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Objective To investigate the biomechanical effects of reduction quality on patients after femoral neck fracture internal fixation. Methods The data of individual patients with femoral neck fractures were reviewed. Data for patients with simple unilateral femoral neck fractures whose reduction quality was evaluated as good by hip X‐ray films after internal fixation were collected from January 2013 to January 2017. The CT data of the patients was used to reconstruct 3D models of the femur and the screw. The spatial displacement after the operation of femoral neck fracture was measured, which included the displacement of the deepest portion of the femoral head fovea, the displacement of the center of the femoral head, and the rotational angle. The cases were followed up by telephone consultation and clinical review to determine whether the osteonecrosis of the femoral head occurred. Follow‐up time should be more than 18 months after surgery. The cases were grouped according to the results into an osteonecrosis of the femoral head group and a non‐osteonecrosis of the femoral head group. Finally, the differences in postoperative spatial displacement between the two groups were compared and analyzed. In addition, a mechanical analysis of femoral force during gait was performed via finite element analysis. Results Data for 241 patients with femoral neck fractures who were treated with closed reduction and internal fixation were collected. 3D measurement showed the average displacement value, including the center of the femoral head (5.90 ± 3.4 mm), the deepest portion of the femoral head fovea (9.32 ± 4.8 mm), and the rotational angle (16.1° ± 9.4°). After telephone consultation and clinical review, osteonecrosis of the femoral head was diagnosed in 28 (11.62%) of the patients. In the osteonecrosis of the femoral head (ONFH) group, the displacement of the deepest portion of the femoral head fovea was 10.92 ± 9.18 mm; the displacement was 8.86 ± 6.29 mm in the non‐ONFH group. The displacement of the center of the femoral head in the ONFH group was 7.575 ± 5.69 mm and 5.31 ± 4.05 mm in non‐ONFH group. The rotational angle was 20.11° ± 10.27° in the ONFH group and 14.19° ± 11.09° in the non‐ONFH group. The statistical analysis showed that the postoperative spatial displacements, including the displacement of the deepest portion of the femoral head fovea, the displacement of the center of the femoral head, and the rotational angle between the two groups, had statistical differences. Finite element analysis showed that as the spatial displacement increased, the stress, the displacement, and the equivalent strain of the proximal femur also increased. Conclusion Poor reduction quality after femoral neck fracture is a risk factor for re‐fracture and femoral head necrosis, and the measurement method of this study can be used to predict the occurrence of femoral head necrosis early after femoral neck fracture.

Background Displaced femoral neck fractures usually are treated with hemiarthroplasty. However, the degree to which the design of the implant used (cemented or uncemented) affects the outcome is not known and may be therapeutically important. Questions/purposes In this randomized controlled trial, we sought to compare cemented with cementless fixation in bipolar hemiarthroplasties at 5 years in terms of (1) Harris hip scores; (2) femoral fractures; (3) overall health outcomes using the Barthel Index and EQ-5D scores; and (4) complications, reoperations, and mortality since our earlier report on this cohort at 1-year followup. Methods We present followup at a median of 5 years after surgery (range, 56–65 months) from a randomized trial comparing a cemented hemiarthroplasty (112 hips) with an uncemented, hydroxyapatite-coated hemiarthroplasty (108 hips), both with a bipolar head. Results were previously reported at 1-year followup. Harris hip scores, Barthel Index, and EQ-5D scores were assessed by one research nurse and one