Aims. Fixation techniques used in the treatment of slipped capital femoral epiphysis (SCFE) that allow continued growth of the femoral neck, rather than inducing epiphyseal fusion in situ, have the advantage of allowing remodelling of the deformity. The aims of this study were threefold: to assess whether the Free-Gliding (FG) SCFE screw prevents further slip; to establish whether, in practice, it enables lengthening and gliding; and to determine whether the age of the patient influences the extent of glide. Methods. All patients with SCFE who underwent fixation using FG SCFE screws after its introduction at our institution, with minimum three years’ follow-up, were reviewed retrospectively as part of ongoing governance. All pre- and postoperative radiographs were evaluated. The demographics of the patients, the grade of slip, the extent of lengthening of the barrel of the screw and the restoration of Klein’s line were recorded. Subanalysis was performed according to sex and age. Results. A total of 19 hips in 13 patients were included. The mean age of the patients at the time of surgery was 11.5 years (9 to 13) and the mean follow-up was 63 months (45 to 83). A total of 13 FG SCFE screws were used for the fixation of mild or moderate SCFE, with six contralateral prophylactic fixations. No hip with SCFE showed a further slip after fixation and there were no complications. Lengthening occurred in 15 hips (79%), with a mean lengthening of the barrel of 6.8 mm (2.5 to 13.6) at final follow-up. Remodelling occurred in all hips with lengthening of the barrel. There was statistically more lengthening in patients who were aged < 12 years, regardless of sex (p = 0.002). Conclusion. The FG SCFE screw is effective in preventing further slip in patients with SCFE. Lengthening of the barrel occurred in most hips, and thus allowed remodelling. This was most marked in younger children, regardless of sex. Based on this study, this device should be considered for use in patients with SCFE aged < 12 years instead of standard pinning in situ. Cite this article: Bone Joint J 2023;105-B(2):215–219

Aims. This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. Methods. We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. Results. Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. Conclusion. The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients. Cite this article: Bone Joint J 2023;105-B(2):180–189

Aims. The aim of this study was to compare the mid-term patient-reported outcome, bone remodelling, and migration of a short stem (Collum Femoris Preserving; CFP) with a conventional uncemented stem (Corail). Methods. Of 81 patients who were initially enrolled, 71 were available at five years’ follow-up. The outcomes at two years have previously been reported. The primary outcome measure was the clinical result assessed using the Oxford Hip Score (OHS). Secondary outcomes were the migration of the stem, measured using radiostereometric analysis (RSA), change of bone mineral density (BMD) around the stem, the development of radiolucent lines, and additional patient-reported outcome measures (PROMs). Results. There were no statistically significant differences between the groups regarding PROMs (median OHS (CFP 45 (interquartile range (IQR) 35 to 48); Corail 45 (IQR 40 to 48); p = 0.568). RSA showed stable stems in both groups, with little or no further subsidence between two and five years. Resorption of the femoral neck was evident in nine patients in the CFP group and in none of the 15 Corail stems with a collar that could be studied. Dual X-ray absorbiometry showed a significantly higher loss of BMD in the proximal Gruen zones in the CFP group (mean changes in BMD: Gruen zone 1, CFP -9.5 (95% confidence interval (CI) -14.8 to -4.2), Corail 1.0 (95% CI 3.4 to 5.4); Gruen zone 7, CFP -23.0 (95% CI -29.4 to -16.6), Corail -7.2 (95% CI -15.9 to 1.4). Two CFP stems were revised before two years’ follow-up due to loosening, and one Corail stem was revised after two years due to chronic infection. Conclusion. The CFP stem has a similar clinical outcome and subsidence pattern when compared with the Corail stem. More pronounced proximal stress-shielding was seen with the CFP stem, suggesting diaphyseal fixation, and questioning its femoral neck-sparing properties in the long term. Cite this article: Bone Joint J 2022;104-B(5):581–588

