A 68-year-old man is brought to the hospital 18 hours after a fall at home. Radiographs show a displaced intracapsular fracture of the femoral neck (Garden grade IV). Intraoperative assessment reveals that the fracture reduction is unstable and the bone quality is poor (osteoporotic). The surgeon is unable to achieve secure fixation with cannulated screws. What is the most appropriate next step?

Explanation

## Management of Failed ORIF in Displaced Intracapsular Femoral Neck Fracture ### Clinical Scenario This patient has a **displaced Garden IV intracapsular fracture** with **poor bone quality** and **failed internal fixation attempt**. The surgeon has intraoperatively determined that cannulated screws cannot achieve stable fixation—a critical finding that mandates conversion to arthroplasty. ### Why Hemiarthroplasty? **Key Point:** When internal fixation is technically impossible (poor bone quality, unstable reduction, or failed fixation attempt), conversion to **hemiarthroplasty** is the standard of care. This eliminates the risk of AVN and non-union and allows immediate weight-bearing. **High-Yield:** Hemiarthroplasty is indicated in: - Displaced intracapsular fractures in patients >65–70 years with poor bone quality - Failed ORIF attempts (as in this case) - Fractures with significant comminution - Patients with dementia or poor compliance (early mobilization is critical) **Clinical Pearl:** Cemented hemiarthroplasty is preferred over uncemented in elderly osteoporotic patients because cement provides immediate stability and reduces the risk of early loosening and subsidence. ### Why Other Options Are Incorrect | Option | Why Inappropriate | |---|---| | **DHS + side plate** | DHS is for **extracapsular** (intertrochanteric/subtrochanteric) fractures, not intracapsular. It does not address the failed fixation or poor bone quality. | | **Skeletal traction** | After a failed ORIF attempt, traction is futile. It delays definitive treatment, increases infection risk, and leads to poor outcomes (non-union, AVN, prolonged immobility). | | **Conservative management** | A displaced intracapsular fracture cannot be managed non-operatively. This leads to malunion, non-union, and severe functional disability. | **Mnemonic: FAILED ORIF + POOR BONE = HEMIARTHROPLASTY** — Do not persist with fixation; convert to arthroplasty. ### Decision Tree for Intracapsular Femoral Neck Fracture ```mermaid flowchart TD A[Displaced Intracapsular NOF Fracture]:::outcome --> B{Patient age & bone quality?}:::decision B -->|Young/good bone| C[Attempt ORIF with cannulated screws]:::action B -->|Elderly/poor bone| D[Consider hemiarthroplasty]:::action C --> E{Fixation stable?}:::decision E -->|Yes| F[Proceed with ORIF]:::action E -->|No| G[Convert to hemiarthroplasty]:::action D --> H[Proceed with hemiarthroplasty]:::action G --> I[Cemented prosthesis]:::action H --> I I --> J[Early weight-bearing & mobilization]:::action J --> K[Good functional outcome]:::outcome ``` ### Hemiarthroplasty vs. Total Hip Arthroplasty | Feature | Hemiarthroplasty | Total Hip Arthroplasty | |---|---|---| | **Indication** | Displaced intracapsular NOF (most common) | Preexisting osteoarthritis of hip | | **Operative time** | Shorter | Longer | | **Blood loss** | Less | More | | **Dislocation rate** | ~10% | ~2–5% | | **Acetabular wear** | Yes (long-term issue) | No | | **Preferred in NOF** | Yes, standard | Only if OA present | [cite:Campbell's Operative Orthopaedics 13e Ch 56; Rockwood & Green's Fractures in Adults Ch 53]