We report the clinical and radiological outcome of subcapital osteotomy of the femoral neck in the management of symptomatic femoroacetabular impingement (FAI) resulting from a healed slipped capital femoral epiphysis (SCFE). We believe this is only the second such study in the literature. . We studied eight patients (eight hips) with symptomatic FAI after a moderate to severe healed SCFE. There were six male and two female patients, with a mean age of 17.8 years (13 to 29). . All patients underwent a subcapital intracapsular osteotomy of the femoral neck after surgical hip dislocation and creation of an extended retinacular soft-tissue flap. The mean follow-up was 41 months (20 to 84). Clinical assessment included measurement of range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster Universities Osteoarthritis score (WOMAC). Radiological assessment included pre- and post-operative calculation of the anterior slip angle (ASA) and lateral slip angle (LSA), the anterior offset angle (AOA) and centre head–trochanteric distance (CTD). The mean HHS at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6) and 3.6 (0 to 19) respectively. There was a statistically significant improvement in all the radiological measurements post-operatively. The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°) (p <  0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4° (8° to 21°) (p < 0.01). The mean AOA decreased from 64.4° (50° to 78°) 32.0° (25° to 39°) post-operatively (p < 0.01). The mean CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0) (p < 0.01). Two patients underwent further surgery for nonunion. No patient suffered avascular necrosis of the femoral head. Subcapital osteotomy for patients with a healed SCFE is more challenging than subcapital re-orientation in those with an acute or sub-acute SCFE and an open physis. An effective correction of the deformity, however, can be achieved with relief of symptoms related to impingement. Cite this article: Bone Joint J 2014;96-B:1441–8

Options for the treatment of subcapital femoral neck fractures basically fall into two categories: internal fixation or arthroplasty (either hemiarthroplasty or total hip arthroplasty). Historically, the treatment option has been driven by a diagnosis-related approach (non-displaced neck fractures versus displaced neck fractures). More recently, the traditional paradigm has changed. Instead of a diagnosis-related approach, it has become more of a patient-related approach. Treatment options take in to consideration the patient’s age, functional demands, and individual risk profile. A simple algorithm can be helpful in terms of directing the treatment. Non-displaced fractures, regardless of age of the patient, should be treated with closed reduction and internal fixation. For displaced femoral neck fractures, the treatment differs depending on the age of the patient. The younger patient should be treated with urgent ORIF with the goal of an anatomic reduction. For displaced femoral neck fractures in the elderly, cognitive function should be determined. For those who are cognitively functioning, total hip arthroplasty appears to be the best option. In the cognitively dysfunctional, a bipolar hemiarthroplasty or a total hip arthroplasty with use of larger heads (32 mm or 36 mm) and/or constrained sockets are a viable option

1. Practical experience has shown that subcapital fractures of the femur unite freely if reduction is stable and fixation is secure. 2. Stable reduction is obtained when the muscular and gravitational forces tending to redisplace the fracture are opposed by equal and opposite counterforces, and inherent stability is believed to depend upon the integrity of the flared cortical buttress at the postero-inferior junction of the femoral neck and head. 3. In the stable subcapital fracture a state of equilibrium is reached when the forward and upward thrust of the fixation appliance in the femoral head is opposed by the counterthrust of the closely applied and cleanly broken fragments at the postero-inferior aspect of the fracture. When the postero-inferior cortical buttress is comminuted, inherent stability is lost, lateral rotation deformity recurs and the fixation device is avulsed from the cancellous bone of the head. 4. Stability may be restored by reduction in the "valgus" position, by various forms of osteotomy, by refashioning the fracture fragments or by a postero-inferiorly positioned bone graft. Theoretically, stability may also be obtained by a double lever system of fixation in which an obliquely placed fixation device or bone graft is combined with a horizontally disposed wire, pin, nail or screw crossing it anteriorly. Multilever fixation by three or more threaded wires or pins inserted at different angles and lying in contact at their point of crossing may likewise provide stability. 5. Fixation by two crossed screws has been chosen for clinical trial in 100 displaced subcapital fractures. Imperfect positioning of the screws in seven patients has been followed by early breakdown of reduction and non-union, but satisfactory positioning has been associated with radiological union in fifty patients who have been observed for twelve months or more. 6. Ultimate breakdown in some of these fractures is certain to follow avascular necrosis, and this complication has already been seen in a few patients treated by cross screw fixation more than two years ago. It is also expected that non-union will occur in some of those patients still under observation for less than a year. Even so, these preliminary findings indicate a percentage of union far greater than that obtained by previous methods of treatment, and, although statistically inadequate, they are presented in support of the belief that it should no longer be considered impossible to achieve the same percentage of union in subcapital fractures of the femur as we are accustomed to expect in the treatment of fractures elsewhere. It is not implied, however, that this ideal will be reached merely by the adoption of some form of double or multilever fixation, and much will continue to depend upon the quality of the radiographic services, the precision of reduction and the perfection of operative technique. 7. Every advance in our understanding of what is meant by "perfection of operative technique" lends increasing support to the ultimate truth of Watson-Jones's (1941) dictum: "A perfect result may be expected from a technically perfect operation; an imperfect result is due to imperfect technique." But the simple and foolproof method of fixation which will end the search for technical perfection in the treatment of the displaced subcapital fracture has yet to be evolved, and many questions remain to be answered about this injury. Nevertheless, it is clear that the surgeon should now be prepared to attribute early mechanical failure in the treatment of femoral neck fractures to his own shortcomings, and the temptation to blame capital ischaemia for every disaster should be resisted

