Abstract: Objectives: The objective of this study was to determine the difference in failure rates of surgical repair for displaced femoral neck fractures in patients younger than 60 years of age according to fixation strategy.
Design: This is a retrospective, comparative cohort study.
Setting: Twenty-six Level 1 North American trauma centers.
Patient Selection Criteria: Patients younger than 60 years of age with a displaced femoral neck fracture (OTA 31-B2, B3) undergoing surgical repair from 2005 to 2017.
Outcome Measures and Comparisons: Patient demographics, injury characteristics, repair methods used, and treatment failure (nonunion/failed fixation, avascular necrosis, and need for secondary surgery) were compared according to fixation strategy.
Results: Five hundred and sixty-five patients met inclusion criteria and were studied. The mean age was 42 years, 36% were female, and the average Pauwels' angle of fractures was 55 degrees. There were 305 patients treated with multiple cannulated screws (MCS) and 260 treated with a fixed-angle (FA) construct. Treatment failures were 46% overall, but was more likely to occur in MCS constructs versus FA devices (55% vs. 36%, P < 0.001). When FA constructs were substratified, the use of a sliding hip screw with addition of a medial femoral neck buttress plate (FNBP) and "antirotation" (AR) screw demonstrated better results than either FNBP or AR screw alone or neither with the lowest overall construct failure rate of 11% (P < 0.036).
Conclusions: Historically used fixation constructs for femoral neck fractures (eg, multiple cannulated screws and sliding hip screw) in young and middle-aged adults performed poorly compared with more recently proposed constructs, including those using a medial femoral neck buttress plate and an antirotation screw. Fixed-angle constructs outperformed multiple cannulated screws overall, and augmentation of fixed-angle constructs with a medial femoral neck buttress plate and antirotation screw improved the likelihood of successful treatment. Surgeons should prioritize fixation decisions when repairing displaced femoral neck fractures in patients.
Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Competing Interests: The authors report no conflict of interest.
(Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)
References: Collinge CA, Finlay A, Rodriguez-Buitrago A, et al. Treatment failure in femoral neck fractures in adults less than 50 years of age: analysis of 492 patients repaired at 26 North American Trauma Centers. J Orthop Trauma. 2022;36:271–279.
Probe R, Ward R. Internal fixation of femoral neck fractures. J Am Acad Orthop Surg. 2006;14:565–571.
Slobogean GP, Sprague SA, Scott T, et al. Complications following young femoral neck fractures. Injury. 2015;46:484–491.
Wang CT, Chen JW, Wu K, et al. Suboptimal outcomes after closed reduction and internal fixation of displaced femoral neck fractures in middle-aged patients: is internal fixation adequate in this age group? BMC Musculoskelet Disord. 2018;19:190.
Collinge CA, Harris P, Sagi HC, et al. Comparative analysis of supplemental medial Buttress Plate fixation for high-energy displaced femoral neck fractures in young adults. J Orthop Trauma. 2023;37:207–213.
Chang CH, Tsai SW, Wu PK, et al. Suboptimal outcomes after internal fixation for displaced intracapsular femoral neck fractures in 50- to 60-year-old patients. Hip Int. 2020;30:474–480.
Gardner S, Weaver MJ, Jerabek S, et al. Predictors of early failure in young patients with displaced femoral neck fractures. J Orthop. 2015;12:75–80.
Liporace F, Gaines R, Collinge C, et al. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008;90:1654–1659.
Hoshino CM, Christian MW, O'Toole RV, et al. Fixation of displaced femoral neck fractures in young adults: fixed-angle devices or Pauwel screws? Injury. 2016;47:1676–1684.
Luttrell K, Beltran M, Collinge CA. Preoperative decision making in the treatment of high-angle “vertical” femoral neck fractures in young adult patients. An expert opinion survey of the Orthopaedic Trauma Association's (OTA) membership. J Orthop Trauma. 2014;28:e221–e225.
Slobogean GP, Sprague SA, Scott T, et al. Management of young femoral neck fractures: is there a consensus? Injury. 2015;46:435–440.
Xian H, Cheng W, Xie W, et al. Does the angle between dynamic hip screw and anti-rotation screw affect the outcome of vertically oriented femoral neck fractures? A biomechanical analysis and clinical results. Injury. 2024;55:111317.
Nwankwo CD, Schimoler P, Greco V, et al. Medial plating of Pauwels type III femoral neck fractures decreases shear and angular displacement compared with a derotational screw. J Orthop Trauma. 2020;34:639–643.
Giordano V, Alves DD, Paes RP, et al. The role of the medial plate for Pauwels type III femoral neck fracture: a comparative mechanical study using two fixations with cannulated screws. J Exp Orthop. 2019;6:18.
Matzkin EG, DeMaio M, Charles JF, et al. Diagnosis and treatment of osteoporosis: what orthopaedic surgeons need to know. J Am Acad Orthop Surg. 2019;27:e902–e912.
Black DM, Rosen CJ. Clinical practice. Postmenopausal osteoporosis. N Engl J Med. 2016;374:254–262.
Kazley JM, Banerjee S, Abousayed MM, et al. Classifications in brief: garden classification of femoral neck fractures. Clin Orthop Relat Res. 2018;476:441–445.
Van Embden D, Rhemrev SJ, Genelin F, et al. The reliability of a simplified Garden classification for intracapsular hip fractures. Orthop Traumatol Surg Res. 2012;98:405–408.
Shen M, Wang C, Chen H, et al. An update on the Pauwels classification. J Orthop Surg Res. 2016;11:161.
Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium—2018. J Orthop Trauma. 2018;32(suppl 1):S1–S170.
Xu JL, Liang ZR, Xiong BL, et al. Risk factors associated with osteonecrosis of femoral head after internal fixation of femoral neck fracture:a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20:632.
Sultan AA, Mohamed N, Samuel LT, et al. Classification systems of hip osteonecrosis: an updated review. Int Orthop. 2019;43:1089–1095.
Haidukewych GJ, Rothwell WS, Jacofsky DJ, et al. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004;86:1711–1716.
Weil YA, Khoury A, Zuaiter I, et al. Femoral neck shortening and varus collapse after navigated fixation of intracapsular femoral neck fractures. J Orthop Trauma. 2012;26:19–23.
Stockton DJ, Lefaivre KA, Deakin DE, et al. Incidence, magnitude, and predictors of shortening in young femoral neck fractures. J Orthop Trauma. 2015;29:e293–e298.
Zlowodzki M, Brink O, Switzer J, et al. The effect of shortening and varus collapse of the femoral neck on function after fixation of intracapsular fracture of the hip: a multi-centre cohort study. J Bone Joint Surg Br. 2008;90:1487–1494.
Zielinski SM, Keijsers NL, Praet SFE, et al. Femoral neck shortening after internal fixation of a femoral neck fracture. Orthopedics. 2013;36:e849–e858.
Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J Bone Joint Surg Am Vol. 1976;58:689–695.
Swiontkowski MF, Winquist RA, Hansen ST Jr. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am Vol. 1984;66:837–846.
Aminian A, Gao F, Fedoriw WW, et al. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques. J Orthop Trauma. 2007;21:544–548.
Johnson JP, Borenstein TR, Waryasz GR, et al. Vertically oriented femoral neck fractures: a biomechanical comparison of 3 fixation constructs. J Orthop Trauma. 2017;31:363–368.
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