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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Full length article

Good functional outcome but not regained health related quality of life
in the majority of 20–69 years old patients with femoral neck fracture
treated with internal fixation
A prospective 2-year follow-up study of 182 patients
Pierre Campenfeldta,b , Margareta Hedströma,c , Wilhelmina Ekströmd , Amer N. Al-Ania,e,*
a
Karolinska Institutet, Department of Clinical Science, Intervention and Technology (CLINTEC), Stockholm Sweden
b
Norrtälje Hospital, TioHundra AB. Box 905, 761 29 Norrtälje, Sweden
c
Department of Orthopaedics, Karolinska University Hospital, Huddinge, Stockholm, Sweden
d
Karolinska Institutet, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Department of Orthopaedics Karolinska
University Hospital Solna, Stockholm, Sweden
e
Orthopaedic Clinic, Vällingby-Läkarhuset, Praktikertjänst AB, 16268 Vällingby, Sweden

A R T I C L E I N F O A B S T R A C T

Article history: Background and purpose: Prospective studies on patient related outcome in patients <70 years with a
Received 3 June 2016 femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related
Received in revised form 7 October 2017 quality of life (HRQoL) in 20–69 years old patients with a FNF treated with internal fixation.
Accepted 16 October 2017
Patients and methods: 182 patients, 20–69 years with a FNF treated with internal fixation were
prospectively included in a multicenter study. Follow up included radiographic and clinical examination
Keywords: at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and
Femoral neck fracture
SF-36), fracture healing and re-operations.
Young
Functional outcome
Results: At 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85%
Fracture healing of the patients with a non-displaced fracture (p = 0.15). Of the patients with displaced fracture (n = 120),
HRQoL 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of
the patients with non-displaced fracture (n = 50) had an NU, 12% had a radiographic AVN and 8% needed a
re-operation. The mean EQ-5Dindex in patients with displaced fracture decreased from 0.81 to 0.59 at 4
months, 0.63 at 12 months and 0.65 at 24 months (p < 0.001). The corresponding values for patients with
non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p < 0.001). The mean SF-total score in
patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24
months (p < 0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74
and 76 respectively (p < 0.001).
Interpretation: Two thirds of the patients with displaced femoral neck fracture healed after one operation
and three quarters reported good or excellent functional outcome at 24 months. However, they did not
regain their pre-fracture level of HRQoL.
© 2017 Elsevier Ltd. All rights reserved.

Introduction patients’ future functional demand. Furthermore, the longer life

expectancy in these patients might increase the risk of surgical
Femoral neck fractures in younger patients are uncommon but revisions if treated with a hip arthroplasty. However, there is
may result in lifetime disability. The recommended treatment for currently a growing trend in Sweden to treat patients with a
patients <70 years with a femoral neck fracture is anatomic displaced femoral neck fracture in the age range of 60–69 years
fracture reduction and internal fixation regardless of the degree of with a total hip replacement (THR) [2]. A similar trend has been
displacement [1]. The rationale behind this recommendation is the reported in the USA and in other countries [3,4], yet, studies
desire to preserve the native hip joint, which may facilitate the supporting this approach are missing.
There is a lack of prospective studies on younger patients. A
majority of the studies are retrospective, have a low sample size
and are not conducted on western population. Moreover, the
* Corresponding author at: SE – 162 68 Vällingby, Sweden.
E-mail addresses: [email protected], [email protected] (A.N. Al-Ani). national registers as well as most previously published studies on

