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Femoral neck system vs conventional fixation: Long-term outcomes from a single-center study
⁎Corresponding author: Grégoire Châtelier. gregoire.chatelier@chu-bordeaux.fr
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
The Femoral Neck System (FNS) is a minimally invasive fixation device for femoral neck fractures, but its comparative long-term performance versus conventional fixation remains debated.
In this single-center retrospective study (Jan 2020–Oct 2022) all patients treated surgically for femoral neck fractures were included. Primary outcomes were operative time, peri-operative bleeding, fixation failure, avascular necrosis, reoperation, mortality, and autonomy using Parker score. A multivariable logistic regression assessed risk of postoperative loss of autonomy. FNS results were compared to a large multicenter series from the literature.
total of 143 patients (mean age 78.7 ± 13.8 years; 58.7 % women) were included and grouped by implant: 31 FNS, 62 triple cannulated screws, 50 dynamic hip screw (DHS). Operative time differed across groups with DHS being the longest. Peri-operative bleeding, fixation failure, infection, and mortality did not differ significantly between groups. In adjusted analysis, each additional year of age increased the risk of postoperative loss of autonomy by 5.1 % independently of the surgical system. Mean follow-up was approximately two years enabling detection of later complications.
FNS provided outcomes broadly comparable to conventional fixation with shorter operative time than DHS. Given the older, more displaced case-mix and longer follow-up, cautious interpretation is warranted. Age emerged as the strongest predictor of functional outcome.
Keywords
Femoral neck fracture
Femoral neck system
Elderly patients
Dynamic hip screw
1 Introduction
Femoral neck fractures are frequent, severe injuries in the elderly, leading to loss of autonomy and major socio-economic burden.1,2 Their global incidence is expected to rise sharply with population aging.2,3 Presently, it stands as the third highest expenditure in French social welfare systems. The management of this condition, therefore, represents a critical socio-economic challenge.4
Surgery is the standard treatment, using either osteosynthesis or arthroplasty, but no consensus exists on the optimal implant. Current osteosynthesis techniques present complications such as fixation failure, shortening, nonunion, and avascular necrosis.5–11
Advancements in the understanding of bone biomechanics and implant design have paved the way for continued exploration of femoral neck fractures osteosynthesis in the years to come.12–15 One such recent innovation is the femoral neck system (FNS) introduced by Depuy-Synthes, a device combining locked plating, anti-rotation, and minimally invasive insertion. Biomechanical studies show superior stability to cannulated screws, though clinical results remain inconsistent.16,17
This study compares outcomes of FNS versus dynamic hip screw (DHS) and triple screws (TS) in all patients hospitalized for femoral neck fractures and treated surgically within the past two years and incorporates recent literature to evaluate its effectiveness and safety.18
2 Methods
2.1 Patients
All patients admitted in our hospital, eligible for conservative surgical management of a femoral neck fracture between January 2020 and October 2022 were included in this study. A total of 143 patients’ (84 females, 59 males) information was retrospectively collected with a femoral neck fracture. All patients underwent radio-clinical follow-up consultations at 6 weeks, 6 months, and 1 year postoperatively. Because this study was retrospective and based on anonymized data, written informed consent was not required according to national regulations. All patients were informed that their clinical data could be used for research purposes, and no patient objected to participation.
2.2 Surgery procedure
Full weight-bearing was allowed in all patients immediately after surgery. All surgical procedures were standardized across operators. Patients were positioned on an orthopedic table, and fracture reduction was achieved by external manipulation.
2.3 Methods of assessment
The recorded data included patient characteristics (age, sex, BMI, preoperative and postoperative autonomy assessed by the Parker geriatric score), fracture characteristics (Garden classification, Pauwels classification, laterality), intraoperative information (bleeding, operative time), and follow-up information (duration of hospital stay, occurrence of complications, survival).
Radiographic classification according to the Garden and Pauwels classifications was systematically performed by the operating surgeon and verified by a third party.
Postoperative data were collected from the electronic medical records of the patients, including.-Duration of follow-up evaluated based on the date of the last consultation,-Perioperative bleeding, assessed by the need for packed red blood cell transfusion and quantified by the number of units transfused during hospitalization,-Duration of hospital stay,-Implant failure without femoral head necrosis,-Aseptic necrosis, determined by radiographic evidence of femoral head involution without implant failure up to 24 months postoperatively,-Need for reoperation during the follow-up period. If a reoperation occurred, the time interval between the initial surgery and the revision surgery, as well as the nature of the intervention performed, were recorded,-Geriatric autonomy score according to the Parker assessment, obtained through systematic communication with the patient's primary care physician.
