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Background: The relationship between bone density and fracture has been widely studied and recognized, and the role of cortical bone in proximal femoral fractures has also been increasingly studied. However, both the determination of bone mineral density (BMD) and the determination of cortical mass are expensive and cumbersome. The purpose of this study is to investigate whether two readily available indicators, Hounsfield Units (HUs) and femoral cortical index (FCI), can be used to predict hip fracture classification and prognosis., Methods: A retrospective study was conducted on 110 patients with hip fragility fractures. Cortical index was calculated on fractured and contralateral femur FCI, with HUs calculated on the proximal femur. The correlation of the FCI and HU with diabetes, hypertension, and related indicators, such as albumin, creatinine, and urea nitrogen levels, were also analyzed in the study., Results: Both the Evans classification of intertrochanteric fractures and the Garden and Pauwels classifications of femoral neck fractures showed that as the severity of the fracture increased, the HUs and FCI decreased. Age and albumin level also had a negative correlation with HUs and FCI. There was also a significant correlation between HUs and FCI., Conclusions: The HUs and FCI, which can be easily and quickly obtained, can be used to predict the classification and prognosis of hip fractures., Competing Interests: Declaration of competing interest On behalf of all authors, the corresponding author states that there is no conflict of interest., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Previous studies have reported that positive buttress is as effective as anatomical reduction in treating young femoral neck fractures, but whether this effect is related to the Pauwels classification remains unclear. The purpose of this study was to retrospectively analyze the clinical prognosis of positive buttress in young femoral neck fractures with different Pauwels classifications, as well as to assess its biomechanical properties., Methods: A total of 170 young patients with femoral neck fractures who were treated with three cannulated screws were included in this study. Patients were divided into three groups based on their preoperative Pauwels classification. Each group was divided into three subgroups based on the reduction quality: positive buttress, negative buttress and anatomical reduction. The femoral neck shortening, the incidence of necrosis of the femoral head (AVN) and the Harris hip scores at the last follow-up were compared across the three reduction quality within each Pauwels classification. Subsequently, a volunteer was recruited, CT data of the hip was obtained, and finite element models representing different reduction quality under varying Pauwels classifications were established. The biomechanical properties of each model were then evaluated following the application of strains., Results: In Pauwels type I, there were no significant differences in postoperative femoral neck shortening, incidence of AVN, or Harris score among the three types of reduction quality (P > 0.05). However, positive buttress provided superior biomechanical stability compared to negative buttress and anatomical reduction. In Pauwels type II, the incidence of AVN was similar between the positive buttress and the anatomical reduction groups, and both were significantly lower than that in the negative buttress (P < 0.05). The Harris score of the positive buttress was higher than that of the negative buttress, and there was no significant difference in the occurrence of femoral neck shortening between the three groups (P > 0.05). Finite element analysis showed that the biomechanical stability of positive buttress was equivalent to anatomical reduction, and both were better than negative buttress. In Pauwels type III, the incidence of AVN in the anatomical reduction group was lower than that in both the positive buttress and negative buttress (P < 0.05). There was no significant difference in the occurrence of AVN or femoral neck shortening between positive buttress and negative buttress (P > 0.05). There was also no difference in postoperative Harris scores between the three reduction qualities (P > 0.05). Both positive buttress and negative buttress exhibited identical biomechanical qualities and were inferior to anatomical reduction., Conclusions: The biomechanical and clinical dominance of positive buttress correlates with Pauwels type. Specifically, Positive buttress is biomechanically stable in Pauwels types I and II. In Pauwels type III, positive buttress is not advantageous. As the Pauwels angle increases, the biomechanical benefit of the positive buttress is lost. Therefore, regardless of the Pauwels classification, negative buttress should be avoided after reduction of femoral neck fractures in young patients., (© 2024. The Author(s).)

Purpose: Numerous classification systems have been developed for neck of femur fractures, but none have been tested for reliability in gunshot injuries. Our primary objective was to assess the inter-observer and intra-observer reliability of the AO/OTA classification system when applied to intracapsular neck of femur fractures secondary to low-velocity civilian gunshots wounds (GSWs). Our secondary objective was to test the reliability of the AO/OTA classification system in guiding surgeon treatment choices for these fractures., Patients and Methods: Eighteen reviewers (six orthopaedic traumatologists, six general orthopaedic surgeons and six junior orthopaedic fellows) were given a set of 25 plain radiographs and CT scans of femur neck fractures secondary to GSW. For each clinical case, all reviewers selected a classification as well as treatment option from a list of given options. Inter-observer reliability was measured at the initial classification. The exercise was repeated 10-12 weeks later by the same 18 reviewers to test intra-observer reliability., Results: The Fleiss kappa values indicate only slight agreement amongst raters, across all experience levels, for both injury classification and treatment. Intra-observer agreement was fair across all experience levels for both injury classification and treatment., Conclusion: The AO/OTA classification showed only slight reliability in classification of gunshot fractures of the femur neck. With only fair reliability, it also failed to guide surgical treatment thus rendering its routine use in daily clinical practice of questionable value., (© 2024. The Author(s).)

Objectives: The goal of this study is to establish radiographic features and characteristics of patient injury in cases of femoral shaft fractures that predict the presence of ipsilateral femoral neck fractures (IFNFs)., Methods: Patient data was retrospectively assessed from a single level I trauma center through the electronic health record using (Current Procedural Terminology) CPT codes for both isolated and combined ipsilateral femoral shaft and neck fractures. Demographic information, injury characteristics, and independently reviewed radiographic features were collected and compared against the same information from a group of isolated femoral shaft fractures. Multivariable logistic regression was performed to identify risk factors for concomitant IFNFs and their respective odds ratios. A probability algorithm for assessing ipsilateral femoral neck fractures based on independent multivariate predictors was constructed and used., Results: A total of 113 patients with either isolated femoral shaft fractures or combined femoral shaft and IFNF (n = 33) met inclusion criteria and were identified for this study. Fracture displacement was most strongly associated with increased risk of combined injury with an aOR of 25.64 (95 %CI = 5.96-110.28) for every 100 % displacement. Motorcycle crash (MCC) was the mechanism associated with the highest risk of combined injury, with an aOR of 9.85 (95 % CI = 1.99-48.74). Combined injury was also correlated with lower Winquist score and presentation with a closed fracture, with aORs of 0.38 (95 %CI = 0.21 - 0.68) and 11.61 (95 %CI = 1.93-69.94), respectively. Presence of at least 3 of the statistically significant variables produced a positive predictive value (PPV) of ≥ 89 % for combined femoral shaft and IFNF., Conclusions: Identification of combined femoral shaft and IFNF is of critical importance when caring for orthopedic trauma patients. While diagnosis remains a challenging task, MCC mechanism, >100 % fracture displacement, and lower Winquist classification were found to be associated with combined injuries. The combination of these variables might assist in predicting the probability of combined injury and potentially guide decision making on the appropriateness of obtaining single sequence MRI or implementing prophylactic femoral neck fixation., Level of Evidence: Level III., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Effectiveness in health care is a specific characteristic of each intervention and outcome evaluated. Especially with regard to surgical interventions, organization, structure and processes play a key role in determining this parameter. In addition, health care services by definition operate in a context of limited resources, so rationalization of service organization becomes the primary goal for health care management. This aspect becomes even more relevant for those surgical services for which there are high volumes. Therefore, in order to support and optimize the management of patients undergoing surgical procedures, the data analysis could play a significant role. To this end, in this study used different classification algorithms for characterizing the process of patients undergoing surgery for a femoral neck fracture. The models showed significant accuracy with values of 81%, and parameters such as Anaemia and Gender proved to be determined risk factors for the patient's length of stay. The predictive power of the implemented model is assessed and discussed in view of its capability to support the management and optimisation of the hospitalisation process for femoral neck fracture, and is compared with different model in order to identify the most promising algorithms. In the end, the support of artificial intelligence algorithms laying the basis for building more accurate decision-support tools for healthcare practitioners., (© 2024. The Author(s).)

