Details all types internal fixation of the displaced neck of femur fracture with advantage and disadvantage
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I now have comprehensive information from Campbell's Operative Orthopaedics. Let me now compose a thorough, well-structured answer.
Internal Fixation of Displaced Femoral Neck Fractures
Displaced femoral neck fractures (Garden III and IV) are intracapsular injuries that compromise the tenuous blood supply to the femoral head via the retinacular arteries. In younger patients (<65 years, physiologically active), internal fixation is preferred to preserve the native femoral head. In the elderly (physiologically older), arthroplasty is now strongly recommended by the AAOS. The discussion below focuses on internal fixation options specifically.
1. Cannulated Cancellous Screws (CCS)
The most widely used method. Typically 3 screws (6.5, 7.0, or 7.3 mm, partially threaded) placed in an inverted triangle configuration - one inferiorly along the calcar (calcar screw) and two superiorly - providing rotational stability, compression, and load distribution.
Technique: Closed reduction on fracture table -> fluoroscopic confirmation -> percutaneous placement of 3 parallel screws. Open reduction (Smith-Petersen or Watson-Jones approach) is used if closed reduction is inadequate.
| Advantages | Disadvantages |
|---|---|
| Minimally invasive, percutaneous technique | High nonunion rate in displaced fractures (20-30%) |
| Preserves periosteal blood supply | Significant femoral neck shortening - >1 cm in 42% of Garden I and 63% of Garden II fractures |
| Technically simple | Rotational instability if not placed correctly |
| Low implant cost | Cannot support vertical shear (Pauwels III) fractures adequately |
| Allows controlled dynamic compression | No fixed-angle stability |
| Early mobilization possible | Higher nonunion rate than fixed-angle devices (though not statistically significant in FAITH trial) |
| Short operative time | Risk of screw back-out and loss of fixation in osteoporotic bone |
Key pearl: Three screws in an inverted triangle with the inferior screw along the calcar is biomechanically superior to parallel horizontal configuration.
2. Screw-Side Plate Device (Dynamic Hip Screw / Sliding Hip Screw)
A large-diameter lag screw (typically 135 degrees) inserted into the femoral head, coupled with a side plate fixed to the lateral femoral cortex. The screw can telescope (slide) within the barrel, allowing dynamic controlled collapse.
Variants: Standard DHS; DHS + derotational screw (supplemental anti-rotation cannulated screw above the main lag screw).
| Advantages | Disadvantages |
|---|---|
| Excellent rotational and axial stability | More invasive than percutaneous screws |
| Dynamic controlled collapse promotes union | Higher rate of AVN reported (9% vs. 5% for cannulated screws in FAITH trial) |
| Biomechanically superior for basicervical fractures | Large implant - more bone destruction |
| FAITH trial subgroup: potential benefit in displaced fractures, basicervical fractures, and smokers | Requires a tap in non-osteoporotic bone |
| DHS + derotational screw biomechanically stronger than 3 CCS in unstable basicervical fractures | Not ideal without supplemental derotational screw (which was not used in FAITH protocol) |
| Lower reoperation rate than CCS in some retrospective studies | Risk of cut-out in osteoporotic bone |
FAITH Trial: No statistically significant difference in reoperation between CCS and screw-side plate for low-energy femoral neck fractures overall, but subgroup analysis favoured screw-side plate in displaced and basicervical fractures.
3. Fixed-Angle Proximal Femoral Locking Plate (PFLP)
Angle-stable plate systems (e.g., Targon FN, CONQUEST FN) with multiple locking screws directed into the femoral head, providing fixed-angle stability without relying on dynamic collapse.
| Advantages | Disadvantages |
|---|---|
| Superior biomechanical stability in Pauwels type III (vertical shear) fractures vs. CCS and DHS | Clinical results have been disappointing overall |
| Fixed-angle construct resists shear forces | High incidence of catastrophic failure reported (cut-out, plate breakage) |
| Multiple diverging locking screws distribute load | More extensive surgical exposure required |
| Useful when significant femoral neck comminution is present | Does not allow controlled shortening - leads to stress concentration |
| Targon locking plate allows some controlled shortening - improved design | Femoral neck shortening linked to pain and decreased mobility in >500 patient study |
| High cost |
Clinical reality: Reserved for fractures with significant posterior femoral neck comminution or when other implants are inappropriate. Not a routine first-line choice.
