What surgery is done for subcapital femur (thigh bone) fractures?

Surgical Management of Subcapital Femur Fractures

For subcapital femur fractures, the surgical approach should be determined by patient factors: stable/non-displaced fractures require percutaneous cannulated fixation, while displaced fractures require either total hip arthroplasty (THA) in healthy active patients or hemiarthroplasty in frail elderly patients. 1

Treatment Algorithm Based on Fracture and Patient Characteristics

Non-displaced Subcapital Fractures

• Internal fixation with multiple screws or a sliding hip screw is the preferred treatment 2
• Conservative treatment carries a 30-50% risk of subsequent displacement and is generally avoided 2

Displaced Subcapital Fractures

• Patient age and functional status determine optimal treatment:

  • Younger, active patients (<60 years):

    • Urgent open reduction and internal fixation (ORIF) with anatomic reduction 1, 3
    • Early fixation (within 12 hours) is associated with lower rates of avascular necrosis 4

  • Elderly patients (>60 years):

    • Cognitively intact, active patients: Total hip arthroplasty (THA) 1, 3
    • Frail or cognitively impaired patients: Hemiarthroplasty (unipolar or bipolar) 1, 3
    • Cemented arthroplasty is preferred over uncemented for better hip function and lower postoperative pain 2

Surgical Considerations and Techniques

Internal Fixation

• Multiple cannulated screws or sliding hip screws are commonly used 2, 1
• Anatomic reduction is critical, especially in younger patients 4, 3
• Weight-bearing restrictions may be necessary until fracture healing occurs 5

Arthroplasty Options

• Hemiarthroplasty:

  • Thompson or Austin Moore prosthesis
  • Anterolateral approach may have lower mortality compared to posterior approach 6
  • Lower dislocation risk compared to THA, making it suitable for frail patients 1

• Total Hip Arthroplasty:

  • Better long-term functional outcomes and less pain compared to hemiarthroplasty 7
  • Consider larger femoral heads (32-36mm) or constrained sockets in patients at high risk for dislocation 3

Complications and Considerations

Major Complications

• Avascular necrosis: More common with delayed fixation of displaced fractures 4
• Non-union: Risk is higher with internal fixation (up to 25% revision rate) 7
• Dislocation: Higher risk with arthroplasty (10-12% may require reduction) 7
• Bone cement implantation syndrome: Risk during cemented arthroplasty, characterized by hypoxia, hypotension, or loss of consciousness 1

Perioperative Management

• Multimodal analgesia including peripheral nerve blocks is strongly recommended 1
• Consider tranexamic acid to reduce blood loss, especially with extracapsular fractures 1
• Early mobilization and weight-bearing as tolerated after surgery improves outcomes 1
• Venous thromboembolism prophylaxis is essential 1

Pitfalls to Avoid

• Delaying surgery beyond 12 hours for displaced fractures in younger patients increases avascular necrosis risk 4
• Underestimating blood loss, particularly with extracapsular fractures 2
• Failing to evaluate for osteoporosis and implement secondary fracture prevention 1
• Using uncemented arthroplasty in elderly patients, which may lead to more pain and poorer function 2

The surgical approach should be tailored based on fracture pattern, patient age, functional status, and comorbidities, with the goal of optimizing mobility, minimizing pain, and reducing complications.