Rationale

Urgent or emergent reduction and fixation of displaced femoral neck fractures has been postulated to decrease postoperative rates of AVN of the femoral head. Optimal timing of intervention is an ongoing debate.

Clinical comment

Proper management of displaced femoral neck fractures in young adult patients remains controversial. Treatment is associated with historically high complication rates including AVN, malunion, nonunion, and implant failure.^1–4 With the treatment goal being joint preservation, the most feared complication is AVN of the femoral head. Efforts have been made to reduce and stabilize the fracture in an urgent or emergent fashion to decrease this risk. However, there are currently no studies that can support the routine practice of emergent (<6 hours) surgical fixation in these patients.

Available literature and quality of the evidence

There is a lack of literature investigating optimal timing of fixation in young adult patients with femoral neck fractures. Recent literature includes a level I prospective randomized study comparing outcomes and complications in young patients with displaced femoral neck fractures.⁵ Additionally, there is one retrospective cohort and one meta‐analysis (level II), which both analyze the correlation of time to fixation with rates of AVN.^6,7

Findings

Upadhyay and colleagues performed a prospective randomized multicenter study on 92 patients with Garden grades III and IV femoral neck fractures.⁵ Patients aged 15–50 years who underwent closed or open reduction with internal fixation were followed clinically and radiographically for two years. Secondary measures included risk factors affecting the development of AVN and nonunion. Forty‐two patients had a delay of femoral neck fixation of >48 hours, and 15 femoral heads developed AVN. Of the 16 femoral necks that developed nonunion, 7 (43.8%) consisted of a delay of fixation of >48 hours (odds ratio [OR] = 1.37; 95% confidence interval [CI]: 0.20–9.50). They concluded that no factors investigated, including time of surgery, increased the risk of developing AVN.⁵

Razik et al. performed a retrospective study investigating effect of time delay to fixation in patients with femoral neck fractures.⁶ Patients underwent fixation with either SHS, CS, or SHS with a de‐rotation screw. Ninety‐two patients under the age of 60 followed for a mean of two years were retrospectively analyzed. Time to fixation was divided into intervals including ≤ 6 hours, 6–12 hours, 12–18 hours, 18–24 hours, 24–48 hours, and >48 hours. The percentage of patients who developed AVN was 14.1%. Two had nondisplaced fractures and 11 had displaced fractures. Utilizing a binary logistic regression model, incidence of AVN did not increase significantly past the six‐hour time to surgery interval, with no significant difference demonstrated between time intervals and rate of AVN.⁶

A meta‐analysis performed by Papakostidis et al. reported on timing of internal fixation of femoral neck fractures.⁷ Out of 492 studies that investigated outcomes of acute femoral neck fractures, seven met final inclusion criteria and six consisted of young adult patients. A meta‐analysis was performed to compare time of internal fixation with rates of AVN and nonunion. Groups included fixation within six hours versus fixation after six hours, fixation within 12 hours versus fixation after 12 hours, fixation within 24 hours versus fixation after 24 hours, and fixation within 6 hours versus fixation after 24 hours. There was no association between AVN and any time interval. However, the odds of nonunion tripled with patients who underwent internal fixation after 24 hours (p = 0.004).⁷

Resolution of clinical scenario

Related posts:

The Direct Anterior Approach Patient‐Specific Instrumentation in Total Knee Arthroplasty Management of Glenoid Bone Loss Distal Femur Fractures Periprosthetic Fractures: Knee Spinal Infections

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