case study fracture neck of femur

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Femoral neck fracture after femoral head necrosis: a case report and review of the literature

• Wenjie Xia 1 ,
• Aiqi Zhang 2 ,
• Binsong Qiu 3 ,
• Yuan Chen 4 &
• Mingxiang Kong 3  

BMC Musculoskeletal Disorders volume  24 , Article number:  853 ( 2023 ) Cite this article

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Introduction

Pathological fractures of the femoral neck caused by necrosis of the femoral head are extremely rare. Here, we report a rare case of bilateral femoral head osteonecrosis extending to the femoral neck, with bilateral pathological fractures of the femoral neck occurring within a short period of time.

Case report

A 65-year-old male with a 25-year history of daily consumption of 750 ml of liquor, presented with right hip pain after labor for 1 month. He subsequently sustained a right femoral neck fracture without trauma and underwent a right total hip arthroplasty. Two months later, he suffered a non-traumatic left femoral neck fracture and underwent a left total hip arthroplasty. Histopathological examination revealed osteonecrosis of the femoral head and neck, along with the presence of osteoclasts and granulomatous inflammation. Bone mineral density testing also showed osteoporosis. The bilateral femoral neck fractures were ruled out to be caused by any other pathological factors.

This is the first report of pathological fractures of the bilateral femoral neck caused by femoral head necrosis. During the literature review process, we found that this case conforms to the histological characteristics of rapidly destructive hip disease and analyzed the etiology of femoral head necrosis and the pathogenesis of femoral neck fractures.

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Necrosis of the femoral head is a common cause of hip pain. It can be categorized into traumatic and non-traumatic causes [ 1 , 2 ]. Traumatic necrosis is mainly caused by femoral neck fractures or hip dislocations, which can damage the local blood vessels of the femoral head, leading to bone necrosis [ 3 ]. The pathogenesis of non-traumatic femoral head necrosis is not yet clear, but it is generally believed to be related to the use of large amounts of oral corticosteroids and heavy alcohol consumption [ 4 ]. Necrosis of the femoral head is a lengthy process and can lead to subchondral fractures, resulting in the appearance of the crescent sign [ 3 ]. Here, we report a rare case of a 65-year-old male patient who had been drinking heavily for years and developed avascular necrosis of the femoral head and neck in a short period of time. However, there was no obvious subchondral fracture or crescent sign, and he subsequently suffered from bilateral femoral neck fractures without any apparent traumatic factors. Previous studies have not reported cases of bilateral non-traumatic avascular necrosis of the femoral head with femoral neck fractures. This study aims to provide clinical practitioners with a reference for diagnosing the etiology of this rare condition by reporting such a case.

The patient was informed that their data would be made public and they agreed. The patient was a 65-year-old male with a height of 160 cm, weight of 45 kg, and a body mass index (BMI) of 17.5 kg/m 2 . He presented with dull pain in the right hip during labor, with tenderness in the anterior aspect of the hip joint. Two weeks after onset, the patient’s pain intensified, and an X-ray of the right hip revealed a subcapital femoral fracture (Fig.  1 ). A computed tomography (CT) scan of the right hip also showed a subcapital femoral fracture (Fig.  2 ). The patient reported a 25-year history of daily alcohol consumption, with three glasses of white wine (approximately 250 mL) per day, and a 20-year history of smoking, with approximately 5 cigarettes per day. To rule out the possibility of femoral head necrosis, the patient underwent a magnetic resonance imaging (MRI) of the hip. The MRI examination revealed the presence of subchondral edema in both femoral heads, indicating arthritis and necrosis (Fig.  3 ). A right femoral neck fracture and abnormal signal in the left femoral neck were also noted. The patient underwent right total hip replacement surgery. Follow-up X-rays of the right hip after the surgery were obtained (Fig.  1 ). Histopathological examination of the femoral head tissue revealed necrosis and inflammatory exudation on the surface of the femoral head, synovial tissue hyperplasia, chronic inflammation, and hemosiderin deposition, with dead bone formation in some areas and necrosis and hemorrhage in the bone marrow tissue (Fig.  4 ). This indicated that the patient had already experienced necrosis in some areas of the femoral head. We advised the patient to quit smoking and drinking. Regular outpatient follow-up was recommended after the patient was discharged. However, the patient did not quit smoking or drinking.

Anteroposterior radiographs of the patient’s hip joint before and after surgery

Patient hip CT

Hip joint MRI of a patient with first-time femoral neck fracture. ( A ) The T1-weighted image revealed low signal intensity in the right femoral neck and linear low signal intensity in the left femoral neck, which may be indicative of necrosis. ( B ) The T2-weighted image reveals the presence of subchondral edema in the right femoral head, high signal intensity in the femoral neck indicating femoral neck fracture, and local high signal intensity in the left femoral head without any evidence of trauma. ( C - D ) T2-weighted images revealed subchondral edema in both femoral heads, indicating osteonecrosis. There was also edema in the femoral neck on the right side, which was caused by a fracture of the femoral neck

Pathology of the patient’s left femoral head ( A - B ) and femoral neck ( C - D )(hematoxylin-eosin staining) ( A ) There is necrosis of the subcapital cartilage of the femoral head, disordered trabecular structure in part of the bone, and necrosis of the bone marrow. ( B ) An enlarged image on the left shows a small number of osteoclast giant cells and a large number of inflammatory cells. ( C and D ) There is a disordered arrangement of bone trabeculae, formation of dead bone, an increased number of macrophages, granuloma formation, and the presence of osteoclastic giant cells associated with bone fragments

The patient experienced left hip pain and discomfort after lifting heavy objects two months after discharge. One week later, the pain worsened and was unbearable, with significant aggravation during walking and an inability to straighten the left leg when lying flat, causing severe pain that prevented walking. Left hip X-rays showed a subcapital femoral fracture (Fig.  1 ), and a left hip CT scan confirmed the diagnosis of subcapital femoral fracture (Fig.  2 ). The patient underwent left total hip arthroplasty. Postoperative pathological biopsies were performed on the femoral head and neck tissues, and the histopathological results indicated the presence of necrotic lesions in both the femoral head and neck. In addition, a large number of osteoclasts and granulomas were found in the femoral neck (Fig.  4 ). Postoperative left hip X-ray (Fig.  1 ). To investigate the cause of bilateral femoral neck fractures, the patient underwent dual-energy X-ray absorptiometry, revealing a T-score of -2.9 for the left femoral neck and − 3.5 for the lumbar spine, indicating osteoporosis. The patient’s parathyroid hormone level was 13.5 pg/mL (normal range 15–65), while β-C-telopeptide of type I collagen β (CTX-Iβ) was 766.5 pg/mL (normal range <704), and N-terminal propeptide of type I procollagen (PINP), bone calcium, and vitamin D levels were normal. Thyroid function was normal, and ultrasound of the parathyroid and thyroid regions showed no positive findings. The patient has no history of non-steroidal anti-inflammatory drugs or corticosteroid use. In addition, postoperative pathological examination also ruled out factors such as tumors and infections.

As far as we know, this is the first reported case of pathological fracture of the bilateral femoral neck following femoral head necrosis. Only one rare case of extensive necrosis of the femoral head extending to the femoral neck in a short period of time has been reported in the literature, but there was no secondary femoral neck fracture [ 5 ]. Two cases of epiphyseal displacement similar to femoral neck fracture have been reported. Shoji Baba et al. [ 6 ]reported a case of a long-term steroid user with necrosis of the femoral head, which resulted in epiphyseal displacement of the femoral head shaft. The authors suggest that stress concentration in the lateral portion of the femoral epiphyseal leads to abnormal shear stress in the epiphyseal scar, resulting in a femoral epiphyseal slip fracture. Takanori Miura et al. [ 7 ]reported an 86-year-old female with osteoporosis who developed epiphyseal displacement of the femoral head shaft following necrosis of the femoral head. The author proposed that such cases represent a rapidly destructive hip disease (RDHD). Considering the characteristics of the disease reported in previous literature and in our case, we hypothesize that our patient had RDHD and that abnormal shear stress acting on the weakened area of the femoral neck due to osteoporosis led to bilateral femoral neck fractures.

Rapidly destructive hip disease (RDHD) is a progressive hip joint disease that results in rapid destruction. The natural history of RDHD includes rapid and progressive bone destruction, which typically occurs within 6–12 months of the onset of symptoms, even in the absence of significant pre-existing anatomical abnormalities or mild bone and joint changes [ 8 ]. The disease is often accompanied by osteoporosis [ 9 , 10 ]. Lequesne et al. [ 11 ]first proposed the concept of RDHD in 1970 and defined it as a joint space reduction of 50% or more or a loss of articular cartilage greater than 2 mm within one year. The exact nature of this disease is not fully understood, with some reports suggesting it is a type of femoral head necrosis [ 12 , 13 ], while others believe it is a type of osteoarthritis [ 14 , 15 ]. Yamamoto et al. found granulomatous lesions in the bone marrow of RDHD and considered the presence of bone fragments and articular cartilage debris to be a characteristic feature of RDHD [ 16 ]. A histological and morphological study of 15 RDHD patients found a large number of granulomas in the bone marrow and synovium, with abnormal activation of osteoclasts in synovial fluid being a major cause of femoral head and acetabular bone destruction [ 17 ]. However, the cause of abnormal osteoclast activation remains unclear. Yamakawa et al. [ 18 ] studied RDHD femoral head sections and found that the middle surface of the femoral head was significantly vascularized and contained a large number of osteoclasts, which may be related to the development of RDHD. In addition, Soskolne et al. found that osteoclasts form synapses that are directly connected to vascular endothelial cells [ 19 ]. Therefore, the accumulation and abnormal activation of osteoclasts in the bone marrow and synovium of RDHD patients may be one of the important mechanisms of RDHD pathogenesis.

Our patient presented with non-traumatic femoral neck fracture on the right side after one month of hip pain. Two months after receiving total hip replacement therapy, the patient developed non-traumatic femoral neck fracture on the contralateral side, and the disease progressed rapidly. The main MRI features of RDHD include extensive bone marrow edema in the femoral head and neck, flattening of the femoral head, and cystic-like subchondral defects [ 14 ]. Our study demonstrated the presence of irregular low signal lines on the left femoral head and femoral neck in the T1-weighted phase of MRI, indicating localized osteonecrosis. The T2-weighted phase revealed a bone marrow edema signal extending from the femoral head to the femoral neck, which is consistent with the MRI features of RDHD. Histopathological analysis of the femoral head and neck revealed bone necrosis, which was formed by osteoclasts and granulation tissue, and elevated CTX-Iβ suggested that osteoclasts were abnormally activated. In addition, our case had a long history of heavy alcohol consumption. Previous studies have shown that excessive alcohol consumption also induces the expression of genes related to osteoclast differentiation [ 20 ]. Therefore, excessive alcohol consumption may be one of the reasons for osteoclast activation in this case. Therefore, based on the patient’s history, imaging findings, and histological features, we believe that our patient may have a more specific form of RDHD. In our case, flattening of the femoral head and subchondral defects were not found, which may be due to bilateral femoral neck fractures that occurred early in the disease process and disrupted the natural course of the disease.

The bone trabeculae within the necrotic lesion showed fracture and disorganized arrangement, with local vascular and fibrous tissue proliferation leading to the formation of scar tissue and decreased stress resistance. Our case also exhibited osteoporosis in the left femoral neck (bone mineral density T-score − 2.9), likely resulting from long-term alcohol consumption, smoking, and advanced age, which are known risk factors for the condition [ 21 , 22 ]. PINP and CTX-Iβ are commonly used clinical markers of bone formation and resorption, respectively [ 23 ]. We found that the patient had elevated levels of CTX-Iβ at 766.5 pg/ml (normal range < 704), as well as a low level of parathyroid hormone (PTH) at 13.5 pg/ml (normal range 15–65 pg/ml). PTH exerts its effects by binding to PTH receptors and directly stimulating osteoblast differentiation and proliferation [ 24 ]. Therefore, the low level of PTH may also contribute to the patient’s osteoporosis. In addition, the presence of numerous granulomas and osteoclasts in the femoral neck suggests strong bone resorption activity in this area, which may have contributed to the pathological fracture. Abnormal shear stress can be generated when stress is concentrated along the weak area of the femoral neck located on the outer side of the femoral trochanter [ 6 ], which may have also contributed to the fracture in this case. Therefore, the combination of femoral head necrosis and osteoporosis, as well as the presence of abnormal shear stress, may be the underlying causes of the pathological fracture in this patient, and the mechanism of bilateral fractures may be similar. In this case, the patient underwent total hip arthroplasty and achieved favorable clinical outcomes. Furthermore, recent studies have indicated that ultra-short non-cemented total hip arthroplasty can be used for the treatment of femoral head necrosis, and the mid-term clinical and radiological outcomes are satisfactory [ 25 ].

