Chapter 44

Fractures of the Neck of the Femur

Ross K. Leighton
Hip fractures are devastating injuries that most often affect the elderly and have a tremendous
impact on both the health care system and society in general. Despite marked improvements
in implant design, surgical technique, and patient care, hip fractures continue to consume a
substantial proportion of our health care resources. More than 250,000 hip fractures occur in
the United States each year, and this number is projected to double by the year 2050 as the
population ages (1,2,3,4,5,6,7,8).
The incidence of hip fractures and dislocations is also increasing among younger individuals
secondary to a rising incidence
P.1754

of high-energy trauma. In addition, the concentration of these types of injuries in regional

trauma centers in a number of countries has made their frequency more apparent. The
fractures essential. This chapter delineates the anatomy, mechanism, etiology, and treatment
of femoral neck fractures.
ANATOMY
Skeletal Anatomy
The femoral head is not a perfect sphere, and the joint is congruous only in the weight-bearing
position (9). In 1838 the internal trabecular system of the femoral head was described by
Ward (10). The orientation is along lines of stress, and thicker lines come from the calcar and
rise superiorly into the weight-bearing dome of the femoral head. Forces acting in this arcade
are largely compressive. Lesser trabecular patterns extend from the inferior region of the
foveal area across the head and superior portion of the femoral neck into the trochanter and
lateral cortex. The presence of osteoporosis is important, especially in patients being
considered for internal fixation, because the ability of osteoporotic bone to hold an internal
fixation device is poor, and such bone can affect treatment alternatives. Singh et al (11) used
the trabecular pattern seen on x-rays of the upper end of the femur as an index for the
diagnosis and grade of osteoporosis. This system is based on the presence or absence of the
five normal groups of trabeculae in the proximal femur, as described by Ward (10). Although
Khairi and associates experienced difficulty in interpreting the Singh index, it may be used as
a general indication of the degree of osteoporosis present in the proximal femoral fragments
as noted on the initial x-rays (Fig. 44-1) (11).
According to Harty (12) and Griffin (13), the calcar femorale is a dense vertical plate of bone
extending from the postero-medial portion of the femoral shaft under the lesser trochanter and
radiating lateral to the greater trochanter, reinforcing the femoral neck posteroinferiorly (Fig.
44-2). The calcar femorale is thicker medially and gradually thins as it passes laterally
(13,14,15).
The external and internal geometry of the femur and its effect on experimental fracture
production have been well described (16). Rydell (16), using a femoral prosthesis with a
strain gauge, made considerable contributions regarding the forces acting on the femoral head.
He showed that standing on one leg generated a force 2.5 times body weight on that hip. In
one-leg support, with a cane in the opposite hand, the force across the hip was reduced to
body weight. At rest with two-leg support, there was a force of about half the body weight
across each hip joint. Running was noted to increase these forces to 5 times body weight (16).
Rydell (16) also found that lifting the leg from a supine position with the knee straight
produced a force of 1.5 times body weight across the hip joint.
Vascular Anatomy
The hip joint capsule is a strong fibrous structure that encloses the femoral head and most of
its neck. The capsule is attached anteriorly at the intertrochanteric line; posteriorly, however,
the lateral half of the femoral neck is outside the capsule (17). That portion of the neck that is
within the capsule has essentially no cambium layer in its fibrous covering to participate in
peripheral
P.1755

callus formation during the healing process (17). Therefore, healing in the femoral neck area
is dependent on endosteal union alone. Unless the fracture fragments are impacted, synovial
fluid can lyse blood clot formation and thereby destroy another mode of secondary healing by
preventing the formation of cells and scaffolding that would allow for vascular invasion of the
femoral head. For all practical purposes, the femoral head is rendered largely avascular by a
displaced femoral neck fracture (18). Fracture union can occur despite an avascular fragment,
although the incidence of nonunion is increased (18). However, even with optimum treatment,
signs of aseptic necrosis and later segmental collapse can still occur.

FIGURE 44-1 Singh's index grades osteopenia from normal (grade 6; all trabecular groups are visible)
to definite (grade 3; thinned trabeculae with a break in the principal tensile group) to severe (grade
1; only the primary compressive trabeculae are visible, and they are reduced) based on the ordered
reduction in trochanteric, tensile, and ultimately primary compressive trabeculae. The grade is
determined from a true antroposterior projection of an intact proximal femur. (Adapted from Singh
M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of
osteoporosis. J Bone Joint Surg Am 1970;52:457–467, with permission.)
FIGURE 44-2 Left. The calcar femorale is a vertical plate of bone that originates in the
posteromedial portion of the femoral shaft under the lesser trochanter and radiates laterally
toward the posterior aspect of the greater trochanter. Right. The calar femorale fuses with the
posterior aspect of the femoral neck superiorly and extends distally anterior to the lesser
trochanter and fuses with the posteromedial aspect of the femoral diaphysis.

The arterial supply to the proximal end of the femur has been studied extensively (19). The
description by Crock seems the most appropriate because it is based on three-plane analysis
and provides a standardization of anatomic nomenclature (19). Crock (19) described the
arteries of the proximal end of the femur in three groups: (a) an extracapsular arterial ring
located at the base of the femoral neck; (b) ascending cervical branches of the extracapsular
arterial ring on the surface of the femoral neck; and (c) the arteries of the round ligament.
The extracapsular arterial ring is formed posteriorly by a large branch of the medial femoral
circumflex artery and anteriorly by branches of the lateral femoral circumflex artery (Fig 44-
3).
The superior and inferior gluteal arteries also have minor contributions to this ring.
The ascending cervical branches arise from the extracapsular arterial ring. Anteriorly, they
penetrate the capsule of the hip joint at the intertrochanteric line, and, posteriorly, they pass
beneath the orbicular fibers of the capsule. The ascending cervical branches pass upward
under the synovial reflections and fibrous prolongations of the femoral head from its neck.
These arteries are known as retinacular arteries, described initially by Weitbrecht (20). The
proximity of the retinacular arteries to bone puts them at risk for injury in any fracture of the
femoral neck.
As the ascending cervical arteries traverse the superficial surface of the femoral neck, they
send many small branches into the metaphysis of the femoral neck. Additional blood supply
to the metaphysis arises from the extracapsular arterial ring and may include anastomoses
with intramedullary branches of the superior nutrient artery system, branches of the ascending
cervical arteries, and the subsynovial intra-articular ring. In the adult, there is communication
through the epiphyseal scar between the metaphyseal and epiphyseal vessels when the
femoral neck is intact (20). This excellent vascular supply to the metaphysis explains the
absence of avascular changes in the femoral neck as opposed to the head.
The ascending cervical arteries can be divided into four groups (anterior, medial, posterior,
and lateral) based on their relationship to the femoral neck. Of these four, the lateral group
provides most of the blood supply to the femoral head and neck. At the margin of the articular
cartilage on the surface of the neck of the femur, these vessels form a second ring, which
Chung (21) has termed the subsynovial intra-articular arterial ring. At the subsynovial intra-
articular ring, epiphyseal arterial branches arise that enter the femoral head. Disruption of this
arterial ring has significance in high intracapsular fractures. Indeed, Claffey (22)
demonstrated that in all femoral neck fractures that communicated with the point of entry of
the lateral epiphyseal vessels, aseptic necrosis occurred.
Once the arteries from the subsynovial intra-articular ring penetrate the femoral head, they are
termed the epiphyseal arteries. Two distinct groups of vessels within the femoral head were
described by Trueta and Harrison (23) as the lateral epiphyseal and inferior metaphyseal
arteries. However, Crock (19) reported that these two groups of arteries actually arise from
the same arterial ring and, hence, are both epiphyseal arteries.
The artery of the ligamentum teres is a branch of the obturator or the medial femoral
circumflex artery (19). The functional presence of this artery has been variably reported in the
literature. Howe et al (24) found that although the vessels of the ligamentum teres did supply
vascularity to the femoral head, they were often inadequate to assume the major nourishment
of the femoral head after a displaced femoral neck fracture (24). Claffey (22) also reported
that simple patency of the vessels of the ligamentum teres did not make them capable of
keeping the femoral head alive if all other sources of blood supply were interrupted.
Trueta and Harrison (23) reported that the femoral epiphyseal blood supply in the adult arose
largely from the lateral epiphyseal arteries that enter the head posterosuperiorly and
secondarily from the medial epiphyseal artery entering through the ligamentum teres. Sevitt
and Thompson (18) also demonstrated that the superior retinacular and lateral epiphyseal
vessels were responsible for most femoral head circulation. The vessels in the ligamentum
teres (medial epiphyseal) were unimportant
P.1756

in most femoral heads, being responsible only for a small area of subsynovial circulation.
Anastomoses between the artery of the ligamentum teres and other arteries of the head and
neck are variable.
FIGURE 44-3 Vascular anatomy of the femoral head and neck. Top. Anterior aspect. Bottom

Clinical Significance of Vascular Anatomy

Femoral head circulation arises, therefore, from three sources: (a) intraosseous cervical vessels that
cross the marrow spaces from below; (b) the artery of the ligamentum teres (medial epiphyseal
vessels); and (c) the retinacular vessels, branches of the extracapsular arterial ring, which run along
the femoral neck beneath the synovium. When a femoral neck fracture occurs, the intraosseous
cervical vessels are disrupted; femoral head nutrition is then dependent on remaining retinacular
vessels and those functioning vessels in the ligamentum teres (23). The amount of the femoral head
supplied by the medial epiphyseal

P.1757

vessels varies from a small area just beneath the fovea to the entire head (18). The injection studies
of Trueta and Harrison (23) and Judet and Judet (25) demonstrated anastomoses between the
various groups of vessels within the femoral head. In practice, however, such anastomoses
frequently may be insufficient to nourish the whole head. Sevitt and Thompson (18) reported that
the anastomoses between the subfoveal vessels and other vessels in the femoral head may be
insufficient to support viability (26).

The femoral head has been recognized for some time to be avascular, either partially or totally, in
most cases after displaced femoral neck fractures. Phemister (27), Catto (28,29), and others
demonstrated that revascularization occurs through the remaining blood supply by the process of
creeping substitution. Bonfiglio (30) in 1982, emphasized that although such revascularization
through the marrow spaces may occur rapidly, actual repair of the necrotic bone is a much slower
process, thereby setting the stage for late segmental collapse. This revascularization after the
vascular insult arises from three sources (2,22). The first is areas of the femoral head that remain
viable, especially the subfoveal area supplied by the medial epiphyseal vessels (27). The importance
of this source of revascularization is dependent on intraosseous vascular anastomoses between the
medial and lateral epiphyseal vessels. Therefore, every attempt should be made to protect the
remaining vascular supply to the femoral head after fracture (31).

The second source of revascularization is vascular ingrowth across the fracture site. This is known to
be slower than revascularization from the remaining viable subfoveal area (23). In addition, if the
fracture site is first stabilized by fibrous tissue, this tissue may prevent vascular ingrowth into the
head. The ingrowing vascular buds can be repeatedly torn by motion at a poorly stabilized fracture
site. Increased stability that protects these vascular buds may explain the reported decreased
incidence of aseptic necrosis after open reduction and posterior bone grafting after femoral neck
fracture (32). Although revascularization across a fracture can be slow and incomplete (29), studies
by Ray in 1964 demonstrated that a bone graft can be revascularized within hours and suggested
lumen-to-lumen connection of existing blood vessels. Bonfiglio (30,33,34,35,36,37) demonstrated
revascularization of the subchondral zone within 2 weeks of a grafting procedure. These facts favor
prompt reduction and stable fracture fixation in the treatment of femoral neck fractures with the
hope that the metaphyseal vessels will promptly reestablish and restore circulation before late
segmental collapse occurs.

ETIOLOGIC FACTORS FOR FRACTURES

Quality of Bone

Femoral neck fractures are very rare in young individuals with normal bone and in older patients of
races in which osteoporosis is uncommon, such as the black American and the South African Bantu
(38,39). Hinton and Smith (40) report that the rate of occurrence of hip fractures in the United States
is highest in white women, followed by white men, black women, and, finally, black men. The ratio of
intertrochanteric to femoral neck fracture increases with age in both white and black women.
Interestingly, in men, the ratio of intertrochanteric to femoral neck fractures is stable across all ages
for both races (41).

The average age of patients who sustain a femoral neck fracture is 3 years younger than that of those
with trochanteric fracture, both of which occur most commonly in the eighth decade. Elffors et al
(42) reported that the risk of hip fracture increases exponentially with age in both men and women.

Studies suggest that femoral neck fractures should be considered fractures through pathologic bone
(43). An association between osteomalacia and femoral neck fractures has been suggested by
Alffram and Chalmers and Irvine (44). Anderson et al (45) reported osteomalacia in 4% of unselected
elderly woman, and Chalmers and Irvine (44) revealed that 12% of patients with osteomalacia initially
present with femoral neck fractures. However, Wilton et al reported a 2% incidence of iliac crest
bone biopsy–proven osteomalacia in patients with femoral neck fractures. These authors
concluded that osteomalacia is not a significant predisposing factor in the development of these
fractures.

Although osteomalacia may be an underlying cause in some patients, the more commonly held
concept is that femoral neck fractures are preceded by the development of osteoporosis (46). Aitkin
(47), in 1984, demonstrated that 84% of patients with femoral neck fracture had either mild or
severe osteoporosis. Although bone mass measurement may not be reliable in identifying patients at
risk for hip fracture, patients with hip fractures often have bone that is more osteoporotic than that
of age- and sex-matched control subjects, as has been documented by iliac biopsy photomicrographs,
lumbar spine films (43), and metacarpal cortical thickness evaluation. However, Makin (48) could not
confirm that the degree of osteoporosis is related to the incidence of proximal femoral neck
fractures. He concluded that the incidence of proximal femoral fractures is related to other factors in
addition to the degree of osteoporosis.

A history of minor trauma associated with most femoral neck fractures further suggests that these
fractures are secondary to primary skeletal pathology. Hofeldt suggested that the decrease in
calcium absorption seen in the elderly plays a major role in the development of osteopenia. In
addition, Cummings et al (41) reported that femoral neck fractures are much more common in
elderly women.

Dorne and Lander (49) have used the term insufficiency fracture to describe femoral neck fractures in
elderly individuals with osteoporosis. These authors described a group of patients who sustained
femoral neck fractures spontaneously without apparent traumatic cause. These authors warned that
a completely displaced stress fracture of the femoral neck cannot be distinguished clinically or
radiographically from traumatic femoral neck fractures. Histologic examination of the femoral heads
in these patients indicated that the entity is a dynamic metabolic

P.1758

process (53). Importantly, these insufficiency stress fractures are different from the stress fractures
seen in younger patients, in whom strenuous, repetitive activity results in fractures through normal
bone.

