Skip to main content
Log in

Undisplaced intracapsular hip fractures in the elderly: predicting fixation failure and mortality. A prospective study of 162 patients

  • Original Article
  • Published:
Journal of Orthopaedic Science



Reported revision of internal fixation for undisplaced intracapsular hip fractures is between 12 and 17 % at 1 year. This risk is greater for elderly patients, for whom mortality after such a fracture is also higher. Our purpose was to identify predictors of fixation failure and mortality for elderly patients sustaining undisplaced intracapsular hip fractures, and to assess whether their socioeconomic status affected their outcome.


During a 3-year period we prospectively compiled a consecutive series of 162 elderly (≥65 years old) patients who underwent internal fixation for an undisplaced (Garden stage I or II) intracapsular hip fracture. Patient demographics, American Society of Anesthesiologists (ASA) grade, and posterior tilt (measured on the lateral radiograph) were recorded pre-operatively. All patients were followed up for a minimum of 1 year. Each patient’s socioeconomic status was assigned by use of the Scottish Index of Multiple Deprivation. Patient mortality was established by use of the General Register Office for Scotland.


There were 28 failures of fixation during the study period. In Cox regression analysis, ASA grade and the presence of posterior tilt (p < 0.0001) were significant independent predictors of fixation failure. Overall unadjusted mortality at 1 year was 19 % (n = 30/162). Cox regression analysis also affirmed ASA grade to be the only significant independent predictor of 1-year mortality (p = 0.003). The standardised mortality rate for the cohort was 2.3 (p < 0.001), and was significantly greater for patients less than 80 years of age (p = 0.004). Socioeconomic status did not affect outcome, but the most deprived patients sustain their fracture at a significantly younger age (p = 0.001).


We have demonstrated that ASA grade and posterior tilt of the femoral neck are independent predictors of fixation failure of undisplaced intracapsular hip fractures in elderly patients, and ASA grade was also an independent predictor of mortality.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others


  1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37:691–7.

    Article  PubMed  Google Scholar 

  2. Holt G, Smith R, Duncan K, Finlayson DF, Gregori A. Early mortality after surgical fixation of hip fractures in the elderly: an analysis of data from the Scottish hip fracture audit. J Bone Joint Surg Br. 2008;90:1357–63.

    PubMed  CAS  Google Scholar 

  3. Kannus P, Niemi S, Parkkari J, Palvanen M, Vuori I, Jarvinen M. Nationwide decline in incidence of hip fracture. J Bone Miner Res. 2006;21:1836–8.

    Article  PubMed  Google Scholar 

  4. Parliament UK. (2011). Accessed 10th Dec 2011.

  5. Holt G, Smith R, Duncan K, Hutchison JD, Gregori A. Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit. J Bone Joint Surg Br. 2008;90:480–3.

    PubMed  CAS  Google Scholar 

  6. Gjertsen JE, Engesaeter LB, Furnes O, Havelin LI, Steindal K, Vinje T, Fevang JM. The Norwegian hip fracture register: experiences after the first 2 years and 15,576 reported operations. Acta Orthop. 2008;79:583–93.

    Article  PubMed  Google Scholar 

  7. Gjertsen JE, Fevang JM, Matre K, Vinje T, Engesaeter LB. Clinical outcome after undisplaced femoral neck fractures. Acta Orthop. 2011;82:268–74.

    Article  PubMed  Google Scholar 

  8. Conn KS, Parker MJ. Undisplaced intracapsular hip fractures: results of internal fixation in 375 patients. Clin Orthop Relat Res. 2004;421:249–54.

    Article  PubMed  Google Scholar 

  9. Lagerby M, Asplund S, Ringqvist I. Cannulated screws for fixation of femoral neck fractures. No difference between Uppsala screws and Richards screws in a randomized prospective study of 268 cases. Acta Orthop Scand. 1998;69:387–91.

    Article  PubMed  CAS  Google Scholar 

  10. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006;88:249–60.

    Article  PubMed  CAS  Google Scholar 

  11. Wiles MD, Moran CG, Sahota O, Moppett IK. Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur. Br J Anaesth. 2011;106:501–4.