This study has some limitations. Firstly, we did not analyze markers such as prostaglandins and proteolytic enzymes in the patients’ synovial fluid, which have been reported to be elevated and can aid in distinguishing primary hip joint diseases [ 26 ]. Additionally, due to the limited number of cases (only one patient), we were unable to comprehensively discuss all the potential causes of RDHD reported in the literature.

In conclusion, we report a case of bilateral femoral head necrosis resulting in pathologic fracture of the femoral neck, which may represent a rapidly progressive bone and joint disease. Our case highlights the importance of recognizing the potential for femoral neck fracture in patients with femoral head necrosis and osteoporosis, which may progress to RDHD. As the aging population grows, the number of these patients is likely to increase. Early diagnosis of femoral neck fracture in these patients allows for timely surgical intervention with total hip arthroplasty. Therefore, a detailed evaluation, including MRI and careful follow-up, is necessary in elderly patients with hip pain.

Data Availability

The datasets used during the current study are available from the corresponding author on reasonable request.

Abbreviations

Computed tomography

Magnetic resonance imaging

β-C-telopeptide of type I collagen β

N-terminal propeptide of type I procollagen

• Rapidly destructive hip disease

Parathyroid hormone

Nontraumatic necrosis of bone (osteonecrosis).

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Acknowledgements

We would like to express our gratitude to all the staff in the department, as well as the patients and their families, for their contributions and consent to use clinical data for this research.

This study was supported by the Medical and Health Science and Technology Project of Zhejiang Province (2020KY029, 2021KY035, 2021KY061 and 2023KY046), and Public Welfare Technology Application Research Project of Zhejiang Province under Grant No. LGF21H160030.

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Contributions

WJX and AQZ have made equal contributions. WJX and AQZ contributed to case interpretation and manuscript. YC collected the data and analyzed it with WJX. BSQ performed the surgery. MXK prepared the study design and had full access to all the data in the study. All authors read and approved the final version of the manuscript.

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Correspondence to Mingxiang Kong .

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This study was approved by the Ethics Committee of Zhejiang Provincial People’s Hospital and obtained written informed consent from the patient and family members.

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Xia, W., Zhang, A., Qiu, B. et al. Femoral neck fracture after femoral head necrosis: a case report and review of the literature. BMC Musculoskelet Disord 24 , 853 (2023). https://doi.org/10.1186/s12891-023-06992-9

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DOI : https://doi.org/10.1186/s12891-023-06992-9

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• Femoral neck fracture
• Femoral head osteonecrosis
• Osteoporosis
• Total hip replacement

BMC Musculoskeletal Disorders

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Bilateral femoral neck fractures in an adult male following minimal trauma after a simple mechanical fall: a case report

• Asheesh Sood 1 ,
• Christopher Rao 2 &
• Ian Holloway 1  

Cases Journal volume  2 , Article number:  92 ( 2009 ) Cite this article

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Despite being rare there are several reports in the medical literature of bilateral femoral neck fractures in adult patients. They have been reported to have occurred following major trauma, or as a result of primary or secondary bone disease. In this case report we describe for the first time in the literature bilateral femoral neck fractures in a patient following minimal trauma after a simple mechanical fall.

Case presentation

We describe the case of an 84-year-old gentleman who sustained bilateral intracapsular fractures following a simple mechanical fall. Prompt diagnosis and early surgical intervention resulted in a satisfactory outcome.

This case highlights that in the elderly, even in the absence of primary and secondary bone disease, bilateral neck of femur fractures can occur following relatively minor trauma. Consequently, the orthopaedic surgeon, emergency physician and general practitioner should be aware of this injury, particularly when managing traumatic injuries in confused patients.

Bilateral fractures of the Neck of the Femur (NOF) have been reported to have occurred following major trauma, or as a result of primary or secondary bone disease. We describe the case of an 84-year-old gentleman who sustained bilateral intracapsular fractured NOF following a simple mechanical fall. Early diagnosis, resuscitation, surgical intervention, post-operative mobilisation and discharge; according to best practice guidelines [ 1 ]; resulted in a satisfactory outcome.

Following a review of the published literature we undertake to discuss the importance of prompt diagnosis and early surgical treatment in achieving a satisfactory outcome following this injury. Finally, we aim to discuss the implications of this case on our routine orthopaedic practice.

An 84-year-old gentleman presented to the Accident and Emergency Department in the early hours of the morning after a mechanical fall down three stairs. He was an active, independent gentleman with no significant co-morbidities. He was also the full time carer for his wife who suffered from multiple sclerosis. His pre-morbid mobility was good and he did not require any walking aids.

He was immediately resuscitated in the Accident and Emergency Department. Clinical examination revealed external rotation of both legs and pain on passive movement of both hips. X-ray of his pelvis showed completely displaced intracapsular hip fractures on both sides [Figure 1 ].

Anterioposterior radiograph of the pelvis showing bilateral completely displaced intracapsular fractures of the neck of femur .

The fractures were treated by cemented hemiarthroplasty using Thompson prostheses. This was undertaken with the patient in the supine position within 24 hours of admission using an antero-lateral approach by two senior Orthopaedic surgeons [Figure 2 ]. He had a satisfactory post-operative recovery and was able to mobilise and fully weight-bear within 2 days of the surgery.

Anterioposterior radiograph of the pelvis showing bilateral fractures of the neck of femur treated by cemented Thompson hemiarthroplasties .

Simultaneous bilateral NOF fractures are rare. They are however, several reports in the medical literature of bilateral NOF fractures occurring as a result of primary or secondary bone disease. For example, hypocalcemia [ 2 ], osteomalacia [ 3 ], osteoporosis, renal osteodystrophy [ 4 ], radiotherapy [ 5 ] and multiple myeloma. Bilateral NOF fractures have also been reported to have occurred following persistent, sustained stress [ 5 ].

Uncomplicated trauma is a rare cause of bilateral fractured NOF [ 6 ]. There have been reports of bilateral NOF fractures after seizures secondary to epilepsy, drugs, and electrocution [ 6 ]. Intracapsular fractures of the NOF prior to the fifth decade of life usually result from severe injury [ 5 ]. Konforti et al [ 7 ] described bilateral NOF fractures in a 37-year-old gentleman crushed during a mining accident. Carrell et al [ 8 ] described the case of an 8 year old boy who sustained a bilateral neck fractures following a 25 foot fall. More recently Gunal et al [ 9 ] describe bilateral traumatic NOF fractures.

In the case we describe an otherwise fit and well gentleman who sustained bilateral NOF fractures following a low energy injury fall down three stairs. This is a common mechanism of injury which often leads to a unilateral NOF fracture. It is important to note that this patient gave a definite history of a fall which led to the injury in contrast to fatigue fractures [ 5 ] where patients describe their leg giving way followed by pain. Bilateral fractured NOF have been reported in the literature in the elderly following minimal trauma [ 10 ]. However, in this case described the patient had a background of corticosteroid induced osteoporosis, gross obesity and rheumatoid arthritis.

Guidelines for the management of hip fractures recommend that surgical intervention should be carried out within 48 hours of the fracture occurring [ 1 ]. As well as causing distress to the patient, delay in surgery is associated with increased morbidity and mortality, and a reduced chance of success and rehabilitation [ 11 ]. Surgery should be performed as soon as the medical condition of the patient allows, provided that appropriate staffing and facilities are available [ 11 ]. However, it has also been demonstrated that surgical treatment conducted as night-time emergency cases are associated with increases mortality [ 11 ].

Our management of this patient was entirely consistent with these guidelines. The fractures were diagnosed early and the patient was resuscitated appropriately. The patient was reviewed by the physicians and anaesthetists on the day of admission and optimized medically. Both hip fractures were managed by simultaneous cemented hemiarthroplasty within 24 hours of admission on a day-time trauma list. McBryde et al [ 12 ] have demonstrated the safety of simultaneous hip arthroplasties, albeit in the context of elective surgery. The operation was performed in the supine position, to avoid repositioning the patient, in order to shorten the total operating time. There is however, no evidence to support the superior efficacy of any position and we feel the surgeon should use the position with which he is most comfortable.

All hip injuries presenting to the Accident and Emergency Department in our hospital have an anterioposterior radiograph of the pelvis with both hips included as part of initial assessment. This is an important precaution as there may be an injury of the opposite hip which could easily be missed. As a result of this case, our junior surgical staff have been trained to be particularly vigilant to the possibility of bilateral NOF fractures, particularly in the very elderly, in cases where there may be primary or secondary bone disease, when the mechanism of injury is high-impact or unknown, and when patients are confused and unable to localize pain.

In this case report we present a rare combination of injuries occurring simultaneously in an elderly gentleman. While a unilateral hip fracture is a very common injury managed appropriately on a regular basis by Orthopaedic surgeons, bilateral injuries of this nature presenting simultaneously can prove to be a diagnostic and therapeutic challenge. Early recognition and prompt surgical intervention can lead to good outcomes despite the severity of this injury. Bilateral anterioposterior radiographs should be taken as a matter of routine in patients presenting with suspected fractured NOF and orthopedic staff should be vigilant to the possibility of bilateral NOF fractures.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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AS and CR were responsible for drafting the case study. IH was responsible for revising it critically for important intellectual content and was the consultant ultimately responsible for managing this patient. All authors have made substantial contribution to the conception of this case report, read and approved the final version to be submitted.

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Sood, A., Rao, C. & Holloway, I. Bilateral femoral neck fractures in an adult male following minimal trauma after a simple mechanical fall: a case report. Cases Journal 2 , 92 (2009). https://doi.org/10.1186/1757-1626-2-92

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• Management of neck of femur fracture in an adult with short stature and learning disability
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• Viraj Gandbhir ,
• Ashok Ramavath and
• Asim Rajpura
• Orthopaedics , Wrightington Wigan and Leigh NHS Foundation Trust , Wrightington , UK
• Correspondence to Viraj Gandbhir; drvirajg{at}gmail.com

Neck of femur fractures (NOFF) are one of the major health concerns, with their incidence and the cost of care rising each year. Though a plethora of literature remains available on NOFF and its management, we found very little evidence for management of NOFF in patients with short stature and learning disability. Because of this unique combination of conditions in our patient, we had to deviate from the standard practice in terms of the implant choice. The usage of cemented Asian C stem AMT with a 36 mm metallic head which is normally reserved for total hip replacements, helped us obtain the desired hip joint stability. This was supplemented by early involvement of the learning disability physiotherapy team and eventually the patient had a satisfactory outcome at 8 months of follow-up. This rare amalgamation of NOFF, short stature and learning disability deserves more attention which our case report hopes to achieve.

• hip implants
• memory disorders (psychiatry)
• physiotherapy (rehabilitation)
• orthopaedic and trauma surgery

https://doi.org/10.1136/bcr-2021-245937

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Patients with neck of femur fractures (NOFF) present with significant morbidity and mortality risks. 1 Their timely surgical management as well as comprehensive care is of paramount importance. 2 The NICE guidelines for NOFF suggest the appropriate plan based on the patient profile. 3 As our patient had a unique combination of short stature, Down’s syndrome and autism associated with a NOFF, we had to deviate from the normal as regards the implant choice. With out of the box thinking and involvement of the learning disability team, our patient had a satisfactory outcome.

Case presentation

An independently mobilising woman in her late 50s presented to the emergency department of our hospital following an unwitnessed fall at her sheltered accommodation. She was unusually short for her age at 142.2 cm and weighed 33 kg. She had a background of Down’s syndrome with learning disability in the form of autism and remained non-communicative, verbally or non-verbally. On admission, her left lower limb was found to be shorted and externally rotated without neurovascular deficit for which she underwent further radiological investigations.

Investigations

On the radiographs and Computed Tomography (CT) scan, she was found to have a left displaced intracapsular NOFF with a comminuted greater trochanteric fracture ( figure 1 ). Her femoral head size measured from the CT images was 34.7 mm which corroborated with intraoperative findings ( figure 2 ).

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(A) and (B) Anteroposterior radiograph of the pelvis with both hips and coronal CT slice showing a left neck of femur fracture, respectively. (C) Axial CT slice showing comminuted left greater trochanteric fracture.

(A) Femoral head size measurement on sagittal CT slice. (B) Femoral head being measured intraoperatively.

After discussing the risks and the benefits with her guardian, she underwent cemented hemiarthroplasty through anterolateral approach in the morning after her admission. The implants used for her were an Asian C stem AMT with a metallic femoral head of 36/+5. The greater trochanter was repaired with non-absorbable sutures in figure of 8 configuration. Postreduction, the joint was stable in all planes and the limb lengths were restored.

