1. Femoral Neck Fractures Brian Boyer, MD

2. Anatomy Physeal closure age 16 Neck-shaft angle 130° ± 7° Anteversion
10° ± 7°
Calcar Femorale
Posteromedial
dense plate of bone

3. Blood Supply Lateral epiphysel artery Artery of ligamentum teres
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

4. Blood Supply fracture displacement=vascular disruption
revascularization of the head
intact vessels
vascular ingrowth across fracture site
importance of quality of reduction
metaphyseal vessels

5. Epidemiology 250,000 Hip fractures annually At risk populations
Expected to double by 2050
At risk populations
Elderly: poor balance&vision, osteoporosis, inactivity, medications, malnutrition
incidence doubles with each decade beyond age 50
higher in white population
Other factors: smokers, small body size, excessive caffeine & ETOH
Young: high energy trauma

6. Classification
Pauwels [1935]
Angle describes vertical shear vector

7. 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

8. Classification Functional Classification Stable Unstable
Impacted (Garden I)
Non-displaced (Garden II)
Unstable
Displaced (Garden III and IV)

9. Treatment Goals Improve outcome over natural history
Minimize risks and avoid complications
Return to pre-injury level of function
Provide cost-effective treatment

10. Treatment Options Non-operative Operative very limited role
Activity modification
Skeletal traction
Operative
ORIF
Hemiarthroplasty
Total Hip Replacement

11. Treatment Decision Making Variables
Patient Characteristics
Young (arbitrary physiologic age < 65)
High energy injuries
Often multi-trauma
High Pauwels Angle (vertical shear pattern)
Elderly
Lower energy injury
Comorbidities
Pre-existing hip disease
Fracture Characteristics
Stable
Unstable

12. Treatment Young Patients (Arbitrary physiologic age < 65)
Non-displaced fractures
At risk for secondary displacement
Urgent ORIF recommended
Displaced fractures
Patients native femoral head best
AVN related to duration and degree of displacement
Irreversible cell death after 6-12 hours
Emergent ORIF recommended

13. Treatment Elderly Patients
Operative vs. Non-operative
Displaced fractures
Unacceptable rates of mortality, morbidity, and poor outcome with non-operative treatment [Koval 1994]
Non-displaced fractures
Unpredictable risk of secondary displacement
AVN rate 2X
Standard of care is operative for all femoral neck fractures
Non-operative tx may have developing role in select patients with impacted/ non-displaced fractures [Raaymakers 2001]

14. Treatment Pre-operative Considerations
Skin Traction not beneficial
No effect on fracture reduction
No difference in analgesic use
Pressure sore/ skin problems
Increased cost
Traction position decreases capsular volume
Potential detrimental effect on blood flow

15. Treatment Pre-operative Considerations
Regional vs. General Anesthesia
Mortality / long term outcome
No Difference
Regional
Lower DVT, PE, pneumonia, resp depression, and transfusion rates
Further investigation required for definitive answer

16. Treatment Pre-operative Considerations
Surgical Timing
Surgical delay for medical clearance in relatively healthy patients probably not warranted
Increased mortality, complications, length of stay
Surgical delay up to 72 hours for medical stabilization warranted in unhealthy patients

17. Hemi
ORIF
THR

18. 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

19. ORIF Ideal reduction is Anatomic
Acceptable: < 15º valgus < 10º AP angulation
* may need to open in order achieve reduction
Fixation: Multiple screws in parallel
No advantage to > 3 screws
Uniform compression across fracture
In-situ pin impacted fractures
* ↑ AVN with disimpaction [Crawford 1960]
Fixation most dependent on bone density

20. ORIF Screw location Avoid posterior/ superior quadrant
Blood supply
Cut-out
Biomechanical advantage to inferior/ calcar screw
[Booth 1998]

21. ORIF Compression Hip Screws No clinical advantage over parallel 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