Frangakis (54) reported that femoral neck fractures are secondary to the senile osteoporosis that is
seen in older women. By 65 years of age, 50% of women have bone mineral content below fracture
threshold, and by 85 years of age, 100% of women have a bone mineral content below this threshold
(11,55). Barnes et al (56) also have demonstrated an increasing degree of osteoporosis with
advancing age, especially in women. Bonfiglio believed that women sustain fractures of the neck of
the femur because of “osteoporosis secondary to inactivity and aggravated by disease”
(30,34,35,36,37,38). Astrom et al (57) reported that women who sustain femoral neck fractures have
been much less active physically in their younger years compared with members of the control
population They concluded that active women build up denser bone mass by the time of menopause,
so that postmenopausal bone loss takes much longer to reduce bone mass to a level compatible with
a fracture. They postulated that this is one of the many reasons for the recent increase in the
incidence of hip fractures. If the 30% to 50% bone loss that occurs between 40 and 70 years of age
could be prevented, a reduction in the incidence of hip fractures should occur (30,34,35,36,37,38).

Not only does osteoporosis play a role in the etiology of femoral neck fractures, it also plays an
important role in their treatment (58). Osteoporotic bone may result in more marked comminution
of the posterior cortex of the femoral neck and decreased quality of internal fixation secondary to
the inability of the bone to hold internal fixation devices (58). Arnold (59) demonstrated a
relationship between the failure rate of internal fixation and nonunion and the presence of
osteoporotic bone. Swinontkowski et al (60), in an excellent review of intracapsular fractures of the
hip, reported that the critical element in stability of fixation of femoral neck fractures is the quality of
the bone.

Mechanism of Injury

Most patients with femoral neck fractures have sustained a low-energy injury. Only a few injuries
involve major (high-impact) trauma (60). Kocher (61) suggested two mechanisms of injury in femoral
neck fractures. The first is a fall producing a direct blow over the greater trochanter (20). This
mechanism was confirmed by Linten (62). The second mechanism is external rotation of the
extremity (61). In this mechanism, the head is firmly fixed by the anterior capsule and iliofemoral
ligaments while the neck rotates posteriorly. The posterior cortex impinges on the acetabulum, and
the femoral neck buckles. This mechanism is compatible with the marked posterior comminution of
the femoral neck. A third suggested mechanism is cyclical loading, which produces microfractures
and macrofractures (60). Forces within physiologic limits have been shown to produce fractures in
osteoporotic bone (63). It has been suggested that a stress fracture of this type becomes complete
after a minor torsional injury preceding the fall that the patient identifies with the fracture. Muscle
forces have been shown to produce an axial load along the longitudinal axis of the femoral neck and,
coupled with external pressure, help to determine the fracture pattern (64).

In the case of young individuals who sustain a femoral neck fracture, the resultant trauma is major,
usually resulting in a direct force along the shaft of the femur, with or without a rotational
component (65). The increased magnitude of trauma leads to more marked soft tissue
devascularization and comminution, which give rise to the increased incidence of treatment failure in
young adults. The other mechanism of injury in this age-group is a stress fracture seen in runners and
military recruits. This is rare but must be considered in any young patient presenting with “hip
pain.”

CLASSIFICATION OF FEMORAL NECK FRACTURES

Classification Based on Patient Characteristics

 The elderly individual who complains of hip pain

 Patients with distracting injuries (other fractures such as a femoral shaft)

 Young adult less than 40 years of age with repetitive strain injuries (stress fracture)

 Patients with Paget's disease

 Patients with Parkinson's disease

 Patients with spastic hemiplegia

 Postradiation of the pelvis

 Metastatic disease of bone

 Patients with hyperparathyroidism

Classification Based on Fracture Classifications

The four common classifications of femoral neck fractures are those based on (a) anatomic location
of the fracture (66), (b) direction of the fracture angle (67), and (c) displacement of the fracture
fragments (68).

Anatomic Location

Some authors classify intracapsular fractures of the neck of the femur anatomically into subcapital
and transcervical types (66). The so-called base of the neck fracture (basicervical) is extracapsular
and, therefore, not included in this discussion. The term subcapital is used to describe fractures that
occur immediately beneath the articular surface of the femoral head along the old epiphyseal plate
(69). Transcervical fractures pass across the femoral neck between the femoral head and the greater
trochanter (69). Klenerman and Marcuson (69) and Garden (68) suggested that the exact location of
the fracture in the femoral neck cannot be determined precisely by radiography. Bayliss and
Davidson (70) reported that there was no functional difference

P.1759

between subcapital and transcervical fractures. Askin and Bryan (67) agreed that subcapital and
transcervical fractures are essentially the same and that any identified difference is artifactual
secondary to x-ray parallax. In addition, Klenerman and Marcuson (65) were unable to find a true
transverse cervical femoral neck fracture in their series, the fractures all being of the subcapital type.
Banks (68,69), on the other hand, divided his patients' injuries anatomically into four types: classic
subcapital fracture, wedge subcapital fracture, inferior beak fracture, and midneck fracture. In
essence, his first three types were all of the subcapital variety. He, too, found the transcervical type
to be extremely rare. Because of the relative infrequency of true transcervical fractures and the
difficulty of describing the fractures by radiography, as noted in the preceding series, this
classification has not been used extensively.

Fracture Angle (Pauwels Classification)

Pauwels (63) divided femoral neck fractures into three types based on the direction of the fracture
line across the femoral neck. Type I is a fracture 30 degrees from the horizontal; type II, 50 degrees
from the horizontal; and type III, 70 degrees from the horizontal (Fig. 44-4). Type I fractures are much
more horizontal than type III fractures, which are almost vertical. Pauwels attributed nonunion in
type III to the increased shearing force of this vertical fracture. However, Boyd and Salvatore (70)
were unable to demonstrate a direct relationship between the angle of the fracture and the
incidence of aseptic necrosis or nonunion. Type II fractures had 12% nonunion and 33% aseptic
necrosis rates compared with type III fractures, which had only 8% nonunion 30% aseptic necrosis
rates. In addition, Cassebaum and Nugent (71) and Ohman et al (72) could find no relation between
end results and the Pauwels fracture type.

The Pauwels classification is based on the x-ray shadow of the fracture line. Garden (73) stated that
because the femoral neck is spiral, it is the x-ray projection of the fracture line and not the fracture
line itself that varies in obliquity with rotation of the distal fragment (73). Garden (73) found the
fracture line to be remarkably constant at 50 degree from the horizontal on the frontal x-ray.
Garden (73,74,75) believed that any change in obliquity was the result of a misinterpretation of the
x-ray examination. Therefore, he thought that the Pauwels classification was a better measure of
reduction than an indication of the angle at which the femoral neck was broken. Linton (58) stressed
that the direction of the fracture line on the x-ray could be altered by changing the direction of the
beam or the position of the limb. To be accurate, the x-ray must be made with the femoral neck
parallel to the film. This is rarely possible because of pain. Linton (58) also found that the inclination
of the fracture surface did not vary greatly, with more than 85% being between 45 and 60 degrees.
He proposed that various types of femoral neck fractures represented different stages of the same
displacing movement. Because of the findings of Garden (73,74,75) and Linton (58), and the fact that
Boyd and Salvatore found little difference between the nonunion and aseptic necrosis rates of type II
and III, the Pauwels classification system is used today to diagnose and treat femoral neck delayed
and nonunions.

Pearls and Pitfalls

The Pauwels classification should not be used to treat an acute femoral neck fracture. However, a
high-grade Pauwels, postreduction, may be predictive of outcome. Some feel it may indicate the
quality of the reduction, but this has not been shown conclusively to date.

Fracture Displacement (Garden Classification)

Garden proposed a classification system based on the degree of displacement of the fracture noted
on prereduction anteroposterior (AP) x-rays (Fig. 44-5) (73,74,75). This measurement is taken in the
AP view only, in the classic paper by Garden. Obviously the lateral can be used to confirm the AP
measurements regarding partial or complete displacement versus angulation of the fragments.
Garden agreed with Linton, who suggested that the various types of subcapital fractures actually
were different degrees of displacement of a single fracture type (58).

The Garden I fracture is an incomplete or impacted fracture. In this fracture, the trabeculae of the
inferior neck are still intact. This group includes the “abducted impaction fracture.” A Garden II
fracture is a complete fracture without displacement. The x-ray demonstrates that the weight-
bearing trabeculae are interrupted by a fracture line across the entire neck of the femur. A Garden III
fracture is a complete fracture with partial displacement. In this fracture, there frequently is
shortening and external

P.1760

rotation of the distal fragment. The retinaculum of Weitbrecht remains attached to, and maintains
continuity between, the proximal and distal fragments (20). In the Garden III fracture, the trabecular
pattern of the femoral head does not line up with that of the acetabulum, demonstrating incomplete
displacement between the femoral fracture fragments. A Garden IV fracture is a complete fracture
with total displacement of the fracture fragments. In this fracture, all continuity between the
proximal and distal fragments is disrupted. The femoral head assumes its normal relationship in the
acetabulum. Therefore, the trabecular pattern of the femoral head lines up with the trabecular
pattern of the acetabulum. Frandsen et al (76) evaluated the Garden classification of femoral neck
fractures. They reported that only 22% of 100 femoral neck fractures were classified the same by
eight trained observers. In addition, in 33% of the fractures, the observers disagreed as to whether
the fractures were even displaced. The authors concluded that their observers had a poor ability to
delineate the varied stages of the Garden classification.

FIGURE 44-4 The Pauwels classification of femoral neck fractures is based on the angle the fracture
forms with the horizontal plane. As fracture progresses from type I to type III, the obliquity of the
fracture line increases and, theoretically, the shear forces at the fracture site also increase

Finally, Eliasson-Eiskjaer and Ostgard (77) and, recently, Kreder (78) demonstrated that classification
and neck displacement does not alter treatment or outcome in Garden stage I compared with stage II
fractures nor in Garden stage III fractures as compared with stage IV fractures (77,78). Because of
these

P.1761

findings, they recommended simply distinguishing between undisplaced (Garden I and II) and
displaced (Garden III and IV) femoral neck fractures.

Orthopaedic Trauma Association (OTA) Classification

In the Orthopaedic Trauma Association (OTA) alphanumeric fracture classification, femoral
neck fractures are designated type 31B, in which 31 is the proximal femur group and B the
femoral neck subgroup (Fig 44-6). B1 fractures are subcapital fractures with slight
displacement, B2 fractures are transcervical fractures, and B3 fractures are displaced
subcapital fractures. Subcategorical codes further describe the fracture pattern and amount of
fracture displacement. This schema is mainly used for research purposes.
DIAGNOSIS
Stress Fractures and Impacted Fractures
Patients with stress fractures and those with impacted fractures may complain only of slight
pain in the groin or referred pain along the medial side of the knee (79,80,81). They may be
able to walk with a limp and, therefore, delay seeking treatment, thinking that they are
suffering only from a muscle problem (82,83). Physical examination may reveal no obvious
clinical deformity. Only minor discomfort may be produced by active or passive range of
motion of the hip, but some muscle spasm usually is associated with the extremes of motion.
Percussion over the greater trochanter may be particularly painful. Failure to recognize
nondisplaced or impacted fractures may result in subsequent fracture displacement on weight-
bearing. This complication can be prevented if all patients complaining of hip or thigh pain
after an injury, or those exposed to repetitive stress (for example, military recruits, joggers),
are assumed to have a fractured hip (82). If the initial x-rays are normal but pain persists, the
patient still should be examined for a suspected femoral neck fracture. In some cases, x-ray,
tomograms, MRI, or bone scans may be required for the diagnosis of these fractures (84).
Fairclough et al (85) reported that a painful hip with a normal x-ray after a fall is a common
finding in elderly individuals. They found that a bone scan done within 48 hours of hospital
admission was an effective way of detecting a fracture of the femoral neck when the x-ray
was normal. None of 30 patients with normal bone scans later proved to have a femoral neck
fracture, whereas all 13 patients with abnormal bones scans eventually had radiographic signs
of a femoral neck fracture. The authors reported no false-positive or false-negative bone scans
results with a minimum follow-up of 3 months.
Rizzo et al (86) compared bone scans with MRI in the diagnosis of occult fractures about the
hip. They found MRI to be as accurate as bone scans in the assessment of these fractures.
Importantly, the sensitivity of MRI performed within 24 hours of hospital admission was
greater than that of bone scans performed 72 hours after admission. Because bone scans must
be delayed for up to 72 hours in older patients with osteopenia to ensure accurate diagnosis,
some authors recommended the use of MRI to obtain an earlier diagnosis and shorten the
hospital stay (87).
Gaunche et al (88) and Evans et al (89) both confirmed that MRI is more accurate and easier
to perform than radioisotope scanning in the diagnosis of suspected femoral neck fractures.
According to Stoller and Genant (90), an MRI obtained on the first day after an injury will
demonstrate findings consistent with an acute fracture.
It is my present recommendation that a patient presenting to hospital with a suspected but
unconfirmed fracture involving the femoral neck should receive an MRI acutely, to determine
whether the femoral neck is broken. This will identify the fracture more accurately and is
easier to perform than radioisotope scanning. It allows placement of the patient into the right
treatment group of either surgical treatment or early mobilization and discharge.
Displaced Fractures
Patients with displaced intracapsular fractures usually complain of pain in the entire hip
region. They lie with the leg in external rotation, abduction, and slight shortening. These
patients may not have the extreme deformity that is present in dislocations of the hip or
intertrochanteric fractures because of a partially intact capsule (82,83). One should not
attempt to perform range-of-motion movement of the hip. The diagnosis in displaced fractures
is easily confirmed by routine x-ray. X-ray evaluation of the fracture type, degree of posterior
comminution, and presence or absence of osteoporosis is essential before selection of the
treatment regimen. The routine x-ray evaluation of a patient with a hip fracture should include
an AP view of the pelvis, a true AP view of the hip with the maximum degree of internal
rotation possible, and a cross-table lateral x-ray (91).
The use of Buck's traction before surgery is controversial. The advantages of splinting or
relative immobilization of the
P.1763

limb in patients with a fractured hip include: (a) reduction of the soft tissue injury and
preservation of the remaining blood supply to the injured hip; (b) maintenance of the patient
in bed, so he or she does not exit the bed over the railings, because some of these patients may
be very confused; and (c) provision of some element of pain relief by stabilizing the limb and
preventing unnecessary movement at the fracture site. Proponents of use of a pillow under the
ipsilateral knee argue that use of Buck's traction places the limb in a position that decreases
the capsular hip volume and may be a source of increased pain.
TREATMENT OF IMPACTED AND NONDISPLACED FRACTURES (GARDEN I AND
II)
Nonoperative Treatment
Operative management consisting of fracture reduction and stabilization, which permits early
patient mobilization and minimizes many of the complications of prolonged bedrest, has
become the treatment of choice for most femoral neck fractures. There nevertheless remain
situations in which surgery cannot be performed and treatment must be nonoperative. One
example involves the elderly person whose medical condition carries an excessively high risk
of mortality from anesthesia and surgery (for example, one who has sustained a recent
myocardial infarction). Nonambulatory patients who have minimal discomfort following
fracture should also be treated nonoperatively and permitted early bed-to-chair mobilization.
If a patient with a femoral neck fracture is to be treated nonoperatively, the patient should be
taken out of bed to chair once pain permits with acceptance of any proximal femoral
deformity.
Operative Treatment
Operative treatment options for impacted and nondisplaced fractures include the following:

 Internal fixation with multiple cancellous lag screws. In all patients, an undisplaced or
a valgus impacted fracture should be stabilized with internal fixation using three
parallel cancellous screws (Fig. 44-7). Although the issue of surgical timing after hip
fracture is controversial, I feel that fracture reduction and internal fixation should be
performed within 24 hours, if possible (92,93).
 Sliding hip screw (94). The advantages of a sliding hip screw include biomechanical
strength greater than multiple cancellous screws, minimization of risk of subsequent
subtrochanteric fracture secondary to a stress riser effect, and placement of
compression across the fracture at the time of reduction. Disadvantages of the sliding
hip screw for femoral neck fracture stabilization include a larger surgical exposure and
the potential to create rotational malalignment of the femoral head at the time of screw
insertion.