2.4 Statistical analysis
All statistical analyses were performed using RStudio software (R version 4.2.2). Qualitative variables were presented by their count and frequency, while quantitative variables were presented by their mean and standard deviation. Qualitative data were compared using the chi-square test or Fisher's exact test. Quantitative data were compared using univariate Analysis of Variance (ANOVA) followed by post-hoc Tukey tests after confirming a priori assumption. In case of violation of the a priori assumptions, a non-parametric ANOVA test or Kruskal-Wallis test followed by the non-parametric Wilcoxon test was used. The comparison between our data and the literature was performed using a Student's t-test.
Pre- and post-surgery Parker autonomy score differences were studied using a binary variable, accounting for the non-normal distribution of the variable, defined as follow: 0 = no observed Parker score difference pre- and post-operatively; 1 = observed Parker score difference. Association with the surgical technique and Parker autonomy score difference was tested using a mixed logistic regression model adjusted for sex, age, Garden score, Pauwels score, and BMI according to the following equation: Parker autonomy score difference ∼ Surgical system + Sex + Age + Garden + Pauwels + BMI. Normality of the variable and the model's residuals were satisfied.
3 Results
3.1 Population characteristics
Overall, 143 patients were included in the study (mean age 78.7 ± 13.8 years; 84 women) of which 31 (mean age 77.3 ± 13.6 years; 19 women) were treated with FNS, 62 (mean age 82.2 ± 10.5 years; 40 women) underwent percutaneous triple cannulated screw fixation (TS), and 50 (mean age 75.3 ± 16.5 years; 25 women) received dynamic hip screw plating (DHS). Population characteristics, fractures characteristics, peri-operative and follow-up data are presented in Table 1.
| FNS | TS | pvalue | DHS | pvalue | Global pvalue | |
| Patients | 31 | 62 | 50 | |||
| Age [years] (mean, SD) | 77.3 (13.6) | 82.2 (10.5) | 0.06 | 75.3 (16.5) | 0.57 | 9.1E-02 |
| Sex (%) | ||||||
| Male | 12 (39) | 22 (35.5) | 1.00 | 25 (50) | 0.17 | 5.3E-02 |
| Female | 19 (61) | 40 (64,5) | 25 (50) | |||
| BMI (mean, SD) | 22.9 (3.3) | 23.5 (4.3) | 0.82 | 23.0 (3.7) | 0.99 | 9.4E-01 |
| Fracture classification Garden [N] (%) | ||||||
| Gardens 1-2 | 10 (32.2) | 39 (62.9) | 0.01 | 10 (20) | 0.32 | 1.3E-05 |
| Gardens 3-4 | 21 (67.8) | 23 (37.1) | 40 (80) | |||
| Fracture classification Pauwels [N] (%) | ||||||
| Pauwels 1 | 6 (19.3) | 41 (66.1) | 4.93E-05 | 10 (20) | 1.00 | 1.91E-06 |
| Pauwels 2 | 14 (45.2) | 14 (22.6) | 23 (46) | |||
| Pauwels 3 | 11 (35.5) | 7 (11.3) | 17 (34) | |||
| Hospital stay [days] (mean, SD) | 10.9 (8.1) | 8.6 (6.3) | 0.13 | 9.6 (6.9) | 0.41 | 0.19 |
| Operation time [min] (mean,SD) | 31.2 (5.1) | 29.2 (13.8) | 0.46 | 56.0 (29.1) | <0.01 | <0.01 |
| Peri-operative bleeding [red blood cells] (mean, SD) | 0.2 (0.6) | 0.4 (0.9) | 0.29 | 0.3 (0.8) | 0.45 | 0.77 |
| Follow-up time [days] (mean, SD) | 581.4 (389.8) | 615.2 (212.6) | 0.59 | 652.5 (302.2) | 0.36 | 0.04 |
| Reoperation [N] (%) | 9 (29) | 9 (14,5) | 0.10 | 13 (26) | 0.80 | <0.01 |
| Failure fixation [N] (%) | 2 (6.5) | 9 (14.5) | 0.33 | 9 (18) | 0.19 | 0.37 |
| Necrosis [N] (%) | 6 (19.4) | 3 (4.8) | 0.05 | 6 (12) | 0.52 | 0.08 |
| Infection [N] (%) | 1 (3.2) | 0 (0) | 0.33 | 0 (0) | 0.38 | 0.36 |
| Death [N] (%) | 6 (19,4) | 22 (35,5) | 0.15 | 7 (14) | 0.55 | 0.07 |
| Autonomy score Parker (mean, SD) | ||||||
| Pre-surgery | 5.9 (2.9) | 4.7 (2.8) | 0.06 | 6.5 (2.6) | 0.39 | 0.21 |
| Post-surgery | 4.1 (3.1) | 3.3 (3.2) | 0.27 | 4.9 (3.3) | 0.30 | 0.24 |
Regarding the patient's characteristics, no differences were observed between the 3 groups (FNS, TS and DHS) in terms of sex ratio and BMI (Table 1, Fig. 1).