4. Femoral Neck System (FNS)
A newer, single implant (Synthes) combining a lag bolt into the femoral head with a small anti-rotation pin and a short lateral plate. It is a dynamic angle-stable construct - a hybrid between a DHS and a locking plate.
| Advantages | Disadvantages |
|---|---|
| Biomechanical stability similar to DHS, superior to multiple CCS | Newer device - less long-term data |
| Lower reported rates of AVN compared with CCS | Limited availability in all centers |
| Reduced femoral neck shortening vs. CCS | Technical learning curve |
| Decreased fluoroscopy use (shorter operative time) | Early failure reported in some series (associated with technical errors) |
| Improved functional outcomes vs. CCS in emerging data | |
| Less implant bulk than PFLP | |
| Single implant - less hardware in femoral head |
5. Fully Threaded Screws (Length-Stable Fixation)
A modification of cannulated screw technique: partially threaded screws are used initially for compression, then exchanged for fully threaded screws one by one to lock length and prevent shortening.
| Advantages | Disadvantages |
|---|---|
| Prevents femoral neck shortening (mean shortening ~1.7 mm vs. >10 mm with partial threads) | Technically demanding |
| Union rate up to 94% in selected series (Boraiah et al., 54 patients) | Requires anatomic reduction first - if reduction is poor, non-union risk is high |
| Preserves abductor lever arm and functional outcome | Larger series currently lacking |
| Compatible with open reduction techniques | At least one study reported high complication rates |
6. Medial Buttress Plate (Supplemental)
A small-fragment plate applied to the medial femoral neck/calcar region, used as an adjunct to screws or FNS in high-energy displaced fractures in young adults with comminution of the medial cortex.
| Advantages | Disadvantages |
|---|---|
| Lower failure rates vs. screws alone in comminuted fractures | Requires open approach with wider dissection |
| Directly supports the medial cortex where compressive forces are greatest | Risk of injury to medial femoral circumflex artery |
| Evidence: Collinge et al. showed lower failure rates in young adults with high-energy displaced fractures | Additional implant and complexity |
| Useful for Pauwels III fractures | Not routinely needed in low-energy fractures |
7. Cephalomedullary Nail (Reconstruction Nail)
An intramedullary nail with proximal locking screws directed into the femoral head and neck. Primarily used for ipsilateral femoral neck + shaft fractures, but also considered in some isolated femoral neck fractures.
| Advantages | Disadvantages |
|---|---|
| Load-sharing device (intramedullary - biomechanically favourable) | Technically demanding nail insertion |
| Ideal for ipsilateral femoral neck + shaft fractures | High rates of complication in isolated displaced neck fractures |
| Minimal soft tissue dissection | Less controlled compression across neck fracture |
| Not ideal for isolated subcapital/transcervical fractures |
Summary Table
| Device | Best Indication | Key Risk |
|---|---|---|
| Cannulated screws (3) | Most displaced NOF in young patients; subcapital | Nonunion, shortening |
| DHS ± derotational screw | Basicervical, displaced, smokers | AVN (slightly higher) |
| Femoral Neck System (FNS) | Displaced fractures; good bone stock | Early failure if technical error |
| Proximal femoral locking plate | Comminuted neck fractures | Catastrophic plate failure |
| Fully threaded screws | When length preservation is priority | Technically demanding |
| Medial buttress plate | Comminuted, Pauwels III, young high-energy | Wider dissection; vascular risk |
| Cephalomedullary nail | Ipsilateral neck + shaft fracture | Technical complexity |
Clinical Context - When to Choose Internal Fixation
- Young patient (<65 years, physiologically active): Internal fixation is the default strategy to preserve the femoral head, regardless of displacement.
- Elderly displaced fracture (Garden III/IV): AAOS strong recommendation for arthroplasty - hemiarthroplasty or THA depending on activity level. Internal fixation in the elderly for displaced fractures is associated with 20% implant-related complication rates vs. 6% for arthroplasty.
- Reduction quality is the single most important predictor of success with any internal fixation device. Anatomic or near-anatomic reduction must be achieved before implant insertion.
