A retrospective cohort across 12 North American Level 1 trauma centers looked at 234 adults aged 18-65 with displaced femoral neck fractures fixed internally. It asked what drives the choice of open reduction, and whether open versus closed reduction changes the risk of reoperation. Propensity-score adjustment was used to account for why surgeons chose to open the fracture.
The long-held teaching is that open reduction is worth the surgical cost because it delivers a better reduction, and reduction quality is the single most important surgeon-controlled factor in these fractures. This study challenges that: opening the hip did not improve radiographic reduction (71% vs 69%) yet was tied to a 2.4-fold higher hazard of reoperation, driven specifically by nonunion.
The authors attribute this to the biologic cost of the approach. The anterior and anterolateral exposures put the lateral femoral circumflex branches, which supply 48% of the anteroinferior neck, at risk, and prolonged external rotation adds ischemia.
Read the design carefully before changing practice. This is a Level III retrospective cohort with 58% loss to follow-up and a 1.5-year median that may censor late AVN, and confounding by injury severity is only partly handled by the propensity score.
The practical rule the authors endorse: do not accept a bad closed reduction just to avoid opening the hip, because an unreduced fracture is never acceptable.
A retrospective cohort across 12 North American Level 1 trauma centers looked at 234 adults aged 18-65 with displaced femoral neck fractures fixed internally. It asked what drives the choice of open reduction, and whether open versus closed reduction changes the risk of reoperation. Propensity-score adjustment was used to account for why surgeons chose to open the fracture.
The long-held teaching is that open reduction is worth the surgical cost because it delivers a better reduction, and reduction quality is the single most important surgeon-controlled factor in these fractures. This study challenges that: opening the hip did not improve radiographic reduction (71% vs 69%) yet was tied to a 2.4-fold higher hazard of reoperation, driven specifically by nonunion.
The authors attribute this to the biologic cost of the approach. The anterior and anterolateral exposures put the lateral femoral circumflex branches, which supply 48% of the anteroinferior neck, at risk, and prolonged external rotation adds ischemia.
Read the design carefully before changing practice. This is a Level III retrospective cohort with 58% loss to follow-up and a 1.5-year median that may censor late AVN, and confounding by injury severity is only partly handled by the propensity score.
The practical rule the authors endorse: do not accept a bad closed reduction just to avoid opening the hip, because an unreduced fracture is never acceptable.