Purpose: The purpose of this study was to introduce a new classification system for paediatric femoral neck fractures (PFNFs) and to evaluate its reliability., Methods: Two hundred and eight unilateral PFNFs (mean patient age: 9.0 ± 4.8 years) were included. Based on preoperative radiographs, the new classification system distinguished PFNFs without anterior or posterior translation (Type I), PFNFs with anterior (Type II) or posterior (Type III) translation, PFNFs with a comminuted medial or posterior column (Type IV), and subtrochanteric femoral fractures (SFFs; Type V). Radiographs were evaluated twice with an interval of two weeks by 19 raters with different specialties, experiences and geographical origins. The results were compared with a selection of 50 patient age-matched unilateral PFNFs and SFFs (mean patient age: 9.1 ± 4.9 years). These were graded twice by the same graders according to the Delbet-Colonna (D-C) classification., Results: Four radiologists and 15 paediatric orthopaedic surgeons from Europe and Asia graded the radiographs. Fair agreement was found between radiologists (κ = 0.296 ± 0.01) and surgeons (κ = 0.3 ± 0.005) (P = 0.17), although more experienced surgeons performed better than less experienced ones; a similar fair assessment was found for raters from Europe (κ = 0.309 ± 0.021) and Asia (κ = 0.3 ± 0.006) and for type II, III and IV fractures; the κ value in the first evaluation (0.309) was similar to that in the second evaluation (0.298). The overall κ value of the D-C classification subtypes was significantly higher (0.599 ± 0.217) than that of the new classification, 0.326 ± 0.162 (t = 3.190 P = 0.005)., Conclusions: The new classification system showed fair reliability relative to the D-C classification. The reliability of the new classification system was not affected by the specialty or geographic origin of the rater or the evaluation round, only by rater experience level. The concordance was worse for PFNFs with anterior or posterior translation or with a comminuted medial or posterior columns., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Femoral neck stress fractures (FNSFs) are increasingly common, particularly in military training. The usual mode of classifying these injuries is based on the involvement of the compression or tension side of the femoral neck; however, this may oversimplify and fail to address factors such as the orientation of the fracture line. We present a novel subtype of a compression-sided FNSF affecting the subcapital femoral neck and report the treatment outcomes in a military trainee population. A retrospective analysis of patients with a subcapital, compression-sided FNSF was identified from a single U.S. Army basic trainee installation. Radiographic evaluation as well as treatment outcomes associated with the ability to complete military training were reported. A total of three patients with a subcapital compression-sided FNSF were identified in a military trainee population, accounting for 10% of all FNSFs that developed over a 3-month period. Of these individuals, one was treated operatively while the other two were treated non-operatively. Overall, one patient was able to return to and successfully complete military training., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Rationale: Pipkin III femoral head fracture dislocation (FHFD) is rarely observed in clinical practice, and its outcome is alarming. A considerable proportion of Pipkin III fractures result from repeated or forceful closed reduction of an irreducible FHFD. Pipkin type III fractures pose a therapeutic challenge. Most patients underwent total hip arthroplasty., Patient Concerns: A 34-year-old man experienced high-energy trauma to the left hip from a terrible traffic accident. Radiography and computed tomography (CT) at the local hospital revealed a left posterior FHFD. Emergency close reduction of the hip was performed.48 hours later, the patient was transferred to our institution. New radiography and CT examinations demonstrated an iatrogenic femoral neck fracture (FNF) associated with FHFD. In addition, a right talar fracture was observed., Diagnosis: Pipkin III fracture combined with contralateral talar fracture., Interventions: Considering his Pipkin fracture classification (Pipkin Type-III) and the time to surgery after his injury (>48 hours), the patient underwent left total hip arthroplasty uneventfully, followed by below-ankle plaster cast immobilization for his right ankle., Outcomes: At the 6-month follow-up, the patient was able to walk pain-free, and plain radiographs were satisfactory, with no evidence of heterotopic ossification or osteonecrosis of the talus., Lessons: Before emergency closed reduction, early recognition of the unique characteristics of an irreducible FHFD is essential to avoid iatrogenic femoral neck fracture., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

As one of the leading causes of elderly patients' hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients' outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients., (© 2021. The Author(s).)

Objectives: To evaluate the long-term efficacy of cannulated internal fixation in patients who sustain femoral neck fracture (FNF) and risk factors influencing the outcomes., Methods: This retrospective study analyzed data from 73 elderly patients aged ≥60 years old, hospitalized for FNF and treated with cannulated internal fixation between August 2008 and July 2016. The inclusion criteria were: (i) patients aged ≥60 years; (ii) patients with recent femoral neck fracture, with times of injury ranging from 12-72 h; and (iii) patients who underwent Garden II-IV closed reduction and internal fixation. Patients were classified based on the Garden fracture type and Pauwels angle. Clinical data and radiographs before and after the surgery were collected. Subsequently, surgery was performed with the patient in supine position, under general or lumbar epidural anesthesia. Closed reduction was performed until satisfactory fracture reduction quality was achieved. The weight of all included patients were <75 kg, and thus, minimal internal fixation was performed. The ischemic necrosis of the femoral head was diagnosed by considering the symptoms, signs, and radiological findings. Harris hip scores were used to evaluate postoperative recovery of hip function. Furthermore, relationships between Garden fracture type and necrosis rate of the femoral head, Pauwels angle and necrosis rate of the femoral head, Garden fracture type and Harris hip score, and age and Harris hip score were analyzed., Results: The mean duration of surgery was 1 ± 0.17 h and blood loss for all the patients was approximately 15 mL. The included patients were followed up for 13-128 months, with an average follow-up of 61 months. Among the included 73 patients, 65 (89.0%) exhibited satisfactory union, seven (9.6%) had femoral head necrosis, and one (1.4%) had nonunion. For seven patients with femoral head necrosis, there were two, two, and three patients classified as Garden IV, Garden III, and Garden II, respectively, and two and five patients classified as Pauwels II and Pauwels III, respectively. Among the seven cases, four underwent hip replacement. Garden fracture type was not significantly associated with femoral head necrosis (χ 2 = 0.44, P > 0.05) or Harris score (χ 2 = 1.43, P > 0.05). Patients with Pauwels I (0%) and II (4.3%) fractures exhibited a significantly lower necrosis rate than those with Pauwels III fractures (41.7%) (P < 0.05)., Conclusions: Cannulated internal fixation was more suitable for older Chinese patients with Pauwels I/II fractures than those with Pauwels III fractures., (© 2020 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Background: Little is known about how biomechanics govern the five fixtures such as DHS, MLS, DHS + LS, LP, and HA are accepted as common therapeutic techniques. Aims and objectives: A series of numerical models for a femoral neck fracture of Pauwels-I will be constructed by innovative approach of finite element in order to determine the most optimized option in comparison with biomechanical performance. Method: Twenty sets of computer tomography scanned femora were imported onto Mimics to extract 3 D models; these specimens were transferred to Geomagic-Studio for a simulative osteotomy and kyrtograph; then, they underwent UG to fit simulative solid models; 5 sorts of fixture were then expressed by Pro-Engineer virtually. After processing with HyperMesh, all compartments (fracture model + internal implant) were assembled onto 5 systems: "Dynamic Hip Screw (DHS), Multiple Lag screw (MLS), DHS + LS, femoral Locking Plate (LP) and HemiArthroplasty (HA)." Eventually, numerical models of the finite-elemental analysis were exported to AnSys to determine the solution. Result: Four models of fixation and a simulation of HA for Pauwels-I were established, validated, and analyzed with the following findings: In term of displacement, these 5 fixtures ranged between 0.3801 and 0.7536 mm have no significant difference; in term of stress, the averages of peaks for integral assemblage are b(MLS) = 43.5766 ≈< d(LP) = 43.6657 ≈< e(Ha) = 43.6657 < c(DHS + LS) = 66.5494 < a(DHS) = 105.617 in MPa indicate that MLS, LP and HA are not significantly different, but less than DHS + LS or DHS in each. Conclusion : A fixture of MLS or LP with optional HA should be recommended to clinically optimize a Pauwels-I facture.

