Orthopedics

Subcapital Fractures: In the Bucket or On Top of the Neck?

Richard F. Kyle, MD

  • Orthopedics. 2010;33(9)
  • Posted September 1, 2010

Abstract

Femoral neck fractures have a 30% reoperation rate when internally fixed. To reduce the reoperation rate, the surgeon must accurately decide which fractures are best fixed and which fractures require a prosthesis. The literature supports the fact that nondisplaced fractures should be internally fixed. Fractures in patients physiologically younger than 65 years should also be fixed if they have no comorbidities. The most important factors in reducing failure rate of fixation are patient selection and anatomic reduction. A femoral neck fracture left in varus is doomed to failure and reoperation.

Femoral neck fractures that are displaced in patients older than 65 years require a decision-making algorithm to decide how they should be treated. In the physiologically active patient older than 65 years, internal fixation may be considered. In most patients older than 65 years, prosthetic replacement should be considered. Nursing home patients and patients with comorbidities who are not expected to live longer than 6 to 7 years should receive a hemiarthroplasty. Studies show a high reoperation rate if the patient with hemiarthroplasty survives more than 6 or 7 years.

In the active elderly patient with little or no comorbidities, a total hip replacement should be considered. This is not only cost effective but provides the best pain relief of any of the treatment options for displaced femoral neck fractures. Treatment of femoral neck fractures remains a challenge, but the surgeon must develop an algorithm to select proper treatment options for the patient. The decision-making process is always shared with the patient.

Femoral neck fractures remain an unsolved fracture. Speed1 reported an avascular necrosis rate of 20%, nonunion rate of 30%, and reoperation rate of 36%. Have we improved our treatment in the last 70 years? In 2003, Bhandari et al’s2 meta-analysis reported an avascular necrosis rate of 10% and nonunion rate of 15%. When compared with Speed’s1 data, we really have not done that much better. Reoperations range somewhere between 20% and 36%. We need to improve our treatment of patients with femoral neck fractures.

How do you decide which to perform, an arthroplasty or internal fixation? Looking at the literature, nondisplaced fractures do well (Garden I and II fractures).3-5 Garden III and IV displaced fractures are problematic.3-5

Pauwel’s angle is still important.6,7 With a transverse fracture, you can compress the fracture site with screws and make a strong construct that resists varus deformity. With a sharp shear angle (high Pauwel’s angle), it is difficult to treat that fracture with multiple screws and resist the shear forces. In a fracture with a high shear angle, I like to use a standard compression hip screw with a derotation screw placed above it. Displaced fractures are a problem and require an algorithm for treatment. For the patient who is physiologically younger than age 65 years, the fracture needs to be closed or openly reduced and fixed.

How can you predict which hip fractures are going to do well? Anatomic reduction is the key to success. A femoral neck fracture cannot be left in varus. This fracture has to be anatomically reduced. Bone density is important. The very osteoporotic individuals do worse than those with good bone density. Patients with renal failure do not heal their femoral neck fractures and require a prosthesis. Rheumatoid arthritis and other arthritic comorbidities are also problematic, and these patients should be considered for a prosthesis.

A randomized, prospective study by Keating et al8 looked at hemiarthroplasty, total joint replacement, and internal fixation for treatment of displaced femoral neck fractures. Over a 2-year period, the patients treated with the total hip did best.

Overall cost is a…

Abstract

Femoral neck fractures have a 30% reoperation rate when internally fixed. To reduce the reoperation rate, the surgeon must accurately decide which fractures are best fixed and which fractures require a prosthesis. The literature supports the fact that nondisplaced fractures should be internally fixed. Fractures in patients physiologically younger than 65 years should also be fixed if they have no comorbidities. The most important factors in reducing failure rate of fixation are patient selection and anatomic reduction. A femoral neck fracture left in varus is doomed to failure and reoperation.

Femoral neck fractures that are displaced in patients older than 65 years require a decision-making algorithm to decide how they should be treated. In the physiologically active patient older than 65 years, internal fixation may be considered. In most patients older than 65 years, prosthetic replacement should be considered. Nursing home patients and patients with comorbidities who are not expected to live longer than 6 to 7 years should receive a hemiarthroplasty. Studies show a high reoperation rate if the patient with hemiarthroplasty survives more than 6 or 7 years.

In the active elderly patient with little or no comorbidities, a total hip replacement should be considered. This is not only cost effective but provides the best pain relief of any of the treatment options for displaced femoral neck fractures. Treatment of femoral neck fractures remains a challenge, but the surgeon must develop an algorithm to select proper treatment options for the patient. The decision-making process is always shared with the patient.

