In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function. Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck

1. Seventy patients with impacted fractures of the femoral neck treated from 1953 to 1965 have been reviewed. Forty-seven were treated conservatively and twenty-three by primary internal fixation. 2. The complications of both methods of treatment are recorded. 3. The prognosis following impacted femoral neck fractures is good. Seventy-nine per cent treated conservatively and 96 per cent treated by primary internal fixation had excellent or good results. 4. Primary internal fixation is the treatment of choice

Aims. We aimed to quantify the relative contributions of the medial femoral circumflex artery (MFCA) and lateral femoral circumflex artery (LFCA) to the arterial supply of the head and neck of the femur. Materials and Methods. We acquired ten cadaveric pelvises. In each of these, one hip was randomly assigned as experimental and the other as a matched control. The MFCA and LFCA were cannulated bilaterally. The hips were designated LFCA-experimental or MFCA-experimental and underwent quantitative MRI using a 2 mm slice thickness before and after injection of MRI-contrast diluted 3:1 with saline (15 ml Gd-DTPA) into either the LFCA or MFCA. The contralateral control hips had 15 ml of contrast solution injected into the root of each artery. Next, the MFCA and LFCA were injected with a mixture of polyurethane and barium sulfate (33%) and their extra-and intra-arterial course identified by CT imaging and dissection. Results. The MFCA made a greater contribution than the LFCA to the vascularity of the femoral head (MFCA 82%, LFCA 18%) and neck (MFCA 67%, LFCA 33%). However, the LFCA supplied 48% of the anteroinferior femoral neck overall. Conclusion. This study clearly shows that the MFCA is the major arterial supply to the femoral head and neck. Despite this, the LFCA supplies almost half the anteroinferior aspect of the femoral neck. Cite this article: Bone Joint J 2016;98-B:1582–8

The incidence and long-term outcome of undisplaced fatigue fractures of the femoral neck treated conservatively were examined in Finnish military conscripts between 1970 and 1990. From 106 cases identified, 66 patients with 70 fractures were followed for a mean of 18.3 years (11 to 32). The original medical records and radiographs were studied and physical and radiological follow-up data analysed for evidence of risk factors for this injury. The development of avascular necrosis and osteoarthritis was determined from the follow-up radiographs and MR scans. The impact of new military instructions on the management of hip-related pain was assessed following their introduction in 1986. The preventive regimen (1986) improved awareness and increased the detected incidence from 13.2 per 100 000 service-years (1970 to 1986) to 53.2 per 100 000 (1987 to 1990). No patient developed displacement of the fracture or avascular necrosis of the femoral head, or suffered from adverse complications. No differences were found in MRI-measured hip joint spaces at final follow-up. The mean Harris Hip Score was 97 (70 to 100) and the Visual Analogue Scale 5.85 mm (0 to 44). Non-operative treatment, including avoidance of or reduced weight-bearing, gave favourable short- and long-term outcomes. Undisplaced fatigue fractures of the femoral neck neither predispose to avascular necrosis nor the subsequent development of osteoarthritis of the hip

Aims. Our aim was to examine the Elixhauser and Charlson comorbidity indices, based on administrative data available before surgery, and to establish their predictive value for mortality for patients who underwent hip arthroplasty in the management of a femoral neck fracture. Patients and Methods. We analyzed data from 42 354 patients from the Swedish Hip Arthroplasty Register between 2005 and 2012. Only the first operated hip was included for patients with bilateral arthroplasty. We obtained comorbidity data by linkage from the Swedish National Patient Register, as well as death dates from the national population register. We used univariable Cox regression models to predict mortality based on the comorbidity indices, as well as multivariable regression with age and gender. Predictive power was evaluated by a concordance index, ranging from 0.5 to 1 (with the higher value being the better predictive power). A concordance index less than 0.7 was considered poor. We used bootstrapping for internal validation of the results. Results. The predictive power of mortality was poor for both the Elixhauser and Charlson comorbidity indices (concordance indices less than 0.7). The Charlson Comorbidity Index was superior to Elixhauser, and a model with age and gender was superior to both indices. Conclusion. Preoperative comorbidity from administrative data did not predict mortality for patients with a hip fracture treated by arthroplasty. This was true even if association on group level existed