We reviewed prospectively, after skeletal maturity, a series of 24 patients (25 hips) with severe acute-on-chronic slipped capital femoral epiphysis which had been treated by subcapital cuneiform osteotomy. Patients were followed up for a mean of 8 years, 3 months (2 years, 5 months to 16 years, 4 months). Bedrest with ‘slings and springs’ had been used for a mean of 22 days (19 to 35) in 22 patients, and bedrest alone in two, before definitive surgery. The Iowa hip score, the Harris hip score and Boyer’s radiological classification for degenerative disease were used. The mean Iowa hip score at follow-up was 93.7 (69 to 100) and the mean Harris hip score 95.6 (78 to 100). Degenerative joint changes were graded as 0 in 19 hips, grade 1 in four and grade 2 in two. The rate of avascular necrosis was 12% (3 of 25) and the rate of chondrolysis was 16% (4 of 25). We conclude that after a period of bed rest with slings and springs for three weeks to gain stability, subcapital cuneiform osteotomy for severe acute-on-chronic slipped capital femoral epiphysis is a satisfactory method of treatment with an acceptable rate of complication

Quantitative polarised light microscopy was applied to sections of unfixed, undecalcified bone taken at operation from patients with two types of proximal femoral fracture, subcapital and trochanteric. Specimens were also taken from the equivalent sites in otherwise normal subjects at autopsy, and from various other sites of traumatic fractures; these two latter groups acted as controls. Analysis of the 57 specimens disclosed changes in the nature of the bone at the site of subcapital fractures, namely the presence of relatively large crystals of hydroxyapatite and a change in the molecular orientation, but not total content, of the acidic proteoglycans of the bone matrix. Our results have confirmed and extended the findings of others on subcapital fractures, and have also shown very similar changes in the trochanteric fractures. It thus appears that the bony changes in the two types of proximal femoral fracture are not as different as has been suggested

This study reviews Total Hip Arthroplasty (THA) in the subcapital femoral neck fracture population looking at early complications. Primary THA’s performed in our institution for femoral neck fractures between 1999 and 2001 were reviewed. The case records were obtained from the hospital patient information database. Medical charts, including operation and outpatient notes, were used to obtain information on the level of experience of the surgeon, supervision and complications. Sixty five THA’s were performed on 65 patients with the average age of 77. Trainee Registrars performed 62%, 15% with a consultant assistant and consultants performed 38%. There were 19 (30%) medical complications giving a total complication incidence of 38%. All of the procedures were performed via the Hardinge direct lateral approach. There were 6 (9%) surgical complications, including one deep infection requiring revision. There were no dislocations or peri-operative deaths. The one-year mortality was 9% (equal to expected mortality of age related population without fracture). Primary THA’s for displaced subcapital fracture in “community ambulators” is a safe and reliable procedure with an acceptable rate of surgical complications. Although there were a large number of minor medical complications documented, the 12-month mortality for this group remained the same as the population normal

