Session II - Femur

Internal Fixation of Ipsilateral Femoral Neck and Shaft Fractures ­ A Radiographic Study of the Accuracy of Reduction

Asheesh Bedi, MD¹ (n); Troy Caron, DO² (n); Eric Lindvall, DO² (n); H. Claude Sagi, DO² (n); Roy W. Sanders, MD² (b-Smith+Nephew, b-DePuy); George J. Haidukewych, MD² (b-DePuy) (n);

¹Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA;

²Orthopaedic Trauma Service & Florida Orthopaedic Institute, Tampa, Florida, USA

Purpose: Controversy surrounds the ideal treatment of ipsilateral fractures of the femoral neck and shaft. Prior studies have established that reduction quality affects the long-term outcome of both fractures. The purpose of this study was to critically review the quality of reduction of both fractures in a large consecutive series of patients to learn more about the efficacy of various fixation techniques and devices.

Methods: Between 1989 and 2006, 33 consecutive patients underwent internal fixation of an ipsilateral femoral neck and shaft fracture at our Level I trauma center. Patients with displaced femoral neck fractures were routinely treated with two devices and underwent formal open reduction of the femoral neck. Patients with nondisplaced neck fractures were treated with either one or two devices based on surgeon preference. Radiographs were reviewed to critically evaluate quality of reduction of each fracture using previously published criteria. Clinical correlation of outcome as related to reduction quality was performed.

31 of 33 patients (94%) had sufficient radiographs to assess accuracy of femoral neck and shaft reduction. 16 males and 15 females, age range 18-73 (mean, 38 years), sustained 15 left and 16 right ipsilateral neck-shaft fractures respectively. The femoral neck fractures were displaced in 18 patients and nondisplaced in 13 patients. Femoral shaft fractures included 5 Winquist I, 10 Winquist II, 10 Winquist III, and 6 Winquist IV patterns. Eight neck fractures (7 nondisplaced and 1 displaced) were addressed with a single implant (7 cephalomedullary devices and 1 10-hole sliding hip screw) and 23 with two devices (17 retrograde intramedullary nails with cannulated screw or sliding hip screw fixation, 1 compression plate with sliding hip screw fixation, and 1 antegrade intramedullary nail with cannulated screw fixation). Clinical follow-up was available on 22 patients with a mean duration of 21 months (range, 3-112 months).

Results: 30 patients (97%) demonstrated good to excellent femoral neck reductions. The only poor reduction occurred in the case of a displaced femoral neck fracture treated with a single implant. 29 excellent (94%) and 2 poor shaft reductions were obtained (both in comminuted fracture patterns). All but one femoral neck fracture (95%) with sufficient follow-up united without complication. Two cases demonstrated progressing union at 3 months. One case of femoral neck fixation failure required conversion to hip arthroplasty. No cases of osteonecrosis were noted. Two femoral shaft nonunions required revision internal fixation, both occurring in the cases of poor reduction.

Conclusions: In the current series, formal open reduction and internal fixation of the femoral neck fracture followed by retrograde nailing of the femoral shaft allowed accurate reduction of both fractures in the vast majority of patients. Reduction quality correlated with clinical outcomes. We advocate the use of two devices for displaced femoral neck fractures associated with ipsilateral shaft fractures.