orthopaedic surgeon. Complications and reoperations were determined by chart review and radiographs examined by three orthopaedic surgeons. Sixty patients (56%) had died in the cemented group and 63 (60%) in the uncemented group. Respectively, three and two patients (2.7% and 1.9%) were completely lost to followup. Results Harris hip scores at 5 years were higher in the uncemented group than in the cemented group (86.2 versus 76.3; mean difference 9.9; 95% confidence interval [CI], 1.9–17.9). The prevalence of postoperative periprosthetic femoral fractures was 7.4% in the uncemented group and 0.9% in the cemented group (hazard ratio [HR], 9.3; 95% CI, 1.16–74.5). Barthel Index and EQ-5D scores were not different between the groups. Between 1 and 5 years, we found no additional infections or dislocations. The mortality rate was not different between the groups (HR, 1.2; 95% CI, 0.82–1.7). Conclusions Both arthroplasties may be used with good medium-term results after displaced femoral neck fractures. The uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures. Level of Evidence Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Objective To investigate the efficacies of Femoral Neck System (FNS) and the three cannulated screws fixation (3CS) as therapeutic options for femoral neck fractures. Method This was a retrospective study involving 69 patients (26 males and 43 females; mean age of 54.9 years (range, 28–66 years)) subjected to either FNS or 3CS for femoral neck fracture therapy. These patients were treated in our hospital from October 2019 to May 2020. Patient follow up was done at 1, 2, 3 and 6 months. During the short‐term (6 months) follow‐up period, surgical procedures for the two groups and incidences of complications were analyzed. Perioperative parameters were recorded and analyzed. Postoperative hip joint functions were measured and compared using the Harris score. The assessed perioperative parameters included surgical time, hemoglobin loss, fluoroscopy duration, hospitalization length and hospitalization cost. The main complications at last follow‐up (6 months) included varus tilting, femoral neck shortness, and implant removal. Results Differences in the number of patients, age, Garden type of fracture and time from injury to surgery between the two groups were not significant (P > 0.05). With regards to perioperative parameters, compared to 3CS, FNS treatment performed better in surgical time (60.00 ± 12.44 vs 76.81 ± 13.10 min, P = 0.000), blood loss (13.67 ± 8.02 vs 16.58 ± 4.16 g/L, P = 0.059) and fluoroscopy time (39.73 ± 9.57 vs 58.14 ± 9.15 s, P = 0.000). Differences in hospitalization length and cost between the groups were not significant (P > 0.05). During the whole follow‐up period, all patients did not exhibit dysfunction, pulmonary embolism or even death as a result of long‐term immobilization of affected limbs. Surgical incisions for all patients healed well without infections. During the 6‐month follow‐up period, the FNS group exhibited a higher Harris score (84.61 ± 3.42 vs 78.67 ± 3.72, p = 0.000). In addition, treatment‐associated complications (FNS vs 3CS) included femoral neck varus tilt (3.03% vs 11.11%), femoral neck shortness (6.06% vs 13.89%), and implant removal (0% vs. 13.89%). Implant removal rate for the FNS group was significantly less than that of the 3CS group (P = 0.026). Differences in incidences of femoral neck varus tilt (P = 0.196) and femoral neck shortness (P = 0.282) between the two groups were not significant. However, the difference in number was significant (FNS group was less). Conclusion FNS treatment is associated with a smaller surgical trauma, stronger stability, and reductions in post‐operative complication incidences, therefore, it is a potential therapeutic option for femoral neck fractures. The Femoral Neck System (FNS) as a new surgical option has been used to treat femoral neck fractures. Its advantages include anti‐rotation, angular stability, dynamic fixation and minimally invasive surgical procedures.

