Femoral Neck Fractures Steven A. Olson, MD Original Author: Brian Boyer, MD; March 2004; New Author: Steven A. Olson, MD; Revised March 2006 - PowerPoint PPT Presentation

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Femoral Neck Fractures Steven A. Olson, MD Original Author: Brian Boyer, MD; March 2004; New Author: Steven A. Olson, MD; Revised March 2006

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Femoral Neck Fractures Steven A. Olson, MD Original Author: Brian Boyer, MD; March 2004; New Author: Steven A. Olson, MD; Revised March 2006 Anatomy Physeal closure ... – PowerPoint PPT presentation

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Title: Femoral Neck Fractures Steven A. Olson, MD Original Author: Brian Boyer, MD; March 2004; New Author: Steven A. Olson, MD; Revised March 2006


1
Femoral Neck FracturesSteven A. Olson,
MDOriginal Author Brian Boyer, MD March
2004 New Author Steven A. Olson, MD Revised
March 2006
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
  • 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
  • Greater fracture displacement greater risk of
    vascular disruption to femoral head
  • 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
  • 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
  • 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
  • very limited role
  • Activity modification
  • Skeletal traction
  • Operative
  • ORIF
  • Hemiarthroplasty
  • Total Hip Replacement

11
TreatmentDecision Making Variables
  • Patient Characteristics
  • Young (arbitrary physiologic age lt 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
TreatmentYoung Patients(Arbitrary physiologic
age lt 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
TreatmentElderly 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
TreatmentPre-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
TreatmentPre-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
TreatmentPre-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 lt 5
  • Minimal complications
  • AVN lt 8
  • Infection lt 5
  • Relatively quick procedure
  • Minimal blood loss
  • Early mobilization
  • Unrestricted weight bearing with assistive device
    PRN

19
Open Reduction or Closed Reduction?
  • Open reduction can be considered for any
    displaced femoral neck fractures that are treated
    with reduction and internal fixation
  • Open reduction is indicated after an attempt at
    gentle closed reduction results in a non-anatomic
    reduction
  • Primary open reduction is preferred in young
    patients with a displaced femoral neck fracture

20
Approach For Open Reduction
  • Smith-Peterson
  • Anterior approach
  • Best for transcervical and subcapitol fractures
  • Fixation is performed through a second approach

21
Approach For Open Reduction
  • Watson-Jones
  • Anteriolateral exposure
  • Best for basalar neck and IT patterns
  • Allows placement of sliding hip screw through
    same incision

22
What Reduction Is Acceptable?
  • Ideal reduction is Anatomic
  • Acceptable lt 15º valgus lt 10º AP angulation
  • Any varus is unacceptable
  • Fixation Multiple screws in parallel
  • No advantage to gt 3 screws
  • Uniform compression across fracture
  • In-situ pin impacted fractures
  • ? AVN with disimpaction Crawford
    1960
  • Fixation most dependent on bone density

23
Screw Fixation
  • Screw location
  • Avoid posterior/ superior quadrant
  • Blood supply
  • Cut-out
  • Biomechanical advantage to inferior/ calcar screw

  • Booth 1998

24
Sliding Compression 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

25
Intracapsular Hematoma
  • incidence- 75 have some intracapsular
    pressure
  • no difference displaced/nondisplaced
  • sensitive to leg position
  • extension internal rotation bad
  • animal models intracapsular pressure
    perfusion
  • Theoretical benefit with NO clinical proof
  • but it doesnt hurt

26
Case Example 42 yo male, MVC
27
Open reduction via Smith-Pete approach, screw
fixation placed through separate incision
28
Displaced FracturesHemiarthroplasty vs. ORIF
  • ORIF is an option in elderly
  • Surgical emergency in young patients
  • Complications
  • Nonunion 10 -33
  • AVN 15 33
  • AVN related to displacement
  • Early ORIF no benefit
  • Loss of reduction / fixation failure 16

29
Displaced FracturesHemiarthroplasty vs. ORIF
  • Hemi associated with
  • Lower reoperation rate (6-18 vs. 20-36)
  • 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

30
HemiarthroplastyUnipolar vs. Bipolar
  • Bipolar theoretical advantages
  • Lower dislocation rate
  • Less acetabular wear/ protrusio
  • Less Pain
  • More motion

