This week’s Orthopaedic Crossfire® debate was part of the 32nd Annual Current Concepts in Joint Replacement® (CCJR) – Winter meeting, which took place in Orlando December 2015. This week’s topic is “ORIF for Displaced Femoral Neck Fx’s in the 50-60 Year Old Patient.” For the proposition George J. Haidukewych, M.D., Orlando Health Orthopedic Institute, Orlando, Florida. Opposing is Edwin P. Su, M.D., Hospital for Special Surgery, New York, New York. Moderating is Paul F. Lachiewicz, M.D., Duke University Medical Center, Durham, North Carolina.
Dr. Haidukewych: Fractures of the femoral neck are life-changing injuries and their management, as you’ll see, is highly controversial. My purpose is to discuss why young, active patients—those under 60—should keep their own femoral head if possible and give you some tips and tricks on the technical aspect of obtaining anatomic reduction and stable internal fixation.
I concede to Ed that for elder patients, infirmed patients, patients over age 60, arthroplasty is clearly the better choice and the data supports that. Why? Because the bone is poor quality.
There are several studies I’m sure that Ed will bring up that show superiority of total hip. But remember, these are patients who are 65 and older. Arthroplasty in that cohort does offer a lower re-operation rate, better function, same mortality, same medical risk and a lower cost to society.
However, in the young, healthy, under 60 patient, the best femoral head you can have is your own. There’s no activity restriction on your own hip. No dislocations, no osteolysis. You never have to check a cobalt chrome level. There are no infections and if you need a hip later, you’re young and healthy, you can tolerate that.
What is the rate of re-operation for a younger cohort treated with internal fixation?
In an older cohort—60 plus—the failure rate is 40% or higher. In the younger patient, using our own series, only 15% had a re-operation. In other studies, about 20% needed a re-operation if you repaired a femoral neck fracture in a young patient. So the take-home point is…only 1 in 5 young patients treated with open reduction internal fixation (ORIF) will need conversion to total hip arthroplasty. Our survivorship at 10 years, after ORIF – 85% still had their own femoral head.
The results of ORIF, however, are strongly dependent on the technical component, which is the quality of reduction and the implant choice.
Fixation should be done efficiently. You need to do a good job. Choose a fixation device based on fracture verticality. Nondisplaced fractures are treated the same regardless of age. We treat that with three screws. If we have good peripheral and calcar support, we can expect uneventful healing with a very low failure rate.
What about younger patients with vertical, difficult fractures? We see that reduction matters. In our series, if you did a good job fixing the fracture, the non-union rate is 4%. If you did a poor job, 8 out of 10 went on to non-union or AVN [avascular necrosis], so a lot of it is in our hands. Look at the shear angle when you pick your fixation device. Pauwel’s classification is very effective at helping us predict this going from a low shear angle to a high shear angle.
For higher shear angle fractures, the femoral head’s going to want to displace due to the vertical joint reactive force. You need to neutralize that somehow. You can do that with a variety of devices. My preferred device is a side plate with a derotation screw, to avoid this problem.
The Liporace, et al series showed a two-fold higher failure rate if you used screws alone. The Gardner, et al series showed a seven-fold higher rate if you used screws alone. Do something to neutralize the shear force. The open reduction technique typically involves some visualization of the anterior aspect of the hip. I’ll perform a capsulotomy…look at the fracture, look at the contour of the femoral head and neck in two views; get an anatomic reduction; stabilize the fracture; get good solid neutralizing fixation. Be careful not the spin the head. You may need to tap for that central lag screw.
So, for the young active patient, somebody under 60, that’s healthy, ORIF is clearly the best choice. If I have an 85% chance of keeping my own hip and I’m under 60, please give me that shot. I’m healthy enough to have a conversion to total hip if it fails.
Dr. Su: I’m going to take the position that open reduction internal fixation is not the best choice for a displaced femoral neck fracture in the 50-60 year old patient.
So you’ve just heard from George. He’s articulate, has countless publications, movie star good looks and he’s both trauma and arthroplasty fellowship trained.
So I have a really difficult task here.
But I do have a trump card. My trump card is that this meeting is called Current Concepts in Joint Replacement, not Current Concepts in Internal Fixation.
I think most of the audience here is going to agree with me, George. And if they don’t, I’m going to overwhelm them with evidence and reason.
Our goal is to restore function of the patient to his/her pre-operative status as closely as possible. We’d like to perform an operation for his/her entire life with the lowest complication rate possible. I concede to you that the benefits of internal fixation are the retention of the patient’s own bone; less invasive surgery in most cases, although this can be questionable; there’s no need for restrictions upon activity or movement once it’s healed and there’s no risk of joint dislocation. So this certainly is attractive for the younger patient.
However, I think it comes with a price. I think there’s definitely a longer healing time. It may progress to arthritis in the future. We certainly realize with a displaced femoral neck fracture that there is a possibility of osteonecrosis and there’s also a possibility of loss of fixation due to poor bone quality, leading to malunions and poor biomechanics.
In general, internal fixation should be performed for younger patients and minimally displaced fractures and the retention of one’s own joint gives them the potential to return to full activity. However, we definitely realize there’s concern regarding implant longevity and a risk of AVN with internal fixation—about 30%.