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Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority
of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
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younger patients with femoral neck fracture focus on re-operation The mechanism of injury was classified as low-energy trauma
rates [1,5–7]. Studies analysing functional outcome and health (fall at the same level), sport injury (mainly cycling or ice skating)
related quality of life (HRQoL) after a femoral neck fracture in and high-energy trauma (traffic accident, riding accident and fall
younger patients are needed [8]. The aim of this study was to from a height). Alcohol consumption was evaluated with Alcohol
investigate functional outcome, HRQoL and fracture healing Use Disorder Identification Test (AUDIT), which is a validated
complications in patients aged 20–69 with a femoral neck fracture instrument that identifies hazardous and harmful alcohol use, as
treated with internal fixation. well as possible dependence [11]. Current smokers were coded as
smokers.
Materials and methods The ASA score was assessed by the attending anaesthesiologist.
The ASA score [10] describes the physical status of the patients and
This was a prospective multicenter study with a 24 months classifies them according to 6 scores (ASA 1–6).
follow-up. Patients aged 20-69 with a femoral neck fracture The health-related quality of life was rated using the EQ-5D [12]
admitted to any of the four university hospitals in Stockholm, and SF-36 [13]. In order to acquire baseline values of EQ-5D and SF-
Sweden during a period of 3.5 years were included. Patients living 36, patients were asked to report their pre-fracture quality of life
independently and who were able to walk before the fracture were from the week before the fracture. The EQ-5D has five dimensions:
included in the study. Patients with psychotic disease or severe mobility, self-care, usual activities, pain/discomfort, and anxiety/
cognitive impairment according to Short Portable Mental Status depression. Each dimension is divided into three degrees of
Questionnaire (SPMSQ <3) [9] were excluded. Subjects with risk severity: no problem, some problems, and major problems. Dolan
factors for secondary osteoporosis (chronic renal failure and et al. [14] used the time trade-off (TTO) method to rate these
hyperparathyroidism) and those with simultaneous fracture of the different states of health in a large UK population (UK EQ-5D Index
lower extremity were excluded. Similarly, a fracture older than Tariff). We used the preference scores generated from this
48 h before admission and patients with previous pathology in the population when calculating the scores for our study population.
fractured hip were not included in the study. A value of 0 indicated the worst possible state of health and a value
of 1 the best possible.
At inclusion SF-36 is a questionnaire used to measure HRQoL originally
developed by RAND corporation [13]. It contains 36 items on 8
All assessments, except the American Society of Anaesthesiol- different domain scales. The scales are; physical functioning (PF),
ogists (ASA) classification [10] and fracture classifications were role-physical (RF), bodily pain (BP), general health (GH), vitality
carried out by specially trained research nurses. The following (VT), social functioning (SF), role-emotional (RE) and mental health
variables were recorded at inclusion: age, gender, pre-fracture (MH). By adding the scores from the first 4 scales and dividing by 4
living conditions, walking ability, alcohol consumption, current a SF-36 physical score is calculated with a range of 0–100. The
smoking, ASA score, fracture type and mechanism of injury. Living mental score is calculated in a similar fashion, by adding the scores
conditions were registered as independent (i.e. own home or block from the last 4 scales and dividing by 4. The total score is calculated
of serviced flats) or as institutionalized. Walking ability was by adding the 8 scales and diving by 8. The changed score between
recorded as walking outdoors, walking indoors or unable to walk. baseline and 24-month follow up was compared to minimally
Use of walking aids was recorded. important difference (MID) to evaluate whether the change was of

Fig. 1. X-ray showing the position of the screws. It was considered as good when the distal screw was introduced at the level of the lesser trochanter (A) and positioned on the
inferior calcar (B). The proximal one should be parallel and at least 2 cm away from the distal one (<10
) (C). Both screw tips should be less than 5 mm from the subchondral
bone (D). On the lateral projection the screws should be parallel and lie on the central or posterior third of the femoral head and neck (E). The Garden angle is the angle formed
between the shaft of the femur (F) and medial trabeculae in the neck-head of the femur (G).The reduction was categorised depending on degree of fracture displacement (H),
Garden angle 16-0175
and posterior head angulation (I).

