormonal changes in the postmenopausal period, however, in older patients, gender does not have a significant effect on the incidence of the disease (Vakulenko V.M. 2010).

Mortality during the first year after a hip fracture can be 16–28% and during the second year increases to 32.9% (Kurtinaitis J. et al. 2012). It is also important to note the significant functional impairment that develops in patients after a fracture (Johnell O., Kanis JA 2004). The quality of life of patients and mortality largely depend on whether surgical treatment was performed (Lesnyak O. et al. 2007). In recent decades, hip replacement has been considered the leading treatment method for femoral neck fractures. However, at present, some authors note the advantages of organ-preserving operations, mainly intramedullary osteosynthesis (Karev D.B. 2010; Sachse D. et al. 2014). Osteosynthesis operations take less time, cause fewer complications and are associated with less mortality (Parker MJ, white A., Boyle A. 2008). In this regard, more and more new metal structures are appearing for osteosynthesis of femoral neck fractures, which require study, improvement, and the formulation of selection criteria.

Anatomical aspects of femoral neck fractures

The proximal femur includes the head, neck, intertrochanteric and subtrochanteric regions of the femur. The neck of the bone is bounded by the boundaries of the head superiorly, the intertrochanteric line anteriorly, and the intertrochanteric ridge posteriorly (Babhulkar S., Tanna DD 2013). The plates of the spongy substance of the head and neck of the femur form a special system of trabeculae, the direction of the bundles of which corresponds to the lines of force. The intersections of the arcuate fascicle with the trochanteric and cephalic fascicles form two arches that can withstand heavy loads. In this case, the area between the two arches is the weakest and most susceptible to osteoporosis. Fractures of the femoral neck most often pass through this area (Kapandzhi A.I. 2010).

With a femoral neck fracture, there is also a disruption in the blood supply to the femoral head due to damage to the arteries and compression of the vessels by the intracapsular hematoma, while the greatest risk occurs with intra-articular femoral neck fractures. In subcapital fractures, when the fracture line passes distal to the entry into the head of the feeding vessels, only 8% of the blood flow is retained from a small number of vessels in the subcapital area and the vessels of the round ligament, which can lead to aseptic necrosis of the femoral head (Zhilyaev R.A., Tyazhelov A. .A., Zaritsky A.B. 2009).

It has been shown that different types of femoral neck fractures are accompanied by varying degrees of nutritional loss. Thus, subcapital abduction fractures without displacement are characterized by impaired blood supply within 10.2%, which provides a good prognosis in such patients and allows treatment with intramedullary osteosynthesis to be considered. With subcapital fractures with displacement, the most significant disturbance in the nutrition of the femoral head is observed (loss of up to 54.4%), which, taking into account age and general condition, may be an indication for endoprosthetics of the damaged joint (Litvinov A.A. 2002).

To take into account possible disturbances in the blood supply to the femoral head when choosing treatment tactics, the Garden classification is used. This division is based on the degree of valgus dislocation of the femoral head. When displacement occurs, the likelihood of necrosis of the femoral head increases due to disruption of its blood supply (Yang JJ et al. 2013). Therefore, non-displaced fractures of type I, II according to Garden are most favorable for treatment (Murphy DK, Randell T. 2013). In patients under 65 years of age with Garden I and II femoral neck fractures, osteosynthesis is preferred (Parker MJ, white A., Boyle A 2008).

Thus, due to its structural characteristics and blood supply, the femoral neck is one of the most vulnerable sections, which emphasizes the relevance of the problem of choosing treatment tactics depending on the specific clinical case. Determining the type of fracture according to different anatomical classifications makes it possible to predict the outcome of treatment and select the most appropriate treatment method for a given clinical case. However, difficulties in treatment can be caused not only by the location of the fracture and the presence of displacement, but also by other features of this area.

Possibilities of osteosynthesis in the treatment of fractures of the proximal femur

The proximal femur has a complex biomechanical structure that protects the area from fracture under axial loads. When implanting structures for osteosynthesis, a change in the biomechanics of the system occurs, which causes stress remodeling - a change in the composition, structure, volume and properties of bone tissue. If mechanical stresses exceed the tensile strength of bone tissue, then its destruction occurs, which must be taken into account when choosing a structure for osteosynthesis (Be'eryLipperman M., Gefen A. 2006).

It is obvious that the biomechanical features and characteristics of the blood supply to the proximal femur largely determine the healing process, which must be taken into account both in the conservative and surgical treatment of these fractures. To achieve a good treatment result, the following principles must be observed: anatomically accurate reposition of fragments, their reliable fixation, early activation of patients, gentle surgical intervention (Gilfanov S.I. 2010).

