Management of intracapsular femoral neck fractures in the elderly; is it time to rethink our strategy?

We reviewed 100 adult patients who had a traumatic intracapsular femoral fracture internally fixed prior to 1998, with full clinical and radiological data available. End points were complete clinical and radiological union of the fracture, non-union, avascular necrosis or fixation failure. The incidence of non-union and avascular necrosis was found to be 13 and 11%, respectively. The following factors did not influence the development of avascular necrosis or non-union; fracture displacement, screws inserted (two or three), osteoporosis, parallelism of screws, presence of screws in each "quadrant" and the experience or seniority of the surgeon. The factors influencing a poor outcome were the age of the patient at injury, reduction gap at the fracture site, alignment after reduction of the fracture especially on AP view and having all screw threads crossing beyond the fracture site. We conclude that the incidence of non-union and avascular necrosis following fixation of femoral neck fractures in our study is less than generally reported with no statistical difference between displaced and undisplaced fractures. Traditional fixation factors such as screw position and number do not seem to significantly affect the outcome with the quality of reduction being most important. Thus, the majority of patients under the age of 70 with displaced intracapsular fracture should be considered for internal fixation.