Fracture of the femoral neck. II. Relative importance of primary vascular damage and surgical procedure for the development of necrosis of the femoral head

The opinion is widely held that interruption of the arterial flow through the retinacular arteries to the femoral head is the main cause of avascular necrosis after fracture of the neck. In this study the state of the vascular supply to the femoral head was assessed--prior to osteosynthesis--by means of intramedullary pressure measurements in the femoral head and neck in 72 patients with medial neck fractures. The patients were followed 2 or 3 years or until avascular necrosis became evident. The relative importance of primary avascularity and surgical technique for the development of necrosis suggests that damage to the retinacular arteries may not be the single decisive factor in the pathogenesis of femoral head necrosis. Proper fracture reduction with extensive contact between the cancellous bone surfaces and stable fixation seemed to be more important, probably because they offer the best possibilities for re-establishment of transosseous blood flow across the fracture site.     

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children

OBJECTIVES: To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents. DESIGN: A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail. PATIENTS/PARTICIPANTS: Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes. INTERVENTION: Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter. MAIN OUTCOME MEASUREMENTS: Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing. RESULTS: Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications. CONCLUSIONS: The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Summary Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.      

Treatment of ipsilateral hip and femoral shaft fractures with reconstructive intramedullary interlocking nail

Objective: To evaluate the results of reconstructive intramedullary interlocking nail in the treatment of ipsllateral hip and femoral shaft fractures. Methods: From August 1997 to November 2001, 13 patients were treated with the reconstructive intramedullary interlocking nail. Nine patients were associated with ipsllateral femoral neck fractures, three with ipsilateral intertrochanteric fractures, and one with subtrochanteric fracture. Results: The follow-up time was from 6 to 38 months with an average of 14 months. All the femoral shaft and hip fractures healed up well. There was no nonunion of the femoral neck, and only one varns malunion. No patient had avascular necrosis of the femoral head. The average healing time for femoral neck fracture was 4.6 months and for shaft fracture 5.8 months. The joint movement and other functions were fairly resumed. Conclusions: The reconstructive intramedullary interlocking nail, with less trauma, refiable fixation, and high rate of fracture healing, is an ideal method of choice in the treatment of ipsilateral hip and femoral shaft fractures.     

Avascular necrosis of the femoral head after intertrochanteric fractures

OBJECTIVE: To determine factors that may influence the appearance of avascular necrosis after intertrochanteric fractures. DESIGN: Retrospective. SETTING: University hospital. PATIENTS: Twelve patients between the ages of fifty-nine and eighty-eight who had developed avascular necrosis of the femoral head after treatment of an intertrochanteric femur fracture at our institution between 1976 and 1995. Fractures were classified according to Kyle and Gustilo. There were three Type I, two Type II, six Type III, and one Type IV fractures. MAIN OUTCOME MEASURES: Risk factors for osteonecrosis, fracture pattern, surgical influence, location of the nail within the femoral head, and valgus malalignment. RESULTS: All fractures healed. Five patients had risk factors for osteonecrosis. Intertrochanteric fractures with a proximal fracture line appeared in five patients. The nail tip was situated in every quadrant of the femoral head. Valgus malalignment occurred in three cases. CONCLUSIONS: Avascular necrosis of the femoral head is an uncommon complication after intertrochanteric fractures. The pathogenesis is unknown, but in patients developing pain who have had intertrochanteric fractures, osteonecrosis should be included in the differential diagnosis, especially in cases with risk factors for osteonecrosis or a proximal intertrochanteric fracture line that perhaps disrupts the vascular anastomotic ring at the base of the femoral neck.     