The results of osteosynthesis of the femoral neck vary significantly. The success of treatment is largely determined by an individual approach to each patient, careful selection of osteosynthesis techniques, competent technical execution, as well as attentive postoperative care. Errors that lead to a decrease in the rates of positive outcomes of osteosynthesis include: inadequate assessment of the severity of osteoporosis, incorrect interpretation of radiographs and characteristics of the fracture, incorrect selection and location of the fixator, insufficient adaptation of fragments, premature loading on the operated leg (Karev D.B., Boltrukevich S.I., Karev B.A. 2009).

Despite existing errors, treatment success, according to most authors, is observed in more than 70% (Zhang NN et al. 2013). The main percentage of negative results of treatment of intra-articular femoral neck fractures is mainly due to the frequent development of complications. These indicators reflect the need for a comparative analysis of the results of using various osteosynthesis techniques in the treatment of intra-articular fractures of the femoral neck.

Modern methods of osteosynthesis of femoral neck fractures

The most common methods of treating the femoral neck today include osteosynthesis with cancellous screws.

The main disadvantage of the method is the lack of stability due to the lack of fixation of the neck-diaphyseal angle. This leads to varus deformation in the fracture area due to the pressure of the screws on the lateral cortical bone (Parker MJ, Raghavan R., Gurusamy K. 2007). It is also highly likely to develop shortening of the femoral neck, which changes the biomechanics of the hip joint and negatively affects the functional result (Liu Y. et al. 2013). Another disadvantage of the method is the risk of migration of metal structures due to the movement of screws to the lateral side as the fracture consolidates. A retrospective analysis of 116 intra-articular femoral neck fractures stabilized with cancellous screws showed lack of consolidation and avascular necrosis of the femoral head in 14.7% of cases (Lee KB, Howe TS, Chang HC 2004). In another study, the formation of a false joint was found in 19.4% of cases (Basov A.V. 2012). It was shown that the majority of cases of lack of consolidation occurred in displaced fractures (Lu QH, Yu FP 2012).

Osteosynthesis with a dynamic hip screw (DHS) is widely used in the treatment of femoral neck fractures. The peculiarity of this screw is its ability to “spring”. The so-called monoaxial dynamization along the axis of the femoral neck causes dynamic compression of the fracture line necessary for bone consolidation. The screw is secured using an extramedullary plate located on the outer surface of the femur, which ensures fixation of the neck-diaphyseal angle (Ananko A.A., Babko A.N. 2007).

However, when using a dynamic hip screw in patients with intra-articular femoral neck fractures, a positive result was achieved only in 73.4% of cases (Majernicek M. et al. 2009). It should be noted that in addition to standard complications, DHS osteosynthesis in some cases may be accompanied by migration of the screw and displacement of bone fragments (Hrubina M., Skotak M., Behounek J. 2010). There is also a very strong possibility of rotational misalignment given the lack of a derotation component in the design. Although the DHS system is widely used in patients with trochanteric fractures, there are insufficient studies on the treatment of intra-articular neck fractures to confirm its effectiveness in these patients.

The obvious disadvantage of this technique is the relatively high invasiveness of the operation.

The least traumatic methods of treating femoral neck fractures include osteosynthesis with a bundle of wires. The method is minimally invasive and minimally damages bone tissue. However, it is noted that osteosynthesis with wires is not cruel enough and creates a high risk of infection spreading along the parts of the wires protruding above the skin (Karev D.B. et al. 2009). One of the options for osteosynthesis with a bundle of wires is osteosynthesis with bundles of V-shaped wires. When inserting bundles of V-shaped wires, the bone beams are moved apart without their destruction along the perimeter of the fixator, which distinguishes the method from osteosynthesis using large structures. In combination with dynamic tension in the system, this creates optimal conditions for healing even against the background of osteoporosis.

However, when using this method, non-union of the fracture was observed in 17.6% of cases, and in the long term a large percentage of unsatisfactory results were noted, mainly associated with shortening of the femoral neck (Ardashev I.P. 2012). There also appears to be a high risk of varus deformity due to the lack of fixation of the neck-diaphyseal angle.

The undoubted advantage of this technique is its unprecedented low cost.

The Targon FN (TFN) fixation system was developed taking into account all the shortcomings of previously used methods. The system includes a plate with four holes for insertion of cancellous and bicortical screws. Telescopic cancellous screws allow you to control the consolidation of the fracture, while preventing the migration of structures into the soft tissue. The presence of a femoral plate for securing the screws ensures fixation of the neck-shaft angle and rotational stability.