22. ORIF Intracapsular Hematoma
incidence- 75% have some 
no difference displaced/nondisplaced
? Amount of  > 100 mm in 25%
sensitive to leg position
extension + internal rotation= bad
animal models: pressure= perfusion
Theoretical benefit with NO clinical proof
but it doesn’t hurt

23. Displaced Fractures Hemiarthroplasty vs. ORIF
ORIF is an option in elderly
** Surgical emergency in young patients **
Complications
Nonunion %
AVN 15 – 33%
AVN related to displacement
Early ORIF no benefit
Loss of reduction / fixation failure 16%

24. Displaced Fractures Hemiarthroplasty vs. ORIF
Hemi associated with
Lower reoperation rate (6-18% vs %)
Improved functional scores
Less pain
More cost-effective
Slightly increased short term mortality
Literature supports hemiarthroplasty for displaced fractures [Lu-yao JBJS 1994]
[Iorio CORR 2001]

25. Hemiarthroplasty Unipolar vs. Bipolar
Bipolar theoretical advantages
Lower dislocation rate
Less acetabular wear/ protrusio
Less Pain
More motion

26. Hemiarthroplasty Unipolar vs. Bipolar
Disadvantages
Cost
Dislocation often requires open reduction
Loss of motion interface (effectively unipolar)
Polyethylene wear/ osteolysis not yet studied for Bipolars

27. Hemiarthroplasty Unipolar vs. Bipolar
Complications / Mortality / Length of stay
No Difference
Hip Scores / Functional Outcomes
No significant difference
Bipolar slightly better walking speeds, motion, pain
Revision rates
Unipolar 20% vs. Bipolar 10% (7 years)
Unipolar more cost-effective
Literature supports use of either implant

28. Hemiarthroplasty Cemented vs. Non-cemented
Cement (PMMA)
Improved mobility, function, walking aids
Most studies show no difference in morbidity / mortality
Sudden Intra-op cardiac death risk slightly increased:
1% cemented hemi for fx vs % for elective arthroplasty
Non-cemented (Press-fit)
Pain / Loosening higher
Intra-op fracture (theoretical)

29. Hemiarthroplasty Cemented vs. Non-cemented
Conclusion:
Cement gives better results
Function
Mobility
Implant Stability
Pain
Cost-effective
Low risk of sudden cardiac death
Use cement with caution

30. Treatment Pre-operative Considerations
Surgical Approach
Posterior approach to hip
60% higher short-term mortality vs. anterior
Dislocation rate
No significant difference [Lu-Yao JBJS 1994]

31. Total Hip Replacement Dislocation rates: Reoperation:
Hemi 2-3% vs. THR 11% (short term)
2.5% THR recurrent dislocation [Cabanela Orthop 1999]
Reoperation:
THR 4% vs. Hemi 6-18%
DVT / PE / Mortality
no difference
Pain / Function / Survivorship / Cost-effectiveness
THR better than Hemi [Lu –Yao JBJS 1994]
[Iorio CORR 2001]

32. Keating et al OTA 2002
ORIF or Replacement?
Prospective, randomized study ORIF vs. cemented bipolar hemi vs. THA
ambulatory patients > 60 years of age
37% fixation failure (AVN/nonunion)
similar dislocation rate hemi vs. THA (3%)
ORIF 8X more likely to require revision surgery than hemi and 5X more likely than THA
THA group best functional outcome

33. Stress Fractures Patient population: Females 4–10 times more common
Amenorrhea / eating disorders common
Femoral BMD average 10% less than control subjects
Hormone deficiency
Recent increase in athletic activity
Frequency, intensity, or duration
Distance runners most common

34. Stress Fractures Clinical Presentation
Activity / weight bearing related
Anterior groin pain
Limited ROM at extremes
± Antalgic gait
Must evaluate back, knee, contralateral hip