Aims: The aim of the study is to present early results in the treatment of hallux valgus with a new 3D subcapital metatarsal osteotomy, based on a original Wilson osteotomy. 3D subcapital metatarsal osteotomy is a simple and fast procedure where we shift capitis of metatarsal bone to lateral and plantar, and fix with K-wire. Materials and methods: In the period from 1997 to 2003, 25 patients (all females) and 34 feet were operated. The patients were followed up from 1 to 7 years. The age of the patients varied from 33 up to 60 years (median value – 45 years of age). Indications for the corrective metatarsal osteotomy were the angle of hallux valgus more than 20 degrees, intermetatarsal angle more than 20 degrees as well as pain due to shoe pressure over the medial side of metatarsophalangeal joint, and aesthetic reasons. In this study all feet were evaluated (radiological, clinical and subjective evaluation). Results: The angle of hallux valgus was 20 to 50 degrees (mean value – 32.3 degrees) preoperatively, and dropped to 2 to 35 (mean value – 12.47 degrees) postoperatively. Intermetatarsal angle was 10 to 22 (mean value – 15 degrees) before operation, and 3 to 15 degrees (mean value 5 degrees) after operation. The DMA angle was 0 to 30 (mean value – 15 degrees) before operation, and 0 to 20 degrees (mean value – 20 degrees) afterwards. Shortening of first metatarsal bone was 1 to 8 mm (mean – 3 mm). We did not have any complications. Conclusion: Early results of this study show that new 3D subcapital metatarsal osteotomy in treatment of hallux valgus is a good method. It is necessary to follow strict and precise criteria in the indication of operative procedure in treating hallux valgus. The procedure itself is simple and fast

Subcapital fractures about the hip continue to be a common clinical scenario with which we all face. There are estimated to be over 350,000 hip fractures annually in the U.S. with 40% being displaced femoral neck fractures. The mean cost is over $30,000. Optimizing surgical care is essential with the overall goal being to perform the most effective treatment with the lowest risk of reoperation that provides the best postoperative function and pain relief. In the “young” (which is often defined as whatever age is younger than you!) reduction and internal fixation is often the most effective retaining the native femoral head. The risk of non-union and AVN is often less than potential complications that can follow an arthroplasty with 40% of displaced fractures treated with ORIF eventually requiring reoperation. Essentially for every 100 patients that undergo ORIF for displaced femoral neck fracture, choosing arthroplasty instead results in 17 conversions avoided. In the “elderly” in general we treat all displaced fractures with a total hip replacement which reduced re-admissions and is more cost effective for displaced femoral neck fractures. Aside from the medical morbidity following an arthroplasty dislocation is the primary concern. We have found the anterolateral approach reduces this significantly. Non-displaced fractures that are valgus impacted and biomechanically stable are treated with cannulated screws. Perhaps it can be argued that a hemiarthroplasty (bipolar or monopolar) has a lower risk of dislocation compared to a total hip replacement if performed by a surgical team with less frequent total hip replacement experience. However, total hip replacement results in less pain and better function when the patients are independent with intact mental status (patient not the surgeon…!). My algorithm is non-displaced valgus impacted or “stable” fractures undergo cannulated screws and the displaced fractures receive a total hip arthroplasty via an anterolateral approach

We report a prospective study of 198 cases of subcapital fracture of the femur treated by closed reduction and fixation with a sliding compression screw-plate. This was done without regard to the patient's age or the Garden stage of the fracture. Early weight-bearing was encouraged. Of the displaced fractures 23% failed in the first year because of non-union or infection. Of the fractures which united 27% had developed avascular necrosis after three years. Despite this we believe that the sliding compression screw-plate, of proven value in the treatment of intertrochanteric fractures, is also useful for the fixation of subcapital fractures

Between 1999 and 2005, 10 264 patients who had undergone total hip replacement (THR) for subcapital fracture of the hip were compared with 76 520 in whom THR had been performed for other reasons. All the cases were identified through the Swedish Hip Arthroplasty Register. The THRs performed as primary treatment for fracture were also compared with those done after failure of internal fixation. After seven years the rate of revision was higher in THR after fracture (4.4% vs 2.9%). Dislocation and periprosthetic fracture were the most common causes of revision. The risk was higher in men than in women. The type of femoral component and the surgical approach influenced the risk. After correction for gender, type of component and the surgical approach the revision rates were similar in the primary and secondary fracture THR groups. Total hip replacement is therefore a safe method for both the primary and secondary management of fracture of the hip