The surgical technique makes it possible to perform manipulations through mini-approaches and avoid complications such as bending of the guide pin and sinking of the pin into the pelvis (MJ Parker, R. Raghavan, Gurusamy K. 2007). A large study of this system included 320 patients. Of the 112 non-displaced fractures, in three cases (2.7%) the fracture did not heal or secondary displacement occurred, and in five cases (4.5%) necrosis of the bone head occurred. Among 208 patients with displaced fractures, consolidation could not be achieved in 32 (15.4%), and necrosis developed in 23 (11.1%). In addition, the work revealed cases of secondary fractures in the area of the structure (1.9%) (Parker M., Cawley S., Palial V. 2013).

R. Biber proposed the following tactics for managing patients with intra-articular fractures of the femoral neck. Patients under 60 years of age underwent osteosynthesis with a TFN construct regardless of the fracture characteristics, while elderly patients received TFN only for Garden types I and II. At the same time, the frequency of postoperative complications was 16.4% and prevailed in patients with displaced fractures (Biber R., Brem M., Bail HJ 2014). According to the authors, the main complication of osteosynthesis with this system is perforation of the metal structure, which does not agree with the data of other studies (Parker MJ, Stedtfeld Hw 2010).

TFN has proven to be a more effective method of osteosynthesis for intra-articular fractures of the femoral neck compared to DHS, cancellous screws and wires, however, it is worth noting a complication uncharacteristic of other techniques - a fracture in the area of insertion of the structure.

Discussion

In the literature one can find studies on the results of using various designs for osteosynthesis of the femoral neck, but the question of which method is the most effective remains open. E. Brandt showed that the TFN design can withstand twice the load than a dynamic hip screw and is comparable in strength to a design of three cannulated screws (Brandt E., Verdonschot N. 2011). A comparison of the results of surgical treatment of 52 patients with femoral neck fractures showed that TFN osteosynthesis is less often accompanied by migration of metal structures than DHS (Eschler A. et al. 2014).

Displaced intra-articular fractures are less treatable than others. According to a retrospective analysis of the treatment of 78 patients with such fractures, osteosynthesis with a TFN construction is accompanied by a lower incidence of nonunion compared with cancellous cannulated screws (3.2% compared to 46.8%) (ein R. et al. 2014).

The temporary disadvantage of the TFN system is associated with a specific method of installing the structure, which requires mastery and experience (Korver RJ et al. 2013). At first, this may lead to longer surgery times and higher radiation exposure compared to the widely used methods of osteosynthesis with cancellous screws and DHS.

Due to the fact that femoral neck fractures heal less well in older people, a comparison of osteosynthesis with TFN and cancellous screws in patients over 65 years old, conducted in the UK, is relevant (Gri n xL et al. 2014). It was found that both methods are equally effective for intra-articular femoral neck fractures in elderly people. At the same time, certain complications develop with the same frequency. The authors of one study draw attention to the need to evaluate factors such as the traumatic nature and duration of the operation, the amount of blood loss during surgery and the length of hospitalization when treating elderly people (Lee YS et al. 2008).

According to the data presented, the most promising method of osteosynthesis of femoral neck fractures at the moment is TFN. Although there is no difference in mortality between different techniques and in the incidence of major complications such as fracture nonunion and avascular necrosis of the bone head, TFN is able to withstand greater loads and migrates less frequently into soft tissue.

conclusions

1. Osteosynthesis is an organ-preserving operation and is therefore the preferred option for surgical treatment of the femoral neck.

2. The main criteria for determining the tactics of surgical treatment of femoral neck fractures are the type of fracture and the age of the patient.

3. Determining the type of fracture according to different anatomical classifications makes it possible to predict the outcome of treatment and choose the optimal surgical tactics. Namely, to make a choice between osteosynthesis and hip replacement.

4. The severity of the circulatory disturbance and, consequently, the frequency of development of avascular necrosis and fracture pseudarthrosis, first of all, depends on the degree of displacement in the fracture zone. In view of this, the leading classification for choosing a method of surgical treatment is the Garden classification, since it is based on the degree of fracture displacement.

5. All existing methods of osteosynthesis, such as osteosynthesis with cannulated screws, DHS, intramedullary osteosynthesis, osteosynthesis with tension wires, osteosynthesis with the Targon FN system, etc. When performed according to indications, in the vast majority of cases, fracture consolidation can be achieved.

6. The optimal fixation should combine the principle of dynamic fixation, rigid fixation of the neck-diaphyseal angle and the presence of a derotational component.

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OVERVIEW:OSTEOSYNTHESISOFINTRACAPCULARFEMORALNECK FRACTURE

A. YU. ZAROV, VR GUDKOV

IM Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow Central Clinical Hospital of St. Alexis of the Moscow Patriarchate

Information about the authors:

Zarov Alexey Yurevich – St. Alexius Central Hospital; e-mail

Gudkov Vitaliy Robertovich – St.Alexius Central Hospital

At the present time it is becoming more common to choose conserving surgery for managing femoral neck fracture. Peculiarities of anatomy and blood supply of this region lead to a particular therapeutic approach to intracapsular fracture of the femoral neck. In this article we review modern variants of osteosynthesis including cancellous screws xation, osteosynthesis with dynamic hip screw and Targon FN xation system.

