Schizophrenia is a long-term, complicated mental health condition that manifests in a variety of ways, including delusions, hallucinations, disorderly behavior or speech, and diminished cognitive function. ¹ The prevalence of the schizoaffective disorder from 2008 to 2015 was 6.2 per 1000 individuals aged 15 to 64 years, with a greater frequency in men than in women. ² Femoral neck fractures occur in 63.3 out of every 100,000 women, 27.7 out of every 100,000 men, and 5.54 out of every 1000 patients with schizophrenia. People under the age of 50 accounted for 23% of them. ^{3 , 4} After controlling for potential confounders, a case-control study from the United Kingdom (n = 44,500) discovered that both current and prior antipsychotic use, as well as the duration of antipsychotic use, were associated with a small significant increase (OR 1.3, 1.3, r 2 = 0.88, respectively) in hip/femur fractures as the side.

At least 30 days after the fracture, a neglected femoral column fracture can be promptly identified with a history and X-ray examination. ⁵ Bone grafting is frequently used to treat the early stages of untreated femoral neck fractures. However, arthroplasty may be an useful treatment option in unique circumstances that result in an early malformation of the femoral head or acetabulum. ³

In November 2021, an Austronesian unemployed 41-year-old man who had been found in a ditch complained to the emergency department that he had been unable to walk for four weeks. After an X-ray indicated schizophrenia, the patient's femoral neck fracture was determined to be the cause. After the patient acknowledged having schizophrenia since he was 25 and used haloperidol often, the diagnosis was changed to a first-generation antipsychotic drug-induced neglected femoral neck fracture. ⁶

Physical examination, as shown in Figure 1, reveals that the patient is unable to lift the right leg but is able to move the right leg to the right and to the left. The right hip also exhibits signs of exhalation, has flexion in the knee and hip, and is erythematous and warm to the touch. Other physical examination findings include crepitus, pain and motion (+), and a limited range of motion (ROM) of six joint movements (flexion, extension, abduction, addition, rotation) and a physical examination revealed a body temperature of 37.6°C, a blood pressure of 134/85 mmHg, a pulse rate of 97 beats per minute, and a respiratory rate of 20 beats per minute. An evaluation by a psychiatrist indicated auditory hallucinations (+) and a speech disability.

A right femoral head fracture was suspected after a radiological evaluation that can be seen in Figure 2, of the pelvis and the right femur's PA view revealed an osteochondroma in the middle third of the right femur. The discomfort and potential for falls prevented the adoption of the lateral perspective.

Registration for right femoral reconstruction and hemiarthoplasty as opposed to bone grafting is part of the management of femoral neck fractures. As depicted in Figure 3, a right femoral osteotomy and hemiarthoplasty was carried out in December 2021. This treatment was chosen because removing the femoral head from the acetabulum caused the femoral head and neck to rejoin.

Seven days after the surgery, monitoring and follow-up were carried out before outpatient management was put into action. Following surgery, monitoring of the patient's general health, vital signs, surgical scars, and ROM was done. Along with educating patients and family about the disease (neglected femoral neck fracture along with his schizophrenia condition), treatment, post-operative problems, and prognosis, physiotherapists and rehabilitation professionals constantly monitored ROM patients after surgery. The patient was instructed in deep breathing relaxation techniques as well as how to immobilize the right femur (abduction and exorotation). In order to treat the patient's pain, analgesic therapy was also offered. However, despite being given schizophrenia medication, dislocation still happened because he frequently performed hip flexion and endorotation movements to their maximum extent, the outpatient was reluctant. Moreover, the effect of prolonged use of the drug may cause lytic lession that worsen the patient condition. ⁵

Three months post-surgery X-ray shows the acetabulum dysplasia and lytic lesion that provide drug-induced bone destruction by the first-generation antipsychotic drug.

Figure 4 depicts the patient's state three months after surgery. Abduction and endorotation of the right hip joint in the image suggest a dislocation at that hip joint as well as a lytic lesion inside the acetabulum. The lytic lesion exhibits fast loss of bone density that may be brought on by chronic haloperidol use. The patient has a good prognosis if the hip immobilization and effective physical treatment are carried out effectively. However, if the aforementioned parameters are not met, the prognosis may become poor.

This case report gives a presentation of a rare medical condition. The presentation included the history, pathogenesis, limitation of the treatment, and suggested treatment. This information may be useful to other practitioners. However, the lack of follow up is a main limitation of this case report.

