What is the prognosis for non-displaced femoral neck fractures treated with a strict protocol? Analysis of a prospective cohort treated with internal fixation versus arthroplasty.

What is the prognosis for non-displaced femoral neck fractures treated with a strict protocol? Analysis of a prospective cohort treated with internal fixation versus arthroplasty. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article What is the prognosis for non-displaced femoral neck fractures treated with a strict protocol? Analysis of a prospective cohort treated with internal fixation versus arthroplasty. Tomas Zamora, Hari Castro, Francisco Silva, Catalina Vidal, Jorge Faundez, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4555193/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Non-displaced femoral neck fractures (FNF) are common in elderly patients, but the best treatment approach is still uncertain. The decision should be based on several factors, including fracture angulation and comminution, to ensure the best possible clinical and functional outcomes in the mid-to long-term. In this study, we report on the treatment of non-displaced FNF in elderly patients using a personalized protocol with either internal fixation or arthroplasty. Our objectives were to evaluate the clinical and functional outcomes of both treatment options and to compare the results between the two groups. Methods Analysis of a prospectively collected cohort of patients treated from 2010 to 2022 with a geriatric non-displaced femoral neck fracture. Patients were treated with internal fixation if no significant angulation, cortical gap, comminution, or significant osteoarthritis was observed. In case any of the later was present, a joint replacement was selected. Primary outcomes recorded were complications, reoperations, and mortality. Results One hundred and nineteen patients were included. 75% were female. Nintynine patients were treated with internal fixation, while eighteen had a partial or total hip replacement. Two patients did not undergo surgery because of their general condition. Patients were followed for a median of 4 years. Severe complications were observed in 5% of cases, while reoperations were performed in 4%. 30-day mortality and one-year mortality were 1% and 6%, respectively. There were no significant differences in reoperations, complications, or mortality between the internal fixation group and the arthroplasty group. Conclusions Surgical management of non-displaced femoral neck fractures with internal fixation or arthroplasty is both safe and effective as long as a strict protocol is followed, and careful analysis of radiographic features is performed. Fragility fracture femoral neck fracture non-displaced hip fracture hip arthroplasty cannulated screws. Figures Figure 1 Figure 2 Figure 3 Introduction Femoral neck fractures (FNF) are a common and complicated problem among elderly patients worldwide( 1 ). These fractures can result in significant morbidity( 2 , 3 ), have a huge economic impact( 3 ), and pose a high risk of mortality( 4 ). Therefore, it is essential to provide appropriate surgical treatment for these patients and ensure a safe and complication-free rehabilitation process. The classic treatment for non-displaced FNF frequently consists of fixation with the use of cannulated screw osteosynthesis. However, recent literature, including results from randomized clinical trials, had advocated for a more aggressive approach in order to improve clinical outcomes such as satisfaction, pain relief, and reoperations( 5 – 8 ) for this subset of patients. Still, it is crucial to understand that not all fractures of the femoral neck (FNF) are identical. Both randomized controlled data and retrospective series tend to overlook this important fact, which can result in inadequate resource allocation and treatment selection. Therefore, careful analysis of the fracture's morphology and consideration of established risk factors, such as posterior tilt, comminution, and calcar gap( 9 – 12 ), could optimize decision-making and global outcomes, taking advantage of the best of both surgical alternatives. Nonetheless, reports centered on this patient-tailored approach are scarce. Our objective is to report the mid- to long-term clinical and functional outcomes after the treatment of nondisplaced FNF in elderly patients treated with a strict and personalized protocol with internal fixation or arthroplasty. As a second objective, we compared the outcomes between both groups. Patients and methods Ethical institutional review board approval was obtained before this study was performed in accordance with the Declaration of Helsinki. in accordance with the Declaration of Helsinki. From 2010, patients admitted to our institution with a low-energy fragility FNF have been prospectively identified and followed. We included geriatric patients more than 60 years of age who were admitted for a low-energy nondisplaced FNF, as initially determined on anteroposterior (AP) x-rays. Pathologic fractures, non-femoral neck fractures, and patients who didn’t complete their treatments at our institution were excluded. Patients were followed for a minimum of 12 months to be included in this study. All patients were treated following a strict protocol based on current evidence and institutional practice. We began by assessing all patients with pelvic AP and hip AP and lateral (crosstable) x-rays. If the fracture morphology was not clearly assessed on plain x-rays, patients underwent a CT scan to further characterize it (27% of patients), as it is shown that clinical conduct and treatment could be modified by this addition( 13 ). Treatment was then decided based on the fracture's morphology and the patient's characteristics. Patients with a nondisplaced FNF fracture (Garden 1 or 2) with a minimum posterior tilt (defined as less than 20 degrees) and no posterior comminution, cortical gap, or significant previous symptomatic osteoarthritis were treated with internal fixation through the use of 6.5 mm or 7.3 mm cannulated screws (two as a minimum, mostly completely threaded) or a sliding hip screw (SHS). All other patients were treated with a cemented hemiarthroplasty or a total hybrid hip arthroplasty through a direct lateral approach, based on the patient’s global status and functionality. Patients under 85 years of age, with good function, no use of canes or significant osteoarthritis were considered for a total hip arthroplasty; all others received a cemented bipolar hemiarthroplasty. Patients were followed at four weeks, then at 3, 6, and 12 months postoperatively or until consolidation was achieved in case of internal fixation. Patients with hip arthroplasty were also followed consecutively every year with x-rays. All patients were treated with prophylactic intravenous antibiotics for