aaos geriatric trauma

Selected

Instructional

Course Lectures

The American Academy of Orthopaedic Surgeons

ROBERT A. HART

EDITOR, VOL. 63

COMMITTEEROBERT A. HARTCHAIR

CRAIG J. DELLA VALLEMARK W. PAGNANOTHOMAS W. THROCKMORTONPAUL TORNETTA III

EX-OFFICIO

DEMPSEY S. SPRINGFIELDDEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY

FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy ofOrthopaedic Surgeons. This article, as well as other lecturespresented at the Academy’s Annual Meeting, will be availablein March 2014 in Instructional Course Lectures, Volume 63.The complete volume can be ordered online at www.aaos.org,or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

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Downloaded From: http://jbjs.org/ by PAUL DUWELIUS MD on 01/02/2014

Geriatric Trauma: The Role ofImmediate Arthroplasty

Andrew H. Schmidt, MD, Jonathan P. Braman, MD, Paul J. Duwelius, MD, and Michael D. McKee, MD, FRCS(C)

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Periarticular fractures in the elderly aredifficult to stabilize, and nonoperativetreatment is not well tolerated. Surgeryis usually indicated, but standard tech-niques of internal fixation often fail in thisage group because of osteopenic boneand fracture comminution. These factorsoften prevent sufficient fixation to allowearly weight-bearing, which is of criticalimportance in the geriatric patient.

In contrast, immediate arthro-plasty of periarticular fractures in theelderly allows immediate mobilizationof the patient. The purpose of thisInstructional Course Lecture is to reviewthe role of immediate arthroplasty infour common fractures that occur in theelderly: the proximal and distal end ofthe humerus, the acetabulum, and theproximal part of the femur.

Shoulder Arthroplasty for ProximalHumeral FracturesProximal humeral fractures are the thirdmost common fracture in the elderlyafter wrist and hip fractures. They have asubstantial impact on quality of life evenwhen they are minimally displaced and

do not require surgery1. Factors consis-tently associated with poor outcomesafter either nonoperative managementor open reduction and internal fixation(ORIF) are advanced patient age, frac-ture comminution, varus angulation ofthe humeral head, and osteoporosis2-7.Appropriate indications for shoulderarthroplasty in patients with a complexproximal humeral fracture are a dys-vascular humeral head, a patient whocannot tolerate the limitations that ac-company nonsurgical treatment, anda comminuted and/or varus displacedfracture pattern, especially when asso-ciated with poor bone quality thatprecludes ORIF.

Shoulder function followinghemiarthroplasty depends on anatomicreduction and secure, stable tuberosityfixation8. Reverse total shoulder arthro-plasty is an attractive option for elderlypatients with displaced proximal hu-meral fractures since restoration of ro-tator cuff function is not as critical.Expected patient activity level and lon-gevity are the primary considerations forchoosing between reverse total shoulder

arthroplasty and shoulder hemiarthro-plasty: reverse total shoulder arthro-plasty is better for sedentary and elderlypatients, while shoulder hemiarthro-plasty is better for patients with higheractivity levels (Figs. 1-A and 1-B)9,10.Although short and intermediate-termresults of reverse total shoulder arthro-plasty are reasonable, no long-term datathat estimate the longevity of thesedevices in these patients are available,and salvage options are limited.

Hemiarthroplasty of the ShoulderSurgery is performed using a long(15-cm) deltopectoral approach with thepatient in the beach-chair position. Thecoracoacromial ligament is preservedsince this is an important secondaryrestraint preventing anterosuperior es-cape of the humeral head if the greatertuberosity does not heal. We tenodese thebiceps tendon. Large sutures are placedat the bone-tendon interface of thegreater and lesser tuberosities to providecontrol of the greater and lesser tuber-osity fragments. External rotation of thearm improves reduction of the greater

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of anyaspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of thiswork, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one ormore of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influencewhat is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version ofthe article.

J Bone Joint Surg Am. 2013;95:2231-9

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 95-A d NU M B E R 24 d D E C E M B E R 18, 2013GE R I AT R I C TR AU M A : TH E RO L E O F IM M E D I AT E AR T H R O P L A S T Y


tuberosity. If there is a periosteal sleevethat remains in place, we attempt to leaveit to facilitate reduction and stability.However, in fractures that are more thana few days old, contracture of the peri-osteum can preclude reduction of thetuberosities and release may be needed. Afracture-specific stem may improve theoutcome and should allow conversion toa reverse total shoulder arthroplasty ifnecessary11-13. Suture fixation must pro-vide interfragmentary compression fixa-tion between tuberosity fragments,between the tuberosities and the humeralshaft, and around the neck of theimplant14.

Proper positioning of the stem canbe difficult because the normal osseouslandmarks of the proximal part of thehumerus no longer exist. Achieving boththe correct retroversion and height ofthe humeral head are critical for resto-ration of shoulder biomechanics andfunction. Typically, the prosthetic hu-meral head should be placed in slightlyless than anatomic retroversion (20�) to

reduce tension on the greater tuberosityrepair. Restoration of the height of thehumeral head is also challenging.Krishnan et al. described the ‘‘Gothicarch’’ to help to obtain the correcthemiarthroplasty height15. Fortunately,the pectoralis major tendon israrely torn in this injury, and bothMurachovsky et al.16 and Greiner et al.17

described its use as a landmark for theassessment of humeral head height.According to Murachovsky et al., themean distance (and 95% confidenceinterval) between the top of the humeralhead and the top of the pectoralis majortendon is 5.6 ± 0.5 cm, which will helpin the accurate restoration of the hu-meral head position. Stems should becemented to obtain rotational control.

Total Shoulder ArthroplastyMany surgeons perform reverse totalshoulder arthroplasty through the delto-pectoral interval because of their comfortwith this approach. Additionally, ORIFcan be performed using the same

approach, facilitating conversion fromone procedure to the other if intraoper-ative findings warrant. Other authors havepreferred the superolateral approach forreverse total shoulder arthroplasty18. Thisapproach releases the anterior deltoidmuscle from the acromion and uses a splitin the anterolateral raphe of the deltoidfor access to the humeral shaft. Thehumerus is exposed and reamed, and theglenoid is addressed. Excellent en faceglenoid access is imperative for reversetotal shoulder arthroplasty. The height ofthe implant is determined by assessingtension in the deltoid and coracobrachi-alis muscles, which should be tightenough so that the implants do notdislocate, but are not difficult to reduce.Tuberosity fixation is important in reversetotal shoulder arthroplasty followingfracture as it allows proper rotationalcontrol of the arm after healing. Conse-quently, secure suture repair of the tu-berosities to the humeral shaft, humeralstem, and to each other is performed.Humeral stems should be cemented in

Fig. 1-A Fig. 1-B

Figs. 1-A and 1-B A seventy-five-year-old woman who sustained a four-part fracture of the proximal part of the humerus, including comminution of the

humeral head and displacement of the tuberosities, in a fall from a standing height that involved her nondominant arm. Fig 1-A Preoperative

anteroposterior radiograph of the injured shoulder. Fig. 1-B Radiograph made after reverse total shoulder arthroplasty.

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reverse total shoulder arthroplasty toprovide rotational stability of theconstruct.

OverviewReverse total shoulder arthroplasty andshoulder hemiarthroplasty are both sur-gical options for comminuted fracturesof the proximal part of the humerus inelderly patients with a dysvascular humeralhead and/or severe fracture comminution.Younger patients should be treated withORIF whenever possible. Patients who aremore active or physiologically youngershould undergo shoulder hemiarthro-plasty with a convertible implant. Reversetotal shoulder arthroplasty may be morepredictable for restoring the ability toperform the activities of daily living forelderly or sedentary patients with thisinjury, especially those with an expectedlife span of less than ten years.

Total Elbow Arthroplasty forFractures of the Distal Endof the HumerusImproved surgical techniques, triceps-sparing approaches, and anatomic pre-

contoured plates have improvedoutcomes following ORIF of intra-articular distal humeral fractures.However, complications remain fre-quent in elderly patients with severefracture comminution and poor bonequality. Suboptimal plate fixation inosteopenic bone often leads to nonun-ion and more complications. Nonunionor malunion of the distal end of thehumerus causes substantial impairmentin the functional ability and level ofindependence of a patient19.

Total elbow arthroplasty is analternative to ORIF for comminuted,intra-articular distal humeral fracturesin elderly patients (Figs. 2-A and 2-B).Total elbow arthroplasty is reserved forelderly patients only; it is not an optionfor younger, higher-demand individ-uals. Primary total elbow arthroplastyfor elbow fracture was first reported, toour knowledge, in 1997 by Cobb andMorrey, who described twenty-oneelbows in twenty patients (mean age,seventy-two years) with comminuteddistal humeral fractures that weremanaged with a primary total elbow

arthroplasty, resulting in a good orexcellent outcome in 95% of the twentyelbows with complete data and onlyone reoperation in the entire cohort20.Other retrospective reviews from singlecenters have confirmed similar, con-sistently reliable results21,22. In the firstcomparative study, Frankle et al. per-formed a retrospective comparison ofORIF and total elbow arthroplasty forintra-articular distal humeral fracturesin twenty-four women older than sixty-five years23. At the time of the short-term follow-up, the patients who hadtotal elbow arthroplasty had excellentor good results, with improved rangeof motion and less need for physicaltherapy than those who had ORIF, and25% of patients treated with ORIF hada mechanical failure that required re-vision to total elbow arthroplasty. Re-cently, in a randomized prospectivetrial comparing ORIF and total elbowarthroplasty for comminuted intra-articular distal humeral fractures inelderly patients, McKee et al. reportedthat total elbow arthroplasty improvedfunctional outcome compared with

Fig. 2-A Fig. 2-B

Figs. 2-A and 2-B A ninety-year-old man with an intra-articular distal humeral fracture. Fig. 2-A Preoperative axial computed tomographic image showing the

displaced distal humeral fragments. Fig. 2-B Lateral elbow radiograph made three months after total elbow reconstruction.

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ORIF on the basis of both objectiveelbow performance scores and patient-rated upper extremity disability andsymptoms24. They emphasized that themean age of the patients in their studywas close to eighty years of age, and thatthis procedure is not suitable foryounger patients.

Indications and ContraindicationsWhile total elbow arthroplasty producesreliably good results in the appropriatepatient, careful adherence to patientselection and surgical technique arecritical.

Indications• A low-demand patient with an age

of more than sixty-five years• Preexisting, symptomatic arthritis

of the elbow• Articular comminution (typically

three or more articular fragments)• A closed or type-1 open fracture25

(if the arthroplasty is done within eightto twelve hours of injury and satisfactorydebridement is obtained)

• Delayed presentation with articu-lar fragmentation rendering reconstruc-tion unfeasible

• Associated severe ligamentous dam-age and/or elbow instability

Contraindications• Active infection or insufficient

soft-tissue coverage• Advanced dementia or noncom-

pliance issues (e.g., substance abuse)• Extensor mechanism disruption (a

relative contraindication)• A type-2 or 3 open fracture• A young, active, high-demand

patient• Simple fracture pattern (i.e., two

articular fragments)

TechniqueTotal elbow arthroplasty for a fracturerequires the correct implant, equip-ment, and an experienced operating-room staff and surgeon. The fracture issplinted until conditions are optimizedfor surgery; a wait of up to fourteendays is rarely detrimental if required. Acemented, linked, or semiconstrainedprosthesis is the treatment of choice for

total elbow arthroplasty following adistal humeral fracture. While somepromising preliminary results areavailable for distal humeral hemiar-throplasty (typically with an anatomicdistal humeral replacement) that mayextend the indications for this proce-dure to younger patients, such anapproach should be considered exper-imental at present26.

