Guidelines or State Civil Codes in the Management of Femoral Neck Fracture? An Analysis of the Reality of Care Provision in North Rhine-Westphalia: Astonishing Differences in Care Provision

by Prof. Dr. med. Rüdiger Smektala, Dr. med. Angelika Grams, Prof. Dr. med. Ludger Pientka, Dr. med. Dr. PH. Ulrich Schulze Raestrup in volume 16/2008

In addition to the frequency of operations and the prompt provision of care, the chosen surgical method in patients with femoral neck fracture is worth considering. As the authors said in their article, there is a big difference between the surgical methods used by orthopedic surgeons and those used by emergency surgeons, with regard to endoprosthesis for treatment of femoral neck fracture.

As an orthopedic surgeon, I revisit a whole range of dual-head prostheses that were implanted after femoral neck fracture. Although studies have not shown a direct disadvantage of dual-head prosthesis compared with total endoprosthesis, orthopedic surgeons seem to have less confidence in the dual-head prosthesis, as the study shows. In the patients affected, the joint cartilage seems to be damaged in more cases than has hitherto been assumed (1, 2). Perhaps the difference in care is due to the fact that patients who register complaints after having a dual-head prosthesis visit primarily orthopedic specialists. Orthopedic doctors therefore seem to favor total endoprosthesis to treat femoral neck fractures, on the basis of their experience with painful dual-head prostheses. In view of the fact that any care administered should, at least in the medium term, enable the patient to live free of pain, total endoprosthesis should be preferred in those patients who are still able to walk and are mobile outside their four walls.

With the possibility of using large-head endoprosthesis (minimum 36 mm), luxation should not occur. The advantage in minimizing luxation with large heads by far outweighs the disadvantages of increased polyethylene abrasion.

Monoblock prostheses should be used only in bedridden patients, since the remaining cartilage will be abraded massively and potentially required hip surgery would be made difficult by the monoblock.

It would be welcomed if the authors' data were to enable further studies that could shed light on the long term results of the chosen surgical method.
DOI: 10.3238/arztebl.2008.0540a


Prof. Dr. med. Martin Lukoschek
Vincentius Krankenhaus AG
Untere Laube 2
78462 Konstanz, Germany
[e-mail]

References

1. Dalldorf PG, Banas MP, Hicks DG, Pellegrini VD Jr: Rate of degeneration of human acetabular cartilage after hemiarthroplasty. J Bone Joint Surg Am 1995; 77: 877–82.

2. Minihane KP, Turner TM, Urban RM, Williams JM, Thonar EJ, Sumner DR: Effect of hip hemiarthroplasty on articular cartilage and bone in a canine model. Clin Orthop Relat Res 2005; 437: 157–63.