Session III - Femur

Outcomes of Operative Treatment of Femoral Neck Fractures in Patients 15 to 50 Years of Age

George J. Haidukewych, MD; Walter S. Rothwell; David J. Jacofsky; MD; Michael E. Torchia, MD; Daniel J. Berry, MD; Mayo Clinic, Rochester, Minnesota, USA

Purpose: There is a paucity of data evaluating the outcomes of treatment of femoral neck fractures in young patients. The purpose of this retrospective review was to evaluate a large consecutive series of femoral neck fractures in young patients treated with contemporary methods of internal fixation to learn more about the results and complications of treatment of these potentially devastating injuries.

Materials and Methods: Between 1975 and 2000, 82 consecutive patients with 83 nonpathologic fractures of the femoral neck (OTA type 31B) were treated with internal fixation at our level I trauma center. There were 53 men and 29 women with a mean age of 36 years (range, 15 to 50). Fifty-nine fractures were displaced and 24 were nondisplaced; 43 of the 59 displaced fractures were treated with closed reduction and internal fixation and 16 required formal open reduction and internal fixation. Two patients died and 8 (9.8%) were completely lost to follow-up. We observed 73 fractures to union, revision operation, or a minimum of 2 years with a mean clinical follow-up of 6.3 years (3 months to 23 years) and a mean radiographic follow-up of 5.3 years (3 months to 23 years). Clinical and radiographic data were retrospectively reviewed, and results and complications were analyzed. Functional assessment at follow-up was performed by evaluating pain, ambulatory status, need for gait aids, and need for secondary surgical procedures. Reductions were graded as excellent, good, fair, or poor based on angulation and displacement.

Results: For the group as a whole, 54 of 73 (74 %) fractures achieved successful bony union without evidence of avascular necrosis at the last follow-up. Seventeen of 73 fractures (23%) developed avascular necrosis (1 Ficat stage 1, 5 stage 2, 5 stage 3, and 6 stage 4); 6 fractures (8%) developed nonunion. Of the 51 fractures that were initially displaced, 5 (9.8%) developed nonunion, and 14 (27%) developed avascular necrosis. Of the 22 nondisplaced fractures, only 1 (4.5%) developed nonunion, and 3 (14%) developed avascular necrosis. At follow-up, 11 of 73 (15%) patients required conversion to hip arthroplasty and 5 required secondary surgical procedures to achieve union (two valgus osteotomies, two muscle pedicle bone grafts, and one repeat open reduction internal fixation). Sixty-eight of 73 (93%) fractures had good-to-excellent reductions, of these, 14 (20%) developed avascular necrosis, and 3 (4%), nonunion. Five of 73 had fair or poor reductions, 4 (80%) developed avascular necrosis, nonunion, or both.

Conclusions and Significance: Femoral neck fractures in young patients remain challenging injuries to treat. Despite contemporary techniques of internal fixation and the very high percentage of excellent reductions, the incidence of avascular necrosis and nonunion remains concerning. For the 73 patients with mean clinical follow-up of 6.3 years, the native femoral head was successfully salvaged in 85% of patients. Functional status of patients with salvaged femoral heads was excellent. These data represent the largest series with the longest follow-up and supports continued efforts to obtain the best reduction possible when treating these injuries.