Predictors of early failure of the cannulated screw system in patients, 65 years and older, with non-displaced femoral neck fractures

  • Carlo BizEmail author
  • Jacopo Tagliapietra
  • Filippo Zonta
  • Elisa Belluzzi
  • Nicola Luigi Bragazzi
  • Pietro Ruggieri
Original Article



Hip fractures represent the most common injury and the main cause of morbidity and mortality among patients 65 years and older. About 20% of all femoral neck fractures (FNFs) are non-displaced or valgus impacted, for which internal fixation with the cannulated screws system (CSS) is indicated.


The aim of this study was to identify predictors of early failure of CSS.


Patients with non-displaced FNFs (Garden type I and II) treated operatively using the CSS were enrolled. Their characteristics, Pauwels angle, and posterior tilt were assessed and related with outcomes. The primary outcome was fixation failure within 6 months.


259 patients were included with a mean age of 81.44 years. Most patients were female with ASA 3. The majority of fractures were classified as Garden I and Pauwels I. On average, Pauwels angle was 27°, while posterior tilt was 12°. A linear correlation between Pauwels angle and posterior tilt was found; the failure rate was 9.7%. Using the adjusted Cox competing risk regression analysis, posterior tilt was found to be independently associated with failure rate (sub-distribution hazard ratio or SHR 1.14 [95% CI 1.05–1.24], p = 0.0020). A posterior tilt greater than 18° resulted predictive of failure. The 1-year mortality rate was 12%.


Non-displaced Garden type II fractures, Pauwels type II or III fractures, and a posterior tilt greater than 18° represent radiographic predictors of CSS early failure in the elderly.

Level of evidence

Level IV, retrospective cohort study.


Elderly patients Non-displaced femoral neck fractures Internal fixation Cannulated screws 



This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Singer BR, McLauchlan GJ, Robinson CM et al (1998) Epidemiology of fractures in 15,000 adults: the influence of age and gender. J Bone Joint Surg Br 80:243–248CrossRefGoogle Scholar
  2. 2.
    Chevalley T, Guilley E, Herrmann FR et al (2007) Incidence of hip fracture over a 10-year period (1991–2000): reversal of a secular trend. Bone 40:1284–1289CrossRefGoogle Scholar
  3. 3.
    Ju DG, Rajaee SS, Mirocha J et al (2017) Nationwide analysis of femoral neck fractures in elderly patients: a receding tide. J Bone Joint Surg Am 99:1932–1940CrossRefGoogle Scholar
  4. 4.
    Piirtola M, Vahlberg T, Isoaho R et al (2007) Incidence of fractures and changes over time among the aged in a Finnish municipality: a population-based 12-year follow-up. Aging Clin Exp Res 19:269–276CrossRefGoogle Scholar
  5. 5.
    Katsoulis M, Benetou V, Karapetyan T et al (2017) Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project. J Intern Med 281:300–310CrossRefGoogle Scholar
  6. 6.
    Biz C, Berizzi A, Crimi A et al (2017) Management and treatment of femoral neck stress fractures in recreational runners: a report of four cases and review of the literature. Acta Biomed 88:96–106PubMedPubMedCentralGoogle Scholar
  7. 7.
    Florschutz AV, Langford JR, Haidukewych GJ et al (2015) Femoral neck fractures: current management. J Orthop Trauma 29:121–129CrossRefGoogle Scholar
  8. 8.
    Conn KS, Parker MJ (2004) Undisplaced intracapsular hip fractures: results of internal fixation in 375 patients. Clin Orthop Relat Res 421:249–254CrossRefGoogle Scholar
  9. 9.
    Gjertsen J-E, Fevang JM, Matre K et al (2011) Clinical outcome after undisplaced femoral neck fractures. Acta Orthop 82:268–274CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Lin JC-F, Liang W-M (2015) Outcomes after fixation for undisplaced femoral neck fracture compared to hemiarthroplasty for displaced femoral neck fracture among the elderly. BMC Musculoskelet Disord 16:199CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Lu Q, Tang G, Zhao X et al (2017) Hemiarthroplasty versus internal fixation in super-aged patients with undisplaced femoral neck fractures: a 5-year follow-up of randomized controlled trial. Arch Orthop Trauma Surg 137:27–35CrossRefGoogle Scholar
  12. 12.
    Palm H, Gosvig K, Krasheninnikoff M et al (2009) A new measurement for posterior tilt predicts reoperation in undisplaced femoral neck fractures. Acta Orthop 80:303–307CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Rogmark C, Flensburg L, Fredin H (2009) Undisplaced femoral neck fractures—no problems? A consecutive study of 224 patients treated with internal fixation. Injury 40:274–276CrossRefGoogle Scholar
  14. 14.
    Phillips JE, Christie J (1988) Undisplaced fracture of the neck of the femur: results of treatment of 100 patients treated by single Watson-Jones nail fixation. Injury 19:93–96CrossRefGoogle Scholar
  15. 15.
    Xu DF, Bi FG, Ma CY et al (2017) A systematic review of undisplaced femoral neck fracture treatments for patients over 65 years of age, with a focus on union rates and avascular necrosis. J Orthop Surg Res 12:28CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Do LND, Kruke TM, Foss OA et al (2016) Reoperations and mortality in 383 patients operated with parallel screws for Garden I-II femoral neck fractures with up to ten years follow-up. Injury 47:2739–2742CrossRefGoogle Scholar
  17. 17.
    Clement ND, Green K, Murray N et al (2013) Undisplaced intracapsular hip fractures in the elderly: predicting fixation failure and mortality. A prospective study of 162 patients. J Orthop Sci 18:578–585CrossRefGoogle Scholar
  18. 18.
    Schep NWL, Heintjes RJ, Martens EP et al (2004) Retrospective analysis of factors influencing the operative result after percutaneous osteosynthesis of intracapsular femoral neck fractures. Injury 35:1003–1009CrossRefGoogle Scholar
  19. 19.
    Dolatowski FC, Adampour M, Frihagen F et al (2016) Preoperative posterior tilt of at least 20° increased the risk of fixation failure in Garden-I and -II femoral neck fractures. Acta Orthop 87:252–256CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    SJöholm P, Otten V, Wolf O et al (2019) Posterior and anterior tilt increases the risk of failure after internal fixation of Garden I and II femoral neck fracture. Acta Orthop 3:1–8Google Scholar
  21. 21.
    Lapidus LJ, Charalampidis A, Rundgren J et al (2013) Internal fixation of garden I and II femoral neck fractures: posterior tilt did not influence the reoperation rate in 382 consecutive hips followed for a minimum of 5 years. J Orthop Trauma 27:386–390CrossRefGoogle Scholar
  22. 22.
    Garden RS (1971) Malreduction and avascular necrosis in subcapital fractures of the femur. J Bone Joint Surg Br 53-B:183–197CrossRefGoogle Scholar
  23. 23.
    Padulo J, Oliva F, Frizziero A et al (2016) Muscles, ligaments and tendons journal—basic principles and recommendations in clinical and field science research: 2016 update. Muscles Ligaments Tendons J 6:1–5PubMedPubMedCentralGoogle Scholar
  24. 24.
    Klestil T, Röder C, Stotter C et al (2018) Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Sci Rep 8:13933CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Italian Ministry of Health. Percentuale interventi per frattura del femore effettuati entro due giorni, p 7. Accessed 27 Sept 2019
  26. 26.
    Bout CA, Cannegieter DM, Juttmann JW (1997) Percutaneous cannulated screw fixation of femoral neck fractures: the three point principle. Injury 28:135–139CrossRefGoogle Scholar
  27. 27.
    Hackett NJ, De Oliveira GS, Jain UK et al (2015) ASA class is a reliable independent predictor of medical complications and mortality following surgery. Int J Surg (London, England) 18:184–190CrossRefGoogle Scholar
  28. 28.
    Garden RS (1961) Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br 43-B:647–663CrossRefGoogle Scholar
  29. 29.
    Der schenkelhalsbruch: Ein mechanisches Problem. By Dr. Friedrich Pauwels (Aachen). Royal 8vo. Pp. 157, with 186 illustrations. 1935. Stuttgart: Ferdinand Enke. Paper covers, RM. 13.60; bound, RM. 15.00 (1936). BJS 23:874–874Google Scholar
  30. 30.
    Gardner S, Weaver MJ, Jerabek S et al (2015) Predictors of early failure in young patients with displaced femoral neck fractures. J Orthop 12:75–80CrossRefGoogle Scholar
  31. 31.
    Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet (London, England) 359:1761–1767CrossRefGoogle Scholar
  32. 32.
    Friedman SM, Mendelson DA (2014) Epidemiology of fragility fractures. Clin Geriatr Med 30:175–181CrossRefGoogle Scholar
  33. 33.
    Doyle DJ, Garmon EH (2019) American Society of Anesthesiologists Classification (ASA Class). In. StatPearls Publishing LLC., Treasure IslandGoogle Scholar
  34. 34.
    Bartonicek J (2001) Pauwels’ classification of femoral neck fractures: correct interpretation of the original. J Orthop Trauma 15:358–360CrossRefGoogle Scholar
  35. 35.
    Cha YH, Yoo JI, Hwang SY et al (2019) Biomechanical evaluation of internal fixation of Pauwels Type III femoral neck fractures: a systematic review of various fixation methods. Clin Orthop Surg 11:1–14CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Liporace F, Gaines R, Collinge C et al (2008) Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg Am 90:1654–1659CrossRefGoogle Scholar
  37. 37.
    Ye Y, Chen K, Tian K et al (2017) Medial buttress plate augmentation of cannulated screw fixation in vertically unstable femoral neck fractures: surgical technique and preliminary results. Injury 48:2189–2193CrossRefGoogle Scholar
  38. 38.
    Hoelsbrekken SE, Dolatowski FC (2017) The influence of the hips position on measurements of posterior tilt in a valgus-impacted femoral neck fracture. Injury 48:2184–2188CrossRefGoogle Scholar
  39. 39.
    Parker MJ, White A, Boyle A (2008) Fixation versus hemiarthroplasty for undisplaced intracapsular hip fractures. Injury 39:791–795CrossRefGoogle Scholar
  40. 40.
    Hui AC, Anderson GH, Choudhry R et al (1994) Internal fixation or hemiarthroplasty for undisplaced fractures of the femoral neck in octogenarians. J Bone Joint Surg Br 76:891–894CrossRefGoogle Scholar
  41. 41.
    Sikand M, Wenn R, Moran CG (2004) Mortality following surgery for undisplaced intracapsular hip fractures. Injury 35:1015–1019CrossRefGoogle Scholar
  42. 42.
    Stewart NA, Chantrey J, Blankley SJ et al (2011) Predictors of 5 year survival following hip fracture. Injury 42:1253–1256CrossRefGoogle Scholar
  43. 43.
    Iskrant AP (2010) The classic: the etiology of fractured hips in females. 1968. Clin Orthop Relat Res 468:1731–1735CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Barnes R, Brown JT, Garden RS et al (1976) Subcapital fractures of the femur. A prospective review. J Bone Joint Surg Br 58:2–24CrossRefGoogle Scholar
  45. 45.
    Min BW, Kim SJ (2011) Avascular necrosis of the femoral head after osteosynthesis of femoral neck fracture. Orthopedics 34:349PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Orthopaedic, Traumatological and Oncological Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOGUniversity of PadovaPaduaItaly
  2. 2.Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology DiSCOGUniversity of PadovaPaduaItaly
  3. 3.Department of Mathematics and Statistics, Laboratory for Industrial and Applied Mathematics (LIAM)York UniversityTorontoCanada

Personalised recommendations