Operative issues may be slightly different; there have been reports of more blood loss with a
sliding hip screw. More importantly, Templeman and Bray (95) have shown a slightly higher
avascular necrosis rate in patients treated with a sliding hip screw than parallel cancellous
screws.
AUTHORS' PREFERRED TREATMENT
The treatment of undisplaced femoral neck fractures in my institution consists of
cannulated or solid cancellous screws placed in an inverted triangle configuration. The screws
are positioned in the periphery of the femoral head, with the inferior screw placed along the
inferior femoral neck. The posterior screw lies along the posterior cortex of the femoral neck
and the anterior screw just anterior to the midsection of the femoral neck. The screws should
be positioned within 5 mm of the subchondral bone of the femoral head if possible. Care
should be taken to always initiate the starting point of the inferior screw above the lesser
trochanter to minimize the risk a subsequent subtrochanteric fracture.
Cannulated Screw Fixation in Nondisplaced Femoral Neck Fractures
The patient is positioned on the fracture table with the contralateral leg flexed 90 degrees, to
allow full visualization of the femoral neck and head on the lateral view. The injured leg is
placed in moderate traction and slight internal rotation. A good AP and lateral view should be
obtained before the start of surgery. Under image guidance a small incision (3 to 4 cm) is
made just distal to the lesser trochanter and the iliotibial band incised. The vastus lateralis is
reflected anteromedial and the bone surface visualized. A guide wire is placed anterior to the
femoral neck and
P.1764
visualized on the lateral view to determine the anteversion of the femoral neck. Three 6.5-
cancellous lag screws are then placed into the femoral head. A triangle or inverted triangle
configuration is used, with the distal screw placed first to compress the inferior neck
segments. The other two screws are then placed, one next to the posterior cortex and the other
anterior. All three screws should be positioned within 5 mm of the subcondral bone of the
femoral head. Multiple views (AP, 30-degree, 60-degree, and full lateral) should be obtained
with flouroscopy to confirm fracture reduction and screw placement within the femoral head.
Displaced Femoral Neck Fractures
Nonoperative Treatment
Most displaced femoral neck fractures are best treated surgically. The indications for
nonoperative treatment are as described in the previous section.
Surgical Options
There are a number of treatment options, including parallel cancellous lag screws, sliding hip
screw, Austin-Moore hemiarthroplasty, Thompson hemiarthroplasty, bipolar or unipolar
modular hemiarthroplasty, and total hip replacement.
For discussion, the Austin-Moore (AM) arthroplasty will be assumed to be a cementless
implant (Fig. 44-8) The Thompson is a cemented implant (Fig. 44-9) The AM and Thompson
prostheses were one-piece nonmodular designs. The bipolar and modern unipolar are modular
devices and are assumed to be equal in outcome. The main differences in the use of a modular
unipolar and bipolar implant appear to be geographical, training of the surgeon in their own
local area, and the cost of the component. For example, in Canada a bipolar costs about the
same or less than a modern unipolar, whereas in the United States the modern modular
unipolar appears to be cheaper than the bipolar in most areas. In most of the studies completed
to date, it appears that the differences in outcome are not between the modern unipolar and
bipolar, but between nonmodular and modular type of components |a modern modular and
bipolar components versus an AM or Thompson device (96,97)|. The significant differences
between these two types of implants (modular versus nonmodular) are as follows:

 In the modular type of component, the neck length of the component can be adjusted to
tension the abductors.

 If required, the offset of the femoral neck can be adjusted without increasing the leg length.

 A modular implant can more easily be converted to a total hip replacement, if necessary.

Obtaining the best fit of the femoral component along with the ability to adjust the femoral neck to
the appropriate offset and length has allowed surgeons to make the hip more function more
mechanically (97).

In the rest of the treatment section, and particularly in this chapter, the modern unipolar and bipolar
devices (modular hemiarthroplasty components) will be treated as exactly the same component from
an outcome perspective.

Open Reduction and Internal Fixation

Fixation options include cancellous lag screws and a sliding hip screw (94). Moreover, in a young
patient with a high Pauwels angle there has been some suggestion that crossed nonparallel

P.1765
cannulated screws, to reduce the medial displaced fragment, may be indicated (Fig. 44-10) (64).

Operative Technique for Internal Fixation

Parallel Cancellous Lag Screws
The mechanism for stabilizing the femoral neck and head has been described by many, but the
preferred method seems to be that of a triangle or inverted triangular configuration with the
first screw running along the calcar, controlling inferior displacement of the head of the femur
by having the shaft of the screw resting right on the calcar (Fig. 44-11). Figure 44-11D, when
three screws are utilized, is the author's preferred configuration. The second screw is placed
posterosuperior, along the neck of the femur, with the shaft of the screw being as close as
possible to the posterior cortex of the femoral neck. This screw is used to prevent the femoral
head from drifting posteriorly. A final screw is placed anterior superior, as additional support.
The inverted triangle may also reduce the chance of a stress fracture occurring at the level of
the lesser trochanter (98). However, some surgeons report the triangle configuration to be
stronger and better able to resist deformation. Successful use of three or four screws for both
nondisplaced and displaced fractures have been reported in some studies (2,99,100,101). The
fourth screw, if added, should be placed along the posterior cortex of the neck and would be
indicated to support gross posterior comminution. The importance of initiating the screw
fixation above the level of the lesser trochanter cannot be over emphasized (98,102).
Sliding Hip Screw
Other types of fixation, such as a sliding hip screw, have been used with some success. It
would usually be used with a derotation screw placed above the sliding hip screw to prevent
rotation of the head while inserting the large-diameter lag screw. (94). The outcomes have
been similar, with a slightly higher risk of avascular necrosis using a sliding hip screw (103).
However, use of a sliding hip screw would protect against a subsequent subtrochanteric
fracture by preventing a stress riser effect at the lesser trochanter. It is important that the tip to
apex distance be honored, because the risk for lag screw cut out has been shown to increase
dramatically in intertrochanteric fractures if the tip to apex distance exceeds a threshold of 25
mm (Fig. 44-12). Therefore, the lag screw should be placed as close as possible to the center
of the head in both the AP and lateral views.
A sliding hip screw is the treatment of choice in fractures that extend to the base of the
femoral neck, because it allows for more stable fixation (94). Severely osteopenic bone would
usually demand replacement of the femoral head, but in rare situations it could be considered
as an indication for a sliding hip screw. A derotation screw or pin should be used when
placing a sliding hip screw for stabilization of a femoral neck fracture.
Operative issues may be slightly different; there have been reports of more blood loss with the
sliding hip screw. More importantly, Templeman and Bray (95) have shown a slightly higher
avascular necrosis rate with use of a sliding hip screw than parallel cancellous lag screws.
When to perform an open reduction with internal fixation has been extremely controversial,
and the final choice usually takes into account many multifactorial indices. However, most
authors have agreed that in a young patient, under the age of 60, open reduction with internal
fixation should be attempted in all fracture grades, provided an adequate timely reduction can
be achieved. Fixation with three parallel cancellous screws, in most cases, is the treatment of
choice (98,102,104).
The other patient profile that appears to fall into the same category has been the higher
demand older individual. In other words, the patient who has presented over the age of 60 but
has
P.1766
been performing, from a functional point of view, as a younger individual. This patient
profile, even with a displaced femoral neck fracture, usually has been treated in my practice as
noted above. These individuals, usually between the ages of 60 to 70 years, have been
excellent candidates for open reduction with internal fixation (99,100,101).
In adults younger than 60 years of age, with a displaced fracture, timely treatment should be done
with a closed or open reduction with internal fixation using parallel cancellous lag screws. Capsular
release of the hip joint has been suggested by some to be an integral part of the initial surgery. This
has been somewhat controversial and has never been shown with level I evidence to make any
difference in the avascular necrosis rate (105). However, some authors continue to feel very strongly
that this should be performed to reduce intracapsular pressure (106,107,108).

The treatment for displaced femoral neck fractures has remained very geographical. For example, in
Rotterdam, 94% of patients who sustain a subcapital fracture, displaced or nondisplaced, would
receive a hemiarthroplasty, whereas in Sweden, 80% to 90% would receive open reduction with
internal fixation. This wide geographical difference was reported in the Journal of Trauma in 1997. In
another study done across Ontario, Canada, the authors reported a ninefold difference in
hemiarthroplasty versus open reduction with internal fixation in patients with displaced femoral neck
fractures. Some areas showed a 9% incidence for hemiarthroplasty, in other areas it was as high as
83% (78).

In the most recent randomized controlled trials, Parker et al (109), Tidermark et al (110), and
Rogmark et al (111) compared internal fixation with hemiarthroplasty for displaced femoral neck
fractures in elderly individuals. The advantages shown with internal fixation included decreased
blood loss, decreased operative time, lower transfusion requirements, decreased length of stay, and
early improved mortality in debilitated patients (112). However, the disadvantages of internal
fixation were illustrated by a reoperation rate at 2 years of 30% to 46%, more pain with internal
fixation than with hemiarthroplasty, and decreased early function in the internal fixation group,
compared to hemiarthroplasty. Loss of fixation or reduction was 9% to 30% and was increased if a
varus malreduction or poor position of fixation was obtained. Avascular necrosis rate was reported at
16% and nonunion rate was 33% (74,113). These authors concluded that hemiarthroplasty may have
advantages over internal fixation in the elderly.

Open reduction with internal fixation issues have revolved around patient age and functional level,
anatomic reduction, implant selection, and fixation techniques. In younger age-groups, open
reduction with internal fixation is the preferred treatment. However, most reports would indicate
replacement of the femoral head to be the treatment of choice for displaced fracture of the femoral
neck in the elderly individual.

Hemiarthroplasty

In general, replacement of the femoral head in displaced femoral neck fractures has best been
accomplished with a bipolar or unipolar modular component (3,114,115). A cemented stem has been
considered the standard treatment in the elderly osteopenic population. Methylmethacrylate is used
to create instant stability of the femoral stem. The prevalence of postoperative acetabular pain has
been uncommon with this type of cemented component with minimum 10-year follow-up (45).
Moores Hemarthoplasty The Austin-Moore arthroplasty, historically, has functioned as a good
component over the years, and there are many case reports of these actually lasting a long of time
(>20 years). However, these case reports are not the norm. Its main advantages in the past were its
reduced cost and relatively reduced operative time. Its disadvantages were the relatively poor
outcomes in active patients secondary to poor femoral fixation and a marked potential for acetabular
erosion. Therefore, at this time, the indication for a Moore's arthroplasty

P.1767

should be reserved for very limited or nonambulatory, low-demand patients (65,116,117). This was
the patient profile for which it was originally designed by Moore. A typical patient would be a nursing
home resident who was very low demand and had low mobility.

The Thompson arthroplasty has not performed any better than the Moore's from a functional
standpoint. It is a cemented component, nonmodular, with a fixed limited offset and no capacity for
length adjustments. Because of the cement mantle, it had better stability in the femur but did not
achieve reproduction of the tension of the hip girdle. It too has been associated with failure through
acetabular erosion and pain (20% at 2 years), so it should be limited to the low-demand patient,
similar to a Moore arthroplasty (104).

Modular Hemiarthroplasty

The modular hemiarthroplasty has been the implant of choice for displaced femoral neck fractures
over the last 10 years (Fig. 44-13). In most cases, it is inserted as a cemented femoral stem, with neck
length, offset, and acetabular adjustments. This theoretically decreases the stress on the acetabular
cartilage. It can be used with a fixed head (unipolar) or bipolar head and provides a relatively easy
conversion to a total hip arthroplasty, if required in the future. It is, therefore, the implant of choice
for most patients with a displaced subcapital neck fracture that are community ambulators (118).

What does the recent literature say about hemiarthroplasty versus open reduction with internal
fixation in displaced femoral neck fractures? Skinner et al (118), in a prospective randomized study,
showed that use of open reduction with internal fixation resulted in a higher incidence of revision
surgery compared to use of a bipolar hemiarthroplasty. Parker et al (119,120,121,122) and
Pertananen et al (123) reviewed a series of randomized trials and reported a significantly higher
reoperation rate in the open reduction and internal fixation group, compared to the
hemiarthroplasty group, particularly for use in displaced femoral neck fractures.