Aims. The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty. Methods. This nationwide, retrospective cohort study used data from the Japanese Diagnosis Procedure Combination database. We included older patients (aged ≥ 60 years) who underwent THA or hemiarthroplasty after a femoral neck fracture, between July 2010 and March 2022. A total of 165,123 patients were included. The THA group was younger (mean age 72.6 (SD 8.0) vs 80.7 years (SD 8.1)) and had fewer comorbidities than the hemiarthroplasty group. Patients with dementia or malignancy were excluded because they seldom undergo THA. The primary outcome measures were mortality and complications while in hospital, and secondary outcomes were readmission and reoperation within one and two years after discharge, and the costs of hospitalization. We conducted an instrumental variable analysis (IVA) using differential distance as a variable. Results. The IVA analysis showed that the THA group had a significantly higher rate of complications while in hospital (risk difference 6.3% (95% CI 2.0 to 10.6); p = 0.004) than the hemiarthroplasty group, but there was no significant difference in the rate of mortality while in hospital (risk difference 0.3% (95% CI -1.7 to 2.2); p = 0.774). There was no significant difference in the rate of readmission (within one year: risk difference 1.3% (95% CI -1.9 to 4.5); p = 0.443; within two years: risk difference 0.1% (95% CI -3.2 to 3.4); p = 0.950) and reoperation (within one year: risk difference 0.3% (95% CI -0.6 to 1.1); p = 0.557; within two years: risk difference 0.1% (95% CI -0.4 to 0.7); p = 0.632) after discharge. The costs of hospitalization were significantly higher in the THA group than in the hemiarthroplasty group (difference $2,634 (95% CI $2,496 to $2,772); p < 0.001). Conclusion. Among older patients undergoing surgery for a femoral neck fracture, the risk of early complications was higher after THA than after hemiarthroplasty. Our findings should aid in clinical decision-making in these patients. Cite this article: Bone Joint J 2024;106-B(9):986–993

Aims. The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients. Methods. We undertook a longitudinal cohort study linking the Swedish Hip Arthroplasty Register with the National Patient Register, including patients with a neurological disease presenting with a femoral neck fracture and treated with HA, a conventional THA (cTHA) with femoral head size of ≤ 32 mm, or a dual-mobility component THA (DMC-THA) between 2005 and 2014. The dislocation rate at one- and three-year revision, reoperation, and mortality rates were recorded. Cox multivariate regression models were fitted to calculate adjusted hazard ratios (HRs). Results. A total of 9,638 patients with a neurological disease who also underwent unilateral arthroplasty for a femoral neck fracture were included in the study. The one-year dislocation rate was 3.7% after HA, 8.8% after cTHA < 32 mm), 5.9% after cTHA (= 32 mm), and 2.7% after DMC-THA. A higher risk of dislocation was associated with cTHA (< 32 mm) compared with HA (HR 1.90 (95% confidence interval (CI) 1.26 to 2.86); p = 0.002). There was no difference in the risk of dislocation with DMC-THA (HR 0.68 (95% CI 0.26 to 1.84); p = 0.451) or cTHA (= 32 mm) (HR 1.54 (95% CI 0.94 to 2.51); p = 0.083). There were no differences in the rate of reoperation and revision-free survival between the different types of prosthesis and sizes of femoral head. Conclusion. Patients with a neurological disease who sustain a femoral neck fracture have similar rates of dislocation after undergoing HA or DMC-THA. Most patients with a neurological disease are not eligible for THA and should thus undergo HA, whereas those eligible for THA could benefit from a DMC-THA. Cite this article: Bone Joint J 2022;104-B(1):134–141