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clinical significance. The MID was previously calculated as 8.2 for Statistical analysis
SF-36 total score [15].
All radiographs were assessed in consensus by 3 orthopaedic Statistical calculations were performed using SPSS version 22
surgeons who are well experienced in hip fracture surgery. The for Windows (IBM, SPSS Statistics). Mean, standard deviation,
femoral neck fracture was classified into non-displaced (Garden 1– median, range and percentage were used for descriptive purposes.
2) and displaced (Garden 3–4) [16]. All patients were operated Normally distributed independent variables were tested for
with closed reduction and fixation with two cannulated screws differences with Student’s t test. Contingency tables were tested
(Olmed1). Surgery was performed by both consultants and for differences with Pearson’s chi-square test. Exact methods were
residents. Fracture reduction was carried out by closed methods utilized wherever needed. In all analyses, a p value of less than 0.05
with the aid of image intensifier and patients on extension table was considered statistically significant.
and fixed with two cannulated screws (Olmed 1). The reduction
was categorised into good (displacement <2 mm, Garden angle Results
160–175
, posterior angulation <10
), fair (displacement 2-5 mm,
Garden angle 160-175
, posterior angulation <20
) or poor There were 182 patients included with a median age of 59 years
(displacement >5 mm Garden angle <160
or >175
, posterior (range 20–69, 47% male). Demographic and baseline data are
angulation >20
) (Fig. 1). presented in Table 1. At 24-month data was available for 170
The Garden angle is the angle formed between the shaft of the patients, (120 patients with displaced fracture and 50 patients
femur and medial trabeculae in the neck-head of the femur on the with non-displaced fracture). Seven patients were deceased and 5
frontal view [16] (Fig. 1). patients were not able to attend at last follow-up. Background data
The screw position was considered good when the distal screw on these patients was previously published [15,22].
was introduced at the level of the lesser trochanter and positioned As for patients with displaced fractures, the quality of reduction
on the inferior femoral calcar. The proximal screw should be placed was considered good in 80% (n = 101), fair or poor in 20% (n = 26). In


parallel and at least 2 cm apart from the distal one (< 10 ) with one patient the post-operative radiographic examinations were
both screw tips less than 5 mm from the subchondral bone. On the missing. The screw position was considered good in 76% (n = 97)
lateral projection the screws should be parallel and lie on the and not good in 24% (n = 30). In those with non-displaced fractures
central or posterior third of the femoral head and neck. If one or the position of the screws was good in 85% (n = 46) and not good in
more of these criteria were not fulfilled the position was 15% (n = 8).
considered not good [17] (Fig. 1).

Follow up
Table 1
An orthopaedic surgeon performed the follow-ups during Baseline data for all patients younger than 70 years with a femoral feck fracture
regular outpatient’s visits including radiographic and clinical (n = 182) divided by fracture type. Values are expressed as mean +/ SD for age and
examinations, recording of complications and evaluation of hip BMI, and N (%) for other variables.
function as well as EQ-5D and SF-36 at 4, 12 and 24 months. All patients Non-displaced Displaced P-value
Fractures were considered healed if x-ray showed trabecular
N = 182 N = 54 N = 128
bone across the fracture line. Fractures which re-displaced at 4-
Age mean  SD 57  8 57  8 58  9 0.39*
month follow-up or showed absence of visible trabecular bone
BMIa mean  SD, kg/m2 24  4 23  3 25  4 0.008*
across the fracture line at 12- or 24-month follow-up were both N (%) N (%) N (%)
considered non-union (NU). Only patients that were re-operated
with arthroplasty were considered to be NU. Fractures healed with Gender n (%)
any position were not regarded as NU. Avascular necrosis (AVN) Women 97 (53) 35 (65) 62 (48) 0.043x
Men 85 (47) 19 (35) 66 (52)
was defined as segmental collapse, loss of sphere of the femoral
head or subchondral fracture [18]. Re-operations were registered ASA scoreb n (%)
and the reasons were categorised as NU, AVN, deep wound 1 67 (37) 22 (41) 45 (35) 0.66x
infection and new fracture near the implant. Extraction of the 2 81 (44) 25 (46) 56 (44)
3 30 (17) 6 (11) 24 (19)
screws was recorded as a minor re-operation. General complica-
4 4 (2) 1 (2) 3 (2)
tions and mortality were recorded at each follow-up.
The hip function was evaluated using Harris Hip Score (HHS) Alcohol AUDITc n (%)
[19] at 4, 12 and 24 months. HHS is a validated instrument that High 41 (23) 7 (13) 34 (27) 0.043x
evaluates pain, function, range of motion and deformity of the hip. Low 137 (77) 46 (87) 91 (73)
It has a scale of 100 points in which pain constitutes 44 points. No
Smoking 72 (40) 20 (37) 52 (41) 0.651x
pain gives a value of 44 and severe pain at rest gives a value of 0.
Function has a maximum level of 43 points and includes evaluation Trauma mechanism
of daily activities and walking ability. Absence of deformities gives Low-energy trauma 137 (75) 39 (72) 98 (77) 0.56x
4 points and maximum range of motions gives 5 points. Harris Hip Sport injury 31 (17) 9 (17) 22 (17)
High-energy trauma 14 (8) 6 (11) 8 (6)
Score has 3 categories: excellent if >80, good between 70 and 80
and poor if <70 points. ASA: American Society of Anaesthesiologists classification; BMI: Body Mass Index;
AUDIT: Alcohol Use Disorders Identification Test.
All patients were treated according to the protocols at the a
missing = 1.
participating hospitals and the study was conducted according to b
missing = 5.
the Helsinki Declaration [20]. The protocols were approved by the c
missing = 4.
*
local Ethics Committee (Dnr. 01-427). Reporting of the study = P-value for difference in mean using Student’s T-test.
x
conforms to STROBE guidelines [21]. = P-value for difference in chi-square distribution across groups using Pearson’s
chi-square test.