a minimum of 24 hours post-operative and deep venous thrombosis (DVT) prophylaxis for a minimum of 4 weeks after surgery. Clinical and radiological information was collected from the electronic charts. Mortality was collected through the health ministry database, which is publicly accessible and allows for complete follow-up. The primary outcomes assessed were surgical complications, reoperations, and mortality. All alive patients were contacted by telephone and mail for updated clinical status and asked for postoperative quality of life (QOL) outcome assessments. From 69 living patients at the final follow-up, 40 refused to collaborate for unspecified reasons. QOL assessment was successfully achieved postoperatively in 29% of patients (20/69), and it included the SF-12 health survey and the Hip disability and Osteoarthritis Outcome Score-12 (HOOS-12). A comparison between patients treated with an internal fixation and those with an arthroplasty was made with the Wilcoxon rank sum (two-sample) test or Mann-Whitney test for continuous variables and the Fisher exact test for categorical ones. P-value < 0.05 was considered to be a statistically significant difference. All analyses were performed using SPSS Statistics, version 29 (IBM Corp., Armonk, NY, USA). Results A total of 119 patients were included in the study. The median age of the patients was 79 years (Interquartile range – IQR 69–86), with 73% being female. Median age-adjusted Charlson Comorbidity Index was 4 points (IQR 3–5). Ninety-nine patients had fractures without significant angulation or comminution; hence, they were treated with internal fixation. Eighteen patients were treated with hip arthroplasty (11 total hip arthroplasty, 7 hemiarthroplasty), and two patients did not undergo surgery because of their overall medical condition. Table 1 shows patients’ demographics and surgery details. Table 1 Patients demographics and surgery details Gender (n; %) Female 87 (73%) Male 32 (27%) Age (median; IQR) 79 years (69–86) Charlson Score (median; IQR) 4 ( 3 – 5 ) Side (n, %) Left 61 (51%) Right 58 (49%) Treatment (n, %) Non-operative 2 (2%) Operative 117 (98%) Internal fixation Cannulated Screws 94 (79%) Sliding Hip Screw 5 (4%) Hemiarthroplasty 7 (6%) Total Hip Arthroplasty 11 (9%) IQR = Interquartile range Patients with an internal fixation had a median of 12 (IQR 8–16) degrees of posterior angulation preoperative. Ninety-four patients were treated with canulated screws (79%). Of these, eighteen patients were fixed with a two-screw configuration (19%) and seventy-six (81%) with a three-screw inverted triangle configuration. Five patients (4%) were treated with a SHS. The arthroplasty group had a median of 29 (IQR 20–38) degrees of posterior angulation preoperatively. Criteria for arthroplasty were posterior angulation in 13 cases, important comminution, or cortical gap in 2 cases, advanced osteoarthritis in 2 cases, and a combination of comminution and posterior angulation in one case. There were no significant differences between the arthroplasty group and the osteosynthesis group in any of the baseline patient characteristics, including gender, age, CCI, or preoperative hematocrit. Patients were followed for a median of 4 years (IQR 3–9). Six cases had severe post-surgical complications (5%). Two cases presented avascular necrosis, and one case had fracture non-union, both in the internal fixation group (Figs. 1 and 2) . Also, one patient fell within the first month and had a peri-implant fracture in the same group. All of these patients had to be converted to a total hip arthroplasty, with one patient developing a severe post-surgical periprosthetic infection. One other patient in the internal fixation group had to undergo hip arthroplasty due to severe osteoarthritis 4 years after the initial fracture, resulting in a total of five patients requiring reoperation (4%). In the arthroplasty group, one patient developed a superficial site infection that resolved with oral antibiotics, and another patient developed transient peroneal palsy with chronic neuropathic pain (Fig. 3) . No patient died during hospitalization. The median length of stay was 4 days (IQR 3–6). 30-day mortality and one-year mortality were 1% (1 case) and 6% (6 cases), respectively, with no cases directly related to their surgery. There was no significant difference between both groups in overall mortality, complications, reoperations, or length of hospital stay (Table 2). Table 2. Outcomes for internal fixation versus arthroplasty patients Internal Fixation Arthroplasty p-value (n=99) (n=18) 30-days mortality (n, %) 1 (1%) 0 1 1-year mortality (n, %) 6 (7%) 0 1 Lenght of hospital stay (days, median; IQR) 4 days (IQR 3-7) 4.5 days (IQR 3-7) 0.462 Postoperative complications (n of patients, %) 4 (4%) 2 (11%) 0.230 Reoperations (n, %) 5 (5%) 0 1 The median HOOS-12 score was 86.5 (IQR 45–96) for the entire group, while the median score for the mental and de physical components of SF12 were 51 (IQR 34–54) and 54 (IQR 50–60), respectively. Discussion In recent decades, there have been significant advances in the management of fragility hip fractures. However, deciding whether to fix or replace the hip femur after a non-displaced FNF remains a matter of debate. Our protocol for making this decision has shown to achieve satisfactory outcomes with a low complication, reoperation, and mortality rate. Our findings contribute important information to the recently published data. Although the internal fixation group demonstrated a higher reoperation rate (4%) than the arthroplasty group (none) as part of the primary outcomes, this difference was not statistically significant. Moreover, it was still much lower than the previously reported data, which has ranged from 10–32% in both randomized and observational series ( 5 , 8 , 14 – 16 ). This is an important factor to consider, indicating that careful analysis of fracture morphology and patient characteristics may effectively reduce reoperation rates, potentially avoiding the need for a more invasive surgery for elderly and frail patients. Similarly, it shows that overall severe complications were scarce, mostly limited to failure of internal fixation and standard complications related to reconstructive surgery (such as infection and neurologic complications). In our study, we noted that there were no cases of implant removal due to symptomatic hardware. This could have contributed to the overall low reoperation rate. However, it also highlights the difference between the elderly population and young adults, where this outcome could be more frequent due to longer expected follow-up, increased functionality, and needs. On the other hand, the overall mortality for this group of patients was low, with a 1-year mortality rate of six percent for elderly patients with non-displaced fractures