Recent evidence (2024-2025):
- A network meta-analysis (PMID 39533559) comparing four fixation devices in young adults found no single device definitively superior - all have comparable reoperation rates when reduction quality is controlled.
- A meta-analysis on fully threaded vs. partially threaded screws (PMID 39695853) supports fully threaded screws for minimizing shortening.
- A 2025 meta-analysis (PMID 40369314) suggests combined pedicled bone grafting with internal fixation may improve outcomes in Garden III/IV fractures in young patients.
Source: Campbell's Operative Orthopaedics, 15th Ed. 2026, Chapter 60 (Femoral Neck Fractures), pp. 3434-3447
Systematic review of internal fixation of displaced neck of femur fracture
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FAITH trial femoral neck fracture fixation hip fractures
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"femoral neck fracture" AND "avascular necrosis" AND "internal fixation" AND risk
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PMID: 31165917
I now have comprehensive data from 14+ high-quality systematic reviews and RCTs. Here is the full synthesized review:
Systematic Review: Internal Fixation of Displaced Femoral Neck Fractures
Overview of Evidence Base
This review synthesizes findings from 14 systematic reviews/meta-analyses and 1 landmark RCT (FAITH trial, n=1,108), covering over 15,000 patients. The evidence spans implant comparisons, screw configuration, reduction method, fixation failure risk factors, and patient-specific factors.
SECTION 1 - Burden of Disease and Complication Rates
Slobogean et al. 2015 - Meta-Analysis of Young Patients (n=1,558) [PMID: 25480307]
The foundational reference for complication incidence after internal fixation in patients ≤60 years:
| Complication | Overall Rate | Displaced Fractures |
|---|---|---|
| Reoperation | 18.0% | Higher |
| Avascular Necrosis (AVN) | 14.3% | Higher |
| Nonunion | 9.3% | Higher |
| Malunion | 7.1% | - |
| Implant failure | 9.7% | - |
| Surgical site infection | 5.1% | - |
Key finding: Displaced fractures are significantly more likely to result in reoperation, AVN, and nonunion compared to nondisplaced fractures. These complication rates persist even with optimal technique, which is why the choice of implant and reduction quality are so debated.
SECTION 2 - Cannulated Screws (CS) vs. Dynamic Hip Screw (DHS) / Sliding Hip Screw
FAITH Trial 2017 - Landmark RCT (n=1,108, age ≥50) [PMID: 28262269]
The highest-quality direct comparison (Lancet):
- Primary outcome (reoperation at 24 months): Sliding hip screw 20% vs. cannulated screws 22% - no significant difference (HR 0.83, 95% CI 0.63-1.09; p=0.18)
- AVN: Significantly higher with sliding hip screw vs. cancellous screws (9% vs. 5%, HR 1.91, 95% CI 1.06-3.44; p=0.032)
- Subgroup benefits for sliding hip screw: smokers, displaced fractures, basicervical fractures
Conclusion: Neither implant is universally superior for reoperation. The sliding hip screw carries a higher AVN risk but may benefit select subgroups.
Shehata et al. 2019 - Systematic Review + Meta-Analysis (10 RCTs, n=1,934) [PMID: 31165917]
- Blood loss: Significantly more with sliding hip screw (MD = +110 ml; p=0.00002)
- No significant difference in operative time, hip function, nonunion, AVN, reoperation, infection, fracture healing, pain, or mortality
- Cancellous screws preferred for reduced intraoperative blood loss
Xia et al. 2021 - Meta-Analysis [PMID: 33446230]
Consistent with FAITH: sliding hip screws and cannulated screws have comparable outcomes for most endpoints, though sliding hip screw may have a modest advantage in displaced/basicervical subtypes.