Background: Hip fractures represent the most common injury and the main cause of morbidity and mortality among patients 65 years and older. About 20% of all femoral neck fractures (FNFs) are non-displaced or valgus impacted, for which internal fixation with the cannulated screws system (CSS) is indicated., Aims: The aim of this study was to identify predictors of early failure of CSS., Methods: Patients with non-displaced FNFs (Garden type I and II) treated operatively using the CSS were enrolled. Their characteristics, Pauwels angle, and posterior tilt were assessed and related with outcomes. The primary outcome was fixation failure within 6 months., Results: 259 patients were included with a mean age of 81.44 years. Most patients were female with ASA 3. The majority of fractures were classified as Garden I and Pauwels I. On average, Pauwels angle was 27°, while posterior tilt was 12°. A linear correlation between Pauwels angle and posterior tilt was found; the failure rate was 9.7%. Using the adjusted Cox competing risk regression analysis, posterior tilt was found to be independently associated with failure rate (sub-distribution hazard ratio or SHR 1.14 [95% CI 1.05-1.24], p = 0.0020). A posterior tilt greater than 18° resulted predictive of failure. The 1-year mortality rate was 12%., Conclusions: Non-displaced Garden type II fractures, Pauwels type II or III fractures, and a posterior tilt greater than 18° represent radiographic predictors of CSS early failure in the elderly., Level of Evidence: Level IV, retrospective cohort study.

Purpose: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns., Methods: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test., Results: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure., Conclusion: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP., Competing Interests: Declaration of Competing Interest The authors of this study report no relevant financial or personal relationships that could inappropriately influence or bias the work presented in this manuscript., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: The Centers for Medicare & Medicaid services proposed that transitioning from the 9th to the 10th revision of the International Classification of Disease (ICD) would provide better data for research. This study sought to determine the reliability of ICD-10 compared with ICD-9 for proximal femur fractures., Methods: Available imaging studies from 196 consecutively treated proximal femur fractures were retrospectively reviewed and assigned ICD codes by three physicians. Intercoder reliability (ICR) was calculated. Collectively, the physicians agreed on what should be the correct codes for each fracture, and this was compared with coding found in the medical and billing records., Results: No significant difference was observed in ICR for both ICD-9 and ICD-10 exact coding, which were both unreliable. Less specific coding improved ICR. ICD-9 general coding was better than ICD-10. Electronic medical record coding was unreliable. Billing codes were also unreliable, yet ICD-10 was better than ICD-9., Discussion: ICD-9 and ICD-10 lack reliability in coding proximal femur fractures. ICD-10 results in data that are no more reliable than those found with ICD-9., Level of Evidence: Level I diagnostic.

Background and purpose - Preoperative posterior tilt of the femoral head as seen on lateral radiographs has been reported to affect the risk of fixation failure in cases of minimally displaced femoral neck fractures (Garden I-II). We investigated radiological risk factors of treatment failure.Patients and methods - We included 417 patients (68% women, median age: 78 years (50-108) with a minimally displaced femoral neck fracture (Garden I-II) treated with internal fixation in a retrospective cohort study. The patients were followed for 3.4 years (2-14). Data on age, sex, housing, cognitive impairment, implant angulation, pre- and postoperative tilt, hip complications, and reoperations were recorded. The risk of fixation failure was assessed using Cox proportional hazards regression analysis.Results - The overall reoperation rate was 17%, and the rate of treatment failure (fixation failure, nonunion, avascular necrosis, or posttraumatic osteoarthritis) was 13%. Cox proportional hazard analysis revealed an increased risk of treatment failure with a preoperative posterior tilt of at least 20° and a preoperative anterior tilt greater than 10°. A failure occurred in 13 of the 65 patients with a posterior tilt of at least 20° and in 5 of the 9 patients with an anterior tilt greater than 10°.Interpretation - A preoperative posterior tilt of 20° and an anterior tilt greater than 10° in cases of Garden I and II femoral neck fractures increase the risk of fixation failure necessitating additional surgery. In this group of patients, there is a need for future interventional studies regarding the feasibility of primary hip arthroplasty.

Introduction: Femoral neck fractures are uncommon injuries in children, but the high incidence of long-term complications makes it important clinical entity. Early surgical treatment to achieve optimal results and to avoid a high rate of complications is widely advised. The purpose of this study was to retrospectively analyze the outcome of 8 children who sustained a femoral neck fracture., Patients and Methods: The patients (6 boys and 2 girls with an average age of 9.2 years) were treated within 24 h following admission to hospital by closed reduction and internal fixation. The type of fracture was distinguished according to Delbet's classification system. The outcome was analyzed using Ratliff's criteria, and a detailed record of complications was maintained., Results: According Delbet's classification system, there were 3 type I, 2 type II, 2 type III, and 1 type IV fractures. The average follow-up was 39.2 months (range 8-95). A satisfactory outcome was obtained in 6 (75%) children. Avascular necrosis was the most notable complication, which was reported in the 2 fair outcomes (25%)., Conclusions: Early and aggressive surgical treatment aimed at anatomical reduction result in a satisfactory outcome in pediatric femur neck fractures. Development of avascular necrosis is the main complication., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The management of nondisplaced femoral neck fractures (FNFs) has evolved, with emphasis in radiographic features such as posterior displacement. However, the role of advanced imaging in this scenario is still not well defined. Therefore, our objective is to assess the impact of a computed tomography scan (CT) on interobserver agreement (IA) of fracture classification, posterior tilt measurement, and treatment decisions in nondisplaced FNF in elderly patients., Methods: Eleven patients with a nondisplaced (Garden 1-2) FNF were assessed by six hip surgeons. On a first stage, fracture classification, posterior tilt, and treatment plan (fixation/arthroplasty) were determined only with clinical information and X-rays. On a second stage, a CT was added. The kappa coefficient ( κ) and intraclass correlation coefficient (ICC) were used to determine IA., Results: IA for Garden classification was only slight in X-rays and with the addition of a CT, with a κ = 0.13 (0-0.28) and 0.18 (0.03-0.33), respectively. Conversely, posterior tilt measurement agreement was excellent in both schemes, with an ICC = 0.92 (0.83-0.98) and 0.92 (0.82-0.98). The IA for the proposed treatment was slight with X-rays ( κ = 0.44; 0.29-0.6), but moderate with the addition of a CT scan ( κ = 0.67; 0.52-0.82). Changes in surgical decision where made in 14 of 66 evaluations with an OR = 1.4 (0.62-3.2) for choosing an arthroplasty if a CT was used., Conclusion: IA for fracture classification and posterior tilt evaluation in nondisplaced FNF was not altered by the usage of a CT. There is improvement in treatment agreement when a CT scan is added to conventional imaging, with changes in treatment in 21% of cases.