Total Hip Arthroplasty

Total hip replacement for displaced femoral neck fractures is common in some centers and countries
(113,125,126). It has very good predictable long-term results but a higher risk of early dislocation
than hemiarthroplasty. There is an increased cost compared to unipolar or bipolar arthroplasty;
however, proponents of total hip replacement for acute femoral neck fracture treatment argue that
it may reduce the overall costs due to its theoretical improved long-term implant survival
(113,125,126). The disadvantages of total hip replacement include: (a) a greater magnitude of
surgery; (b) increased blood loss; (c) an increased early dislocation rate compared to
hemiarthroplasty; and (d) possibly an increased infection rate, but this has not been reported in
other studies.

Total hip arthroplasty has commonly been performed to salvage complications of femoral neck
fractures such as nonunion and aseptic necrosis (127,128). It has also been used extensively to
manage failed endoprostheses inserted primarily for femoral neck fractures. The short-term results
of total hip arthroplasty for nonunion, aseptic necrosis, and failure of internal fixation of femoral
neck fractures have been uniformly good (93,129,130). However, there are no guidelines for the use
of total hip arthroplasty in the management of acute femoral neck fractures. Sim and Stauffer (128)
recommended total hip arthroplasty in patients with preexisting arthritis involving the acetabulum.

Although it is considered an indication for primary total hip arthroplasty, preexisting hip disease
associated with femoral neck fracture is not common. Ostrup (131) reported that osteoarthritis of
the hip, although associated with femoral neck fractures, is usually seen more commonly in
association with intertrochanteric fractures. Wand et al (132) also reported a higher incidence of
extracapsular than intra-articular fractures with osteoarthritis of the hip. They concluded that
osteoarthritis may protect the hip from femoral neck fracture.

Julkunen (133) reported that 8% of patients with intracapsular hip fractures have rheumatoid
arthritis. Stephen (51) and Strömqvist (134) reported poor results for internal fixation of femoral
neck fractures in patients with rheumatoid arthritis. Both Stephen (51) and Vahvanen (80) noted that
subcapital fractures of the femur in patients with rheumatoid arthritis have a poor union rate, and
loss of fixation occurred in a high percentage of their patients. Strömqvist et al (106) recommended
that in patients with rheumatoid arthritis only nondisplaced femoral neck fractures be treated by
internal fixation. They reported that in 19 of 20 patients (95%) with displaced femoral neck fractures
treated by internal fixation, position was lost, nonunion developed, or segmental femoral head
collapse occurred. Because of the high incidence of complications in displaced fractures, these
authors recommended total hip replacement for displaced femoral neck fractures in patients with
rheumatoid arthritis. Bogoch et al (135) also suggested that elderly individuals with rheumatoid
arthritis and displaced femoral neck fractures be treated by primary total hip arthroplasty.

Eftekhar (127) recommended primary total hip replacement in patients with coexisting osteoarthritis,
rheumatoid arthritis, severe osteoporosis or pathologic conditions with acetabular involvement such
as Paget's disease. Finally, Delamarter and Moreland (136) reported excellent results after total hip
replacement for femoral neck fractures in patients with preexisting hip disease.

Total hip arthroplasty has also received attention and support in the literature for use in active
individuals without preexisting hip disease. Tidermark (110), Rogmark (111), and Lee and Yao (137)
indicated support for acute total hip replacement. All reported prospective randomized trials that
compared open reduction with internal fixation to total hip replacement (cemented) confirmed
better results with total hip replacement.

Coates and Armour (138) suggested use of total hip arthroplasty in elderly individuals with a
displaced femoral neck fracture. Their goal was to prevent the high incidence of complications seen
after internal fixation of these subcapital fractures and the acetabular erosion and migration seen
after Moore's and Thomson hemiarthroplasty (38,138). Although the mortality and postoperative
infection rates were comparable to those found after hemiarthroplasty, the early dislocation rate
was much higher (138). Gregory et al (139) reported a high incidence of early dislocation after total
hip replacement for subcapital femoral neck fracture. An important finding was that both the
infection and dislocation rates were higher than noted after elective total hip arthroplasty. The
dislocation rate was felt to be higher in the acute fracture group because of a preexisting better
range of motion and lack of capsular scarring.

Gebhardt et al (140) compared total hip arthroplasty and hemiarthroplasty for the treatment of
acute femoral neck fracture. They concluded that hemiarthroplasty should be used in older patients
who are occasionally active outside the home. Elderly individuals who are in good health and are
more active benefit from a total hip replacement compared to hemiarthroplasty (140).

However, some of the literature is not as promising with use of a total hip replacement in the elderly
individual with an acute femoral neck fracture. Sim and Stauffer (128) reported medical
complications in 21% and surgical complications in 22% of patients undergoing primary total hip
replacement for femoral neck fracture. Taine and Armour (141) reported a 12% revision rate after
total hip replacement for displaced fractures of the femoral neck. Greenough and Jones (142)
reported that 49% of patients 70 years of age or younger at the time of total hip replacement for
femoral neck fractures had undergone or were awaiting revision surgery at 10 years. An additional
11% had definite radiologic signs of loosening. These authors concluded that primary total hip
replacement is not recommended for subcapital fractures in patients who do not have preexisting
symptomatic conditions of the hip. They suggested that patients who

P.1769

have preexisting hip disease already will have adapted to a less active lifestyle and, thus, will place
less demand on a total hip replacement.

In reviewing the literature and comparing the outcomes, it is clear that a dichotomy exists between a
higher dislocation rate with total hip arthroplasty in femoral neck fracture patients and improved
long-term outcomes. Functional outcome seems to be higher after total hip arthroplasty compared
to hemiarthroplasty. Studies done at the Mayo clinic indicated that a bipolar or modular unipolar
hemiarthroplasty has very good functional outcomes to about 8 years, at which time the total hip
function tends to surge ahead. Longer-term outcomes are not available for this age-group of
patients; therefore, no significant difference in long-term (>10 years) outcome has been well
documented.

Therefore, the recommendations that would support performing a total hip replacement for a
displaced femoral neck fracture remain (66,113,125,126,128,130): (a) associated symptomatic hip
disease; (b) a highly active patient; (c) an extremely cooperative patient with an excellent mental
status examination who statistically would likely survive greater than 10 years; and (d) metastatic
fracture involving the acetabulum (66).

AUTHORS' PREFERRED TREATMENT

In patients over the age of 60 who have a displaced fracture involving the femoral neck, it is rare to
regret doing a bipolar or unipolar modular arthroplasty. However, it is very common to regret doing
an open reduction with internal fixation in this particular group.
My recommendations are as follows: (a) in nondisplaced stable fractures, one should undertake an
internal fixation with parallel cancellous lag screws; (b) basicervical fractures of the neck are a special
subtype of femoral neck fractures best treated with a two- to four-hole sliding hip screw and an
antirotation screw; (c) in displaced femoral neck fractures in the elderly, one should replace the head
of the femur using a cemented modular hemiarthroplasty; and (d) total hip replacement is
recommended for those accepted indications noted above or as a salvage for a failed open reduction
with internal fixation or hemiarthroplasty.

Displaced Femoral Neck Fractures in Young Adults

Younger individuals with a femoral neck fracture usually sustain these injuries secondary to high-
energy trauma; they may have other associated injuries in the musculoskeletal system and other
major organ systems. I feel that treatment of the femoral neck fracture should be considered an
orthopaedic emergency. Anatomic reduction and stable fixation should be achieved as soon as
possible (143). If a closed reduction cannot be obtained, then an open reduction should be
performed (144,145).

Femoral neck fractures in young adults have been considered as a separate group, because they tend
to occur in normal bone and are relatively uncommon (67,146,147). As stressed by McDougall (148),
this bone is usually very hard and considerable forces required for it to fracture. According to Bray
(95), Templeman, and Swiontkowski et al (107), young individuals with femoral neck fractures
secondary to high-velocity trauma do not fit well into either the Garden or Pauwels classification. The
fracture in this age-group is usually a high-angle shear-type fracture that extends nearly to the lesser
trochanter. In addition to the relative rarity of the injury, there has been a high incidence of aseptic
necrosis and nonunion reported in the literature. The recommended management of these fractures
has been distinctly different from the elderly (61,147,149,150). Proztman and Burkhalter (61) have
reported that aseptic necrosis is more likely to be symptomatic in younger individuals. In addition,
reconstructive procedures such as total hip replacements are more likely to fail in younger individuals
(61).

Adults between 20 and 40 years of age have been studied because this group has the adult vascular
pattern and the greatest skeletal mineral density (67,151). Proztman and Burkhalter (61) reported 21
cases of femoral neck fractures in this population that resulted in a 62% nonunion and a 90% aseptic
necrosis rate. Massie (150) described 10 patients between 20 and 40 years of age who sustained a
femoral neck fracture. Of these, six had aseptic necrosis and five had delayed union or nonunion.
Kuslich and Gustilo (147) reported 20 femoral neck fractures in young adults; the nonunion rate was
25% and the aseptic necrosis rate was 45%, reemphasizing the poor outcome associated with this
fracture. These tragic results also were demonstrated by Badgley (151) and by Cave (152). In
contrast, Askin and Bryan (67) reported that in 17 patients between the ages of 20 and 40 years who
had a femoral neck fracture, the aseptic necrosis rate was only 18.7% and none of the fractures
developed nonunion. However, only 6 of these 17 patients had a clinically normal hip joint at latest
follow-up.

Protzman and Burkhalter (61) emphasized three basic differences between these femoral neck
fractures in young adults and those in elderly individuals: (a) they are distinctly uncommon; (b) the
reported results of treatment are notably poorer than those in more elderly patients; and (c) there is
a significant difference in the severity of trauma required to cause this fracture in young adults.
Cave (152) encouraged anatomic reduction in all femoral neck fractures, but stated that it is
particularly important in younger individuals. He recommended that if one attempt at closed
reduction fails, the surgeon should proceed directly to an open reduction through an anterior
approach. Badgley (151) also performed open reduction on most patients in his series. However, a
series comparing open reduction versus closed reduction in femoral neck fractures in young patients
has not been available for analysis.

Meyers et al (32) reported the use of a posterior muscle pedicle graft in 23 patients less than 40
years of age who sustained a femoral neck fracture. He reported no cases of late

P.1770

segmental collapse and only one case of nonunion. Neither the quality of reduction nor a detailed
analysis of these patients was presented. Use of the posterior pedicle graft to prevent avascular
necrosis in young patients has not been validated in studies by other authors.

Swiontkowski et al (107,108,153) reported 27 patients between the ages of 12 and 49 years who
sustained a femoral neck fracture. The fractures were treated by open reduction with internal
fixation with 6.5-mm cancellous screws in a box pattern and a concurrent capsulotomy. The surgical
procedures usually were done within 8 hours of injury. All fractures united. Aseptic necrosis
developed in 20% of patients. Sixty percent of patients who had aseptic necrosis had symptoms that
ultimately required surgical revision of the hip. The authors attributed the absence of nonunion and
the low (20%) incidence of radiographic evidence of aseptic necrosis to early fracture reduction and
internal fixation. They recommended that in young, active individuals, the screws be removed after
12 to 14 months. Finally, they recommended that femoral neck fractures in young patients be
treated as an orthopaedic emergency. They felt that the femoral neck fracture should be treated as
soon as life-threatening injuries have been managed.

Similarly, Tooke and Favero (112) described 32 patients less than 50 years of age who had a femoral
neck fracture. Multiple devices were used for fixation; a capsulotomy was performed in only one hip.
All patients with a Garden I or II fracture healed without osteonecrosis. Patients with Garden III or IV
fractures had a 5.5% rate of nonunion and a 33% rate of osteonecrosis. Tooke and Favero (112)
emphasized that excellent function can be achieved in the face of osteonecrosis after femoral neck
fracture in young patients. Half of their patients with osteonecrosis, even at long-term follow up, had
an excellent result. They emphasized that not all cases of avascular necrosis showed complete
femoral head involvement, but could be only partial or segmental. Segmental avascular necrosis,
particularly if it did not include the superior dome area of the head, was compatible with a very
functional hip joint. The authors also reported that femoral neck fractures, uncomplicated by
nonunion or avascular necrosis function extremely well over the long term (112). They concluded
that hemiarthroplasty is not indicated in young adults with a femoral neck fracture.

According to Bray (95) and Templeman, there are three criteria for successful treatment of femoral
neck fractures in young adults: (a) fixation must be achieved within 12 hours of injury or as soon as
possible; (b) anatomic reduction must be obtained through closed manipulation or open reduction, if
necessary; and (c) the fracture should be stabilized with some form of multiple screw fixation. The
authors believed that circulation would improve after anatomic reduction and fixation.
A prospective randomized multicenter study reported by Kyle (103), found that femoral neck
fractures in young adults treated with multiple screw fixation had a 19% incidence of avascular
necrosis and a 14% incidence of nonunion compared with patients treated with compression hip
screw, in which the aseptic necrosis rate was 33% and the nonunion rate was 57%.

AUTHORS' PREFERRED TREATMENT

Open reduction with internal fixation with parallel cancellous screws in an inverted triangular
configuration is my preferred treatment. This is accomplished by attaining anatomic reduction of the
femoral neck through a closed or open reduction. The inverted triangle configuration is usually
chosen because it reduces the stress riser effect at the lesser trochanteric level. The one exception is
the “base of neck fracture,” which is first reduced and pinned temporarily to control rotation
of the femoral neck during definitive fixation. A two- or four-hole sliding screw plate is then applied,
along with a 6.5-mm superior derotation screw.

The timing of the surgery in the young adult is recommended to occur in the first 6 to 12 hours.

I do not perform these at 3:00 in the morning, but I would initiate them up to midnight or,
alternatively, put them on as the first case (7:30 AM) in the morning. There are always exceptions to
this protocol because some patients present in a very delayed fashion and have to be treated on a
case-by-case basis.

Techniques for Internal Fixation with Parallel Cancellous Screws

Internal Fixation Surgical Techniques

Closed reduction of a femoral neck fracture requires an intensifier (fluoroscopy) and a radiolucent
fracture table. This fracture table must permit longitudinal traction and hip flexion and rotation. The
table should allow gentle manipulation and reduction of the fracture, plus be capable of maintaining
the patient and the limb in the appropriate position for internal fixation.

Operative Technique: Parallel Screw Fixation of Femoral Neck Fractures

In the parallel screw technique, the starting point for the screws should be above the lesser
trochanter. Screw placement is optimum using an inverted triangle configuration with a screw along
the inferior femoral neck, a posterior screw up against the neck posteriorly and the anterior superior
screw peripherally in the head of the femur. If posterior comminution exists, some authors would
favor four screws with two screws up against the neck posteriorly and two screws along the calcar
inferiorly.