Nutritional osteomalacia is a metabolic bone disorder common among the Asian female immigrant population in the United Kingdom. We describe the case of a female of Asian origin, who was found to have a unilateral undisplaced pseudofracture of the neck of the femur during pregnancy. Although not operated on the fracture was treated successfully with calcium and vitamin D supplement therapy. Within one month of treatment, the bone pain subsided and she was able to bear full weight. Subsequent radiological follow-up showed the pseudofracture to have healed sufficiently with no evidence of avascular necrosis. There should be a high index of suspicion of this disease, particularly among Asian patients presenting with persistent and non-specific musculoskeletal pain

In a prospective, randomised trial, we compared the use of three Ullevaal hip screws with that of two Hansson hook-pins in 278 patients with fractures of the femoral neck. Background factors were similar in both groups. Follow-up was for two years. There were no significant differences between the groups in length of time of surgery, hospital stay, general complications, mortality, pain or walking ability. Likewise, the rates of early failure of fixation, nonunion, and the need for reoperation did not differ significantly between the groups. The use of hook-pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6, p= 0.05) and a lower incidence of necrosis of the femoral head (odds ratio 3.5, p = 0.04). There was a strong relationship between poor reduction and fixation of the fracture and subsequent reoperation (p = 0.0005 and p = 0.0001, respectively). Likewise, peroperative drill penetration of the femoral head was associated with a greater risk of reoperation (p = 0.038). Both methods gave favourable results. In total, 22% of the patients needed a major reoperation (usually hemiarthroplasty), while in 7% of the cases the fixation device needed to be removed. Osteosynthesis as the sole method for operation of all fractures of the femoral neck was thus successful in 78% of patients. With selective treatment most of the remaining patients would have benefited if treated by a primary arthroplasty. Accurate selection requires the development of better prognostic methods

A study of a collected series of femoral neck fractures in seventy-one children observed for one to nineteen years shows:. 1. This injury is rare but occurs in children of all ages from three to sixteen years old. 2. The fractures may be classified as transepiphysial, transcervical (the commonest), basal and pertrochanteric. Displacement was frequent. 3. The fracture usually followed severe violence, especially falls from a height or motor accidents. 4. Complications were frequent and included avascular necrosis, delayed union (seventeen cases), non-union (seven cases) and disturbances of growth at both the upper and lower ends of the femur. 5. Avascular necrosis occurred in thirty patients (42 per cent). Three patterns of necrosis are described : diffuse, localised and confined to the femoral neck. The radiographic appearances of avascular necrosis after this fracture are different from those of pseudocoxalgia (Legg-Calvé-Perthes' disease). 6. Non-union did not occur after adequate primary internal fixation or after primary subtrochanteric osteotomy. 7. The management of an undisplaced fracture presented no great problem and the results were good. A plaster spica is recommended for treatment of this fracture. Exceptionally, avascular necrosis developed. 8. Treatment of the displaced fractures (forty-nine cases) was less satisfactory. A good result was obtained from primary treatment in only fifteen patients. 9. The value of different methods of primary treatment is discussed, including manipulative reduction and immobilisation in a plaster spica, manipulative reduction and internal fixation, and primary subtrochanteric osteotomy. Manipulative reduction and immobilisation in a plaster spica is not recommended. 10. Salvage operations were required in nineteen patients. Late subtrochanteric osteotomy is of value in the management of some of these problems

We compared the clinical and radiological outcomes of two cementless femoral stems in the treatment of patients with a Garden III or IV fracture of the femoral neck. A total of 70 patients (70 hips) in each group were enrolled into a prospective randomised study. One group received a short anatomical cementless stem and the other received a conventional cementless stem. Their mean age was 74.9 years (50 to 94) and 76.0 years (55 to 96), respectively (p = 0.328). The mean follow-up was 4.1 years (2 to 5) and 4.8 years (2 to 6), respectively. Perfusion lung scans and high resolution chest CTs were performed to detect pulmonary microemboli. At final follow-up there were no statistically significant differences between the short anatomical and the conventional stems with regard to the mean Harris hip score (85.7 (66 to 100) versus 86.5 (55 to 100); p = 0.791), the mean Western Ontario and McMaster Universities Osteoarthritis Index (17 (6 to 34) versus 16 (5 to 35); p = 0.13) or the mean University of California, Los Angeles activity score (5 (3 to 6) versus 4 (3 to 6); p = 0.032). No patient with a short stem had thigh pain, but 11 patients (16%) with a conventional stem had thigh pain. No patients with a short stem had symptomatic pulmonary microemboli, but 11 patients with a conventional stem had pulmonary microemboli (symptomatic in three patients and asymptomatic in eight patients). One hip (1.4%) in the short stem group and eight (11.4%) in the conventional group had an intra-operative undisplaced fracture of the calcar. No component was revised for aseptic loosening in either group. One acetabular component in the short stem group and two acetabular components in the conventional stem group were revised for recurrent dislocation. Our study demonstrated that despite the poor bone quality in these elderly patients with a fracture of the femoral neck, osseo-integration was obtained in all hips in both groups. However, the incidence of thigh pain, pulmonary microemboli and peri-prosthetic fracture was significantly higher in the conventional stem group than in the short stem group

