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Plating of Femoral Neck Fractures: When and How?

Florschutz, Anthony V. MD, PhD*; Donegan, Derek J. MD; Haidukewych, George MD*; Liporace, Frank A. MD

Journal of Orthopaedic Trauma: April 2015 - Volume 29 - Issue - p S1–S3
doi: 10.1097/BOT.0000000000000288
Supplement Article

Summary: Intracapsular femoral neck fractures are common in the elderly population after a simple fall. However, femoral neck fractures in the physiologically young are less common. Regardless, femoral neck fractures can be a source of significant morbidity and mortality if not treated correctly. Multiple management strategies have been described. The decision for the ideal treatment involves careful consideration of the patient's age, activity, and medical comorbidities. Plating techniques of femoral neck fractures continue to evolve. The authors describe the current indications and plating options for the treatment of femoral neck fractures.

*Department of Orthopaedic Surgery, Orlando Regional Medical Center, Orlando, FL;

Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA; and

Department of Orthopaedic Surgery, NYU-HJD, New York, NY.

Reprints: Derek J. Donegan, MD, Penn Musculoskeletal Center, Department of Orthopaedic Surgery, University of Pennsylvania, 7th Floor, 3737 Market St, Philadelphia, PA 19014 (e-mail: derek.donegan@gmail.com).

G. Haidukewych receives royalties from Depuy and Biomet, Inc, does consulting work for Depuy and Biomet Inc, and owns stock in Institute for Better Bone Health and Orthopediatrics. F. A. Liporace has received royalties for lower extremity intramedullary nails from Biomet, Inc, Warsaw, IN. The remaining authors report no conflict of interest.

Accepted January 09, 2015

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INTRODUCTION

Femoral neck fractures are the source of significant morbidity and mortality. There are a number of operative treatment options that include closed reduction and internal fixation (CRIF), open reduction and internal fixation (ORIF), hemiarthroplasty, and total hip arthroplasty.1,2 Indications for specific management are based on age, function, concurrent medical comorbidities, bone quality, and fracture characteristics.3,4 CRIF and ORIF of femoral neck fractures with plate implants are established treatment options offering mechanically stable fixation with good long-term implant survival and functional results when appropriately used.

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INDICATIONS

On initial evaluation, all patients who present with a femoral neck fracture require a thorough history and physical examination that should include assessment of functional status and medical comorbidities in addition to appropriate fracture films. The use of CRIF and ORIF with plate fixation is generally indicated for patients younger than 65 years old, certain relatively healthy higher functioning older patients, and in cases of nondisplaced/minimally valgus impacted fractures in the elderly.5 The aims of intervention are to optimize patient function, achieve long-term joint preservation, and prevent medical complications.

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SURGICAL APPROACH AND ANATOMIC REDUCTION

Plating femoral neck fractures necessitates adequate exposure of the proximal femur for placement of the selected implant and sufficient exposure of the femoral neck in cases requiring open anatomic reduction. The accuracy of primary anatomic reduction is vital for successful bone healing and long-term joint preservation as malreduction is a strong indicator for healing complications and reoperation.6–10 Although closed reduction maneuvers (eg, Leadbetter technique) may be occasionally efficacious,11 there should be little reluctance to proceed with open reduction to establish precise anatomic alignment.12 The direct anterior (Smith-Peterson), anterolateral (Watson-Jones), and lateral (Hardinge) approaches are the chief surgical approaches to access the proximal femur and femoral neck. Both the Watson-Jones and Hardinge approaches offer exposure of the femoral neck for reduction and lateral cortex for plate placement by a single incision. If precise anatomic alignment cannot be achieved using these 2 approaches, then a Smith-Peterson approach may be used to provide excellent visualization of the femoral neck and access for reduction. Some surgeons suggest that the location of the femoral neck fracture can guide surgical approach. Transcervical femoral neck fractures and distal can often be treated through a single laterally based approach (Watson-Jones or Hardinge). Whereas, transcervical femoral fractures and proximal often necessitate dual approaches. As such, it is essential that a surgeon who manages femoral neck fractures be proficient in performing these exposures. One must keep in mind that any of these approaches for open reduction only allow direct assessment of the anterior femoral neck. Therefore, care must be taken not to promote a relative apex anterior deformity by flattening the anterior surface. Direct assessment of the anterior surface in concert with care fluoroscopic evaluation, especially of the lateral, is paramount.

