Femoral head preservation following subcapital fracture of the femur.

Primary fixation of displaced subcapital fractures offers a low morbidity and low mortality approach to a very common problem. The vast majority of patients receiving this form of treatment will not require further surgery. When contrasted with the problems of primary arthroplasty which included a higher morbidity and higher mortality, a higher infection rate, and the possibility of prosthetic loosening, prosthetic dislocation, acetabular wear to subsequent pain, and protrusio, the choice seems very clear. We would reserve arthroplasty for the following: Patients with pathologic fractures of the femoral neck secondary to metastatic disease. Patients with displaced fractures of the femoral oral neck who have primary hip disease such as rheumatoid arthritis. Patients with coexistent serious illness with a grossly limited life expectancy. Enfeebled elderly patients with minimal demands (senile, demented, minimal ambulatory or not ambulatory before fracture. (We would not perform primary arthroplasty in patients with neurologic disorder leading to spasticity or contracture, since we found the dislocation rate in such patients to be unacceptably high). In patients under 60 years of age with displaced subcapital fractures of the femoral neck we would advocate the following: Anatomic reduction (open, if necessary); Sound secure fixation; Staged muscle pedicle graft to promote increased fixation and ideally femoral head vascularity; No weight bearing until the fracture unites. In patients greater than 60 years of age we would advocate the following: Anatomic or slight valgus reduction of the fracture; Sound secure fixation; Impaction of the fracture; Weight bearing as tolerated. If these principles are followed, the results of a policy of femoral head preservation in displaced subcapital fractures will be very acceptable for both the patient and surgeon alike. In our opinion, prosthetic replacement equals salvage surgery, and it should be delegated to that role.