“orthopzedies Traumatology: Surgery & Research 105 (2019) 945-990 Contonts lists availabe at ScienceDirect = Orthopaedics & Traumatology: Surgery & Research ELSEVIER journal homepage: www.elsevier.com je= Original article Non-operative treatment is a reliable option in over two thirds of patients with Garden I hip fractures. Rates and risk factors for failure oar in 298 patients Delphine Amsellem*®, Sébastien Parratte*”, Xavier Flecher*, Jean-Noél Argenson*”, Matthieu Ollivier*° “Deparment of otopard on arate, state of movement and consti St Maruti hopta 12009 Mal, ance ARTICLE INFO ABSTRACT Ire on Background: Non-operative treatment for impacted femoral neck atures sa now rarely sed strategy feceied 10 Getaber2018 whose indications are controversial. No outcome predictors have been convincingly identified. in part Accepted 2019 Ave tothe small sies of avallable studies. We conducted a large retrospective study with the following —— jective: (1) 0 evaluate the percentage of patents odes than 95 yeas of age with non-opeatvely Keywords treated Garden femoral neck ractureswho expetence secondary displacement, (2)t0identify predictors Femoral aektrcure of secondary displacement, nd (2) to determine the fequency of non-operaive treatment fre due Gatden thoon-dsplaced accue ‘geo yats ‘Nos-operative ueanmeat to any cause ané requiring joint replacement surgery. Hypothesis: Non-operative treatment is cliable inpatients older than 65 years of age with Garden 1 femoral neck races, [Material and methods: Approval was obtained from the French data protection authority to conduct aret- rospective observational study of nformation in the Marseille university hospitals database. Consecutive patients who were older than 65 yeatsofage at raumatology department admission for Garden femoral neck fractures managed non-operativly between January 2007 and Decemiber2017 were included, Non- operative treatment consisted in a walking test on day 1 followed by radiographs on days 2, 7. 14,21 and 45 and after 3 and 12 months. Patients with secondary displacement underwent hip arthroplasty Demographic data, cognitive performance, and radiological parameters were collected for each patient. ‘We evaluated the rates of secondary displacement avasculat necrosis, ané non-union. Result: We included 298 patients with amean age of 82 years (range, 65-101)-Mean follow-up was5=3 ‘years Secondary displacement occurred in 9 (30%) patients, at a mean of 16 days (range 2-45 days) ater ‘he fracture Avascular necrosis ofthe femoral hea developed in 13 (432) patients and non-union in 11 (3.7% patients. Secondary displacement was significantly associated with hypaotc treatment (OR, 4.1 958C1_2.2-75: p=0.039)institutionalisation (OR 6.7; 95XCI. 31-148; p=0.028), ahistory of repeated falls (OR, 135; 95%C1 6 3-84; p<0.0001), having three or more comorbidities (OR, 3.2; 95%C1, 17-58; 1p 0.048), and having dementia (OR, 35; 95%, 17-69; p-00003), Secondary displacement occurred {18 (12%) ofthe 151 communty- om wo Tee ron ig. 2. Kaplan-Meier carve of survival without secondary displacement 2, Material and methods 2.1. Patients Armulticentre retrospective cohort study was conducted in con- secutive patients older than 65 years of age who were admitted to traumatology departments in the university hospital network in Marseille, France, between January 2007 ané December 2017 and who received non-operative management of a true Garden I femoral neck fracture, Approval was first obtained from the French, data protection authority (Commission de 'nformatique et des Lib- ertés, CNIL) Inclusion criteria were age older than 65 years: true, intially impacted, Garden 1 femoral neck fracture visible on antero- posterior and lateral pelvic radiographs: and non-operative management. Exclusion criteria were age younger than 65 years at the time of the fracture; pathological fracture; non-displaced Garden ior displaced Garden, Il or IV fracture; pertrochanteric or subtrochanteric fracture; and peri-prosthetc facture. We included, the 298 patients who met all the inclusion criteria and none of the exclusion criteria, 22. Methods Non-operative management involved eatly ambulation in a ‘walking frame to decrease weight-bearing on the affected side and Fig. 1. Radiographs taken at admission then 1 and 5 yeas ater in 77-year-old weInan with a Garden I ractute onthe lft hip.Anselm ea / Orthopaedics Traumatology: Surgery & Research 1052018) a walking test on the day after the fracture (day 1) conducted by a physiotherapist under medical supervision, Follow-up radiographs consisting of an antero-posterior view of the pelvis and antero- posterior and lateral views of the affected hip were scheduled on days 2,7, 14,21, and 45; after3 and 12 months; and annually there- atter (Fg. 1)- Patients were informed that secondary displacement ‘ight occur and would require arthroplasty. 