Objective: To investigate the early clinical outcomes of hip anterior short incision and open reduction and internal fixation for the treatment of children with Delbet Ⅱ femoral neck fracture. Methods: A retrospective analysis of 12 children with DelbetⅡ femoral neck fractures was performed with the anterior short incision approach at Department of Pediatric Orthopaedic, Children's Hospital, Nanjing Medical University from January 2014 to August 2016. There were 7 males and 5 females including 8 cases at left side and 4 cases at right side,aged (11.5±0.8) years (range: 8-14 years).Patients underwent surgery in (12.0±0.9) hours (range: 6-20 hours) after the injury. Displaced fractures were treated by open reduction if closed reduction failed.The surgical incision was performed with the anterior inferior iliac spine centered on, extending along the groin crease, and the length was 3 to 4 cm. The interval between the sartorius and the tensor fascia latae was applied, and the direct and indirect head of rectus femoris were resected to visualize the hip joint capsule. T-shaped incision was made in the capsule. After the reduction was obtained, two or three compression canulated screws were used to fix the fracture site. The healing time, complications and corresponding record outcome by X-ray and clinical examination were recorded. At the latest follow-up,the results were analyzed using the Ratliff criteria and clinical outcomes were assessed by pain, restrictive hip movement, normal activity or the avoidance of games, and the femoral neck in the radiograph. Results: Twelve patients had been followed-up for (30.0±4.1)months(range: 24-36 months). X-ray showed the fractures' healing time was (8.0±0.4) weeks(range: 7-9 weeks). Ten of the 12 fractures healed after one operation and were associated with no evidence of osteonecrosis of the femoral head. One case occurred premature physeal closure. There were no cases with fracture relocation, coaxvara, delayed union and nonunion or any significant postoperative complications. There was no infection, flexible internal fixation or ruptures. According to Ratliff grade, 9 cases of 12 patients were fine and 3 cases was acceptable. Conclusions: Satisfactory short-term effects can be achieved by a mini-incision on the anterior hip for Delbet Ⅱ pediatric femur neck fractures. The anterior incision has the advantage of less trauma, smaller incision scar, better fracture reduction and fixation, and less wound complications.

Proximal femoral fragility fractures are common and result in significant morbidity and mortality along with a considerable socioeconomic burden. The goals of this article are to review relevant proximal femoral anatomy together with imaging, classification, and management of proximal femoral fragility fractures, and their most common complications. Imaging plays an integral role in classification, management and follow-up of proximal femoral fragility fractures. Classification of proximal femoral fragility fractures is primarily based on anteroposterior hip radiographs. Pertinent imaging features for each category of proximal femoral fractures that would guide management are: differentiating nondisplaced from displaced femoral neck fractures, distinguishing stable from unstable intertrochanteric fractures, and determining the morphology and comminution of subtrochanteric fractures. Treatment of proximal femoral fragility fractures is primarily surgical with either arthroplasty or internal fixation. Intramedullary nailing is used in the treatment of some types of proximal femoral fragility fractures and may be associated with unique complications that become evident on postoperative follow-up radiographs.

Purpose: The aim of our study is to compare the mechanical resistance of two screw configurations in fixating type II Pauwels femoral neck fractures., Methods: Fifteen synthetic models of femur bones in young adults were divided into three equal groups: intact (G1), models with fixation of a 5.0-mm failure zone created in the posterior cortex of the femoral neck using an L-shaped screw arrangement (G2, n = 5), and models with an identical failure zone fixated using an inverted triangle assembly (G3, n = 5). Model strength (axial loading) and rotational deviation of the fragments were load-tested until a 5.0-mm displacement was reached (step 1) and then until failure, here considered as 10.0 mm displacement in G2 and G3 or femoral neck fracture in G1 (step 2)., Results: In step 1, the mean resistance in G1 was 1593 N (standard deviation [SD] of 62 N); this value in G2 was 1261 N (SD 49 N) and in G3 was 1074 N (SD 153 N). During step 2, the value for G1 was 2247 N (SD 84 N), for G2 was 1895 N (SD 69 N), and for G3 was 1523 N (SD 280 N). G3 (the inverted triangle assembly) showed a significantly lower maximum load than the group using the L-shaped assembly (G2) and the control group (G1), which was significant using Kruskal-Wallis analysis of variance (p = 0.002)., Conclusion: Under test conditions in synthetic bone, fixation using a L-shaped screw assembly provides greater mechanical resistance than an inverted triangle assembly.

The aim of this study was to compare the union time, functional outcome and complications in patients with femoral neck fractures treated with percutaneous cannulated screws or dynamic hip screw (DHS) plus antirotational screw. We selected 117 consecutive patients having a hip fracture at any level within the Garden classification, treated at the Orthopedics and Traumatology Clinic in Perugia from 2010 to 2011. Average patient age was 67.8 years. Patients received either a treatment including cannulated screws (group I) or a DHS plate with anti-rotational screw(group II). All patients were followed up for a minimum of 1 year. The Harris Hip Score at 12 months was used to evaluate functional outcome. Between the two treatment groups, the differences in union time and functional outcome were not statistically significant. Moreover blood loss was significantly lower in group I. The results of our study did not suggest a superiority of one surgical technique over the other, when considering the union time and functional outcome. Regarding complications, the incidence of avascular necrosis was found to be significantly related to the Garden classification but not to synthesis type. Level of evidence: IV, Retrospective case series.

Objective: The objective of this study is to assess the clinical utility of internal rotation traction radiography in the classification of proximal femoral fractures., Materials and Methods: The study cohort included 78 consecutive patients who were surgically treated for a proximal femoral fracture and for whom preoperative physician-assisted internal rotation traction radiographs of the fractured hip were obtained in addition to standard radiographs. Two radiologists who were blinded to clinical information independently classified each fracture without the traction view and then with the traction view. The radiologists also reported their confidence (expressed as a percentage) in their classifications. The reference standard was the consensus interpretation of intraoperative C-arm fluoroscopic images by two orthopedic surgeons and one radiologist. Classification accuracy was compared using the McNemar test. Subjective confidence and confidence-weighted accuracy were compare using paired t tests. Agreement with the reference standard and interreader agreement were calculated using the kappa statistic and were compared using the z-test after bootstrapping was performed to obtain the standard error., Results: With the traction view, the pooled accuracy increased from 44.9% to 72.4%, subjective confidence increased from 87% to 94%, and confidence-weighted accuracy increased from 51.7% to 74.3% (p < 0.001). With the traction view, the kappa statistic for agreement with the reference standard increased from 0.530 to 0.791 and from 0.381 to 0.625 for the two readers, and interreader agreement increased from 0.480 to 0.678 (p < 0.001)., Conclusion: The addition of an internal rotation traction radiographic view significantly improves radiologist accuracy and confidence as well as interreader agreement in the classification of proximal femoral fractures, all of which would be expected to best guide appropriate surgical management.

In the pediatric population, femoral neck fracture is a relatively uncommon injury with a high complication rate, despite appropriate diagnosis and management. The anatomy and blood supply of the proximal femur in the skeletally immature patient differs from that in the adult patient. Generally, these fractures result from high-energy trauma and are categorized using the Delbet classification system. This system both guides management and aids the clinician in determining the risk of osteonecrosis after these fractures. Other complications include physeal arrest, coxa vara, and nonunion. Multiple fracture fixation methods have been used, with the overall goal being anatomic reduction with stable fixation. Insufficiency fractures of the femoral neck, although rare, must also be considered in the differential diagnosis for the pediatric patient presenting with atraumatic hip pain.