Outcome and follow-up

A day after her surgery she remained a bit hesitant to mobilise as a result of the communication difficulty faced with the local team. With the help of learning disability physiotherapy team on the second postoperative day, she could be mobilised from sitting to standing and subsequently full weight bearing using a Zimmer frame. On the 10th postoperative day, while the patient was being helped to the hospital bed, her operated leg was found to be excessively internally rotated and adducted. Clinical and radiological evaluation confirmed a posterosuperior dislocation ( figure 3 ). The dislocation was reduced under anaesthesia and postreduction, the hip was found to be stable in flexion, adduction, external rotations and internal rotation of up to 30°. She was subsequently mobilised with an abduction brace due to her previous poor compliance to instructions. At 8 months of follow-up ( figure 4 ), she was mobilising full weight bearing without a brace.

Anteroposterior X-ray of the left hip showing dislocation.

Anteroposterior X-ray of pelvis at 8 months showing satisfactory alignment.

Hip fractures are one of the the most common fractures in the United Kingdom, with 70 000 to 75 000 occurring every year. The annual cost of care is estimated to be 2 billion pounds and increasing every year. 3 Their prolonged hospital stay is often complicated by occurrence of infection which further adds to the costs. 4 There is an abundance of research articles and guidelines related to neck of femur fractures and their management. But there seems to be a dearth of information about NOFF in patients with short stature and learning disability. To the best of our knowledge, our case report is the only one detailing the challenges faced and the management of NOFF in a patient with short stature and learning disability.

The prevalence of hip osteoarthritis and dysplasia in Down’s syndrome stands at 8%–28% for which total hip arthroplasty has been advised. 5 However, the native hip morphology was normal in our patient ( figure 1 ). The patient was planned for a hemiarthroplasty considering the patient’s cognitive impairment, limited functional requirements and poor bone quality, in line with the NICE guidelines. 6 The anterolateral approach was chosen as in the general population, the posterior approach has almost eight times higher risk of dislocation postoperatively and found to have poorer end result. 7 The risk of dislocation is even higher in patients with Down’s syndrome as the syndrome is associated with generalised muscular hypotonia and unstable gait pattern. 8

We used CT scan to accurately gauge the true femoral head size as the radiographs which provide only a two-dimensional view, have been found to be inaccurate. 7 The main challenge centred around obtaining a suitable implant for the small native femoral head which measured only 34.7 mm on the preoperative images. The smallest head sizes available for a unipolar or a bipolar hemiarthroplasty were 41 mm and 39 mm, respectively, and as a result could not be used. Patient-specific implants which could have been a viable option in an elective setting were found unsuitable as the waiting time for the implants would have significantly increased her morbidity and mortality risks. 9 As a result of the unique set of limitations we faced, we had to think out of the box and make an exception. We replaced her femoral head with implants which are normally reserved for total hip replacement in patients with abnormal proximal femur anatomy (Asian C stem AMT with a metal femoral head). We took due care to maintain the offset and achieve equal limb lengths which has been shown to be crucial during total hip replacements in Down’s syndrome. 10 The joint remained stable on intraoperative evaluation. Postoperatively she had an uneventful recovery till the dislocation episode on the 10th day. Ancillary measures such as hip spica and abduction braces have been recommended by a few studies to avoid dislocation immediately after a total hip arthroplasty or a hemiarthroplasty but their prophylactic use remains controversial. 10 We believe the dislocation was more due to awkward positioning of the leg rather than an unstable joint. This is further corroborated with a stable joint postreduction and satisfactory mobilisation and recovery thereafter.

Patient’s perspective

I am writing this on behalf of my sister who suffers from learning disability and finds it difficult to understand what is happening to her. After the accident, I was contacted by the surgeon to explain the procedure and the possible risks involved with the surgery. We both agreed that it needed to be done to maintain her quality of life as her mobility has always been satisfactory. After the surgery her recovery was slow at first but that was mainly due to her hesitancy and lack of understanding. She was reluctant to use her leg and this contributed to a slow start to her recovery. Once she had gained her confidence with the help of the physiotherapists and learning disability team, she started to move much better. She is now fully mobile without any pain or problems.

Learning points

Neck of femur fracture (NOFF) remains an important health condition with incidence and economic burden rising each year.

There is paucity of literature on NOFF in patients with short stature and learning disability.

Usage of implants reserved for total hip replacement remains a viable option in NOFF patients with short stature.

Prompt involvement of learning disability physiotherapy team helped our patient recover satisfactorily.

There could be an argument for prophylactic use of abduction brace in patients with learning disability undergoing hip arthroplasty surgeries where compliance is a worry.

Ethics statements

Patient consent for publication.

Consent obtained from next of kin.

• Shen J , et al
• Albers A , et al
• Basilico M ,
• Vitiello R ,
• Oliva MS , et al
• Abdelsabour H ,
• Vijimohan SJ , et al
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Contributors VG - Writing of manuscript; performed ground work; collection of material; literature review. ARam - Idea behind the case report; guidance; review of manuscript. ARaj - Finalised the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Segmental neck of femur fractures: A unique case report of an ipsilateral subcapital, greater trochanteric and intertrochanteric fracture and proposed management algorithm

Affiliations.

• 1 Imperial NHS Trust, London, United Kingdom. Electronic address: [email protected].
• 2 Imperial NHS Trust, London, United Kingdom.
• PMID: 24727209
• PMCID: PMC4021178
• DOI: 10.1016/j.ijscr.2014.03.012

Introduction: Neck of femur fractures are now increasingly common in an ageing population. The management is well known and has been described in great detail. Concomitant ipsilateral segmental fractures of the neck of femur (SFNOF) however are rare and their investigation and management is poorly described.

Presentation of case: We present the surgical management of a unique and complex case of an ipsilateral subcapital, greater trochanteric and intertrochanteric fracture sustained in an 87-year-old female following a low trauma injury. This fracture configuration has not been described in the literature to date, neither has our method of reconstruction for this fracture, namely hemiarthorplasty, trochanteric stabilising plate and cerclage wires.

Discussion: 15 cases from 1989 to 2011 managed by 8 different fixation devices and followed up for an average of 17 months (2-58 months). There was an initial mortality rate of 13% (n=2). All associated with low energy trauma occurred in female (n=8), and most with high energy trauma occurred in males (83%; n=5). The diagnosis was delayed or missed in 20% of cases, and the most common pattern was a concomitant undisplaced subcapital and intertrochanteric fracture (37.5%, n=6). The overall risk of avascular necrosis was 20%, with a greater risk in patients greater than 65 years of age (33%).

Conclusion: Ipsilateral SFNOF are rare injuries with a bimodal distribution, and carry a greater risk of AVN. We advise that all SFNOF should have pre-operative CT planning and propose an algorithm to treat these patients with a standardised surgical approach.

Keywords: Dynamic hip fixation; Hemiarthroplasty; Hip fracture; Neck of femur fracture; Segmental fracture.

Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

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Femoral Neck Fracture with Misdiagnosis of Osteonecrosis of the Femoral Head: A Two-Case Report

Ting-hsien kwan, chen-hao chiang, wei-hsing chih, cheng-ming chou.

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Correspondence: [email protected]

Received 2024 Jun 5; Revised 2024 Jun 23; Accepted 2024 Jun 26; Collection date 2024 Jul.

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( https://creativecommons.org/licenses/by/4.0/ ).

We report two rare cases of femoral neck fracture resulting from osteonecrosis of the femoral head (ONFH) that was undiagnosed at the patients’ initial visits. The patient in the first case had sequential bilateral displaced femoral neck fractures. Because no osteonecrosis of the femoral head was visible on X-ray film and the data of liver function tests were normal, ONFH was not diagnosed. In addition, because the patient was a 55-year-old man with normal everyday functioning, closed reduction with cannulated screws was performed at both visits. Nine months later, he came to our outpatient department with bilateral hip pain; X-rays revealed nonunion and implant failure at both hips. The patient subsequently underwent bilateral total hip arthroplasty (THA) and had a satisfactory outcome at his 4-year follow-up. The patient in the second case had a left displaced femoral neck fracture after trivial trauma two months prior. ONFH was not diagnosed upon examination of X-ray findings. The patient was 52 years old with liver cirrhosis and had bipolar hemiarthroplasty performed because of a chronic displaced fracture and poor general condition. After 2 years, she began to have right hip pain. X-rays revealed massive necrosis and sclerosis of the femoral head. Computed tomography scans for ONFH staging revealed impending fracture lines at the subcapital site of the patient’s previous left femoral neck fracture. Right THA was then performed, and the outcome was satisfactory.

Keywords: spontaneous femoral neck fracture, osteonecrosis, femoral head, total hip arthroplasty, misdiagnosis

1. Introduction

Osteonecrosis of the femoral head (ONFH) is common in young to middle-aged patients. The disease presents itself with persistent hip pain and is diagnosed using X-ray or MRI. In rare cases, ONFH is associated with spontaneous fracture of the femoral neck [ 1 , 2 ].

When it comes to femoral neck fracture in young adults, surgical management with osteosynthesis is recommended to achieve an anatomic reduction in the fracture to preserve the blood supply and effectively prevent ONFH, and to provide a stable fixation while preserving bone stock to achieve union. Hence, compressive screws are suggested in Garden type I and II femoral neck fracture, whereas a dynamic hip screw is suggested in Garden type III and IV femoral neck fracture [ 3 ].

If ONFH is not identified at the fracture presentation, osteosynthesis with internal fixation may be performed in accordance with the above-stated principle. In this kind of scenario, osteosynthesis is doomed to fail because of the necrotic femoral head bone quality, and a secondary procedure for arthroplasty must be performed, resulting in a longer, more difficult recovery. Moreover, misdiagnosis of ONFH may lead to litigation.

In this report, we present two rare cases of femoral neck fracture with misdiagnosis of ONFH.

2. Detailed Case Descriptions

This case report study was approved by our institution’s review board. The patient in the first case was a 55-year-old man with a history of hypertension. The patient had a history of alcohol consumption, drinking one cup of 22% alcohol every day for 30 years. He visited our outpatient department on 7 May 2018. His chief complaint was a falling accident one week prior with minor right hip trauma. The patient experienced mild right hip pain that became intolerable over the next 2 days. X-ray film revealed a right femoral neck subcapital fracture with displacement ( Figure 1 a). The lab data for GOT, GPT, INR, and platelets were all within normal limits. Because no osteonecrosis of the femoral head was noted in the X-ray film, and the patient had led a normal life prior to the fracture, closed reduction and internal fixation with cannulated screws were performed ( Figure 1 b). He was discharged without any incident. Five weeks later, he came to our outpatient department complaining of severe left hip pain. X-rays revealed no left hip trauma; his left hip was severely strained due to overcompensating for a previous right hip condition. X-rays revealed a left femoral neck subcapital fracture without gross ONFH, a pattern identical to that observed in his previously injured right hip ( Figure 1 c). Closed reduction and internal fixation using cannulated screws were then performed ( Figure 1 d), and he was discharged without any incident. He did not follow up at our outpatient department until 9 months after the initial procedure when he came to our clinic complaining of bilateral hip pain. X-rays revealed bilateral nonunion and implant failure in both hips ( Figure 1 e). He then received sequential bilateral THA ( Figure 1 f). Pathology reports indicated bilateral avascular necrosis at both femoral heads. The patient recovered well in both hips when followed up after four years.

Case 1: A fifty-five-year-old man with a history of hypertension and a drinking history of 30 years. ( a ) Right femoral neck subcapital fracture without gross ONFH. ( b ) Internal fixation with cannulated screws for the right femoral neck fracture. ( c ) Left femoral neck subcapital fracture without gross ONFH. ( d ) Internal fixation with cannulated screws for the left femoral neck fracture. ( e ) Bilateral hips nonunion and implant failure. ( f ) Sequential bilateral total hip arthroplasty (THA). ( g , h ) Pathology reports of bilateral avascular necrosis at both femoral heads.

The patient in the second case was a 52-year-old woman with a history of liver cirrhosis. She had a history of drinking two cups of alcohol every day for 30 years. She visited our outpatient department for left hip pain on 20 May 2021 after a minor falling accident 2 months prior. X-rays revealed a left femoral neck subcapital fracture with displacement ( Figure 2 a). Due to the chronic nature of the fracture and the patient’s limited mobility caused by her liver cirrhosis, left hip bipolar hemiarthroplasty ( Figure 2 b) was performed. After surgery, she experienced habitual prosthesis dislocation due to acetabular dysplasia and bone loss at the dislocation site. Treatment was changed to THA ( Figure 2 c) and the patient had a satisfactory outcome. After 2 years, she revisited our outpatient department, complaining of right hip pain over the previous 2 months. X-rays revealed right ONFH over a large area ( Figure 2 d). A CT scan was conducted for ONFH staging and showed an impending fracture line in the subcapital area at the same site as her previous left femoral neck fracture ( Figure 2 e,f). Right THA ( Figure 2 g) was performed, and pathology reports indicated bilateral avascular necrosis at both femoral heads. After follow-up, she had a smooth postoperative recovery.