3.2 Fractures characteristics
Fractures were defined according to the classifications of Garden and Pauwels. Regarding those classifications, fractures observed in the 3 groups were significantly different (Garden: Pvalue-global = 1.3 × 10−5; Pauwels: Pvalue-global = 1.9 × 10−6) (Table 1, Fig. 2). FNS and DHS patients presented predominantly Garden 3–4 and Pauwels 2 and 3 fractures whereas TS patients presented largely Garden 1–2 and Pauwels 1 fractures.
3.3 Peri- and post-operative clinical indicators
No differences were observed in hospitalization time or peri-operative bleeding in our 3 groups. However, operative time was significantly different, with the longest operative time observed in DHS patients (56.0 min) and the shortest in TS patients (29.2 min), mean operative time for the patients treated with FNS was 31 min (Fig. 3).
Following surgery, there was no difference in the rates of failure fixation, infection or death between the groups observed (Table 1). However, the proportion of osteonecrosis, the reoperation rate, follow-up time and post-operative Parker autonomy score did not differ significantly between the 3 groups studied. Moreover, DHS patients presented the highest reoperation rate, but also the longest follow-up time and the highest post-operative Parker autonomy score (Table 1).
3.4 Post-operative scores
To assess the loss of autonomy following the surgery, we focused on the difference of the Parker autonomy score before and after surgery. In view of the different characteristics of our patient groups, we tested the association between Parker autonomy scores and the type of surgery (Methods). Interestingly, this analysis highlights the fact that each 1-year increase in age is associated with a 5.1 % increase in the risk of loss of autonomy (OR = 1.051 over 1-year increase; pvalue = 0.004), whatever the age after adjustment for the type of surgery used. Moreover, compared to patients with a Pauwels type 1 fracture, those with a Pauwels type 2 or 3 fracture have a 76 % increased risk of loss of autonomy, although this result does not reach conventional statistical significance (OR = 1.76; p = 0.088) (Fig. 4).
3.5 Literature comparison
Focusing our analysis on FNS patients, we compared our data obtained in a French center with data from the literature. We used data from a 4-center English multicenter study involving 380 patients treated for true cervical fractures using FNS. Results comparing the patient's demographics, fractures characteristics, peri-operative and follow-up data are presented in Table 2. Comparing the participants demographics, the mean age in our study was significantly higher, at 77.6 years versus 62.6 years in the literature and the sex ratio was approximately identical, with a slightly higher proportion of women in our study (60 % versus 50 % in the literature). Concerning the fracture classification, due to availability of literature data, we focused on the Garden classification where the majority of our patients presented a Garden 3–4 fracture (68 %) whereas the literature shows a majority of Garden 1–2 fractures (52 %). Interestingly, even if the hospital duration was significantly higher in our study, the operation time was significantly shorter. This comparison showed a higher proportion of reoperations in our cohort, with approximately three times more revision surgeries than in the literature, as well as a follow-up period that was about 2.5 times longer.