Aims. To evaluate the rate of dislocation following dual mobility total hip arthroplasty (DM-THA) in patients with displaced femoral neck fractures, and to compare rates of dislocation, surgical-site infection, reoperation, and one-year mortality between DM-THA and bipolar hemiarthroplasty (BHA). Methods. Studies were selected based on the following criteria: 1) study design (retrospective cohort studies, prospective cohort studies, retrospective comparative studies, prospective comparative studies, and randomized controlled studies (RCTs)); 2) study population (patients with femoral neck fracture); 3) intervention (DM-THA or BHA); and 4) outcomes (complications during postoperative follow-up and clinical results). Pooled meta-analysis was carried out to evaluate the dislocation rate after DM-THA and to compare outcomes between DM-THA and BHA. Results. A total of 17 studies (ten cohort studies on DM-THA and seven comparative studies of DM-THA and BHA) were selected. These studies included 2,793 patients (2,799 hips), made up of 2,263 DM-THA patients (2,269 hips) and 530 BHA patients (530 hips). In all, 16 studies were analyzed to evaluate dislocation rate after DM-THA. The cumulative dislocation rate was 4% (95% confidence interval (CI) 3 to 5). Seven studies were analyzed to compare the rates dislocation and surgical-site infection. The rate of dislocation was significantly lower in the DM-THA group than in the BHA group (risk ratio (RR) 0.3; 95% CI 0.17 to 0.53, p < 0.001, Z −4.11). There was no significant difference in the rate of surgical-site infection between the two groups (p = 0.580). Six studies reported all-cause reoperations. The rate of reoperation was significantly lower in the DM-THA group than in the BHA group (RR 0.5; 95% CI 0.32 to 0.78, p = 0.003, Z −3.01). Five studies reported one-year mortality. The mortality rate was significantly lower in the DM-THA group than in the BHA group (RR 0.58 95% CI 0.45 to 0.75, p < 0.0001, Z −4.2). Conclusion. While the evidence available consisted mainly of non-randomized studies, DM-THA appeared to be a viable option for patients with displaced fractures of the femoral neck, with better reported rates of dislocation, reoperation, and mortality than BHA. Cite this article: Bone Joint J 2020;102-B(11):1457–1466

Aims. Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA. Methods. Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer’s perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions. Results. DM-THA was found to be cost-effective, with an estimated incremental cost-effectiveness ratio (ICER) of CAD $46,556 (£27,074) per quality-adjusted life year (QALY). Sensitivity analysis revealed DM-THA was not cost-effective across all age groups in the first two years. DM-THA becomes cost-effective for those aged under 80 years at time periods from five to 15 years, but was not cost-effective for those aged 80 years and over at any timepoint. To be cost-effective at ten years in the base case, DM-THA must reduce the risk of dislocation compared to SB-THA by at least 62%. Probabilistic sensitivity analysis showed DM-THA was 58% likely to be cost-effective in the base case. Conclusion. Treating patients with a displaced femoral neck fracture using DM-THA components may be cost-effective compared to SB-THA in patients aged under 80 years. However, future research will help determine if the modelled rates of adverse events hold true. Surgeons should continue to use clinical judgement and consider individual patients’ physiological age and risk factors for dislocation. Cite this article: Bone Joint J 2021;103-B(12):1783–1790

Aims. Despite few good-quality studies on the subject, total hip arthroplasty (THA) is increasingly being performed for displaced intracapsular fractures of the neck of femur. We compared outcomes of all patients with displacement of these fractures treated surgically over a ten-year period in one institution. Methods. A total of 2,721 patients with intracapsular fractures of the femoral neck treated with either a cemented hemiarthroplasty or a THA at a single centre were retrospectively reviewed. The primary outcomes analyzed were readmission for any reason and revision surgery. We secondarily looked at mortality rates. Results. We found no difference in the overall revision rate or rate of infection. However, the rates of readmission due to dislocation, pain, and trochanteric bursitis were significantly higher in the THA group (p = 0.001, p < 0.001, p < 0.001, and p = 0.001, respectively). Conclusion. Our study, comparing the outcomes of neck of femur fractures treated with a cemented hemiarthroplasty and THA, revealed the perceived superiority of THA was not borne out by our results. This should be carefully considered before any radical change in practice regarding the use of THA for displaced intracapsular fractures of the femoral neck. Cite this article: Bone Joint J 2020;102-B(6):693–698

Aims. Dislocation is the most common indication for further surgery following total hip arthroplasty (THA) when undertaken in patients with a femoral neck fracture. This study aimed to assess the complication rates of THA with dual mobility components (THA-DMC) following a femoral neck fracture and to compare outcomes between THA-DMC, conventional THA, and hemiarthroplasty (HA). Methods. We performed a systematic review of all English language articles on THA-DMC published between 2010 and 2019 in the MEDLINE, EMBASE, and Cochrane databases. After the application of rigorous inclusion and exclusion criteria, 23 studies dealing with patients who underwent treatment for a femoral neck fracture using THA-DMC were analyzed for the rate of dislocation. Secondary outcomes included reoperation, periprosthetic fracture, infection, mortality, and functional outcome. The review included 7,189 patients with a mean age of 77.8 years (66.4 to 87.6) and a mean follow-up of 30.9 months (9.0 to 68.0). Results. THA-DMC was associated with a significantly lower dislocation rate compared with both THA (OR 0.26; 95% CI 0.08 to 0.79) and HA (odds ratio (OR) 0.27; 95% confidence interval (CI) 0.15 to 0.50). The rate of large articulations and of intraprosthetic dislocation was 1.5% (n = 105) and 0.04% (n = 3) respectively. Conclusion. THA-DMC when used in patients with a femoral neck fracture is associated with a lower dislocation rate compared with conventional arthroplasty options. There was no increase in the rates of other complication when THA-DMC was used. Future cost analysis and prospective, comparative studies are required to assess the potential benefit of using THA-DMC in these patients. Cite this article: Bone Joint J 2020;102-B(7):811–821

