SICOT e-Newsletter

Introduction:

Femoral neck fractures are common and occur in 3% of young adults and this incidence rises to 97% above 60 years of age. However, many aspects of treatment are debatable. It has been reported in the literature that the incidence of AVN in young adults ranges from 0-86% and non-union 0-45% (1), hence careful attention should be given to those injuries that present frequently in our orthopaedic department. In a trial to answer these debates we conducted an Internet search and found thousands of reports.

The following review covers the evidence based answers for the options of treatment available, the implants, timing of treatment, whether to perform a capsulotomy or not, to do open or closed reduction and the choice of prosthesis in case arthroplasty was the chosen method of treatment.


What are the treatment options?

The treatment options available for femoral neck fractures include non-operative, internal fixation and different forms of arthroplasty.

When can we use non-operative option? This treatment is nowadays reserved for non-ambulators, patients with prohibitive medical co-morbidities that absolutely contraindicate surgery, and patients who are neurologically impaired. This concept is supported by a report of 247 undisplaced fractures showing 16% complications and 20% displacement in non-operative group compared to 3% and 0% consecutively in operative group (2).

Undisplaced fractures showed a variable incidence of non-union and AVN amounting to 6.4% and 5.8% in many studies. In 2011 the Norwegian Hip fracture registry published the clinical outcome of 4,468 undisplaced fractures with 89% implant survival at 1 year (3). Since failure rate is only 10%, and the technique is safe, simple and can be done percutaneously, internal fixation is considered the best option for undisplaced fractures (4). The second parameter to be considered is stability, valgus impacted are considered stable and are treated by percutaneous fixation.

Internal fixation; how and when? It can be performed percutaneously and is indicated in undisplaced, valgus impacted, and in cases of displaced fractures after success of closed reduction. It is considered a reliable option in displaced fractures in the young but has a high failure rate in older patients. Alternatively, irreducible displaced fractures are treated by open reduction and internal fixation, as the quality of reduction is the single most important factor affecting the result (5-6).

In 2004 Upadhyay et al conducted a RCT of 102 patients between 15-50 years comparing the results and complications of closed versus open reduction in displaced and found no significant difference between the groups in terms of union and AVN (7).


What is the best timing for fixation?

Many reports were published supporting early fixation before 12 hours and others that contradict this factor as being valuable (7-10). Damany et al performed a meta-analysis of 18 studies in 2005; found conflicting evidence and concluded that the difference in the incidence of non-union and avascular necrosis for early versus late surgery was not statistically significant (1).

Literature does not support the fixation as being an emergency procedure and Davidovitch et al 2010 recommended that femoral neck fractures in young should be addressed surgically in an urgent as opposed to emergent fashion (5). However, as there does not seem to be any increased morbidity associated with operating earlier rather than later, a widely displaced fracture is likely best treated within 12 hours after injury or as a first priority in the next day’s operative schedule (5).


Should a capsulotomy be done?

There is no evidence base for doing a Capsulotomy, results showed no significant difference in many studies RCT (1,7,11). However since it theoretically relieves intracapsular hematoma, it can be performed closed using image intensifier, it is simple, and adds no morbidity, then consider it in young patients with undisplaced fractures as they still have a reported incidence of AVN (5,12).


What is the choice of implant?

To choose screws or DHS is another debate, generally cannulated screws are preferred, Bhandari and 14 other authors conducted an international survey asking about preference of 442 surgeons and found that for undisplaced fractures: 92% preferred fixation (90% screws vs. 10% DHS) and in displaced only 25% favoured fixation (out of whom 68% screws vs. 32% DHS) (13).

Cannulated screws: 3 parallel screws in an inverted triangle or base down configuration (8,14) with one screw in AP view close to calcar to prevent varus displacement and another screw in the lateral view close to posterior cortex to prevent retroversion. In fractures with posterior comminution some authors recommended a fourth screw (8,15). While biomechanically there is some benefit to a fourth screw placed for posterior comminution. Those with severe posterior comminution generally are better treated with a dynamic hip screw (DHS) (5,16).

DHS: remember to use an anti rotation screw in cases of femoral neck fractures. Baitner et al found less femoral head displacement, less shearing displacement at the fracture site, and greater load to failure using DHS (16). Others found increased non-union rate, and higher AVN incidence (17). A meta-analysis of 25 RCT including 4,925 patients with femoral neck fractures found no significant difference between screws and DHS (18).


What factors affect the outcome of fixation?

Quality of reduction is the most important factor for a good outcome (6), so aim at anatomical reduction, if not possible less than 10° angulation antero-posterior, 10° valgus can be acceptable but no varus is allowed. Immediate weight bearing can be allowed (8).

Does arthroplasty have a role? The indications for arthroplasty are primarily in the elderly, low demand, and osteoporotic patients and secondarily in failed fixation, non-union, and AVN after femoral neck fractures. The options are unipolar fixed or modular, bipolar hemiarthroplasty, and total hip prosthesis (THA), whether to do cemented or uncemented prosthesis. Endless publications compared internal fixation and arthroplasty, different forms of arthroplasty, and cement fixation versus use of uncemented prostheses. We will try to summarise the conclusions of those publications.