Background: Basicervical femur neck fracture (FNF) is a rare type of fracture, and is associated with increased risk of fixation failure due to its inherent instability. The purpose of this study was (1) to investigate the incidence of fixation failure and (2) to determine risk factors for fixation failure in basicervical FNF after internal fixation., Methods: To identify basicervical FNF with a minimum of 12 months follow-up, we retrospectively reviewed records of 3217 patients who underwent hip fracture surgery from May 2003 to March 2016. Among the identified 77 patients with basicervical FNF, 69 patients were followed up for at least 12 months. We evaluated the rate of collapse of fracture site and reoperation due to fixation failure. We performed a multivariable analysis to determine risk factors associated with fracture site collapse and fixation failure., Results: Among the 69 patients with basicervical FNF, 17 (24.6%) showed collapse of fracture site, and 6 (8.6%) underwent conversion to arthroplasty because of fixation failure. In the multivariable analysis, use of extramedullary plating with a sliding hip screw was an independent significant risk factor for both collapse of fracture site (odds ratio 6.84; 95% confidence interval 1.91-24.5, p = 0.003) and fixation failure (odds ratio 12.2; 95% confidence interval 1.08-137.7, p = 0.042)., Conclusions: Basicervical FNF treated with extramedullary plate with a sliding hip screw is more likely to fail than that treated with intramedullary nail with a helical blade. Our results suggested that intramedullary nail with a helical blade is more recommended for basicervical FNF compared with extramedullary plate with a sliding hip screw., Level of Evidence: III, Retrospective cohort study., (Copyright © 2018. Published by Elsevier Ltd.)

Rationale: Pipkin III fracture, which is characterized by high risk of avascular necrosis of the femoral head, is extremely rare. It is more difficult to treat and has a worse prognosis when accompanied with severe acetabular fractures. Few studies show that both Pipkin type III femoral head fracture-dislocation and complicated acetabular fracture presented in one patient., Patient Concerns: A 34-year-old male suffered a terrible traffic accident with a serious damage to the left side when he was sitting in the car's cockpit. Pelvic radiograph and 3-dimensional reconstruction of computed tomography revealed characteristics of fractures before the emergency operation., Diagnosis: Pipkin III fractures combined with complicated acetabular fracture., Interventions: Firstly, we used combined anterior and posterior approach for treatment to fix the femoral head fractures. Then, we completed anatomical reduction of fractures with countersunk head screw, hollow screw, and reconstruction plate., Outcomes: At the 12-months follow-up, the patient could walk freely and perform activities of daily living without necrosis of femoral head and heterotopic ossification., Lessons: Although there are serious complications in Pipkin III fractures combined with complicated acetabular fracture, early surgical treatment with appropriate approach and fixation could get satisfactory results., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine the effect of site of fracture on the prognosis for patients of elderly hip fracture., Methods: From January 2012 to December 2014, 667 patients with hip fractures were divided into femoral neck fracture group and intertrochanteric fracture group according to the site of fracture. There were 304 cases of intertrochanteric fracture, including 96 males and 208 females, with an average age of (80.33±7.94) years old. There were 217 cases of femoral neck fracture, including 74 males and 143 females, with an average age of (79.82±9.33) years old. Patients' data, mortality and activities of daily living were compared between two groups., Results: There were no significant differences in age, gender, comorbidity, ASA classification, and anesthesia between two groups, but the time of admission to surgery, duration of operation, blood loss of intra-operative, volume of drainage, and the average of transfusion were shown to have significant differences. The levels of White blood cell count (WBC) for intertrochanteric fracture group were shown to be higher than that of femoral neck fracture patients at admission, 1, 3 and 5 days after operation. The levels of hemoglobin, and albumin for intertrochanteric fracture were lower than that of femoral neck fracture patients at all period of time. The mortality of intertrochanteric fracture group during hospitalization, 1, 3, 6, and 12 months were higher than that of femoral neck fracture, but did not reach significant difference. In patients who survived, the scores of ADL for femoral neck fracture were higher than that of intertrochanteric fracture at discharge, 1, 3 months after operation, but there was no significant difference for ADL at 6 and 12 months between two groups., Conclusions: The response of stress for intertrochanteric fracture were more than femoral neck fracture, but the mortality was similar than that of femoral neck fracture after excluding the influence of age, sex, comorbidity, and other factors. Compared to intertrochanteric fracture, the femoral neck fracture patients had a better functional recovery during early stage, and the two groups reached a similar functional recovery at 1 year after operation., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Background: Femoral neck fractures typically occur as a result of high-energy mechanisms among non-geriatric patients. Complications, including femoral neck shortening, non-union, and avascular necrosis, are relatively common after the internal fixation of this fracture pattern. These complications have serious effects on young patients. The Pauwels classification, which is the first biomechanical classification for femoral neck fractures, is still frequently used to determine and prescribe the appropriate treatment for femoral neck fractures. However, we lack a unified standard for measuring the Pauwels angle, which may make the classification unreliable. Understanding the relationship between the Pauwels classification and the complications arising from the internal fixation of femoral neck fractures is necessary. Meanwhile, a Pauwels type III femoral neck fracture among young adults, which involves a high shear load at the fracture site, is difficult to treat successfully. In addition, the recognized internal fixation for this fracture pattern remains uncertain., Main Body: This review aims to provide an update on the viewpoint on the Pauwels classification including the measurement of the Pauwels angle and to present evidence to prove the aforementioned relationship. Moreover, this article also discusses the optimal internal fixation for femoral neck fractures based on the Pauwels classification., Conclusion: A unified standard of measurement should be established for the Pauwels classification, which is still frequently used in the literature and in determining appropriate treatment for femoral neck fractures, to achieve a credible classification. In addition, more randomized, multicentric, and prospective trials should be conducted in the future to clearly understand the relationship between the Pauwels classification and complications arising from the internal fixation of femoral neck fractures and, consequently, to explore ideal fixations for a Pauwels type III femoral neck fracture.

Purpose: To evaluate whether surgeons' experience affect inter- and intra-observer reliability among mostly used classification systems for femoral neck fractures., Material and Methods: A power point presentation was prepared with 107 slides which were antero-posterior radiographs of each femoral neck fracture. Five residents, 5 orthopaedic surgeons and 5 senior orthopaedic surgeons reviewed this presentation and classified the fractures according to Garden, Pauwels and AO classifications. The order of the slides was changed and reviews were repeated after 3 months. Fleiss kappa and intraclass correlation coefficient values were calculated to evaluate inter and intra-observer reliability., Results: Garden and AO classifications' inter-observer reliabilities were similar and higher than Pauwels classification. Among three experience groups, the inter-observer reliability for Garden classification was highest in senior surgeon group, the interobserver reliability for AO classification was highest in surgeon group, and interobserver reliability of Pauwels classification was highest in low experienced groups (residents and surgeons). Intra-observer reliability was highest for Garden and lowest for Pauwels classifications. Surgical experience was found to be not effective for intraobserver reliability., Conclusion: Both Garden and AO classifications were more reliable than Pauwels classification. Surgical experience was not significantly important on these three classification systems' evaluation., Level of Evidence: Level IV, Diagnostic study., (Copyright © 2016 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