Aims: This is a retrospective study, comparing prosthesis survivorship, complications and functional results in geriatric patients treated with different types of prosthetic replacement for subcapital fractures of the hip. Methods: In the years 1985–1999, 292 elderly (aged 65–80 years) patients with displaced, nonpathologic sub-capital hip fractures were operated on. Of those, 143 were lost to follow-up; therefore, prospectively collected data of 149 patients were retrospectively reviewed. 54 patients received a unipolar, 48 a bipolar prosthesis and 47 underwent a primary total hip arthroplasty (THA). Mean follow-up was 5.3 years. The patients did not differ in pre-injury characteristics. Analysis of variance was used to compare the three patient groups in terms of early and late complications, need for revision surgery, and functional outcome. Results: A statistically signiþ-cant difference was noted, regarding need for revision surgery, since 5 (9.25%) of the unipolar and 5 (10.4%) of the bipolar prostheses had to be re-operated, compared to 2 (4.25%) from the THA group. Of note, 4 of the revised bipolar prostheses had loose stems. The THA group also proved superior, when recovery of instrumental activities was investigated. Conclusions: Elderly patients, whose biologic age poses high functional demands on them, with a displaced subcapital hip fracture, should receive a total hip arthroplasty. Stem loosening seems more likely, as a mode of failure, in bipolar prostheses, than acetabular erosion

Articular cartilage from the femoral heads of 27 patients having an arthroplasty for subcapital fracture was studied, and its mechanical and chemical properties compared to those of a group of 33 age-matched macroscopically normal autopsy specimens. Water and proteoglycan contents were measured, as were swelling ability, compressive and tensile strength of the cartilage, and the density of the underlying bone. Cartilage from the fracture specimens had a significantly reduced proteoglycan content, as measured by fixed charge density, and increased swelling ability. These results indicate that this group differs from the "normal" population and care should be taken before they are accepted as control material for studies on osteoarthritic cartilage. Another finding was that bone density was much the same in the fracture and the normal group. This casts some doubt upon the concept that patients who sustain subcapital fractures are more osteoporotic than the average for the same age range

Purpose: We will present our experience regarding sub-capital femoral fractures that were treated by cemented bipolar hemiarthroplasty with Chanley stem during the years 1987 to 2002. Method: We treated 159 patients with subcapital femoral fractures, type Garden stage 3 and 4. Of those 57 were men and 102 women aged between 65 and 85 years old. All the patients underwent surgical treatment by the same surgeon team, using cemented bipolar hemi-arthroplasty Hastings types, with Chanley stem. The preferred surgical approach was the anterolateral with partial incision of the gluteus medius muscle and preservation of the posterior capsule of the hip joint, so that the prosthesis would be stable and the abductor muscles retained their strength. Results: The observation time ranged from 6 months to 15 years. During this period 38 patients passed away and 24 never returned for follow up. The observed complications were: 1 aseptic loosening of the femoral stem that was dealt with THA, 1 superficial inflammation that was taken care of with surgical cleaning and antibiotic administration and 1 dislocation of the metal cup (with the internal polyethylene bearing) from the femoral stem that was corrected by OR. Postoperative hip mobility was found to be excellent (62%), fair (32%), poor (6%). 6 patients reported light to moderate pain during walking. We observed that the dual motion of the bipolar prosthesis is considerably reduced and eventually disappears over time. Conclusions: From our long time experience regarding subcapital femoral fractures types Garden 3 and 4 in patients aged between 65 and 80 years old, we believe that the cemented bipolar hemiarthroplasty is a very good method of choice

The results of primary total hip arthroplasty for sub-capital femoral neck fracture in previously normal hips are reported. Thirty-seven patients aged 70 or less at the time of surgery were reviewed at an average follow-up of 56 months. Eighteen (49%) had undergone or were awaiting revision surgery. A further four (11%) had definite radiological signs of loosening. Harris hip scores were calculated and correlated well with the results of gait analysis; these suggested that it was the more vigorous patients that were more liable to early failure. Consequently, primary total hip replacement is not recommended for subcapital fractures in the younger patient without pre-existing hip pathology

