PROXIMAL FEMUR FRACTURES.

DEFINITION, EPIDEMIOLOGY, ANATOMY, BIOMECHANICS

1.1 Introduction
Nowadays, the most important socioeconomic problem
is osteoporosis; its incidence increases steadily.
The expression and the most severe complication of
its senile form is the proximal femur fracture
that contributes considerably to the mortality in
old people due to preexisting diseases and to the
complications resulting from confinement to bed.
During the second half of the 20th century the
average age of the population increased markedly
while the incidence of hip fractures grew many
times, particularly in industrialized countries. Although
the age-specific incidence varies from country
to country, a continued increase worldwide is
expected during the first half of the 21st century. In
Scandinavian countries every third or fourth
hospital bed was occupied by these patients
in the eighties; moreover, these patients spend
yearly more days in hospital than cancer patients
(Thorngren, 1991a). In spite of the fact that
medicine and society spend ever increasing energy
on prophylaxis and efficient therapy of osteoporosis,
successes have been mainly limited to postmenopausal
bone loss (Hofeldt, 1987; Nilsson, 1991; Poor,
1992). Consequently, we must expect in the future a
rise in femoral neck fractures, necessitating a continuous
development of therapeutic and surgical
methods and rehabilitation.
In the meantime, the treatment costs have
also risen. These expenses have reached in Sweden
levels reaching those for persons suffering from
diabetes and hypertension (Borgquist et al,
1991; Thorngren, 1991b). In 1992 the care of a quarter
million proximal femur fractures amounted in
USAto 8.7 billion dollars; the expenses multiplied
in instances of complications (Kyle et al, 1994).
Diagnosis and surgery further increased the expenses
caused by introduction of newer techniques
(MRI, CT, DSA, image intensification) and a multitude
of newer implants and instruments for internal
fixation and joint replacement. Should the old patient
be unable to return to his previous home, an
expensive in-house rehabilitation is unavoidable
(Holmberg and Thorngren, 1988).
To alleviate this situation a proper treatment,
avoidance of complications, lowering of the mortality
rate, a speedy, effective and a socioeconomic
restoration of quality of life become a priority for our
society.
Two types of proximal femoral fractures must be
distinguished: femoral neck fractures and
trochanteric fractures, although in principal
they give rise to the same problems. The latter are
characterized by a more severe course, a greater
blood loss, a higher death rate and usually more
general complications. The break itself does not
cause problems; it even heals under conservative
management (Lawton et al, 1981; Jakobssen and
Stenstrom, 1984; Elmerson et al, 1986; Hedlund et
al, 1987; Koval et al, 1996; Wirsing et al, 1996).
For displaced femoral neck fractures, on the
other hand, a healing can only be expected when
the stability can be restored successfully during
surgery. This does not present a problem in
younger patient with a good bone stock; internal
fixation is recognized worldwide as the treatment
of choice in persons less than 60 years of age. As a
stable fixation in older patients with porotic bones
always present problems, a joint replacement is
often the treatment of choice.
Well-known orthopedic surgeons and traumatologists
have recognized already decades ago: the optimal
place for a viable femoral head is its replacement
on the femoral neck (Dickson, 1953; Nicoll,
1963; Sarmiento, 1973). For this reason, research focused
in many countries on the improvement of stability
of internal fixation – in Hungary for economic
reasons. The main question was: is it possible to
obtain a stable fixation even in the presence
of a porotic bone? Since comprehensive insurance
coverage had been available in the past decades (reimbursement
for prostheses and adequate rehabilitation)
in the majority of industrialized countries,