Objective: To retrospectively study postoperative Garden III femoral neck fractures in the elderly so as to explore the different degree of displacement of Garden III femoral neck fracture, and discuss the basis and clinical significance of the subtype classification., Methods: A total of 492 patients with complete clinical data out of the 1397 patients with femoral neck fractures treated by closed reduction and internal fixation with cannulated compression screws from September 2005 to September 2010 were included in the study. Each patient's frontal Garden Index was measured. On the basis of the frontal Garden Index, these cases were divided into three types:type A, which frontal Garden Index was more than or equal to 140°, included 53 males and 84 females with an average age of(65.3±7.2) years old ranging from 60 to 75 years old; type B, more than 120°and less than 140°, included 79 males and 172 females with an average age of (67.5±3.6) years old;and type C, less than or equal to 120°, included 38 males and 66 with an average age of(68.6±5.7) years old. Aspects were followed up including complications, consequences and hip joint function. The fracture healing and femoral head necrosis were compared among three types., Results: Operative incision of 492 cases was primary healing, and no infection and other complications occurred. All patients were followed up from 2 to 10 years with an average of 6.3 years, the healing of femoral neck fracture occurred in 432 cases, and the total union rate was 87.8%. Femoral head necrosis occurred in 83 cases, and the total necrosis rate of femoral head was 16.9%. The nonunion rate of type A was 6.6%, type B was 13.5%, and type C was 16.3%, there were significant differences among three types( χ ²2AB=4.377, P =0.036; χ ²2AC=5.872, P =0.015; χ ²2BC=0.469, PBC=0.494). The necrosis rate of femoral head of group A was 8.8%, group B was 16.7%, and group C was 27.9%, there were significant differences among three groups( χ ²2AB=4.704, P =0.030; χ ²2AC=15.317, P =0.000; χ ²2BC=5.715, P =0.017)., Conclusions: It is different for the degree of displacement of Garden III femoral neck fracture in the elderly. Based on frontal Garden Index to differentiate degree of fracture displacement, Garden III femoral neck fracture would be divided into A, B and C subtypes. The prognosis of Garden III femoral neck fracture in the elderly is negatively related to its degree of displacement, which has clinical significance to make treatment plan for Garden III femoral neck fracture in the elderly., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Objective: To explore the reduction and clinical effect in the near future of percutaneous K-wire relative poking reduction techniques for difficult to reduction of complex insert and forward angulation femoral neck fracture., Methods: The clinical data of traumatic femoral neck fractures treated in our hospital from January 2012 to September 2015 were retrospective analysis, 15 patients with skeletal traction and distal elevation still can not eliminate the fracture angulation deformity were treated by percutaneous K-wire relative poking reduction technique to correct the angular and using cannulated screw fixation, including 5 males and 10 females, aged from 44 to 72 years with an average of 60.06 years old. The fractures were Garden type III. The reduction effect was evaluated according to Garden alignment index and clinical evaluation in the near future outcome was assessed according to Harris Hip Score., Results: All patients were healed by first intention without pulmonary infection and deep vein thrombosis. The patients were followed up for 6 months to 3 years, all the fractures healed, and 1 case had limited necrosis of the femoral head. According to Garden alignment index, 14 cases were level I reducation, and 1 case was level II. Limb shortening was 1 to 5 mm with an average of (2.73±1.37) mm. Functional evaluation according to Harris score standard, at the latest follow-up the average value of pain, function, deformity and joint activity were 42.1±2.5, 37.2±4.6, 3.2±0.5, 4.1±0.3, the total average value was 86.6±9.5;13 cases were excellent, 1 case was good, 1 case was poor., Conclusions: Percutaneous K-wire relative poking reduction technique to correct the difficult to reduction of complex insert and forward angulation of the femoral neck fracture is simple, repeatable, and achieve the precision of the reset;the effect of blood supply of the hip joint is small, which provides favorable conditions for fracture healing., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Introduction: Historically routine work up of a patient with a proximal femoral fracture always included anterior-posterior (AP) and a lateral film of the hip. The aim was to define the role of the lateral X-ray in the assessment and surgical planning of proximal femur fractures., Methods: Radiographs of 320 consecutive patients with proximal femoral fractures who were admitted over a 12 months period were divided into lateral and AP views. Two blinded reviewers independently assessed the AP view alone and then the AP plus the lateral view. Fracture classification was noted for each X-ray and then compared with intraoperative diagnosis which was our study's gold standard. A 2 × 2 contingency square table and Pearson's x(2) test were used for statistical analysis., Results: The rate of correct classification by the reviewers enhanced by the assessment of the lateral X-ray in addition to the AP view for intracapsular fractures (p = 0.018) but not for extracapsular fractures (p = 0.29). Operative management did not change for intracapsular fractures which appeared displaced on initial AP view after reviewing the lateral X-ray. The only advantage of obtaining a lateral view in intracapsular fracture was the detection of displacement were the fracture appeared to be undisplaced on initial AP view., Conclusions: This study provides statistical evidence that one view is adequate and safe for majority of proximal femoral fractures. The lateral radiograph should not be performed on a routine basis thus making considerable saving in time and money, and avoiding unnecessary radiation exposure and discomfort to the patient., (Copyright © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Introduction: We retrospectively analyzed the clinical results of treatment of impacted or undisplaced femoral neck fractures (Garden types 1 and 2) by osteosynthesis in elderly patients >70-year old., Materials and Methods: We retrospectively reviewed the radiological results of 52 patients who were followed up for at least 6 months from April 2002 to December 2008. The average age of the patients was 77.6 years (range 70-97 years), and 38 patients were females. The mean follow-up period was 11.7 months (range 6-19 months). Thirteen cases were Garden type 1 fractures, and 39 were Garden type 2 fractures. We assessed the relationships between the occurrence of complications and age, sex, Garden stage, bone mineral density (BMD), history of contralateral hip fracture, and any additional hip injury., Results: Major complications occurred in 18 cases (34.6 %), including nonunion (8 cases), osteonecrosis (6 cases), stress fracture of the subtrochanter (2 cases), excessive pull-out of a screw (1 case), and deep infection (1 case). The development of complications was associated with Garden stage 2, BMD, and additional hip injury. However, other factors were not associated with complications. Reoperations were performed in 16 cases (30.1 %), and 2 of the patients died during follow-up., Conclusion: A relatively high rate of complications or reoperations developed after treatment of Garden 2 femoral neck fractures in senile patients >70 years of age with osteoporosis. Although internal fixation has been recommended in the literature for undisplaced femoral neck fractures, primary arthroplasty may be a better option for treatment of Garden type 2 fractures in elderly patients.

Background: The most serious complication of femoral neck fractures in children and adolescents is osteonecrosis. Although a number of factors have been implicated in the development of osteonecrosis, no specific cause-and-effect relationship has been determined. The primary purpose of this study was to determine the prevalence of osteonecrosis in children and adolescents after femoral neck fractures and to identify risk factors for its development., Methods: This retrospective review identified 70 patients between the ages of 1.3 and 18.1 years who were treated for a femoral neck fracture between 2000 and 2011 at a single level I pediatric trauma center and followed until clinical and radiographic union. Demographic information, injury event details, type of surgical treatment, associated injuries, time from injury to treatment, and postoperative alignment were recorded from chart and radiographic review. The primary outcome was the presence of osteonecrosis, which was determined by review of available imaging. Multivariable logistic regression analysis tested age, time to treatment, type of fixation, mechanism of injury, postoperative alignment, and capsular decompression as possible risk factors for the development of osteonecrosis., Results: Osteonecrosis occurred in 20 (29%) of the 70 patients. The median time to diagnosis of osteonecrosis was 7.8 months. Multivariable predictors of osteonecrosis included fracture displacement (P=0.01) and fracture location (P=0.02). Patient age, type of fixation, mechanism of injury, capsular decompression, postoperative alignment, and performance of reduction were not predictive of osteonecrosis after femoral neck fracture. Finally, time to treatment also was found to be a positive predictor of osteonecrosis (P=0.004), with osteonecrosis more likely in patients treated in less than 24 hours, but this finding is likely due to confounding because injury severity was closely linked to time to treatment., Conclusions: Regardless of the treatment, the prevalence of osteonecrosis after femoral neck fractures remains high. Recognizing factors that are predictive of the development of osteonecrosis can help surgeons counsel patients and families appropriately about the risk of this complication.