23. Assessment methods For each patient, we recorded the following information from the electronic patient files in the hospital databases: age, sex body ‘mass index, institutionalisation at the time of the fall, use of hyp- otic agents, comorbidities, and the Parker score (Table 1). The radiographs were reviewed by two different physicians, one of ‘whom was a senior surgeon (MO), The following were measured ‘on the radiographs obtained at admission: Pauwel’s angle (1,2, or 3), degree of valgus on the antero-posterior radiograph of the hip, and degree of femoral head retroversion on the lateral radiograph of the hip. During follow-up, the radiographs were evaluated for evidence of secondary displacement, which was defined as varus displacement and classified as Garden Il or V. The primary outcome measure was the occurrence of secondary displacement during follow-up. The secondary outcome measures ‘were time to secondary displacement, hospital stay length, type of surgery. and morbidity and mortality associated with secondary displacement. Arthroplasty during follow-up was recorded as a marker for failure of non-operative management due to any cause (avascular necrosis, pain, o non-union), 24, Statistical analysis, ‘We compared the groups with and without secondary displace- ‘ment (primary outcome measure). Distribution of each variable was assessed to guide the choice between parametric and non- parametrictests for comparing quantitative and qualitative criteria, Kaplan-Meier curves were plotted to assess survival without delayed surgery for any reason and for secondary displacement. There were no missing data, ‘A multivariate logistic regression analysis was performed to identify predictors of secondary displacement. First, univariate analyses were done to identity variables whose distribution dif fered between the groups with and without displacement, with p values <0.20). These variables were then entered into the mul tivariate model, The adjusted odds ratios (ORs) were computed with their 95x confidence intervals (95%Cls). Correlations between ‘quantitative parameters were assessed by computing Spearman's correlation coefficient (R2). Values ofp lower than 0.05 were taken to indicate significant differences. 3. Results 3.1, Secondary displacement rate Over the 11-year study period, 298 patients met our selection criteria, including 245 (86%) women. Mean age was 81.5 years (range, 65-101 yeats) and 183 (61%) patients were older than 80 years, Mean follow-up was 53 years, The right hip was fractured in 154 512) patients, Secondary displacement occurredin 1 (30%) patients, atamean ‘of 16 days (range, 245 days) after the fracture, and was consis tently managed by arthroplasty. Times to secondary displacement ‘were as follows: =2 days, n=2; 3-5 days, n= 17; 6-8 days, n= 14; 9-40 days.nn=7; 11-15 days, n= 14; 16-20 days,n1=5; 21-30 days, n=21; and 31-45 days, n=11 32, Non-operative treatment failure rate Avascular necrosis of the femoral head occurred in 13 (43%) patients, Surgery was requited in 11 (3.72) patients for non-union ‘or pain, Mean hospital stay length was 8 days (range, 2-34 days) ‘overall, 7 days (range, 2-20 days) inthe group without secondary displacement, and 13 days (range, 5-34 days) in the group with secondary displacement. Of our 298 patients, 26 (9%) died during follow-up, ata mean of 19 months (range, 03-96 months) after the fracture, Mean 5-year survival without secondary surgery (for any ‘ause) was 70% = 26% and mean 5-year survival without secondary displacement was 68.8% +27.4% (Fig. 2), 3.3, Predictors of secondary displacement Age, sex, and body mass index were not significantly assoct- ated with secondary displacement, Six factors were significantly associated with secondary displacement, namely insitutionalisa- tion, dementia, use of hypnotics, a history of falls, three or more ‘comorbidities, and a smaller angle of valgus displacement (Table 2) ‘The multivariate logistic regression analysis identified five fac- tors independently associated with a higher risk of secondary displacement (Table 2), ie, use of hypnotic agents (OR, 4.1; 95%CL, 22-75; p= 0.039), institutionalisation (OR, 6.7; 95%C1, 3.1-148: (028), a history of repeated falls (OR, 13.5; 992Ci, 6.3-8.46: P<0.0001), three or more comorbidities (OR, 3.2; 95%C1, 17-58; 046), and dementia (OR, 35; 952C1, 17-9; p=0.0003). The ngle of valgus displacement, in contrast, correlated with a lower risk of nonoperative treatment failure (R?