no impetus for serious research in respect to a biologic

approach existed. Recently this situation has
changed as health care providers make efforts to
contain costs.
The attainment of a stable internal fixation of a
porotic bone with the least possible interference
with blood flow and without putting too great a
strain on the patient was the goal of our research endeavors,
as presented in this book. We analyzed the
bone structure of the elderly and the vascularization,
the fracture types and the biomechanics.
This led to the development of a set
of implants allowing an adequate, stable internal
fixation of fractures that range from undisplaced to
severely comminuted and displaced fractures to
trochanteric fractures.
Up to the eighties our results were analyzed and
published mostly using our own criteria. In 1990 we
followed the call in the Acta Orthopedica Scandinavica
for a Multicenter Hip Fracture Study
(Editorial, Acta Orthop Scand, 1988; Thorngren et
al, 1990; Thorngren, 1993; Kitamura et al, 1998;
Tolo et al, 1999; Cserhati et al, 2002a; Partanen et
al, 2002). On the international level this study represents
an equivalent to the Swedish “Rikshoft”
project that led to excellent results over many
decades. In 1990, we treated 754 patients with recent
hip fractures. Standard questionnaires containing
details as to the initial care, the follow-up
results after four months, one and five years, were
analyzed with the help of a computer. We published
the results in several scientific journals (Cserhati et
al, 1992; Laczko et al, 1992; Laczko et al, 1993; Cserhati
et al, 1997; Kazar et al, 1997; Cserhati et al,
2002a). In 1994, two members of our research team
received a stipend to analyze our data at the
Swedish institute responsible for the development
of the study (University of Lund, Orthopedic Hospital).
This excellent cooperation led to an invitation
from Prof. Thorngren to join the SAHFE (Standardized
Audit of Hip Fracture in Europe) sponsored by
the European Union. We were one of the eight
founding members and the only member from the
former East block countries (Thorngren, 1998;
Parker et al, 1998c; Cserhati et al, 2002b). The participants
of this cooperation, at present including 16
countries, list in a standardized fashion their patients
with hip fractures including their treatment.
It is hoped that this wealth of material will allow to
formulate the principles of optimal surgery and rehabilitation
of femoral neck and trochanteric fractures
currently still controversial (Cserhati et al, 2002b).
The parameters of our patients who were
treated with the cannulated screw since 1990 were
prospectively documented using an adaptation of
the multicenter study. In 1992, we presented our
first results in Freiburg-Germany. In Hungary during
a symposium at the University of Debrecen
(1995) we reported together with several Hungarian
departments our results and analyzed them. Since
1998 our surgical technique has also been introduced
in other countries particularly at the Trauma
Department of the Hannover Medical School,
Germany (Fekete et al, 2000b; Fekete et al, 2000c;
Bosch et al, 2001; Strauli et al, 2001; Bosch et al,
2002; Szita et al, 2002).
Therefore we are confident that a comparison of
our results with those of other authors will become
possible. This will then be our contribution to the
establishment of proper principles, indications and
treatment of femoral neck fractures (Kazar et al,
1993b; Fekete et al, 1997b; Fekete et al, 2002; Szita
et al, 2002).

