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Direct anterior total hip arthroplasty (THA) with ceramic-on-polyethylene bearing
2%
70/4082
Closed reduction and fixation with parallel cannulated screws
12%
499/4082
Closed reduction and fixation with parallel cannulated screws and Pauwel screw
6%
251/4082
Open reduction and internal fixation
78%
3171/4082
Closed reduction and fixation with a cephalomedullary nail
1%
60/4082
Select Answer to see Preferred Response
This young patient has a displaced transcervical femoral neck fracture (FNF). The recommended surgery is open reduction and fixation with a dynamic hip screw ± anti-rotation screw or cannulated screws. In young adults, the recommended treatment is to perform ORIF of the femoral neck fracture. The goals are to avoid osteonecrosis and nonunion. Arthroplasty is not ideal given the younger age and high functional levels. Anatomic reduction and stable fixation is essential for optimal outcomes. Other issues such as closed versus open reduction, capsulotomy and the time to surgery remain controversial. Callaghan et al. reviewed the treatment of displaced subcapital femoral neck fractures. They recommend urgent anatomic reduction and ORIF for the young patient. In the cognitively functioning elderly patient, they recommend THA. In the cognitively dysfunctional, they recommend bipolar hemiarthroplasty or THA with larger heads (32 mm or 36 mm) and/or constrained liners to minimized dislocation risk. Bhandari et al. performed a meta-analysis including 9 trials and 1162 patients comparing ORIF vs THA for FNF. The relative risk of revision surgery was less after THA than ORIF. There was an increase in early mortality after THA. Finally, they found that patients who had THA had increased risk of infection, dislocation, greater blood loss and operative times. Figures A and B show a displaced transcervical femoral neck fracture in a young patient. Illustration A shows the Pauwel classification. Incorrect Answers: Answer 1: Because of higher activity levels and functional demands, arthroplasty is less ideal. Because of increased activity, younger patients may also require multiple revisions in the course of their lifetime. Answers 2,3: In a young patient, displaced FNFs should be treated with ORIF (rather than closed reduction and fixation). A fixation construct comprising 3 parallel cannulated screws is an option. A 4th cannulated screw is sometimes added when there is posterior comminution. A dynamic hip screw (or an additional Pauwel screw) is an option for Pauwel 3 fracture configurations (vertical fracture line). Answer 5: A nail is not recommended for this fracture configuration.
1.9
(10)
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