JOT - 2026-07-02 - Journal Article
An analysis of risk factors for failure after operative treatment of displaced femoral neck fractures in patients 18-60 years of age.
Roddy E, Rockov Z, Firoozabadi R
Topics
Key Takeaway
In patients aged 18–60 with displaced femoral neck fractures treated operatively, overall failure rate was 30%, with cannulated screws carrying 3.7× higher odds of nonunion/fixation failure versus fixed-angle implants.
Summary Depth
Choose how much analysis to show on this article page.
Summary
This single-center retrospective cohort examined risk factors for failure (nonunion/fixation failure, AVN, malunion) after operative fixation of displaced femoral neck fractures in patients aged 18–60. Nonunion/fixation failure occurred in 13%, AVN in 19%, and malunion in 5%, for an overall failure rate of 30%. On multivariable analysis, cannulated screws versus fixed-angle implants (OR 3.7), increased initial displacement (OR 7.1), and good versus excellent reduction (OR 5.6) independently predicted nonunion, while medial fracture exit <1 cm from the cranial edge of the lesser trochanter was protective against AVN (OR 0.13).
Key Limitation
Retrospective design at a single institution over 19 years introduces significant variability in surgical technique, implant selection, and reduction quality assessment without a standardized protocol.
Original Abstract
OBJECTIVES
To identify risk factors for failure after operative treatment of displaced femoral neck fractures in patients 60 years of age and younger.
METHODS
Design: Retrospective cohort study.
SETTING
Single level 1 academic trauma center.
PATIENT SELECTION CRITERIA
All patients ages 18-60 years who underwent operative fixation of a displaced femoral neck fracture (AO/OTA 31B) between 2005 and 2024 were eligible for inclusion. Patients who were lost to follow-up prior to 6 months, or who had clear indications for hemiarthroplasty but underwent fixation due to medical and or social circumstances, were excluded.
OUTCOME MEASURES AND COMPARISONS
The primary outcome was treatment failure, defined as femoral neck nonunion/fixation failure, development of avascular necrosis (AVN), and/or malunion (shortening ≥ 15mm or varus angulation). Patient, injury, and treatment factors were examined as risk factors for failure.
RESULTS
Two hundred and twenty-three patients were included. The average age was 39 years (SD 12, range 18-60) and 78% were male. The rates of nonunion/fixation failure, AVN, and malunion were 13%, 19%, and 5%, respectively. The overall failure rate was 30%. In multivariable analysis, increased initial fracture displacement (OR 7.1, 95% CI 1.5-33.5, p=0.013), treatment with cannulated screws versus a fixed angle implant (OR 3.7, 95% CI 1.4-10.0, p=0.009), and good (rather than excellent) reduction (OR 5.6, 95% CI 2.0-15.7, p=0.001) were independently associated with nonunion/fixation failure. In multivariable analysis, medial fracture exit <1cm from the cranial edge of the lesser trochanter was associated with a decreased risk of AVN (OR 0.13, 95% CI 0.03-0.64, p=0.011), while increasing age (OR 1.07, 95% CI 1.01-1.15, p=0.036) and low energy mechanism (OR 9.5, 95% CI 2.4-38.6, p=0.002) were associated with increased risk of malunion. In univariable analysis, treatment with a static vs dynamic implant was not associated with risk of AVN, nonunion/fixation failure, or malunion (p>0.05 for all).
CONCLUSIONS
In patients aged 18-60 with displaced femoral neck fractures treated with operative fixation, the overall failure rate (including AVN, nonunion, and malunion) was 30%. Medial fracture exit < 1cm from the cranial edge of the lesser trochanter was protective against the development of AVN. Increased initial fracture displacement, treatment with non-fixed angle implants, and achieving only good (rather than excellent) reduction were independently associated with increased risk of nonunion.
LEVEL OF EVIDENCE
III.