Cochran’s database assessment for choice of implant for internal fixation for femur neck fracture
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Cochrane Database Assessment: Choice of Implant for Internal Fixation of Femoral Neck Fractures
The Primary Cochrane Reference
The landmark systematic review specifically addressing implant choice for internal fixation of femoral neck (intracapsular) fractures is:
Parker MJ & Stockton G. Internal fixation implants for intracapsular proximal femoral fractures in adults. Cochrane Database of Systematic Reviews 2001; Issue 4: CD001467. (DOI: 10.1002/14651858.CD001467)
This was preceded by their influential meta-analysis of 25 RCTs (4,925 patients) published in Acta Orthopaedica Scandinavica (1998): "Choice of implant for internal fixation of femoral neck fractures."
Key Conclusions from the Cochrane/Parker Assessment
1. Screws vs. Pins
Screws are superior to pins. Analysis of multiple trials showed screws yielded better outcomes in terms of fixation failure and revision rates. Pins have largely been abandoned.
2. Cannulated Cancellous Screws (CCS) - The Standard
Three parallel partially-threaded cannulated screws in an inverted triangle configuration remain the most widely supported construct for intracapsular femoral neck fractures, particularly for:
- Non-displaced fractures (Garden I and II) in elderly patients
- Displaced fractures in young patients with good bone quality
Key technical points from Campbell's Operative Orthopaedics (15th Ed, 2026):
- Three screws in inverted triangle; four screws in diamond configuration for comminuted patterns
- Inferocentral screw should be within 4 mm of the calcar
- Starting point should NOT be below the lesser trochanter (risk of peri-implant subtrochanteric fracture)
- Varus malreduction is strongly correlated with fixation failure
3. Optimal Number of Screws
The Cochrane analysis found it was not possible to determine the optimal number or specific type of screws. More recent evidence (StatPearls) suggests no significant outcome difference between 3 and 4 screws, though 3-screw inverted triangle is preferred over 2 screws.
4. Sliding Hip Screw (SHS) vs. Cannulated Screws
This is the most clinically debated comparison within internal fixation:
| Parameter | Sliding Hip Screw (SHS) | Cannulated Cancellous Screws |
|---|---|---|
| Indication | Basicervical, vertical (Pauwels III), unstable fractures | Subcapital, transcervical, stable fractures |
| Angular stability | Greater (fixed-angle device) | Less |
| Biological footprint | Larger (requires lateral plate) | Smaller (percutaneous) |
| Blood loss (intraop) | More (110 mL more; p = 0.00002) | Less |
| AVN risk | May be higher than CCS | Possibly lower |
| Nonunion, reoperation, function | No significant difference | No significant difference |
Cochrane conclusion (Parker 2001, confirmed by Shehata et al. 2019 meta-analysis of 10 RCTs / 1,934 patients [PMID 31165917]): No superiority of one device over the other for most outcomes. SHS causes more intraoperative blood loss. The choice is largely fracture-pattern dependent.
- Rockwood & Green's Fractures in Adults (10th Ed, 2025): "The decision on whether to use a sliding hip screw or three cannulated screws is controversial. Usually in isolated femoral neck fractures, lag screws are used for subcapital and transcervical fractures, whereas a sliding hip screw is more commonly used for basicervical fractures."
- Miller's Review of Orthopaedics (9th Ed): "SHS may have a higher AVN risk than cannulated screws."
5. No Advantage for Implants with a Side-Plate (for typical intracapsular fractures)
The original Parker & Blundell 1998 meta-analysis explicitly concluded: "No advantage was shown for an implant with a side-plate" for standard subcapital/transcervical fractures.
6. Fixed-Angle Devices (e.g., Femoral Neck System - FNS)
Newer fixed-angle devices are gaining traction. A 2023 meta-analysis (Jiang et al., BMC Musculoskelet Disord, PMID 37055749; 8 studies, 448 patients) compared the Femoral Neck System (FNS) vs. cannulated screws:
| Outcome | Favors FNS |
|---|---|
| Femoral neck shortening | FNS (WMD = -2.01 mm; p < 0.001) |
| Fracture healing time | FNS (WMD = -1.54 months; p < 0.001) |
| AVN (femoral head necrosis) | FNS (OR = 0.27; p = 0.02) |
| Implant failure/cutout | FNS (OR = 0.28; p = 0.02) |
| Harris Hip Score | FNS (+4.15 points; p = 0.01) |
| X-ray exposures | FNS (fewer; p < 0.001) |
Caveat: High heterogeneity (I² up to 92% for some outcomes); larger multicenter RCTs needed.