SECTION 3 - Network Meta-Analysis: CS vs. DHS vs. Hemiarthroplasty vs. THA
Ramadanov et al. 2023 - Frequentist Network Meta-Analysis (33 RCTs, n=5,703) [PMID: 37626370]
This is the most comprehensive head-to-head comparison of all four operative strategies:
| Outcome | Ranking (Best to Worst) |
|---|---|
| Shortest operation time | CS > DHS > HA > THA |
| Least intraoperative blood loss | CS > DHS > HA > THA |
| Best functional outcome (HHS at 2 years) | THA > HA > CS > DHS |
| Best quality of life (EQ-5D at 2 years) | THA > HA > CS > DHS |
| Lowest reoperation risk | THA > HA > DHS > CS |
Reoperation ORs (vs. THA as reference):
- CS: OR 9.98 (95% CI 4.60-21.63) - highest reoperation risk
- DHS: intermediate
- HA: lower than CS/DHS
Interpretation: CS and DHS are faster and less invasive, but carry substantially higher reoperation risk for displaced fractures in older patients. THA delivers best long-term function but at higher operative cost.
SECTION 4 - Internal Fixation vs. Arthroplasty (for Displaced Fractures in Elderly)
Bhandari et al. 2003 - Meta-Analysis (14 RCTs, n=1,901) [PMID: 12954824]
The seminal meta-analysis on this question:
- Arthroplasty reduces revision surgery risk: relative risk 0.23 (p=0.0003)
- Internal fixation may have lower early mortality risk (trend toward higher early mortality with arthroplasty, especially DHS vs. screws: RR 1.75; p<0.05)
- Arthroplasty increases infection risk (RR 1.81; p=0.009)
- Greater blood loss and longer operative time with arthroplasty
- Pain and function at 1 year were similar (RR 1.12 and 0.99 respectively)
Ye et al. 2016 - Systematic Review + Meta-Analysis (8 RCTs, n=2,206) [PMID: 27779172]
- Arthroplasty: significantly lower complication rate (RR 0.56), reoperation (RR 0.17), revision (RR 0.11), and better function
- No significant difference in mortality, infection, or DVT
- Recommendation: Arthroplasty as primary treatment for displaced intracapsular fractures in elderly; IF reserved for very frail patients unfit for larger surgery
SECTION 5 - Femoral Neck System (FNS) vs. Cannulated Screws
Jiang et al. 2023 - Systematic Review + Meta-Analysis (8 studies, n=448) [PMID: 37055749]
FNS significantly outperformed CS on all key endpoints:
| Outcome | FNS vs. CS | Result |
|---|---|---|
| X-ray exposures | WMD -10.16 (95% CI -11.44 to -8.88) | FNS better |
| Fracture healing time | WMD -1.54 months (95% CI -2.38 to -0.70) | FNS better |
| Femoral neck shortening | WMD -2.01 mm (95% CI -3.11 to -0.91) | FNS better |
| Femoral head necrosis | OR 0.27 (95% CI 0.08-0.83; p=0.02) | FNS better |
| Implant failure/cut-out | OR 0.28 (95% CI 0.10-0.82; p=0.02) | FNS better |
| VAS pain score | WMD -1.27 (95% CI -2.51 to -0.04) | FNS better |
| Harris Hip Score | WMD +4.15 (95% CI 1.00-7.30; p=0.01) | FNS better |
Patel et al. 2023 - Systematic Review + Meta-Analysis (8 studies, n=509, mean age 50.8 yrs) [PMID: 36201031]
- FNS: significantly reduced complications (p<0.001), less neck shortening (p<0.001), faster union (p=0.002), better functional scores (p<0.001)
- Only advantage of CCS: significantly less blood loss (p<0.001)
- Conclusion: FNS is superior to CCS for adult femoral neck fractures
FNS vs. DHS - Jiang et al. 2024 Meta-Analysis (6 studies, n=577) [PMID: 38419236]
- FNS: shorter operation time, less blood loss, lower fixation failure rate, better Harris Hip Score (all p<0.05)
- No significant difference in complication rate or femoral neck shortening
- Both are comparable in complication rates - FNS optimises operative efficiency
SECTION 6 - Fully Threaded vs. Partially Threaded Cannulated Screws
Jia et al. 2024 - Systematic Review + Meta-Analysis [PMID: 39695853]
| Outcome | Fully Threaded (FCS) vs. Partially Threaded (PCS) |
|---|---|
| Femoral head necrosis | OR 0.60 (95% CI 0.37-0.98; p=0.04) - FCS lower |
| Internal fixation failure | OR 0.37 (95% CI 0.22-0.62; p=0.0002) - FCS lower |
| Femoral neck shortening | OR 0.27 (95% CI 0.19-0.40; p<0.00001) - FCS dramatically lower |
| Harris Hip Score | No significant difference |
| Nonunion rate | No significant difference |
Interpretation: Fully threaded screws significantly reduce AVN, hardware failure, and neck shortening - with no sacrifice in union rates or hip function. This challenges the traditional use of partially threaded screws.