The patient is placed in the lateraldecubitus position with the affected armfree-draped over a bolster, with a tour-niquet applied. A posterior approach isused; the ulnar nerve is identified andprotected. The olecranon is not osteo-tomized; this compromises the insertionand stability of the ulnar component.When the fractured articular fragmentsor condyles are excised, this creates a so-called working space allowing the hu-merus and ulna to be instrumentedand the components inserted withoutdetaching the triceps. Condylar resec-tion does not appear to negativelyaffect forearm or wrist strength, andthe condyles are not required for liga-ment attachment or stability when alinked prosthesis is used27. If greaterexposure is required, the triceps can besplit or peeled from the olecranon28,29.Following insertion of the prosthesis,thorough irrigation and standard clo-sure are performed: the ulnar nerveremains in a tension-free position me-dially. A major benefit of the linkedtotal elbow arthroplasty in generaland the so-called triceps-on approachin particular is the ability to allowimmediate full range of active motionpostoperatively. This enhances theelbow-specific outcome, rapidly re-stores independent function to thepatient, and minimizes hospital andrehabilitation time.

OverviewPrimary semiconstrained total elbowarthroplasty has a role in the treat-ment of comminuted intra-articularfractures of the distal end of thehumerus in selected elderly patients.In this specific group, it results inimproved patient outcome comparedwith ORIF, enhances the returnto independent function, and minimizes

hospital stay and rehabilitationtime.

ORIF and Immediate Total HipReplacement for the Managementof Selected Displaced AcetabularFractures in the ElderlyThe recommended treatment for mostdisplaced acetabular fractures is ORIF30,31.Acetabular fractures in the elderly are anincreasingly common injury pattern32-34.In the elderly, these fractures are morelikely the result of a low-energy fall thanhigh-energy trauma34,35, yet they are oftencomminuted with major displacementand impaction of the articular sur-face32,33,36. Early mobilization of thesefragile patients is of primary importancein restoring them to their preinjury levelof function, as well as preventing com-plications from prolonged recumbency37.The difficulty of obtaining a satisfactoryresult with internal fixation and thecommon need for a delayed total hipreplacement to treat failed internal fixa-tion in these patients makes initial pros-thetic replacement attractive38-43. Oneapproach is to initially manage thesepatients nonoperatively, performing de-layed total hip replacement once thefracture has healed in symptomatic pa-tients36. However, delayed arthroplastyfollowing acetabular fracture in the el-derly has inferior results compared withprimary arthroplasty for degenerativedisease41. Immediate total hip replace-ment with acetabular reconstruction al-lows early mobilization and lessens therisk of subjecting the patient to twomajor surgical procedures in a relativelyshort time period (Figs. 3-A and 3-B).

The challenge of immediate totalhip replacement is to obtain stable ace-tabular component fixation, and to beable to allow the patients early activitywithout compromising fixation of theimplants or hip stability. In fact, reports ofthis approach published several decadesago noted problems with fixation of thecemented acetabular component44. Inthe last decade, there has been renewedinterest in treating selected acetabularfractures with early total hip replace-ment33,42,45-48. Beaule et al. reported thecases of ten patients managed with openreduction and acute total hip replacement

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utilizing a direct anterior surgical ap-proach for anterior wall or columnfractures in the elderly46. At an averagefollow-up of three years, none of the

patients had nonunion or componentloosening or migration. One patient hadan anterior dislocation that was treatedsuccessfully with closed reduction and

immobilization. The average Merled’Aubigne and Postel score was 16, indi-cating a good outcome. More recently,Boraiah et al. described eighteen patientswho were treated by a protocol verysimilar to ours and were followed for atleast one year; those authors also reportedone early acetabular failure requiringrevision surgery, while 81% of theirpatients had good or excellent resultsaccording to the Harris hip score48.

