Hip fractures (fractures of the femoral neck) and hip replacements

Treatment principles and specialised therapy for fractures of the femoral neck

The following treatment principles apply to patients with age-related fractures of the femoral neck:

• Surgical procedures should permit the patient to walk immediately after the operation.
• The surgery should take place as soon as possible (ideally within 24-48 hours); however, it may have to be postponed for some time, e.g. if the patient is taking anticoagulants that would make immediate surgery too risky.
• Effective treatment adjusted to the patient’s individual needs before the surgery, including pain treatment, the optimisation of factors that influence the risk of bleeding, comfortable positioning, and sufficient fluid intake via a drip during the fasting period required before surgery.
• Prophylactic administration of an antibiotic shortly before the surgery in order to reduce the risk of infection.
• Cooperative interdisciplinary treatment of elderly patients by physicians, nursing experts and therapists who specialise in geriatric traumatology.
• Professional discharge planning including the organisation of treatment in a rehabilitative institution

In all cases, the goal of the treatment is to ensure that the patient’s mobility and physical stamina are restored as quickly as possible. Lengthy periods of immobilisation or bed rest must be avoided in order to prevent complications such as pneumonia, blood clotting (thrombosis) and muscle wasting. Fractures of the femoral neck are usually treated surgically.

Conservative treatment is only rarely administered, and only to special fractures with practically no misalignment.

The surgery may involve either the preservation or the replacement of the femoral head depending on the type of fracture and the patient’s circumstances.

If the femoral head is to be preserved, the fracture of the femoral neck is stabilised using a plate/screw or nail/screw system. The ends of the fracture are initially repositioned to eliminate the misalignment, fixed in place with implants, then compressed. It is hoped that this form of stabilisation will preserve the blood supply to the hip and allow the fracture to heal. This procedure is preferred for younger patients with good bone quality. The surgery is usually followed by a post-treatment phase in which the patient uses crutches for approx. 6-7 weeks, allowing them full use of the hip joint. If the femoral head is to be replaced, the femoral head and neck are removed and the hip joint replaced by an artificial joint, a total hip prosthesis or a femoral head prosthesis.

The femoral head prosthesis (known in its simplest form as a monopolar prosthesis) is an efficient, tried-and-tested treatment option for many elderly patients with fractures of the femoral neck whose mobility was already limited before the fall. Intraoperative stress is reduced by the shorter operation time, and this prosthesis effectively enables the patient to move and put strain on the joint immediately after the surgery. Bipolar hip prostheses consist of a head (made of metal or ceramic), a plastic inlay and a metal cap. This system consists of two centres of rotation that move against each other. The head of the prosthesis can rotate freely in the plastic inlay. This makes the joint more stable and reduces the risk of it becoming dislocated.

The prosthetic shaft is inserted into the medullary cavity of the femur. A wide variety of shaft designs can be used. These hip prostheses can bear the patient’s full weight immediately after the surgery, i.e. the patient can be moved from the bed to a standing position with the help of physiotherapy and can place strain on the affected lower extremity as his or her symptoms permit.

Surgical treatment of fractures of the femoral neck (hip replacement)

A total hip arthroplasty (replacement of the femoral head and neck) is a routine operation with manageable intraoperative and postoperative risks.

For this, we use a minimally invasive surgical procedure which spares the soft tissue. This involves the insertion of the hip prosthesis through a relatively small (approx. 10-15 cm) incision in the front of the hip. The stabilising muscles that surround the site are held to one side rather than being severed. This method helps minimise blood loss during the operation, reduces postoperative pain and ensures that the muscles retain most of their function, which means that the patient can be mobilised shortly after the surgery.

Complications and risks that can arise during and after surgery on a fracture of the femoral neck

General risks and complications:

• Haematoma
• Impaired wound healing
• Wound infection
• Deep vein thrombosis in the leg
• Vascular injury
• Embolism, nerve injury
• Discrepancy in leg length

Specific risks:

• Prosthesis dislocation (springing out, loosening of the prosthesis)
• Wear and tear on components that may make a replacement necessary.

Post-operative treatment of fractures of the femoral neck – key points

• Early mobilisation with full use of joint, x-ray follow-up approx. 6 weeks after the surgery.
• Treatment in cooperation with geriatric internal medicine: Early rehabilitative complex geriatric treatment, evaluation of risk factors predisposing the patient for falls, further clarification of geriatric internal diseases
• Respiratory therapy, early mobilisation, avoidance of pressure sores caused by long periods of bed rest, early removal of bladder catheters (within 24-48h)
• Review of patient’s nutritional status: Calorie intake 1,500-2,000 kcal, high-protein diet, dietary supplements if necessary
• Initiation of osteoporosis treatment for all patients with age-related fractures, regardless of their bone density: Basic therapy: Calcimagon D3 forte 1×1; additional saturation with vitamin D if the patient is deficient in this vitamin (2,000 IU a day for 4 weeks)
• Geriatric discharge management: Transfer to acute geriatric care, geriatric rehabilitation. Osteoporosis work-up incl. DEXA scan for specific ongoing treatment in Department of Geriatrics

Prognosis: average life expectancy or useful life of a hip prosthesis

Nowadays, it is nothing unusual for a hip prosthesis to last 15 years or more if it is correctly and securely fixed. The useful life of a prosthesis depends on the wear and tear on its components, its stability, how well it can be anchored in the bone, and the condition of the surrounding soft tissue. Progressive osteoporosis can cause the hip replacement to become loose.

However, patients with hip prostheses are also at risk of infections and falls leading to fractures in the vicinity of the prosthesis shaft (see below).

Long-term risks: periprosthetic fractures

Falls following the insertion of a hip prosthesis are a significant risk, since they can lead to periprosthetic fractures, i.e. fractures in the vicinity of the hip prosthesis. When treating these fractures, an attempt is first to preserve the prosthesis and stabilise the fracture. This is possible if the prosthesis is still sufficiently firmly anchored in the medullary cavity. However, if the fracture has caused the prosthesis to loosen, it will have to be replaced. These prosthesis replacements or revision procedures are extensive surgical interventions that can be extremely stressful for the patient.

Summary (injuries and fractures of the femoral neck)

A fracture of the femoral neck is a serious injury that can have far-reaching consequences. These fractures are typically age-related; they are the leading cause of loss of independence and may make the patient reliant on long-term nursing care.

It must be expected that approx. one third of patients who suffer a broken hip will experience such a significant loss of mobility that they will have to be admitted to a nursing home. Greater importance must be attached to fracture prevention in order to limit the steady increase in the number of cases.

The treatment options for fractures of the femoral neck include hip replacement surgery, which is carried out using the latest minimally invasive methods. These surgical procedures, which preserve the soft tissue as far as possible, enable the patient to be mobilised immediately after the surgery and allow them to place their full body weight on the affected leg early in the postoperative phase. This helps prevent complications and allows the patient to return to their accustomed social setting following successful rehabilitation.

The Center for Geriatric Traumatology at Zurich University Hospital has established a “geriatric traumatology co-management” system order to implement this treatment concept successfully. This interdisciplinary approach requires cooperation between many professional groups and ensures that patients are offered the best possible treatment and care. Along with traumatologists and specialists in geriatric medicine, specially trained experts in the fields of nursing, physiotherapy, occupational therapy, nutrition and pain management work together in close cooperation with these patients.