Arthroplasty is a superior choice for these fractures. It treats both the fracture and any co-existing arthritis without a risk of avascular necrosis developing. You essentially excise the fracture and obviate the need for fracture healing. Historically, however, total hip replacement has had a higher dislocation rate when you perform it for a fracture versus osteoarthritis.
I would submit to you that total hip technology has improved to better address these concerns of dislocation and wear. We have highly cross-linked polyethylene. It’s been performing extremely well up to 15 years. It gives us larger head sizes, dual mobility options, and less concern for wear and longevity. We also have the proliferation of alternative surgical approaches such as the direct anterior and direct lateral approaches to address those concerns of stability.
The benefits, in my mind, of total hip arthroplasty are that it gives the patient immediate ambulation. So I would submit to you, George, that my patient who gets a total hip is going to be up and walking faster than your patient who gets internal fixation. It is the definitive operation for the hip. One and done. That’s my motto.
So obviously we have to weigh the risks and benefits in these patients. And looking at the literature, in a meta-analysis of more than 2, 000 patients comparing arthroplasty versus internal fixation, arthroplasty had fewer complications, fewer reoperations, with no significant difference in mortality at 30 days or 1 year.
In another meta-analysis looking at over 2, 500 patients, arthroplasty reduced the risk of major complications, reoperations, with better function, better pain relief, albeit I’ll concede to George, that these are in older patients.
A study looking at internal fixation in younger patients, as well as looking at the risk of AVN, found that in the overall cohort of displaced fractures, it’s about a 10% risk of AVN. And interestingly, if you stratify by age, less than 60 years of age, there is a 1-in-5 chance of developing AVN. This is thought to be due to the higher energy needed to displace those younger patients’ bone.
Finally, I would submit to you that open reduction internal fixation will very likely result in future surgery in maybe 30%-40% of cases. I think a total hip replacement is a better operation with a lower rate of complications and reoperation. It has a faster recovery, better pain relief. Cross-linked polyethylene decreases my concern of wear and osteolysis. I think we have technologies that can address the dislocation rate and additional surgical approaches to enhance stability.
Moderator Lachiewicz: George, let me ask you a couple of questions. I’m concerned, like Ed, about opening the capsule anteriorly and having to use those dynamic hip screws (DHS) for these patients. How often do you do that, actually open the capsule to check reduction and use the DHS.
Dr. Haidukewych: It’s actually routine. As far as using the DHS, that’s more based on the fracture verticality. If you have a horizontal fracture, albeit rare, in a young patient…usually at a vertical and high energy. You’ve got to neutralize the shear and you’ve got to get those reduced right. Nobody says you have to open a hip to get an anatomic reduction, but most people do just to make sure. And you’re right there through your lateral approach to be able to put in your implant.
What is your concern with the DHS? You’re worried about spinning the head?
Moderator Lachiewicz: It was just in terms of your later reconstruction that you may have to use a longer stem. You may have more blood loss intraoperatively removing it.
Dr. Haidukewych: Good news is you’re only going to have to do that in 1 out of 5 if you do a good job fixing the fracture. So you’ll get over the concern, I think, and it’s relatively easy to bypass. It’s pretty easy to bypass stress risers with a modular stem. Or even with a full coat. I use a short side plate, typically, on those. You don’t need to use a 4-hole or 6-hole. All you need is a neutralization force, you can use a 2 or 3 hole and then you can bypass that with a primary length of stem which is usually in the neighborhood of 170mm length.
Moderator Lachiewicz: I think that’s an important point that if you are using a side plate, to use a 2-hole plate. What I see is that surgeons are using 4-hole, 5-hole side plates because that’s what they have in their hospitals.
Dr. Su: So, George, if you look at your own primary total hip arthroplasty practice, do you ever put a total hip in a 50 or 60 year old patient?
Dr. Haidukewych: Routinely.
Dr. Su: Routinely. And you probably tell that patient this is a great operation, it’s going to transform their life.
Dr. Haidukewych: Yes, but after their joint is trashed and they have a lot of pain. These joints and femoral heads look good. There’s tons of cartilage. They were having no pain until they got hit by a bus and now…
Dr. Su: So why would you deny the 50 to 60 year old patient with a displaced femoral neck fracture that same wonderful operation?
Dr. Haidukewych: Because I can provide that with internal fixation for 4 out of 5 patients and they have no activity restriction, no dislocation, no poly wear, no taper corrosion, no reoperations for prosthetic complications, and no metal-on-metal. For all the reasons we’re all born with our own total hips, our own hips, not total hips.
Moderator Lachiewicz: Okay, what about a heavier patient, or someone who said that they ran marathons and they were hit by a cab on Fifth Avenue? Should that patient have a total hip?
Dr. Su: Yeah, so impact sports might sway the decision, so if somebody wants to do impact sports, that might be better suited for internal fixation.
Moderator Lachiewicz: Okay, thank you very much gentlemen.
Please visit www.CCJR.com to register for the 2016 CCJR Winter Meeting, December 14 – 17 in Orlando.