空心钉与髓内钉治疗青壮年股骨颈不稳定骨折的疗效观察

目的分析在直接前侧入路(DAA)辅助下空心螺钉与Intertan髓内固定治疗青壮年移位不稳型股骨颈骨折的临床疗效。 方法回顾分析浙江新安国际医院骨科2014年1月至2016年12月采用DAA入路切开复位治疗青壮年移位不稳定型(Garden Ⅲ、Ⅳ型)股骨颈骨折患者,资料均为GardenⅢ、Ⅳ不稳定型股骨颈骨折,24 h之内完成手术,年龄<60岁且随访资料完整;排除同侧转子间骨折、转子下骨折、股骨干骨折,长期使用大剂量激素或酗酒患者。DAA辅助空心钉螺钉内固定组(空心钉组)90例,DAA辅助Intertan髓内钉固定组(髓内钉组)89例,采用SPSS 21.0统计学软件对数据进行统计学分析。采取t检验和χ²检验比较手术时间、透视次数、出血量、住院日、骨折愈合时间、骨折不愈合及股骨头缺血性坏死率、Harris评分。 结果两组在年龄、性别、Garden分型比较上,差异无统计学意义(均P>0.05),有可比性。空心钉组在手术时间(45.4±15.6)min、透视次数(6.5±3.4)次、出血量(90.5±24.5)ml方面优于髓内钉组[分别为(75.2±12.4)min,(9.3±4.6)次,(159.7±40.2)ml](均为P<0.01);空心钉组在住院日(7.2±2.1)d方面与髓内钉组(8.2±1.3)d没有差异(t＝－1.567,P>0.05)。髓内钉组愈合时间(2.8±0.8)月,短于空心钉组[(3.8±0.7)月,(t＝5.375,P<0.01)]。髓内钉组骨折不愈合、股骨头缺血性坏死4例明显少于空心钉组15例(χ²＝6.005,P<0.05);Harris评分优良率空心钉组低于髓内钉组(χ²＝7.338,P<0.01)。 结论青壮年移位不稳定型股骨颈骨折早期采用DAA辅助入路Intertan髓内固定方法治疗可在直视下完成骨折复位,术后恢复快,骨折愈合率高,股骨头坏死发生率低,疗效满意。     

青少年型锁定髓内钉治疗儿童股骨干骨折的疗效

目的 评估青少年型锁定髓内钉治疗儿童股骨干骨折的疗效.方法 采用经大转子外侧置入锁定髓内钉治疗21例儿童股骨干骨折.评估患侧髋、膝关节的功能,测量双下肢长度、股骨颈干角及股骨颈直径,记录切口感染、股骨头缺血性坏死、髋外翻和股骨颈狭窄等并发症发生情况.结果 患儿均获得随访,时间8～34个月.骨折均愈合,时间10～28周....     

Modified Pauwels' intertrochanteric osteotomy in neglected femoral neck fractures in children: a report of 10 cases followed for a minimum of 5 years

OBJECTIVES: To evaluate the role of a modified Pauwels' intertrochanteric osteotomy (MPIO) in neglected femoral neck fractures in children. DESIGN: Prospective study with retrospective analysis. SETTING: Tertiary care Postgraduate Institute of Medical Sciences. PATIENTS: Ten children (8 males, 2 females) with an average age of 10.2 years with neglected femoral neck fractures were seen from 1990 to 1998. A femoral neck fracture was considered neglected when no proper medical treatment was instituted for at least 1 month following the fracture. Nonunion was accompanied by coxa vara and resorption of the femoral neck in 9 patients; a 10th patient had a neglected femoral neck fracture for 1 month without coxa vara. Three patients at time of presentation with Delbet Type II displaced fractures with associated nonunion and coxa vara (2 with Ratliff Type III and 1 with Type I) also had avascular necrosis using plain radiographic criteria of increased density. INTERVENTION: Modified Pauwels' intertrochanteric osteotomy. The children were immobilized in a hip spica for 6-10 weeks postoperatively and weightbearing was started after hip spica removal. MAIN OUTCOME MEASUREMENTS: Fracture healing, neck-shaft angle, avascular necrosis, and functional outcome. RESULTS: Patients were followed for an average of 8.2 years (range 5-12 years). All patients had union of their fracture within an average of 16.6 weeks (12-20 weeks) and of the osteotomy site within 8.2 weeks (7-9 weeks). Radiologic signs of avascular necrosis disappeared completely in the 3 patients who presented with avascular necrosis. In 1 patient with a preoperatively viable femoral head, radiologic signs of Ratliff Type I avascular necrosis appeared between 60 and 98 weeks. This radiologic finding became normal again, indicating viability of the femoral head somewhere between 98 to 205 weeks of follow-up. Postoperatively, an average of 135-degree neck-shaft angle was achieved (range 125-160 degrees). The average preoperative neck-shaft angle was 104.4 degrees (range 92-120 degrees) and on the normal hip side it was 127.7 degrees (range 124-132 degrees). Significant improvement in the neck-shaft angle was seen compared with the preoperative angle (P < 0.001) and normal hip angle (P < 0.05). Coxa vara and signs of chondrolysis were not observed in any of the patients. Premature proximal femoral epiphyseal closure resulting in a 1-cm and a 1.5-cm leg-length discrepancy was seen in 2 patients as compared with their normal side. A mild Trendelenburg gait was observed in 1 patient (10%). Using Ratliff's criteria, 9 patients (90%) were graded as a good result and 1 patient (10%) was graded as a fair result. The osteotomy plate was removed in 1 patient (10%). CONCLUSION: An MPIO creates a biomechanical environment conducive to healing of a neglected femoral neck nonunion in a child while simultaneously correcting an associated coxa vara. The procedure also seems to have a biological role in helping restore viability to a noncollapsed femoral head with avascular necrosis.     

