Objectives:To evaluate the biomechanical performance of femoral neck system (FNS) in comparison with established methods for fixation of femoral neck fractures in a cadaveric model.Methods:Twenty pairs of fresh-frozen human cadaveric femora were instrumented either with dynamic hip screw and antirot

Biomechanical Evaluation of the Femoral Neck System in Unstable Pauwels III Femoral Neck Fractures: A Comparison with the Dynamic Hip Screw and Cannulated Screws.

Femoral neck fractures typically occur as a result of high-energy mechanisms among non-geriatric patients. Complications, including femoral neck shortening, non-union, and avascular necrosis, are relatively common after the internal fixation of this fracture pattern. These complications have serious effects on young patients. The Pauwels classification, which is the first biomechanical classification for femoral neck fractures, is still frequently used to determine and prescribe the appropriate treatment for femoral neck fractures. However, we lack a unified standard for measuring the Pauwels angle, which may make the classification unreliable. Understanding the relationship between the Pauwels classification and the complications arising from the internal fixation of femoral neck fractures is necessary. Meanwhile, a Pauwels type III femoral neck fracture among young adults, which involves a high shear load at the fracture site, is difficult to treat successfully. In addition, the recognized internal fixation for this fracture pattern remains uncertain. This review aims to provide an update on the viewpoint on the Pauwels classification including the measurement of the Pauwels angle and to present evidence to prove the aforementioned relationship. Moreover, this article also discusses the optimal internal fixation for femoral neck fractures based on the Pauwels classification. A unified standard of measurement should be established for the Pauwels classification, which is still frequently used in the literature and in determining appropriate treatment for femoral neck fractures, to achieve a credible classification. In addition, more randomized, multicentric, and prospective trials should be conducted in the future to clearly understand the relationship between the Pauwels classification and complications arising from the internal fixation of femoral neck fractures and, consequently, to explore ideal fixations for a Pauwels type III femoral neck fracture.

/pdf/an-update-on-the-pauwels-classification-589e6laymp.pdf

An update on the Pauwels classification

Introduction Young femoral neck fracture patients require surgical fixation to preserve the native hip joint and accommodate increased functional demands. Recent reports have identified a high incidence of fracture shortening and this may have negative functional consequences. We sought to determine if fracture shortening is associated with poor functional outcome in young femoral neck fracture patients. Patients and methods One hundred and forty-two patients with femoral neck fractures age 18–55 were recruited in this prospective cohort study across three Level 1 trauma hospitals in Mainland China. Patient-reported and objective functional outcomes were measured with the Harris Hip Score (HHS), Timed Up and Go (TUG), and SF-36 Physical Component Summary (SF-36 PCS) at 12 months. Radiographic fracture shortening was measured along the long axis of the femoral neck and corrected for magnification. Severe shortening was defined as ≥10 mm. The primary analysis measured associations between severe radiographic shortening and HHS at one-year post-fixation. Results One hundred and two patients had complete radiographic and functional outcomes available for analysis at one year. The mean age of participants was 43.7 ± 10.8 years and 53% were male. Fifty-five percent of fractures were displaced and 37% were vertically orientated (Pauwels Type 3). The mean functional outcome scores were: HHS 90.0 ± 10.8, TUG 12.0 ± 5.1 s, and PCS 48.5 ± 8.6. Severe shortening occurred in 13% of patients and was associated with worse functional outcome scores: HHS mean difference 9.9 (p = 0.025), TUG mean difference 3.2 s (p = 0.082), and PCS mean difference 5.4 (p = 0.055). Conclusions Severe shortening is associated with clinically important decreases in functional outcome as measured by HHS following fixation of young femoral neck fractures, occurring in 13% of patients in this population. The principle of fracture site compression utilized by modern constructs may promote healing; however, excessive shortening is associated with worse patient-reported outcomes and objective functional measures.

Femoral neck shortening in adult patients under the age of 55 years is associated with worse functional outcomes: Analysis of the prospective multi-center study of hip fracture outcomes in China (SHOC)

Background and purpose — Most often, the goal of non-geriatric femoral neck fracture surgery is to preserve the native hip joint. However, reoperations for painful implants, osteonecrosis, and nonu...

https://tandfonline.com/doi/pdf/10.1080/17453674.2018.1558380

High rate of reoperation and conversion to total hip arthroplasty after internal fixation of young femoral neck fractures: a population-based study of 796 patients.

Objectives: To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure. Design: Large multicenter retrospective cohort series. Setting: Twenty-six North American Level 1 trauma centers. Patients: Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017. Intervention: Operative repair of FNF. Main outcome measurements: The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure. Results: Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction [odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41–13.31], chronic alcohol misuse (OR = 3.08, 95% CI = 1.59–6.38), comminution (OR = 2.63, 95% CI = 1.69–4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30–2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17–2.67), and increasing age (OR = 1.03, 95% CI = 1.01–1.06). Women (OR = 0.57, 95% CI = 0.37–0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41–0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10–0.33) had lower odds of failure. Conclusions: FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. 

Treatment Failure in Femoral Neck Fractures in Adults Less Than 50 Years of Age: Analysis of 492 Patients Repaired at 26 North American Trauma Centers

OBJECTIVES: To describe the incidence and magnitude of femoral neck fracture shortening in patients age younger than 60 years. Secondarily, to examine predictors of fracture shortening.
DESIGN: Retrospective chart review.
SETTING: Level I trauma centre.
PATIENTS/PARTICIPANTS: Sixty-five patients with a median age of 51 years (interquartile range: 42-56 years) were included. Seventy-one percent were male, 75% were displaced fractures, and 78% were treated with cancellous screws.
INTERVENTION: Internal fixation with multiple cancellous screws or sliding hip screw (SHS) + derotation screw.
MAIN OUTCOME MEASUREMENTS: Radiographic femoral neck shortening at a minimum of 6 weeks after fixation.
RESULTS: Fifty-four percent of patients had ≥5 mm of femoral neck shortening (22% had between ≥5 and <10 mm and 32% ≥10 mm). Initially, displaced fractures shortened more than undisplaced fractures (mean: 8.1 vs. 2.2 mm, P < 0.001), and fractures treated with SHS + derotation screw shortened more than fractures with cancellous screws alone (10.7 vs. 5.5 mm, P = 0.03). Even when adjusting for initial fracture displacement, fractures treated with SHS + derotation screw shortened an average of 2.2 mm more than fractures treated with screws alone (P = 0.03).
CONCLUSIONS: The incidence of clinically significant shortening in our young femoral neck fracture population was higher than anticipated, and 32% of patients experienced severe shortening of >1 cm. Our findings highlight the need for further research to determine the impact of severe shortening on functional outcome and to determine if implant selection affects fracture shortening.
LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

https://www.zora.uzh.ch/id/eprint/118260/1/00005131-201509000-00011.pdf

Incidence, Magnitude, and Predictors of Shortening in Young Femoral Neck Fractures.

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Incidence, Magnitude, and Predictors of Shortening in Young Femoral Neck Fractures.