Aims. Various surgical techniques have been described for total hip arthroplasty (THA) in patients with Crowe type III dislocated hips, who have a large acetabular bone defect. The aim of this study was to evaluate the long-term clinical results of patients in whom anatomical reconstruction of the acetabulum was performed using a cemented acetabular component and autologous bone graft from the femoral neck. Methods. A total of 22 patients with Crowe type III dislocated hips underwent 28 THAs using bone graft from the femoral neck between 1979 and 2000. A Charnley cemented acetabular component was placed at the level of the true acetabulum after preparation with bone grafting. All patients were female with a mean age at the time of surgery of 54 years (35 to 68). A total of 18 patients (21 THAs) were followed for a mean of 27.2 years (20 to 33) after the operation. Results. Radiographs immediately after surgery showed a mean vertical distance from the centre of the hip to the teardrop line of 21.5 mm (SD 3.3; 14.5 to 30.7) and a mean cover of the acetabular component by bone graft of 46% (SD 6%; 32% to 60%). All bone grafts united without collapse, and only three acetabular components loosened. The rate of survival of the acetabular component with mechanical loosening or revision as the endpoint was 86.4% at 25 years after surgery. Conclusion. The technique of using autologous bone graft from the femoral neck and placing a cemented acetabular component in the true acetabulum can provide good long-term outcomes in patients with Crowe type III dislocated hips. Cite this article: Bone Joint J 2021;103-B(2):299–304

Aims. Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes. Methods. A total of 1,199 patients with femoral neck fractures presented to a large UK teaching hospital over a three-year period. All patients had nutritional assessments performed using the Malnutrition Universal Screening Tool (MUST). Malnutrition risk was compared to mortality, length of hospital stay, and discharge destination using logistic regression. Adjustments were made for covariates to identify whether malnutrition risk independently affected these outcomes. Results. Inpatient mortality was 5.2% (35/678) in the group at low risk of malnutrition, 11.3% (46/408) in the medium-risk group, and 17.7% (20/113) in the high-risk group. Multivariate analysis showed each categorical increase in malnutrition risk independently predicted inpatient mortality with an odds ratio (OR) of 1.59 (95% confidence interval (CI) 1.14 to 2.21; p = 0.006). An increased mortality rate persisted at 120 days post-injury (OR 1.64, 95% CI 1.20 to 2.22; p = 0.002). There was a stepwise increase in the proportion of patients discharged to a residence offering a greater level of supported living. Multivariate analysis produced an OR of 1.34 (95% CI 1.03 to 1.75; p = 0.030) for each category of MUST score. Median length of hospital stay increased with a worse MUST score: 13.9 days (interquartile range (IQR) 8.2 to 23.8) in the low-risk group; 16.6 days (IQR 9.0 to 31.5) in the medium-risk group; and 22.8 days (IQR 10.1 to 41.1) in the high-risk group. Adjustment for covariates revealed a partial correlation coefficient of 0.072 (p = 0.008). Conclusion. A higher risk of malnutrition independently predicted increased mortality, length of hospital stay, and discharge to a residence offering greater supported living after femoral neck fracture. Cite this article: Bone Joint J 2021;103-B(1):164–169

