Commentary & Perspective

Commentary & Perspective on
"Operative Treatment of Femoral Neck Fractures in Patients Between the Ages of Fifteen and Fifty Years"
by George J. Haidukewych, MD, et al.

Commentary & Perspective by
J. Lawrence Marsh, MD*,
Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa

Femoral neck fractures that occur in patients with nonosteopenic bone are severe injuries and are associated with a high risk of complications. These injuries are unusual in younger adults, so most surgeons do not have extensive experience on which to base management decisions for that younger population. Unfortunately, the literature on this subject is controversial and provides little information on the results obtained from intermediate or long-term follow-up study. To address this deficiency in the literature and to shed light on the controversies regarding treatment, Haidukewych et al. retrospectively reviewed a large consecutive series of young patients who had femoral neck fractures. The authors have shown that femoral neck fractures in young patients are very unusual injuries. Over a twenty-five-year period at a large institution that has level-1 trauma-center status, a femoral neck fracture was seen in only eighty-three adult patients who were less than fifty years old.

Unfortunately, this retrospective study has certain limitations. The entry criteria for this study group were relatively broad. For example, ten of the fractures were stress fractures, and patients as young as fifteen years old were included. In addition, the study may have included a few patients (such as those on renal dialysis or those who had long-term use of corticosteroid medications to treat a rheumatologic disorder) with severe osteopenia. The treatment issues for patients with osteopenia are different from those for a young patient with normal bone who has sustained a high-energy injury. The study also had a small but potentially important rate of patients who were lost to follow-up study. These deficiencies must be accepted when the study design calls for a longer follow-up of trauma patients with unusual injuries.

Nevertheless, since the outcome was good for most patients, the results of this study reaffirm the belief that reduction and internal fixation is the correct operation for young patients with femoral neck fractures. The femoral head had been preserved in sixty of seventy-three fractures (82%) after a mean duration of follow-up of greater than six years. Although this study was based on a review of clinic notes, the data stating that most patients had a well-functioning hip were convincing. However, complications of treatment, most commonly osteonecrosis, occurred in a substantial minority of patients, and treatment failed to salvage the hip in thirteen patients, necessitating subsequent arthroplasty. The surgeon must choose initial treatments that minimize the chances of this adverse outcome, and this is where the controversy occurs. To try and address these controversies, the authors analyzed their results further. Unfortunately, the low number of patients in this study (due to patients lost to follow-up, nonsystematic use of treatment strategies, multiple variables, and difficult assessment techniques) prevents the authors from resolving any of these controversies.

The authors analyzed the effect of timing of surgery by comparing the results for fractures that were treated less than twenty-four hours after diagnosis with those that were treated more than twenty-four hours after diagnosis. They were not able to demonstrate a difference in complication rates between these two groups. Theoretically, the sooner that displaced femoral neck fractures are reduced and internally fixed, the better the chances are that the blood supply to the femoral head will be preserved or restored. Another recent retrospective study with small patient numbers showed less radiographic necrosis in fractures that had been reduced and fixed within twelve hours compared with those treated after twelve hours, but the authors were not able to identify clinical differences between the two groups¹.

The quality of the reduction is considered to be one of the most important factors under the surgeon's control, but a perfect reduction is not always easy to achieve, and the effect of small variations in reduction is largely unknown^1,2. The authors radiographically assessed the quality of reduction with the use of four classification categories, but, for statistical purposes, they combined good and excellent reductions and compared them with fair and poor reductions. Since four of the five fractures in the fair-to-poor group had poor outcomes, this study provides support for the belief that it is better not to accept a poor reduction. However, the authors did not analyze differences between the truly excellent reductions and the good-only reductions, which leads the reader to question whether the difference between these two qualities of reduction is clinically relevant. Exactly how perfect the reduction must be and which types of slight malreduction are most harmful remain uncertain.

Some of the patients in this series were managed with hip capsulotomy to release intracapsular hematoma and decrease pressure in the hip as a means of minimizing osteonecrosis. Studies that have measured the intracapsular pressure have clearly shown that both displaced and nondisplaced femoral neck fractures may have pressure increases to a level likely to compromise the blood supply^3,4. However, demonstrating that a capsular release makes a clinical difference has been more difficult. In the current study, no significant differences were found between patients who underwent capsulotomy and those who did not. However, the study is inadequately powered to assure surgeons that there are not subgroups of patients for whom capsulotomy might prevent osteonecrosis.

In summary, this study suggests that most well-reduced and internally fixed femoral neck fractures in young patients will result in a healed fracture with a high likelihood of good function for many years. However, it also suggests that a large subgroup of patients will have poor results and will require a subsequent arthroplasty. Unfortunately, even with the benefit of data culled from patients treated over a period of twenty-five years, the important questions regarding treatment decisions, such as whether it is preferable to perform emergent rather than urgent surgery, obtain an absolutely anatomic reduction, or perform a capsulotomy to release hematoma, remain unanswered because the benefit of such treatment has not been proven in this retrospective review of outcome.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR, Mahomed NN. Comparison of early and delayed fixation of subcapital hip fractures in patients sixty years of age or less. J Bone Joint Surg Am. 2002;84:1605-12.
2. Swiontkowski MF, Winquist RA, Hansen ST Jr. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am. 1984;66:837-46.
3. Maruenda JI, Barrios C, Gomar-Sancho F. Intracapsular hip pressure after femoral neck fracture. Clin Orthop. 1997;340:172-80.
4. Bonnaire F, Schaefer DJ, Kuner EH. Hemarthrosis and hip joint pressure in femoral neck fractures. Clin Orthop. 1998;353:148-55.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.