The purpose of this study was to employ a new three-dimensional (3D) reconstruction and modeling method to measure displacement of undisplaced femoral neck fractures (Garden stages I and II). We also aimed to evaluate the effectiveness of the Garden classification for determining the displacement of undisplaced femoral neck fractures. A total of 120 consecutive patients with undisplaced femoral neck fractures were enrolled between 2012 and 2014, including 60 within the Garden I group and 60 within the Garden II group. The displacements of the femoral head center (d1) and the lowest point of the fovea capitis femoris (d2) and rotational displacement of the femoral head (α) in the 3D model were measured with 3D computed tomography reconstruction and modeling. Five observers, trauma surgeons, were asked to found the centers of the femoral heads and the deepest points of the foveae. The intraobserver and inter-observer agreements were calculated using Fleiss' kappa. The inter-observer and intra-observer kappa values were 0.937 and 0.985, respectively. Current method has good reliability. We discovered that many participants in our study had been misclassified by an anterior-posterior radiograph as having an "incomplete" fracture. In incomplete fracture of Garden stage I group, the average displacements d1 and d2 were 3.69 ± 1.77 mm and 14.51 ± 1.91 mm, respectively. The mean α was 4.91° ± 2.49°. For impacted fracture of Garden stage I, significant spatial displacement in the impacted fractures was observed (d1: 6.22 ± 3.36 mm; d2: 10.30 ± 5.73 mm; and α: 17.83° ± 10.72°). Similarly, significant spatial displacement was observed among the Garden stage II group (d1: 7.16 ± 4.58 mm; d2: 12.95 ± 8.25 mm; and α: 18.77° ± 9.10°). There was no significant difference in α, d1, and d2 between impacted fracture and Garden stage II groups (P > 0.05). However, significant differences were found between incomplete fracture and Garden stage II groups (P < 0.05). Our findings suggest that 3D reconstruction and modeling may be a better tool for assessing femoral neck fractures than the Garden classification. Undisplaced femoral neck fractures showed variable degrees of displacement and were not undisplaced, stable fractures. Garden classification for undisplaced femoral neck fractures has certain limitations.

Hip fractures are increasingly common, given the increasing ageing, osteoporotic population with significant medical comorbidities. This review summarizes the anatomy of the proximal femur, reviews classification systems and gives recommendations for use of each treatment modality.

Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.

Introduction: We quantified the risk and the time of occurrence of secondary fracture displacement in non-operatively treated femoral neck fractures in our clinic, as well as investigated potential predicting patient- and fracture-related factors., Methods: The records of 593 patients with femoral neck fractures from January 2000 to December 2009 were reviewed. Sixty-one patients [mean age 83.0 years (SD 9.9)] with undisplaced femoral neck fractures initially received non-operative treatment. The occurrence and the time of secondary fracture displacement were documented, as well as demographics and radiological parameters. Radiographs were evaluated independently by two surgeons. Multivariable regression and Kaplan-Meier survival analyses were used., Results: Thirty-four (55.7 %) fractures showed secondary displacement occurring within the first 12 weeks after initiation of non-operative treatment. Twenty (38 %) fractures originally classified as Garden I were found to be Garden II. The risk of secondary displacement was three times higher (RR = 2.8; 95 % CI 1.7-4.8, p < 0.001) for these fractures in comparison with those confirmed as Garden I. Patients with a history of previously diagnosed osteoporosis were at a higher risk of secondary displacement as well (RR = 1.3; 95 % CI 1.0-1.5)., Conclusions: Non-operative treatment of femoral neck fractures is a treatment option, but only in well-selected cases. The majority of secondary displacements were associated with initial misdiagnosis using the Garden classification. For Garden II, primary surgical treatment is likely a better option, and therefore careful application of the Garden classification in this context is essential.

Aim: To ensure a more reliable classification system for the femur neck fractures by estimating pressure and tensile force on the fracture crevice., Methods: The study compared the kappa coefficient for the inter and intraobserver agreement of the same five observers on the same radiographic sample of the femur neck fracture with a time gap of one year for the AO group and original proposal of estimated dominant pressure and tensile force on the femur neck fracture's crevice., Results: The kappa coefficient for the AO group was 0.49 and for the system for estimating the dominant force on the fracture's crevice it was 0.78. For the observer our proposal is easier to use than the AO system., Conclusion: The estimation system of the dominant force on the fracture's crevice is more reliable and thus more acceptable than the AO group system for femoral neck fractures.

Background: Vascular injury after femoral neck fracture can determine its prognosis. This study aimed to determine methods of evaluating femoral neck fracture and accurately predicting the prognosis., Methods: Forty-five patients with a single femoral neck fracture all underwent digital subtraction angiography (DSA) and were divided into three types by DSA. DSA showing three to six supporting band vascular images crossing the fracture line was classified as type I. DSA showing one to two supporting band vascular images crossing the fracture line was classified as type II. When DSA did not show vascular images crossing the fracture line, it was classified as type III. The 45 patients were divided according to age into elderly, middle-aged and youth groups. All cases were given internal fixation operations by a hollow screw under a C-brachial machine. After a follow-up of 6-60 months, avascular necrosis of the femoral head (ANFH) and fracture healing of different type and different ages of patients were evaluated according to symptoms and imaging examinations., Results: (1) For DSA types I, II and III, the rates of ANFH were 0, 7.14 and 100 %, respectively, and the rates of fracture disunion were 13.3, 7.15 and 0 %, respectively. Therefore, the rate of ANFH is negatively related to the visible supporting band vascular amount on DSA. (2) In the young group, the proportions of types I, II and III were 6.7, 26.67 and 66.7 %, respectively, 18.18, 36.36 and 45.45 % in the middle-aged group and 63.16, 31.58 and 5.27 % in the elderly group. The rates of necrosis for elderly, middle-aged and youth were 10.53, 45.45 and 66.67 %, respectively, and the rates of fracture disunion were 0, 0 and 6.67 %, respectively. So we can draw the conclusion that the amount of supporting band vascular images is inversely proportional to age and the union is directly related to age, but independent of the supporting band vascular amount of DSA showing., Conclusion: The new classification after superselective angiography is valuable for predicting the prognosis of femoral neck fractures.

Aim: To determine which of the classification systems for the femoral neck fracture between AO group, AO subgroup, Garden and Pauwels is much more reliable and reproducible to predict a method of treatment, radiological prediction of nonunion and prediction of outcomes., Methods: Five observers classified 77 randomly selected anterior- posterior (AP) and lateral view preoperative radiographs of the femoral neck fractures according to AO group, AO subgroup, Garden and Pauwels classification systems. The procedure was repeated on the same radiographs after three months. First classification is used to calculate interobserver agreement by kappa value between observers, while the first and second classification has served to calculate intraobserver kappa value for each examiner., Results: Overall mean for classification system for interobserver agreement is: AO 0.44, AO subgroup 0.17, Garden 0.41 and Pauwels 0.19. Mean intraobserver agreement for AO group was 0.56, AO subgroup 0.38, Garden 0.49 and Pauwels 0.38 coefficient kappa value., Conclusion: Garden and AO group are useful for the division of femoral neck fractures without displacement and with displacement, but they are not for clinical use. AO subgroup and Pauwels classification are not recommended for further use.