Complications of rigid intramedullary rodding of femoral shaft fractures in children

BACKGROUND: Intramedullary rodding of femoral shaft fractures has been frequently performed in adults, but until recently rarely in children. It was the purpose of this study to investigate the experience with this treatment method at a pediatric trauma center. METHODS: From 1987 to 1998, 54 children were treated for traumatic femoral fractures with intramedullary rods at a major pediatric trauma center. The average age was 15 years 3 months, ranging between 11 years 4 months and 17 years 11 months. The average follow-up was 5 years 3 months, ranging from 20 months to 10 years 1 month. RESULTS: All of the fractures occurred secondary to trauma and the most common anatomic fracture site was the femoral midshaft. Complications encountered included 8 instances of minor limb length discrepancy, 11 instances of discomfort because of rod prominence, 1 case of avascular necrosis of the femoral head, 2 instances of heterotopic ossification over the rod tip, 1 broken rod, and 3 cases that demonstrated decreased external rotation of the affected limb. One child developed osteomyelitis after intramedullary rodding for a fracture previously treated with external fixation. There were no cases of surgically induced nonunion or malunion and only one delayed union secondary to infection. CONCLUSION: Results of this series demonstrate intramedullary rodding to be an effective treatment modality for femoral fractures in skeletally mature children. In children with open femoral physes, rigid rodding should be avoided because of the small but serious occurrence of avascular necrosis of the femoral head. Intramedullary rodding is not recommended in children initially treated with external fixation because of the increased risk of infection.     

Magnetic resonance imaging of the femoral head after acute intracapsular fracture of the femoral neck

In fifteen patients who had a subcapital fracture of the femoral neck (twelve displaced fractures and three non-displaced fractures), magnetic resonance imaging of the femoral head was done with two-dimensional Fourier transform spin-echo technique within forty-eight hours of injury. The magnetic resonance image did not show avascular necrosis of the femoral head in any of the patients. In eleven patients, there was a decreased signal at the base of the femoral head, immediately adjacent to the fracture. This decreased signal corresponded to a recognized band of necrosis and hemorrhage next to the site of the fracture and was not related to the viability of the femoral head. No other changes were seen on the images. We concluded that this type of magnetic resonance imaging is inadequate to determine the viability of the femoral head within forty-eight hours after a patient sustains an acute intracapsular fracture of the femoral neck.     

Proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures

The purpose of this study was to evaluate the efficacy and safety of the proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures. A prospective study was performed in 41 patients with femoral neck fractures treated with a proximal femoral locking plate with cannulated screws between January 2005 and December 2008. Twenty-five men and 16 women had a mean age of 47 years (range, 21-65 years). The time from injury to surgery ranged from 2 hours to 7 days. Three patients had a Garden type I fracture, 9 a type II, 18 a type III and 11 a type IV. Operative time, intraoperative blood loss, fracture healing time, Harris Hip Score for hip function, and complications were recorded to evaluate treatment effects.Mean operative time was 63.6 minutes (range, 40-90 minutes), with mean intraoperative blood loss of 84.2 mL (range, 50-200 mL). Mean time to union was 15.5 weeks (range, 12-36 weeks). Two patients (Garden type III and type IV) did not achieve union, and 4 patients (1 Garden type III and 3 type IV) had avascular necrosis of the femoral head. In patients with nonunion, 1 (Garden type III) underwent intertrochanteric osteotomy, and the other underwent total hip replacement (THR). In patients with avascular necrosis, 2 required THR and the others (1 Garden type III) required no further surgery. Twenty-six (63%) patients had excellent results, 8 (20%) had good results, 3 (7%) had moderate results, and 4 (10%) had poor results. These findings suggest that the proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures is effective and results in fewer complications, especially for Garden type I, II, and III fractures.     