ORIF of the acetabulum and im-mediate total hip replacement is acomplex procedure that should beperformed by surgeons adept at bothsurgical fixation of acetabular fracturesand total hip replacement. Publishedresults have indicated that functionaloutcomes are similar to those afterprimary total hip replacement forosteoarthritis35,46.

TechniquePatients undergo surgery as soon aspossible after admission and thoroughevaluation by the orthopaedic, trauma,and/or internal medicine services asindicated by their injuries and medicalcomorbidities (if any). Surgical proce-dures are usually done within twoto four days. Patients with fracture-dislocations have their hip reduced im-mediately in the emergency departmentwith deep intravenous sedation. If thehip is unstable following closed reduc-tion, skeletal traction is placed, typicallythrough the distal end of the femur.Subcutaneous heparin (5000 unitsthree times daily) and pneumaticcompression stockings are routinelyused for prophylaxis against venousthromboembolism.

We initially repair the acetabularfracture using standard techniques ofinternal fixation as appropriate for thefracture pattern. The goal of the internalfixation is to reduce and stabilize theanterior and/or posterior columns, not torestore the articular surface. In patientswith major displacement of the anteriorcolumn, an ilioinguinal approach orStoppa approach with the patient supineis used to reduce and plate the pelvic brim(Figs. 3-A and 3-B). Next, or for fracturesprimarily involving the posterior walland/or column, a Kocher-Langenbeck

Fig. 3-A

Fig. 3-B

Figs. 3-A and 3-B A seventy-six-year-old woman with osteoporosis who sustained a displaced ace-

tabular fracture on the right side. Fig. 3-A Preoperative anteroposterior pelvic radiograph showing

the displaced acetabular fracture with the femoral head protruding into the fracture site. Fig. 3-B

Anteroposterior pelvic radiograph after internal fixation and immediate total hip replacement.

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approach is used with the patient in thelateral decubitus position. Following ex-posure of the greater trochanter, the shortexternal rotators are released and taggedwith suture for later repair. A hip capsu-lotomy is performed, maintaining cap-sular flaps for later repair. The femoralhead is dislocated, the femoral neck cut,and the femoral head removed in thestandard fashion. A cobra retractor isplaced over the anterior wall of theacetabulum, and any posterior wall frag-ments are identified. The acetabularlabrum is excised. If there is a fracture ofthe posterior column, the posterior col-umn is carefully exposed and reducedwith clamps. If the posterior wall requiresreconstruction, an acetabular trial that issimilar in size to the resected femoralhead is selected and placed in the ace-tabulum for use as a template for recon-struction. The posterior wall fragment(s)are repositioned against the acetabulartrial component, and the posterior walland column of the acetabulum are stabi-lized with a posterior buttress plate.

After the posterior wall and/orcolumn are stabilized, any residual bonedefects resulting from articular impac-tion or comminution are bone-graftedusing cancellous bone from the patient’sfemoral head. Following repair of theacetabulum, total hip arthroplasty isthen performed through the same inci-sion. The acetabulum is prepared withstandard reaming with medialization ofthe cup to the floor of the cotyloid fossa.For uncemented cups, once bleedingsubchondral bone is reached, a cup1 mm larger than the outside diameterof the last reamer is selected andimplanted with an interference fit. Theacetabular component is anchoredwith additional screw fixation into theilium. Standard femoral canal prepara-tion and femoral stem placement areemployed, using uncemented, proxi-mally porous-coated implants in mostpatients (Figs. 3-A and 3-B).

Postoperative TreatmentPatients receive prophylactic antibioticsfor twenty-four hours and are started onwarfarin or low-molecular-weight hep-arin postoperatively, which is continuedfor four weeks following discharge.

Prophylaxis against heterotopic ossifi-cation using low-dose radiation (a singledose of 600 Gy) is recommended formale patients who have a posteriorfracture-dislocation. Patients with dis-placed anterior or posterior columnfractures are mobilized with crutches ora walker for six weeks. Patients withisolated posterior wall fractures areallowed full weight-bearing immedi-ately. Patients are instructed to avoid hipflexion beyond 90� and to sleep with apillow between their legs.

