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Hip Fracture Threatens Independence and Mobility in the Elderly

Despite all efforts to prevent hip fractures, this injury remains a major problem among adults 65 and older. And with the aging Baby Boom population (born between 1946 and 1964) now entering Medicare, this problem isn't expected to go away.

In fact, estimates are that there will be half a million hip fractures per year in the next 30 years. That amounts to a big chunk of change for Medicare and an even bigger inconvenience (even disability or death) for our seniors. Loss of mobility and independence are major concerns with any hip fracture in this age group.

While prevention of hip fractures in older adults remains an important step, treatment once such a break occurs is equally important. But like many other medical decisions with the elderly, there are often compounding factors that make treatment decisions and the treatment itself both complex and challenging.

There are different types of hip fractures based on location. The femur is the long thigh bone with a round bony "head" at the top. The femoral head fits inside the acetabulum or hip socket. Fractures can occur anywhere in the long shaft of the femur, the neck (between the shaft and the femoral head), and the acetabulum. There is also intertrochanteric fractures. The intertrochanteric region of the hip is just below the femoral neck.

In this article, Dr. Robert Probe, an orthopedic surgeon in Texas offers some insight into surgical treatment of femoral neck fractures. Two of the major problems that develop with femoral neck fractures are loss of blood to the femoral head and shortening of the femoral neck. Unless the patient cannot tolerate surgery for some reason, femoral fractures are best treated surgically.

But that's where the decision becomes much more complicated. Is the fracture stable enough to pin it back together until it heals? Will it heal? Are there patient factors that might result in a nonunion? How likely is a nonunion? Should the femoral head be replaced? If the decision is made to replace the femoral head, then the surgeon must choose between a cemented or uncemented stem (the piece that fits down into the shaft of the femur).

That's not the end of the possibilities. The femoral head is available in several different models with different options (e.g., unipolar, bipolar) for achieving movement of the femoral head. It may be necessary to perform a complete hip joint replacement (femoral head and stem along with replacing the acetabulum). Should the surgeon try and save the hip knowing the patient may end up in surgery again in order to replace a failed fixation?

Fixation refers to the use of screws, nails, pins, and metal plates to hold the broken pieces of bone together until healing can take place. This option is only available to a limited number of patients. The fracture must be stable. If displaced (separated), it must be possible to bring the pieces together and precisely match them up again.

Dr. Probe describes the technique he uses when placing screws in the hip for a stable femoral neck fracture. He also discusses the use of a fixed-angle hip compression screw fixation. The compression screw keeps the femur from further bone displacement that would change the angle of the femur as it places the femoral head in the acetabulum (hip socket).

If the surgeon sees reasons and predictive factors that point to the strong possibility of nonunion and failed fixation, then hip replacement is the treatment of choice. Older adults who are active and wish to remain active may prefer this approach as well. It bypasses the possibility of a second surgery (from fixation to replacement). Current studies show fixation failure at 25 per cent right now.

Results of total hip replacement (measured by pain, function, and revision rates) have been good-to-excellent for the "active and fit" older adults. Benefits and risks of this surgery for this age group with femoral neck fractures are still being investigated and reported.

In summary, femoral neck fractures in older adults can be complex and challenging to treat. The surgeon makes every effort to save the natural anatomy. Patient health, strength of the bone, mobility, level of community activity, and predicted life span are all taken into consideration when making a decision about fracture fixation versus hip replacement. With more and more older adults remaining active later in life, we can expect to see a higher number of total hip replacement procedures for femoral neck fractures.

Reference: Daniel L. Stahl, and Robert A. Probe, MD. Treatment of Femoral Neck Fractures in the Elderly. In Current Orthopaedic Practice. September/October 2011. Vol. 22. No. 5. Pp. 400-404.