应用吻合血管的游离腓骨移植治疗陈旧性股骨颈骨折

目的 对股骨颈骨折内固定失败和骨不连采用吻合血管的游离腓骨移植术治疗并进行临床评价。方法 对自2000年11月～2003年10月，采用吻合血管的游离腓骨移植术治疗的9例股骨颈骨折骨不连伴早期股骨头坏死的病例进行随访，平均随访时间22．5月。结果 9例骨折均获愈合，骨折愈合时间4～6月。在X线片上，所有病例的股骨头骨密度都表现明显增高，未见股骨头坏死加重的表现。Harris评分89．2分。结论 吻合血管的游离腓骨移植术是治疗股骨颈骨折内固定失败伴早期股骨头坏死的有效方法。     

Intramedullary locked nailing in the treatment of proximal femoral fractures]

INTRODUCTION: The aim of the study is evaluation of results of operative treatment the proximal femoral fractures with intramedullary locked nailing. MATERIAL AND METHOD: In years 1996-2004 44 patients were treated because of proximal femoral fractures with closed reduction and stabilization with intramedullary locked nailing. There were 15 women and 29 men in average age 60 years (18-95 years). There were 2 femoral neck fractures and 42 peritrochanteric fractures. The fracture of femoral shaft in 2 patients accompanied the fracture of proximal part of femur. The morphology of fractures was estimated according to AO classification. Clinical results were evaluated with Harris hip score (HHS). RESULTS: The average follow up is 8 months (from 6 to 24 months). There was good reduction of 27 fractures on postoperative radiograms. The average 15 degrees of varus lack of reduction was noted in 17 peritrochanteric fractures (from l0 to 35 degrees). There were mainly 31.A.3 unstable fractures according to AO classification. 3 patients died during three postoperative months from causes not connected with operative treatment. 39 fractures united in the period from 10 to 16 weeks. Delayed union--after 6 months occurred in 2 persons. Fatigue fracture of intramedullary rods occurred to both of this patients. The average Harris Hip Score was 86 points (from 70 to 100 points) after union of fractures. CONCLUSIONS: (1) The use of intramedullary locked nailing in the treatment of fractures of proximal part of femur leads to union without additional immobilization. (2) Closed intramedullary locked nailing in the treatment of unstable intertrochanteric fractures is connected with the risk of varus malalignment of fragments, which does not delay union, but decreases functional outcome. (3) Proper operative technique decreases the number of intra- and postoperative complications.     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.     

不同时间段空心加压螺钉内固定治疗老年移位型股骨颈骨折疗效分析

目的 比较急诊与延期行空心加压螺钉内固定术治疗老年移位型股骨颈骨折的临床效果。方法 回顾性分析2000年12月～2010年12月我院采用空心加压螺钉内固定治疗股骨颈骨折的患者99例,分成急诊组52例,延期组47例,比较术后的骨折复位质量、骨折愈合情况,术后1年、2年股骨头缺血坏死、塌陷发生率以及髋关节功能情况及全身并发症等治疗效果的差异性。结果 骨折愈合率、股骨头坏死率、髋关节功能优良率、急诊组股骨头坏死率较延迟组高,两组间均有显著性差异（P<0.05）。结论 对于老年移位型股骨颈骨折患者,采用闭合复位空心加压螺钉内固定治疗,急诊手术疗效优于延期手术。     

老年股骨颈骨折的内固定治疗

目的 探讨内固定治疗老年股骨颈骨折的疗效. 方法回顾研究2000年1月至2007年12月采用内固定治疗且获得随访的139例老年股骨颈骨折患者资料,其中男52例,女87例;年龄65～93岁,平均71.6岁;受伤至入院时间为1 h～30 d,平均56.7 h.骨折按Garden分型:Ⅰ型17例,Ⅱ型43例,Ⅲ型62例,Ⅳ型17例.移位骨折79例,非移位骨折60例.内固定材料:空心钉131例,动力髋螺钉5例,动力髋螺钉加空心钉3例.对患者住院时间、骨折愈合率、术后并发症、股骨头缺血坏死率、内固定失效率及患者功能恢复情况进行总结分析. 结果 139例患者住院时间为5～59 d,平均15.4 d.术后获7～77个月(平均35个月)随访.骨折愈合126例,占90.6%(126/139);愈合时间2～12个月,平均6.2个月.其中22例患者术后出现并发症.骨折不愈合内固定失效13例,占9.4%(13/139);股骨头缺血性坏死9例,占6.5%(9/139).正常行走者81例,占58.3%(81/139),需要助行器械者50例,占36.0%(50/139),不能行走者8例,占5.7%(8/139).结论 老年股骨颈骨折内固定治疗骨折愈合率高,股骨头缺血坏死率较低,内固定治疗老年股骨颈骨折具有积极意义.术前病情评估和合并症的积极治疗非常重要,条件允许时应尽早手术.     

