Editorial: Sub-capital hip fracture: best treatment options

Most orthopaedic surgeons base their decision to treat subcapital fractures of the hip on a set of guidelines. Garden1 in 1971 provided a simple system of grades to guide surgeons. The system is based on displacement of the fracture fragments and relies on the survival of live osteocytes in a compromised, if not totally disrupted, vascular bed. The most displaced fracture—Garden type IV—has no intact nutrient or neck vessels. Only the vessel of the ligamentum teres may survive. Two additional conditions affect the vitality of the displaced femoral head: patient age and the time lapse since fracture. While intra-osseous vessels may not be affected by age, extra-osseous vessels are. Osteocytes do not survive long in the complete absence of a blood supply. Although a few dying osteocytes have been observed within intact femoral head trabeculae for up to 3 weeks after a sub-capital fracture, they appear to be fatally harmed after 12 hours of ischaemia.2 After subcapital fracture, there are no completely reliable techniques to determine whether the femoral head is alive or dead. Even intravital tetracycline labelling and technetium-methylenediphosphonate radionuclide imaging,3 is not completely ‘fool-proof’. Therefore many surgeons do not attempt to treat this fracture by reduction and pinning and opt, from the outset, for an arthroplasty. Preoperative contemplation and planning should bear in mind the acetabular labrum and the posterior capsule. If a monopolar replacement is chosen, the capsule of the hip should be carefully preserved and, in particular, the acetabular labrum. The labrum increases the dimensions of the acetabular space and reduces the likelihood of postoperative dislocation. In patients who are likely to be sitting in bed or in a wheelchair, an anterior approach will reduce the risk of hip dislocation. The converse is true following a posterior approach. The patient’s level of activity must also be considered. It influences the choice of arthroplasty. Few people at high risk for subcapital hip fracture are tennis players, but if an individual is very active, a total hip arthroplasty (THA) is better able to withstand hard work and heavy-duty sports, such as skiing, than other treatment options.4 Blood transfusion increases the risk of wound infection and should be avoided if at all possible. Among patients who have had surgery for intracapsular fractures of the hip, the overall risk of wound infection is about 4.5%. It is about 7.0% in those who are transfused in contrast with only 3.71% in the non-transfused.5 Hence a ‘less-blood-losing’ operation would seem particularly advantageous in this type of surgery, although it is best to avoid blood transfusions in any type of surgery. The above-listed caveats influence the decision on the best choice of femoral head replacement.