7. Predictors of Fixation Failure (Kalsbeek et al. 2023, Injury, PMID 36437167)
This systematic review of 16 studies identified significant risk factors:
- Female sex (OR 1.78)
- Smoking (OR 3.64)
- Age > 50 years (OR 3.64)
- Inadequate fracture reduction (OR 2.28) - most modifiable factor
- Cannulated screws or pins vs. fixed-angle devices (OR 2.16) - suggests fixed-angle devices may reduce failure
Summary: Implant Hierarchy by Evidence
| Situation | Preferred Implant | Evidence Level |
|---|---|---|
| Non-displaced (Garden I/II), elderly | 3 cannulated screws (inverted triangle) | Cochrane level |
| Displaced (Garden III/IV), young patient | 3 cannulated screws OR SHS (fracture-pattern dependent) | RCT level |
| Basicervical / Pauwels III (vertical) | SHS or fixed-angle device (blade plate/FNS) | RCT/biomechanical |
| Any intracapsular fracture - implant with side-plate? | No advantage shown | Cochrane meta-analysis |
| Screws vs. pins | Screws superior | Cochrane |
| FNS vs. CCS (emerging evidence) | FNS may be superior | Meta-analysis 2023 (limited quality) |
Current Trend (2026)
The AAOS guidelines recommend arthroplasty over fixation for unstable (displaced) femoral neck fractures (Strong recommendation). For internal fixation when chosen, no single implant has definitively superior evidence over another - the choice remains fracture-pattern, patient, and surgeon-dependent. Novel implants (FNS, biplane double-supported screws) have theoretical advantages but await large RCT confirmation.
Note on nondisplaced fractures: A 2023 meta-analysis (Sattari et al., J Orthop Trauma, PMID 36575572; 3 RCTs, 400 patients) found that hemiarthroplasty was superior to internal fixation even for nondisplaced (Garden I/II) fractures in elderly patients: lower 6-month HHS, lower reoperation rate (20.1% IF vs. 6.0% HA), though HA carried more blood loss. This challenges the traditional preference for internal fixation in non-displaced fractures.
Key references:
- Parker MJ, Stockton G. Cochrane Database Syst Rev 2001;(4):CD001467
- Parker MJ, Blundell C. Acta Orthop Scand 1998;69(2):138-143 (25 RCTs, 4,925 patients)
- Shehata MSA et al. Eur J Orthop Surg Traumatol 2019 [PMID 31165917] (SHS vs. CCS meta-analysis)
- Jiang J et al. BMC Musculoskelet Disord 2023 [PMID 37055749] (FNS vs. CCS)
- Kalsbeek JH et al. Injury 2023 [PMID 36437167] (risk factors for fixation failure)
- Sattari SA et al. J Orthop Trauma 2023 [PMID 36575572] (IF vs. HA for non-displaced)
- Campbell's Operative Orthopaedics 15th Ed 2026; Rockwood & Green's Fractures in Adults 10th Ed 2025; Miller's Review of Orthopaedics 9th Ed
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Latest Cochrane & High-Level Evidence (2024-2026): Implant Choice for Internal Fixation of Femoral Neck Fractures
Status of the Cochrane Review (CD001467) - Critical Update
The original Cochrane review (Parker MJ & Stockton G, CD001467) has NOT been updated since 2011. Its last search was performed in 2011 with no change in conclusions. The Cochrane Library history confirms:
- 2001: Original publication
- 2003: Amended
- 2008: Converted to new format
- 2011: Last updated (added 2 new studies; conclusions unchanged)
- 2024-2025: No new update published
However, a successor Cochrane review now covers this topic for older adults:
The Active Cochrane Review (2021) - CD013409
Lewis SR, Macey R, Eardley WGP, et al. Internal fixation implants for intracapsular hip fractures in older adults. Cochrane Database Syst Rev 2021; Issue 3: CD013409.pub2 [PMID 33687067]
This is the current authoritative Cochrane evidence. It included 38 studies (32 RCTs + 6 quasi-RCTs), 8,585 participants, and evaluated 4 major comparisons:
Comparison 1: Smooth Pins vs. Fixed-Angle Plate (4 studies, 1,313 participants)
- Very low-certainty evidence of little or no difference in independent mobility, early mortality, 12-month mortality, and unplanned return to theatre
- Smooth pins are largely obsolete; screws have superseded them
Comparison 2: Screws vs. Fixed-Angle Plates (11 studies, 2,471 participants)
- Low-certainty evidence of no clinically important difference in functional status (WOMAC) or HRQoL (EQ-5D)
- Little or no difference in 12-month mortality
- Key GRADE note: Evidence quality was low to very low due to risk of bias, imprecision, and inconsistency
- Conclusion: No proven superiority of screws over fixed-angle plates or vice versa
Comparison 3: Screws vs. Screws (different types) (multiple studies)
- Fully-threaded vs. partially-threaded cannulated screws - inconclusive at time of 2021 review; see updated evidence below
Comparison 4: Pins vs. Screws
- Screws appear superior to pins (consistent with Parker 1998/2001 findings)
Overall Cochrane 2021 Conclusion: "We are uncertain about whether any implant provides better outcomes than another, primarily because the evidence is of low to very low certainty. The clinical significance of differences is unclear."
New High-Level Evidence (2024-2026): What Has Changed?
The most significant updates are in the FNS (Femoral Neck System) vs. traditional implants comparison and the fully-threaded vs. partially-threaded screw debate.
1. Fully-Threaded vs. Partially-Threaded Cannulated Screws
Jia M, Ding C, Zhao X et al. J Orthop Surg Res 2024 [PMID 39695853]
- Meta-analysis; literature up to April 2024; Cochrane Library searched
- Fully-threaded cannulated screws (FCS) superior to partially-threaded (PCS):
| Outcome | Result | Significance |
|---|---|---|
| Femoral head necrosis | OR 0.60 (95% CI 0.37-0.98) | p = 0.04, FCS better |
| Internal fixation failure | OR 0.37 (95% CI 0.22-0.62) | p = 0.0002, FCS better |
| Femoral neck shortening | OR 0.27 (95% CI 0.19-0.40) | p < 0.00001, FCS better |
| Harris Hip Score | No difference | NS |
| Nonunion rate | No difference | NS |
Clinical implication: Fully-threaded screws may be preferable to partially-threaded screws for preventing femoral neck shortening and hardware failure - a significant new finding that was unresolved in the 2021 Cochrane review.
2. FNS vs. Cannulated Screws - Pauwels Type III Specifically
Zhuang K et al. J Back Musculoskelet Rehabil 2025 [PMID 39970468]
- 9 studies, 524 patients; Cochrane Library searched; literature to July 2024
| Outcome | FNS vs. CS |
|---|---|
| Total complications | OR 0.21 (p < 0.001) - FNS better |
| Harris Hip Score | MD +2.89 (p < 0.001) - FNS better |
| Femoral head necrosis | OR 0.38 (p = 0.02) - FNS better |
| Fixation failure | OR 0.17 (p = 0.001) - FNS better |
| Femoral neck shortening | OR 0.30 (p < 0.001) - FNS better |
| Intraoperative blood loss | MD +19.19 mL - FNS more blood loss |
| Operative time | Shorter with FNS (MD -8.69 min) |
| Healing time | Shorter with FNS (MD -0.81 months) |
3. FNS vs. DHS (Dynamic Hip Screw) - 2025 Meta-Analysis
Lim EJ, Shon HC, Yang JY et al. Medicine (Baltimore) 2025 [PMID 41366897]
- 8 studies, 726 patients; Cochrane Library searched to December 2024
| Outcome | Result |
|---|---|
| Operative time | FNS shorter (MD -19.68 min; p < 0.001) |
| Intraoperative blood loss | FNS less (MD -16.89 mL; p < 0.001) |
| Harris Hip Score | FNS better (MD -1.40; p = 0.02) |
| Femoral neck shortening | No significant difference |
| Nonunion | No significant difference |
| Osteonecrosis | No significant difference |
Conclusion: FNS is a viable alternative to DHS with shorter operative time and less blood loss.
4. Three-Way Network Meta-Analysis: FNS vs. DHS vs. CCS (2026 - Most Current)
Liu M, Mao L, Zhao C et al. Front Med (Lausanne) 2026 [PMID 41846886]
- 23 studies, 55,910 patients - the largest network analysis to date
- Literature to March 2025; Cochrane Library searched
| Comparison | Harris Hip Score | Femoral Head Necrosis | Blood Loss |
|---|---|---|---|
| FNS vs. CCS | FNS better (MD 3.79; 95% CI 1.44-6.13) | FNS & CCS both lower than DHS | CCS less blood loss |
| FNS vs. DHS | FNS better | Both better than DHS | FNS less than DHS |
| Fracture healing | FNS shortest (-1.00 months vs. CCS) | - | - |
Critical nuance from the 2026 NMA: "The Harris Hip Score improvement with FNS over CCS did not reach the minimal clinically important difference (MCID), suggesting limited clinical meaningfulness despite statistical significance."
