Gotfried reduction and cannulated screws fixation in the treatment of femoral neck fracture in young adults


 Background: Although many available surgical procedures for displaced femoral neck fractures in young patients, there are still many challenges to achieve satisfactory results. The incidence of avascular necrosis and nonunion rates remain relatively high despite the progress in our understanding and surgical technique. The purpose of this study was to evaluate the clinical efficacy of gotfried reduction and cannulated screw fixation in the treatment of femoral neck fracture for young adults.Methods: A retrospective analysis was made on 67 cases from May 2013 to March 2019. They were divided into three groups according to the first postoperative anteroposterior view of hip X-ray: Anatomic reduction (group A), Gotfried positive buttress reduction (group B), and Gotfried negative buttress reduction (group C). The incidence of avascular osteonecrosis of the femoral head (AVN) and the Harris scores of hip joints were compared in three groups at the last follow-up.Results: There were 21 cases (mean age,49.7 ± 11.6) in group A, 24 cases (mean age, 48.6 ± 11.3) in group B, 22 cases (mean age,48.3 ± 12.4) in group C. No significant difference in general preoperative demographics (P>0．05).The incidence of avascular necrosis of femoral head in Group A, B, and C was 19.05%,20.83%, and 22.73 %, respectively, showing no significant difference between groups(P=0．156). The mean Harris hip scores at the final follow-up for groups A (85．6±6．7)and B (84．5±6．2) were significantly higher than group C (74．3±8.3), and the difference was statistically significant(P=0．043).Conclusions: Gotfried positive buttress reduction and fixation for femoral neck fracture may lead to similar clinical results with anatomic reduction, but much better than Gotfried negative buttress reduction. For the patients of femoral neck fracture with severe displacement and difficulty in reduction, it is not necessary to pursue anatomical reduction。Achieving positive valgus reduction can also obtain satisfactory clinical results, and should try to avoid negative buttress.


Introduction
Displaced femoral neck fractures are usually accompanied by higher complications, such as femoral head necrosis, fracture nonunion, femoral neck shortening, etc. These complications are the leading cause of re-operating [1][2][3][4][5].In elder patients, the preferred treatment for a displaced femoral neck fracture is hemiarthroplasty or total hip replacement (THR) in the majority of cases. However, younger patients with femoral neck fractures are a particular clinical research group. Different from elderly patients, premature hip replacement may increase the risk of revision rate [6][7][8][9][10]. Therefore, reduction of the fracture, rigid xation until the fracture heals, and retention of the hip joint are the main goals of treatment.
The quality of reduction has been considered to be one of the most signi cant factors of successful treatment. Meanwhile, anatomic reduction can promote fracture healing and avoid complications.
However, in 2013, Gotfried et al. Proposed the concept of "non-anatomical reduction of femoral neck fractures" [11]. Even though only 5 case data were provided, the clinical results were satisfactory.
The primary purpose of this study was to analyze the data of 67 patients with femoral neck fractures using the Gotfried reduction method and intern xation retrospectively and to evaluate the clinical e cacy report as follows.

Patients And Methods
Inclusion and exclusion criteria

The General Information
A total of 67 patients who nally met the inclusion criteria and had complete follow-up data were divided into three groups according to the rst Imaging results after surgery. Group A was the anatomical reduction group, Group B was the Gotfried positive buttress reduction group, and group c was Gotfried negative buttress reduction group. There were 21 patients in group A, 12 males, and 9 females; the average age was 49.7 ± 11.6 years; the average follow-up time was 22.4 ± 10.7 months; Garden classi cation of fractures: 7 cases of type I, 5 cases of type II, 4 cases of type III, and 5 cases of type IV; 24 cases in group B, 14 cases of male and 10 cases of the female; the average age was 48.6 ± 11.3 years; the average follow-up time was 22.1 ± 11.2; Garden classi cation of fractures: 8 cases of type I, 6 cases of type , 5 cases of type , and 5 cases of type IV; 22 cases of group C, 13 cases of male, and 9 cases of the female; mean age was 48.3 ± 12.4 years; mean follow-up time was 22.8 ± 11.6; Garden classi cation of fracture: 4 cases of type I, 7 cases of type ,5 cases of type III, and 6 cases of type IV.

Surgical Procedures
All fractures underwent gotfried closed reduction and internal xation with cannulated cancellous screws. The patient was placed on an orthopedic traction bed after anesthesia, and the perineum was protected against the traction site. The lower limb traction was performed on the operative side: lower limb abduction and knee exion, hip exion on the contralateral side for convenient uoroscopy during operation.
Gotfried closed reduction technology could be divided into three different steps as follows: 1. Gradually increased traction is applied in 2 directions: rst, lateral: using a towel that was wrapped around the upper tight and second longitudinal: on the leg utilizing fracture table. 2. Reduction-while under traction in both directions, the lower limb is brought into adduction and internal rotation. Usually, about 45 degrees adduction is required. The third stage, not presented in the drawing: reconstruction-while in adduction and internal rotation, the release of longitudinal and lateral traction.
Percutaneous cannulated screw xation: Insert a threaded guide needle in front of the femoral neck to determine the anteversion angle under uoroscopy. Insert the guide needle at the position of the trochanter slightly above the centerline of the femur. The direction is parallel to the rst positioning needle, guide-pin is drilled into place along the medial cortex of the femoral neck and head to within 5 mm of subchondral bone; Measure the length of each cannulated screw and screw in the corresponding length of the cannulated screw. The C-arm con rms the quality of fracture reduction and the screws' position to prevent the screw from penetrating the hip joint.