Displaced Femoral Neck Fractures:The Case for Total Hip ReplacementTotal hip replacement for the treatmentof displaced femoral neck fractures(Fig. 4) in the elderly leads to improvedoutcomes, fewer complications, anddecreased cost compared with othertreatment techniques of internal fixa-tion or hemiarthroplasty. The inci-dence of hip fractures in the UnitedStates in 1996 was approximately250,000 cases, with projections that this

would increase to 500,000 fractures peryear by 204049. Thus, the managementof femoral neck fractures in a cost-effective manner is of societal impor-tance, not to mention the consequencesfor the individual patient when com-plications of care occur.

This section reviews the role ofarthroplasty in the management offractures of the femoral neck: whento replace the hip, which device to use,and whether to cement or press-fit theimplant. Hemiarthroplasty has been thepreferred management for femoral neckfractures that are not ideal for internalfixation because of advanced patient ageand/or osteopenia. Advantages of hem-iarthroplasty compared with total hiparthroplasty are the quick and relativelysimple surgical technique and a docu-mented low risk of dislocation50. Themain disadvantages of hemiarthroplastyinclude the potential for rapid wear ofacetabular articular cartilage (requiringconversion to total hip replacement) andpain related to the metallic femoral head

Fig. 4

Preoperative (left) and postoperative (right) radiographs of a displaced femoral neck fracture in a

seventy-three-year-old woman who was treated with primary total hip arthroplasty.

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against the host acetabulum(chondrolysis).

The justification for prostheticreplacement in the treatment of femoralneck fractures resides in the fact thatarthroplasty provides optimal func-tional recovery. The literature over-whelmingly supports arthroplasty forthe treatment of the displaced femoralneck fracture in the elderly51-65. Com-plications and the need for multipleprocedures are decreased when total hipreplacement is utilized over other treat-ment options.

Schmidt et al. recently provided acomprehensive review of the literatureregarding the optimal arthroplasty fordisplaced femoral neck fractures63. Iorioet al. conducted a survey in 2006 thatrevealed that most surgeons preferredtreating geriatric patients with displacedfemoral neck fractures with bipolar ar-throplasty66. However, at the time of theirsurvey, surgical practice was changingbecause of the recent introduction ofhighly cross-linked polyethylene andlarger femoral heads to decrease disloca-tion rates. Newer stem designs also wereproven to be successful in elderly patientswith femoral neck fractures67. The Dis-placed Femoral (neck fracture) Arthro-plasty Consortium for Treatment andOutcomes reported the results of theirprospective, multicenter randomizedclinical trial comparing hemiarthroplastyand total hip arthroplasty in 2008, findingthat total hip replacement had superiorresults58.

Treatment choices for displacedfemoral neck fractures might differdepending on which outcome criteria weconsider. Possible criteria include com-plication rates, cost-effectiveness, andshort and long-term outcomes. Iorioet al. presented a cost-effectiveness anal-ysis of four surgical treatments for adisplaced femoral neck fracture68. Thisseries considered initial hospital costs,rehabilitation costs, and costs of reoper-ations and complications. Those authorsdetermined that cemented total hipreplacement was the most cost-effectivetreatment and that internal fixation wasthe most expensive option68.

A highly compelling study is theScottish Trial of Arthroplasty or Reduc-

tion (STARS) for subcapital femoralneck fractures57. This multicenter ran-domized study showed that long-termfunction was best after total hip re-placement. The STARS study revealedan incidence of osteonecrosis of 20%and nonunion rates of 30% in the ORIFgroup, consistent with prior studies. Thereoperation rate was much higher forthe internal fixation group, which had afailure rate of 37%. Chondrolysis, whichgenerally manifested itself as pain, oc-curred in 20% of the bipolar-monopolartreatment group, with a reoperation rateof 5%. A systematic review of fixationoptions indicated that cemented hipreplacement is associated with less painthan uncemented hip replacement inpatients with a hip fracture69. Thisfinding was further substantiated in arecent study supporting cemented stemsas being superior to bone ingrowthstems70. In the STARS study, the total hipreplacement treatment group had thebest functional outcome and the leastpain, the lowest cost, and a reoperationrate of 9%. Healy and Iorio also reportedbetter results and lower cost with totalhip replacement71. Several randomizedprospective series lend credence to thefact that arthroplasty leads to betterresults than internal fixation of dis-placed femoral neck fractures55-58,60,62,64.