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Fig. 2. Chart showing number of patients at initiation of the study, and at each follow-up (4, 12 and 24 months) with summary of the results in terms of nonunion, avascular
necrosis, deep wound infection, nearby fracture, and re-operation.

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Table 2 In patients with displaced fracture, 23% had a NU and 15% AVN
Postoperative hip function in patients younger than 70 years with a femoral neck
at 24-month follow-up. The re-operation rate was 28%, including
fracture evaluated with Harris Hip Score (0–100).
all patients with NU and seven patients with AVN. Four patients
All Non-displaced Displaced P-value were treated for a deep wound infection and were re-operated
N (%) N (%) N (%) with Girdlestone resection arthroplasty (two of them were later re-
4 monthsa
operated with THR). One patient needed re-operation due to a new
Poor function <70 70 (41) 13 (25) 57 (48) 0.002* nearby fracture. A subgroup analysis of the patients with displaced
Good function 70–80 23 (14) 5 (10) 18 (15) fracture according to different age categories showed that 11% of
Excellent function >80 77 (45) 34 (65) 43 (37) the patients <50 years of age (2/19), 34% of the patients 50–59
years of age (13/39) and 31% (19/62) of the patients 60–69 years of
12 monthsb
Poor function <70 45 (27) 10 (21) 35 (30) 0.005* age with a displaced femoral neck fracture had a re-operation with
Good function 70–80 16 (10) 0 16 (14) hip replacement because of AVN or NU, (p = 0.16).
Excellent function >80 103 (63) 38 (79) 65 (56) Of the patients with a non-displaced fracture at 24-month
follow-up none had a NU and 12% had AVN. Four of the patients
24 monthsc
Poor function <70 38 (24) 7 (15) 31 (27) 0.156*
with AVN had pain that required re-operation with a THR.
Good function 70–80 15 (9) 3 (6) 12 (10)
Excellent function >80 109 (67) 37 (79) 72 (63) Functional outcome
Missing: an = 12, bn = 18, cn = 20. * = P-value for difference in chi-square distribution
across groups using Pearson’s chi-square test. Harris Hip Score at each follow up is shown in Table 2. The
analysis includes those with and without re-operation. The
Fracture healing complications functional outcome favoured patients with non-displaced fracture
at four- and twelve-month follow-ups; however, this levelled out
The distribution of fracture healing complications and re- at the final follow-up (Table 2).
operations by type of fracture (displaced or non-displaced) is Patients with displaced fracture that healed after the index
shown in Fig. 2. operation had good or excellent functional outcome at 24-month

Fig. 3. EQ-5D Index score before fracture and at each follow-up.