who underwent surgical treatment. Other large series have reported a wide range of mortality rates, varying from 0 to 33%( 15 , 17 – 19 ). Furthermore, our series did not show any significant increase in mortality among patients who underwent a more aggressive approach to address the specific challenges of their fracture. Initially, there was concern about a higher risk of surgical injury associated with a hip arthroplasty compared to internal fixation; however, this was not the case, as reported in other published series that have not shown any significant difference in mortality between these two groups( 8 , 20 , 21 ). Alternatives for definitive treatment for non-displaced femoral neck fractures are still a matter of discussion. Several studies have aided in the identification of significant risk factors for failure after an initial internal fixation, especially when cannulated screws have been used. Posterior angulation, cortical gap, and comminution are examples of this. Consequently, the use of this surgical alternative without careful consideration of these features has shown an elevated risk for failure and, specifically, reoperations( 9 , 10 , 19 , 22 ). Moreover, results from recent trials and case series have established the role of arthroplasty as a safe and effective modality of treatment( 5 , 8 ). Our results indicate that a posterior angulation of less than 20 degrees and minimal comminution lead to a reasonably low reoperation rate if an osteosynthesis is performed. On the other hand, endoprosthetic reconstruction should be considered a major surgical procedure that inevitably carries risks of complications such as bleeding, neurologic injury, revision, and infection, even when it´s predictability is extremely high. However, based on our results, a thorough analysis of radiographic features can help determine whether to fix or replace, resulting in satisfactory outcomes with minimal reoperation rates and complications in a global series. Our protocol emphasizes the importance of adapting over time and according to emerging evidence. The traditional treatment for non-displaced femoral fractures with internal fixation and cannulated screws has been challenged in recent years by the safe and reliable results of hip reconstruction in all clinical scenarios. As a result, there has been a noticeable shift in published literature and overall practice towards a more aggressive approach to these patients. However, our results show that internal fixation could still be considered as a safe and effective alternative, as long as specific morphologic freacture features are considered, and patients are involved in the risk benefit analysis. Our study has several limitations. First, it is a retrospective analysis of a prospectively collected cohort, and therefore, it could be subject to several types of bias. Secondly, six different surgeons treated all cases included in this series, so even though our center has well-reported standardized management for this clinical scenario; some variability in surgical technique and indication exist. Additionally, an institutional bias towards certain treatments was also demonstrated with a higher rate of indication for internal fixation versus other alternatives. Furthermore, given the relatively small number of cases in our study, the amount of heterogeneity across the patients and the low rate of complications and mortality, comparisons between subgroups will be biased toward a null difference in statistical comparisons of outcomes. Also, at the time these patients initiated their treatment, QOL outcome assessment was not done preoperatively, and even when all patients were contacted for further assessment, only 25% of our patients responded to the request for questionnaires. Finally, as with any relatively infrequent scenario, our report has a limited sample size, and therefore, it is possible that some differences were not observed due to a lack of study power (type 2 error). In conclusion, a strict patient-specific protocol for deciding whether to fix or replace non-displaced FNF in the elderly could produce adequate outcomes, taking advantage of the best of both treatment alternatives without increasing reoperations nor complications. Declarations Ethics approval and consent to participate: Before the realization of this study, approval from the local institutional ethics committee was obtained. IRB PUC ID: 200416004 Consent publication: Individual consent has been granted for the use of X-rays in this manuscript. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests Funding: No funding has been received for this study or the preparation of this manuscript Authors' contributions: All authors have made substantial contributions to all of the following: (1) the conception and design of the study, acquisition of data, and analysis and interpretation of data, (2) drafting the article (3) final approval of the version submitted to BMC Musculoskeletal Disorders. Acknowledgments: Not applicable. References Mears SC, Kates SL. A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2. Geriatr Orthop Surg Rehabil. 2015 Jun 3;6(2):58–120. Osnes EK, Lofthus CM, Meyer HE, Falch JA, Nordsletten L, Cappelen I, et al. Consequences of hip fracture on activities of daily life and residential needs. Osteoporosis International. 2004;15(7):567–74. Becker DJ, Kilgore ML, Morrisey MA. The societal burden of osteoporosis. Curr Rheumatol Rep. 2010 Jun;12(3):186–91. 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Available from: https://pubmed.ncbi.nlm.nih.gov/18407277/ Goodnough LH, Wadhwa H, Fithian AT, DeBaun MR, Campbell ST, Gardner MJ, et al. Is percutaneous screw fixation really superior to non-operative management after valgus-impacted femoral neck fracture: a retrospective cohort study. Eur J Orthop Surg Traumatol [Internet]. 2021 Jan 1 [cited 2024 May 20];31(1):65–70. Available from: https://pubmed.ncbi.nlm.nih.gov/32710126/ Tidermark J, Zethraeus N, Svensson O, Törnkvist H, Ponzer S. Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. J Orthop Trauma [Internet]. 2002 [cited 2024 May 20];16(1):34–8. Available from: https://pubmed.ncbi.nlm.nih.gov/11782631/ Honkanen JS, Ekman EM, Huovinen VK, Mäkelä KT, Koivisto M, Karvonen MP, et al. Preoperative Posterior Tilt Increases the Risk of Later Conversion to Arthroplasty After Osteosynthesis for Femoral Neck Fracture. 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A systematic review and meta-analysis. Injury [Internet]. 