SECTION 7 - Screw Configuration: Parallel vs. Non-Parallel (Inverted Triangle)
Jia et al. 2026 - Systematic Review + Meta-Analysis (20 studies, n=1,508) [PMID: 41827005]
Non-parallel (inverted triangle/divergent) configuration is significantly superior across all outcomes:
| Outcome | Non-Parallel vs. Parallel | Effect |
|---|---|---|
| Femoral head necrosis | OR 0.50 (95% CI 0.34-0.74; p=0.0005) | 50% reduction |
| Nonunion | OR 0.41 (95% CI 0.26-0.65; p=0.0001) | 59% reduction |
| Femoral neck shortening | OR 0.40 (95% CI 0.28-0.57; p<0.00001) | 60% reduction |
| Fixation failure | OR 0.34 (95% CI 0.22-0.52; p<0.00001) | 66% reduction |
Clinical implication: The inverted triangle (non-parallel) configuration for cannulated screws is strongly supported over parallel placement. The calcar screw (inferior screw) is the key stability element.
SECTION 8 - Medial Buttress Plate (MBP) as Adjunct
McGarry et al. 2025 - Systematic Review (21 studies, n=642) [PMID: 39827529]
Focus on Pauwels type II/III (high vertical shear) fractures:
- Non-union rate: 6%
- AVN rate: 4%
- Overall failure rate: 17.3%
- Mean time to union: 3.9 ± 1.2 months
- Mean Harris Hip Score: 89.5 ± 5.5 at final follow-up
Fixation comparisons:
- MCS + MBP failure rate: 14.6%
- DHS + MBP failure rate: 26.8% (not statistically significant; p=0.164)
- Medial or anteromedial MBP positioning yields better outcomes; anterior placement is associated with high failure rates
- No studies yet on FNS + MBP
Yuan et al. 2024 - Network Meta-Analysis (34 studies, n=2,291, young adults) [PMID: 39533559]
Comparing CCS, FNS, DHS, and MBP in young adults:
| Outcome | Best Device (SUCRA) |
|---|---|
| Lowest intraoperative bleeding | Inverted triangle CCS (SUCRA 0.87) |
| Best Harris Hip Score | MBP (SUCRA 0.85) |
| Lowest complication rate | MBP (SUCRA 0.93) |
| Fastest fracture healing | MBP (SUCRA 0.81) |
| Shortest operation time | FNS (SUCRA 0.77) |
| Least neck shortening | FNS (SUCRA 0.79) |
Conclusion: MBP achieves the best clinical outcomes in young adults but requires open surgery. FNS minimises shortening and is the most time-efficient.
SECTION 9 - Basicervical Fractures: CMN vs. DHS
Yoon et al. 2022 - Systematic Review + Meta-Analysis (7 studies, n=353) [PMID: 35914756]
Basicervical fractures are biomechanically distinct (extracapsular tendency, high rotational demands):
- Fracture union time: CMN significantly faster (MD -0.41 months; 95% CI -0.70 to -0.12; p=0.006; I²=0%)
- Cut-out rate: No significant difference (OR 0.54; 95% CI 0.10-2.82; p=0.47)
- Reoperation rate: No significant difference (OR 0.65; 95% CI 0.15-2.86; p=0.57)
- Recommendation: Both DHS and CMN are acceptable; CMN achieves faster union; choice based on surgeon preference and associated injuries
SECTION 10 - Predictors of Fixation Failure
Kalsbeek et al. 2023 - Systematic Review + Meta-Analysis (16 studies) [PMID: 36437167]
Identified 24 predictors; 5 confirmed in meta-analysis:
| Risk Factor | Odds Ratio | 95% CI |
|---|---|---|
| Female sex | 1.78 | 1.26-2.52 |
| Smoking | 3.64 | 1.68-7.91 |
| Age >50 years | 3.64 | 1.68-7.91 |
| Inadequate fracture reduction | 2.28 | 1.62-3.22 |
| CS/pins vs. fixed-angle devices | 2.16 | 1.03-4.54 |
Key message: Inadequate reduction is the single most modifiable risk factor. Female sex, smoking, and age >50 each independently predict failure. Fixed-angle devices (DHS, FNS) outperform CS/pins in failure resistance.