We report a series of 50 patients under 70 years of age who had an ununited femoral neck fracture treated by a Pauwels abduction osteotomy. At an average follow-up of 7.1 years, seven patients had required prosthetic replacement and 37 others were reviewed in detail. In these patients the Harris hip score averaged 91. Twenty-two hips showed radiographic evidence of avascular femoral head necrosis, but only three of these had been replaced. For active patients with non-union of a femoral neck fracture, Pauwels osteotomy provides a high proportion of good results even in the presence of avascular necrosis of the head, providing there has been no collapse. If osteotomy fails, prosthetic replacement is still possible

1. A technique of transarticular nailing for subcapital and transcervical fractures of the neck of the femur is described. 2. Forty-four operations have been done, and twenty-one patients have been under observation for periods of from one to six years. In one of these pseudarthrosis has developed; in two others there has been delayed union. 3. The method gives sound fixation by a "squeezing effect" on the proximal fragment, which is enhanced by the locking of the adjacent articulation. 4. It is presented as an alternative to prosthetic replacement for treatment of femoral neck fracture in the aged. The nail damages the articular surface of the acetabulum but not the femoral head. 5. The importance of care after operation is stressed. 6. The advantages of the method, the role of circulatory changes in the femoral head and the mechanics of transarticular fixation are discussed

Fractures of the hip are common, often occurring in frail elderly patients, but also in younger fit healthy patients following trauma. They have a significant associated mortality and major social and financial implications to patients and health care providers. Many guidelines are available for the management of these patients, mostly recommending early surgery for the best outcomes. As a result, healthcare authorities now put pressure on surgical teams to ‘fast track’ patients with a fracture of the hip, often misquoting the available literature, which in itself can be confusing and even conflicting.

This paper has been written following an extensive review of the available literature. An attempt is made to clarify what is meant by early surgery (expeditious versus emergency), and we conclude with a personal view for the practical management of these patients of variable age, fitness and type of surgery performed within services that are often under considerable pressure of finance and available operating theatres and qualified staff.

Cite this article: Bone Joint J 2016;98-B:1573–81.

1. Various types of fracture of the femoral neck represent different stages of one and the same displacing movement. 2. The displacement first produces an "abduction fracture" and terminates in an "adduction fracture," passing through the stage of an " intermediary fracture" which is less well recognised. 3. These three types of fracture occur in response to the same injury and they differ only in the degree of displacement. 4. It is a mistake to believe that in " adduction fractures" the femoral head lies medially to the collum : it lies posteriorly. 5. "Impaction" is no more than the first stage of displacement of fractures in which there is limited displacement, with contact still maintained between the fragments. 6. An "impacted fracture" is not necessarily stable—if there is additional strain it may progress to the next stage of a displaced and unstable fracture. 7. These principles apply not only to fractures of the femoral neck but to all other fractures at the ends of long bones

1. At necropsy the arterial distribution within the head and neck of the femur was investigated by arteriographic injection in fifty-seven uninjured hips of mostly elderly subjects. 2. Before injection all vessels to the head except for one or more particular groups were divided. 3. The superior retinacular arteries were found to be the most important arterial supply to the head. Through the widely distributed branches of their lateral epiphysial vessels (superior capital) they supplied the superior, medial, central and usually the lateral parts of the head: through anastomoses they could also supply the anterior and posterior segments, the subfovea and the inferior sector, which receive separate contributions. Sometimes the inferior or the lateral connections were defective. 4. The arteries in the ligamentum teres were either absent or unimportant for the head in most subjects. Either the vessels in the ligament never reached the head or they supplied only a limited subfoveal zone. In only one out of sixteen specimens was the whole head injected through the vessels of the ligamentum teres. 5. The inferior retinacular arteries were found to be of subsidiary importance and generally supplied a variable infero-lateral part of the head, particularly posteriorly. In a small number there was an anastomotic supply to other parts of the head, but only in two out of sixteen specimens was nearly all the head injected through these vessels. 6. The regular anastomotic supply from the superior retinacular arteries to the subfovea and to the inferior part of the head was in curious contrast to the infrequent anastomotic filling of the lateral epiphysial arteries from the inferior retinacular or ligamentum teres arteries. 7. Vessels within the femoral neck sometimes supplied the lateral part of the head but never the medial three-quarters. 8. The neck of the femur received important branches from the superior retinacular arteries but only in a small number (15 per cent) was part of it entirely dependent on this supply