2020 Dec 1 [cited 2024 May 20];51(12):2771–8. Available from: https://pubmed.ncbi.nlm.nih.gov/32980140/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4555193","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318617526,"identity":"4b24a2df-67d7-425b-8733-88f39f5f1a78","order_by":0,"name":"Tomas Zamora","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAoElEQVRIiWNgGAWjYDADfjBZQIRKHhhDsgFEGpCixeAAsVrs2dsffrpRcU/e+EbyA4YfRNnCcyBZOudMseG2G2kGjD1EaZFIOCCd25bAuO1GDgMzcX6Rf9j8G6jFfvMMorVIMLOBbEncIEG0ljNpbNY5ZxKSZ5x5ZnCQKL+wtx9/fDunIsG2vz354YMfFURoQQEHSNUwCkbBKBgFowAHAADgYTCvMmo/NQAAAABJRU5ErkJggg==","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":true,"prefix":"","firstName":"Tomas","middleName":"","lastName":"Zamora","suffix":""},{"id":318617528,"identity":"e7350152-8f0b-43b6-9baa-0fc7aa8b9585","order_by":1,"name":"Hari Castro","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Hari","middleName":"","lastName":"Castro","suffix":""},{"id":318617530,"identity":"d82e1973-374e-40e5-bf67-8d84a5a7e228","order_by":2,"name":"Francisco Silva","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"","lastName":"Silva","suffix":""},{"id":318617532,"identity":"ccf476bd-f297-48fb-bc27-5cf01169867b","order_by":3,"name":"Catalina Vidal","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Catalina","middleName":"","lastName":"Vidal","suffix":""},{"id":318617534,"identity":"4495118b-fe25-49f2-af18-193825857db5","order_by":4,"name":"Jorge Faundez","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Jorge","middleName":"","lastName":"Faundez","suffix":""},{"id":318617536,"identity":"7c7f0a42-2832-4338-9eff-aa4babe70ff3","order_by":5,"name":"Agustin Vial","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Agustin","middleName":"","lastName":"Vial","suffix":""},{"id":318617538,"identity":"7e08d609-dcac-41d3-a15d-ec6726bc3554","order_by":6,"name":"Eduardo Botello","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Eduardo","middleName":"","lastName":"Botello","suffix":""},{"id":318617540,"identity":"6d6d82a7-98dc-4dc2-936d-c85f1ebb52b6","order_by":7,"name":"Ianiv Klaber","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Ianiv","middleName":"","lastName":"Klaber","suffix":""},{"id":318617542,"identity":"23c4b0f3-4d6a-48e5-9612-bfb807b10437","order_by":8,"name":"Maximiliano Carmona","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Maximiliano","middleName":"","lastName":"Carmona","suffix":""},{"id":318617544,"identity":"0b34390e-1fa4-40fe-948d-c9f1738a8988","order_by":9,"name":"Daniel Schweitzer","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Schweitzer","suffix":""}],"badges":[],"createdAt":"2024-06-09 23:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4555193/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4555193/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60618870,"identity":"316a3ca1-30f0-4ee3-90b9-ff128a27cf72","added_by":"auto","created_at":"2024-07-18 20:40:40","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":141791,"visible":true,"origin":"","legend":"\u003cp\u003eA 74-year-old female has a nondisplaced valgus-impacted femoral neck fracture in the AP pelvis (A) and crosstable x-ray (B) with no significant angulation.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4555193/v1/941aa16289a4bb7156e87ce5.jpg"},{"id":60618871,"identity":"0b725a97-84f0-49f8-bffa-afa8ecf384bd","added_by":"auto","created_at":"2024-07-18 20:40:40","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":225510,"visible":true,"origin":"","legend":"\u003cp\u003eSame case as Figure 1. The post-operative x-rays show in situ fixation with three completely threaded 6.5 cannulated screws (A). At the 6-month follow-up, there is evidence of screw breakage and fixation failure (B). The patient underwent a total hip arthroplasty on her left hip, with successful outcomes.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4555193/v1/9421a2adaa7525c505b346d7.jpg"},{"id":60618872,"identity":"7b2fa9a5-fb93-4c86-9c22-1c4fd765e151","added_by":"auto","created_at":"2024-07-18 20:40:40","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":161037,"visible":true,"origin":"","legend":"\u003cp\u003eA 73-year-old active woman with a complete valgus-impacted femoral neck fracture of the right hip. An AP pelvic x-ray (A) and axial CT scan reconstruction (B) show more than 20° posterior angulation and comminution. Postoperative x-ray (C) with a hybrid total hip replacement.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4555193/v1/4e3f3eb2737de4bf67d45edf.jpg"},{"id":63016358,"identity":"604c937b-8c29-4a97-89c4-e5aad10978db","added_by":"auto","created_at":"2024-08-22 06:46:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":868574,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4555193/v1/496565ba-a3d2-4cbe-8a7a-46e4c5b79a67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"What is the prognosis for non-displaced femoral neck fractures treated with a strict protocol? Analysis of a prospective cohort treated with internal fixation versus arthroplasty.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFemoral neck fractures (FNF) are a common and complicated problem among elderly patients worldwide(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These fractures can result in significant morbidity(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), have a huge economic impact(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and pose a high risk of mortality(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Therefore, it is essential to provide appropriate surgical treatment for these patients and ensure a safe and complication-free rehabilitation process.\u003c/p\u003e \u003cp\u003eThe classic treatment for non-displaced FNF frequently consists of fixation with the use of cannulated screw osteosynthesis. However, recent literature, including results from randomized clinical trials, had advocated for a more aggressive approach in order to improve clinical outcomes such as satisfaction, pain relief, and reoperations(\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) for this subset of patients.\u003c/p\u003e \u003cp\u003eStill, it is crucial to understand that not all fractures of the femoral neck (FNF) are identical. Both randomized controlled data and retrospective series tend to overlook this important fact, which can result in inadequate resource allocation and treatment selection. Therefore, careful analysis of the fracture's morphology and consideration of established risk factors, such as posterior tilt, comminution, and calcar gap(\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), could optimize decision-making and global outcomes, taking advantage of the best of both surgical alternatives. Nonetheless, reports centered on this patient-tailored approach are scarce.\u003c/p\u003e \u003cp\u003eOur objective is to report the mid- to long-term clinical and functional outcomes after the treatment of nondisplaced FNF in elderly patients treated with a strict and personalized protocol with internal fixation or arthroplasty. As a second objective, we compared the outcomes between both groups.