Case 2: A fifty-two-year-old woman with a history of liver cirrhosis and a drinking history of 30 years. ( a ) Left femoral neck subcapital fracture with displacement. ( b ) Left hip bipolar hemiarthroplasty for the left femoral neck fracture. ( c ) Left THA was performed after habitual prosthesis dislocation due to acetabular dysplasia and bone loss at the dislocation site. ( d ) X-ray showing ONFH over a large area on the right side. ( e , f ) CT scan in preparation for ONFH staging revealing an impending fracture line in the subcapital area at the same site as the previous left femoral neck fracture. ( g ) Right THA for right ONFH. ( h , i ) Pathology reports of bilateral avascular necrosis at both femoral heads.

To summarize our two cases, a case summary and comparison table are listed below in Table 1 .

Case summary and comparison.

THA: total hip arthroplasty.

3. Discussion

Although the subchondral area is the most common site of bone fracture and collapse in cases of ONFH, there have also been sporadic case reports of ONFH resulting in spontaneous femoral neck fracture [ 1 , 2 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. We reviewed all the reports listed in Table 2 .

Reviews of spontaneous femoral neck fractures after ONFH.

Several conclusions can be drawn from these cases. (1) Femoral neck fracture with ONFH occurs entirely at the subcapital sites. Additionally, the displaced fracture pattern revealed by plain X-ray film is nearly identical in every case. Compared with that of ordinary displaced femoral neck fractures, the fracture site in cases of ONFH is prominently located in the capital areas, the fracture line is straighter, and the fracture edge is smoother. (2) Because ONFH rarely progresses to a spontaneous femoral neck fracture, it is seldom diagnosed. (3) The epidemiology of femoral neck fractures after ONFH is nearly identical to ordinary ONFH, such as age, sex, and other risk factors. (4) All spontaneous femoral neck fractures after ONFH occur without prior trauma or with minor trauma history, suggesting that the actual incidence of spontaneous femoral neck fractures after ONFH may be more widespread than medical professionals realize. (5) In addition to personal history and X-ray film, a study using MRI or scintigraphy can confirm a diagnosis of ONFH. (6) The most common surgical procedures for treating spontaneous femoral neck fractures are bipolar hemiarthroplasty and THA. However, other surgical options are available, namely femoral head resurfacing [ 5 ], bone grafts [ 7 ], pinning or sliding hip screws [ 9 , 10 ], and core decompression [ 12 ].

Corticosteroid use, excessive alcohol consumption, trauma, blood coagulation disorders, hemoglobinopathy, autoimmune diseases, HIV [ 11 ], and smoking are highly correlated with ONFH risk [ 18 ]. These factors should arouse suspicion of ONFH in medical professionals treating a femoral neck fracture without obvious prior trauma. An accurate diagnosis of ONFH is critical to avoiding unnecessary surgical procedures; moreover, an accurate diagnosis of ONFH may enable preventive treatment of contralateral hip conditions before the conditions progress to spontaneous femoral neck fractures.

Furthermore, past studies revealed that ONFH and osteoporosis share common clinical and pathophysiological features, and ONFH is associated with low bone mineral density. One of these studies showed that fractural stages of ONFH were associated with a 5-fold risk of osteoporosis [ 19 ]. In one study, radiofrequency echographic multi-spectrometry (REMS) was developed as a practical ultrasound technique to evaluate osteoporosis, hip fracture risk, and occult hip fractures, which showed a correlation between osteoporosis and hip fracture risk [ 20 ]. One limitation of our case report is that there is no osteoporosis study of the hips before surgical management due to its presentation as fracture patterns at our clinic.

Previous studies have revealed that the pathological femoral neck fracture resulting from ONFH usually occurs at the subcapital area between the interface of necrotic and reparative bone [ 21 , 22 , 23 , 24 ]. When the fracture is without displacement, the femoral head may present as normal, and X-ray film alone is not sensitive enough to enable a conclusive diagnosis of ONFH [ 4 ]; however, if the fracture is displaced, as it often is, X-ray film is sufficient to suggest the presence of ONFH. Furthermore, the displaced fracture pattern was nearly identical in all the research cases discussed in this study. Specifically, in cases of ONFH, fractures are located close to the femoral head, have straight fracture lines, and have smooth fracture edges. The two patients treated in this case report exhibited displaced fracture patterns. In summary, the research we reviewed and the cases we treated suggest that it is reasonable to suspect ONFH-induced fractures if we are more familiar with this pathological situation, even when they are not readily visible on X-ray film.

Once ONFH is suspected from personal history or X-ray film, further studies may be warranted. Our research suggests that MRI can reveal a low-signal intensity band (representing the necrotic–viable bone interface) in T1-weighted images and a double-density line (representing hypervascular granulation tissue at the necrotic–viable bone interface) in T2-weighted images [ 4 , 25 ]. Due to a local inflammatory response from fracture, scintigraphy showed markedly increased radionuclide uptake, rendering it less helpful in identifying ONFH [ 4 , 16 ]. However, Yoon et al. made an ONFH diagnosis using pinhole bone scintigraphy in a case where plain film and MRI findings indicated no ONFH. In the second patient we treated, due to misdiagnosis, we had only a right hip CT scan showing massive ONFH and impending subcapital fracture. This CT scan clearly depicted the left subcapital condition before the spontaneous fracture occurred.

The most common treatment for spontaneous femoral neck fracture following ONFH is arthroplasty, either bipolar hemiarthroplasty or THA. The first patient we treated in this study received bilateral THA after the failure of cannulated screws. The second patient we treated had left bipolar fractures treated as regular femoral neck fractures. Treatment for her condition was changed to THA after frequent dislocation from acetabular dysplasia and bone loss due to bony impact resulting from her habitual dislocation at the site. The patient had ONFH of Ficat’s stage III on the right side with an impending fracture line at the subcapital site, and we performed right THA per our standard practice in such cases.

4. Conclusions

Misdiagnosis of ONFH at a femoral neck fracture may cause surgeons to conduct incorrect surgical strategies that require a second arthroplasty when the initial procedure fails. Moreover, suspicion of ONFH is warranted in cases of subcapital fractures in younger patients with minor trauma. In cases where patients have risk factors for ONFH, we suggest further study using MRI or scintigraphy to diagnose ONFH with greater certainty. Arthroplasty is the standard treatment for spontaneous femoral neck fracture with ONFH.

Acknowledgments

We thank Chang-Hao Lin for administrative support and assistance.

Author Contributions

Conceptualization, C.-M.C.; methodology, C.-M.C.; investigation, T.-H.K. and C.-M.C.; Writing—Original draft preparation, T.-H.K.; Writing—Review and editing, C.-M.C., C.-H.C., W.-H.C. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Ditmanson Medical Foundation’s Chia-Yi Christian Hospital (protocol code 2023064, 4 August 2023).

Informed Consent Statement

Patient consent was waived due to the retrospective design.

Data Availability Statement

The original contributions presented in this study are included in the article, further inquiries can be directed to the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

Funding Statement

This research received no external funding.

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47 Femoral Neck Fracture

• Published: February 2013
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A 72-year-old widow who lives with her oldest son is found on the floor of her bedroom, unable to rise. She tells her son that she slipped on a rug and fell to the floor. She complains of severe pain in her right hip and is unable to stand. Because no physician is immediately available, an ambulance is called, and she is taken to the hospital on a stretcher. On arrival, she is given intravenous morphine to reduce her pain and is made more comfortable by immobilization of her limb with pillows and sandbags and by gentle longitudinal traction. She has no significant past medical or surgical history and takes no medications.

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Open Access

Peer-reviewed

Research Article

A cost-effectiveness analysis of three surgical options for treating displaced femoral neck fractures in active older patients in Japan: A full economic evaluation

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Graduate School of Health Management, Keio University, Kanagawa, Japan

Roles Methodology, Supervision, Validation, Writing – review & editing

Roles Supervision, Writing – review & editing

Affiliation Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Kanagawa, Japan

Affiliation Department of Clinical Epidemiology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan

Affiliation Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan

Affiliation Graduate School of Business Administration, Keio University, Kanagawa, Japan

• Kazutaka Yokoyama, 
• Yoko Akune, 
• Hiroyuki Katoh, 
• Seiji Bito, 
• Yoshinari Fujita, 
• Rei Goto, 
• Keita Yamauchi

• Published: October 29, 2024
• https://doi.org/10.1371/journal.pone.0310974
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For older patients with displaced femoral neck fractures, in which primary osteosynthesis is usually not indicated, there are three primary prosthetic options—bipolar hemiarthroplasty (BHA), single-bearing total hip arthroplasty (SB-THA), and dual-mobility THA (DM-THA). However, the optimal choice for managing displaced femoral neck fractures remains controversial. Accordingly, this study aimed to evaluate the cost-effectiveness of BHA, SB-THA, and DM-THA in active older patients with displaced femoral neck fractures. A decision tree combined with a Markov model was employed to analyze the cost and quality-adjusted life years (QALYs) of BHA, SB-THA, and DM-THA for the management in the Japanese healthcare system. By simulating the five-year trajectory of a 75-year-old woman treated for a displaced femoral neck fracture, the cost-effectiveness of the three surgical options was evaluated. One-way sensitivity analysis and probabilistic sensitivity analysis (PSA) were used to assess parameter uncertainty. Additionally, two scenario analyses were conducted for other settings. The treatment was considered to be cost-effective when the incremental cost-effectiveness ratio (ICER) was below the 5,000,000 yen/QALY threshold. Compared with BHA, SB-THA exhibited higher costs but greater health benefits, resulting in an ICER of 1,499,440 yen/QALY. DM-THA offered additional health benefits compared with SB-THA, with an ICER of 4,145,777 yen/QALY. One-way sensitivity analysis revealed some influential parameters. PSA indicated that the probability of DM-THA, SB-THA, and BHA being cost-effective was 40.1%, 38.5%, and 21.4%, respectively. SB-THA was more cost-effective than BHA in patients aged 65–85 years, while DM-THA was more cost-effective than SB-THA in patients aged 65–75 years. The results suggest that SB-THA is a cost-effective alternative to BHA for displaced femoral neck fractures in active older patients, whereas DM-THA is more cost-effective than SB-THA in relatively younger patients. It is, therefore, recommended that orthopedic surgeons select the most appropriate surgical option based on the individual patient’s physiological age.

Citation: Yokoyama K, Akune Y, Katoh H, Bito S, Fujita Y, Goto R, et al. (2024) A cost-effectiveness analysis of three surgical options for treating displaced femoral neck fractures in active older patients in Japan: A full economic evaluation. PLoS ONE 19(10): e0310974. https://doi.org/10.1371/journal.pone.0310974

Editor: Hans-Peter Simmen, University Hospital Zurich, SWITZERLAND

Received: May 5, 2024; Accepted: September 4, 2024; Published: October 29, 2024

Copyright: © 2024 Yokoyama et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: This study was supported by JST SPRING (grant number, JPMJSP2123) and the Keio University Doctorate Student Grant-in-Aid Program of the Ushioda Memorial Fund. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Hip fractures pose significant risks such as health complications, prolonged hospitalization, and reduced health-related quality of life in older patients [ 1 – 3 ]. These risks have been affecting both patients and their families for a long time, presenting serious public health problems worldwide. According to a new global epidemiological study, the number of hip fractures is estimated to nearly double worldwide from 2018 to 2050 [ 4 ]. This number has also increased in Japan, from 76,600 in 1992 to 193,400 in 2017 [ 5 ], with a projected increase to 290,000 by 2030 [ 6 ].

Considering that primary osteosynthesis is usually not indicated, there are three primary prosthetic options generally available for older patients with displaced femoral neck fractures—bipolar hemiarthroplasty (BHA), conventional single-bearing total hip arthroplasty (SB-THA), and dual-mobility THA (DM-THA), which is the most recent surgical option [ 7 , 8 ]. A randomized controlled trial (HEALTH trial) showed no significant difference between THA and hemiarthroplasty (HA) in terms of the risk of unplanned secondary hip procedures over a period of two years in patients with displaced femoral neck fractures [ 9 ], while the risk of dislocation was higher in the THA group than in the HA group [ 10 ]. Recently, DM-THA implants have been introduced to reduce the risk of dislocation [ 11 ], but intermediate- and long-term data on these surgical options are lacking. In Japan, only a few centers with advanced surgical techniques offer THA as the first choice for femoral neck fractures.

The optimal choice for managing displaced femoral neck fractures remains controversial. Japan became the country with the longest life expectancy in the world in 1985 and has since maintained this status. Since hip fractures are common injuries among older adults, it is important to conduct economic evaluations of the surgical options using Japanese data. However, to date, no study has reported on the cost-effectiveness of the three surgical options for displaced femoral neck fractures using Japanese data.

