femoral neck fractures borrowed heavily from ota core curriculum authors: steven a. olson, md and...
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Femoral neck fractures
Borrowed heavily from OTA core curriculumAuthors: Steven A. Olson, MD and Brian Boyer, MD
Kenneth J Koval, MD
Anatomy
• Physeal closure age 16• Neck-shaft angle
130° ± 7°• Anteversion
10° ± 7°• Calcar femorale
Posteromedial
dense plate of bone
Blood supply
• Lateral epiphysel artery– terminal branch MFC artery– predominant blood supply to
weight bearing dome of head
• Artery of ligamentum teres– from obturator artery– supplies anteroinferior head
• Lateral femoral circumflex a.– less contribution than MFC
Epidemiology
• 250,000 Hip fractures annually– Expected to double by 2050
– 50% are femoral neck fractures
• At risk populations– Elderly: poor balance & vision, osteoporosis, inactivity,
medications, malnutrition• incidence doubles with each decade beyond age 50
– Young: high energy trauma
Classification
• Pauwels [1935]
– Angle describes vertical shear vector
Classification
• Garden [1961]
I Valgus impacted or
incomplete
II Complete
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement
** Portends risk of AVN and Nonunion
I II
III IV
Classification
• Functional Classification – Stable
• Impacted (Garden I)
• Non-displaced (Garden II)
– Unstable• Displaced (Garden III and IV)
Treatment
• Options– Non-operative
• very limited role
– Operative• ORIF
• Hemiarthroplasty
• Total hip replacement
Non-displaced fractures
• ORIF standard of care• Predictable healing
– Nonunion < 5%
• Minimal complications– AVN < 8%
– Infection < 5%
• Relatively quick procedure– Minimal blood loss
• Early mobilization– Unrestricted weight bearing with assistive device PRN
Displaced fractures
ORIF versus replacement
Most important considerations
are life expectancy and activity level
Young adults
• Closed or open reduction and internal fixation is the procedure of choice
• Emergent surgery
ORIF: most important variable is quality of reduction
Approach for open reduction
Smith-Peterson• Anterior approach
• Best for transcervical and subcapital fractures
• Fixation is performed through a second approach
Approach for open reduction
Watson-Jones• Anteriolateral exposure
• Best for basalar neck and IT patterns
• Allows placement of implant through same incision
What reduction is acceptable?
• Ideal reduction is Anatomic– Acceptable: < 15º valgus < 10º AP angulation
• Any varus is unacceptable
Screw fixation
• Screw location– Avoid posterior/ superior quadrant
» Blood supply
» Cut-out
– Biomechanical advantage to inferior/ calcar screw
Sliding hip screw fixation
• Compression Hip Screws– Sacrifices large amount of bone
– May injure blood supply
– Biomechanically superior in cadavers
– Anti-rotation screw often needed
– Increased cost and operative time
• No clinical advantage over parallel screws * May have role in high energy/ vertical shear
fractures
Sedentary elderly
•Arthroplasty is the procedure of choice, usually a hemiarthroplasty
Unipolar vs. bipolar
• Bipolar theoretical advantages• Lower dislocation rate• Less acetabular wear/ protrusio• Less pain
Cochrane collaboration 2010
• Hemiarthroplasty–From the trials to date there is no
evidence of any difference in outcome between bipolar and unipolar prostheses
Cemented versus uncemented
• ? 1% sudden death• less pain• better function
Active elderly
•Treatment of choice for displaced femoral neck fractures is controversial
ORIF vs (hemi) arthroplasty for displaced femoral neck fractures
• ORIF - reduced operative time, operative blood loss, need for transfusion, and risk of deep wound infection
• Arthroplasty - lower revision rate• No differences found in hospital LOS,
mortality, residual pain, or regaining mobility
Cochrane review 2002
Recent re-evaluation for role of THR for treatment
of acute femoral neck fractures in the active
elderly
ORIF vs Bipolar vs THR
• Prospective randomized multicenter• Displaced FN fxs, pts > 60 years• 298 pts- ORIF (118); cemented bipolar (111);
cemented THR (69)• ORIF fixation failure (AVN,NU) - 37%• ORIF – 8x more likely to require revision surgery
than bipolar and 5x than THR• Functional outcome highest for THR
Keating et al, JBJS 2006
Treatment for displaced Femoral neck fractures
• Younger individuals: ORIF• Oldest old: Hemiarthroplasty• Middle range of the elderly: Controversial
– Hemiarthroplasty (unipolar) for displaced femoral neck fractures in sedentary elderly 65-80 years old
– THR for active individuals and those with pre-existing acetabular disease
– ORIF for active elderly with understanding that there is a high risk for revision surgery
Thank you
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