Aims. Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA. Methods. A prospective continuous cohort study was conducted on patients undergoing operation for FNF using DMC by DAA or PLA. Functional outcome was evaluated using the Harris Hip Score (HHS) and Parker score at three months and one year. Perioperative complications were recorded, and radiological component positioning evaluated. Results. There were 50 patients in the DAA group and 54 in the PLA group. The mean HHS was 85.5 (SD 8.8) for the DAA group and 81.8 (SD 11.9) for the PLA group (p = 0.064). In all, 35 patients in the DAA group and 40 in the PLA group returned to their pre-fracture Parker score (p = 0.641) in both groups. No statistically significant differences between groups were found at one year regarding these two scores (p = 0.062 and p = 0.723, respectively). The DAA was associated with more intraoperative complications (p = 0.013). There was one dislocation in each group, and four revisions for DAA and one for PLA, but this difference was not statistically significant. There were also no significant differences regarding blood loss, length of stay, or operating time. Conclusion. In DMC-THA for FNF, DAA did not achieve better functional results than PLA, either at three months or at one year. Moreover, DAA presented an increased risk of intra-operative complications. Cite this article: Bone Joint J 2024;106-B(5 Supple B):133–138

Aims. While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. Methods. In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol. Results. A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024). Conclusion. The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3–8

Aims. Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture. Methods. We retrospectively included 340 patients who underwent conversion THA after internal fixation for femoral neck fracture from January 2008 to September 2020. Those patients constituted two groups: noninfected patients and patients diagnosed with FRI according to the 2013 International Consensus Meeting Criteria. Receiver operating characteristic (ROC) curves were used to determine maximum sensitivity and specificity of these two preoperative ratios. The diagnostic performance of the two ratios combined with preoperative CRP or ESR was also evaluated. Results. The numbers of patients with and without FRI were 19 (5.6%) and 321 (94.4%), respectively. Areas under the ROC curve for diagnosing FRI were 0.763 for MLR, 0.686 for NLR, 0.905 for CRP, and 0.769 for ESR. Based on the Youden index, the optimal predictive cutoffs were 0.25 for MLR and 2.38 for NLR. Sensitivity and specificity were 78.9% and 71.0% for MLR, and 78.9% and 56.4% for NLR, respectively. The combination of CRP with MLR showed a sensitivity of 84.2% and specificity of 94.6%, while the corresponding values for the combination of CRP with NLR were 89.5% and 91.5%, respectively. Conclusion. The presence of preoperative FRI among patients undergoing conversion THA after internal fixation for femoral neck fracture should be determined. The combination of preoperative CRP with NLR is sensitive tool for screening FRI in those patients. Cite this article: Bone Joint J 2021;103-B(9):1534–1540

Aims. The aim of this study was to clarify the factors that predict the development of avascular necrosis (AVN) of the femoral head in children with a fracture of the femoral neck. Patients and Methods. We retrospectively reviewed 239 children with a mean age of 10.0 years (. sd. 3.9) who underwent surgical treatment for a femoral neck fracture. Risk factors were recorded, including age, sex, laterality, mechanism of injury, initial displacement, the type of fracture, the time to reduction, and the method and quality of reduction. AVN of the femoral head was assessed on radiographs. Logistic regression analysis was used to evaluate the independent risk factors for AVN. Chi-squared tests and Student’s t-tests were used for subgroup analyses to determine the risk factors for AVN. Results. We found that age (p = 0.006) and initial displacement (p = 0.001) were significant independent risk factors. Receiver operating characteristic (ROC) curve analysis indicated that 12 years of age was the cut-off for increasing the rate of AVN. Severe initial displacement (p = 0.021) and poor quality of reduction (p = 0.022) significantly increased the rate of AVN in patients aged 12 years or greater, while in those aged less than 12 years, the rate of AVN significantly increased only with initial displacement (p = 0.048). A poor reduction significantly increased the rate of AVN in patients treated by closed reduction (p = 0.026); screw and plate fixation was preferable to cannulated screw or Kirschner wire (K-wire) fixation for decreasing the rate of AVN in patients treated by open reduction (p = 0.034). Conclusion. The rate of AVN increases with age, especially in patients aged 12 years or greater, and with the severity of displacement. In patients treated by closed reduction, anatomical reduction helps to decrease the rate of AVN, while in those treated by open reduction, screw and plate fixation was preferable to fixation using cannulated screws or K-wires. Cite this article: Bone Joint J 2019;101-B:1160–1167