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003e Ethical institutional review board approval was obtained before this study was performed in accordance with the Declaration of Helsinki. in accordance with the Declaration of Helsinki. From 2010, patients admitted to our institution with a low-energy fragility FNF have been prospectively identified and followed. We included geriatric patients more than 60 years of age who were admitted for a low-energy nondisplaced FNF, as initially determined on anteroposterior (AP) x-rays. Pathologic fractures, non-femoral neck fractures, and patients who didn\u0026rsquo;t complete their treatments at our institution were excluded. Patients were followed for a minimum of 12 months to be included in this study.\u003c/p\u003e \u003cp\u003eAll patients were treated following a strict protocol based on current evidence and institutional practice. We began by assessing all patients with pelvic AP and hip AP and lateral (crosstable) x-rays. If the fracture morphology was not clearly assessed on plain x-rays, patients underwent a CT scan to further characterize it (27% of patients), as it is shown that clinical conduct and treatment could be modified by this addition(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Treatment was then decided based on the fracture's morphology and the patient's characteristics. Patients with a nondisplaced FNF fracture (Garden 1 or 2) with a minimum posterior tilt (defined as less than 20 degrees) and no posterior comminution, cortical gap, or significant previous symptomatic osteoarthritis were treated with internal fixation through the use of 6.5 mm or 7.3 mm cannulated screws (two as a minimum, mostly completely threaded) or a sliding hip screw (SHS). All other patients were treated with a cemented hemiarthroplasty or a total hybrid hip arthroplasty through a direct lateral approach, based on the patient\u0026rsquo;s global status and functionality.\u003c/p\u003e \u003cp\u003ePatients under 85 years of age, with good function, no use of canes or significant osteoarthritis were considered for a total hip arthroplasty; all others received a cemented bipolar hemiarthroplasty.\u003c/p\u003e \u003cp\u003ePatients were followed at four weeks, then at 3, 6, and 12 months postoperatively or until consolidation was achieved in case of internal fixation. Patients with hip arthroplasty were also followed consecutively every year with x-rays. All patients were treated with prophylactic intravenous antibiotics for a minimum of 24 hours post-operative and deep venous thrombosis (DVT) prophylaxis for a minimum of 4 weeks after surgery.\u003c/p\u003e \u003cp\u003eClinical and radiological information was collected from the electronic charts. Mortality was collected through the health ministry database, which is publicly accessible and allows for complete follow-up. The primary outcomes assessed were surgical complications, reoperations, and mortality. All alive patients were contacted by telephone and mail for updated clinical status and asked for postoperative quality of life (QOL) outcome assessments. From 69 living patients at the final follow-up, 40 refused to collaborate for unspecified reasons. QOL assessment was successfully achieved postoperatively in 29% of patients (20/69), and it included the SF-12 health survey and the Hip disability and Osteoarthritis Outcome Score-12 (HOOS-12).\u003c/p\u003e \u003cp\u003eA comparison between patients treated with an internal fixation and those with an arthroplasty was made with the Wilcoxon rank sum (two-sample) test or Mann-Whitney test for continuous variables and the Fisher exact test for categorical ones. P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to be a statistically significant difference. All analyses were performed using SPSS Statistics, version 29 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 119 patients were included in the study. The median age of the patients was 79 years (Interquartile range \u0026ndash; IQR 69\u0026ndash;86), with 73% being female. Median age-adjusted Charlson Comorbidity Index was 4 points (IQR 3\u0026ndash;5). Ninety-nine patients had fractures without significant angulation or comminution; hence, they were treated with internal fixation. Eighteen patients were treated with hip arthroplasty (11 total hip arthroplasty, 7 hemiarthroplasty), and two patients did not undergo surgery because of their overall medical condition. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows patients\u0026rsquo; demographics and surgery details.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePatients demographics and surgery details\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eGender (n; %)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (73%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eAge (median; IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79 years (69\u0026ndash;86)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eCharlson Score (median; IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSide (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eTreatment (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eNon-operative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eOperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117 (98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eInternal fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCannulated Screws\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSliding Hip Screw\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHemiarthroplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eTotal Hip Arthroplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eIQR\u0026thinsp;=\u0026thinsp;Interquartile range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePatients with an internal fixation had a median of 12 (IQR 8\u0026ndash;16) degrees of posterior angulation preoperative. Ninety-four patients were treated with canulated screws (79%). Of these, eighteen patients were fixed with a two-screw configuration (19%) and seventy-six (81%) with a three-screw inverted triangle configuration. Five patients (4%) were treated with a SHS.\u003c/p\u003e\n\u003cp\u003eThe arthroplasty group had a median of 29 (IQR 20\u0026ndash;38) degrees of posterior angulation preoperatively. Criteria for arthroplasty were posterior angulation in 13 cases, important comminution, or cortical gap in 2 cases, advanced osteoarthritis in 2 cases, and a combination of comminution and posterior angulation in one case. There were no significant differences between the arthroplasty group and the osteosynthesis group in any of the baseline patient characteristics, including gender, age, CCI, or preoperative hematocrit.