Abstract
Over the past decade there has been a shift in the approach to management of many femoral neck fractures. As noted by Miller et al. those trends are reflected in the practice patterns of surgeons applying for board certification through the American Board of Orthopaedic Surgeons. From 1999 to 2011 there was a trend toward total hip arthroplasty and corresponding small decreases in the use of hemi-arthroplasty and internal fixation for treatment of femoral neck fractures. For many years the treatment approach has been a simple diagnosis-related algorithm predicated upon classification of the fracture as displaced (historically treated with hemi-arthroplasty) or non-displaced (historically treated with internal fixation). More recently, however, the focus has shifted to a patient-centered approach. In the patient-centered approach factors such as age, functional demands, pre-existent hip disease and bone quality should all be considered. In the contemporary setting it is still important to distinguish between displaced and non-displaced fracture patterns. Non-displaced femoral neck fractures, regardless of patient age or activity, are well-suited to closed reduction and internal fixation, most commonly with three cannulated screws. The union rate is high in non-displaced fractures treated with internal fixation and the benefits of preserving the native hip joint are substantial. Displaced femoral neck fractures in younger active patients, particularly those without pre-existent hip arthritis, are best treated with early anatomic reduction and internal fixation. While a subgroup of young, active patients who undergo ORIF may fail, the benefits of native hip preservation in that group are again substantial. Displaced femoral neck fractures in older patients or those with substantial pre-existing hip arthritis are best treated with arthroplasty. The biggest practice change has been the trend to total hip arthroplasty as opposed to hemi-arthroplasty for a subgroup of patients. Total hip arthroplasty is now favored in almost all active, cognitively well-functioning patients as the degree of pain relief is better and the risk of reoperation is lower in the current era (32mm and 36mm femoral heads). Hemi-arthroplasty, either uni-polar or bi-polar, remains an appropriate treatment for cognitively impaired patients who also have limited functional demands in whom the risk of dislocation is particularly high.
