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Comparison of Early and Delayed Fixation of Subcapital Hip Fractures in Patients Sixty Years of Age or Less

Investigation performed at the University Health Network, Toronto Western Hospital, University of Toronto; Sunnybrook and Women's College Health Sciences Centre; and St. Michael's Hospital, Toronto, Ontario, Canada

Rina Jain, MD, FRCS(C)
Division of Orthopaedic Surgery, The Scarborough Hospital, General Division, 895 Don Mills Road, One Morneau Sabeco Centre, Suite 100, Toronto, ON M3C 1W3, Canada

Manfred Koo, MD, MSc
J. Rod Davey, MD, FRCS(C)
Nizar N. Mahomed, MD, ScD, FRCS(C)
Division of Orthopaedic Surgery, University Health Network, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada

Hans J. Kreder, MD, MPH, FRCS(C)
Division of Orthopaedic Surgery, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, MG 365, Toronto, ON M4N 3M5, Canada

Emil H. Schemitsch, MD, FRCS(C)
Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Subcapital hip fractures in younger patients are generally treated with internal fixation rather than with primary hemiarthroplasty, which is generally reserved for older, low-demand patients. Avascular necrosis can occur following this injury because of disruption of the femoral head blood supply. Some believe that emergent fracture reduction is necessary to minimize the risk of avascular necrosis. The purposes of this study were (1) to investigate the functional outcomes of subcapital hip fractures in patients sixty years old or younger and (2) to compare the rates of avascular necrosis after early and delayed fracture fixation.

Methods: This retrospective study included adults in whom a subcapital hip fracture had been treated with reduction and internal fixation when they were sixty years of age or less and who had been followed clinically for a minimum of two years. The patients were divided into two groups: those treated with early fixation (within twelve hours after the injury) and those treated with delayed fixation (more than twelve hours after the injury). Functional outcomes were assessed with use of the Short Form-36 and the Western Ontario and McMaster University (WOMAC) Osteoarthritis Index. The rates of avascular necrosis were compared between the two groups.

Results: Thirty-eight patients (average age, 46.4 years) participated in the study. Twenty-nine patients had a displaced subcapital hip fracture. Fifteen patients underwent early fracture fixation, and the remainder underwent delayed fixation. No differences in the Short Form-36 (p = 0.68) or WOMAC (p = 0.69) scores were seen between the early and delayed fixation groups. Radiographic evidence of avascular necrosis developed in six patients treated with delayed fixation, one of whom had had an undisplaced fracture preoperatively, and in no patient treated with early fixation. The difference in the rates of avascular necrosis was significant (p = 0.03).

Conclusions: Although delayed surgical treatment of subcapital hip fractures was associated with a higher rate of avascular necrosis, this complication did not significantly affect functional outcome. Longer follow-up is required to assess the effect of avascular necrosis on the development of arthritis and on long-term patient function. Although the results could be biased because patients were not randomly assigned to delayed or early fixation, the data suggest that urgent reduction and fracture fixation within twelve hours after a displaced subcapital hip fracture in high-demand patients may be associated with a reduced rate of radiographic signs of avascular necrosis.

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