Femoral Neck Fracture: Surgical Therapy

Surgical therapy represents the first-line treatment for femoral neck fracture:

  • Osteosynthesis – surgical procedure to treat fractures (broken bones) and other bone injuries (e.g., epiphysiolysis) to quickly restore full function. This is done by implants (by means of insertion of force carriers such as screws or plates).
  • Hip endoprosthesis (hip TEP; total endoprosthesis of the hip joint) – artificial hip joint.

Note: The prognosis of older patients with hip fracture worsens with waiting time for surgery. According to one study, the risk of dying within the next year increased by about 5% for every ten hours of additional waiting time. The Joint Federal Committee (G-BA) has decided that, in the future, hospitals will be required to operate on patients with a femur fracture near the hip joint within 24 hours, if their general condition permits.

Indications for osteosynthesis

  • Prophylactic: non-displaced (displaced, displaced), stable fractures.
  • Younger and older patients of active age regardless of fracture type.
  • In older age speak for osteosynthesis:
    • Well preserved physical and mental performance
    • Stable fractures (impacted, Pauwels I, Garden I).
    • No or only slight dislocation (Garden II, possibly III).
    • Well-reducible (resettable) fracture.
    • No significant osteoporosis (bone loss)
    • Large head and neck fragment
    • Large femoral neck diameter
    • Fracture not older than 24 h
    • Ipsilateral paresis (paralysis on the same side).
  • In the case of significantly reduced general condition
    • Frailty
    • Bedriddenness
    • Senile dementia

Indications for endoprosthesis

  • Severely dislocated fracture
  • Fracture not satisfactorily reduced
  • Elderly and mobilizable patients with reduced capacity.
  • Osteoporosis
  • Pathological fracture (spontaneous fracture; bone fracture that occurs “spontaneously”, i.e. without adequate trauma, but due to a weakening of the bone caused by disease).
  • Present coxarthrosis (osteoarthritis / bone wear of the hip joint).

Other indications

  • Analysis of data from the NSQIP database of the American College of Surgeons showed that regardless of the surgical procedure for femoral neck fracture, a cardiac event (myocardial infarction/heart attack or cardiac arrest) occurred 1 month postoperatively (“after surgery”) in 2.2% of cases (= 592 patients). Risk factors were:
    • Age (>65 years)
    • Pre-existing heart disease (angina pectoris () “chest tightness”; sudden onset of pain in the heart area, heart failure (cardiac insufficiency), myocardial infarction (heart attack), and/or PTCA or stent).
    • Chronic obstructive pulmonary disease (COPD).
    • Dyspnea (shortness of breath)
    • Blood clotting disorders
    • Diabetes mellitus
    • Hypertension (high blood pressure)
    • Peripheral arterial vascular disease (pAVK)
    • Wound infections
    • Cerebrovascular (“affecting the blood vessels of the brain”) damage
    • Frequent receipt of blood transfusions

    After accounting for several influencing variables (age, sex, skin color, ASA score), a clear association with postoperative cardiac complication was shown for the following conditions:

    • Renal failure requiring dialysis (odds ratio, OR = 2.22) [preoperative laboratory diagnosis: potassium; presentation to nephrologist]
    • PAVK (OR = 2.11).
    • Apoplexy/stroke (OR = 1.83), COPD (OR = 1.69).
    • Pre-existing heart disease (OR = 1.55) [pre- and operative laboratory diagnostics: troponin, NT-proBNP (N-terminal pro brain natriuretic peptide); presentation to cardiologist if necessary].
  • Hip fracture
    • Patient age >65 years: surgery versus conservative care: 30-day mortality was 3.95-fold higher for the nonsurgically treated patients than for the operated group; 3.84-fold higher after 1 year.
    • Nursing home patients with a hip fracture and advanced dementia: mortality (death rate) was 12% lower for surgically treated patients at two-year follow-up.
  • Dislocated femoral neck fracture: implantation of total endoprosthesis versus hemiprosthesis (which replaces only the femoral head but not the acetabulum (hip joint or pelvic socket); primary end point of the study was a second hip replacement within the first 24 months:
    • Total endoprosthesis (= replacement of femoral head and acetabulum): in 57 of 718 patients (7.9%).
    • Hemiprosthesis: 60 of 723 patients (8.3%).

    The difference was not significant; total endoprosthesis had fewer revisions in the second year than after implantation of hemiprosthesis, which may indicate less long-term durability.