Closed Reduction Techniques

An acceptable reduction has been the key factor in decreasing the risk of aseptic necrosis and
nonunion. Moore (154) demonstrated that when the fragments are not anatomically reduced, actual
bony contact at the fracture site would only be half as much as appeared on x-ray. This decreased
area of contact reduces the area for blood vessels to grow from the base of the

P.1771
neck into the femoral head. Moore believed that this was a significant factor in the incidence of
aseptic necrosis and delayed union. Cleveland and Bosworth (155,156) stressed the need for
correction of rotational displacement of the proximal fragment to improve bony apposition and
union.

The methods recommended to achieve fracture reduction must be well understood because fracture
reduction is one of the few determining factors under the surgeon's control. The method used, open
or closed, should achieve a perfect reduction of the femoral neck (112).

Many surgeons favor closed reduction on the fracture table, which allows for the insertion of internal
fixation devices under two-plane x-ray control or image intensification. Although multiple methods of
closed reduction have been described, none have been documented to be superior.

A femoral neck fracture with minimal displacement can usually be reduced in extension on the
fracture table. Whitman (157) described a reduction method that involved traction on the limb in
extension followed by internal rotation and abduction. The patient is placed on the fracture table
with the leg placed in traction and in a neutral position. The leg is gently internally rotated and
slightly abducted, while viewing the reduction in the AP and lateral views on the imager. The calcar
cortex should align when the fragments are in anatomic position. The leg is fixed in this position and
the screws inserted in the usual manner.

If this “Whitman” method fails or if significant displacement remains, a reduction in flexion

should be performed. The hip is flexed to 90 degrees and the leg externally rotated. Traction plus
external rotation should be applied while the hip is then gently extended and internally rotated.
Extension is combined with internal rotation of the femur. This procedure disengages the fracture
fragments in flexion, reduces the fracture with extension and reengages the fracture segment in
internal rotation.

Leadbetter (158) championed the reduction of femoral neck in full hip flexion. In this technique, the
affected leg is flexed at the hip to 90 degrees and traction (with slight adduction of the femoral shaft)
is applied along the axis of the femur. In this position, the thigh is rotated internally. The leg then is
circumducted into abduction (maintaining internal rotation) and brought down to table level in
extension. Leadbetter (158) evaluated the reduction with the so-called heel/palm test, in which the
heel is placed in the palm of an outstretched hand. If reduction is complete, the leg will not rotate
spontaneously externally. If performed, it should be done very gently and slowly (95). Although this
reduction frequently produces satisfactory alignment on x-ray, the head may be rotated on the
femoral neck, resulting in nonanatomic configuration. Bray (95) and Templeman advised against the
use of the Leadbetter maneuver for fear that it may increase vascular insult to the hip. Smith-
Petersen et al (159) recommended reduction by gentle traction in slight hip flexion while
counterpressure is maintained on the pelvis. This is followed by internal rotation, abduction, and
extension. The limb then is then placed in the fracture table with the foot strapped into the footplate
while maintaining the traction and reduction. This technique, a gentle Leadbetter, continues to be
successful for displaced fractures. The influence of the technique of closed reduction on the end
results has not been clearly defined in the literature. In addition, the number of closed reductions
that should be attempted in an effort to obtain an acceptable reduction has not been clearly defined.
The surgeon should keep in mind the theoretic risks of repeated manipulation versus those of an
open reduction.

Open Reduction of the Femoral Neck

If the fracture has not been acceptably reduced after one to two attempts at closed reduction,
consideration should be given to open reduction. However, open reduction can be a difficult
procedure. McElvenny (160) believed that the open reduction of a femoral neck fracture was the
most difficult surgical procedure about the hip, and Cleveland (155) reported that up to 50% of
fractures treated by open reduction actually become displaced during the process of fixation. Cave
(152) and Schek (161) also expressed hesitancy in performing an open reduction for fear of damage
to the remaining blood supply and difficulty in controlling the “spinning femoral head.” In
addition, Green (162,163) expressed reservations about open reduction because of the limited area
actually available for manipulation of the fracture, even under direct visualization (164,165).

Despite these reservations, Banks (68) demonstrated that open reduction was associated with a
decreased incidence of both nonunion and aseptic necrosis when he compared these patients with a
group of patients in whom an inadequate closed reduction was accepted. Therefore, should closed
reduction fail, open reduction with internal fixation under direct vision must be considered if the
patient is not a candidate for prosthetic hemiarthroplasty.

Technique

Usually, open reduction is performed through an anterior or anterolateral approach in an effort to

prevent further damage to the remaining blood supply and to provide room for fracture
manipulation. A pin can be placed in the femoral head and used as a joystick to spin the femoral head
around to align perfectly with the femoral neck. Once this has been correctly aligned, a lag screw is
placed superior to the lesser trochanter and guided into the head under x-ray control. Once two
screws are placed successfully in the head of the femur, the remaining screws are added where
appropriate.

Radiographic Evaluation

After closed reduction, high-quality radiographs are essential to evaluate the acceptability of the
fracture reduction. Lowell (82,83) demonstrated experimentally that all x-ray images of an anatomic
femoral head-neck junction should reveal the convex outline of the femoral head meeting the
concave outline of the femoral neck, regardless of the x-ray projection. This outline produced the
image of an S curve. In no instance does the

P.1772

concave outline of the femoral neck appear tangent to the femoral head to form an unbroken C
curve (Fig. 44-16). Therefore, if the x-ray image reveals an unbroken C curve, the fracture is not
reduced.

There is some disagreement among authors as to what constitutes an acceptable reduction. A varus
reduction is known to result in an increased incidence of nonunion of the fracture (83). Barnes and
Dunovan (38) reported that the rate of nonunion approached 55% in those fractures with a 20-
degree residual varus displacement after reduction. A valgus reduction is favored by some authors
because of increased bony stability at the fracture, especially in patients with extensive posterior
comminution (55,166,167). According to Arnold (55), the criteria for a good reduction include the
calcar femorale supporting the femoral head, no varus or inferior displacement of the head, and less
than 20 degrees of posterior angulation.

Because of the problems associated with fracture malreduction, most authors favor as near an
anatomic reduction of the femoral neck fractures as is possible (72,168). Authors stressing anatomic
reduction believe that it allows maximum opportunity for the reestablishment of the vascular supply.
Anatomic reduction also prevents the stretching of vessels in the ligamentum teres and the
introduction of abnormal forces along the internal architecture of the femoral head (169,170).
Finally, an anatomic reduction prevents the joint incongruity that is present in a valgus reduction,
because the femoral head is not perfectly spherical (28,29,73). Christophe et al (171) compared the
results of varus, valgus, and anatomic position of the femoral head after reduction and fixation. They
found a marked reduction in the incidence of aseptic necrosis or nonunion in patients in whom the
head was in an anatomic position.

Garden (73,74) investigated the effects of the quality of reduction on both early and late results after
femoral neck fracture. He found that an “acceptable reduction” decreased the incidence of
aseptic necrosis, nonunion, and degenerative joint disease. In an effort to standardize the term
acceptable reduction, he developed an alignment index by which the surgeon could objectively
evaluate the fracture reduction (Fig. 44-17). The alignment index is measured on the AP and lateral x-
rays taken after reduction. These x-rays must be of sufficient quality to allow accurate identification
of the bony trabeculae. In the frontal AP, the angle formed by the central axis of the medial
trabecular system in the capital fragment and the medial cortex of the femoral shaft is measured. In
the normal femoral head and neck, this angle measures about 160 degrees. On the lateral x-ray, the
central axis of the head and the central axis of the neck normally lie in a straight line 180 degrees
(75). Garden (74) believed that an alignment index after reduction within the range of 155 to 180
degrees on both the frontal and lateral views was an acceptable reduction, resulting in a high
percentage of union, and a low rate of late segmental collapse. In his series, when the alignment
index was less than 155 degrees or greater than 180 degrees on either view the incidence of aseptic
necrosis rose from 7.3% to 53.8%.

Stability of Reduction Evaluation of the lateral x-ray after reduction to identify posterior comminution
of the femoral neck has been critical in selecting treatment alternatives. The effect on stability of
posterior comminution at the fracture site has been emphasized by Scheck (161). Posterior
comminution leads to the loss of a buttressing effect posteriorly, with subsequent risk of loss of
reduction and nonunion. Garden (73,74,75) reported that only type III and type IV fractures develop
nonunion, and that was because of an unstable reduction secondary to comminution posteriorly and
inferiorly at the fracture site. Banks (68) also recognized that posterior comminution was an
important

P.1773

factor in nonunion, demonstrating that more than 60% of patients with nonunion had posterior
comminution at the time of initial treatment. Ragnarsson et al (172) reported that the most
pronounced instability of a femoral neck fracture occurred in a displaced fracture and was seen
mainly as a forward or backward rotation of the femoral head in combination with retroversion or
anteversion. These authors also reported that all forms of osteosynthesis are more efficient in
counteracting varus and valgus displacements rather than rotational displacements.

The tensor should then be closed over a Hemovac drain with interrupted suture. This is the most
important layer of the closure. The soft tissue and skin are then reapproximated with suture or
staples. Antibiotics are given preoperatively and continued for 24 hours or until the drain is removed.

Posterior Approach for Hemiarthroplasty

The posterior approach of Moore was initially recommended for the insertion of his endoprosthesis
(154). Although Coventry (176), using the posterior approach for prosthetic hemiarthroplasty, noted
no cases of postoperative dislocation, the posterior approach has historically been related to an
increased incidence of posterior dislocation in the perioperative period (45,177). Anderson et al (45),
using the posterior approach, reported that postoperative dislocations occurred at a higher rate in
individuals with preoperative flexion-adduction contracture before hip fracture. In these patients,
they suggested use an anterolateral approach to avoid this increased risk of dislocation. The incision
that is close to the anus, associated with resection of the posterior capsule, was reported to be an
important causative factor in postoperative infection and posterior dislocation. Therefore, a
recommendation of a slight posterior slope to the incision and no resection of the posterior capsule
plus repair of the posterior capsule at the end of the procedure has been recommended.

The position and offset of the prosthesis has been the most important variable affecting the risk of
dislocation from either the anterior or posterior approach. Excessive retroversion can

P.1775

lead to external rotation deformity and an increased risk of posterior dislocation. Excessive
anteversion can lead to toeing in and anterior dislocation in external rotation (96,97). Use of a
modular component allows a choice of offsets and neck lengths while permitting the use of a mobile
large femoral head. These characteristics ensure a highly functional component with an extremely
low rate of dislocation.

ASSOCIATED FEMORAL NECK AND SHAFT FRACTURES

This section discusses the femoral shaft fracture with an associated femoral neck fracture (173).
About 50% of these fractures are not easily seen at the time of initial presentation. One must be
acutely aware this combination can occur and be alert for it at all times.

Even if the preoperative x-rays do not indicate a neck fracture, a good image should be obtained of
the hip at the completion of the intramedullary nail procedure. A cephalomedullary-style nail with
screws inserted into the femoral head and neck can be used if there is any indication of a
nondisplaced femoral neck fracture. Another solution is to place screws around an already well-
seated intramedullary femoral nail (178).
If the femoral neck and shaft fracture combination are identified preoperatively, the displacement of
the neck fracture determines the treatment protocol.

 Nondisplaced neck fracture: In this situation, a temporary pinning of the neck fracture, a very
careful reaming of the femoral shaft, and insertion of a cephalomedullary nail (screws
through the nail and into the femoral head) would be the treatment of choice. Another
option is use of a retrograde-inserted intramedullary nail to stabilize the femoral shaft
fracture along with the standard fixation of the femoral neck. Care should be taken to
protect the femoral neck fracture during retrograde nailing of the femoral shaft (Fig. 44-19).
A third option is an intramedullary nail with screws placed anterior to the nail and into the
femoral head. This is often performed as a secondary procedure (in the case of a
“missed” femoral neck fracture), but is not recommended as a primary procedure
(179).

 Displaced femoral neck fracture: A displaced fracture of the femoral neck with an associated
shaft fracture requires more careful deliberation. Two schools of thought exist: (a) The
femoral neck should be treated acutely, and the femoral shaft treated secondarily. A clamp
can be placed through a small incision on the femoral shaft and used to manipulate the distal
fragment. The femoral neck is then reduced and stabilized. Once reduction and fixation has
been completed on the femoral neck, the femoral shaft is treated as indicated. (b) The
second school of thought advances the point that it is difficult to reduce the displaced neck
fracture without first stabilizing the femoral shaft fracture. Blair (98) and Kyle (103) both
advocated either a retrograde nail or a plate for the femoral shaft fracture and then using the
stabilized femoral shaft to perform a closed reduction of the neck fracture, followed by
multiple screw fixation. The arguments, of course, are lively, but theoretically fixation of the
shaft adds a potential for injury to the remaining vessels while plating or, particularly, nailing
the femoral shaft fracture. There have been no prospective studies comparing the two
methods in a patient population with a displaced femoral neck and shaft fracture. Therefore,
if there is any concern regarding further injury to the remaining vessels, advocates of initial
fixation of the femoral neck seem to be the more conservative approach to this terrible
injury (178).

Treatment of Specialized Cases

Femoral Neck Fractures in Patients with Paget's Disease

Nicholas and Killoran (175) reported that the incidence of Paget's disease is more common than is
reflected in the literature and actually depends on the extent of the x-ray survey performed on each
patient. According to Barry (180), femoral neck fractures are less common than either
intertrochanteric or subtrochanteric fractures in patients with Paget's disease. Lake (181) found
fractures in patients with Paget's disease to be more common in the earlier vascular phase than in
the later sclerotic phase of the disease.

Pathologic fracture of the neck of the femur through bone

P.1776
involved with Paget's disease presents a formidable problem (182). In pathologic femoral neck
fractures resulting from malignant disease, compromise in standard treatment plans often can be
accepted because of limited life expectancy. This is not possible in patients with Paget's disease,
however, because of the low likelihood that life expectancy will be shortened (182).

Fractures through a femoral neck involved with Paget's disease often do not unite (175). Nicholas
and Killoran (175) reported that nonunion in these fractures usually was secondary to a poor fracture
reduction, distraction, and failure of internal fixation. These technical problems are more likely to
occur in Paget's disease, because of both the deformity of bone and the inherent characteristics of
pagetoid bone. In addition, Lake (181) concluded that fractures unite rapidly in the vascular phase,
whereas union is difficult to achieve when the disease is in the sclerotic phase.