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Fig. 4. SF-36 score before fracture and at each follow-up.

follow-up in 80% (n = 65/81) of cases, compared to 57% (n = 20/35) The mean SF-total score in patients with displaced fracture
in those who required re-operation (p = 0.01). decreased from 76 (SD 20) to 55 (SD 23) at 4 months, 63 (SD 22) at
12 months and 65 (SD 23) at 24 months (p < 0.001). The
Health-related quality of life corresponding values for patients with non-displaced fracture
were 80 (SD 26), 67 (SD 23), 74 (SD 25) and 76 (SD 23) respectively
The HRQoL decreased for all patients (Fig. 3). The mean EQ- (p < 0.001).
5Dindex for patients with displaced fracture decreased from 0.81 Average SF-36 physical and mental scores at baseline and at
(SD 0.27) to 0.59 (SD 0.26) at 4 months (p < 0.001), 0.63 (SD 0.29) at each follow-up are presented in Fig. 4. The figure shows that
12 months (p < 0.001) and 0.65 (SD 0.29) at 24 months (p < 0.001). mental scores recovered to a greater extent compared to physical
The mean EQ-5Dindex in patients with non-displaced fracture scores for all patients’ regardless of the type of femoral neck
decreased from 0.88 (SD 0.18) to 0.69 (SD 0.28) at 4 months fracture.
(p < 0.001), 0.75 (SD 0.25) at 12 months (p < 0.001) and 0.74 (SD Mean SF-36 subscales at baseline and at final follow-up are
0.28) at 24 months (p < 0.001). shown in Table 3 and Fig. 5. In patients with non-displaced
There was no statistically significant difference in HRQoL (EQ- fractures the changes were significant in PF, BP, GH, VT, MH. The
5Dindex) for patients with non-displaced fracture compared to difference in PF and BP was 10 and 14 respectively (Table 3) which
patients with displaced fracture at each follow-up (data not is higher than MID. On the opposite, in patients with displaced
shown). fracture the difference in all sub-scales between baseline and final
The HRQoL (EQ-5Dindex) in patients with displaced fracture that follow-up were significant and higher than MID with the exception
healed after one operation compared to those who required re- of MH and GH subscales were the differences were below MID
operation is shown in Fig. 3. Both patient groups showed a (Table 3). Further, both patients with and without re-operation
noticeable decrease in health-related quality of life at four-month reported significantly lower values in numerous SF-36 subscales at
and did not reach their pre-fracture level at final follow-up. 24 months, particularly in PF, RP, BP and RE (Table 3 and Fig. 5).

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Table 3
SF-36 subscales at baseline and at 24-month follow up with change score. All values presented as mean (SD).

Non- Displaced Displaced fracture

displaced

No major re- With major re-

operation operations

n = 45 n = 113 n = 79 n = 34
Physical functioning (PF)
- Before fracture 85 (23) 75 (29) 78 (29) 68 (31)

- 24-month 71 (31) 58 (31) 64 (30) 44 (29)

- change score 14 (23) 17 (28) 14 (22) 24 (38)

- P-value <0.001 <0.001 <0.001 0.001

Role physical (RP)

- Before fracture 83 (34) 75 (37) 80 (34) 62 (43)

- 24-month 76 (37) 57 (44) 64 (42) 38 (43)

- change score 7 (42) 18 (42) 16 (40) 24 (48)

- P-value 0.2 <0.001 <0.001 0.008

Bodily Pain (BP)

- Before fracture 87 (25) 80 (26) 84 (22) 72 (31)

- 24-month 77 (27) 65 (32) 70 (29) 56 (37)

- change score 10 (27) 15 (30) 14 (24) 16 (41)

- P-value 0.008 <0.001 <0.001 0.025

General Health (GH)