Key words: cancellous screws, DHS, dynamic hip screw, femoral neck fracture, Targon FN.

Signs of a hip fracture

Elderly people fall from their own height causing injuries. A person does not immediately understand that a hip fracture has occurred because he retains general mobility. If a pensioner lives alone, he may not seek medical help for several days. And at this time, the vessels located next to the wound will be injured by the sharp edges of the debris.

Typical signs of injury include the following:

Persistent pain in the groin. It is not pronounced, a person is able to tolerate it for some time. Pensioners often mistake painful sensations for a manifestation of osteoporosis or arthrosis. Gradually, the pain intensifies, especially when supporting the heel area of the foot or active movements.
Turn the foot outward. Rotation becomes noticeable when carefully examining the position of the foot in relation to the knee.
Leg length difference. The affected limb is shortened by about 4 cm. The unusual phenomenon is explained by the contraction of muscles that are grouped next to the injured joint.
Inability to keep the foot in a horizontal position. The leg retains the function of flexion-extension, but is not held in a horizontal plane by weight and slides down.
The appearance of a hematoma in the fracture area.
Pain and discomfort when tapping and pressing on the heel of the injured leg.
Crunching in the injured leg when trying to change its position.

The presence of even one of the listed signs indicates serious disorders that require medical attention. Before the ambulance arrives, the pensioner is placed on a hard surface, given an analgesic, and the injured leg is fixed from the inside and outside, starting from the groin area, with splints or improvised materials.

Symptoms of the disease

Considering that a fracture of the femoral neck in people with osteoporosis can occur even from the most minor injuries, and pain in the hip joint area is common for them, many patients sometimes do not even suspect that they have received a fracture. This is dangerous because the patient continues physical activity and delays treatment, which threatens to worsen the problem. This is why it is so important to know exactly about the symptoms.

The main symptom is pain in the groin. At first it may not be strong and the patient may mistake it for something insignificant. However, over time, the pain begins to increase, intensifying while placing emphasis on the heel of the affected leg.

The presence of a fracture may also be indicated by:

slight shortening of the injured leg;
turning the foot outward;
gait disturbance;
femoral artery pulsation;
joint crunch when walking;
painful sensations when impacting the injured joint;
the appearance of a hematoma.

The appearance of any of these symptoms, and especially a combination of several of them at once, requires immediate consultation with a doctor.

Types of femoral neck fractures

Femur injuries are divided according to the type of injury into open and closed fractures. With an open fracture, the soft tissue is torn and exposed to the outside. Such fractures occur as a result of a gunshot wound. Accompanied by large blood losses.

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A fall or a direct blow to the thigh can cause a closed fracture. Fragments may appear inside and move up and down from their place. If the fracture occurs in the joint itself, the painful sensations are blurred, but hematomas and swelling appear in the tissues. If the lower part of the thigh is injured, the leg in the knee area suffers.

Ultra-modern diagnostics at the Yauza Clinical Hospital

Diagnosis of fractures at the Yauza Clinical Hospital begins with an examination and interview of the patient. Much attention is paid to the sensations experienced by the patient.

If a fracture is suspected, the doctor prescribes an x-ray examination, which is carried out in the hospital using modern, low-dose x-ray equipment of the latest generation. Its distinctive feature is the high accuracy of the images and low radiation exposure, which is comparable to the radiation received by airline passengers.

If a pathological fracture is suspected and the diagnosis is in doubt, the patient is prescribed an MRI (to assess the condition of the surrounding tissues and exclude metastasis as the cause of the fracture). The examination is carried out using a Philips digital tomograph with a power of 1.5 Tesla.

An important diagnostic step is to determine bone density to exclude osteoporosis. For this purpose, our hospital uses multislice computed tomography (CT) and densitometry.

Having all the necessary equipment in one place allows you to conduct an examination and make an accurate diagnosis in the shortest possible time.

Rules for selection and use

In order for the bandage to perform all its functions, it must be chosen correctly. The type of design, the presence or absence of a hinge - all these details are discussed with the doctor. Only an experienced traumatologist can assess the need to use an orthosis and give recommendations regarding its choice.

It is important to choose the correct size according to the waist, hip, and height of the patient. There are retainers designed for patients of different ages. This criterion must also be used. The patient's weight is of paramount importance in the rehabilitation process.

Obese patients have a more difficult time recovering. They are recommended to use only a rigid orthosis, which takes over all the functions of the hip joint. In this way, the load on damaged tissues is significantly reduced.