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AAOS Now

Published 12/1/2012
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Peter Pollack

Hip Fractures Require Different Approaches

Matching the treatment approach to the patient’s fracture is key

Speaking at the annual meeting of the Clinical Orthopaedic Society, Michael D. Stover, MD, addressed various types of hip fractures and approaches to treatment in patients ranging in age from pediatric to elderly.

“For femoral neck fractures in the young,” he said, “open reduction internal fixation (ORIF) is the treatment of choice. Closed reduction rarely results in anatomical alignment, so the threshold for open reduction should be very low. If closed reduction is used, an accurate reduction should be ensured and it should be accompanied by a capsulotomy. Animal studies have shown that capsulotomy helps profusion of the femoral head and decreases intracapsular pressures, although human studies have been inconclusive.


Fig. 1
Radiograph showing a classic reverse obliquity fracture with proximal medial to distal lateral fracture line.
Reproduced from Lee MA, Harvey EJ: Fractures of the Proximal Femur in Schmidt AH, Teague DC (eds)
Orthopaedic Knowledge Update Trauma 4, Rosemont, Ill., American Academy of Orthopaedic Surgeons, 2010, pages 417–430.

 

“In my opinion, timing is an important factor,” he continued. “Nothing has been proven beyond a doubt, but treating a femoral neck fracture in the young individual should have a sense of urgency, because this is truly a preservation procedure. It should be performed as early as feasible by an experienced surgeon.”

Femoral neck fracture in older patients
In an older patient with a similar fracture, however, Dr. Stover recommended arthroplasty, pointing out that some studies have suggested an up to nine times greater risk of failure with fixation. Arthroplasty, he explained, decreases complications and is associated with reduced pain and improved function in older patients.

“But what type of arthroplasty?” he asked. “In a 2012 meta-analysis of studies that looked at fit elderly patients, total hip arthroplasty (THA) resulted in improved patient-reported outcomes compared to hemiarthroplasty, but THA was also associated with higher dislocation rates, with similar major and minor complication rates. My interpretation of the data is that in the active, elderly patient, THA is the treatment of choice for displaced femoral neck fractures, but ways of addressing the complication rate of dislocation are needed. Hemiarthroplasty, in my opinion, should be reserved for the infirm or institutionalized patient.”

Dr. Stover also strongly supported using cemented implants.

“I love cement,” he said. “I use it most of the time in my elderly hip fracture patients. A 2012 randomized clinical trial looked at patients older than age 70 without severe cardiovascular compromise and found that use of cement was not associated with a difference in pain, but did show a decrease in implant-related complications and a trend toward improved function. Although the known risk of sudden death is present when using cement, given modern anesthesia care and appropriate patient selection—such as those without severe cardiovascular problems—I believe cement is the better approach.”

Peritrochanteric fractures
When faced with peritrochanteric fractures in elderly patients, however, Dr. Stover recommends a very different approach: ORIF.

“It’s the gold standard,” he said, “despite its high failure rate. The reasons for this high failure rate are multifactorial and include patient factors such as osteoporosis and the inability to cooperate with postoperative regimens as well as fracture geometry and unstable fracture patterns. Surgeon-related factors include the ability to obtain or maintain a reduction, proper placement of fixation, and implant selection.”

Dr. Stover pointed out that the use of intramedullary (IM) nails in the treatment of peritrochanteric fractures has recently increased, despite the fact that current data seem to suggest that other treatments may be equally effective.

“Nailing might be seen as an improved technique, with less invasive surgery and smaller incisions,” he posited. “Or surgeons may think that nailing improves stability or provides an internal buttress. A preference for nails could also be based on earlier data that associated nailing with shorter operative times, decreased blood loss, less leg-length discrepancy, and decreased sliding potential.

“But data have emerged to suggest that IM nailing offers no superiority over the sliding hip screw for peritrochanteric fractures, and is in fact linked to an increased complication rate,” he continued.

Dr. Stover emphasized that reduction and implant placement are the important, surgeon-related factors to take into account.

“The hip screw should be positioned deeply in the central portion of the femoral head,” he said. “That will decrease cut-out rates: it’s where the best bone is, it has the best sliding potential, and it validates the reduction.”

Reverse oblique fractures
Dr. Stover recommended against the use of sliding hip screws with a side plate, however, in treating reverse oblique fractures (Fig. 1).

“It’s not going to work,” he said. “The data show it. A 2005 meta-analysis looked at these reverse oblique A3 patterns and found lower failure rates when a 95° fixed-angle plate device was used. It also found that using a trochanteric nail may have some benefit.”

Dr. Stover pointed out that using trochanteric nails may also be problematic, however.

“Despite the fact that trochanteric nails may help with some unstable fracture patterns, they are associated with issues such as periprosthetic fracture, penetration of the anterior femoral cortex, implant disengagement, and nail fracture,” he noted. “A lot of bone is lost from the greater trochanter when trochanteric nails are used. If other restoration or surgical reconstruction procedures are being considered, implant disengagement may be a problem.”

Dr. Stover reports no conflicts.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Bottom Line

  • ORIF is the treatment of choice for femoral neck fractures in younger patients.
  • Arthroplasty is the gold standard for femoral neck fractures in active, elderly patients.
  • Although the use of IM nails in treating peritrochanteric fractures is increasing, Dr. Stover recommends the use of ORIF, despite its high failure rate.
  • A 95° fixed-angle plate may be the most appropriate treatment for a reverse oblique fracture.

References

  1. Burgers PT, Van Geene AR, Van den Bekerom MP, Van Lieshout EM, Blom B, Aleem IS, Bhandari M, Poolman RW. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. Int Orthop. 2012 Aug;36(8):1549-60. Epub 2012 May 24
  2. Taylor F, Wright M, Zhu M. Hemiarthroplasty of the Hip with and without Cement: A Randomized Clinical Trial. J Bone Joint Surg Am. 2012 Apr 4;999(2):577-83. doi: 10.2106/JBJS.K.00006.small.test.
  3. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF; Evidence-Based Orthopaedic Trauma Working Group. Unstable pertrochanteric femoral fractures. J Orthop Trauma. 2005 Jan;19(1):63-6.