Displaced femoral neck fracturespose certain problems for the treatingsurgeon. The randomized controlledtrial by Blomfeldt et al., which com-pared bipolar hemiarthroplasty withtotal hip replacement for displaced in-tracapsular fractures of the femoral neckin elderly patients, revealed superiorresults in the total hip replacementgroup in all outcomes parameters com-pared with the bipolar group, utilizingthe anterolateral approach in all cases toreduce the risk of dislocation typicallyassociated with posterior approaches72.However, capsular repair and use of alarge femoral head may mitigate thedislocation risk when posterior ap-proaches are done61,73. Berry et al. fur-ther described how the dislocation ratecan be decreased with careful attentionto detail, such as using larger femoralheads, highly cross-linked polyethylene,and capsular closure74. The surgeon may

therefore use whatever surgical ap-proach he or she is most comfortablewith. Surgical techniques are more dif-ficult in displaced femoral neck fracturescompared with elective total hip re-placement. Poor bone quality, intra-operative instability, and difficultieswith abnormal anatomy due to thedisplaced fracture present unique prob-lems. The surgeon can base his or herpreoperative plan on the nonfracturedside to best evaluate for stem size,head center, limb length, and offset.Technical pearls include the use of alarger femoral head, careful reaming,restoration of appropriate limb lengthand offset, repair of the hip capsule, anduse of multiple acetabular screws withcompromised bone quality. Controversyremains about whether to cement orpress-fit the femoral component53,70,72.

Treatment of these difficult frac-tures involves certain parameters thatare outside the surgeon’s control such asthe patient’s age, mental status, bonequality, fracture pattern, time to diag-nosis, and comorbidities. However, thesurgeon does have control over manyfactors that are critical in the treatmentof these fractures. These include thetiming of surgery, choice of surgicalapproach, restoration of hip center, useof larger femoral heads to decrease theprevalence of dislocation, capsular clo-sure, and surgical experience. No singleapproach works best for all fracturetypes. However, for displaced femoralneck fractures, the surgeon should givestrong consideration to the treatment ofthese difficult fractures with a total hipreplacement to decrease cost, lowercomplications, and restore the bestpostoperative function.

Andrew H. Schmidt, MDDepartment of Orthopedic Surgery,Hennepin County Medical Center,701 Park Avenue, Mailcode G2,Minneapolis, MN 55415.E-mail address: [email protected]

Jonathan P. Braman, MDDepartment of Orthopaedic Surgery,University of Minnesota,2450 Riverside Avenue South,

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#R200, Minneapolis, MN 55454.E-mail address: [email protected]

Paul J. Duwelius, MDOrthopedic and Fracture Specialists,11782 SW Barnes Road, Suite 300,Portland, OR 97225.E-mail address: [email protected]

Michael D. McKee, MD, FRCS(C)Division of Orthopaedic Surgery,Department of Surgery,University of Toronto,St. Michael’s Hospital,55 Queen Street East, Suite 800,Toronto, ON M5C 1R6, Canada.E-mail address: [email protected]

Printed with permission of the American Academyof Orthopaedic Surgeons. This article, as well asother lectures presented at the Academy’s AnnualMeeting, will be available in March 2014 inInstructional Course Lectures, Volume 63. Thecomplete volume can be ordered online atwww.aaos.org, or by calling 800-626-6726(8 a.m.-5 p.m., Central time).

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