Proximal femoral fractures: Principles of management and review of literature

PurposeThe purpose of this study was to review the principles involved in the management of proximal femoral fractures as reported in the literature. Methods: A medical literature search in the MEDLINE (PubMed) and Cochrane database was undertaken to review strategies and principles in proximal femoral fracture treatment. Randomized control trials and meta analysis were given preference while case reports/small series were rejected. Results and conclusions: Early anatomical reduction and surgical fixation remains the best option to reduce the risk of complications like non-union and avascular necrosis in treating fracture neck femurs. Cancellous screws continue to be the preferred treatment for fixation of neck femur fractures in younger population until the benefit of using sliding hip screws is validated by large multicentric studies. In the geriatric age group, early prosthetic replacement brings down the mortality and morbidity associated with neck femur fractures. Sliding hip screw (DHS) is the best available option for stable inter trochanteric fractures. The use of intramedullary nails e.g. PFN is beneficial in treating inter trochanteric fractures with comminution and loss of lateral buttress. Intramedullary implants have been proven to have increased success rates in subtrochanteric fractures and should be preferred over extramedullary plate fixation systems.     

Avascular necrosis of the femoral head after osteosynthesis of femoral neck fracture

The reported incidence of avascular necrosis after femoral neck fracture fixation varies widely, and there is no consensus regarding its risk factors. We evaluated the incidence of avascular necrosis of the femoral head with the use of contemporary techniques for femoral neck fracture fixation. We then sought to determine what potential risk factors influenced the development of avascular necrosis.Between 1990 and 2005, one hundred sixty-three intracapsular femoral neck fractures in 163 patients were treated with internal fixation at our level-I trauma center. All patients were monitored until conversion to total hip arthroplasty or for a minimum of 2 years postoperatively. Ten patients (10 hips) died and 7 patients (7 hips) were lost to follow-up. The remaining 146 patients (146 hips) had a mean 5.2 years of follow-up (range, 3 months to 17 years). The incidence of avascular necrosis was 25.3% (37 hips). The average time to diagnosis of avascular necrosis was 18.8 months (range, 3-47 months). Patient sex, age, interval from injury to surgery, and mechanism of injury were statistically not associated with the development of avascular necrosis. The quality of fracture reduction, adequacy of fixation, degree of displacement, and comminution of the posterior cortex were significantly associated. After we controlled for patient and radiographic characteristics, multivariate analyses indicated that the important predictors for avascular necrosis are poor reduction (odds ratio=13.889) and initial displacement of the fracture (odds ratio=4.693).     

股骨颈骨折临床研究的若干问题与新概念

骨质疏松是引起股骨颈骨折的重要因素。骨质疏松的程度对于骨折的粉碎情况(特别是股骨颈后外侧粉碎)及内固定后的牢固与否有直接影响。年青人股骨颈骨折则多为严重创伤所致。Garden分型是目前应用最为广泛的股骨颈骨折分型。近年来许多医生发现Garden分型在临床应用中存在一些问题,建议将股骨颈骨折简单地分为无移位型(GardenⅠ、Ⅱ型)及移位型(GardenⅢ、GardenⅣ型)。人工关节置换术曾被广泛应用老年人移位型骨折。对于人工关节置换术的应用,不是简单根据年龄及移位程度来定,而应严格掌握适应证。股骨颈骨折后继发的股骨头缺血坏死尚无单独的诊断标准,目前仍然普遍借用股骨头无菌性坏死的Fi-cat-Arlet分期。核磁共振是目前唯一可以早期诊断股骨头缺血坏死并了解其病变范围和位置的方法。     

Long-term outcome of patients with avascular necrosis,after internal fixation of femoral neck fractures

We retrospectively reviewed 84 patients who underwent internal fixation of an intracapsular femoral neck fracture. The mean age was 58 years and the time from injury to operative treatment was 5.3 days. The mean follow-up was 4.7 years (range, 2-8 years). At the latest follow-up, in the 46 patients with undisplaced (Garden I, II) fractures, nonunion occurred in two patients and avascular necrosis of the femoral head in nine. Six of these nine patients had a good or excellent result, one had a fair result, and two had a poor result. Of 35 patients with no sign of avascular necrosis, 32 patients had a good or excellent result, two a fair and one had a poor result. In the group of 38 patients with displaced (Garden III, IV) fractures, nonunion occurred in six patients and avascular necrosis of the femoral head in 15. Of these 15 patients, 10 had a good or excellent result, two had a fair result, and three had a poor result. Of 17 patients with no sign of avascular necrosis, 14 had an excellent result and three patients a poor result. Overall only five of the 24 patients who developed avascular necrosis of the femoral head had undergone total hip arthroplasty. Internal fixation remains a simple and safe, method of treatment for both undisplaced and displaced femoral neck fractures in middle-age patients. Despite the relatively high rate of avascular necrosis after internal fixation of femoral neck fractures, only a few of these patients (20%) required further surgical treatment in the follow-up period of this study.