What is the optimal treatment for a fracture of the femoral neck in a 55-year-old female with no comorbidities?

From the Guidelines

For a 55-year-old woman with a femoral neck fracture and no comorbidities, total hip arthroplasty (hip replacement) is the recommended treatment, as it provides superior functional outcomes and lower reoperation rates compared to internal fixation or hemiarthroplasty. This recommendation is based on the patient's relatively young age and absence of medical complications, as well as the high risk of avascular necrosis and nonunion associated with internal fixation for femoral neck fractures in adults 1. The optimal timing for surgery is within 24-48 hours of injury to reduce complications and mortality, as supported by the updated guidelines from the American Academy of Orthopaedic Surgeons 1.

Prior to surgery, the patient should receive adequate pain management, typically with opioid analgesics titrated to pain level, along with appropriate DVT prophylaxis such as low molecular weight heparin (e.g., enoxaparin 40mg subcutaneously daily) 1. Post-operatively, early mobilization within 24 hours is crucial, along with physical therapy focusing on gait training and strengthening exercises. Weight-bearing status will depend on the specific surgical technique but is often allowed as tolerated with arthroplasty.

Key considerations in the management of femoral neck fractures include:

• The use of cemented femoral stems in arthroplasty, which has a strong recommendation due to the reduced risk of periprosthetic fracture compared to noncemented stems 1
• The importance of an interdisciplinary care program to improve functional outcomes and reduce complications, which has a strong recommendation based on high-quality evidence 1
• The need for venous thromboembolism (VTE) prophylaxis, which has a strong recommendation due to the high risk of VTE in hip fracture patients 1

Overall, the goal of treatment for a femoral neck fracture in a 55-year-old woman with no comorbidities is to achieve optimal functional outcomes, minimize complications, and reduce the risk of reoperation, and total hip arthroplasty is the most effective way to achieve these goals 1.

From the Research

Treatment Options for Fracture Neck of Femur

• The treatment of femoral neck fractures can be done through various surgical methods, including percutaneous cannulated lag screw fixation, which is favored for its minimally invasive nature and firm fixation 2.
• However, traditional freehand screw placement has limitations, such as high screw malposition rates, which can lead to reduced biomechanical stability and increased risk of failure 2.
• Robot-assisted orthopaedic surgery has been proposed as a more precise and minimally invasive treatment method, reducing radiation exposure and improving outcomes 2.

Complications of Internal Screw Fixation

• Internal fixation with cannulated screws for nondisplaced femoral neck fractures in elderly patients has substantial reoperation and mortality rates, with nonunion and osteonecrosis being common complications 3.
• A systematic review found that the overall reoperation rate attributable to surgical complications was 15.2%, with conversion to hip arthroplasty being performed in 12.4% of patients after primary fixation 3.
• Another study found that high Pauwels grade and treatment with cannulated screws were significant factors for non-union, while comorbidities predisposing to avascular necrosis (AVN) were associated with AVN 4.

Comparison of Fully-Threaded and Partially-Threaded Cannulated Screws

• A meta-analysis compared the outcomes of fully-threaded cannulated screws (FCS) and partially-threaded cannulated screws (PCS) in the treatment of femoral neck fractures, finding that FCS had a lower femoral head necrosis rate, internal fixation failure rate, and femoral neck shortening rate compared to PCS 5.
• However, there was no statistically significant difference between the two groups in terms of the Harris hip score or nonunion rate 5.

Novel Guide Devices for Cannulated Screw Placement

• A novel guide device has been developed to improve the accuracy and efficiency of cannulated screw placement in internal fixation of femoral neck fractures, reducing operation time, fluoroscopy numbers, and drilling attempts 6.
• The guide device has been shown to improve screw parallelism and spread, and may be an effective assistant instrument for internal fixation of femoral neck fractures 6.

Treatment for a 55-Year-Old Lady with No Comorbidities

• Considering the patient's age and lack of comorbidities, internal fixation with cannulated screws may be a suitable treatment option, with FCS potentially being a better choice than PCS due to its lower complication rates 5.
• The use of a novel guide device or robot-assisted orthopaedic surgery may also be considered to improve the accuracy and efficiency of screw placement 2, 6.