Background: The Garden classification is used to classify intracapsular proximal femur fractures. The reliability of this classification is poor and several authors advise a simplified classification of intracapsular hip fractures into non-displaced and displaced fractures. However, this proposed simplified classification has never been tested for its reliability., Hypothesis: We estimate simplifying the classification of femoral neck fractures will lead to a higher inter-observer agreement., Materials and Methods: Ten observers, trauma surgeons and residents, from two different institutes classified 100 intracapsular femoral neck fractures. The inter-observer agreements were calculated using the multi-rater Fleiss' kappa., Results: The inter-observer kappa for the Garden classification was 0.31. An agreement of κ0.52 was observed if the Garden classification was simplified and the fractures were classified by our observers as 'non-displaced' or 'displaced'. No difference in reliability was seen for the use of the four-grade Garden classification as well as the simplified classification between trauma surgeons and residents., Discussion: Classification of intracapsular hip fractures according to the four-grade Garden classification is unreliable. The reliability of classification improves when the Garden classification is simplified in a classification using the terms: 'non-displaced' or 'displaced'., Level of Evidence: Level IV. Diagnostic retrospective study., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

The Pauwels classification for the femoral neck fracture is still broadly used in literature and clinical practise. However, this classification has never been tested for its reliability in terms of inter-observer agreement. We assessed whether or not it is reliable to use the Pauwels classification in pre-operative planning. Ten observers classified 100 intra-capsular femur fractures. The inter-observer agreement was calculated using the multi-rater Fleiss' kappa. The Pauwels classification showed an inter-observer agreement of κ0.31 (0.01). Classification of intra-capsular hip fractures according to the Pauwels classification using the Pauwels angle is unreliable and its use should be avoided., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: This study aimed to define the role of the lateral X-ray in the assessment and treatment planning of proximal femoral fractures. Occult fractures were not included., Methods: Radiographs from 359 consecutive patients with proximal femoral fractures admitted to our emergency department over a 12 month period were divided into anteroposterior (AP) views and lateral views. Three blinded reviewers independently assessed the radiographs, first AP views alone then AP plus lateral views, noting the fracture classification for each radiograph. These assessments were then compared with the intra-operative diagnosis, which was used as the gold standard. A 2 × 2 contingency square table was created and Pearson's χ(2) test was used for statistical analysis., Results: The rate of correct classification by the reviewers was improved by the assessment of the lateral X-ray in addition to the AP view for intracapsular fractures (p<0.013) but not for extracapsular fractures (p=0.27). However, the only advantage obtained by assessing the lateral view in intracapsular fractures was the detection of displacement where the fracture appeared undisplaced on the initial AP view., Conclusion: This study provides statistical evidence that one view is adequate and safe for the majority of hip fractures. The lateral radiograph should not be performed routinely in order to make considerable savings in money and time and to avoid unnecessary patient discomfort.

Objectives: In this study we report our initial experience with the use of cementless, bipolar hemiarthroplasty in elderly patients with intracapsular femur neck fractures., Patients and Methods: We operated 67 consecutive patients (39 females, 28 males; mean age 74.4±11.0 years; range 41 to 99 years) who admitted to our clinic June 2007 and November 2009, due to intracapsular femur neck fracture and implanted cementless, rectangular, dual-taper, straight femoral stem (Zweymüller stem) with bipolar head prosthesis. All patients were allowed to full weight bearing with a walker within the first postoperative 48 hours., Results: According to the Garden's classification, there were nine type II, 53 type III and five type IV fractures. Twelve patients were lost to follow-up and 21 deceased during the postoperative follow-up period. Among 34 patients with complete follow-up, 30 were evaluated for the clinical outcome. The mean follow-up time and Harris hip score of the evaluated patients were 19.4 months and 79.4 points, respectively. It was seen that, the patient age significantly correlated with the clinical outcome and a better mean hip score was obtained in the '70 years and younger age group' (83.6 points) as compared to the 'older than 70 years age group' (75.6 points) (p=0.014). Mortality rate was found to be higher in patients older than 70 years (47% vs. 18%; p=0.036) and with displaced fractures (45% vs. 0%; p=0.018)., Conclusion: Zweymüller cementless bipolar hemiarthroplasty may be an alternative treatment method for intracapsular femur neck fractures especially in the patients under the age of 70 years.

The ideal treatment of the intracapsular fracture of the femoral neck still is subject of discussion. The demographic development of the population in Europe with fractures of the neck of femur being typical in the older patient, requires conclusive and stringent concepts of treatment. Adequate and patient oriented therapy should be promoted, regional differences and provisional deficiencies need to be adjusted in order to minimize the rate of complications. The guideline "Schenkelhalsfraktur" of the German board of trauma surgeons, the 'Deutsche Gesellschaft für Unfallchirurgie', and the article at hand are meant to serve as a manual for the trauma surgeon. Based on evaluated data it simplifies rational decision-making for treatment of fractures of the proximal femur. Moreover, secondary prophylaxis as well as the subsequent outpatient treatment and the social reintegration of the patients recovering from fractures of the femoral neck remains vital- ly important. After all, even with ideal treatment of the fracture more than half of the patients are impaired for a long time and one out of four permanently depends on nursing assistance.

Background: Medical diagnosis, like all products of human cognition, is subject to error. We tested the hypothesis that errors of diagnosis in the realm of fracture classification can be reduced by a consensus (group) diagnosis; and that digital imaging and Internet access makes feasible the compilation of a diagnostic consensus in real time., Methods: Twelve orthopaedic surgeons were asked to evaluate 20 hip radiographs demonstrating a femoral neck fracture. The surgeons were asked to determine if the fractures were displaced or not. Because no reference standard is available, the maximal accuracy of the diagnosis of displacement can be inferred from inter-observer reliability: if two readers disagree about displacement, one of them must be wrong. That method was employed here. Additionally, virtual reader groups of 3 and 5 individual members were amalgamated, with the response of those groups defined by majority vote. The purpose of this step was to see if increasing the number of readers would improve accuracy. In a second experiment, to study the feasibility of amassing a reader group on the Internet in real time, 40 volunteers were sent 10 periodic email requests to answer questions and their response times were assessed., Results: The mean kappa coefficient for individual inter-observer reliability for the diagnosis of displacement was 0.69, comparable to prior published values. For 3-member virtual reader groups, inter-observer reliability was 0.77; and for 5-member groups, it was 0.80. In the experiment studying the feasibility of amassing a reader group in real time, the mean response time was 594 minutes. For all cases, a 9-member group (theoretically 99% accurate) was amassed in 135.8 minutes or less., Conclusions: Consensus may improve diagnosis. Amassing a group for this purpose on the Internet is feasible.

Background: Fractures through the proximal femur are broadly grouped into intertrochanteric fractures and intracapsular fractures. It is not clear why a patient may sustain an intertrochanteric fracture as compared with an intracapsular fracture. There is an established relationship between relative hip retroversion and the development of osteoarthritis. We postulate retroversion also may be a risk factor for having intracapsular fractures develop., Questions/purposes: We looked specifically at the geometry of the hip to analyze the possibility of a relationship between acetabular version, femoral version, and Mckibbin's instability index and fracture type., Patients and Methods: We recruited 40 patients with fractures of the femoral neck for the study. There were 15 men and 25 women with a mean age of 80 years (range, 57-92 years). There were 14 intertrochanteric fractures and 26 intracapsular fractures. After treating their fracture, the contralateral hip was scanned in a CT scanner and assessed by two independent observers to establish the acetabular and femoral version., Results: We found no correlation between proximal femoral fracture type and the contralateral femoral version, femoral neck length, acetabular version, or Mckibbin's instability index or between fracture type and age or gender., Conclusions: There appears to be no correlation between proximal femoral fracture type and acetabular or femoral version., Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.