Femoral Neck Fractures

(1) Repair of displaced femoral neck fractures has a high risk of treatment failure compared with most other fractures. These failures often require salvage surgery, including osteotomies or hip arthroplasty. (2) Patient and injury factors other than age have been identified in young patients (<50 years old) that put fracture repair at risk for treatment failure, including (in decreasing order of odds ratio): fair to poor reduction (5.3), chronic alcohol misuse (3.1), fracture comminution revealed by plain radiography (2.6), cannulated screw constructs (2.0), male gender (1.9), and metabolic bone disease (1.8), whereas increasing age over 50 years had limited effect (1.03). (3) Appropriate evaluation of femoral neck fractures includes radiography, and, for those perceived as requiring open reduction and internal fixation, a traction view AP Xray and computed tomography with two-dimensional and three-dimensional reconstructions are extremely valuable for surgical planning. (4) Displaced geriatric intracapsular femoral neck fractures are typically are treated with hemiarthroplasty or total hip arthroplasty (THA) depending on the patient’s functional status and longevity. Younger patients with femoral neck fractures are typically treated with repair, whereas treatment in middle-aged patients currently is not as well defined. (5) Multiple studies have shown that high-quality fracture reduction during repair of femoral neck fractures is necessary for a good outcome. This may be achieved with closed or open methods, but open reduction via a Smith-Petersen approach has become increasingly popular. (6) Intraoperative radiographic assessment of femoral neck fracture (including closed reductions) is difficult, especially early in one’s career or without fellowship training. (7) Complications related to open reduction and internal fixation of femoral neck fractures are not infrequent and include failed fixation, nonunion, malunion (shortening, varus), and osteonecrosis. (8) Technical errors frequently occur during repairs of femoral neck fractures and have been shown to increase risks of failure. Importantly, these include malreduction. (9) Repairs with a fixed-angle device, such as a sliding hip screw or cephalomedullary nail, are associated with better results and fewer complications compared with the use of cannulated screws. This might relate to an inadequate buttressing effect of a distal screw through the fracture comminution, or distal extension down the calcar such that the calcar’s “buttress” is lost, or placing the buttress screw more than a few millimeters from the calcar’s dense cortical bone. (10) Blood supply to the femoral neck and head is tenuous, with the medial femoral circumflex artery being the predominant blood supply. The rate of clinically significant osteonecrosis of the femoral head is about 15% in these fractures