What is the recommended surgical approach for open reduction and internal fixation of neck of femur (femoral neck) fractures?

Surgical Approach for Open Reduction and Internal Fixation of Femoral Neck Fractures

For open reduction and internal fixation (ORIF) of femoral neck fractures, the modified Smith-Petersen approach is recommended over the Watson-Jones approach due to superior exposure of the femoral neck and better visualization of anatomical landmarks. 1

Approach Selection Based on Fracture Type

• For unstable (displaced) femoral neck fractures requiring ORIF, the surgical approach should prioritize optimal exposure for achieving anatomic reduction, which is critical for fracture healing 2, 3
• The modified Smith-Petersen approach provides significantly more exposure area (2.36 cm² additional without rectus tenotomy, 3.33 cm² with tenotomy) compared to the Watson-Jones approach 1
• The modified Smith-Petersen approach allows better visualization and palpation of the medial femoral neck, which is crucial for accurate reduction assessment 1

Anatomical Considerations for Surgical Approach

• The modified Smith-Petersen approach utilizes the interval between the tensor fascia lata and sartorius muscles, providing direct anterior access to the hip joint 1, 4
• This approach enables superior visualization of key landmarks including:
  • The femoral head and neck junction 1
  • The medial femoral neck (visible in 100% of cases vs. only 10% with Watson-Jones) 1
  • The lesser trochanter (palpable in 100% of cases vs. 0% with Watson-Jones) 1

Technical Aspects of ORIF

• Early operation with anatomical reduction is essential for successful outcomes in femoral neck fractures 5
• Proper fixation should achieve:
  • Compression and impaction of fragments 5
  • Firm immobilization with devices that provide lateral cortical fixation 5
  • Slight valgus positioning in certain cases 5
• For young patients (<60 years), anatomic reduction is particularly critical to enhance healing potential, making the superior exposure of the modified Smith-Petersen approach especially valuable 1

Timing of Surgery

• Hip fracture surgery should be performed within 24-48 hours of admission for optimal outcomes 6, 2
• Delayed surgery beyond this window is associated with increased complications and mortality 6, 2

Special Considerations

• For femoral head fractures specifically, the modified Heuter direct anterior approach can also be considered as an alternative 4
• When using the modified Smith-Petersen approach, a rectus femoris tenotomy can provide additional exposure (3.33 cm² more than Watson-Jones) if needed for complex fracture patterns 1
• For stable intertrochanteric fractures, either a sliding hip screw or cephalomedullary device is appropriate 6, 2
• For subtrochanteric or reverse obliquity fractures, a cephalomedullary device is strongly recommended 6, 2

Fixation Methods

• For subcapital fractures amenable to closed reduction and internal fixation, multiple thin pins or screws are commonly used 7
• Proper fixation technique is crucial to prevent complications such as pseudarthrosis and avascular necrosis 7
• In elderly patients with unstable (displaced) femoral neck fractures, arthroplasty is generally preferred over ORIF due to lower reoperation rates 6, 2

Potential Complications

• Avascular necrosis of the femoral head is a significant risk with femoral neck fractures due to disruption of blood supply 7
• Nonunion (pseudarthrosis) can occur, particularly with imperfect reduction or fixation technique 7
• The quality of reduction directly impacts healing potential, with anatomic reduction significantly improving outcomes 1, 5

The modified Smith-Petersen approach provides superior exposure and better access to critical anatomical landmarks for femoral neck fracture fixation, which should translate to improved reduction quality and better healing potential 1.