| FNS | Literature | pvalue | |
| Patients [N] | 31 | 380 | |
| Age [year] (mean ± SD) | 77.3 ± 13.6 | 62.6 ± 16.15 | <0.01 |
| Sex [N] (%) | |||
| Male | 12 (39) | 189 (50) | – |
| Female | 19 (61) | 191 (50) | – |
| Garden classification [N] (%) | |||
| Gardens 1-2 | 10 (32) | 197 (52) | – |
| Gardens 3-4 | 21 (68) | 127 (48) | – |
| Hospital stay [days] (mean ± SD) | 10.9 ± 8.1 | 6.1 ± 3.5 | <0.01 |
| Operating time [min] (mean ± SD) | 31.2 ± 5.1 | 47.1 ± 15.2 | <0.01 |
| Follow-up duration [day] (mean, range) | 581 | 257.3 | – |
| Reoperation | 9 (29) | 39 (9.2) | – |
3.6 Sub-study of non-displaces fractures
To determine, the added value, if any, of FNS to TS and DHS for non-displaced fractures, we focused more specifically on comparing the results of the FNS with those of the TS and the DHS plating, for the garden I and II fractures, representing respectively 10, 39 and 10 patients. There were no differences in the patient's demographics. We could not show any significant differences in the collected data between the FNS and the TS group except for the follow up which was longer in the TS group (mean time was 605 days vs. 303 days respectively). As for the comparison between the FNS and the DHS groups, the operative time was longer in the DHS group (61.2 min vs. 31 min) and the parker score was higher in the DHS group pre- and post-operative (respectively 7.3/6.4 and 6.2/4.2) (Table 3).
| FNS | TS | pvalue | DHS | pvalue | Global pvalue | |
| Patients | 10 | 39 | – | 10 | – | – |
| Age [years] (mean, SD) | 77.9 (9.9) | 79.9 (11.2) | 0.88 | 73.4 (16.7) | 0.68 | 0.32 |
| Sex (%) | ||||||
| Male | 3 (30) | 11 (28.2) | 1.00 | 7 (70) | 0.18 | 0.04 |
| Female | 7 (70) | 28 (71.8) | 3 (30) | 0.67 | ||
| BMI (mean, SD) | 23.4 (2.6) | 22.6 (3.7) | 0.43 | 23.1 (4.3) | 0.85 | 0.66 |
| Fracture classification Pauwels [N] (%) | ||||||
| Pauwels 1 | 4 (40) | 32 (82) | <0.01 | 6 (60) | 0.84 | <0.01 |
| Pauwels 2 | 2 (20) | 7 (18) | 2 (20) | |||
| Pauwels 3 | 4 (40) | 0 (0) | 2 (20) | |||
| Hospital stay [days] (mean, SD) | 6.9 (2.6) | 8.1 (6.1) | 0.35 | 5.6 (1.6) | 0.18 | 0.41 |
| Operation time [min] (mean,SD) | 31 (6.9) | 30.1 (16.1) | 0.79 | 61.2 (49.4) | 0.01 | <0.01 |
| Peri-operative bleeding [red blood cells] (mean, SD) | 0.2 (0.6) | 0.4 (1.1) | 0.44 | 0 (0) | – | 0.40 |
| Follow-up time [days] (mean, SD) | 303 (94.2) | 605 (198.7) | <0.01 | 693.2 (343.9) | <0.01 | <0.01 |
| Reoperation [N] (%) | 2 (20) | 8 (21) | 1.00 | 1 (10) | 1.00 | 0.74 |
| Failure fixation [N] (%) | 1 (10) | 6 (15) | 1.00 | 0 (0) | 1.00 | 0.61 |
| Necrosis [N] (%) | 1 (10) | 0 (0) | 0.20 | 0 (0) | 1.00 | 0.34 |
| Infection [N] (%) | 0 (0) | 0 (0) | – | 0 (0) | – | – |
| Death [N] (%) | 1 (10) | 12 (31) | 0.25 | 2 (20) | 1.00 | 0.37 |
| Autonomy score Parker (mean, SD) | ||||||
| Pre-surgery | 6.2 (3.2) | 5.5 (3.1) | 0.54 | 7.4 (2.4) | 0.34 | 0.21 |
| Post-surgery | 4.2 (2.2) | 4.4 (3.3) | 0.82 | 6.7 (3.1) | 0.04 | 0.24 |
Multivariate analysis did not highlight any significant difference regarding the loss of autonomy as shown by the difference of Parker score pre ant post-surgery (Fig. 5).
4 Discussion
This study presents the clinical results of 143 patients who underwent femoral neck fracture surgery, 31 of whom benefited from the new FNS implant by Depuy-Synthes (January 30, 2019). In summary, our results show that DHS was associated with higher operation times and higher rate of reoperation. TS, mainly used for non-displaced fractures, demonstrated similar operative times and outcomes compared to FNS in this setting. Despite these differences, patients treated with DHS had longer follow-up and maintained higher postoperative autonomy, suggesting that surgical choice cannot be guided by a single parameter. Moreover, the absence of any significant difference in perioperative bleeding between the different groups suggests that bleeding is conditioned by the fracture and not by the surgical procedure. Beyond technical considerations, age clearly emerged as the strongest predictor of functional outcome, regardless of the procedure performed. Taken together, these findings underline the importance of tailoring surgical strategy not only to fracture type but also to patient characteristics, particularly age, in order to optimize long-term autonomy and reduce the risk of complications.
