Complications In Hip Fractures - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes complications associated with hip fractures.

Dislocations: Dislocations occur more in total hip arthroplasty than hemiarthroplasty. Avoid activity that causes dislocation after a total hip surgery! Total hip arthroplasty is done in physiologically active elderly patients with a displaced femoral neck fracture. Although it may increase the risk of dislocation, there is a lower revision rate and a superior long term future outcome.
Failure of Fixation: Quality and maintenance of reduction of the fracture is important. Closed reduction can be attempted, however the reduction must be anatomic. If it is not anatomic reduction, then an open reduction should be done. Open reduction can be done through an anterior approach or a Watson-Jones approach. When the fixation fails, you can attempt to repeat ORIF or you may do prosthetic replacement. It should be noted that in the elderly patient, treatment of displaced femoral neck fractures with screws may have failures and revision rates up to 40%.
Fracture Distal to the Fixation: Probably due to screw placement at or below the lesser trochanter and poor bone quality, especially if you start anteriorly and not laterally. Also may be due to poor angle of the screw fixation and multiple attempts at drilling or guide pins. Treatment will include refixation of the femoral neck and the subtrochanteric fracture.
Nonunion of the Fracture: Femoral neck fractures are considered to be intracapsular fractures which are at a high risk of developing nonunion. It can present itself by groin or buttock pain, pain with hip extension, or with weight bearing. It can occur in about 5% of nondisplaced fractures and in about 25% of displaced fractures. If it occurs in the elderly patient, do arthroplasty. If it occurs in the young patient, do valgus intertrochanteric osteotomy. Vascularized fibular graft may benefit the patient. Nonunion occurs more in the vertically oriented fracture pattern with loss of reduction and varus collapse. In the younger patient, we may possibly reorient the fracture line to be more horizontal by doing the osteotomy.
Medical: There is an increased risk of DVT up to 80%. Some form of prophylaxis is indicated, both mechanical and pharmacological for the patient. Consult the medial team for co-management. The aim of treatment is early embolization of the patient with pulmonary toilet. There is a high mortality rate in the elderly (approximately 30% in one year). Surgical delay more than 72 hours will increase the risk of one year mortality.
Osteonecrosis (AVN): The patient will have groin, buttock or proximal thigh pain. It occurs in 10% of nondisplaced fractures and in 30% of displaced fractures. AVN could occur due to interruption of the terminal branch of the medial femoral circumflex artery by the fracture. AVN may occur due to an increase in the initial displacement, increase in the time to reduce or nonanatomic reduction. In younger patients with less than 50% femoral head involvement, treatment may include a valgus intertrochanteric osteotomy.
Penetration of the Screws into the Hip Joint: Put the screws within 5 mm of the articular cartilage. Use multiple fluoroscopy images to confirm that there is no penetration. The screws have to be parallel so that it allows compression of the fracture. Make sure that the threads of the screws cross the fracture site, otherwise the treads will distract the fracture. You may use long threads or short threads based on the situation.
Shortening: Femoral neck shortening after fracture fixation with multiple cancellous screws can be a problem. The healed femoral neck fracture with shortening is usually associated with a poor functional outcome.

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