Therefore, in the present study, we hypothesized that DM-THA might be a cost-effective option for the active older adults, even though it is the most expensive of the three surgical options. This study aimed to clarify the cost-effectiveness of BHA, SB-THA, and DM-THA and to ascertain whether the higher cost of DM-THA is justified by its clinical benefits over SB-THA and BHA in patients with displaced femoral neck fractures.

Materials and methods

Ethics statement.

All data used in this study were collected from books, articles, and open access data from the Japanese Ministry of Health, Labour and Welfare. Because no individual patient data were used, this study did not require patient consent or institutional review board approval.

Study design

A decision tree model combined with a Markov model was built using TreeAge Pro Healthcare Version 2024 (Build-Id: 24.2.0-v20240709; TreeAge Software, LLC, Williamstown, MA, United States [US]) to evaluate the cost-effectiveness of three surgical options, conduct one-way sensitivity analyses, and perform probabilistic sensitivity analyses (PSAs) ( Fig 1 ). The model was designed and built from the Japanese public healthcare payer’s perspective, and effectiveness was measured using quality-adjusted life years (QALYs). QALYs are calculated by multiplying “quality of life” by “life years.” We examined the costs (Japanese yen [¥]) and QALYs associated with BHA, SB-THA, and DM-THA for the treatment of displaced femoral neck fractures and compared BHA, SB-THA, and DM-THA. Other strategies considered in cases with non-displaced fractures, such as conservative treatment and internal fixation, were not considered in this study.

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While the tree is expanded only for BHA, identical Markov models are also used for SB-THA and DM-THA. BHA, bipolar hemiarthroplasty; DM-THA, dual-mobility total hip arthroplasty; R-THA, revision total hip arthroplasty; RR-THA, re-revision total hip arthroplasty; SB-THA, single-bearing total hip arthroplasty.

https://doi.org/10.1371/journal.pone.0310974.g001

The base case for the model was set to be a 75-year-old woman with a displaced femoral neck fracture and no contraindications for surgery. A 75-year-old woman was chosen as the model base case because femoral neck fractures occur more frequently in women than in men and the age of 75 years is close to the mean age reported in a systematic review and meta-analysis [ 12 ]. Scenario analyses were conducted for other age groups and male patients. Patients with displaced femoral neck fractures were allocated to either BHA, SB-THA, or DM-THA and then assumed to transition into one of the following modeled health states: well post-surgery, dislocation, revision THA (R-THA), re-revision THA (RR-THA), and death. In this model, we mainly focused on “dislocation” because it may be the key factor for quality of life. However, we did not include the “infection” state in the model because there was no significant difference between THA and HA with regard to the risk of infection [ 3 , 10 ]. Transitions were made on an annual cycle basis in the Markov model. An annual cycle was considered to represent a realistic clinical period during which revisions are prone to occur based on previous studies [ 13 , 14 ].

A first-order Monte Carlo simulation (microsimulation) was conducted to evaluate stochastic uncertainty, and a tracker variable was used to consider the occurrence of a dislocation. The number of trials for the microsimulation was set to 100,000. The model assumes that the first dislocation has a possibility to be reduced by closed reduction and to be successfully managed. The second dislocation is assumed to require revision surgery, in which a DM-THA implant is used. In cases where a second revision (RR-THA) is deemed necessary, it is assumed, based on a previous study, that the procedure is successful and requires no further revisions thereafter [ 14 ]. At all times, patients are considered to be at risk of death. Death was considered an absorbing state because no further transitions can occur once a patient has entered this health state.

The time horizon for this analysis was set to five years. Both the cost and effectiveness were discounted at a rate of 2.0% per year in accordance with the Guideline for Preparing Cost-Effectiveness Evaluation to the Central Social Insurance Medical Council [ 15 ]. The age-specific mortality rate and life expectancy were obtained from the data published by the Japanese Ministry of Health, Labour and Welfare in the abridged life table of Japan 2022 [ 16 , 17 ] and are summarized in S1 and S2 Tables. In this study, an “active older patient” is defined as a self-sufficient, physically active person aged 65 years or older whose mortality rate is similar to that provided in the abridged life table of Japan.

The primary outcomes were the cost (in Japanese yen) and effectiveness (in QALY) of the three strategies. The incremental cost-effectiveness ratio (ICER) was estimated to evaluate cost-effectiveness. An ICER is calculated by dividing the “incremental costs” by the “incremental effectiveness.” The results of the ICER were compared with the established willingness-to-pay (WTP) thresholds for cost-effectiveness. A WTP threshold is a value that estimates how much a patient is willing to pay for a health benefit. In general, the Japanese Ministry of Health, Labour and Welfare considers interventions with an estimated ICER of <5,000,000 yen/QALY to be cost-effective. To ensure that the model would not deviate from normal practice, an orthopedic surgeon [YF] evaluated the clinical assumptions, and two health economists [RG and YA] evaluated the methodology and results.

Model inputs

The annual transition probabilities by age group are presented in Table 1 . The probabilities of dislocation after SB-THA for specific age groups were derived from a previous study [ 18 ], and dislocations were managed by either closed or open reduction. The probabilities of revision due to dislocation after SB-THA and those due to causes other than dislocation after SB-THA were calculated using data from two previous studies [ 18 , 19 ]. Other parameters such as clinical effectiveness, disutility, health state utility, and cost data are listed in Table 2 and detailed in S3 Table , which is a summarized table of data published by the Japanese Health Insurance Federation for Surgery [ 20 ].

https://doi.org/10.1371/journal.pone.0310974.t001

https://doi.org/10.1371/journal.pone.0310974.t002

Sensitivity analysis

One-way sensitivity analyses were performed to assess uncertainty and robustness. The tornado diagram summarizes the results of the one-way sensitivity analyses. The range of variation was adopted from available previous studies. When only the point estimate was available, the range of variation was set as follows: “standard error” = “point estimate” × 0.2, “Low” = “point estimate”–“standard error” × 1.96, “High” = “point estimate” + “standard error” × 1.96. In accordance with the Japanese guidelines, the discount rate was subjected to a one-way sensitivity analysis and was changed at the same rate of 0.0–4.0% per year for both cost and effectiveness [ 15 ].

PSA was used to assess uncertainty and evaluate the probability of cost-effectiveness. For the PSA, gamma, log-normal, normal, and beta distributions were used for costs, relative risks, disutilities, and utilities and probabilities, respectively. In the analysis using TreeAge Pro Healthcare, the number of trials for microsimulation was set to 100,000, and the number of samples for the PSA was set to 10,000. For the incremental cost-effectiveness scatter plot, the range of iterations was set from 1 to 10,000.

Scenario analysis

Two scenario analyses (scenario analysis A and scenario analysis B) were performed. First, in addition to the 75-year-old female patient, scenario analyses were conducted for patients of the other age groups and male patients. Specifically, the age range varied from 65 years to 85 years. Second, to assess shorter periods, the time horizon was changed from five years to four years, three years, two years, and one year.

CHEERS guidelines

This study was performed in accordance with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist (see S1 File ).

Fig 2 and Table 3 present the microsimulation results of the model base case of a 75-year-old female patient followed over a period of five years. The cost was 8,326,071 yen, and the QALYs were 3.792 for the BHA strategy; these figures were 8,669,497 yen and 4.021, respectively, for the SB-THA strategy. In other words, SB-THA was more costly than BHA but resulted in more health benefits (measured in QALYs). To explain in more detail, the estimated incremental cost per patient was 343,426 yen, whereas the estimated incremental QALYs were 0.229, resulting in a cost per QALY of 1,499,440 yen/QALY. Similarly, DM-THA was more costly than SB-THA but resulted in more health benefits. The estimated incremental cost per patient was 53,904 yen, whereas the estimated incremental QALYs were 0.013, resulting in a cost per QALY of 4,145,777 yen/QALY.

BHA, bipolar hemiarthroplasty; DM-THA, dual-mobility total hip arthroplasty; ICER, incremental cost-effectiveness ratio; SB-THA, single-bearing total hip arthroplasty.

https://doi.org/10.1371/journal.pone.0310974.g002

https://doi.org/10.1371/journal.pone.0310974.t003

Tornado diagrams were generated by changing the parameters of the model base case group. Looking at the ICER for SB-THA compared with that for BHA ( Fig 3A ), there are two infinite signs and two bars showing threshold values. An infinity sign means that the ICER (“incremental cost”/ “incremental effectiveness”) becomes undefined because the “incremental effectiveness” approaches zero. If “health state utility of well post-BHA” is better than “health state utility of well post-SB-THA,” SB-THA would be “dominated.” If a surgical option is higher in cost but equivalent or lower in effectiveness relative to the comparator, the surgical option is called “dominated.” As for the two bars showing the threshold values, specific values of upper ICER and lower ICER are described. If the initial year cost of SB-THA increases to 2,983,027 yen, with the other parameters remaining the same, SB-THA would no longer be cost-effective (exceeding the 5,000,000 yen/QALY WTP threshold). Similarly, if the initial year cost of BHA decreases to 1,320,872 yen, with the other parameters remaining the same, SB-THA would no longer be cost-effective. Further, looking at the ICER for DM-THA compared with that for SB-THA ( Fig 3B ), there are two infinite signs and four bars showing threshold values. If “health state utility of well post-SB-THA” is better than “health state utility of well post-DM-THA,” DM-THA would be “dominated.” In addition, if parameters such as the “relative risk of revision non-dislocation of DM-THA compared with SB-THA,” “relative risk of dislocation of DM-THA compared with SB-THA,” “disutility due to dislocation,” and “health state utility of well post-R-THA” increases to 0.958, 0.348, -0.081, and 0.83, respectively, DM-THA would no longer be cost-effective (exceeding the 5,000,000 yen/QALY WTP threshold). To explain further, for DM-THA to be cost-effective, the relative risk of dislocation should be less than 0.348, meaning that the number of dislocation events after DM-THA would need to be reduced by at least 65.2% compared with those after SB-THA.

A: SB-THA versus BHA. B: DM-THA versus SB-THA. An infinity sign means that the ICER becomes undefined because the incremental effectiveness approaches zero. Bars crossing the WTP threshold show threshold values, upper ICER, and lower ICER. The yellow line shows the WTP threshold of 5,000,000 yen/QALY. BHA, bipolar hemiarthroplasty; DM-THA, dual-mobility total hip arthroplasty; EV, expected value; ICER, incremental cost-effectiveness ratio; R-THA, revision total hip arthroplasty; RR-THA, re-revision total hip arthroplasty; RR, relative risk; SB-THA, single-bearing total hip arthroplasty; WTP, willingness-to-pay.

https://doi.org/10.1371/journal.pone.0310974.g003

PSA was conducted to assess uncertainty. The incremental cost-effectiveness scatter plot showed uncertainty in this model as the points were distributed across all four quadrants ( S1 and S2 Figs, S4 and S5 Tables). According to the cost-effectiveness acceptability curves of the three surgical options, the probabilities of DM-THA, SB-THA, and BHA being cost-effective were estimated to be 40.1%, 38.5%, and 21.4%, respectively, at the WTP threshold of 5,000,000 yen/QALY for the model case ( Fig 4 ).

The probability that the surgical option is cost-effective at differing willingness-to-pay values for BHA, SB-THA, and DM-THA in female patients aged 75 years. The color of the line denotes the surgical options: red line, BHA; blue line, SB-THA; and violet line, DM-THA. The yellow line shows the willingness-to-pay threshold of 5,000,000 yen/QALY. BHA, bipolar hemiarthroplasty; DM-THA, dual-mobility total hip arthroplasty; SB-THA, single-bearing total hip arthroplasty.

https://doi.org/10.1371/journal.pone.0310974.g004

As in scenario analysis A, microsimulations were conducted for the other age groups and for male patients ( Table 4 ). SB-THA was more cost-effective than BHA for patients aged 65–85 years. In addition, DM-THA was more cost-effective than SB-THA for patients aged 65–75 years at the WTP threshold of 5,000,000 yen/QALY. However, DM-THA was not cost-effective for patients aged 80 years and older in Japan.

https://doi.org/10.1371/journal.pone.0310974.t004

As in scenario analysis B, the time horizon of the model was changed from five years to four years, three years, two years, and one year ( Table 5 ). SB-THA was more cost-effective than BHA for patients with the time horizon from two to five years. In contrast, DM-THA was more cost-effective than SB-THA for patients only with the five-year time horizon.

https://doi.org/10.1371/journal.pone.0310974.t005

In this study, we conducted a full economic evaluation of three surgical interventions—BHA, SB-THA, and DM-THA—for displaced femoral neck fractures in active older patients in Japan, addressing an important gap in the literature. A full economic evaluation is a type of health economic analysis that compares the costs and effectiveness of multiple interventions. Compared with BHA, both SB-THA and DM-THA are considered cost-effective for a 75-year-old woman with a displaced femoral neck fracture because they clear the 5,000,000 yen/QALY threshold. The findings of this study suggest that SB-THA could be a cost-effective alternative to BHA and that DM-THA might be more cost-effective than SB-THA for relatively younger age groups.

Multicenter randomized controlled trials, such as the DUALITY and DISTINCT trials, are currently underway to clarify the risk of hip dislocation after DM-THA [ 28 , 29 ]. If the relative risk of dislocation turns out to be higher than that reported in previous studies, the economic evaluation of DM-THA implants should be reevaluated.

The thresholds for cost-effectiveness are set for each country: 5,000,000 yen per QALY for Japan, 50,000 US dollars (US$) per QALY for the US, and 20,000–30,000 pounds sterling (£) per QALY for the United Kingdom [ 30 ]. The ICER results of scenario analysis A stratified by age and sex over a five-year period were converted to £ and US$ for reference ( Table 4 and S6 Table ) using the average currency conversion rate of the 2022 fiscal year (¥162 is equivalent to £1 and ¥131 is equivalent to US$1) [ 31 ]. Since the model’s costs are specific to Japan, generalizing the results to other countries is not feasible, and the cost-effective boundary for age might differ depending on the ICER threshold and currency conversion rate in each country.

In scenario analysis B ( Table 5 ), SB-THA and DM-THA are not cost-effective with a one-year time horizon. This is partly because the cost of implants and the initial year cost are expensive. SB-THA is more cost-effective than BHA with a two- to five-year time horizon thanks to the incremental QALYs. DM-THA is more cost-effective than SB-THA only with a five-year time horizon partly because the relative risk of dislocation of DM-THA compared with SB-THA is estimated to be 0.17 ( Table 2 ).

Our study has several strengths. First, the comprehensive methodology of the study, employing a decision tree and Markov model combined with sensitivity analyses, enhanced the reliability and applicability of the results. Second, the consideration of different age groups and sexes in the scenario analysis A reflects a thorough approach that acknowledges the diversity of patient populations. We have presented the results for the 75-year-old female group, which represents the majority of the patient population. In addition, the scenario analyses present the results for patients of other age groups and male patients. Third, this study assessed short- and middle-term cost-effectiveness in scenario analysis B. The time horizon was originally set to five years, but we changed the time horizon from five years to four years, three years, two years, and one year. Changing the time horizon broadened the relevance of the study, making it a valuable resource for orthopedic surgeons and healthcare decision-makers. Fourth, to the best of our knowledge, this is the first study to examine the cost-effectiveness of three surgical options for treating displaced femoral neck fractures.

This study also has some limitations. First, the longest time horizon of this study was limited to five years, which may not fully capture the long-term effectiveness and cost associated with these surgical options. Long-term follow-up studies would be beneficial for understanding the sustained effects of these interventions. However, if a surgical option is cost-effective over a five-year period, it is likely to remain cost-effective or even cost-saving (a dominant strategy) over a longer time horizon, as suggested by a previous study [ 14 ]. Additionally, given the five-year mortality rate after a hip fracture in Japan is reported to be 45.6% [ 32 ], a five-year time horizon might be considered acceptable. Second, in this study, we assumed that all second revisions (RR-THAs) would be successful, without considering the possibility of further complications or surgeries. This assumption may underestimate the long-term costs and effectiveness of the surgical options, particularly DM-THA. Third, the PSA revealed a degree of uncertainty in the cost-effectiveness of DM-THA. This uncertainty highlights the need for further research, particularly in regard to the relative risks of dislocation and revision associated with DM-THA. Fourth, data regarding “costs after dislocation” are lacking in Japan. These costs were assumed as the average costs of “closed reduction for hip dislocation” and “open reduction for hip dislocation” ( S3 Table ) calculated to be 220,679 yen, which is similar to those reported in the United Kingdom and Canada [ 13 , 14 ]. Moreover the “costs after dislocation” was not an influential key parameter in one-way sensitivity analyses. Registry data regarding these costs are not available in Japan, so further studies using Japanese registry data are needed to address this gap, presenting a challenge for future studies. Fifth, the study did not explicitly discuss the waiting time for surgery, dementia in patients, skill of orthopedic surgeons, surgical approaches such as the posterior or direct anterior approaches, and use of cement, even though these factors can affect the outcomes [ 11 , 33 , 34 ]. This is partly because studies regarding the effects of these factors are insufficient. More complex models can be developed if real-world clinical studies investigating these factors are published in the future. Sixth, the study does not consider the patient’s condition or decision-making process involved in treating a displaced femoral neck fracture. However, it does contribute to our understanding of cost-effectiveness, which can be useful in guiding the decisions made by both the patient and the doctor.

Although this study provides valuable insights into the cost-effectiveness of surgical options for displaced femoral neck fractures in Japan, its generalizability to other healthcare settings, particularly to those with different healthcare systems and cost structures, is limited. Ethical considerations, such as the potential impact of cost-driven decisions on the quality of patient care, should also be considered when applying these findings to clinical practice.

The findings of this study suggest that SB-THA is a more cost-effective option than BHA for patients aged 65–85 years, while DM-THA is a more cost-effective option than SB-THA for patients aged 65–75 years over a five-year period. For 75-year-old female patients, our results suggest that SB-THA becomes more cost-effective than BHA after two years, and DM-THA becomes more cost-effective than SB-THA after five years. Orthopedic surgeons should select the most appropriate surgical option by considering the patient’s expected mortality and overall health condition.

Supporting information

S1 table. abridged life table of japan, 2022 (male)..

https://doi.org/10.1371/journal.pone.0310974.s001

S2 Table. Abridged life table of Japan, 2022 (female).

https://doi.org/10.1371/journal.pone.0310974.s002

S3 Table. Costs of the currently available surgeries for hip dislocation.

“Costs after dislocation” in Table 2 is considered as the average costs of “closed reduction for hip dislocation” and “open reduction for hip dislocation”: (42,738+398,620)/2.

https://doi.org/10.1371/journal.pone.0310974.s003

S4 Table. Data table of S1 Fig .

IC, incremental cost; ICER, incremental cost-effectiveness ratio; IE, incremental effectiveness; QALY, Quality-adjusted life year.

https://doi.org/10.1371/journal.pone.0310974.s004

S5 Table. Data table of S2 Fig .

https://doi.org/10.1371/journal.pone.0310974.s005

S6 Table. ICER results of scenario analysis A (Japanese yen, pound sterling, and US dollar) stratified by age and sex over a five-year period.

The values in pounds sterling (£) and US dollars (US$) were calculated based on the average currency conversion rates in 2022: ¥162 = £1 and ¥131 = US$1. BHA, bipolar hemiarthroplasty; DM-THA, dual-mobility total hip arthroplasty; ICER, incremental cost-effectiveness ratio; SB-THA, single-bearing total hip arthroplasty.

https://doi.org/10.1371/journal.pone.0310974.s006

S1 Fig. Incremental cost-effectiveness scatter plot of SB-THA and BHA.

The scatter plot shows outcomes of SB-THA versus BHA in a 75-year-old female patient. Each point represents a single simulated result of 10,000 simulations. The green ellipse denotes the 95% confidence ellipse. BHA, bipolar hemiarthroplasty; SB-THA, single-bearing total hip arthroplasty; WTP, willingness-to-pay.

https://doi.org/10.1371/journal.pone.0310974.s007

S2 Fig. Incremental cost-effectiveness scatter plot of DM-THA and SB-THA.

The scatter plot shows cost outcomes of DM-THA versus SB-THA in a 75-year-old female patient. Each point represents a single simulated result of 10,000 simulations. The green ellipse denotes the 95% confidence ellipse. DM-THA, dual-mobility total hip arthroplasty; SB-THA, single-bearing total hip arthroplasty; WTP, willingness-to-pay.

https://doi.org/10.1371/journal.pone.0310974.s008

S1 File. CHEERS 2022 checklist.

From : Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 Explanation and Elaboration: A Report of the ISPOR CHEERS II Good Practices Task Force. Value Health. 2022;25(1):10–31. https://doi.org/10.1016/j.jval.2021.10.008 .

https://doi.org/10.1371/journal.pone.0310974.s009

Acknowledgments

We would like to acknowledge the useful advice provided by the reviewers of PLOS ONE.

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Surgical management of femoral neck fractures.

Zara Hayat ; Vivek Tiwari ; Matthew Varacallo .

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Last Update: May 1, 2024 .

• Continuing Education Activity

Femoral neck fractures are extremely common, demonstrating a bimodal distribution pattern. Intracapsular femoral neck fractures account for approximately 50% of all hip fractures. Intracapsular fractures demonstrate limited healing potential due to the absence of the periosteal layer, so the fracture is only immersed in the surrounding synovial fluid. These injuries occur secondary to low-energy falls in older individuals and higher-energy traumatic mechanisms in younger patients. However, most of these fractures occur in older people with underlying osteoporosis.

This activity for healthcare professionals is designed to enhance learners' competence in determining surgical indications in femoral neck fracture cases. Learners gain a deeper understanding of this condition's intricacies, from its causes and classifications to its diagnostic and treatment modalities. Participants attain proficiency in recognizing the clinical presentations of these injuries and managing them according to evidence-based guidelines, preparing them to work within an interprofessional team caring for affected individuals.

• Determine the surgical indications in a patient with a femoral neck fracture.
• Create a clinically guided diagnostic plan for a patient with a suspected femoral neck fracture.
• Develop a personalized management plan for an individual diagnosed with a femoral neck fracture.
• Collaborate with the interprofessional team to educate, treat, and monitor patients with femoral neck fractures to enhance patient outcomes.
• Introduction

Femoral neck fractures (FNFs) pose a complex and multifaceted orthopedic challenge, necessitating a nuanced understanding to navigate their diagnosis, treatment, and subsequent management effectively. These fractures occur at the critical junction between the femoral shaft and head, representing not only a physical disruption but also a significant threat to the functional independence and overall well-being of affected individuals. FNFs are among the most common fractures in older populations, with a mortality risk at 1 year reaching 36%. [1] [2]  Managing these injuries also entails a significant financial and societal burden. 

FNFs demonstrate a bimodal distribution pattern, with low-impact injuries affecting older people and high-force trauma involving younger individuals. However, most FNFs are seen in older populations, with osteoporosis, female gender, chronic smoking, and low body mass index further increasing the risk. [3] [4]  Understanding the surgical management options for FNFs and their specific indications is essential in improving patient outcomes.

• Anatomy and Physiology

Hip Joint Anatomy

The hip joint is a ball-and-socket joint formed by femoral head articulation with the pelvic acetabulum of the pelvis. This joint allows for a wide range of motion, including flexion, extension, abduction, adduction, and rotation. The femoral neck is a crucial part of the femur, connecting the femoral head to the femoral shaft. This region is prone to fractures, particularly in the elderly population due to osteoporosis. The iliofemoral, pubofemoral, and ischiofemoral ligaments stabilize the hip joint. These fibrous structures maintain hip stability and prevent dislocations.

Intracapsular FNFs account for approximately 50% of all hip fractures. Most of these injuries occur in older individuals with underlying osteoporosis. [5] [6]

FNFs are differentiated from extracapsular hip fracture patterns based on anatomic location (see  Image . Femoral Hip Fractures). Distinguishing these injuries is critical. Intracapsular fractures have limited healing potential as they lack a vascular periosteal layer and depend only on the nutrient-depleted synovial fluid for their structural maintenance and metabolic needs. The hip joint capsule attaches to the intertrochanteric line anteriorly and the iliac crest posteriorly. [7]  Preserving the hip joint capsule in the context of an intracapsular FNF theoretically poses a risk of compromised blood supply to the femoral head due to elevated intraarticular pressures. A tamponade effect that compromises femoral head perfusion has been demonstrated in previous studies. [8]

The femoral head's arterial supply arises from 3 main sources. The first is the profunda femoris artery, which branches into the medial (MFCA) and lateral circumflex femoral arteries (LFCA). The MFCA is the femoral head's predominant contributor through the lateral epiphyseal artery. The LFCA supplies portions of the anterior and inferior femoral head. Retinacular vessels branching from the circumflex arteries also feed the femoral head.

The second is the ligamentum teres, a predominant arterial contributor in pediatric patients that loses importance in adult patients. The third is comprised of minimal contributions from the medullary canal and inferior gluteal artery. [9] [10]  Besides the tamponade effect potentially compromising femoral head blood flow, patients with FNFs risk developing avascular necrosis (AVN) due to retrograde flow and injury to the retinacular vessels. [11]

The hip joint receives innervation from branches of the femoral, obturator, and sciatic nerves. These nerves provide sensation to the joint and motor function to the surrounding muscles.

Treatment Implications

Displaced intracapsular FNFs in older people are typically managed with hip reconstruction procedures. The femoral head and neck are replaced with a reconstruction prosthesis. These procedures typically include hip hemiarthroplasty or total hip arthroplasty (THA). Nondisplaced fractures may be managed with fixation using cannulated screw fixation.

In contrast, extracapsular fractures rarely compromise the femoral head and neck's arterial circulation. Thus, a broader array of surgical fixation techniques may be used to manage these injuries. Femoral head AVN is very rare following extracapsular fractures. [12]

• Indications

General Concepts in FNF Management

The interprofessional approach is often necessary in managing FNFs due to the presence of comorbidities in older patients. Notably, surgery is nearly always indicated for patients presenting with an FNF. [13]  The surgical goals include pain control, mobility and function recovery, and osseous healing. [14]

Femoral Neck Fracture Nonoperative Management Indications

Nonoperative management is rarely indicated in FNFs due to the unacceptably high complication rates. Nonoperative management is reserved only for nonambulatory patients with significant medical comorbidities. [15]  The primary management goals are pain control and gradual mobilization. 

Patients often experience pain on ambulation, likely from forming a functional pelvic girdle stone. Pain management and immobilization are important in the initial stages after the injury. Mobilization may be attempted after callous formation weeks after the injury. The risks associated with nonoperative management include increased rates of pulmonary dysfunction, pneumonia, urinary tract infections, pressure sores (eg, sacral decubitus ulcers), deep vein thrombosis (DVT), and venous thromboembolism (VTE) from immobilization.

Femoral Neck Fracture Surgical Management Indications

FNFs pose significant challenges due to their propensity for AVN and nonunion. Surgical intervention realigns fractured bone fragments, stabilizing the fracture site and promoting optimal healing. The different FNF procedures and their indications are discussed below.

Hemiarthroplasty and Total Hip Arthroplasty

Hemiarthroplasty, or femoral head replacement, is recommended for displaced intracapsular FNFs, especially in older patients with low activity levels. THA is preferred for patients with intact ambulatory function or evidence of hip pain and degenerative arthritis. Implant design and surgical technique advances have been developed despite the higher risk of hip dislocation associated with THA for FNFs. [16] [17]  For active elderly patients with these fractures, using a dual mobility cup during THA reduces dislocation rates and improves functional outcomes without increasing mortality or morbidity compared to hemiarthroplasty. [18]

Girdlestone resection arthroplasty (GRA) may be an option for patients who are unsuitable for hemiarthroplasty due to conditions like systemic infections or severe neurological impairment. However, a retrospective study from Germany reported that patients with hemiarthroplasty after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Thus, the recommendation is to use GRA for FNFs selectively. [19]

Cannulated Screw Fixation

Cannulated screw fixation is indicated in nondisplaced, intracapsular FNFs in older patients and displaced fractures in younger people with ideal bone quality. The technique consists of inserting 3 or 4 cannulated screws in an inverted triangle or diamond configuration, respectively. Outcome differences are not significantly different between procedures using 3 and 4 screws. However, the literature suggests better results with inverted triangle fixation than techniques using only 2 cannulated screws. Recently, the biplane double-supported screw fixation method has been described for FNFs. [20] [21]

In Swedish patients aged at least 75 years, a retrospective study reported that reoperation-free survival 1 year after sustaining an undisplaced FNF was similar whether internal fixation or arthroplasty was performed. However, reoperations were more common after internal fixation, and early deaths were seen more frequently after arthroplasty. [22]

Critical utilization of partially threaded (long or short thread options) screw options should be preoperatively planned before the procedure begins. The surgeon should plan on optimizing the "lag by design" technique. Recently, a femoral neck system implant has been described for the internal fixation of FNFs in young patients with theoretical biomechanical advantages compared to other implants. [23] [24]

Sliding Hip Screw Fixation

The sliding hip screw (SHS) fixation construct is comprised of a large, cancellous lag screw that passes from the lateral, proximal femur across the fracture site and ends near the femoral head's center. The lag screw dynamically slides inside an incorporated metal sleeve, with the latter being connected to a fixation plate that subsequently is secured with multiple screws to the proximal femur. The compression mechanism is amenable and may be used in stable, intertrochanteric hip fractures, basicervical FNF patterns, and vertical FNFs. SHS fixation is superior to cannulated screw fixation in younger patients with vertical fracture patterns.

The fracture can be compressed as weight-bearing forces transfer from the appendicular skeleton through the pelvis and femoral head and neck before propagating distally. Thus, the SHS fixation construct allows for longitudinal sliding and compression as the patient ambulates postoperatively. The fracture compresses down as the lag screw slides into the barrel and further promotes healing. [25]

• Contraindications

Sliding hip screw fixation constructs are contraindicated in the following fracture patterns due to instability:

• Reverse obliquity
• Transtrochanteric involvement
• Comminuted fracture patterns with a large posteromedial fragment, as the medial calcar buttress is absent
• Fracture patterns with subtrochanteric extension  [26]

Hemiarthroplasty and THA are contraindicated in patients with an active hip infection.

All surgical femoral neck procedures require a standard orthopedic tray and should be carried out in an operating theatre equipped with laminar flow. For cannulated screw fixation and SHS, all procedures require the necessary implants, a radiolucent traction table or flat Jackson operating table, and an image intensifier. For hemiarthroplasty and THA, a standard operating table may be used if it has the necessary side supports. Other necessities include a complete implant set and, when applicable, the instruments and materials that allow for incorporating cement fixation. Computer navigation and robotics are increasingly being utilized in THA. [27]

The key personnel involved in FNF surgeries include the operating surgeon and assistant, anesthetist, operating department practitioner, scrub nurses, and circulating staff. A radiographer must also be present during SHS and cannulated screw fixation.

• Preparation

A complete history, physical examination, and appropriate anteroposterior and lateral (APL) hip and pelvis radiographs must be obtained before the procedure. Routine preoperative lab results should be checked, including a complete blood count, basic metabolic panel, and blood typing, screening, and cross-matching. Other routine preoperative examinations include a chest radiograph and electrocardiogram. The anesthesiologist must review the patient's clinical findings and diagnostic results when deciding between spinal and general anesthesia. Preoperative medical service comanagement may include additional consultation services, eg, internal medicine or cardiology, depending on the pertinent medical comorbidities' severity.

Preoperative optimization is essential for patients with comorbidities. Healthcare providers must carefully assess whether these individuals are taking anticoagulants, which may necessitate reversal with vitamin K, or, in patients taking warfarin, fresh frozen plasma. Available reversal agents vary by country and geographic region.

The patient should sign consent forms and be identified appropriately before surgery. Once in the theatre, the World Health Organization checklist should be completed. The patient must be positioned as detailed below and appropriately prepped and draped. Surgical procedures must be finished as soon as possible for better outcomes. [28]

Positioning During  Sliding Hip Screw and Cannulated Screw Fixation

For these procedures, the patient is placed supine on a radiolucent traction table. The foot on the side to be operated on must be in a traction boot. The unaffected side is placed in the lithotomy position, strapped in a leg holder, and placed in flexion, abduction, and external rotation to ensure the radiographic C-arm can access the fracture site appropriately. Gentle traction and internal rotation should be applied to reduce the fracture. Slight abduction may be needed to reduce any varus malalignment. The fracture should be nearly anatomically aligned, with radiographic confirmation, before prepping and draping. Open reduction may be necessary if closed reduction is not possible.

Correct lower extremity rotational alignment is imperative. The patient should be positioned with the patella facing toward the ceiling. [26]  

Positioning During Hemiarthroplasty or Total Hip Arthroplasty

For these procedures, the patient is placed in a lateral decubitus position with support over the anterior superior iliac spine and sacrum. The pelvis should be at 90° to the table. The preoperative radiographs must be reviewed to assess offset or the distance between the femoral head's center and a line drawn down the middle of the femur. The femoral head size should match the patient's own as closely as possible. [29]

• Technique or Treatment

Sliding Hip Screw

For the incision, a direct lateral approach is performed. The skin incision typically begins parallel to the lesser trochanter and extends along the femur, progressing distally. A longitudinal incision through subcutaneous fat is made afterward. The next layer is the fascia lata, cut parallel to the skin incision to reveal the vastus lateralis. The epimysium is then incised. The vastus lateralis can be lifted off the lateral intermuscular septum but is more commonly split along its fibers. 

When exposing the femur, a periosteal elevator (Bristow) is used to clear muscle from the bone. A clear surface is thus left for the plate without soft tissue interposition. One or two self-retaining retractors may help gain adequate exposure for guidewire placement.

During guidewire insertion, a guidewire jig is placed on the femoral shaft. The jig must be aligned properly on the femur's lateral aspect, ensuring equal anterior and posterior distances. During guidewire placement, the wire's tip must be visualized in its eventual position in the femoral head. The lesser trochanter usually marks the entry level for a 135° angle plate. The tip should be within the subchondral bone. The position should be continually assessed using an image intensifier. A measuring device is slid over the guidewire, ensuring it sits on the bone. Typically, 5 to 10 mm are deducted from the measurement.

The guidewire is then over-drilled with a triple reamer to create a channel for both the lag screw and plate barrel. Reaming extends to the depth selected for the screw. Radiography must show that the reamer's 3rd part has engaged with the bone cortex, and the guidewire is not advancing into the pelvis.

Tapping the bone is beneficial in young patients or those with strong bones. Tapping is a process that creates a threaded hole in the bone using a tapping instrument. This process helps ensure implants are correctly placed and securely fit, especially in patients with strong or dense bones.

The lag screw is then applied over the wire and screwed in using the attached handle. The handle's final position should be parallel to the femur to ensure the lag screw will slot into the plating barrel. The plate is then slid over the lag screw. The plate template may be needed to ensure the plate is fully advanced. The guidewire can now be removed. The plate may be secured to the femur using a clamp.

The screws are inserted next. The most distal screw is conventionally placed first. The 3.5-mm drill is used with the neutral drill guide to make the screw holes, drilling through both cortices. The screw holes are then measured using the depth gauge, and the appropriate screw is inserted.

Final APL radiographs should be obtained. The wound is washed, and closure is performed in layers. [30]

Reduction is usually not needed in this procedure, as screws are typically used for nondisplaced fractures. Similar to SHS, a direct lateral approach is taken with a longitudinal incision made at the level of the lesser trochanter. However, the incision is typically much smaller, usually around 5 cm.

Three guidewires are then inserted using a guide or freehand, depending on the surgeon's preference and experience. The typical formation is an inverted triangle with 1 screw distally and 2 proximally placed. The 1st guidewire's entry point should be no lower than the lesser trochanter to reduce the risk of forming a stress riser, which may trigger a comminuted subtrochanteric fracture. Ideally, the guidewire should sit just above the calcar on anteroposterior view and go up to the subchondral bone in the femoral head. The 2nd guidewire is placed superiorly and posteriorly to the 1st. On lateral view, this guidewire should lie next to the posterior cortex. The 3rd wire is placed superiorly and anteriorly to the 1st wire, ideally sitting parallel to the 2nd guidewire on anteroposterior view. All 3 should be within 5 mm of the subchondral bone.

The measure ascertains which screw length will be used. A cannulated drill is then used to ream over the guidewires, usually 5 to 10 mm short of the measured distance. Three partially threaded screws are then inserted before a wire driver is used to remove the guide wires. The screw measurement is typically the same as the original guidewire measurement. The screw threads should be beyond the fracture site to ensure that adequate compression takes place. The screws should be tightened together to ensure uniform compression. Depending on surgeon preference, washers may be used to increase compression further. 

Final APL images should be taken. The wound should be washed with normal saline and closed in layers. [30]

Hemiarthroplasty

This operation may be approached in different ways. [31]  The anterolateral approach, also known as the modified Hardinge approach, is most commonly used. A longitudinal incision over the greater trochanter is made, usually around 20 cm long and curving posteriorly and proximally. The layers encountered are the subcutaneous fat, fascia lata, bursa, and gluteus medius layers.

The fascia lata is initially incised in alignment with the femur, following the original incision line and curving posteriorly. Typically, a small central incision is made using a scalpel to initiate the process. The fascia lata is cut with scissors distally and then proximally. The fascia is then retracted using either self-retainers or a Charnley retractor, with the latter positioned so that the D shape created points toward the knee. The trochanteric bursa is excised using forceps and scissors. The greater trochanter and its attached muscles become visible after this step, with the gluteus medius proximally and vastus lateralis distally.

The assistant should then externally rotate the leg to put the gluteus medius on the stretch. The greater trochanter's tip should be identified, and the gluteus medius fibers split. The superior gluteal nerve is approximately 5 cm proximal to the tip of the greater trochanter.

The hip abductors, the superficial gluteus medius and the deep gluteus minimus, are then detached from the greater trochanter using diathermy. This procedure is typically performed by tracing an "s" or "omega" shape, leaving a sufficient cuff for repair at the end. Splitting some of the vastus lateralis fibers is occasionally necessary. Adequate dissection should reveal the capsule. A T-shaped incision is made in the capsule, staying close to the bone at the femoral neck's base. Dislocating the hip is necessary and can be achieved through external rotation, which exposes the fractured neck as the leg is positioned into the leg bag to improve visibility.

The next step is to make the neck cut, accomplished with an oscillating saw at a 45° angle. This cut is usually measured from a line extending between the neck's superior aspect to 1cm proximal to the lesser trochanter, although it may vary depending on the prosthesis being used, particularly if it includes a collar.

The femoral head may be removed using the corkscrew, which is placed centrally in the head and then twisted in. The head is spun to detach it from the acetabulum. A mallet may be necessary to help engage the corkscrew with the bone. The capsule cut's sufficiency must be checked if the femoral head is difficult to remove. The femoral head must be measured using the guide. If between sizes, most surgeons advise erring on the smaller side to minimize the risk of dislocation. Ensure all soft tissue is removed when preparing the acetabulum. A bone nibbler may be used to remove any remaining soft tissue.

For femoral canal preparation, a Hohmann retractor is used to expose the femoral calcar. The femur is prepared using a box chisel, which is typically placed posterolaterally to open the femoral canal. A T-handled reamer is then introduced into the canal. One hand must be placed on the patient's knee during this step to ensure alignment with the anatomical axis. Reamers of progressively larger sizes are used until rotational movement is impeded. The femoral canal is then smoothed using a rasp, with particular attention given to rasping the lateral side.

The head is trialed, and the hip is reduced to assess size and stability with internal and external rotation, with the hip flexed and extended. Leg length equality is assessed. However, this part is not always performed because of the joint's intrinsic stability. Difficulty reducing the hip may be due to the stem being too proud, offset being too great, or soft tissue obstruction being present. The trial is dislocated if further adjustments are necessary. 

A cement restrictor is inserted, which may need to be sized depending on the kit used. The restrictor is typically 2 cm more than the stem's length. The femoral canal is then washed using copious pulse lavage. Ribbon gauze is inserted into the femoral canal alongside a clean suction catheter. This process ensures the canal is dry and free from fat and blood, allowing the cement to interdigitate with the bone for solid fixation. The cement is then prepared. The gauze is afterward removed, and the cement is inserted into the canal using the cement gun. The nozzle should be inserted fully into the canal, and the cement pressure should push the gun up proximally. Surgeon preference dictates whether the cement is pressurized.

The selected femoral stem is then inserted into the femoral canal. All excess cement must be removed. The femoral stem should ideally have 10 to 15° of anteversion. The degree of anteversion must not change once the stem is in situ at the appropriate depth to prevent a varus stem, which may compromise the outcome. The femoral head is then attached to the trunion, and the hip is reduced. Reduction is achieved with gentle traction and a small degree of internal rotation. Stability should be assessed afterward.

The wound is then washed and closed in layers—capsule, abductors en masse, fascia lata, fat, and skin. A double-layered combination using interrupted and continuous suturing of the abductors helps securely close the wound. [32]

Postoperative Plan

Routine labs must be obtained after the procedure, including a complete blood count and a basic metabolic panel. The results must be checked at various intervals following surgery, with the frequency depending on the patient's overall condition. Formal radiographs may also be ordered, depending on the surgeon's assessment. A posthemiarthroplasty x-ray ensures the joint is reduced and in an ideal position. Postoperative antibiotics and DVT prophylaxis may be initiated as per hospital protocol.

Mobilize full weight-bearing as pain allows with physiotherapists, incorporating partial or touch weight-bearing in cases involving cannulated screws and comminuted fractures managed with an intramedullary nail. Follow-up appointments are scheduled depending on the surgeon's assessment.

• Complications

Patients undergoing an FNF procedure typically have comorbidities that put them at high risk of developing complications. These potential occurrences must be explained to patients to help them make informed decisions about their treatment plans. Possible surgical complications include the following:

• Infection: Sepsis can occur in up to 20% of cases and can result from superficial or deep infection. Healthcare professionals believe the presence of hematoma increases this risk. Antibiotics are usually given at induction, with 2 doses administered postoperatively. [33] [34]  
• Fixation failure: This complication is more likely to occur in patients with pathological bone conditions, for example, rheumatoid arthritis and osteoporosis. Fixation failure may also result from technical errors while operating. Loosening or dislocation can also occur following a hemiarthroplasty. [35]
• Fracture: Hemiarthroplasty procedures themselves have a 4.5% fracture risk. These fractures often occur during hip reduction and commonly affect the neck or greater trochanter. [36]
• DVT and VTE: These complications are significant concerns following FNF procedures due to factors such as immobilization, surgery-related trauma, and underlying comorbidities. Preventive measures, including pharmacological prophylaxis and mechanical interventions, are essential to mitigate the risk of DVT and its possible consequences in patients undergoing FNF procedures.
• Fat embolism: This condition is a potential complication of pressurizing cemented stems and nailing. Hypoxia may be noted during pressurization or after hip reduction. Adequate femoral canal lavage and drying can minimize the risk.
• Leg length discrepancy: This condition may arise in any FNF procedure. Slight differences can be managed with a shoe lift if problematic.
• Nonunion: Patients may present with groin or buttock pain approximately 12 months following fixation. Pain is worse on hip extension or with weight-bearing. Nonunion is thought to occur in up to 25% of displaced fractures and 5% of undisplaced fractures. Management is either with total hip replacement in the elderly or proximal femoral osteotomy in the young. The condition is more common after SHS and cannulated screw fixation than other techniques.
• Dislocation: This complication is often associated with hemiarthroplasty. Patients undergoing THA for an FNF generally exhibit an elevated postoperative dislocation rate compared to those undergoing elective, primary THA procedures for other conditions, eg, osteoarthritis and hip dysplasia.
• AVN: This condition can occur in up to 10% of undisplaced fractures and 30% to 45% of displaced fractures. Patients typically present with groin pain. Sclerosis signs may show on radiographs. Management typically involves conversion to a total hip replacement, but alternatives such as osteotomy or core decompression may be considered in younger patients. [37]
• Malunion: This complication has an incidence of 5% to 30%. Varus malreduction following cannulated screw fixation correlates with fixation failure.
• Death: Mortality is approximately 30% in the elderly in the first year following an FNF.

Many of these surgical complications can be mitigated or effectively managed with vigilant preoperative optimization, meticulous surgical technique, and proactive postoperative care. Collaboration among multidisciplinary healthcare teams, patient education, and adherence to evidence-based protocols are crucial in minimizing the occurrence of complications and optimizing patient outcomes.

• Clinical Significance

The above procedures are commonly performed, though different fracture types and patient characteristics may warrant modifying a surgical approach. Contentious areas in surgical techniques are briefly considered below.

Bipolar versus Unipolar Hemiarthroplasty

Debate exists over the use of bipolar or unipolar implants. In bipolar implants, the femoral head is surrounded by a polyethylene liner within an acetabular shell where it can move. Unipolar implants are simpler and less expensive than bipolar types. Studies suggest that bipolar implants confer the benefits of reduced pain, less acetabular wear, and lower dislocation rates, though these types are more expensive than their unipolar counterparts. Bipolar implants are also easier to convert to a total hip replacement than unipolar types when necessary. However, evidence suggests that bipolar implants also lose movement at the inner bearing and eventually resemble a unipolar implant over time. [38]

Cemented versus Uncemented Hemiarthroplasty

Cemented implants give better functional and mobility-related outcomes than uncemented types. These implants also confer greater stability than uncemented ones. However, cemented implants carry an increased risk of fat embolism, which can cause hypoxemia. Still, research suggests that cemented stems carry a higher overall survival rate than their uncemented counterparts. The cement acts as a grout, creating an interface to distribute the load between the femoral stem's smooth surface and the bone surface's irregularities. [39]  

Uncemented implants carry a higher postoperative and intraoperative periprosthetic fracture risk. [40]  Stability is conferred from the uncemented stem's impaction in the cancellous bone, but poor bone quality impairs impaction and reduces stability. A study reported that cemented femoral component fixation for THA was associated with lower periprosthetic fracture and aseptic revision rates but higher VTE rates in patients with FNF aged 65 and older. [41]

SHS Lag Screw Positioning 

The tip-to-apex distance (TAD) is the distance between the screw tip and the femoral head's apex on the APL view. Baumgaertner et al. found that a TAD less than 20 mm avoided screw cut-out. [42]  A TAD less than 25 mm can minimize failure risk. The lag screw should be slightly inferior on anteroposterior view and slightly posterior on lateral view. Eccentric placement is likely to cause a rotational construct failure. [43]  The anterosuperior region is where bone quality is the poorest.

Arthroplasty Timing

A retrospective FNF study lasting over 6 years in China reported that early THA had a lower risk of pulmonary embolism, DVT, blood transfusion, 30-day readmission, and VTE-related readmission. Similarly, early hemiarthroplasty had a lower DVT and blood transfusion risk than delayed hemiarthroplasty. [44]

Effect of Obesity

A retrospective study reported that obesity increased operative time without increasing postoperative complication risks in hemiarthroplasty and THA for isolated FNFs. However, anesthetic exposure is prolonged in patients with obesity. The postoperative effect of long anesthesia duration must be explored in future studies. [45]

• Enhancing Healthcare Team Outcomes

The interprofessional approach is essential when caring for patients undergoing hip surgery for FNF. Notably, preoperative medical optimization of patients with FNF is vital for an excellent surgical outcome. Specialists within orthogeriatric and medical teams must collaborate to achieve preoperative optimum medical conditions.

Physiotherapists and occupational therapists are also vital to safely mobilize patients with FNFs and ensure a safe hospital discharge. Proper physical therapy can help most patients regain function and muscle strength. Failure to comply with physical therapy may lead to disuse and numerous other complications.

The primary care provider and nurse practitioner must continually follow individuals with FNFs to ensure they ambulate without pain and avoid postsurgical complications. All healthcare professionals involved must coordinate their activities, working as an interprofessional team, to achieve satisfactory rehabilitation and restore limb function in patients with FNFs.

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Femoral Hip Fractures. This image shows the different types of extracapsular (intertrochanteric, lesser trochanteric, greater trochanteric, and subtrochanteric) and intracapsular (transcervical and subcapital) fractures. Contributed by S Bhimji (more...)

Femoral Neck Fracture Contributed by Dr Vivek Tiwari

Femoral Neck fracture Contributed by Jillian Kazley, MD

Disclosure: Zara Hayat declares no relevant financial relationships with ineligible companies.

Disclosure: Vivek Tiwari declares no relevant financial relationships with ineligible companies.

Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Hayat Z, Tiwari V, Varacallo M. Surgical Management of Femoral Neck Fractures. [Updated 2024 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Journal of Pharmaceutical Research International

Published: 2021-12-26

DOI: 10.9734/jpri/2021/v33i60B34922

Page: 2625-2629

Issue: 2021 - Volume 33 [Issue 60B]

Rehabilitation in Operated Case of Neck of Femur Fracture: A Case Report

Anisha K. Sawra

Ravi Nair Physiotherapy College, Datta Meghe Institiute of Medical Science ,Sawangi, Maharashtra, India.

Swapna Jawade *

Department of Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institiute of Medical Science, Sawangi , Maharashtra, India.

Neha Chitale

*Author to whom correspondence should be addressed.

Femoral neck fracture is a common and hazardous condition of the elderly, whose morbidity is constantly increasing with population ageing and has become a serious social burden. Prosthetic joint replacement can successfully relieve pain and restore joint function. As a result, an increasing number of doctors consider it a primary treatment option for displaced femoral neck fractures in the elderly. Patients and society, however, are burdened by the lengthy procedure and hefty cost. The surgery technique for femur fracture neck fractures should be redefined as medical technology advances. Individual therapy options should be determined by the therapeutic indication and the clinical status of the patient. Personalized therapy techniques for elderly patients with femoral neck fractures should be established. The fractures causes radiating pain to the knee. Inability to bear weight. Shortening or sideways rotation of affected leg. It causes external rotation deformity, shortening, unable to ambulate, echymosis, restricted movements. The main cause of femoral neck fracture is a medical condition called osteoporosis which causes the bones to become thin and weak due to loss to bone mass. A femoral neck fracture can tear the blood vessels and cut off the blood supply to the femoral head. If the blood supply to the femoral head is lost, in bone tissue avascular necrosis may occur, leading to the eventual collapse of the bone.

Keywords: Fracture, physical therapy, rehabilitation

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