Furthermore, we compared our results to a recent meta-analysis of 380 patients operated with the FNS implant17–19 with regard to the duration of surgery, length of hospital stay, and number of reoperations. In this comparison, hospital stay was longer in our cohort, whereas operation time was shorter. We also observed a markedly higher proportion of reoperations, with nearly three times more revision procedures than previously reported. This difference may be partly explained by the substantially longer follow-up in our study, which was more than twice that of the published series, increasing the likelihood of capturing late complications and secondary procedures.
From our local hospital data, we observed a higher rate of avascular necrosis in the FNS group compared to the TS group, whereas a recent meta-analysis including 448 patients reported the opposite association when comparing FNS and cannulated screws for femoral neck fractures.17 This discrepancy may be explained by the higher proportion of Garden 3 and 4 fractures in our cohort.
Overall, our findings are consistent with the existing literature. While Jiang et al. reported an advantage of FNS for femoral neck fractures across all fracture types with a follow-up of 3–24 months,17 our results suggest that FNS may provide a specific benefit over screw fixation for Garden 1 and 2 fractures, reducing follow-up duration while maintaining similar pre- and post-operative characteristics and clinical scores. Additionally, a meta-analysis of 509 electronic health records in a younger population (mean age 50.9 years)19 demonstrated the superiority of FNS over cannulated screw fixation in terms of postoperative complications and functional outcomes. Taken together, these data support the relevance of FNS, highlighting a modest advantage over screw fixation, while our study also provides a direct comparison with DHS.
The distinct advantage of our investigation lies in its capacity to contrast our implementation of the FNS with practices adopted by multiple orthopedic centers. It is noteworthy that our center exhibited a heightened reoperation rate in contrast to previously published studies.18 This disparity can be attributed to a twofold rationale. First, our patient population displayed a higher prevalence of displaced fractures, which inherently predisposes them to a greater likelihood of revision surgeries.20 Second, our study's extended follow-up duration further illuminated complications that might not have been evident in the shorter observation periods.
The two-year follow-up allowed detection of late failures, although such follow-up is difficult in elderly patients. FNS operative time remained short despite technical challenges, confirming its ease of use and rapid learning curve. Apart from shorter operative time, FNS and DHS showed no major differences in complications or autonomy.
Some events (early fall, prolonged hospitalization for sepsis, AVN in markedly displaced fractures.21) may have influenced outcomes. The Parker score provided a simple autonomy assessment adapted to this population.20
Limitations include retrospective single-center design and small FNS sample size. Despite this, FNS seems to remains a relevant option particularly for non-displaced fractures consistent with literature positioning it as a valuable alternative to TS and DHS.22–31
5 Conclusion
The FNS appears to be a reliable option for the management of femoral neck fractures, showing comparable outcomes to conventional fixation methods with the advantage of a shorter operative time. In our cohort, the two-year follow-up, allowed us to identify complications that may occur beyond the early postoperative period. This work also underlines the importance of tailoring surgical strategy not only to fracture type but also to patient characteristics, particularly age, in order to optimize long-term autonomy and reduce the risk of complications. Further multicenter prospective studies with longer follow-up and comprehensive functional and geriatric assessments are needed to better define the indications and long-term performance of this implant.
Patient consent
Because this study was retrospective and based on anonymized data, written informed consent was not required according to national regulations. All patients were informed that their clinical data could be used for research purposes, and no patient objected to participation.
Credit author statement
Grégoire Châtelier: Conceptualization, methodology, formal analysis, investigation, data curation, writing – original draft, visualization. Romain Huguet: Writing – review and editing. Igor Benezis: Supervision. Johan Lebecque: Writing – reviewing and editing.
Ethical statement
This retrospective study was conducted in accordance with the ethical standards of the institutional and national research committees and with the 1964 Helsinki declaration and its later amendments. Given its retrospective nature and use of anonymized data, formal ethical approval and written informed consent were not required according to national regulations.
Funding source
None.
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