\u003c/p\u003e\n\u003cp\u003ePatients were followed for a median of 4 years (IQR 3\u0026ndash;9). Six cases had severe post-surgical complications (5%). Two cases presented avascular necrosis, and one case had fracture non-union, both in the internal fixation group \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e(Figs.\u0026nbsp;1 and 2)\u003c/span\u003e. Also, one patient fell within the first month and had a peri-implant fracture in the same group. All of these patients had to be converted to a total hip arthroplasty, with one patient developing a severe post-surgical periprosthetic infection. One other patient in the internal fixation group had to undergo hip arthroplasty due to severe osteoarthritis 4 years after the initial fracture, resulting in a total of five patients requiring reoperation (4%). In the arthroplasty group, one patient developed a superficial site infection that resolved with oral antibiotics, and another patient developed transient peroneal palsy with chronic neuropathic pain \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e(Fig.\u0026nbsp;3)\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eNo patient died during hospitalization. The median length of stay was 4 days (IQR 3\u0026ndash;6). 30-day mortality and one-year mortality were 1% (1 case) and 6% (6 cases), respectively, with no cases directly related to their surgery. There was no significant difference between both groups in overall mortality, complications, reoperations, or length of hospital stay \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e(Table\u0026nbsp;2).\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTable 2. Outcomes for internal fixation versus arthroplasty patients\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\" style=\"margin-right: calc(44%); width: 56%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.025682182985554%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"8.025682182985554%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"8.025682182985554%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"8.025682182985554%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"46.22792937399679%\" valign=\"bottom\"\u003e\n \u003cp\u003eInternal Fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.088282504012842%\" valign=\"bottom\" style=\"width: 13.428%;\"\u003e\n \u003cp\u003eArthroplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.581059390048154%\" rowspan=\"2\" style=\"width: 8.0987%;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.59106529209622%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.59106529209622%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.59106529209622%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.59106529209622%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.48453608247423%\" valign=\"bottom\"\u003e\n \u003cp\u003e(n=99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.151202749140893%\" valign=\"bottom\" style=\"width: 13.428%;\"\u003e\n \u003cp\u003e(n=18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.21153846153846%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003e30-days mortality (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.15384615384615%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.064102564102564%\" valign=\"bottom\" style=\"width: 13.428%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\" valign=\"bottom\" style=\"width: 8.0987%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.21153846153846%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003e1-year mortality (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.15384615384615%\" valign=\"bottom\"\u003e\n \u003cp\u003e6 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.064102564102564%\" valign=\"bottom\" style=\"width: 13.428%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\" valign=\"bottom\" style=\"width: 8.0987%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.21153846153846%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003eLenght of hospital stay (days, median; IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.15384615384615%\" valign=\"bottom\"\u003e\n \u003cp\u003e4 days (IQR 3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.064102564102564%\" valign=\"bottom\" style=\"width: 13.428%;\"\u003e\n \u003cp\u003e4.5 days (IQR 3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\" valign=\"bottom\" style=\"width: 8.0987%;\"\u003e\n \u003cp\u003e0.462\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.21153846153846%\" colspan=\"4\" valign=\"bottom\"\u003e\n \u003cp\u003ePostoperative complications (n of patients, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.15384615384615%\" valign=\"bottom\"\u003e\n \u003cp\u003e4 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.064102564102564%\" valign=\"bottom\" style=\"width: 13.428%;\"\u003e\n \u003cp\u003e2 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.57051282051282%\" valign=\"bottom\" style=\"width: 8.0987%;\"\u003e\n \u003cp\u003e0.230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.077046548956663%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003eReoperations (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.025682182985554%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.22792937399679%\" valign=\"bottom\"\u003e\n \u003cp\u003e5 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.088282504012842%\" valign=\"bottom\" style=\"width: 13.428%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.581059390048154%\" valign=\"bottom\" style=\"width: 8.0987%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe median HOOS-12 score was 86.5 (IQR 45\u0026ndash;96) for the entire group, while the median score for the mental and de physical components of SF12 were 51 (IQR 34\u0026ndash;54) and 54 (IQR 50\u0026ndash;60), respectively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn recent decades, there have been significant advances in the management of fragility hip fractures. However, deciding whether to fix or replace the hip femur after a non-displaced FNF remains a matter of debate. Our protocol for making this decision has shown to achieve satisfactory outcomes with a low complication, reoperation, and mortality rate.\u003c/p\u003e\n\u003cp\u003eOur findings contribute important information to the recently published data. Although the internal fixation group demonstrated a higher reoperation rate (4%) than the arthroplasty group (none) as part of the primary outcomes, this difference was not statistically significant. Moreover, it was still much lower than the previously reported data, which has ranged from 10\u0026ndash;32% in both randomized and observational series (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). This is an important factor to consider, indicating that careful analysis of fracture morphology and patient characteristics may effectively reduce reoperation rates, potentially avoiding the need for a more invasive surgery for elderly and frail patients. Similarly, it shows that overall severe complications were scarce, mostly limited to failure of internal fixation and standard complications related to reconstructive surgery (such as infection and neurologic complications). In our study, we noted that there were no cases of implant removal due to symptomatic hardware. This could have contributed to the overall low reoperation rate. However, it also highlights the difference between the elderly population and young adults, where this outcome could be more frequent due to longer expected follow-up, increased functionality, and needs.