31
HemiarthroplastyUnipolar vs. Bipolar
  • Bipolar
  • Disadvantages
  • Cost
  • Dislocation often requires open reduction
  • Loss of motion interface (effectively unipolar)
  • Polyethylene wear/ osteolysis not yet studied for
    Bipolars

32
HemiarthroplastyUnipolar 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

33
HemiarthroplastyCemented 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. 0.015 for elective
    arthroplasty
  • Non-cemented (Press-fit)
  • Pain / Loosening higher
  • Intra-op fracture (theoretical)

34
HemiarthroplastyCemented 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

35
TreatmentPre-operative Considerations
  • Surgical Approach
  • Posterior approach to hip
  • 60 higher short-term mortality vs. anterior
  • Dislocation rate
  • No significant difference Lu-Yao
    JBJS 1994

36
Total Hip Replacement
  • Dislocation rates
  • 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

37
ORIF or Replacement?
Keating et al OTA 2002
  • Prospective, randomized study ORIF vs. cemented
    bipolar hemi vs. THA
  • ambulatory patients gt 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

38
Stress Fractures
  • Patient population
  • Females 410 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

39
Stress Fractures
  • Clinical Presentation
  • Activity / weight bearing related
  • Anterior groin pain
  • Limited ROM at extremes
  • Antalgic gait
  • Must evaluate back, knee, contralateral hip

40
Stress Fractures
  • Imaging
  • Plain Radiographs
  • Negative in up to 66
  • Bone Scan
  • Sensitivity 93-100
  • Specificity 76-95
  • MRI
  • 100 sensitivity / specificity
  • Also Differentiates synovitis, tendon/ muscle
    injuries, neoplasm, AVN, transient osteoporosis
    of hip

41
Stress Fractures
  • Classification
  • Compression sided
  • Callus / fracture at inferior aspect femoral neck
  • Tension sided
  • Callus / fracture at superior aspect femoral neck
  • Displaced

42
Stress FracturesTreatment
  • Compression sided
  • Fracture line extends lt 50 across neck
  • stable
  • Tx Activity / weight bearing modification
  • Fracture line extends gt50 across neck
  • Potentially unstable with risk for displacement
  • Tx Emergent ORIF
  • Tension sided
  • Unstable
  • Tx Emergent ORIF
  • Displaced
  • Tx Emergent ORIF

43
Stress FracturesComplications
  • Tension sided and Compression sided fxs (gt50)
    treated non-operatively
  • Varus malunion
  • Displacement
  • 30-60 complication rate
  • AVN 42
  • Delayed union 9
  • Nonunion 9

44
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

45
Femoral NeckNonunion
  • Clinical presentation
  • 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

46
Femoral NeckNonunion
  • Treatment
  • Elderly patients
  • Arthroplasty
  • Results typically not as good as primary elective
    arthroplasty
  • Girdlestone Resection Arthroplasty
  • Limited indications
  • deep infection?

47
Femoral NeckNonunion
  • Young patients
  • (must have viable femoral head)
  • Varus alignment or limb shortened
  • Valgus-producing osteotomy
  • Normal alignment
  • Bone graft / muscle-pedicle graft
  • Repeat ORIF

48
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

49
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

50
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

51
Osteonecrosis (AVN)Femoral Neck Fractures
  • Treatment
  • Young Patients
  • NO good option exists
  • Proximal Osteotomy
  • Less than 50 head collapse
  • Arthroplasty
  • Significant early failure
  • Arthrodesis
  • Significant functional limitations
  • Prevention is the Key

52
Femoral Neck FracturesComplications
  • Failure of Fixation
  • Inadequate / unstable reduction
  • Poor bone quality
  • Poor choice of implant
  • Treatment
  • Elderly Arthroplasty
  • Young Repeat ORIF
  • Valgus-producing osteotomy
  • Arthroplasty

53
Femoral Neck FracturesComplications
  • Post-traumatic arthrosis
  • Joint penetration with hardware
  • AVN related
  • Blood Transfusions
  • THR gt Hemi gt ORIF
  • Increased rate of post-op infection
  • DVT / PE
  • Multiple prophylactic regimens exist
  • Low dose subcutaneous heparin not effective

54
Femoral Neck FracturesComplications
  • One-year mortality 14-50
  • Increased risk
  • Medical comorbidities
  • Surgical delay gt 3 days
  • Institutionalized / demented patient
  • Arthroplasty (short term / 3 months)
  • Posterior approach to hip

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