For these reasons, a displaced fracture of the femoral neck in Paget's disease still represents an
unsolved problem. Grundy (183) reported nonunion in all his patients with displaced femoral neck
fractures, whether they were treated by open or closed means. Dove (184) noted a 75% nonunion
rate in fractures treated nonoperatively or by reduction and internal fixation. Patients treated by
primary prosthetic replacement fared much better, with 78% resuming their preoperative
ambulatory status. Milgram (185) suggested replacement arthroplasty over internal fixation because
of the poor rate of union after displaced fractures through pagetoid femoral neck. He pointed out
that such patients may be prone to acquire fractures below the stem of the prosthesis, if this area is
involved in the pagetoid process. Contrary to Milgram's finding, both Barry (180) and Nicolas and
Killoran (175) reported that the results of prosthetic replacement of the femoral head in patients
with Paget's disease were unsatisfactory, presumably because of acetabular involvement with Paget
disease. Sim and Stauffer (128) suggested that total hip arthroplasty would seem to offer the best
chance of salvage, after failure of internal fixation of these fractures.

AUTHORS' PREFERRED TREATMENT

If there is a nondisplaced fracture involving the femoral neck through pagetoid bone, 6.5-mm
cancellous screws are a good treatment choice. Having said this, a nondisplaced neck fracture
through this type of bone is quite unusual.

The options for treatment of a displaced fracture in patients with Paget's disease remain a modular
hemiarthroplasty, cemented in design, or cemented total hip replacement (182).

A lot of the decision making is the same as noted above. If the acetabulum is completely uninvolved,
then a modular hemiarthroplasty would seem to be the treatment of choice. If, indeed, the
acetabulum is involved, then a total hip replacement becomes the treatment of choice.

Pearls and Pitfalls

Pearls to a successful replacement in Pagetoid bone include the following:

 Preoperative planning.

 High-speed reaming tools (Midas Rex type of tools) should be available to cut through this
very hard bone.
  Blood should be available to replace any loss of blood (high risk in Paget's disease)

 Sharp, cannulated and noncannulated reamers are needed to locate and ream the
intramedullary canal. The femoral component should extend below the pagetoid bone to
reduce the postoperative stress on the femoral cortex.

 Cement should be used because it allows good fixation of the component and reduces the
intraoperative and postoperative blood loss.

Before undertaking this operation, complete radiographic evaluation of the proximal shaft of the
femur should be performed to determine whether excessive bowing exists. If the femur is excessively
bowed, it may prevent insertion of a straight component; therefore, femoral components with a bow
must be available in the OR to accommodate the bowed femur. If an individual with Paget's disease
has had a femoral neck fracture that has failed to unite, a total hip replacement is an excellent
salvage procedure (182).

Femoral Neck Fracture in Patients with Parkinson's Disease

Parkinson's disease, a disorder caused by a lesion in the brain stem, is characterized by signs ranging
from a mild tremor to complete incapacitation secondary to rigidity and tremor (185). Patients with
Parkinson disease who sustain fractures of the proximal femur are known to have higher morbidity
and mortality than patients in the normal population (186). Osteoporosis and contractures can make
surgical exposure, stable internal fixation, and secure prosthetic insertion difficult. In addition, the
associated tremor and impaired balance often preclude good functional recovery (187). The poor
results noted in displaced femoral neck fractures treated with internal fixation, have led to the
recommendation for primary endoprosthetic replacement in patients with Parkinson's disease.
Rothermel and Garcia (187) reported excellent restoration of function when primary endoprosthetic
replacement was used in patients with displaced femoral neck fractures. These authors concluded
that in patients whose disease was medically well controlled, the indications for replacement
prosthesis were the same as in the general population.

AUTHORS' PREFERRED TREATMENT

Patients with uncontrolled Parkinson's disease who sustain a nondisplaced femoral neck fracture
should be treated with internal fixation using multiple cancellous screws. A secondary choice would
be a sliding compression hip screw and supplementary antirotation screw.

In patients with uncontrolled Parkinson's disease who sustain a displaced femoral neck fracture,
prosthetic replacement through an anterolateral approach using a modular hemiarthroplasty is
preferred. Because of the rhythmic tremor associated with Parkinson's disease, total hip replacement
has been somewhat contraindicated secondary to a high dislocation rate. Coughlin and Templeton
(186) reported a 6-month mortality rate of 60% in patients with severe uncontrolled Parkinson's
disease who sustained a femoral neck fracture.

In the younger individual with minimal rigidity whose condition is well controlled by medication,
consideration should be given to reduction and internal fixation with multiple screws. Again the
choice would depend on the age, activity, and life expectancy of the patient involved (188).
P.1777

Femoral Neck Fractures in Patients with Spastic Hemiplegia

Femoral neck fracture in patients with hemiplegia is a relatively common complication, affecting up
to 10% of this patient population (189). Despite this frequency, there is scant literature dealing with
this topic. The patient can have varying degrees of flexion and adduction contracture associated with
muscle hypertonicity. Because of hypertonicity, muscle forces about the hip make reduction of
femoral neck fracture difficult. In addition, the associated soft tissue contractures make the surgical
approach more complex (189). Treatment choices should be decided based on displacement of the
fracture, age of the patient, bone quality, and the patient's preinjury function.

AUTHORS' PREFERRED TREATMENT

In choosing between internal fixation and modular hemiarthroplasty, the degree of spasticity
resulting from the cerebrovascular accident is critical. In patients with minimal spasticity and minimal
flexion-adduction deformity and who have been ambulatory before the injury, consideration is given
to the reduction and internal fixation. However, in patients with marked spastic hemiplegia after
cerebrovascular accident, primary hemiarthroplasty would be selected. Total hip replacement could
be considered, but this patient population is associated with a significant dislocation risk.
Consideration should be given to the anterolateral approach that will allow anterior muscle release
while maintaining the posterior structures, thus theoretically decreasing the likelihood of dislocation.
In severely debilitated patients, skillful neglect may be indicated in the management of these
fractures.

Postirradiation Fractures of the Femoral Neck

After irradiation of the pelvis for malignancy, fractures have been noted to occur in the femoral neck
region and, less often, in the acetabulum (171). The most frequently involved malignancies are
carcinoma of the cervix, uterus, and ovary (190). Such fractures occur in about 1.5% of all patients
who receive pelvic irradiation (190). There is a high rate of bilateral involvement, varying from 20% to
40% (190). The interval between the initial exposure to radiation therapy and the appearance of the
pathologic fracture varies substantially ranging from 5 months to 12 years.

Clinical Course

The presenting complaint usually is the spontaneous onset of pain in the hip, groin, or medial thigh.
The pain may be referred to the knee and occasionally takes the form of sciatica (191). It is
characteristic of these fractures that pain antedates the proven fracture for a considerable period,
averaging 1.7 months in Smith's series (169). Initially, the pain is rarely incapacitating and is noticed
only with prolonged walking and standing. There can be a gradual increase in the severity of pain
accompanying increased weight-bearing activity.

On x-ray, the earliest sign is an irregular transverse line of increased density in the femoral neck
(192). On the AP x-ray, when the fracture line is incomplete, it is noted as a separation in the lateral
margin of the femoral neck, with concomitant minimal varus deformity. As weight-bearing continues,
the femoral head goes into more varus displacement. One of the characteristics of the fracture is a
coxa vara deformity on the AP x-ray, with minimal, if any, displacement in the lateral view.
Angulation on the lateral x-ray normally is seen with femoral neck fractures associated with trauma
(170). The surgeon should recognize the acetabular changes that occur in patients after irradiation,
and such changes should not be considered definite signs of metastatic disease (190).

The differential diagnosis includes a pathologic fracture through a metastatic malignant lesion or
osteopenic bone secondary to radiation or other causes. However, metastatic lesions to the neck of
the femur from primary cervical and uterine carcinomas have been noted to be distinctly different in
presentation (193). Therefore, with postirradiation fractures, Bonfiglio (33,37) stressed avoiding the
use of additional irradiation to the hip in these patients under the mistaken assumption that this
might represent metastatic disease. The differential diagnosis should also include a fracture
secondary to major trauma through irradiated bone. The characteristic lack of displacement on the
lateral x-ray and a definite history of trauma should differentiate these two entities (33,37).

Treatment Considerations

All series have demonstrated the tendency of these fractures to heal when displacement has not
been complete (169,190,193). Therefore, early diagnosis before displacement occurs is critical.

Bickel et al (193) recommended simple internal fixation with pins or screws, possibly supplemented
with a bone graft, for

P.1778

nondisplaced femoral neck fractures. They also noted aseptic necrosis to be rare after nondisplaced
femoral neck fractures.

Leabhart and Bonfiglio (190) classified these fractures into four types. Type I is a fracture with a slight
varus deformity, and type IV is a fracture with a complete displacement. Types II and III represent
gradations of severity of varus displacement of the femoral neck fracture. Their recommendation for
the treatment of type I fractures was pinning in situ. In type II and possibly type III fractures,
manipulation may be required before pinning. They suggested the addition of a bone graft with
internal fixation to aid healing in those fractures that have been manipulated. In fractures with
complete displacement (type IV) reconstructive procedures, such as prosthetic arthroplasty were
recommended. A close follow-up for symptoms in the opposite hip is mandatory because of the high
incidence of bilateral fractures. It would be very unusual to find a patient who has symptoms of this
type of stress fracture and a normal life span (190).

If the patient's life expectancy is limited and the pain is substantial, the surgeon should strive to
restore painless function and ambulation as simply as possible. In these cases, a cemented modular
hemiarthroplasty would be recommended.

AUTHORS' PREFERRED TREATMENT

If the patient's life expectancy is normal and the fracture is completely nondisplaced, internal fixation
is recommended. This, of course, would be the rare instance, because most patients would not fall
into this group. Any type of displacement or shortened life span would indicate a patient who should
receive a cemented modular hemiarthroplasty. Again, indications for total hip arthroplasty as noted
above would remain the same (113,124,125).

Pearls and Pitfalls

Consideration should be given to performing arthroplasty via a posterior approach (173,174). The
anterior soft tissue may be contracted as a result of irradiation changes and would not be as
retractable as normal. Therefore, the risk of femoral nerve and vascular injuries would be increased
with the anterolateral approach (173).

Femoral Neck Fractures through Metastatic Disease to Bone

Pathologic fracture occurring through metastatic lesions about the hip are common, accounting for
approximately 10% of metastatic femoral fractures (66). In impending fractures of the femoral neck,
with neoplastic lesions occupying more than 50% of the femoral neck, either prophylactic internal
fixation or replacement should be preferred. Behr et al (9) reported that pathologic fractures
secondary to metastatic breast carcinoma have a better survival prognosis than those caused by
other types of metastatic disease.

Lane et al (194) established the following criteria for surgery and related them to lesions located in
the femoral neck: (a) a painful intramedullary lytic lesion equal to or greater than of the cross-
sectional diameter of the bone; (b) a painful lytic lesion involving a length of cortex equal to or more
than the cross-sectional diameter of the bone or more than 2.5 cm in axial length; and (c) a lesion of
the bone in which pain is unrelieved after conservative treatment including radiation therapy.

In general, if the lesion is large or the fracture displaced, replacement with a modular
hemiarthroplasty or total hip replacement is recommended. The same criteria should be observed as
discussed above when considering hemiarthroplasty or total arthroplasty.

The general preoperative considerations in these patients include those outlined by Parrish and
Murray (195): (a) the patient's condition must be sufficiently good and life expectancy long enough to
justify the surgical procedure; (b) the surgeon must be convinced that the operation is more
beneficial than nonoperative, closed treatment; (c) The quality of bone, both proximal and distal to
the fracture, should be adequate for stable fixation or replacement; and (d) the procedure should
expedite the mobilization of the patient, with reduction of pain or facilitate general care.

AUTHORS' PREFERRED TREATMENT

The primary indication for surgery after pathologic femoral neck fracture is pain. Secondarily, early
mobilization with full weight-bearing is extremely important. In displaced fractures of the femoral
neck and large lesions occupying more than 50% of the bone, including one cortex, a cemented
femoral stem is usually preferred. The stem length is chosen to make sure that the femoral stem
goes by the most distal femoral lesion by at least two and a half times the diameter of the bone
(66,194). A careful x-ray evaluation is performed to make certain that the acetabulum and distal
femur are not involved. If acetabular involvement is noted or suspected, total joint arthroplasty may
be indicated. If the lesion is noted further down the femoral shaft, a long-stem prosthesis is used
with methylmethacrylate to stabilize the involved femoral shaft area. Those patients who have an
impending or completely undisplaced fracture of the femoral neck are treated on a case-by-case
basis. If they meet Lane's criteria, they receive a cemented modular hemiarthroplasty. However, a
prophylactic sliding hip screw device with additional cement fixation can be used in those patients
who have neck lesions alone and are spared femoral head and shaft involvement (66). This allows for
excellent relief of pain and avoids the potential problems of dislocation (66). Salvage of such a lesion
should it extend past the plate in later years would be arthroplasty (130).

P.1779

Femoral Neck Fractures in Patients with Hyperparathyroidism

Hyperparathyroidism usually is diagnosed as a result of finding an elevated serum calcium level

during random blood testing. The principal action of parathyroid hormone is osteoclastic resorption
of bone, which can lead to fracture. The incidence of fracture in hyperparathyroidism is about 10%
(196).

Chalmers and Irvine (44) described five patients with fractures of the femoral neck associated with
hyperparathyroidism. The fracture line was oriented vertically and located near the base of the neck.
None of the fractures united after internal fixation despite appropriate management of the
underlying metabolic disease. The authors did not attribute the lack of healing to
hyperparathyroidism, but rather to the vertical orientation of the fracture and the preexisting coxa
vara. They concluded that primary arthroplasty may be preferable to internal fixation in these
patients.

AUTHORS' PREFERRED TREATMENT

In younger patients with good bone stock, open reduction with internal fixation is performed. If the
fracture line is vertical or there is preexisting coxa vara, an osteotomy in conjunction with internal
fixation is performed. In elderly patients with poor bone stock, primary total hip arthroplasty is
preferred.

COMPLICATIONS SPECIFIC TO FEMORAL NECK FRACTURE

Complications associated with this fracture are summarized in Table 44-1. Arthritis is, of course, a
complication of femoral neck fracture, but it is a complication of any periarticular injury and should
be treated as would be the case for any primary arthritis.

