Injury
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Outcomes after operative treatment of displaced femoral neck fractures in young adults are fraught with high complications rates including non-union and avascular necrosis. Among the therapeutic controversies that persist is the role of open reduction, which would allow surgeons a direct means to improve the quality of reduction, a predictor of successful treatment. We performed a systematic review of the literature to compare the outcomes (nonunion, avascular necrosis, and deep infection) after open reduction with internal fixation (ORIF) to closed reduction with internal fixation (CRIF) of acute (surgery performed less than 6 weeks from injury) femoral neck fractures in young adults (average age of 50 or younger) followed for at least one year. ⋯ In summary, systematic review of the literature reveals a lack of evidence in support of ORIF versus CRIF as a means of treating displaced femoral neck fractures in young patients with respect to union and avascular necrosis; however, the incidence of surgical site infections may be lower with CRIF. Firm conclusions cannot be drawn given the lack of high quality prospective studies and patient reported outcomes. In the future, randomised controlled trials will be required to test the effect of reduction method.
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Anatomic reduction of femoral neck fractures is difficult to obtain in a closed fashion. Open reduction provides for direct and controlled manipulation of fracture fragments. This can be accomplished via multiple approaches. ⋯ These can be performed using a fracture table or with a free leg on a radiolucent table in either supine or lateral positions. Knowledge of the hip and pelvis anatomy is crucial for the preservation of critical femoral neck vasculature. Intra-operative fluoroscopy together with direct visualization provides the framework for successful manipulation of the fracture fragments, temporary stabilization, and ultimately fracture fixation.
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Review
Biomechanical rationale for implant choices in femoral neck fracture fixation in the non-elderly.
Femoral neck fractures represent a relatively uncommon injury in the non-elderly population often resulting from high-energy trauma. The cornerstone of their management is anatomic reduction and stable internal fixation of the femoral neck in an attempt to salvage the femoral head. Complications including avascular necrosis of the femoral head, non-union and post-traumatic osteoarthritis are not uncommon. ⋯ Moreover, in unstable basicervical patterns cannulated screws (triangular configuration) demonstrated a lower ultimate load to failure, whereas in subcapital or transervical patterns both the cannulated screws (triangular configuration) and the sliding hip screw demonstrated no compromise in fixation strength. The fracture pattern appears to be the major determinant of the ideal type of implant to be selected. For a successful outcome each patient needs to be considered on an individual basis taking into account all patient and implant related factors.
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Avascular necrosis (AVN) after internal fixation of intracapsular hip fractures is a progressive multifactorial disease that ultimately results in local ischemia with ensuing osteocyte necrosis and structural compromise. This disease can cause significant clinical morbidity and affects patients of any age, including young and active patients. Effective treatment of this condition among young adults is challenging due to their high functional demands. ⋯ Conversely, arthroplasty in the young adult may require repeat revision procedures throughout the patient's life. Current evidence suggests that modifications of prevailing treatments, in addition to new technologies, have led to the development of management strategies that may be able to alter the course of femoral head osteonecrosis. This review aims to summarise the options available for treatment of AVN in the young adult and review the clinical results.
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Review
Special topic: Ipsilateral femoral neck and shaft fractures - Does evidence give us the answer?
Ipsilateral fractures of the femoral neck and shaft are rare, high-energy injuries that typically occur in young polytrauma patients. The associated fracture of the neck is often vertical in nature and is more frequently non-displaced than in isolated femoral neck fractures. Historically the diagnosis of an associated femoral neck fracture was delayed or missed in approximately one third of cases. ⋯ Fixation of the shaft fracture follows as patient condition allows. The rare nature of this injury makes it very challenging to study and most published series' are retrospective with very small sample sizes. In short, no scientificallycompelling study is available to definitively support any one implant choice or method of stabilzation over another for the treatment of associated fractures of the femoral neck and shaft.