\u003c/p\u003e\n\u003cp\u003eOn the other hand, the overall mortality for this group of patients was low, with a 1-year mortality rate of six percent for elderly patients with non-displaced fractures who underwent surgical treatment. Other large series have reported a wide range of mortality rates, varying from 0 to 33%(\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Furthermore, our series did not show any significant increase in mortality among patients who underwent a more aggressive approach to address the specific challenges of their fracture. Initially, there was concern about a higher risk of surgical injury associated with a hip arthroplasty compared to internal fixation; however, this was not the case, as reported in other published series that have not shown any significant difference in mortality between these two groups(\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAlternatives for definitive treatment for non-displaced femoral neck fractures are still a matter of discussion. Several studies have aided in the identification of significant risk factors for failure after an initial internal fixation, especially when cannulated screws have been used. Posterior angulation, cortical gap, and comminution are examples of this. Consequently, the use of this surgical alternative without careful consideration of these features has shown an elevated risk for failure and, specifically, reoperations(\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Moreover, results from recent trials and case series have established the role of arthroplasty as a safe and effective modality of treatment(\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). Our results indicate that a posterior angulation of less than 20 degrees and minimal comminution lead to a reasonably low reoperation rate if an osteosynthesis is performed. On the other hand, endoprosthetic reconstruction should be considered a major surgical procedure that inevitably carries risks of complications such as bleeding, neurologic injury, revision, and infection, even when it\u0026acute;s predictability is extremely high. However, based on our results, a thorough analysis of radiographic features can help determine whether to fix or replace, resulting in satisfactory outcomes with minimal reoperation rates and complications in a global series.\u003c/p\u003e\n\u003cp\u003eOur protocol emphasizes the importance of adapting over time and according to emerging evidence. The traditional treatment for non-displaced femoral fractures with internal fixation and cannulated screws has been challenged in recent years by the safe and reliable results of hip reconstruction in all clinical scenarios. As a result, there has been a noticeable shift in published literature and overall practice towards a more aggressive approach to these patients. However, our results show that internal fixation could still be considered as a safe and effective alternative, as long as specific morphologic freacture features are considered, and patients are involved in the risk benefit analysis.\u003c/p\u003e\n\u003cp\u003eOur study has several limitations. First, it is a retrospective analysis of a prospectively collected cohort, and therefore, it could be subject to several types of bias. Secondly, six different surgeons treated all cases included in this series, so even though our center has well-reported standardized management for this clinical scenario; some variability in surgical technique and indication exist. Additionally, an institutional bias towards certain treatments was also demonstrated with a higher rate of indication for internal fixation versus other alternatives. Furthermore, given the relatively small number of cases in our study, the amount of heterogeneity across the patients and the low rate of complications and mortality, comparisons between subgroups will be biased toward a null difference in statistical comparisons of outcomes. Also, at the time these patients initiated their treatment, QOL outcome assessment was not done preoperatively, and even when all patients were contacted for further assessment, only 25% of our patients responded to the request for questionnaires. Finally, as with any relatively infrequent scenario, our report has a limited sample size, and therefore, it is possible that some differences were not observed due to a lack of study power (type 2 error).\u003c/p\u003e\n\u003cp\u003eIn conclusion, a strict patient-specific protocol for deciding whether to fix or replace non-displaced FNF in the elderly could produce adequate outcomes, taking advantage of the best of both treatment alternatives without increasing reoperations nor complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Before the realization of this study, approval from the local institutional ethics committee was obtained. IRB PUC ID: 200416004\u003c/p\u003e\n\u003cp\u003eConsent publication: Individual consent has been granted for the use of X-rays in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding: No funding has been received for this study or the preparation of this manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions:\u0026nbsp;All authors have made substantial contributions to all of the following: (1) the conception and design of the study, acquisition of data, and analysis and interpretation of data, (2) drafting the article (3) final approval of the version submitted to BMC\u0026nbsp;Musculoskeletal Disorders.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: Not applicable. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMears SC, Kates SL. A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2. Geriatr Orthop Surg Rehabil. 2015 Jun 3;6(2):58\u0026ndash;120.\u003c/li\u003e\n \u003cli\u003eOsnes EK, Lofthus CM, Meyer HE, Falch JA, Nordsletten L, Cappelen I, et al. Consequences of hip fracture on activities of daily life and residential needs. Osteoporosis International. 2004;15(7):567\u0026ndash;74.\u003c/li\u003e\n \u003cli\u003eBecker DJ, Kilgore ML, Morrisey MA. The societal burden of osteoporosis. Curr Rheumatol Rep. 2010 Jun;12(3):186\u0026ndash;91.\u003c/li\u003e\n \u003cli\u003eKeene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip fractures. Br Med J. 1993;307(6914):1248\u0026ndash;60.\u003c/li\u003e\n \u003cli\u003eDolatowski FC, Frihagen F, Bartels S, Opland V, \u0026Scaron;altytė Benth J, Talsnes O, et al. Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in Elderly Patients: A Multicenter Randomized Controlled Trial. 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Hemiarthroplasty compared with internal fixation for treatment of nondisplaced femoral neck fractures in elderly patients: a retrospective study. Injury [Internet]. 2020 Apr 1 [cited 2024 Apr 6];51(4):1021\u0026ndash;4. Available from: https://pubmed.ncbi.nlm.nih.gov/32147143/\u003c/li\u003e\n \u003cli\u003ePalm H, Gosvig K, Krasheninnikoff M, Jacobsen S, Gebuhr P. A new measurement for posterior tilt predicts reoperation in undisplaced femoral neck fractures: 113 consecutive patients treated by internal fixation and followed for 1 year. Acta Orthop. 2009;80(3):303\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eDolatowski FC, Adampour M, Frihagen F, Stavem K, Erik Utv\u0026aring;g S, Hoelsbrekken SE. Preoperative posterior tilt of at least 20\u0026deg; increased the risk of fixation failure in Garden-I and -II femoral neck fractures: 322 patients followed for a mean of 3 years. 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Fixation versus hemiarthroplasty for undisplaced intracapsular hip fractures. Injury [Internet]. 2008 Jul [cited 2024 May 20];39(7):791\u0026ndash;5. Available from: https://pubmed.ncbi.nlm.nih.gov/18407277/\u003c/li\u003e\n \u003cli\u003eGoodnough LH, Wadhwa H, Fithian AT, DeBaun MR, Campbell ST, Gardner MJ, et al. Is percutaneous screw fixation really superior to non-operative management after valgus-impacted femoral neck fracture: a retrospective cohort study. Eur J Orthop Surg Traumatol [Internet]. 2021 Jan 1 [cited 2024 May 20];31(1):65\u0026ndash;70. Available from: https://pubmed.ncbi.nlm.nih.gov/32710126/\u003c/li\u003e\n \u003cli\u003eTidermark J, Zethraeus N, Svensson O, T\u0026ouml;rnkvist H, Ponzer S. Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. J Orthop Trauma [Internet]. 2002 [cited 2024 May 20];16(1):34\u0026ndash;8. Available from: https://pubmed.ncbi.nlm.nih.gov/11782631/\u003c/li\u003e\n \u003cli\u003eHonkanen JS, Ekman EM, Huovinen VK, M\u0026auml;kel\u0026auml; KT, Koivisto M, Karvonen MP, et al. Preoperative Posterior Tilt Increases the Risk of Later Conversion to Arthroplasty After Osteosynthesis for Femoral Neck Fracture. J Arthroplasty [Internet]. 2021 Sep 1 [cited 2024 May 20];36(9):3187\u0026ndash;93. Available from: https://pubmed.ncbi.nlm.nih.gov/34052100/\u003c/li\u003e\n \u003cli\u003eGjertsen JE, Vinje T, Enges\u0026aelig;ter LB, Lie SA, Havelin LI, Furnes O, et al. Internal screw fixation compared with bipolar hemiarthroplasty for treatment of displaced femoral neck fractures in elderly patients. J Bone Joint Surg Am [Internet]. 2010 Mar 1 [cited 2024 May 20];92(3):619\u0026ndash;28. Available from: https://pubmed.ncbi.nlm.nih.gov/20194320/\u003c/li\u003e\n \u003cli\u003eBj\u0026oslash;rgul K, Reiker\u0026aring;s O. Hemiarthroplasty in worst cases is better than internal fixation in best cases of displaced femoral neck fractures: a prospective study of 683 patients treated with hemiarthroplasty or internal fixation. Acta Orthop [Internet]. 2006 Jun 1 [cited 2024 May 20];77(3):368\u0026ndash;74. Available from: https://pubmed.ncbi.nlm.nih.gov/16819673/\u003c/li\u003e\n \u003cli\u003eNielsen LL, Smidt NS, Erichsen JL, Palm H, Viberg B. Posterior tilt in nondisplaced femoral neck fractures increases the risk of reoperations after osteosynthesis. A systematic review and meta-analysis. Injury [Internet]. 2020 Dec 1 [cited 2024 May 20];51(12):2771\u0026ndash;8. Available from: https://pubmed.ncbi.nlm.nih.gov/32980140/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Fragility fracture, femoral neck fracture, non-displaced hip fracture, hip arthroplasty, cannulated screws. ","lastPublishedDoi":"10.21203/rs.3.rs-4555193/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4555193/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNon-displaced femoral neck fractures (FNF) are common in elderly patients, but the best treatment approach is still uncertain. The decision should be based on several factors, including fracture angulation and comminution, to ensure the best possible clinical and functional outcomes in the mid-to long-term. In this study, we report on the treatment of non-displaced FNF in elderly patients using a personalized protocol with either internal fixation or arthroplasty. Our objectives were to evaluate the clinical and functional outcomes of both treatment options and to compare the results between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of a prospectively collected cohort of patients treated from 2010 to 2022 with a geriatric non-displaced femoral neck fracture. Patients were treated with internal fixation if no significant angulation, cortical gap, comminution, or significant osteoarthritis was observed. In case any of the later was present, a joint replacement was selected. Primary outcomes recorded were complications, reoperations, and mortality.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOne hundred and nineteen patients were included. 75% were female. Nintynine patients were treated with internal fixation, while eighteen had a partial or total hip replacement. Two patients did not undergo surgery because of their general condition. \u0026nbsp;Patients were followed for a median of 4 years.\u003c/p\u003e\n\u003cp\u003eSevere complications were observed in 5% of cases, while reoperations were performed in 4%. 30-day mortality and one-year mortality were 1% and 6%, respectively. There were no significant differences in reoperations, complications, or mortality between the internal fixation group and the arthroplasty group.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eSurgical management of non-displaced femoral neck fractures with internal fixation or arthroplasty is both safe and effective as long as a strict protocol is followed, and careful analysis of radiographic features is performed.\u003c/p\u003e","manuscriptTitle":"What is the prognosis for non-displaced femoral neck fractures treated with a strict protocol? Analysis of a prospective cohort treated with internal fixation versus arthroplasty.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:40:35","doi":"10.21203/rs.3.rs-4555193/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d390480d-0f1c-4e33-8108-a070f9570f3c","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-22T06:38:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:40:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4555193","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4555193","identity":"rs-4555193","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}