The patient in this case study is a 41-year-old male who was identified having a rare and exceptional case of a femoral neck fracture brought on by the misuse of first-generation antipsychotic medications. Treatment with long-term haloperidol had begun at age 25 to treat schizophrenia. ⁶

In comparison to healthy, sex-adjusted controls, schizophrenia patients are more likely to experience hip fractures and have lower hip bone mineral density after long-term therapy. ⁷ The only effective treatment for a desired hip fracture is surgery. ⁸ However, the course of treatment is determined by the patient's age, the severity of any pre-traumatic symptoms, the type of fracture, and its dislocation. ⁹

Compared to second-generation antipsychotics, first-generation antipsychotics (AGPs) seem to have a higher risk of fracture (AGKs). To determine whether there was a link between antipsychotic drug use and fracture, Lee et al (2017) conducted the study that revealed that 1.5 times risk of fracture increase in people with antipsychotics drug usage. The same study also found that the risk of first generation antipsychotic drug with odds ratio 1.67 higher than second generation antipsychotic drug with odds ratio 1.33. ¹⁰

Antipsychotics are prolactin secretion inhibitors and dopamine D2 receptor antagonists. This may prevent the hypothalamic-pituitary-gonadal axis from functioning properly, leading to low BMD and hyperprolactinemia. The release of gonadotropin-releasing hormone (GnRH) from the hypothalamus can be inhibited by an increase in serum prolactin. Low levels of GnRH consequently inhibit the pituitary gland's production of luteinizing hormone and follicle-stimulating hormone, lower levels of estradiol, progesterone, and testosterone, and cause improper bone metabolism and osteoporosis. Antipsychotic-treated schizophrenia patients experienced reduced BMD and more pathological fractures. Numerous epidemiological studies have shown a dose-response association between the use of antipsychotics and the incidence of hip fracture in nursing home patients as well as fracture risk in the Danish population. ^{4 , 5 , 10 , 11} Thus, one effect of long-term antipsychotic medication is the increased risk of fracture development in treating schizophrenia patients. ¹²

These studies' findings support this case and show that antipsychotic usage in schizophrenia patients carries a risk of hip fracture.

Avascular necrosis (AVN) can result from femoral neck fractures, especially if they are not treated right away. The predominant blood supply to the femoral head is provided by the medial rotator cuff femoral artery, lateral radial femoral artery, and obturator artery. The femoral head is supplied by the obturator artery through the round ligament. Osteonecrosis is caused by fractures with dysplasia, which interfere with the artery's terminal branches at the level of the femoral head. ³

The according-to-time type of neglected femoral neck fractures management can be differentiated by the Sandhu classification ³ : 1.

Neglected fracture of femoral neck less than four weeks

Internal fixation and closed or open reduction are the primary therapy options for stage I. Consider bone grafting in a Non-Union (NU) site.

The main treatment option for early-stage neglected femoral neck fracture is the bone grafting procedure. However, hemi hip arthroplasty (HHA) is preferred in this case due to the rapid destruction of the femoral head bone and no acetabular dysplasia detected at first. ^{3 , 4 , 13} In order to prevent post-surgery mechanical complications, longer hospital stays inpatient is preferred. This is also able to maximize the monitoring and evaluation surgery process. ^{1 , 7 , 14} Arthroplasty reduces the need for repeat surgery. This procedure allows early load adaptation. ^{15 – 17}

The case's approach must take into account a number of factors. The initial decision is whether to fix the fracture or replace the joint. Joint replacement may be a sensible option if fracture repair is not practical. Hemi hip arthroplasty, which replaces only the proximal femur, and total hip arthroplasty, which replaces both the proximal femur and the articular surface, are the two basic forms of joint replacement. ^{15 , 16} Hemi hip arthroplasty is indicated when there is no acetabular dysplasia and complete hip arthroplasty is preferred when there is acetabular dysplasia. ⁸ Since there was still no acetabular dysplasia, the patient in this case study was finally treated with a hemi hip arthroplasty. However, three months post-surgery X-ray shows the acetabulum dysplasia and lytic lesion, so we suggest performing total hip arthroplasty (THA) with or without acetabular dysplasia to prevent repeated surgery.

A single impression was used to create the proximal femoral hemiarthroplasty prosthesis, which had the femoral shaft joined to the femoral head and neck. The Austin-Moore prosthesis is a typical illustration. ^{15 , 16}

After cutting the femur's neck to size and prepping the medullary canal, the proximal femoral prosthesis is put into the femur. ¹⁵

When doing an arthroplasty, many surgeons favor an anterior or posterior approach, with the patient laying on their side or back. In this instance, anterior capsule-conserving surgery is advised since it may lower the chance of prosthesis dislocation, particularly for joint dysplasia. ¹⁵ Three months post-surgery X-ray shows the acetabulum dysplasia and lytic lesion that provide drug-induced bone destruction by the first-generation antipsychotic drug.

To lessen the threat of prosthetic hip dislocation for the duration of the primary 6 weeks, the patient has to avoid too many hip joint movements. Adduction throughout the midline, hip flexion extra than 80° to 90°, and inner rotation have to be averted particularly after treatment. ^{16 , 17}

The long-term use of the first-generation antipsychotic drug, haloperidol, tends to cause bone destruction, especially weight-bearing bone, in this case, the head and neck femoral bone. It may lead to early onset first-generation antipsychotic drug-induced neglected femoral neck fracture because the bone destruction was slowly progressive. This made the patient less aware of his disease until complete destruction occurred. It was shown in this case that there was a worsening condition that show acetabular dysplasia along with lytic lesions 3 months after the first hemi hip arthroplasty as the side effect of haloperidol long-term use. The suggested strategy for a similar case in the future will be arthroplasty rather than bone grafting, total hip arthroplasty is suggested rather than hemi hip arthroplasty in order to prevent repeated surgery.

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.