- Before fracture 77 (20) 72 (23) 77 (20) 62 (27)

- 24-month 71 (24) 66 (24) 70 (23) 57 (24)

- change score 6 (18) 6 (21) 7 (18) 5 (25)

- P-value 0.04 0.001 0.002 0.2

Vitality (VT)
- Before fracture 76 (24) 71 (25) 76 (21) 60 (29)

- 24-month 68 (29) 62 (29) 67 (27) 50 (30)

- change score 8 (23) 9 (26) 9 (23) 10 (31)

- P-value 0.03 <0.001 0.002 0.09

Social functioning (SF)

- Before fracture 89 (24) 85 (23) 90 (18) 75 (28)

- 24-month 86 (23) 75 (30) 80 (28) 62 (32)

- change score 3 (24) 10 (27) 10 (24) 13 (31)

- P-value 0.4 <0.001 0.001 0.023

Role emotional (RE)

- Before fracture 83 (31) 80 (36) 87 (29) 64 (45)

- 24-month 74 (42) 65 (44) 74 (41) 44 (46)

- change score 9 (43) 15 (46) 13 (41) 20 (57)

- P-value 0.17 0.001 0.001 0.06

Mental health (MH)

Before fracture 85 (20) 80 (20) 83 (19) 73 (23)
- 24-month 79 (24) 75 (27) 80 (24) 64 (30)

- Change score 6 (18) 5 (24) 3 (23) 9 (28)

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Table 3 (Continued)
Non- Displaced Displaced fracture
displaced