Objective To investigate the efficacy of using pre-sliding technique to prevent postoperative shortening of displaced femoral neck fracture fixed with femoral neck system (FNS). Methods Retrospective analysis of 110 cases of displaced femoral neck fracture treated with femoral neck system from September 2019 to November 2022 in our center, which were divided into 56 cases in the pre-sliding group and 54 cases in the traditional group. The baseline data such as gender, age, side, mechanism of injury, fracture type, operation time, intraoperative bleeding were recorded and compared between the two groups, and the quality of fracture reduction, shortening distance, Tip Apex Distance (TAD), union time, Harris score of the hip were also compared between the two groups. Results The TAD value of the pre-sliding group was smaller than that of the traditional group, and the difference was statistically significant ( P  < 0.001). The shortening distance in both groups on postoperative day 1 was smaller in the pre-sliding group than in the traditional group, but the difference was not statistically significant ( P  = 0.07), and the shortening distance was smaller than in the traditional group at 1, 3, 6, and 12 months postoperatively, and the difference was statistically significant (all P  < 0.001). Of the 110 cases, 34 (30.9%) had moderate or severe shortening, of which 24 (44.4%) were in the traditional group and 10 (17.9%) in the pre-sliding group, and the difference was statistically significant ( P  < 0.001), and the Harris score at 1 year, which was higher in the pre-sliding group than in the traditional group, and the difference between the two groups was statistically significant ( P  < 0.001). There was no statistically significant difference in the comparison of baseline data such as gender, age, side, mechanism of injury, fracture type, operation time, intraoperative bleeding, and quality of reduction between the two groups (all P  > 0.05), and no statistically significant difference in fracture healing time between the two groups ( P  = 0.113). Conclusion The use of the pre-sliding technique of displaced femoral neck fracture fixed with FNS reduces the incidence of moderate and severe shortening, improves the postoperative TAD value, and improves the hip function scores, with a satisfactory midterm efficacy.

Objective This study aimed to compare the biomechanical performance of the femoral neck system (FNS) and four cannulated screws (FCS) on treating young patients with Pauwels type III femoral neck fractures. Methods The model of a young Pauwels type III femoral neck fracture with 70° inclination, FNS, and FCS were established, and the fixations were set up. Under an axial load of 2100 N, the finite element anaysis was performed, and the shear force distribution, von Mises stress (VMS), and displacement of each group of models were recorded to analyze the biomechanical effects. Results The FNS group exhibited localized shear stress, with a peak value of 181.96 MPa, whereas the FCS group displayed a more dispersed shear stress distribution. In the FCS group, the maximum shear stress values were 71.21 MPa, 66.65 MPa, 59.22 MPa, and 84.23 MPa for the upper anterior parallel, upper posterior parallel, transverse, and lower parallel screws, respectively. The maximum shear stress observed in the femur were 113.98 MPa in the FNS group and 89.39 MPa in the FCS group. VMS in the FNS group was predominantly concentrated at the plate-screw junction, reaching a peak of 326.24 MPa, whereas in the FCS group, it was primarily localized near the fracture site in the mid-screw region, with a maximum value of 166.77 MPa. In the femur, VMS was concentrated at the stress application site on the femoral head, with peak values of 197.54 MPa and 154.85 MPa in the FNS and FCS groups, respectively. The greatest displacement of the internal fixators was observed at the screw heads and the two upper parallel screws, measuring 3.36 mm in the FNS group and 3.28 mm in the FCS group. The maximum displacement of the femur occurred at the stress application site on the femoral head, measuring 3.41 mm and 3.33 mm in the FNS and FCS groups, respectively. Conclusion Comparative finite element analysis demonstrates superior biomechanical stability of FCS over FNS, indicating its greater suitability for managing young Pauwels type III femoral neck fractures. Clinical trial number Not applicable.