1.2 Definition and frequency of hip fractures

1.2.1 Definition and basic concepts
In the Anglo-American literature and in the colloquial
language the fractures of the proximal femur
are known as “hip fractures” on account of their frequency
and their medical and socioeconomic impact.
This term is imprecise and has therefore not been
accepted in other languages. In the pertinent literature
one finds terms such as proximal femur fractures,
fractures of the upper third of the femur and
femoral fractures close to the hip.
Two major groups of hip fractures have been
recognized in the pertinent literature and in trauma
surgery. We distinguish between intracapsular
(medial neck-) and extracapsular (lateral neckalso
known as basal, as well as trochanteric
and subtrochanteric) fractures (Figs. 1 and 2).
An increasing number of researchers insist that
in respect to mean age, degree of osteoporosis andgeneral condition a distinction must be
made between
the two fracture types in respect to the patient
collective (Lawton et al, 1981; Hedlund et al,
1987; Karagas et al, 1996; Mautalen et al, 1996; Fox
et al, 1999; Michaelsson et al, 1999; Huang et al,
2000). Moreover, the principle differences in the
causes of the disease and the treatment (surgical
techniques) justify a distinction between both
groups as also accepted by the International Classification
of Diseases (ICD).
Moreover, an essential difference lies in the fact
that the blood loss of the intracapsular fractures
is minimal, that the fracture line in general
lies inside the joint capsule, that the injured person
tolerates the fracture better, that the patient can be
operated immediately and that the incidence of
early mortality is lower (Jakobssen and Stenstrom,
1984; Koval et al, 1996). On the other hand, the
blood loss of extracapsular fracture, particularly
for comminuted fractures, can be considerable
given the great surface of exposed cancellous bone
and the concomitant injury to surrounding blood
vessels. These facts must be considered during
treatment; they may play a role in the increased
incidence of mortality.
Further on, another definite difference is found
in the fact that the blood supply to the femoral
neck is at greater risk in intracapsular fractures
(Manninger, 1963). The retinacular arteries
and veins supplying the femoral head may tear or
become incarcerated between the fragments. If
these vessels are severely injured or if the decompression
is not done in a timely fashion due to a
delayed reduction, a partial or complete necrosis of
the femoral head may result. The consequence is a
nonunion or after consolidation a progressive deformity
and later a collapse of the head resulting
in a severe osteoarthritis.
The displacement of the fracture and the intraarticular
hematoma cause a compression of the
thin-walled veins. Blood drainage can also be impaired
or interrupted by the fracture itself. Therefore,
an impaired drainage must be foremost
expected as well as venous congestion in the
femoral head and a consecutive increase in intraosseous
pressure. This results in the death of
osteocytes (Woodhouse, 1964; Arnoldi and Linderholm,
1969; Arnoldi et al, 1970; Arnoldi and Linderholm,
1972; Arnoldi and Linderholm, 1977). The
intraosseous drainage and the blood supply
can be improved by an early intervention/reduction
that will also restore the retinacular venous circulation.
Should the patient survive an extracapsular
fracture, a consolidation can be expected in the majority
of cases. Late circulatory damages are an
exception. Obviously this influences the analysis
of outcome. For fresh medial neck fractures an
emergency intervention is the procedure of
choice, hopefully restoring the vascularization of
the head. For extracapsular fractures an early intervention
after compensation of the blood loss is
advisable as a blood loss in older patients constitutes
a threatening situation.
1.2.2 Frequency of fractures – international and
Hungarian data
The hip fracture is an injury characteristic for older
patients with osteoporosis. Its incidence depends on
the age distribution of the population. The correlation
is exponential as we could already show 40 years
ago when we analyzed the age and sex distribution
of 1000 patients with femoral neck fractures (Manninger
et al, 1960). This trend was also confirmed by
our later studies (Kazar et al, 1997) (Fig. 3).
The epidemiology of this injury occupies an everincreasing
place in the international literature. According
to Scandinavian and American publications
the incidence in industrialized countries has doubled
between 1960 and 1985 (Nilsson and Obrant,
1978; Zetterberg and Anderson, 1979; Schroder et
al, 1988; Jarnlo et al, 1989; Lutje et al, 1993). The
explanation for this trend can be partially explained
by the absolute increase in number of older patients.
An increased incidence within the same age group
has also been found, most probably due to changed
life style with decreased physical activities.
In Hungary the yearly incidence of hip fractures
is 1:500 persons; in 1998 18435 fractures were registered
(Huszar et al, 2000). This incidence is rather
high in light of the fact that the mean age of both
sexes lies below the European average. The average
age of Hungarian patients with hip fracturesamounted to 78 years. Only 4–6% of patients with
femoral neck fractures were younger than 50 years
(Zetterberg et al, 1982; Manninger et al, 1984;
Fekete et al, 2000a). In children and adolescents
these fractures are even rarer; their complications
constitute, however, a considerable long-term problem
(Zolczer et al, 1972).
International studies have shown an ethnic difference
in the incidence of hip fractures (Solomon,
1968; Levine et al, 1970; Makin, 1987; Karlsson et
al, 1993). The reason for a lower incidence in Japan
in general and in USA and South Africa among the
colored population can be sought in the greater
physical activity of these groups. This view is confirmed
by a Scandinavian study that showed a lower
incidence in the rural than in city dwellers (Finsen
and Benum, 1987; Mannius et al, 1987; Sernbo et al,
1988; Larsson et al, 1989).
A geographic difference is also seen in the distribution
of intra- and extracapsular fractures. In
Northern Europe neck fractures are three times
more frequent than trochanteric breaks. In USA
and Western Europe the ratio is 1:1, whereas in
Southern Europe and in Hungary trochanteric
fractures are more frequent amounting to 3:5
(Alffram, 1964; Melton et al, 1982; Luthje, 1985;
Rasmussen, 1990; Dretakis et al, 1992; Lee et al,
1993; Rowe et al, 1993; Kaastad et al, 1994; Hinton
et al, 1995). More recent reports indicate that in
Scandinavia the incidence of trochanteric fractures
is increasing (Sernbo et al, 1997a; Rogmark et al,
1999) (Fig. 4).
1.2.3 Frequency of femoral neck fractures
at the National Institute of Traumatology
(Budapest) between 1940 and 2002
Since its foundation our Institute is foremost involved
in the treatment of people from the capital.
As the number of weekly admissions, the size of the
area served and the number of beds have changed
several times (the number of beds between 150 and
363), reliable epidemiologic conclusions of the yearly
admissions cannot be drawn. Over a period of 60
years a marked increase in the number of femoral
neck fractures has been registered (Fig. 5). During the first half of the forties mostly
workrelated
accidents were treated at the General Compensation
Board Hospital. After WW II our activities
expanded to the treatment of accidents and the
number of beds increased to 200. Accordingly, the
number of treated hip fractures increased. In 1957,
the trauma department of the hospital in the Peterfy
Sandor Street was opened, a fact that explains the
temporary decrease in the number of injured patients.
Thereafter the number of hip fractures increased
again from year to year. At the end of the
sixties it reached the present level. At the beginning
of the seventies several new trauma departments
were opened in Budapest (in the Csepel-, St. Johns-,
Arpad- and Uzsoki-Hospitals). After a short lasting
decline the number of our patients stabilized between
200 and 250. In 1978, the number decreased
considerably but temporarily due to the forced relocation
of our institute. But already at the beginning
of the eighties we could treat in our 200 beds in the
Baross Street building an average of 200 neck fractures.
After return to our 363 bed institute we treat
more than 300 femoral neck fractures yearly.
The modification of our admission system introduced
in Budapest in 1992 did not alter this number.