Femoral neck fractures remain an unsolved fracture. Speed1 reported an avascular necrosis rate of 20%, nonunion rate of 30%, and reoperation rate of 36%. Have we improved our treatment in the last 70 years? In 2003, Bhandari et al’s2 meta-analysis reported an avascular necrosis rate of 10% and nonunion rate of 15%. When compared with Speed’s1 data, we really have not done that much better. Reoperations range somewhere between 20% and 36%. We need to improve our treatment of patients with femoral neck fractures.

How do you decide which to perform, an arthroplasty or internal fixation? Looking at the literature, nondisplaced fractures do well (Garden I and II fractures).3-5 Garden III and IV displaced fractures are problematic.3-5

Pauwel’s angle is still important.6,7 With a transverse fracture, you can compress the fracture site with screws and make a strong construct that resists varus deformity. With a sharp shear angle (high Pauwel’s angle), it is difficult to treat that fracture with multiple screws and resist the shear forces. In a fracture with a high shear angle, I like to use a standard compression hip screw with a derotation screw placed above it. Displaced fractures are a problem and require an algorithm for treatment. For the patient who is physiologically younger than age 65 years, the fracture needs to be closed or openly reduced and fixed.

How can you predict which hip fractures are going to do well? Anatomic reduction is the key to success. A femoral neck fracture cannot be left in varus. This fracture has to be anatomically reduced. Bone density is important. The very osteoporotic individuals do worse than those with good bone density. Patients with renal failure do not heal their femoral neck fractures and require a prosthesis. Rheumatoid arthritis and other arthritic comorbidities are also problematic, and these patients should be considered for a prosthesis.

A randomized, prospective study by Keating et al8 looked at hemiarthroplasty, total joint replacement, and internal fixation for treatment of displaced femoral neck fractures. Over a 2-year period, the patients treated with the total hip did best.

Overall cost is a big factor in treatment of femoral neck fractures because of their frequency. In a study by Iorio et al,9 the cost of complications is what increases the cost of open reduction and internal fixation (ORIF) of femoral neck fractures. The cost of total joint replacement is less than ORIF when the cost factor is looked at over a long period of time and reoperation is factored in. The cost of attempting an ORIF is the cost of treating the complications. If the complications can be avoided, ORIF is cost effective. Iorio et al9 concluded that arthroplasty, bipolar or total, is associated with a much lower surgical complication rate than ORIF of displaced subcapital fractures.

The technique of arthroplasty has changed. Bigger femoral heads have allowed us to reduce the high dislocation rate. Exposure using an anterolateral approach has also helped lower the dislocation rate. If you use a posterior approach, preserve the capsule.

Conclusion

If femoral neck fractures are nondisplaced, they should be internally fixed. In displaced femoral neck fractures for patients younger than 65 years, closed or open reduction should be used to assure an anatomic reduction before fixation. In patients physiologically older than 65 years, prosthetic replacement may be best; bipolars are used for the low-level community ambulators and patients who have a shorter life expectancy. A total hip replacement is the best procedure for the active elderly.

Our challenge is properly selecting patients for internal fixation. That is key. Hemiarthroplasty and total joint arthroplasty work well but need to be in the appropriate patient. The surgeon must perform an expert surgery done in such a way as to minimize complications and the likelihood of reoperation.

References

  1. Speed K. The unsolved fracture. Surg Gynecol Obstet. 1934; (60):341-352.
  2. Bhandari M, Devereaux PJ, Swiontkowski MF, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am. 2003; 85(9):1673-1681.
  3. Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur. A prospective review. J Bone Joint Surg Br. 1976; 58(1):2-24.
  4. Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br. 1961; (43):647-663.
  5. Garden RS. Malreduction and avascular necrosis in subcapital fractures of the femur. J Bone Joint Surg Br. 1971; 53(2):183-197.
  6. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am. 2003; 85(5):899-904.
  7. Pauwel F. Der Schenkenholsbruck em mechanisches problem. Grandhagen des heilungsvorganges prognose und kausale therapie. Stuttgart, Germany: Ferdinand Engke; 1934.
  8. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006; 88(2):249-260.
  9. Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ. Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness. Clin Orthop Relat Res. 2001; (383):229-242.

Author

Dr Kyle is from Hennepin County Medical Center, Minneapolis, Minnesota.

Dr Kyle receives royalties for total hip acetabular components from Smith & Nephew.

Presented at Current Concepts in Joint Replacement 2009 Winter Meeting; December 9-12, 2009; Orlando, Florida.

Correspondence should be addressed to: Richard F. Kyle, MD, Hennepin County Medical Center, 701 Park Ave S, Minneapolis, MN 55415 (kylex002@yahoo.com).

doi: 10.3928/01477447-20100722-36

Sign up to receive

Journal E-contents