    Article  PubMed  CAS  Google Scholar 

  12. Avery PP, Baker RP, Walton MJ, Rooker JC, Squires B, Gargan MF, Bannister GC. Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial. J Bone Joint Surg Br. 2011;93:1045–8.

    Article  PubMed  CAS  Google Scholar 

  13. Stewart NA, Chantrey J, Blankley SJ, Boulton C, Moran CG. Predictors of 5 year survival following hip fracture. Injury. 2011;42:1253–6.

    Article  PubMed  Google Scholar 

  14. Clement ND, Muzammil A, MacDonald D, Howie CR, Biant LC. Socioeconomic status affects the early outcome of total hip replacement. J Bone Joint Surg Br. 2011;93B:464–9.

    Google Scholar 

  15. Quah C, Boulton C, Moran C. The influence of socioeconomic status on the incidence, outcome and mortality of fractures of the hip. J Bone Joint Surg Br. 2011;93:801–5.

    Article  PubMed  CAS  Google Scholar 

  16. Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br. 1961;43:647–63.

    Google Scholar 

  17. General Register Office for Scotland. (2011). Accessed 11th Dec 2011.

  18. The Scottish Government Scottish Index of Multiple Deprivation 2009: General Report. Vol 2010 ed Edinburgh: The Scottish Government; 2009.

  19. Pauwels F. Der Schenkelhalsbruch: Ein mechaniisched problem. Stuttgart: Ferdinand Enke; 1935.

    Google Scholar 

  20. Garden RS. Malreduction and avascular necrosis in sub capital fractures of the femur. J Bone Joint Surg Br. 1971;53:183–97.

    PubMed  CAS  Google Scholar 

  21. Scottish Intercollegiate Guidelines Network. Management of hip fracture in older people SIGN 111. (2010). Accessed 11th Dec 2011).

  22. General Register Office for Scotland. (2011). Accessed 11th Dec 2011.

  23. Cserhati P, Kazar G, Manninger J, Fekete K, Frenyo S. Non-operative or operative treatment for undisplaced femoral neck fractures: a comparative study of 122 non-operative and 125 operatively treated cases. Injury. 1996;27:583–8.

    Article  PubMed  CAS  Google Scholar 

  24. Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur. A prospective review. J Bone Joint Surg Br. 1976;58:2–24.

    PubMed  CAS  Google Scholar 

  25. Chiu FY, Lo WH, Yu CT, Chen TH, Chen CM, Huang CK. Percutaneous pinning in undisplaced subcapital femoral neck fractures. Injury. 1996;27:53–5.

    Article  PubMed  CAS  Google Scholar 

  26. Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br. 2011;93:811–6.

    PubMed  CAS  Google Scholar 

  27. Parker MJ, Palmer CR. Prediction of rehabilitation after hip fracture. Age Ageing. 1995;24:96–8.

    Article  PubMed  CAS  Google Scholar 

  28. Deneka DA, Simonian PT, Stankewich CJ, Eckert D, Chapman JR, Tencer AF. Biomechanical comparison of internal fixation techniques for the treatment of unstable basicervical femoral neck fractures. J Orthop Trauma. 1997;11:337–43.

    Article  PubMed  CAS  Google Scholar 

  29. Kauffman JI, Simon JA, Kummer FJ, Pearlman CJ, Zuckerman JD, Koval KJ. Internal fixation of femoral neck fractures with posterior comminution: a biomechanical study. J Orthop Trauma. 1999;13:155–9.

    Article  PubMed  CAS  Google Scholar 

  30. Kammerlander C, Roth T, Friedman SM, Suhm N, Luger TJ, Kammerlander-Knauer U, Krappinger D, Blauth M. Ortho-geriatric service–a literature review comparing different models. Osteoporos Int. 2010;21:S637–46.

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations


Corresponding author

Correspondence to N. D. Clement.

About this article

Cite this article

Clement, N.D., Green, K., Murray, N. et al. Undisplaced intracapsular hip fractures in the elderly: predicting fixation failure and mortality. A prospective study of 162 patients. J Orthop Sci 18, 578–585 (2013).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: