Can We Improve the Results of Internal Fixation?

Commentary Wagner et al. remind the reader of the unsolved challenges of managing femoral neck fractures with joint preservation. Their series included 112 patients aged 60 or younger with a femoral neck fracture for which internal fixation was indicated. Despite achieving satisfactory reduction in 90% of patients, 35% of the cohort experienced a reoperation, including almost 20% eventually requiring a total hip arthroplasty within the mean 7-year follow-up. The greatest contribution of this work is the inclusion of long-term patient-reported outcomes. Study participants had a minimum of 2 years of follow-up, and 72% of the patients completed the questionnaires. The patient-reported data confirm clinical experience—if a young adult’s femoral neck fracture heals without complication, the outcomes mirror population norms; in contrast, individuals who experience fracture-healing complications report persistent disability. In this series, the median EQ-5D (EuroQol-5 Dimension), EQ-5D VAS (visual analog scale), and Oxford Hip Score for the overall cohort were better or similar to those of age-matched populations, yet approximately 20% of the respondents reported worse outcomes that exceeded minimum clinically important differences. This finding is consistent with a similar series also suggesting that patient-reported outcomes are excellent if complications are avoided1. The disparities in patient-reported outcomes are most likely related to the fact that the ≤60-year-old adult hip-fracture population comprises 2 distinct groups: (1) high-energy trauma in younger individuals, and (2) low-energy early fragility fractures in patients with advanced biological age. As the authors astutely point out, many of the risk factors for fixation failure in the latter population, such as excessive use of alcohol, are also risk factors for arthroplasty complications. The irreversible nature of primary arthroplasty and the severity of arthroplasty-related complications likely sustain surgeons’ preference for joint preservation in many “young” patients with advanced biological age. However, surgeons should be aware that decision-analysis modeling suggests arthroplasty is likely the optimal treatment for patient groups as young as ≥45-year-olds when they have multiple comorbidities2. There is a clear need to improve femoral neck fracture outcomes for adults for whom fracture fixation is indicated. Despite adamant opinions promoting the need for mandatory open reduction3, buttress plates on the medial neck4, or newer fixed-angle devices5,6, the literature continues to demonstrate that our fixation strategies are associated with major complications in one-third of cases7–9. This complication rate is observed in younger and older populations with a femoral neck fracture. So what should surgeons do? The first step is to be fully cognizant of the 2 adult femoral neck fracture populations. The easiest solution is more liberal use of arthroplasty for middle-aged patients with advanced biological age. However, this will not solve the challenges faced by the younger, high-energy femoral neck fracture population. In these most difficult cases, the Wagner et al. series prompts more inquiry. Only 15% of the procedures were performed by consultants; would more surgeon expertise improve the outcome? Perhaps this could have decreased their rate of coronal plane malreduction. The prior literature has identified radiographic malreduction—varus malalignment, malrotation, or posterior tilt—as a poor prognostic marker10,11; yet, neither meticulous attention to detail nor surgeon hubris seems to be enough to avoid complications in many comminuted and displaced fractures. In fact, even valgus-impacted femoral neck fractures with no posterior tilt have demonstrated a 15% reoperation rate in the elderly12. It is unclear if outcomes of internal fixation for femoral neck fracture will drastically improve. Collinge and colleagues’ recent multicenter series of 565 femoral neck fractures in young and middle-aged individuals suggests that poor outcomes are commonly seen on both sides of the Atlantic13. While I remain optimistic that incremental benefits will be realized with better surgical discernment, I continue to counsel my patients on the uncertain prognosis of their injury.