No major re- With major re-

operation operations

n = 45 n = 113 n = 79 n = 34
- P-value 0.02 0.001 0.25 0.054

Mortality and general complications discussed with the patient to achieve the most successful outcome
[28].
Two patients had pneumonia, three patients had heart failure The functional outcome in younger patients with femoral neck
and 11 patients were treated for urinary tract infections. Seven fracture is not well studied. In the present study, a higher proportion
patients were dead at 24-month follow-up (4%). of patients with non-displaced fracture had a good or excellent
functional outcome at four- and twelve- months follow-up
Discussion compared to those with displaced fracture according to HHS.
However, this statistically significant difference had disappeared at
This study showed that two-thirds of the patients with the final follow-up at 24 months. This could be explained by the fact
displaced fracture healed after one operation and three-quarters that the majority of the patients with fracture healing complication
had good or excellent functional outcome after two years. As for were re-operated with hip replacement and had recovered at the
patients with non-displaced fracture:- all healed after one surgery time of final follow-up. However, those patients who required re-
and eight percent needed reoperation due to AVN. The study operations had inferior outcome at 24-month follow-up. These
further showed that patients did not regain their pre-fracture level results indicate that further studies are required to find risk factors
of HRQol regardless of the type of femoral neck fracture. associated with fracture healing complications and re-operation in
Furthermore, in patients with displaced fracture, no difference this age group. A similar decrease in functional outcome among
in re-operation rate was found between patients in the age group elderly patients with fracture healing complications has been
50–59 and 60–69 (34% and 31% respectively). Thus, one cannot tell reported by Tidermark et al. [29] with a mean follow-up of 17
if the age limit for treating patients with displaced femoral neck months.
fracture with a THR should be lowered and if so to 60 or 50 years of EuroQoL, as a health related quality-of-life instrument, judges
age. This indicates that chronological age may not be reliable when favourably in terms of internal and external validity being only
deciding treatment modality, which contradicts the ongoing trend slightly less sensitive than SF-36 [15]. EuroQol has also been
to treat patients with a displaced femoral neck fracture in the age validated in elderly patients with femoral neck fracture as a
range of 60–69 years with a total hip replacement (THR) [2–4]. It reliable outcome measurement in clinical trials [30–34]. Previous
could therefore be of interest to find risk factors other than age that studies on elderly patients have shown that those with a healed
are associated with increased risk for re-operation due to AVN and non-displaced fracture regained their pre-fracture quality of life
NU. As for patients under 50 years, further studies are needed to level while patients with a healed displaced fracture did not [30].
find the optimal surgical method in order to reduce the risk for On the contrary, this study showed that younger patients with
complications related to the fracture healing [23]. either of the fracture types did not regain their pre-fracture level of
All patients in our study with NU required re-operation. By HRQoL. One could assume that younger patients have higher
contrast, only 46% (11/24) of those with AVN had symptoms that functional demands and a slight functional impairment might
required re-operation at 24-month follow-up. A previous study influence their health related quality of life.
made by Haidukewych et al. [5] found that half of the patients that A previous study suggested that a mean effect size of 0.15 is
developed AVN showed symptoms and required re-operation, considered to be MID for EQ-5D [34]. Our study showed that
which is in accordance with our results. Furthermore, Jain et al. patients with a displaced fracture requiring re-operation had a
[24] found that AVN did not affect functional outcome in younger similar decrease of HRQoL at 4 months, with minimal improve-
patients with femoral neck fracture. ment until 24-month follow-up compared to those with fractures
A meta-analysis conducted by Damany et al. [1] reported that that healed after a single operation. SF-36 showed similar results,
the incidence of NU was 9% and for AVN 23% in patients <50 years the group with non-displaced as well as displaced fractures had a
of age, with displaced femoral neck fracture, which is similar to our loss in both physical and mental scores two years after surgery.
findings. However, the reported incidence of NU in younger Zidén et al. [35] reported similarly “a social and existential crack”
patients varies between 0 and 59% [1,5–7,25,26]. This may be in elderly patients after a hip fracture. To our knowledge this has
explained by several factors, such as different definitions of NU. not been shown in younger patients and should therefore be
Early complications are in some studies considered re-displace- further investigated. Consequently, one could theorize that special
ment, if it occurs 4–6 months after surgery it is instead regarded as rehabilitation program for younger patients are required.
NU [6,27]. In the present study, NU was defined as absence of The strengths of this study were the prospective multicentre
healing regardless of whether it occurs before or after 4 months. design and the long follow-up, including clinical, radiological and
Concerning type of re-operation, there is an agreement that functional outcomes. Another strength was the low dropout rate.
patients over 60 years of age, who are symptomatic due to fracture One limitation of the study was the low number of patients
healing complication, are re-operated with an arthroplasty. < 50 years of age, as the incidence of femoral neck fracture in this
Younger patients are instead treated with more hip preserving group is low. Highly posteriorly angulated Garden I–II fractures
methods. However, further studies are needed and the choice of could behave as displaced fracture but were not allocated to the
the treatment modality must be decided on an individual basis and displaced fracture group, and that this may represent a weakness

Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority
of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
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Fig. 5. Spider diagram showing mean SF-36 subscores before fracture and at 24-months follow-up.

of the study. However, we did not use posterior angulation on the In conclusion, this study has shown that two-thirds of the
axial view to allocate fracture as displaced or non-displaced as this patients with displaced femoral neck fracture healed after one
is not stated in the original criterion of displacement [16]. Further, operation and three-quarters had good or excellent functional
patients with severe cognitive impairment, multiple fractures, outcome. In patients with non-displaced fracture only eight
chronic renal failure or hyperparathyroidism and patients unable percent were re-operated due to AVN. The study further showed
to walk or living in institutions were not included, which limits the that patients did not regained their pre-fracture level of HRQol
generalizability of our results. irrespective of fracture type. The study suggests that internal

Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority
of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028
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JINJ 7461 No. of Pages 10

10 P. Campenfeldt et al. / Injury, Int. J. Care Injured xxx (2017) xxx–xxx

fixation for femoral neck fracture in patients <70 years of age may health survey in 20–69 years old patients with a femoral neck fracture. A 2-
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injury.2016.05.021.
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Supported by grants provided by the Stockholm County Council
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Please cite this article in press as: P. Campenfeldt, et al., Good functional outcome but not regained health related quality of life in the majority
of 20–69 years old patients with femoral neck fracture treated with internal fixation, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.028