Background The femoral neck system (FNS) may be a valid alternative for treating femoral neck fractures, but few studies have compared the outcomes between FNS and cannulated cancellous screws. This study aimed to compare the clinical efficacy and complications of FNS with those of inverted cannulated cancellous screws (ICCS) for the treatment of femoral neck fractures in adults. Methods This retrospective study evaluated patients with femoral neck fractures who underwent FNS or ICCS internal fixation between June 2019 and January 2020. The operative time, intraoperative blood loss, number of fluoroscopies, length of surgical incision, length of hospital stay, time to fracture healing, and other indicators were compared between the two groups. The incidence of complications such as nonunion, avascular necrosis of the femoral head, loosening of the internal fixation, and shortening of the femoral neck during follow-up was also assessed in both groups. Results Among the 92 patients included, 47 and 45 patients were categorized into the FNS and ICCS groups, respectively. Follow-up ranged from 14 to 24 months. There were no significant between-group differences in sex, age, side of the injured limb, and type of fracture and in operative time, intraoperative blood loss, incision length, and length of hospital stay (all P > 0.05). The incidence of complications such as fracture nonunion, avascular necrosis of the femoral head, and screw loosening was also comparable between the two groups. However, the number of fluoroscopies was significantly lower in the FNS group than in the ICCS group ( P < 0.05). The fracture healing time was also significantly lower in the FNS group than in the ICCS group ( P < 0.05). Furthermore, the femoral neck shortening and Harris hip score at the last follow-up were significantly better in the FNS group than in the ICCS group ( P < 0.05). Conclusions FNS for femoral neck fractures improves hip functional recovery and reduces the femoral neck shortening rate and fluoroscopy exposure postoperatively. Thus, FNS can be an alternative to ICCS for the treatment of femoral neck fractures.

Background A better understanding of the blood supply of the femoral head is essential to guide therapeutic strategies for patients with femoral neck fractures. However, because of the limitations of conventional techniques, the precise distribution and characteristics of intraosseous arteries of the femoral head are not well displayed. Questions/purposes To explore the characteristics and interconnections of the intraosseous vessel system between different areas of the femoral head and the possible blood supply compensatory mechanism after femoral neck fracture. Methods The three-dimensional (3-D) structures of the intraosseous blood supply in 30 uninjured normal human femoral heads were reconstructed using angiography methods and microCT scans. The data were imported in the AMIRA ® and MIMICS ® software programs to reconstruct and quantify the extra- and intraosseous arteries (diameter, length). In a separate experiment, we evaluated the residual blood supply of femoral heads in 27 patients with femoral neck fractures before surgery by analyzing digital subtraction angiography data; during the study period, this was performed on all patients in whom hip-preserving surgery was planned, rather than arthroplasty. The number of affected and unaffected subjects included in the three groups (superior, inferior, and anterior retinacular arteries) with different types of fractures (Garden Types I–IV) were recorded and analyzed (Fisher’s exact test) to reflect the affected degrees of these three groups of retinacular arteries in patients after femoral neck fractures. Results The main results of our cadaver study were: (1) the main blood supply sources of the femoral head were connected by three main network structures as a whole, and the epiphyseal arterial network is the most widely distributed and the primary network structure in the femoral head; (2) the main stems of the epiphyseal arteries which were located on the periphery of the intraosseous vascular system have fewer anastomoses than the network located in the central region; (3) compared with the round ligament artery and anterior retinacular artery, the inferior retinacular artery has a relatively large caliber. Digital subtraction angiography of the 27 patients with hip fractures indicated that the inferior retinacular arterial system had a high likelihood of being unaffected after femoral neck fracture (100% [14 of 14] in nondisplaced fractures and 60% [six of 10] in Garden Type III fractures). Conclusions The epiphyseal arterial network and inferior retinacular arterial system appear to be two important structures for maintaining the femoral head blood supply after femoral neck fracture. Increased efforts to protect these key structures during surgery, such as drilling and placing internal implants closer to the central region of the femoral head, might be helpful to reduce the effect of iatrogenic injury of the intraosseous vascular system. Clinical Relevance 3-D anatomic evidence of intraosseous arterial distribution of the femoral head and the high frequency with which the inferior retinacular arteries remained patent after femoral neck fracture lead us to consider the necessity of drilling and placing internal implants closer to the central region of the femoral head during surgery. Future controlled studies might evaluate this proposition.