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IMPLANTS

The gamut of proximal femoral plates developed for the internal fixation of femoral neck fracture include sliding hip screw (SHS) implants, proximal femoral locking plates (PFLP), blade plates, and dynamic locking plates.

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SHS Implants

SHS implants are dynamic fixed-angle devices that are an established option for managing nondisplaced, impacted, and displaced femoral neck fractures (Fig. 1).2,5,13 These implants provide significantly better mechanical stability than cancellous lag screws to resist the shear forces encountered in more vertically oriented fracture patterns (Pauwels III) as well as highly comminuted and basicervical fractures.3,4,14–18 It is important to assure proper implant selection and positioning, as well as to avoid fracture displacement during SHS implant placement. Measurement of the neck-shaft angle (on the uninjured hip) should be assessed preoperatively to select an appropriately angled implant that can be correctly positioned and use the correct aiming jig for femur preparation. The ideal screw position in the femoral head is centered on anteroposterior and lateral radiographs with the side plate centered on the femoral shaft fixed using 2 or more cortical screws depending on the plate length.19 The appropriate placement of the lag screw on the AP radiograph in conjuncture with central placement on the lateral radiograph allows for a superiorly placed antirotational screw which is optimal. If the SHS device is used in combination with a retrograde intramedullary nail (IMN) for internal fixation of an ipsilateral femoral neck-shaft fracture, the screws on the side plate must either be tangentially placed to miss the proximal end of the IMN or passed through the proximal interlocking holes provided that the IMN selected has appropriately spaced transverse interlocking options. In addition, consideration of using an antirotation screw or pin to counteract the torque necessary to insert the cephalic screw aids in preventing rotational malalignment after reduction.14

FIGURE 1

FIGURE 1

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Proximal Femoral Locking Plate

Length-stable implants such as PFLPs have been proposed as solutions for minimizing the amount of femoral neck shortening to potentially improve postoperative outcomes, lower revision rates, and provide good mechanical stability.3,20 Convincing evidence for prospective clinical use was reported in a cadaveric study analyzing the biomechanical stability of different femoral neck fixation techniques and demonstrating that PFLP implants provide the highest level of stability when compared with other fixation methods.3 Unfortunately, the clinical use of PFLPs has been less than optimal with unacceptably high failure rates.21,22 These clinical outcomes are hypothesized to be related to the high stiffness of the implant, which impedes micromotion and subtle compression to promote healing at the fracture site. This often results in failure at the bone–screw interface or fatigue failure of the plate. Based on the present clinical evidence, the PFLP should not be considered an option for managing femoral neck fractures. PFLP can be considered for proximal femur fractures with concomitant femoral neck fractures that are not amenable to intramedullary nailing (Fig. 2).

FIGURE 2

FIGURE 2

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Blade Plate

Blade plates have been described as suitable implants for managing femoral neck fractures. Although these implants are commonly used in conjunction with osteotomies for treating femoral neck nonunions and malunions, there is limited evidence and comparisons available to advocate regular use as a primary treatment option. Clinical experience with the AO 130° blade plate has been reported with acceptable results23–25; however, Driesen et al26 cautioned that results are dependent on experience with the surgical technique.

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Proximal Femoral Dynamic Locking Plate

Although it is not available in the United States, a new dynamic locking plate design with multiple angularly stable sliding screws (Targon FN; Aesculap) has shown promising potential for managing femoral neck fractures.27 These implants are a hybrid between cancellous lag screws and an SHS implant, providing rotational stability, controlled collapse of the femoral neck, and prevention of screws from backing out. Early results have shown similar functional results and less femoral neck collapse when compared with SHS implants28 as well as lower nonunion and revision rates when compared with cancellous lag screws.29 The early results for this dynamic locking plate set as an encouraging implant option that may offer similar or even better results than the established implant standards, but more clinical evidence is necessary to institute and advocate regular use.

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CONCLUSIONS

Femoral neck fractures are the source of significant morbidity and mortality. CRIF and ORIF of femoral neck fractures with plate implants are established treatment options offering mechanically stable fixation with good long-term implant survival and functional results when appropriately used. The aims of intervention are to optimize patient function, achieve long-term joint preservation, and prevent medical complications. To avoid these complications, careful evaluation of the patient and consideration of all of the options to successfully treat a femoral neck fracture is paramount. Appropriate surgical approach and choice of implant is critical for optimizing the treatment and ultimate outcome of patients with femoral neck fractures.

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Keywords:

femoral neck fractures; femoral neck; femur fracture

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