Internal fixation or arthroplasty? Several prospective RCT’s were performed with no clear overall advantage of either method. So a meta-analysis by Bhandari et al 2003 (19), and a database systematic review by Masson et al 2003 (20) were performed and found a higher reoperation rate 35% and 33% (consecutively) with internal fixation compared to 11% with arthroplasty. Another meta-analysis of 14 RCT involving 2,289 patients by Rogmark and Johnell in 2006 (21) showed the rate of failure of internal fixation to be 21-57%, a reoperation of 14-53% in contrast to 7% after arthroplasty. In 2010 Gjertsen et al (22) compared fixation with bipolar HA for 4,335 displaced fractures in elderly >70 years old, fixation in 1,823 and HA in 2,512 patients. After 1-year reoperation rate was 22.6% for fixation vs. 2.9% for HA. The pain score, patient satisfaction and quality of life were all in favour of arthroplasty (19-23). THA should be considered in any fit older patient with a displaced femoral neck fracture. Patients with concomitant osteoarthritis, rheumatoid arthritis, or renal failure do badly with other forms of treatment and should also have a THA. Randomized trials have shown THA to be a cost-effective treatment with lower complication rates than reduction and fixation. It also appears to be better than hemiarthroplasty, but larger trials are needed to confirm this observation (24).

Bipolar or Unipolar? Cochrane systematic review by Parker & Rajan 2001 included 4 trials with 391 patients and another by Parker & Gurusamy in 2006 with 6 trials and 549 patients found no significant difference in incidence of dislocation, acetabular erosion, wound infection, reoperation rate, DVT, mortality, walking or functional outcome. The only difference was that Bipolar is more costly, and they even thought that it becomes unipolar within months (25-26). Considering the higher cost of bipolar hemiarthroplasty and the potential consequences of polyethylene wear debris on implant fixation in bipolar hemiarthroplasty, many authors advocated reserving the use of a bipolar implant for the younger, more active patient, discouraging its use in the elderly (27-28).

Should we do cemented or cementless prosthesis? The same two Cochrane reviews showed good evidence that cementing the prostheses in place will reduce post-operative pain at one year and lead to better mobility (25-26). Cement disadvantages include increased operative time by 15 minutes, cost, arrhythmias, and cardio-respiratory collapse (29). Whether to cement or not should be determined by whether a stable prosthesis will result. Many older patients have very wide proximal femoral canals and are best managed with a cemented stem and this statement was supported by 14 references in an editorial in the Injury journal (23).

Is Total Hip Arthroplasty (THA) indicated? We will try to summarize the most recent evidence here. Some authors recommend consideration of primary total hip replacement in the elderly patients with a displaced femoral neck fracture who are independent, physically healthy, mentally lucid, and active so that they engage in recreational activities beyond simple walking (30). The criteria defined by Blomfeldt et al seem most appropriate and can be considered to be evidence-based: acute (less than 48 hours) non pathologic fracture, good cognitive function, non-institutionalized independent living status, and pre-injury independent walking capability with or without aids (31). In 2008 a prospective, multicenter, RCT of 40 out of 114 patients; 17 with THA and 23 with HA; Macaulay et al found at 2 years follow-up that the SF-36 score was significantly better with THA, WOMAC also was significantly better with THA, and pain much less with THA, however complications showed no significant difference (27). There is some evidence that a total hip replacement leads to better functional outcome than a HA in a series of 400 patients (32). When comparing internal fixation to unipolar, bipolar, and total hip, a study in 2004 showed that at 2 years, the best result from a pain standpoint is a total hip replacement. The best result from a functional standpoint is a total hip arthroplasty, and that survivorship is also higher with a total hip arthroplasty (33). Another series in 2006 comparing total hip replacement to internal fixation in 298 healthy patients aged 60 and above, found it is 8 times more likely that there will be a need for revision in the ORIF group. The best function is with total hip replacement, and long term is more cost effective (34). The same results were confirmed by a meta-analysis of 407 patients in 3 trials published in 2009 (35). In March 2011; the orthopaedic trauma directions published an update to an older report from April 2007 including 5 studies comparing THA with HA and concluded: more dislocation with THA, more mobility with THA, more revision with HA, no difference in the mortality rate and difference in pain was inconclusive (36).
 

Conclusion:

Careful choice of the line of treatment should be based on age, function, and the evidence we have available and which we tried to gather in this chapter. In young patients <55-60 years; fixation is the treatment of choice, from 60-80 years treatment is still debatable THA being considered, and >80 years HA preferably cemented is used. However, trials with enough power and methodological rigour are needed to answer the questions that are still inconclusive (37).


Institutional recommendations:

• In young patients <60 years; fixation is the treatment of choice.
• Internal fixation for impacted, young (3 screws Percutaneous) or displaced (CR or ORIF Watson-Jones 3-4 screws/DHS).
• Timing: within 48 hours or first case in the operative list next morning if possible. 
• Outcome: accurate reduction, screw placement & posterior comminution affect AVN > delay.
• Capsulotomy: theoretical, young, un- or minimally displaced, fluoroscopy assisted.
• 60-70 years; fixation, HA or THA can all be used according to the activity level of the patient and pre-existing OA of the hip.
• >70 years cemented HA is used.
• Non-operative treatment is reserved for non-ambulators, and patients with prohibitive medical comorbidities that absolutely contraindicate surgery.
  

Acknowledgement:

Thanks to Dr Suthorn Bavonratanavech, Senior Director of the Bangkok Orthopedic Center, for a lecture at an AO course that inspired and pointed out some of these data.
 

References:

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