Treatment Principles and Specific Therapy for Femoral Neck Fractures
For patients with a“ femoralneckfracture” —a typical age-related fracture—the following treatment principles apply:
- Surgical procedures should be used that allow patients to walk immediately after surgery.
- The surgery should be performed as soon as possible (ideally within 24–48 hours) or, if necessary, postponed slightly—for example, if blood-thinning medications make immediate surgery too dangerous.
- High-quality, patient-centered preoperative care that includes pain management, optimization of factors that influence the risk of bleeding, comfortable positioning, and adequate fluid intake via an IV drip during the preoperative fasting period.
- A prophylactic dose of an antibiotic administered shortly before surgery to reduce the risk of infection.
- Joint, interdisciplinary care for elderly patients provided by physicians, nursing experts, and therapists who specialize in geriatric trauma care.
- Professional discharge planning, including the arrangement of a rehabilitation facility
In every case, the goal of treatment is to ensure that the affected person regains mobility and physical capacity as quickly as possible. Prolonged immobility or bed rest should be avoided at all costs to prevent complications such as pneumonia, blood clots (thrombosis), and muscle atrophy. In addition, surgical treatment is generally used for femoral neck fractures.
Conservative treatment is rarely used for specific fractures with virtually no displacement.
When it comes to surgical treatment methods, a general distinction can be made—depending on the type of fracture and the patient’s condition—between “head-preserving surgery” and “head-replacement surgery.”
In a head-preserving procedure, the femoral neck fracture is stabilized using a plate-and-screw system or a nail-and-screw system. The fracture ends are first aligned to correct the misalignment, and then fixed in place with implants and set under compression. With this stable support, it is hoped that blood flow to the femoral head can be maintained and the fracture will heal. These procedures are used specifically for younger patients with good bone quality. Surgery is usually followed by a recovery period during which patients are allowed to bear their full weight for approximately 6–7 weeks while using forearm crutches. In a hip replacement surgery, the femoral neck and femoral head are removed, and the hip joint is replaced with a joint replacement—either a total hip replacement or a femoral head prosthesis.
For many elderly patients with a femoral neck fracture who already had limited mobility prior to the fall, a head prosthesis (in its simplest form, a so-called monopolar prosthesis) is a good and proven treatment option. Intraoperative stress is reduced due to a shorter operating time, and postoperatively, this prosthesis allows for good and immediate weight-bearing and mobilization. Bipolar head prostheses consist of a head (either metal or ceramic), a plastic inlay, and a metal cap. In this system, there are two centers of rotation that move relative to each other. The prosthesis head can rotate freely within the plastic inlay. This results in increased stability and reduces the risk of the prosthesis dislocating.
The prosthetic stem is inserted into the medullary cavity of the femur. A wide variety of shaft shapes can be used. Hip replacements can bear full weight immediately after surgery; that is, with the help of physical therapy, the patient can be mobilized from bed to a standing position and may bear weight on the affected lower extremity depending on the severity of their symptoms.
Surgical Procedures for Femoral Neck Fractures (Hip Replacement)
The implantation of a total hip prosthesis (replacement of the femoral head and acetabulum) is considered a standard surgical procedure with manageable intraoperative and postoperative risks.
We use a minimally invasive surgical technique that is gentle on soft tissues. This means that the hip prosthesis can be inserted through a relatively small, anterior incision measuring approximately 10–15 cm. The surrounding, stabilizing muscles are not severed, but merely held to the side. This surgical technique is designed to help minimize blood loss during surgery, reduce postoperative pain, and preserve muscle function to a large extent, thereby enabling rapid postoperative mobilization.
Complications and Risks During and After Surgery for a Femoral Neck Fracture
General Risks and Complications:
- Hematoma
- Impaired wound healing
- Wound infection
- deep vein thrombosis in the leg
- Vascular injury
- Embolism, nerve injury
- Leg-length discrepancy.
Specific risks:
- Prosthesis dislocation (dislocation, loosening of the prosthesis)
- Wear and tear on the components, which may necessitate a prosthesis replacement.
Forecast: Average Life Expectancy or Service Life of a Hip Prosthesis
With proper and secure fixation of the hip prosthesis, service lives of 15 years or more are not uncommon these days. The lifespan of a prosthesis depends on the wear and tear of its components, the strength and stability of the prosthesis within the bone, and the condition of the surrounding soft tissues. Progressive osteoporosis can cause the prosthesis to become loose.
However, the hip prosthesis is also at risk from infections and falls resulting in bone fractures in the area of the prosthetic stem (see below).
Long-Term Risks: Periprosthetic Fractures
There is a significant risk of recurrent falls in patients with a hip prosthesis. So-called periprosthetic fractures may occur. In cases of fractures involving an implanted prosthesis, the first step is to attempt to preserve the prosthesis and stabilize the fracture. This will be possible if the prosthesis is still sufficiently stable within the medullary cavity. However, if the prosthesis has become loose from its anchorage due to the bone fracture, the prosthesis must be replaced. These prosthesis replacements or revision surgeries are extensive surgical procedures that can be very taxing for patients under certain circumstances.
Summary (Femoral Neck Injury, Femoral Neck Fracture)
A femoral neck fracture is a serious injury because it can have far-reaching consequences. These common age-related conditions are among the leading causes of loss of independence and can lead to a need for long-term care.
It must be assumed that approximately one-third of patients who suffer a hip fracture experience such a significant loss of mobility that admission to a nursing home becomes necessary. To limit the steady rise in the number of cases, greater emphasis must be placed on fracture prevention.
A femoral neck fracture can be treated, among other methods, with a hip prosthesis, which is implanted using modern minimally invasive surgical techniques. It is precisely these surgical techniques, which are gentle on soft tissues, that allow for immediate mobilization of the patient and full weight-bearing on the affected leg during the early postoperative phase. This helps prevent complications and allows the patient to return to their usual social environment after successful rehabilitation.
To successfully implement this treatment approach, a program known as “traumatological-geriatric co-management” was established at the Center for Geriatric Traumatology at the University Hospital of Zurich. Using an interdisciplinary therapeutic approach, many different professional groups work together to provide patients with the best possible treatment and care. In addition to traumatologists and geriatricians, specially trained professionals in nursing, physical therapy, occupational therapy, and nutrition counseling, as well as pain management specialists, work together to treat these patients in close collaboration and coordination.