~0.43 and p<0.0001), Thus, impaction in valgus protected against secondary displace- ‘ment Of the SO institutionalised patients with dementia, 37 (75%) ‘experienced secondary displacement. In contrast, of the 151 sell- sufficient community-dwelling patients without repeated falls or ‘cognitive disorders, only 18(12%) experienced secondary displace- ‘ment, 4, Discussion To date, no consensus exists about the optimal management ‘of Garden I fractures. Available treatment options include arthro- plasty, internal fixation, and non-operative treatment. Fixation using three percutaneously inserted screws is another alternative to arthroplasty that decreases the risk of secondary displacement while allowing early ambulation. However, a secondary displace- -ment rate of 5.4% has been reported with this technique 10), whichoss Ansell ea Orthopadi & Traumatology Surgery & Research 1052018) 985-890 Feauresn of pallens or mean range Ne dplnerea Displacement Peale vas 243 (5-05 201 2-49) Femoral ead retroverion’ 145 (0-35, 125 (0-42 rable? Muldvanate analysis of facors potential independent predictors f secondary dsplacement el sideright side NS Pater sore 15(as-23) ypnote agents aar7s) 0039 story ettals 13s (63-284) 0.0001 Thre or mote comorbidities 3217-58) as vals 301 (2-49) ss emotal ead revrovetsion” 125 (00) SS NS non-anieat also exposes patients to complications related to the anaesthesia and to the surgery itself (eg. surgicalsite infections) [11], as well ‘a5 toaneed for material removal |12)-To the best of our knowledge, no previous study has demonstrated associations linking secondary displacement to institutionalisation, hypnotic agent use, or a his- tory of repeated falls. Assessments of these potential risk factors are not usually performed, as they would require splitting small patient groups, thereby reducing statistical power. The large num- ber of patients in our study combined withthe in-depth evaluation that older patients receive at admission in our hospital network allowed us to demonstrate significant associations linking the non- ‘operative treatment success tate to institutionalisation, dementia, medication use, and a history of repeated falls rather than to older age atthe time o the fll. Our findings confirm our working hypoth- ‘esis that non-operative treatment is reliable in patients older than 665 years admitted for Garden I femoral neck fractures. Among the entire population of patients older than 65 years and admitted to university hospitals in Marseille between 2007 and 2017, 70% achieved a full recovery with non-operative treatment alone, The risk of secondary displacement was not associated with age, sex, ‘of body mass index (12.14). Significant risk factors for secondary displacement were institutionalisation, dementia, hypnotic agent Use, three of more comorbidities, anda history of repeated falls. In previous studies, the proportion of patients with secondary displacement ranged from 20% 15] 0 66% 16] (Table 4).Aprospec- tive study by Buord etal. [7] o 56 patients older than 65 years and treated by unrestricted mobilisation starting 48h after the frac- ture showed a secondary displacement rate of 33%. In their work reported 1978, Hansen et al. (17 described a 28% secondary dis- placement rate after weight bearing resumption, similar to that found in our study. Verheyen et al.[13) observed a high secondary displacement rate of 46% ina retrospective review of patients with Garden I fractures managed non-operatively with partial weight bearing. Of their 110 patients, 5 were excluded when a review of ‘theirradiographs showed that they had Garden Ifor Il fractures. In our study, the rate of avascular necrosis was 4.3% (13 patients). This complication is classified among treatment failures, as it requires arthroplasty. In a study of 319 patients managed non-operatively Raaymakers et al.|18] found an 11% rate of avascular necrosis after 2 years of follow-up. ‘A 2002 study by Raaymakers [21] (Table 5) demonstrated that the risk of secondary displacement was higher in patients older ‘than 70 years. na SOFCOT symposium multicentre study reported by Simon et al. in 2008 [22], secondary displacement occurred in 31% of patients and correlated with age. In contrast, age was not significantly associated with secondary displacement in our pop- ulation. This apparent discrepancy may be ascribable to the many confounding factors, such as cognitive function, use of hypnotic agents, and place of residence, which were identified in our study: ‘we suggest that these factors, rather than older age, were associ ated with a higher risk of secondary displacement. In studies of impacted femoral neck fractures conducted by Hansen and Sol- gard [17] and Otremski et al. [23], secondary displacement was not associated with Pauwvel's angle, valgus displacement, or femoral head retroversion. In our population, in contrast, valgus impaction protected against secondary displacement(24.3" inthe group with- fut vs. 20.1" in the group with secondary displacement), and the difference was statistically significant (p=0.004« Our retrospective cohort design was a hybrid of an epidemi- ological study and a descriptive analysis. We therefore obtained data over a short period in a specific population. Furthermore, our study relied entirely on the Garden Classification, which has aArea ea Orthopardis 