Postoperative Management
Intravenous prophylactic antibiotics (Cefazolin 2.0 g) were routinely administered 30 minutes preoperatively. All patients were kept in absolute bed rest for 3 days and mobilized with crutches without weight-bearing on the seventh postoperative day on the affected side. The patients received partial weight-bearing exercises with crutches after 8 weeks, and usual weight-bearing activities after 12 weeks. These patients had a positive compression ultrasound for deep-vein thrombosis and received anticoagulant therapy on the next day after the operation.
Evaluation criterion and observation index 1. Follow-up data: The follow-up duration was measured from the time of operation to the last follow-up date, and the avascular necrosis of the femoral head, malignant or nonunion of the fracture, was recorded at the last follow-up. Harris hip scoring (HHS) system was used to measure the hip function. The quality of fracture reduction is divided into anatomical reduction and non-anatomical reduction. The non-anatomical reduction is divided into Goffried positive support reduction and negative support reduction.
Statistical analysis SPSS software was used to take the statistical analysis, Normal distribution of data tested using the Shapiro-Wilk W-test. The patient's age, follow-up time, and Harris score were normally distributed data, exhibited homogeneity of variance. Analyses were carried out using one-way ANOVA in 3 groups. If the difference was statistically signi cant, then the SNK-q test was used to compare the two groups. P < 0.05 considered that the difference was statistically signi cant signi cance.

Clinical Outcome
The average follow-up periods in the three groups were ( 22.4 ± 10.7) (22.1 ± 11.2) 22.8 ± 11.6 months, which showed no statistical difference(F = 0.053, P = 0.964). There was no wound infection, fracture nonunion, and implant failure in either group. No signi cant differences were noted preoperatively between the three groups regarding age, time of operation, gender, and average time of follow-up ((P > 0.05). There was no statistically signi cant difference in the femoral head necrosis rate among the three groups (P = 0.156). At the last follow-up, the Harris scores in group A and group B were signi cantly higher than group c, and the difference was statistically signi cant (P < 0.05, Table 2).

Discussion
The treatment of femoral neck fracture in young patients faces many challenges, and if clinicians fail to provide improper treatment, it may lead to catastrophic consequences for patients [2][3][4][5][12][13][14]. The proportion of patients with femoral neck fractures under 65 years who underwent total hip arthroplasty increased from 1.4-13.1% from 1999 to 2011 [14]. However, due to the longevity of the hip joint and the high activity requirements, arthroplasty surgery is not the best option [3,4,10]. For younger patients (under 65 years), anatomical reduction, rigid xation, and preservation of their hip joints are the primary treatment goals, especially to those who have an abundance of daily activities [6,7,10,15]. In a survey of 540 orthopedic surgeons, 78% of surgeons prefer to use multiple cannulated screws for the treatment of nondisplaced femoral neck fracture. For displaced fractures, multiple screws (46%) and sliding hip screws (SHS, 49%) were rst taken into consideration for the majority of orthopedic surgeons [12]. Most of the studies were reported higher rates of avascular necrosis, premature epiphyseal fusion, and heterotopic ossi cations after open reduction [8]. The closed reduction has the advantages of less trauma, less intraoperative bleeding, and shorter operation time theoretically reduced the risk of postoperative surgical complications [16].
Consequently, closed reduction and internal xation of fracture is the preferred method of treatment. The repeated reduction should be avoided as much as possible to preserve the blood supply and reduce surgical trauma. Once the closed reduction fails, we should consider adopting open reduction and internal xation.
The inadequate reduction is the leading cause of complications such as femoral head necrosis, fracture nonunion, femoral neck shortening, etc. There is a large body of literature repeatedly emphasized the importance of reduction. It has been regarded as a key to effective treatment [6,12,17]. To achieve anatomical reduction, many scholars have made many attempts and explored some techniques, such as Whitman, Leadbetter, Deyerler reduction method.
Although achieving anatomical reduction is the goal of treating femoral neck fractures, it does not guarantee a good prognosis. To achieve anatomical reduction, it probably requires repeated manipulations but instead appears to increase the odds of femoral head necrosis and fracture nonunion [9]. Therefore, Gotfried et al. believe that anatomical reduction is not strictly necessary [11]. The anatomical reduction may not promote fracture healing and reduce the occurrence of femoral head avascular necrosis [18]. In a group of young patients, there is a good reduction in postoperative radiography. However, Nonunion occurred in 8%, 11.5% of avascular necrosis of the femoral head [1]. Gotfried  In the present study, Gotfrired reduction and all cases cannulated screw xation were taken in all cases. The Harris score in patients with positive support was signi cantly better than those in the negative support group, close to that of the anatomical reduction group. There was no signi cant difference in the short-term e cacy between the Gotfried positive support group and the anatomical reduction group.

Conclusion
Therefore, for patients who have achieved positive support and valgus reduction, they may not need to pursue an anatomical reduction. Excessive pursuit of anatomical reduction will damage the blood supply and may cause femoral head necrosis. We recommend that if you do not use open reduction, you need to pay attention to 1. To get an anatomical reduction as much as possible; 2. if anatomical reduction cannot be obtained, to get a positive reduction as much as possible 3. Avoid negative support.

Declarations
Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics declarations
Ethics approval consent to participate This study was approved by the medical ethics committee of our institution. All of the enrolled patients had written informed consent before participating in this study.

Consent for publication
All of the collected patients had written informed consent before participating in this study, and the consent of publication was obtained from patients.

Competing for publication
The authors declare that they have no competing interests