SECTION 11 - Open vs. Closed Reduction
Ghayoumi et al. 2015 - Systematic Review (21 studies) [PMID: 25554424]
- Nonunion: CRIF 11.6% vs. ORIF 14.9% (p=0.25) - not significant
- AVN: CRIF 17.2% vs. ORIF 17.7% (p=0.91) - not significant
- Deep infection: CRIF 0.49% vs. ORIF 3.9% (p=0.0019) - significantly lower with closed reduction
- Conclusion: No evidence supporting open over closed reduction for reducing union/AVN; ORIF carries 8x higher infection risk. CRIF preferred when an adequate closed reduction can be achieved.
Synthesis: Key Evidence-Based Conclusions
| Clinical Question | Evidence-Based Answer | Source |
|---|---|---|
| IF vs. arthroplasty in elderly displaced FNF | Arthroplasty superior (lower reoperation, better function) | Ye 2016; Ramadanov 2023 |
| IF vs. arthroplasty in young patients | IF preferred (preserves native femoral head) | - |
| CS vs. DHS overall | No difference in reoperation; DHS higher AVN but benefits displaced/basicervical/smokers | FAITH trial 2017 |
| FNS vs. CS | FNS significantly better (AVN, shortening, union, function) | Jiang 2023; Patel 2023 |
| FNS vs. DHS | FNS better operative efficiency; similar complication rates | Jiang 2024 |
| Parallel vs. non-parallel screws | Non-parallel (inverted triangle) dramatically superior | Jia 2026 |
| Fully vs. partially threaded screws | Fully threaded: less AVN, less failure, less shortening | Jia 2024 |
| MBP in Pauwels II/III | Best outcomes in young adults (lowest complications/best HHS) | Yuan 2024; McGarry 2025 |
| CMN vs. DHS in basicervical | Both acceptable; CMN achieves faster union | Yoon 2022 |
| Open vs. closed reduction | CRIF preferred (no difference in AVN/nonunion; ORIF 8x infection risk) | Ghayoumi 2015 |
| Risk factors for fixation failure | Smoking, age >50, female sex, poor reduction, CS use | Kalsbeek 2023 |
Evidence Grading Summary
| Study | Design | N | Evidence Tier |
|---|---|---|---|
| FAITH trial (Lancet 2017) | Multicentre RCT | 1,108 | Tier 1 RCT |
| Ramadanov 2023 | Network meta-analysis (33 RCTs) | 5,703 | Tier 1 |
| Ye 2016 | Systematic review + MA (8 RCTs) | 2,206 | Tier 1 |
| Shehata 2019 | Systematic review + MA (10 RCTs) | 1,934 | Tier 1 |
| Slobogean 2015 | Meta-analysis (41 studies) | 1,558 | Tier 2 |
| Bhandari 2003 | Meta-analysis (14 RCTs) | 1,901 | Tier 2 |
| Jia 2026 (parallel screws) | Systematic review + MA (20 studies) | 1,508 | Tier 1 |
| Yuan 2024 | Network meta-analysis (34 studies) | 2,291 | Tier 1 |
| Patel/Jiang 2023 (FNS vs. CS) | Systematic review + MA | 448-509 | Tier 1 |
| McGarry 2025 (MBP) | Systematic review | 642 | Tier 1 |
| Kalsbeek 2023 | Systematic review + MA (16 studies) | - | Tier 1 |
| Ghayoumi 2015 | Systematic review (21 studies) | - | Tier 1 |
Bottom line from the evidence: For displaced femoral neck fractures treated with internal fixation, the FNS is emerging as the preferred implant over traditional cannulated screws, with the best balance of reduced AVN, less shortening, faster union, and better function. For high-shear Pauwels III fractures in young adults, medial buttress plate augmentation yields the best reported outcomes. The inverted-triangle (non-parallel) screw configuration and fully-threaded screws should be used when CS is chosen. Reduction quality remains the single most modifiable determinant of success across all implants.
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