Background Femoral neck fractures in patients with pituitary dwarfism present significant surgical challenges due to anatomical variations, compromised bone quality, and limited therapeutic options. The management of such cases requires careful consideration of both the anatomical constraints of and the potential complications associated with various fixation methods. Case presentation This report presents the case of a 30-year-old female with congenital pituitary dwarfism who sustained a subcapital femoral neck fracture following trauma. After suffering a workplace injury due to a fall, the patient experienced left hip pain, limited mobility, and difficulty walking. The patient presented with characteristic features of dwarfism, including diminutive stature (1.2 m), multiple skeletal abnormalities, and significant osteoporosis. X-ray and hierarchical phase-contrast tomography examinations of the left hip joint revealed a displaced subcapital femoral neck fracture with compromised bone quality and a notably narrow medullary cavity. Surgical treatment was subsequently performed on the patient. After the onset of combined spinal-epidural anesthesia, the patient was placed on a traction bed and closed reduction was attempted three times, all unsuccessfully. The direct anterior approach in the supine position was then chosen for open reduction of the left subcapital femoral neck fracture. After surgery, pain relief and treatment to prevent venous thrombosis were provided. A postoperative digital radiography examination of the left hip showed good alignment of the fracture fragments. Two weeks post-surgery, the stitches were removed and the patient was discharged. Conclusions This study aimed to fill the gap in the literature on the selection of internal fixation methods for femoral neck fractures in patients with pituitary dwarfism. Compared with the widespread use of three cannulated screws, the femoral neck system (FNS), a type of internal fixation device for treating femoral neck fractures, was chosen for internal fixation within the medullary cavity due to stenosis. This method avoided the need for multiple drillings with guide pins to ensure internal fixation. Although the procedure prolonged the surgery, it provided better stability and compression capability at the fracture site. The outcome showed that the FNS was a better choice for patients with a similar condition.

Background Although it is generally believed that the femoral neck fracture is related to the femoral neck geometric parameters (FNGPs), the association between the risk of osteoporotic fracture of the femoral neck and FNGPs in native Chinese women is still unclear. Methods A total of 374 female patients (mean age 70.2 ± 9.32 years) with osteoporotic fracture of the femoral neck, and 374 non-fracture control groups were completely matched with the case group according to the age ratio of 1:1. Using DXA bone densitometer to measured eight FNGPs: the outer diameter (OD), cross-sectional area (CSA), cortical thickness (CT), endocortical diameter (ED), buckling ratio (BR), section modulus (SM), cross-sectional moment of inertia (CSMI), and compressive strength index (CSI) at the narrowest point of the femoral neck. Results Compared with the control group, the average values of OD (2.9%), ED (4.5%), and BR (26.1%) in the patient group significantly increased ( p  = 0.015 to < 0.001), while CSA (‒15.3%), CT (‒18.2%), SM (‒10.3%), CSMI (‒6.4%), and CSI (‒10.8%) significantly decreased (all p  < 0.001). The prevalence of osteoporosis in the lumbar spine, femoral neck, and total hip was, respectively, 82%, 81%, and 65% in fracture patients. Cox proportional hazard model analysis showed that in the age adjusted model, the fracture hazard ratio (HR) of CSA, CT, BR, SM, and CSI significantly increased (HRs = 1.60‒8.33; 95% CI = 1.08‒16.6; all p  < 0.001). In the model adjusted for age and femoral neck BMD, HRs of CT (HRs = 3.90‒8.03; 95% CI = 2.45‒15.1; all p  < 0.001) and BR (HRs = 1.62‒2.60; 95% CI = 1.20‒5.44; all p  < 0.001) were still significantly increased. Conclusion These results suggest that the majority of osteoporotic fractures of the femoral neck of native Chinese women occur in patients with osteoporosis. CT thinning or BR increase of FNGPs may be independent predictors of fragility fracture of femoral neck in native Chinese women unrelated to BMD.

Patients who were 50 years of age or older and had a displaced femoral neck fracture were randomly assigned to total hip arthroplasty or hemiarthroplasty. Total hip arthroplasty did not differ significantly from hemiarthroplasty with regard to the incidence of secondary procedures and led to clinically unimportant improvement over hemiarthroplasty in function over 24 months.