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.
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.
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.
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.
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
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).
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.
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.
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.
1. Fisher MA, Matthei JD, Obirieze A, et al.. Open reduction internal fixation versus hemiarthroplasty versus total hip arthroplasty in the elderly: a review of the National Surgical Quality Improvement Program database. J Surg Res. 2013;181:193–198.
2. Bhandari M, Devereaux PJ, Tornetta P III, et al.. Operative management of displaced femoral neck fractures
in elderly patients. An international survey. J Bone Joint Surg Am. 2005;87:2122–2130.
3. Aminian A, Gao F, Fedoriw WW, et al.. Vertically oriented femoral neck fractures
: mechanical analysis of four fixation techniques. J Orthop Trauma. 2007;21:544–548.
4. Collinge CA, Mir H, Reddix R. Fracture morphology of high shear angle “vertical” femoral neck fractures
in young adult patients. J Orthop Trauma. 2014;28:270–275.
5. Luttrell K, Beltran M, Collinge CA. Preoperative decision making in the treatment of high-angle “vertical” femoral neck fractures
in young adult patients. An expert opinion survey of the Orthopaedic Trauma Association's (OTA) membership. J Orthop Trauma. 2014;28:e221–e225.
6. Krischak G, Beck A, Wachter N, et al.. Relevance of primary reduction for the clinical outcome of femoral neck fractures
treated with cancellous screws. Arch Orthop Trauma Surg. 2003;123:404–409.
7. Weinrobe M, Stankewich CJ, Mueller B, et al.. Predicting the mechanical outcome of femoral neck fractures
fixed with cancellous screws: an in vivo study. J Orthop Trauma. 1998;12:27–36; discussion 36–37.
8. Lowell JD. Results and complications of femoral neck fractures
. Clin Orthop Relat Res. 1980;152:162–172.
9. Bedi A, Karunakar MA, Caron T, et al.. Accuracy of reduction of ipsilateral femoral neck
and shaft fractures—an analysis of various internal fixation strategies. J Orthop Trauma. 2009;23:249–253.
10. Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al.. Operative treatment of femoral neck fractures
in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004;86-A:1711–1716.
11. Leadbetter GW. A treatment for fracture of the neck of the femur. Reprinted from J Bone Joint Surg
20:108–113, 1938. Clin Orthop Relat Res. 2002;399:4–8.
12. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures
in young adults. J Bone Joint Surg Am. 2008;90:2254–2266.
13. Chen CY, Chiu FY, Chen CM, et al.. Surgical treatment of basicervical fractures of femur—a prospective evaluation of 269 patients. J Trauma. 2008;64:427–429.
14. Massoud EI. Fixation of basicervical and related fractures. Int Orthop. 2010;34:577–582.
15. Liporace F, Gaines R, Collinge C, et al.. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures
. J Bone Joint Surg Am. 2008;90:1654–1659.
16. Blair B, Koval KJ, Kummer F, et al.. Basicervical fractures of the proximal femur. A biomechanical study of 3 internal fixation techniques. Clin Orthop Relat Res. 1994;306:256–263.
17. Stiasny J, Dragan S, Kulej M, et al.. Comparison analysis of the operative treatment results of the femoral neck fractures
using side-plate and compression screw and cannulated AO screws. Ortop Traumatol Rehabil. 2008;10:350–361.
18. Bonnaire FA, Weber AT. Analysis of fracture gap changes, dynamic and static stability of different osteosynthetic procedures in the femoral neck
. Injury. 2002;33(suppl 3):C24–C32.
19. Baumgaertner MR, Curtin SL, Lindskog DM, et al.. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77:1058–1064.
20. Boraiah S, Paul O, Hammoud S, et al.. Predictable healing of femoral neck fractures
treated with intraoperative compression and length-stable implants. J Trauma. 2010;69:142–147.
21. Berkes MB, Little MT, Lazaro LE, et al.. Catastrophic failure after open reduction internal fixation of femoral neck fractures
with a novel locking plate implant. J Orthop Trauma. 2012;26:e170–e176.
22. Glassner PJ, Tejwani NC. Failure of proximal femoral locking compression plate: a case series. J Orthop Trauma. 2011;25:76–83.
23. Broos PL, Vercruysse R, Fourneau I, et al.. Unstable femoral neck fractures
in young adults: treatment with the AO 130-degree blade plate. J Orthop Trauma. 1998;12:235–239; discussion 40.
24. Goodman SB, Schatzker J. Internal fixation of femoral neck fractures
: a prospective study. Can J Surg. 1986;29:351–356.
25. Visuri T, Vara A, Meurman KO. Displaced stress fractures of the femoral neck
in young male adults: a report of twelve operative cases. J Trauma. 1988;28:1562–1569.
26. Driesen R, Nijs S, Broos PL, et al.. Unstable femoral neck fractures
treated with a 130 degrees blade plate. Acta Orthop Belg. 1994;60:322–327.
27. Parker M, Cawley S, Palial V. Internal fixation of intracapsular fractures of the hip using a dynamic locking plate: two-year follow-up of 320 patients. Bone Joint J. 2013;95-B:1402–1405.
28. Eschler A, Brandt S, Gierer P, et al.. Angular stable multiple screw fixation (Targon FN) versus standard SHS for the fixation of femoral neck fractures
. Injury. 2014;45(suppl 1):S76–S80.
29. Thein R, Herman A, Kedem P, et al.. Osteosynthesis of unstable intracapsular femoral neck
fracture by dynamic locking plate or screw fixation: early results. J Orthop Trauma. 2014;28:70–76.