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff’s clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN. Cite this article: Bone Joint J 2013;95-B:135-41

We describe a method of internal fixation for femoral neck fractures which has been newly developed to reduce the frequency of early complications. Two cannulated screws are inserted in the axis of the femoral neck to reach into the subchondral bone of the femoral head. The screws are inserted over guide pins and the tip of the screw is self-tapping and designed to provide good anchorage in the femoral head. We used this method in 44 consecutive patients in a prospective study with no exclusions, followed for a minimum of 24 months. All fractures healed within 12 months, and there were no cases of early loosening or nonunion. In four cases, late segmental collapse had developed during the mean follow-up period of 30 months

We studied the rate of revision in 84 consecutive total hip replacements performed for failed osteosynthesis of femoral neck fractures and compared it with that for primary arthroplasty for osteoarthritis. The age and sex adjusted risk of prosthetic failure was 2.5 times higher after failure of fixation, but all the excess risk was in patients over 70 years of age. There were radiographic signs of loosening of the femoral component at five to 12 years after secondary arthroplasty in six of 33 survivors. In general, the results of secondary replacement were no worse than those obtained after primary arthroplasty for femoral neck fracture. We consider that internal fixation should be the primary procedure: total hip replacement is a safe secondary procedure when osteosynthesis fails

We report retrospective and prospective studies to identify the causes of fracture of the femoral neck associated with femoral shaft nailing on the same side. Of a total of 14 neck fractures in a series of 152 shaft nailings, eight were not visible on the initial pelvic radiographs. We used CT scans before and after operation, and fluoroscopy during the procedure in our prospective series, and reviewed abdominal CT scans retrospectively with the window set to bone level. Six of the eight undisplaced fractures were shown to have been present before operation, but two were iatrogenic. We recommend the preoperative use of CT scans of the femoral neck in high-risk patients such as those with associated fractures of the acetabulum, the distal femur or the patella. Early diagnosis will allow better general management and early fixation of the neck fracture

We adduce the following conclusions from our experience of using this spring-loaded compression screw on completely displaced medial fractures of the femoral neck:. 1. That this method probably eliminates non-union when the head is fully viable. 2. That primary "first-intention" osseous union occurs in approximately 33·3 per cent of cases. 3. That a vascular complication, of varying severity, undetectable by orthodox radiological tests, is revealed by extrusion of the screw in 66·6 per cent of cases. 4. That these observations disprove the idea that the main obstacle to revascularisation of an ischaemic head is the existence of forces so inclined to the axis of the femoral neck as to cause "shear.". 5. That, compared with the Smith-Petersen nail used for completely displaced fractures, continuous spring compression can materially reduce the incidence of utter mechanical failure within the first year after operation. This is the result of "mushroom" impaction which itself can resist shearing strain and so can permit function as a fibrous union. 6. That early and rapid extrusion is a sensitive indication of a vascular complication in the head. Forewarned by this, activity can be restricted, or possibly other measures adopted, to anticipate or permanently postpone serious trouble

Aims. The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons. Patients and Methods. We present a multicentre prospective case series with a follow-up of one year. All patients aged ≤ 60 years with a displaced FNF treated with the DLBP between 1st August 2010 and December 2014 were included. Patients with pathological fractures, concomitant fractures of the lower limb, symptomatic arthritis, local infection or inflammation, inadequate local tissue coverage, or any mental or neuromuscular disorder were excluded. Primary outcome measure was failure in fracture healing due to nonunion, avascular necrosis, or implant failure requiring revision surgery. Results. In total, 106 consecutive patients (mean age 52 years, range 23 to 60; 46% (49/106) female) were included. The failure rate was 14 of 106 patients (13.2%, 95% confidence interval (CI) 7.1 to 19.9). Avascular necrosis occurred in 11 patients (10.4%), nonunion in six (5.6%), and loss of fixation in two (1.9%). Conclusion. The rate of fracture healing after DLBP fixation of displaced femoral neck fracture in young patients is promising and warrants further investigation by a randomized trial to compare the performance against other contemporary methods of fixation. Cite this article: Bone Joint J 2018;100-B:443–9