Early Complications

mortality

Reported mortality rate in elderly individuals during the first year after hip fractures are wide
ranging. Reports go from 14% to 50% in the first year; after the first year the mortality rate seems to
approach that of age-matched controls (3,4,5,6,7,72).
It is obvious that the mortality risk is highest during the perioperative period and then gradually
reduces (72). It stays, however, high over the first 6 months. Several patient factors affect mortality,
including the individual's age and gender, concomitant medical and psychiatric conditions, level of
preinjury functioning, and the presence of end-stage renal disease. Even in the latest literature, with
improved fixation techniques and early mobilization and rapid return to a home environment, the
perioperative death rate still approached 5%, with mortality staying at 25% in the first year. The
range is obviously quite wide depending on what studies are reviewed, but this would be a
reasonable figure to use when discussing the issue with the patients and family (8).

Table 44-1 Complications of Femoral Neck Fracture

Early
Mortality
Infection
Deep vein thrombosis, with or without associated pulmonary embolism
Dislocation
Late
Nonunion
Aseptic necrosis
Heterotopic bone
Pain—long term

Infection

Use of antibiotic prophylaxis has decreased the risk of infection with Staphylococcus aureus from 5%
to 1% for major wound infections, and from 11% to 4% for minor wound infections (197,198).
Postoperative infection with concomitant osteomyelitis, septic arthritis, and possibly, septic
dislocation is catastrophic (197,198). Barr (197,198) demonstrated that infected femoral neck
fractures are much more likely to have hip joint involvement than are infected intertrochanteric
fractures. Because femoral neck fractures are intracapsular, deep sepsis of these fractures is more
likely to involve the hip joint (198).

When infection with joint involvement occurs, the femoral neck fracture will not usually unite.
Salvage of the femoral head is unlikely in this situation. Perioperative antibiotics have been shown to
significantly reduce the incidence of postoperative hip infections and, therefore, are recommended
on a routine basis in patients undergoing surgical treatment of femoral neck fractures. The antibiotic
most often used is a cephalosporin (Kefzol) 1 g, given intravenously immediately before surgery. This
is continued at 1 g every 8 hours for three doses after the surgery. Alternatives include vancomycin
and clindamycin.

The incidence of postoperative sepsis varies from 2% to 20% (45,199,200). As mentioned, the
incidence seems to be increased in patients in whom a true posterior (Moore) surgical approach is
performed (200). Sepsis may become evident soon

P.1780

after surgery, or it may be diagnosed after discharge from the hospital (201). The modified (new)
posterior approach has not been associated with any increase in infection. Early infections can be
either superficial or deep (202). In the immediate postoperative period, incisional pain, inflammation
with drainage, and temperature elevation are noted in superficial infection. Early, deep infections
vary in their presentation from an acute, potentially fatal clinical course, with septic shock to a mild,
low-grade infection with pain in the upper groin or thigh (202).

Late, deep infections are more difficult to detect (176). Unusual pain, prosthetic dislocation,
persistent thigh swelling, elevated sedimentation rate, and, finally, x-ray evidence of bone erosion
suggest the diagnosis. Aspiration of the hip with culture and sensitivity of the aspirant may confirm
the suggested diagnosis (176). If the results are negative, synovial biopsy for culture may be required
(176).

In those patients in whom the infection is diagnosed in the immediate postoperative period, incision
and debridement, along with intravenous antibiotics, may salvage the prosthesis (60%) (201,202).
Infections that are diagnosed later usually cannot be salvaged without removal of the prosthesis
(176). Infection after an endoprosthetic replacement has been reported to result in an extremely
high mortality rate (203).

Deep Vein Thrombosis

Pulmonary embolism is the fourth most common cause of death in hip fracture patients. Bleeding
can be a major problem if prophylaxis is undertaken, occurring in as high as 24% of patients. In the
older age-group, prophylactic agents can have a rapid effect, and can be quite hard to control.

Without prophylaxis, deep vein thrombosis risk has been reported to be greater than 50% and fatal
pulmonary embolism 0.5% to 2%. Review of prophylactic treatment for prevention of deep vein
thrombosis in fractured hip patients indicate: (a) placebo has a relative risk reduction (RRR) of 0; (b)
aspirin has a relative risk reduction of 29%; (c) regular heparin (unfractionated) has a RRR of 44%; (d)
low molecular weight heparin has a RRR of 44%; and (e) warfarin has RRR of 48%. The duration of
prophylaxis is controversial, with recent European studies extending prophylaxis to 6 weeks, whereas
North American studies seem to reject out of hospital prophylaxis for this group of patients. In
European studies looking at low molecular weight heparin, Plancher and Donshik (204), Pertananen
et al (134), and Davis et al (205) showed a substantial incidence of asymptomatic deep vein
thrombosis, ranging from 19% to 26% in the 29 to 35 days after surgery. North American studies of
Laclerc, Anderson and Leighton, and Colwell et al indicated that clinically relevant deep vein
thrombosis occurs in only 3% to 4% of patients receiving warfarin or low molecular weight heparin
after 7 to 10 days in the hospital. Fatal pulmonary embolus occurred in only 0.08% of patients.
Surveillance is, of course, expensive, and has not been shown to reduce the incidence of venous
thrombosis in fatal embolus.

AUTHORS' PREFERRED TREATMENT

At my institution, low molecular weight heparin (Fragmin 5,000 units) subcutaneously once a day is
initiated on patient's admission to hospital or the night after surgery, if surgery is done within 24
hours of admission. The only reason for delay of thromboprophylaxis is if anesthesia contemplates
doing a spinal anesthetic, because there have been known complications of epidural bleeds occurring
on patients who have received low molecular weight heparin before the surgery.
While in hospital, patients are kept on low molecular weight heparin and in some instances (high-risk
patients) are discharged home on Fragmin or aspirin for 6 weeks, if it is not contraindicated. However
the majority of fractured hip patients are discharged home without any at-home prophylaxis.

Dislocation

The incidence of dislocation after endoprosthetic replacement varies in reported series. Anderson et
al (45) and Hinchey and Day (206) reported a dislocation rate of 1% or less while Lunt (114) reported
a dislocation rate of 10%. Factors associated with dislocation include excessive anteversion or
retroversion of the prosthesis, posterior capsulectomy (206), and excessive postoperative flexion or
rotation with the hip adducted (202). It is important to remember that infection is a common cause
of dislocation, being present in up to one third of dislocated arthroplasties (202). Therefore, in the
absence of a definite mechanical etiology, infection must be considered and investigated.

With prompt recognition and reduction, dislocation is unlikely to jeopardize the end result (199).
Once a dislocation is noted, reduction under general anesthesia or conscious sedation is indicated. If
several attempts at closed reduction fail, open reduction is indicated. After reduction, traction for a
few days and bracing in 15 degrees of abduction and a limit of 70 degrees of flexion for 6 weeks until
soft tissue healing occurs, is recommended (202).

Late Complications

Nonunion

Femoral neck nonunion has been reported to occur in as many as 20% to 30% of patients with a
displaced femoral neck fracture (3,4,5,6,7,8,74). It is rare in those patients with nondisplaced femoral
neck fractures. The question is why does a displaced femoral neck fracture have such a high rate of
nonunion? Anatomically it is not as well supplied with the necessary tools to heal at a normal rate.
The cambium layer of the periosteum is missing, and this is the layer that produces callus (19).
Therefore, the femoral neck must heal via direct endosteal healing. This obviously has been planned
well, because callus would reduce the

P.1781

range of hip motion and cause impingement. The range of motion of the hip is dependent on the
head to neck ratio, so this ratio would be disturbed by excessive callous in the neck area. However,
the lack of callous also reduces the rate of union and increases the duration of time required to
achieve clinical and radiologic union. This creates a clinical race between fixation failure and union.

Femoral neck fractures should unite by 6 months. If there is no evidence of healing, or the patient
continued to have pain at 3 to 6 months after surgery, then a delayed (3 months) or nonunion (6
months) should be contemplated. When trying to differentiate a nonunion versus avascular necrosis
in a patient, the source of the pain must be determined. The diagnostic procedure of choice would be
MRI, however, it can be difficult to get a reliable picture with stainless steel or even titanium present
in the femoral head (92,126,207,208,209). Some newer CT scans and MRIs can dampen the effect of
the screws (209); however, even with titanium screws, it can be difficult to get a sufficiently clear
picture of the femoral head to make a firm diagnosis of avascular necrosis (209). A bone scan with
pin colometer view has an 85% to 90% sensitivity for avascular necrosis, so it is a good investigation
to distinguish avascular necrosis from nonunion (207). In my institution, the investigation of choice
would be a bone scan to decide whether there is avascular necrosis (208). If that is negative, a CT
scan is done to evaluate the fracture (94). A CT scan is extremely helpful to diagnose a femoral neck
nonunion (207). It is important to note that avascular necrosis and nonunion are independent
events, because avascular necrosis is based on the vascular supply within the femoral head, whereas
nonunion is based on the healing process.

Cleveland and Bosworth (156) noted a direct correlation between poor fracture reduction and
internal fixation and the instance of nonunion. In addition, Barnes and Dunovan (38) reported that
the quality of reduction directly affects union. Pauwels (63) was the first to note that shearing
stresses, present in fractures with a vertical inclination, increase the risk of nonunion.

The options that should be considered for the treatment of a femoral neck nonunion include fracture
reduction and initial fixation, valgus osteotomy to add compression to the fracture site, and
arthroplasty.

Comminution of the fracture site, especially posteriorly was noted by Banks to be present in 60% of
patients in whom nonunion eventually developed (68,69). Barnes also reported that the rate of union
decreased as the patient's age and degree of osteoporosis increased (38).

In the Elderly

Treatment in the elderly patient for femoral neck nonunion is a replacement arthroplasty (129,130).
The type of arthroplasty chosen should be consistent with the patient's age and bone quality. In a
cooperative, independent individual with a normal life span, total hip replacement is the treatment
of choice (129). In a confused elderly individual, who is uncooperative or a nursing home type of
patient, a hemiarthroplasty may be used (210,211).

In Young Patients

Classification

To clarify the treatment options, a classification of femoral neck nonunions was established to
elucidate a treatment protocol (Table 44-2 and Figs. 44-20 and 44-21). The type of femoral neck
nonunion determines the treatment needed. Available treatment techniques include osteosynthesis,
osteotomy at the fracture site, or at the intertrochanteric area (63,212), and Meyer's posterior
pedicle bone graft (32).

Treatment

Type I. Treatment of a type I nonunion involves removal of fixation, an osteotomy through the
fracture site, and reinsertion of more stable fixation. Type I usually occurs with an inadequate
reduction or with early failure of the initial fixation. This normally occurs in the first 6 weeks after
surgery. Most patients exhibit no healing at the fracture site. The femoral neck deformity is typically
varus, with a posterior anterior angulation at the fracture. The femoral head may exhibit posterior
inferior subluxation.

Table 44-2 Leighton's Classification of Femoral Neck Nonunion

Typ
e Description Presentation

I Inadequate fixation or Relatively early because early implant failure or inadequate

nonanatomic reduction reduction

II Loss of fixation with fracture Later, as the fracture slowly drops into varus and into an
displacement inferior posterior location relative to the femoral neck (see
Fig. 44-20)

III Fibrous nonunion with no Usually late, with activity-related pain, a reduction in stamina
displacement and intact fixation and the need for a walking aid (see Fig. 44-21)
(rare)

Meyers et al (32) initially advocated open reduction with internal fixation of femoral neck fractures
with a muscle pedicle graft posteriorly to prevent avascular necrosis. Unfortunately, no other authors
who performed this procedure could reproduce their results. But what the graft did do, which had
not been well documented, was improve the rate of union of the femoral neck fracture (213).
Waddell et al (213) reported the results of Meyer's bone graft for femoral neck fractures as a union
rate of more than 95%, if the Meyer's graft was performed within 6 months of the initial fracture.

Type II. The most common presentation of this type of nonunion usually occurs late, greater than 3
months postinjury. The presenting deformity is usually varus, with posterior inferior displacement of
the femoral head on the neck. Patients usually complain of a painful hip and have an obvious loose or
broken fixation device.

The solution that has been proposed by Pauwels (63), which has proven extremely successful to date,
has been an intertrochanteric osteotomy. In principle, the valgus osteotomy is utilized to create a
Pauwels I from a Pauwels III. To obtain this, the initial fixation must be removed and the deformity
corrected by performing a subtrochanteric osteotomy with an osteotomy plate using a compression
device. For a type II nonunion it would not be recommended to approach the femoral neck nonunion
directly. The goal of the procedure is to change a shear force on the neck fracture into a compression
force. Preplanning is essential and should include the following (63): (a) identification and
documentation of the vascular status of the femoral head; (b) a preoperative drawing to

P.1783

determine the change that will occur in leg lengths; and (c) a preoperative drawing to determine the
position of the femoral head after the osteotomy (this drawing should be present in the OR while the
surgery is performed). The procedure is usually performed on the fracture table, with an image
intensifier.

Type III. Type III is a rare scenario. All of items described for types I and II occur with type III, but no
deformity at the fracture site is present. The individual usually complains of mild pain and irritation,
but more importantly has marked fatigue and reduced stamina when attempting to walk any
distance. The fixation device appears to be solid on the preoperative x-rays.

The fracture has not healed with bone but has established a fibrous union. The solution
recommended is to drill out the nonunion, with or without added bone graft, and fix the fracture
with absolute stability. This usually requires a fixed angled device such as a sliding hip screw or blade
plate. This is a new concept for this anatomic region. However, the same principles are used in most
other anatomic areas with established fibrous nonunions.

The procedure focus is to drill out or open the endosteal canal to allow revascularization and
endosteal healing of a previous fibrous nonunion. The thick fibrous union occurs between the two
ends of the femoral neck and, if left alone, will not permit osseous union (63). In other areas with
long-standing nonunions, it has been important to clean out the intramedullary canal on both sides,
to make sure that endosteal healing can occur. In the femoral neck, this can be accomplished by
placing numerous drill holes (4.5 to 8.0 mm in diameter) from the lateral cortex into the head,
through the femoral neck. These are inserted over guide pins, using cannulated drills. A Meyer's
vascularized graft should be added, to stimulate bone union of the femoral neck, posteriorly.