35. Stress Fractures Imaging Plain Radiographs Bone Scan MRI
Negative in up to 66%
Bone Scan
Sensitivity %
Specificity 76-95%
MRI
100% sensitivity / specificity
Also Differentiates: synovitis, tendon/ muscle injuries, neoplasm, AVN, transient osteoporosis of hip

36. Stress Fractures Classification Compression sided Tension sided
Callus / fracture at inferior aspect femoral neck
Tension sided
Callus / fracture at superior aspect femoral neck
Displaced

37. Stress Fractures Treatment
Compression sided
Fracture line extends < 50% across neck
“stable”
Tx: Activity / weight bearing modification
Fracture line extends >50% across neck
Potentially unstable with risk for displacement
Tx: Emergent ORIF
Tension sided
Unstable
Displaced

38. Stress Fractures Complications
Tension sided and Compression sided fx’s (>50%) treated non-operatively
Varus malunion
Displacement
30-60% complication rate
AVN 42%
Delayed union 9%
Nonunion 9%

39. Femoral Neck Nonunion Definition: not healed by one year
0-5% in Non-displaced fractures
9-35% in Displaced fractures
Increased incidence with
Posterior comminution
Initial displacement
Inadequate reduction
Non-compressive fixation

40. Femoral Neck Nonunion Clinical presentation Imaging
Groin or buttock pain
Activity / weight bearing related
Symptoms
more severe / occur earlier than AVN
Imaging
Radiographs: lucent zones
CT: lack of healing
Bone Scan: high uptake
MRI: assess femoral head viability

41. Femoral Neck Nonunion Treatment Elderly patients Arthroplasty
Results typically not as good as primary elective arthroplasty
Girdlestone Resection Arthroplasty
Limited indications
deep infection?

42. Femoral Neck Nonunion Young patients Varus alignment or limb shortened
(must have viable femoral head)
Varus alignment or limb shortened
Valgus-producing osteotomy
Normal alignment
Bone graft / muscle-pedicle graft
Repeat ORIF

43. Osteonecrosis (AVN) Femoral Neck Fractures
5-8% Non-displaced fractures
20-45% Displaced fractures
Increased incidence with
INADEQUATE REDUCTION
Delayed reduction
Initial displacement
associated hip dislocation
?Sliding hip screw / plate devices

44. Osteonecrosis (AVN) Femoral Neck Fractures
Clinical presentation
Groin / buttock / proximal thigh pain
May not limit function
Onset usually later than nonunion
Imaging
Plain radiographs: segmental collapse / arthritis
Bone Scan: “cold” spots
MRI: diagnostic

45. Osteonecrosis (AVN) Femoral Neck Fractures
Treatment
Elderly patients
Only 30-37% patients require reoperation
Arthroplasty
Results not as good as primary elective arthroplasty
Girdlestone Resection Arthroplasty
Limited indications

46. Osteonecrosis (AVN) Femoral Neck Fractures
Treatment
Young Patients
NO good option exists
Proximal Osteotomy
Less than 50% head collapse
Arthroplasty
Significant early failure
Arthrodesis
Sugnificant functional limitations
** Prevention is the Key **

47. Femoral Neck Fractures Complications
Failure of Fixation
Inadequate / unstable reduction
Poor bone quality
Poor choice of implant
Treatment
Elderly: Arthroplasty
Young: Repeat ORIF
Valgus-producing osteotmy
Arthroplasty

48. Femoral Neck Fractures Complications
Post-traumatic arthrosis
Joint penetration with hardware
AVN related
Blood Transfusions
THR > Hemi > ORIF
Increased rate of post-op infection
DVT / PE
Multiple prophylactic regimens exist
Low dose subcutaneous heparin not effective

49. Femoral Neck Fractures Complications
One-year mortality 14-50%
Increased risk:
Medical comorbidities
Surgical delay > 3 days
Institutionalized / demented patient
Arthroplasty (short term / 3 months)
Posterior approach to hip
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Lower Extremity
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