The management of displaced subcapital fracture of the hip is still controversial because of the high incidence of complications after internal fixation or hemiarthroplasty. To avoid some of these complications we have used primary total hip replacement for independently mobile patients over 65 years of age. A total of 163 cases, operated on over four years, have been reviewed. There were relatively more dislocations after operation for fracture than after total replacement for arthritis, and these were associated with a posterior approach to the hip. Only seven revision operations have been required. Of 57 patients who were interviewed an average of 42 months after replacement, 62% had excellent or good results as assessed by the Harris hip score. All the others had major systemic disease which affected their assessment. This inadequacy of current systems of hip assessment is discussed. It is concluded that total hip replacement is the best management for a selected group of patients with this injury, and that further prospective studies are indicated

Introduction:- We reviewed 69 patients with subcapital fracture neck of femur treated with two hole plate DHS and parallel de-rotation screw into the cranial part of the femoral head between January 2000 to January 2005. Methods:- Patients were selected for fixation by having Garden 1 to 4 fractures, being younger, more active and mobile. Reduction was classified as “good” when residual angulation in the lateral projection was less than 15 degrees, no varus angulation and good alignment in the calcar area. Screw position was considered “good” when there was less than 10 degrees deviation in the direction of screws, screw threads not bridging the fracture site, screw tips less than 5mm from subchondral bone and no signs of intra-articular penetration. The fracture was considered healed when bridging of trabecular bone was present. Patients were reviewed until they were pain free at rest or on walking and had radiological healing of fracture. Results:- 13 had Garden 3 & 4, 46 had Garden 1 & 2 and 10 had impacted fractures. Sixty eight patients had operation within 24 hours in the next available trauma list. Average age at operation was 70 years (range 21– 89) and hospitals stay 13 days (range 2–52). Good reduction was achieved in 61 patients, 54 of these had good screw position, 8 patients (11%) had combination of poor reduction and poor screw position; five of them had loss of fixation within 6 to 12 weeks postoperatively, one each had segmental collapse and avascular necrosis between 12 to 24 months of operation. Conclusion:- Their was no re-displacement, non-union, avascular necrosis or segmental collapse when fractures were well reduced and had good screw position. Two hole plate DHS and a parallel de-rotation screw has high rate of fracture union. We recommend its use for treatment of subcapital femoral neck fractures

This abridged account of a report to the British Medical Research Council describes a long-term investigation of 1,503 subcapital fractures of the femur, almost all of which were treated by reduction and internal fixation. With three exceptions, union occurred in all Garden Stage I and Stage II fractures and in 67% of Stage III and Stage IV fractures, of which only 14-5% were united at six months. In women, late segmental collapse was seen after union had occurred in 16% of Stage I and in 27-6% of Stage III and Stage IV fractures. Delay of up to one week before operation had no significant effect on the incidence of non-union or of late segmental collapse. The incidence of union followed by late segmental collapse was higher in women with normal bone density than in those with osteoporosis. Smith-Petersen nailing was found to be the least effective form of fixation in displaced fractures. The age and physical state of the patient, the accuracy of reduction, and the security of fixation had the greatest influence on union

1. The long-term results in a consecutive series of 323 healed subcapital fractures of the femur show that, with few exceptions, the capital fragment maintains its integrity when the fragments are aligned within the narrow limits of good reduction, but undergoes superior segmental collapse when reduction is poor. 2. The effect of malreduction on the congruity of the hip joint is examined, and a remodelling response to malalignment of the aspherical femoral head in the imperfectly round acetabulum is proposed as an alternative interpretation of the radiological changes now considered to be the result of capital ischaemia

Between December 1982 and June 1986, 98 displaced subcapital femoral neck fractures were treated using the Charnley-Hastings bipolar hemiarthroplasty. Although the patients were elderly, often with associated medical problems, the operation was well tolerated and the mortality at one and six months was 14.4% and 24.5% respectively. Fifty-four hips were reviewed after an average follow-up of 33 months; 64.8% of patients had a good or excellent result. The fair or poor results were seen mainly in patients with poor pre-operative mobility and multiple medical problems. A significant cause of morbidity was dislocation (two interprosthetic) which occurred in six hips. There were two cases of deep sepsis but neither patient was fit for further surgery. There were no cases of acetabular erosion requiring revision surgery

A retrospective study of 200 cases of subcapital fracture of the neck of the femur treated by sliding nail-plate fixation has been carried out. Failure of fixation within three months occurred in forty-two cases (21 per cent). These failures could, in part, be attributed to a combination of the severity of the fracture and various imperfections in technique. The age of the patient and the angle of the nail-plate had no significant effect on the result