5. Screw Configuration: Rhombic (Diamond/4-Screw) vs. Inverted Triangle (3-Screw)
Rajnish RK et al. J Clin Orthop Trauma 2024 [PMID 39040625] - (erratum published)
- 7 studies; Cochrane Library searched
| Outcome | Rhombic (4-screw) | Inverted Triangle (3-screw) |
|---|---|---|
| Nonunion | Lower (OR 0.46; p = 0.03) | Higher |
| Early full weight bearing | Earlier (MD -3.09 days; p = 0.009) | Later |
| Better hip function (HHS) | - | Better (MD 3.72; p = 0.008) |
| Intraoperative blood loss | More | Less |
Interpretation: 4-screw rhombic may reduce nonunion; 3-screw inverted triangle causes less blood loss and may give better functional scores.
6. Network Meta-Analysis - 4 Devices in Young Adults
Yuan D et al. Medicine (Baltimore) 2024 [PMID 39533559]
- 34 studies, 2,291 young adult patients; Bayesian framework NMA
| Device | Best at... | SUCRA ranking |
|---|---|---|
| Medial Buttress Plate (MBP) | Harris Hip Score, fewest complications, fastest healing | 0.84-0.93 |
| FNS | Shortest operative time, least femoral neck shortening | 0.77-0.79 |
| Inverted-triangle CCS | Least intraoperative blood loss | 0.87 |
| DHS | Comparable but generally inferior | Lower |
Conclusion: For young adults, MBP augmentation may provide the best overall outcomes; FNS is best for minimizing neck shortening.
7. Medial Buttress Plate (MBP) - Emerging Evidence
McGarry L et al. Injury 2025 [PMID 39827529]
- 21 studies, 642 patients; Pauwels II and III fractures specifically
- MBP augmentation outcomes:
- Non-union rate: 6%
- AVN rate: 4%
- Overall failure rate: 17.3%
- Mean HHS: 89.5 at final follow-up
- MCS + MBP: failure rate 14.6% vs. DHS + MBP: 26.8% (NS)
- Medial/anteromedial positioning yields best results
- No studies yet examined FNS + MBP combination
Summary: 2024-2026 Evidence Update at a Glance
| Question | 2021 Cochrane Answer | 2024-2026 Update |
|---|---|---|
| Cochrane CD001467 updated? | Last updated 2011 | No update |
| Best Cochrane review (current) | Lewis 2021 (CD013409) | No 2024-2025 update |
| Screws vs. fixed-angle plates | No proven difference (low certainty) | FNS (fixed-angle) may be marginally better; MCID not reached |
| Fully vs. partially threaded screws | Inconclusive | Fully-threaded screws superior for AVN, failure, shortening |
| FNS vs. CCS | Emerging, not in 2021 Cochrane | FNS consistently better in meta-analyses (especially Pauwels III) |
| FNS vs. DHS | Not evaluated | FNS: shorter time, less blood loss, better function |
| Best implant for young adults | Unclear | MBP (by NMA SUCRA ranking) |
| 4-screw vs. 3-screw configuration | Not addressed | 4-screw: less nonunion; 3-screw: less blood loss, possibly better function |
Bottom Line for Clinical Practice (2026)
-
No new Cochrane review has been published in 2024-2025 specifically on implant choice for femoral neck fracture internal fixation. The relevant Cochrane reviews remain CD001467 (last updated 2011) and CD013409 (Lewis 2021, still the current version).
-
The FNS is emerging as a superior implant in multiple recent meta-analyses vs. CCS for Pauwels III and displaced fractures - but the Harris Hip Score benefit does not consistently exceed the MCID, and most included studies are retrospective. Large multicenter RCTs (e.g., NCT04462172, PROSPERO CRD420251014243) are ongoing.
-
Fully-threaded cannulated screws appear superior to partially-threaded screws - a clinically actionable finding from the 2024 meta-analysis.
-
Medial Buttress Plate augmentation is gaining traction for high-angle (Pauwels II-III) fractures in young adults and may represent the next evolution in fixation technique.
-
The fundamental Cochrane conclusion remains: no single implant has proven definitive superiority with high-certainty evidence - patient selection, fracture pattern, and Pauwels classification continue to guide implant choice.
Key references:
- Lewis SR et al. Cochrane Database Syst Rev 2021 [PMID 33687067] - Current Cochrane review
- Liu M et al. Front Med (Lausanne) 2026 [PMID 41846886] - 3-way NMA, 55,910 patients
- Yuan D et al. Medicine 2024 [PMID 39533559] - 4-device NMA, young adults
- Jia M et al. J Orthop Surg Res 2024 [PMID 39695853] - Fully vs. partially threaded screws
- Zhuang K et al. J Back Musculoskelet Rehabil 2025 [PMID 39970468] - FNS vs. CS, Pauwels III
- Lim EJ et al. Medicine 2025 [PMID 41366897] - FNS vs. DHS
- McGarry L et al. Injury 2025 [PMID 39827529] - Medial buttress plate review
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