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Displaced Femoral Neck Fractures in Patients <60 Years of Age

Stephen T. Gardner, M.D., Michael J. Weaver, M.D., Seth A. Jerabek, M.D., Mark S. Vrahas, M.D., Paul T. Appleton, M.D., Mitchel B. Harris, M.D.

Brigham and Women’s Hospital, Massachusetts General Hospital, Beth Isreal Deaconess Hospital, Boston, MA, USA

Displaced femoral neck fractures in young patients are relatively rare and potentially devastating injuries. Primary arthroplasty is increasingly advocated for the older patient but is rarely indicated for patients <60 years of age. The two most common methods of fixation of these fractures are percutaneous cannulated lag screw (PCS) fixation and a sliding hip screw (SHS). This paper reports the outcomes of these two different fixation techniques in displaced femoral neck fractures in patients younger than 60 years of age.

A retrospective review of a prospectively enrolled trauma database was performed at three Level I trauma centers spanning the years 2000–2010. The electronic medical records and radiographs of all patients <60 years of age with displaced femoral neck fractures (OTA 31.B) treated by open or closed reduction and PCS fixation or SHS were individually reviewed. Quality of reduction was recorded for each fracture fixation construct and tip-apex distance (TAD) was recorded for each SHS construct. Exclusion criteria included all patients treated primarily with hip arthroplasty, follow-up <6 months, pathologic fracture through a bone lesion, or femoral neck fractures in association with acetabular or femoral head fractures. The primary outcome measurement was a return to the operating room within 6 months of the index procedure due to implant failure, or loss of reduction. Secondary outcomes were defined as loss of fixation after 6 months, symptomatic osteonecrosis requiring surgery, or nonunion requiring repair or conversion to total hip arthroplasty. A two-tailed Fisher exact test was used to compare independent outcome variables. P value was set at 0.05 to indicate statistical significance.

A retrospective review of a prospectively enrolled trauma database was performed at three Level I trauma centers spanning the years 2000–2010. The electronic medical records and radiographs of all patients <60 years of age with displaced femoral neck fractures (OTA 31.B) treated by open or closed reduction and PCS fixation or SHS were individually reviewed. Quality of reduction was recorded for each fracture fixation construct and tip-apex distance (TAD) was recorded for each SHS construct. Exclusion criteria included all patients treated primarily with hip arthroplasty, follow-up <6 months, pathologic fracture through a bone lesion, or femoral neck fractures in association with acetabular or femoral head fractures. The primary outcome measurement was a return to the operating room within 6 months of the index procedure due to implant failure, or loss of reduction. Secondary outcomes were defined as loss of fixation after 6 months, symptomatic osteonecrosis requiring surgery, or nonunion requiring repair or conversion to total hip arthroplasty. A two-tailed Fisher exact test was used to compare independent outcome variables. P value was set at 0.05 to indicate statistical significance.

Results: 133 displaced femoral neck fractures were identified in 132 patients <60 years of age. 64 patients were excluded: primary arthroplasty (n = 41), follow-up <6 months (n = 17), pathologic fracture through a bone lesion (n = 3), and complex combined injury (n = 3). Our final study cohort was 69 femoral neck fractures in 68 patients. 40 patients were treated with SHS and 29 were treated by PCS fixation. Mean age in the groups was similar (SHS: 42.4 years, PCS: 43.7 years). Excluding patients with early failure, follow-up ranged 6 to 84 months (median, 18 months). TAD was <25 mm in 34 of 40 SHS patients. Reduction quality was graded as excellent (n = 19), good (n = 31), or fair (n = 8). 11 patients did not have immediate postoperative radiographs and quality of reduction could not be determined. At 6 months, only 1 (3%) patient in the SHS group lost fixation compared to 6 (21%) patients in the PCS group (P = 0.02). However, overall complication rates at most recent follow-up were similar between patients treated with SHS (25%) or PCS (31%) (P = 0.60).

There remains controversy regarding the optimal fixation method for displaced femoral neck fractures in younger patients. Biomechanical data suggest that SHSs are stronger than PCS constructs. It has been our clinical experience that fixation with SHS leads to a significantly lower short-term mechanical failure rate. The longer-term failure rate in our series is similar to other published reports and appears to be independent of fixation method. This suggests that biologic, and not mechanical, factors are most important in determining long-term outcome in these injuries.