Surgical interventions consisting of internal fixation (IF) or total hip replacement (THR) are required to restore patient mobility after hip fractures. Conventionally, this decision was based solely upon the degree of fracture displacement. However, in the last ten years, there has been a move to incorporate patient characteristics into the decision making process. Research demonstrating that joint replacement renders superior functional results when compared with IF, in the treatment of displaced femoral neck fractures, has swayed the pendulum in favour of THR. However, a high risk of dislocation has always been the concern. Fortunately, there are newer technologies and alternative surgical approaches that can help reduce the risk of dislocation. The authors propose an algorithm for the treatment of femoral neck fractures: if minimally displaced, in the absence of hip joint arthritis, IF should be performed; if arthritis is present, or the fracture is displaced, then THR is preferred. Cite this article: Bone Joint J 2014;96-B(11 Suppl A):43–7

During hip resurfacing arthroplasty, excessive valgus positioning or surgical technique can result in notching of the femoral neck. Although mechanical weakening and subsequent fracture of the femoral neck are well described, the potential damage to the retinacular vessels leading to an ischaemic event is relatively unknown. Using laser Doppler flowmetry, we measured the blood flow in 14 osteoarthritic femoral heads during routine total hip replacement surgery, before and after notching of the femoral neck. In ten hips there was a reduction in blood flow of more than 50% from the baseline value after simulated notching of the femoral neck. Our results suggest that femoral head vascularity in the osteoarthritic state is similar to the non-arthritic state, where damage to the extraosseous vessels can predispose to avascular necrosis. Surgeons who perform resurfacing arthroplasty of the hip should pay careful attention to these vessels by avoiding excessive dissection around the femoral neck and/or notching

The results of meta-analysis show a revision rate of 33% for internal fixation of displaced fractures of the femoral neck, mostly because of nonunion. Osteopenia and osteoporosis are highly prevalent in elderly patients. Bone density has been shown to correlate with the intrinsic stability of the fixation of the fracture in cadaver and retrospective studies. We aimed to confirm or refute this finding in a clinical setting. We performed a prospective, multicentre study of 111 active patients over 60 years of age with a displaced fracture of the femoral neck which was eligible for internal fixation. The bone density of the femoral neck was measured pre-operatively by dual-energy x-ray absorptiometry (DEXA). The patients were divided into two groups namely, those with osteopenia (66%, mean T-score −1.6) and those with osteoporosis (34%, mean T-score −3.0). Age (p = 0.47), gender (p = 0.67), delay to surgery (p = 0.07), the angle of the fracture (p = 0.33) and the type of implant (p = 0.48) were similar in both groups. Revision to arthroplasty was performed in 41% of osteopenic and 42% of osteoporotic patients (p = 0.87). Morbidity (p = 0.60) and mortality were similar in both groups (p = 0.65). Our findings show that the clinical outcome of internal fixation for displaced fractures of the femoral neck does not depend on bone density and that pre-operative DEXA is not useful

Aims. The aims of this study were to evaluate the abductor function in moderate and severe slipped capital femoral epiphysis (SCFE), comparing the results of a corrective osteotomy at the base of the femoral neck and osteoplasty with 1) in situ epiphysiodesis for mild SCFE, 2) contralateral unaffected hips, and 3) hips from healthy individuals. Patients and Methods. A total of 24 patients (mean age 14.9 years (. sd. 1.6); 17 male and seven female patients) with moderate or severe SCFE (28 hips) underwent base of neck osteotomy and osteoplasty between 2012 and 2015. In situ epiphysiodesis was performed in seven contralateral hips with mild slip. A control cohort was composed of 15 healthy individuals (mean age 16.5 years (. sd. 2.5); six male and nine female patients). The abductor function was assessed using isokinetic dynamometry and range of abduction, with a minimum one-year follow-up. Results. We found no differences in mean peak abductor torque between the hips that underwent osteotomy and those that received in situ epiphysiodesis (p = 0.63), but the torque was inferior in comparison with contralateral hips without a slip (p < 0.01) and hips from control individuals (p < 0.001). The abduction strength was positively correlated with the range of hip abduction (R = 0.36; p < 0.001). Conclusion. Although the abductor strength was not restored to normal levels, moderate and severe SCFE treated with osteotomy at the base of the femoral neck and osteoplasty showed abductor function similar to in situ epiphysiodesis in hips with less severe displacement. Cite this article: Bone Joint J 2018;100-B:1524–32