Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls. Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures. However, for the physiologically young patients, preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands. The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures. Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population. Furthermore, other management variables such as surgical timing, the role of capsulotomy and the choice of implant for fixation remain controversial. This review will focus both on the demographics and injury profile of young patients with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.

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Sickle cell disease (SCD) is an autosomal recessive disorder that is characterized by abnormal “sickle-shaped” erythrocytes. Because of their shape, these erythrocytes are more likely to become trapped in small slow-flowing vessels, leading to vaso-occlusion. Because this commonly happens in the bones, patients with SCD are at an increased risk for orthopaedic manifestations such as osteomyelitis, septic joint, or osteonecrosis. Osteomyelitis is a serious and potentially disabling condition but can be difficult to differentiate from benign conditions of SCD, such as vaso-occlusive crisis. Diagnosis of osteomyelitis requires careful evaluation of the clinical presentation, laboratory testing, and imaging. Treatment of osteomyelitis in patients with SCD may be medical or surgical, but considerations in antibiotic selection and management preoperatively and postoperatively must be taken to ensure optimal outcomes.

Treatment with acetylsalicylic acid prevents short to mid-term radiographic progression of nontraumatic osteonecrosis of the femoral head: a pilot study Background: Nontraumatic osteonecrosis of the femoral head (ONFH) is a progressive disease in young adults producing substantial morbidity and frequently resulting in total hip arthroplasty. Although hip-preserving surgical procedures represent the current mainstay of treatment for early disease, medical therapies targeting specific pathways in the ONFH pathogenesis could help prevent disease progression while producing less morbidity. Acetylsalicylic acid (ASA) is a promising alternative to other therapies for ONFH owing to its anti-inflammatory and antithrombotic mechanisms of action and its relatively benign side effect profile. Methods:We followed a prospective cohort of 10 patients (12 hips) with precollapse ONFH who were given ASA to prevent disease progression. Their outcomes were compared with those of a historic control group taken from the literature.Results: Progression occurred in 1 of 12 (8%) patients taking ASA compared with 30 of 45 (66.6%) controls (p = 0.002) at a mean follow-up of 3.7 years. Patients taking ASA also tended to exhibit decreased femoral head involvement at the end of therapy. Conclusion:This hypothesis-generating study leads us to believe that ASA may be a simple and effective treatment option for delaying disease progression in patients with early-stage ONFH.Contexte : L'ostéonécrose non traumatique de la tête fémorale (ONTF) est une maladie progressive qui affecte les adultes jeunes, s'accompagne d'une morbidité substantielle et mène souvent à une arthroplastie totale de la hanche. Même si les interventions chirurgicales visant à préserver la hanche représentent la pierre angulaire actuelle du traitement pour la maladie au stade précoce, les traitements médica-menteux qui ciblent les voies spécifiques de la pathogenèse de l'ONTF pourraient contribuer à prévenir la progression de la maladie tout en atténuant la morbidité. L'acide acétylsalicylique (AAS) est une solution de rechange prometteuse aux autres traitements indiqués pour l'ONTF en raison de ses propriétés anti-inflammatoires et antithrombotiques et de son profil d'innocuité relativement bénin.Méthodes : Nous avons suivi une cohorte prospective de 10 patients (12 hanches) présentant une ONTF au stade précollapsus qui ont reçu de l'AAS pour prévenir la progression de la maladie. Leurs résultats ont été comparés à ceux d'un groupe témoin historique de patients décrits dans la littérature.Résultats : La progression a affecté 1 patient sur 12 (8 %) traités par AAS, contre 30 témoins sur 45 (66,6 %) (p = 0,002) après un suivi moyen de 3,7 ans. Les patients sous AAS avaient tendance à présenter une atteinte moins prononcée de la tête fémorale à la fin du traitement. Conclusion :Cette étude exploratoire nous amène à croire que l'AAS pourrait être une option thérapeutique simple et efficace pour retarder la progression de la maladie chez les patients au stade précoce d'une ONTF.

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Two-stage exchange arthroplasty remains the treatment of choice for chronic periprosthetic joint infections. This retrospective study conducted between 2009 and 2015 examined the diagnostic value of biomarkers for residual infection between stages. The biomarkers evaluated included C-reactive protein prior to reimplantation, preimplantation synovial fluid white blood cell count and percent neutrophils, and the intraoperative histologic synovial white blood cell count per high-power field (×400) on permanent sections. Residual infection was defined as either positive cultures (more than 1) at second stage, any further surgery (eg, amputation, arthrodesis, or another 2-stage revision), or the need for infection suppression with antibiotics. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios were calculated accordingly. A total of 182 two-stage exchange operations that included 109 (59.9%) prosthetic hips and 73 (40.1%) prosthetic knees met the inclusion criteria. Residual infection was present in 38 (20.9%) of the procedures. The area under the curve–receiver operating characteristic values were 0.677 for C-reactive protein ( P =.002), 0.506 for aspiration white blood cell count ( P =.944), 0.623 for aspiration percent neutrophils ( P =.200), and 0.524 for white blood cell count per high-power field ( P =.801). Positive and negative predictive values were poor and ranged between 26% and 57% and 78% and 85%, respectively. Analyses using specific combinations of biomarkers did not significantly improve predictive values. This study showed that classic markers perform poorly in identifying residual infection prior to second-stage revision. Further research is necessary to evaluate the diagnostic utility of other, more recently introduced biomarkers to determine whether infection has been eradicated between stages. [ Orthopedics . 2019; 42(1):34–40.]