Meyer's Bone Graft

The Meyer's bone graft is placed using a posterolateral approach (32) (Fig. 44-22). Once the posterior
approach to the hip has been performed, the capsule is identified and the superior and inferior
aspect of the neck identified. The femoral neck and capsule are opened via a T-type incision (Fig. 44-
23A). The quadratus femoris is identified and marked to allow for removal of its attachment on the
posterior aspect of the greater trochanter (Fig. 44-23B). The quadratus femoris is cut out with a high-
speed tool (Ultradrive or Midas Rex). The nonunion is curetted out, and a trough is created from the
greater trochanter into the head (Fig. 44-23B). The muscle pedicle is then obtained with a length of 4
cm, width 1.5 cm, and depth of 1 cm. This is then slotted into place by sliding it underneath the
peripheral rim of the head and then levered into place (Fig. 44-23C). The graft is usually fixed by a
single screw and washer (Fig. 44-24). If, indeed, the graft is cracked, two screws with washers or two
screws with a three-hole semitubular plate can salvage this and provide the necessary support.

Intertrochanteric Osteotomy

An intertrochanteric osteotomy is usually performed at the level of the lesser trochanter to allow
good bone healing (212). The initial approach is a lateral incision, similar to that used for a sliding hip
screw. The image intensifier is used to seat the osteotomy plate in the appropriate position, similar
to the preoperative drawings. The plate used is usually a 100- to 120-degree plate, depending on the
amount of correction required. It is important to perform a preoperative plan to ensure leg length
equality. The tendency is to slightly lengthen the leg when performing a valgus osteotomy. Rotational
alignment is important and should be controlled by placing marks or pins in the femur on the lateral
cortex.

The incidence of avascular necrosis in nondisplaced fractures is 11% (38,74). The incidence of
avascular necrosis increases as the fracture becomes more displaced. The distinction between total
avascular necrosis and partial or segmental avascular necrosis is under much debate. Catto (28,29)
found evidence of partial or total avascular necrosis in 66% of patients with displaced femoral neck
fractures. Sevitt (18) indicates that 84% of patients with femoral neck fractures may have a partial or
total avascular necrosis. Obviously all of these are not clinically evident.

Late segmental collapse can develop and has been reported to occur as late as 17 years after femoral
neck fracture. However, 80% or more of segmental collapse will occur within 2 years of fracture
(29,74). The incidence of late segmental collapse after femoral neck fractures varies from 7% to 27%.
The incidence is higher in Garden III and IV displaced femoral neck fractures (74). It is somewhat
higher in women than in men (74). The incidence of late segmental collapse rises substantially in
patients who undergo revision surgery after failure of reduction and fixation (212).

Vascularity of the femoral head after femoral neck fractures is dependent on preservation of the
remaining vascular supply and revascularization repair of the necrotic area before collapse of the
necrotic segment can occur. All the vessels within the femoral neck and most of the retinacular
vessels are disrupted in widely displaced fractures. When such displacement occurs, femoral head
survival is dependent on the vessel of the ligamentum teres and the subfoveal arterial anastomosis
between these vessels and the lateral epiphyseal vessels (19). The terminal branch of the lateral
epiphyseal vessels and the vessels of the ligamentum teres anastomose in the subfoveal area. There
are two reasons why this communication does not always provide adequate nutrition for femoral
head survival when all the retinacular vessels have been completely disrupted (19,75): (a) the quality
of the vessels of the ligamentum teres is variable. In some patients the vessels are very small and do
not actually reach the femoral head; and (b) the degree of anastomosis between the vessels of the
ligamentum of teres and the remaining vessels in the femoral head is variable and incomplete.

Strömqvist et al (134) and Linde et al (215) reported that increasing the total amount of metal in
the femoral head may be deleterious to femoral head vitality. The position of the implant in the
femoral head also can interfere with the blood supply. Claffey (22) demonstrated that implants in the
superior aspect of the femoral head can inadvertently interrupt the lateral epiphyseal vessels that
supply most of the blood to the femoral head. In addition, inadvertent perforation of the fovea in a
patient whose femoral head is dependent on the medial epiphyseal vessels for revascularization
could change a partial necrosis to a total head necrosis (28).

Revascularization occurs as vessels grow into the necrotic area from three sources: (a) in cases of
partial necrosis, ingrowth

P.1786

can occur from the remaining viable portions of the head, such as the subfoveal area; (b) vascular
ingrowth can occur across the uniting fracture line in the femoral neck fragment. This is a slower
process than ingrowth from the subfoveal area. It is important to remember that these tender
vascular buds can be torn if there is persistent motion at the fracture site, as a result of poor fracture
stabilization; and (c) some vascular ingrowth can occur from tissue over the part of the femoral head
that is not covered by articular cartilage.

Anatomic reduction and stable internal fixation are the major factors that help preserve the
remaining blood supply and provide the stability necessary for these revascularization buds to grow
into the area of necrosis (64,73,74,75,154,168). Revascularization is noted to be more rapid and
complete under these conditions. In addition, Moore demonstrated that in a poor reduction, the
surface area for blood vessels to grow up the remaining neck is decreased, so the instance of
avascular necrosis and late segmental collapse is increased when the fracture is poorly reduced
(154). Although Phemister believed that the fate of the head of the femur is sealed at the time of the
fracture (27,214), there may exist a time between the injury and the final fracture fixation, in which
protection by splinting of the extremity may protect the remaining vascular supply to the femoral
head. In addition, other authors have demonstrated that additional vascular injury also can occur at
the time of reduction and internal fixation.

Smith (170) demonstrated that extensive rotation about the longitudinal axis or excessive valgus
displacement at the time of reduction can obstruct the remaining blood supply in the ligamentum
teres. Fielding et al (216) and Lowell (83) found that the insertion of a large-diameter screw for
fixation can rotate the femoral head fragment, thereby obstructing the remaining blood supply
through the ligamentum teres. Barnes and Dunovan (38) reported that only 30% of patients with late
segmental collapse required further surgery. Late segmental collapse may not necessarily result in a
symptomatic hip, although most patients, given, time would eventually develop arthritis.

Diagnosis

The x-ray appearance of aseptic necrosis is increased density. This density may be secondary to new
bone being laid down on necrotic spicules, which produces an absolute increase in density (179), or a
relative increase in density owing to the osteoporosis of disuse present in surrounding vascular bone,
or calcification that may be present in the necrotic marrow. The x-ray appearance of late segmental
collapse is flattening and fracture in the subchondral bone and articular cartilage overlying the
infarct. This produces joint incongruity arthritis (1,217).

The diagnosis of avascular necrosis is best obtained with an MRI (207,209). However, its accuracy in
early detection of aseptic necrosis immediately after femoral neck fracture is unclear. Lang et al (218)
colleagues reported that Gd-DTPA–enhanced MRI is useful as a noninvasive imaging technique to
assess femoral head perfusion after acute femoral neck fracture. Although this study provides
information on vascular perfusion at the time the study is performed, it does not indicate whether
the changes are reversible or clinically significant. Asnis et al (219) noted that avascular bone can be
indistinguishable from normal bone on both MRI and histologic sections long after the vascular insult
has occurred. These authors concluded that MRI is not a prognosticator for post-traumatic
osteonecrosis for at least 2 weeks after fracture. In addition, the presence of metallic fixation devices
after surgery makes MRI technically unreliable. Bone scan with pin coulometer view will allow
diagnosis of avascular necrosis in 85% to 90% of patients (208). In patients with total head avascular
necrosis it is even higher, approaching 95% to 100%. Differentiation between avascular necrosis and
nonunion is important, and a CT scan will usually identify the nonunion site in the femoral neck, if
present (207).

Treatment

The treatment in the elderly patient is revision of the fixation to a total hip replacement or
hemiarthroplasty, as indicated above. Indications for a modular hemiarthroplasty or total hip implant
remain the same, and are dependent on the patient's age, activity level and comorbidities. The
treatment for avascular necrosis in a younger patient is beyond the scope of this chapter. According
to Anderson et al (45), the treatment alternatives include symptomatic treatment, osteotomy of the
femur, bone grafting (cancellous or vascularized), endoprosthetic replacement, and total hip
replacement.

In the elderly population, and even in the younger patient, non-weight-bearing is really not an option
over an extended period. Non-weight-bearing of the patient for over 2 years would be needed to
allow for vascular ingrowth into the devascularized area. This would not be consistent with the initial
goals of restoring the bone to its previous anatomic construct and allowing early mobilization of the
patient.

Heterotopic Ossification

Periarticular ossification after endoprosthetic replacement has been reported to occur in 25% to 40%
of patients in one series (202). However, this ossification only significantly interfered with hip
function in 6% of patients (220). Salvati et al (202) also reported that, in most cases, the ossification
was minimal, and did not interfere with hip function. In the unusual instance in which hip motion is
markedly restricted, surgical excision of the ossification may be considered.

Pain

The principal late complication after endoprosthetic replacement is pain (203). Although Hinchey and
Day (206) reported good long-term results in 84% of patients and Sharma and Sankaran (221) in
more than 90% of patients, other authors report good long-term pain relief in only 50% to 60% of
patients who received a hemiarthroplasty (199). It is important that both Moore (154) and Hinchey
and Day (206) found that functional limitations after surgery were dependent more on preexisting
medical conditions than on failure of the prosthesis itself. The poor early results were all based on
the Moore and Thomson

P.1787

type of prosthesis. The early results with “modular” unipolar and bipolar devices have been
excellent in 95% to 98% of cases (128,211).

In cases in which hip pain is present, it can be associated with x-ray changes, prosthetic loosening, or
distal or proximal prosthetic migration (176,203).

D'Arcy and Devas (177) reported that 26% of patients less than 70 years of age treated with a
Thompson prosthesis had pain and acetabular erosion at follow-up and that 6% to 12% of patients
had stem loosening. Loosening and migration are evidenced initially by a sudden onset of pain in the
hip, thigh, groin, or knee, which is increased by rotational stress or weight-bearing. Later, inability to
perform straight leg raising and deterioration of the abductor muscle power secondary to pain may
be present.

Prosthesis loosening is detected on x-ray by the presence of a radiolucent zone around the prosthesis
(176,201,202). In questionable cases, push-pull or rotation films may be helpful (176,202). Distal
migration or settling of the prosthesis is best assessed by comparing recent and earlier x-rays. Calcar
resorption (201) or a change in distance from the collar of the prosthesis to the lesser trochanter is
suggestive of loosening (202). Proximal migration of the prosthesis is noted on radiography as
protrusion of the femoral head into the acetabulum, usually with a concomitant loss of joint space
(176,202). If clinical signs and symptoms are significant and loosening or migration is present,
revision to total hip arthroplasty may be indicated (138).

It is important to recognize that some patients with endoprostheses remain in pain without signs of
sepsis, migration, or loosening (222). In these patients, it is possible that articular cartilage wear and
involvement of the underlying bone are the cause for pain (201). The surgeon must remember that
pain, either idiopathic or associated with signs of loosening or migration, frequently is associated
with sepsis (177). Before revision, therefore, sepsis must be carefully excluded.

CONTROVERSIES AND FUTURE DIRECTIONS

Acute Hip Aspiration Following Femoral Neck Fracture

The possibility that increased pressure within the hip joint will damage the already tenuous
circulation has been mentioned by several authors, including Deyerle (223,224,225), who
recommended aspiration of the hip if surgery was delayed more than a few hours. He also
recommended decompressive capsulotomy at the time of internal fixation. Drake and Meyers (226)
reported that preoperative aspiration of the hip joint after femoral neck fracture is unlikely to
influence the vascularity of the femoral head because the volume of hemarthrosis is small and the
pressure they measured in the capsule is well below that of the diastolic blood pressure.

Alternatively, Crawford (227) confirmed that a hemarthrosis under high pressure can occur after an
intracapsular fracture. They also demonstrated by ultrasound that this results in capsular distention.
They found that the pressure of the arthrosis can exceed the diastolic blood pressure and, thus, can
embarrass the blood supply to the femoral head. The authors concluded that it may be important to
decompress the hip joint by fenestration of the capsule or aspiration of the hemarthrosis at an early
stage in an effort to protect the vascularity of the femoral head (108).

Strömqvist et al (214,228,229,230,231,232,233) and associates demonstrated by scintimetry that

reduced uptake in the femoral head before aspiration was improved in most patients after
aspiration. The authors concluded that intracapsular tamponade of the hip may be one reason to
explain the occurrence of segmental collapse of the femoral head after subcapital fracture with
minor displacement. Accordingly, Wingstrand and Strömqvist et al (214,228,229,230,231,232,233)
suggested that the results in undisplaced fracture of the femoral neck may be improved by aspiration
of the hemarthrosis, which tamponades the capsular vessels.

Finally, although Holmberg and Dalen (31) reported that intracapsular pressure in patients with
nondisplaced femoral neck fractures exceeded the normal intracapsular pressure, the authors
believe that further investigation was needed to determine whether evacuation of the hemarthrosis
should be recommended.

This continues to be controversial both in practice and in the literature. The timing and necessity, as
well as the clinical relevance, remains in question. Swionkowski's strong work on this topic has been
very convincing but this procedure still has not been considered “standard of care.”

Displaced Femoral Neck Fractures in Active 60- to 70-Year-Old Individuals

The controversial treatment group with a displaced femoral neck fracture continues to be patients
between 60 and 70 years of age who, although chronologically older, function and act as younger
individuals. This group could be selected for an arthroplasty or could be considered excellent
candidates for open reduction and internal fixation, if no other absolute criteria for a replacement
were present (143,144,145). More randomized clinical trials are necessary to determine the
appropriate treatment for patients in this age range.

Future Randomized Prospective Studies

Factors predictive of outcome after hip fracture are dependent on the definition of
“outcome.” Traditionally, outcome has focused on the result of the fracture (that is, union,
avascular necrosis). In today's cost-sensitive environment, a more comprehensive definition of
outcome after hip fracture is the restoration of function (that is, ambulation, self-care, and social
reintegration) (115).

As our population ages, the incidence of hip fracture is projected to double by the year 2040,
increasing from 250,000 to 500,000 cases per year. This presents a significant potential

P.1788

burden on the health care system (42). Up to 60% of patients with hip fractures may require
institutional care (234). Therefore, avoiding nursing home placement and restoring independence in
a home environment are important outcomes. Restoring independent ambulation, defined as
walking without verbal or physical assistance from another person, is a critical part of this outcome
(235).

Compared with patients treated in a conventional manner, patients treated in a multidisciplinary

program had few postoperative complications, fewer intensive care unit transfers, and a significantly
improved ambulatory status at the time of hospital discharge. In addition, fewer of these patients
were discharged to a nursing home (86,236). These results support the use of a multidisciplinary
approach to improve the hospital care of elderly patients with hip fractures. The orthopedic surgeon
is an essential part of this team.