6 Trauataloy: Surgery & Research 1052018) 85-90 oo Tathors Tefpaieas Age years Followup Seconeary Treatment netiod epacerent Taneenand soirai7) a a> aman ae Immediate paral weigh beating with canes Coetate a 13) 2 Ment 2 ox Tb day of bearer weigh bearing ater 8 week Raaymakers and Martil16) 167 1498 Emontseloyears 18% 7 days of bedres then pl weight bestng with canes Betetal 2 e100 Sa yeas so TO day ol bedcert weigh bearing aller Gwe “Tanaka eta 1) 3s S02 Gmomhs-ryears 14 days of cet weight bearing fer 6 weeks ether et 13) 10s 1797 ments years 45% Inumediate pata weight eseng Shugiang ta 20), 3 Gos months Sears 48 trmobiisation for weeks Tanset at [8 a $796 Dmonthe Seas S58 Immediate pata weight beating with eae Potetal predictors of secondary displacement evaluated previous studies Facer died aswel angle aun f val ely weight bearing. fetroversion>20° (0009) Solgar [17] asymakers (21) 6 “Tanaka cat [19 a eter a [15) B , Vesheyen eta [5] 15 Shuglang et a 20), us Bord etal 7 Tana eal [8 8 ur study. 2018 28 Bed este14 day (p<001) Dementia (p «005 ‘Age 60-80 yess (p00) Garden (p<0.00) DOsteoparone(p=0.028) SSomorbiiies cements instuionalsaton hypnotic gens repeated ls ‘Ace, sex amount of valgus, emer ‘Age, omorbies, place a csidence ‘ge, Pauwels ASA ‘ASA Pauwels ‘Age, sex dementia. comorbid, auwels angle amount of valgus ‘Age sex BML, ASA, istoy of act, Conitalaerl THA ‘Age, sex BML Parker score amount of ‘alas femoral heed rettovesion, Pauwels ante ‘number of imitations as pointed outby Van Embden etal [24]. The Garden types can be simplified into displaced and non-displaced {ractures, For rare potential risk factors of secondary displacement, the number of patients may have been too small to provide su ficient statistical power to detect significant associations. In our daily practice, we do not obtain computed tomography scans in patients with impacted femoral neck fractures, Our study therefore relied on radiographic criteria, which were both qualitative (type of fracture) and quantitative (displacement, change in trabecular orientation). Determining the exact value of Pauwels angle [25] requites a true antero-posterior radiograph, which may be dificult toobtainin older patients with pain froma fracture [26).Zhangetal, [27] described a new angle that was measured more reliably than Pauwel'sanglein patients with early failure of femoral neck fracture fixation using three compression screws. Femoral head retrover- sion can be measured only on a true lateral radiograph of the hip, ‘whose acquisition requires sedation in hip fracture patients (28 Finally, our study does not provide data on important points such as quality of life and medical and surgical complications assoct- ated with non-operative treatment alone and with non-operative ‘treatment followed by delayed surgery. 5. Conclusion Non-operativetreatmentalone provided a ull recovery in about, 70% of elderly patients with Garden I fractures followed up for a ‘meanofS years. Dementia, institutionalisation, hypnotic agent use, ‘multiple comorbidities, and a history of repealed falls were asso- ciated with a higher risk of secondary displacement. Awareness of these criteria can help to select patients for non-operative treat ‘ment: thus, among self-sufficient commmunity-dwelling patients with no history of repeated falls, only 14% experienced secondary displacement. Disclosure of interest None of the authors has any conflicts of interest to declare in relation to this work. Delphine Amsellem declares he has no competing interest. Sébastien Parratte is an educational consultant for Zimmer, Adler, Arthcex, and Newelip. Xavier Flecher is an educational consultant for Zimmer and Adler. Matthieu Ollivier is an educational consultant for Stryker, Arthrex, and Newclip. Jean-Noel Argenson is a consultant for Symbios, Zimmer, and ‘diet and receives royalties from Symbios and Zimmer, Funding ‘This research did not receive any specific grant from funding. agencies in the publi commercial, or not-for-profit sectors. Contributions of each author Delphine Amsellem and Matthieu Olivier conceived the project, designed the protocol, processed the study data, performed the statistical analysis, and wrote the manuscript980 Arse eal Orthopadis& Troumatalgy Surgery & Research 105 (2018) 885-890 Sébastien Parratte, Jean-Noel Argenson, and Xavier Flecher revised the manuscript for important intellectual content, References In} Neter FH. Aras aatomie humaine Beme edition: 2015 [2] Autanc OF Jones WN, Hans Wit Undepaced frnral neck fracture JAMA IB] Garden Lavangie fxationin a brisenss-647-33 [a] Ovi, Le Corer. Blane G, Parte S ChampsaueP. Chabran Fea. adiogiapie bone extue pass catelaced with 3D mvouteatectate the emerl hese and improves the estimation of the femoral neck aete Trkwhen combined with bone mineral eens Bie] Raa 01382 1494-8 Is] Bel J. 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