ORIGINAL ARTICLE
Effects of Technical Errors on the Outcomes of Operatively
Managed Femoral Neck Fractures in Adults Less than 50
Years of Age
Cory A. Collinge, MD,a Andrea Finlay, PhD,b Payton Harris, DO,a Andres Rodriguez-Buitrago, MD,c d
Guadalupe de la Fuente, MD,a Michael Beltran, MD,e Phillip Mitchell, MD,c Michael Archdeacon, MD,e
Paul Tornetta III, MD, PhD,f Hassan R. Mir, MD, MBA,g Michael Gardner, MD,h H. Claude Sagi, MD,e
George F. LeBus, MD,i Lisa K. Cannada, MD,j
Brooke Smyth, BAk and Young Femoral Neck Fracture Working Group
Objective: To evaluate the effect of technical errors (TEs) on the
outcomes after repair of femoral neck fractures in young adults.
Design: Multicenter retrospective clinical study.
Setting: 26 North American Level 1 Trauma Centers.
Patients: Skeletally mature patients younger than 50 years of age
with 492 femoral neck fractures treated between 2005 and 2017.
Intervention: Operative repair of femoral neck fracture.
Main Outcome Measurements: The association between TE
(malreduction and deviation from optimal technique) and treatment
failure (fixation failure, nonunion, malunion, osteonecrosis, malunion,
and revision surgery) were examined using logistic regression analysis.
Results: Overall, a TE was observed in 50% (n = 245/492) of oper-
atively managed femoral neck fractures in young patients. Two or more
TEs were observed in 10% of displaced fractures. Treatment failure in
displaced fractures occurred in 27% of cases without a TE, 56% of cases
with 1 TE, and 86% of cases with 2 or more TEs. TEs were encountered
less frequently in treatment of nondisplaced fractures compared with
Accepted for publication January 3, 2023.
From the aDepartment of Orthopedic Trauma, Harris Methodist Fort Worth
Hospital, Fort Worth, TX; bCenter for Innovation to Implementation (Ci2i),
VA Palo Alto Health Care System; cDepartment of Orthopaedic Surgery,
Vanderbilt University Medical Center, Nashville, TN; dDepartment of
Orthopaedic Surgery, Fundación Santa fe de Bogota, Bogota, Colombia;
e
Department of Orthopedic Surgery, University of Cincinnati, Cincinnati,
OH; fBoston University Medical Center, Boston, MA; gOrthopaedic
Trauma Service, Florida Orthopaedic Institute and University of South
Florida, Tampa, FL; hDepartment of Orthopaedic Surgery, Stanford
University, Stanford, CA; iTexas Orthopaedic Associates, Fort Worth,
TX; jNovant Health Orthopedic Fracture Clinic, Charlotte, NC; and
k
Department of Life Sciences, Brigham Young University, Provo, UT.
The following authors reported a conflict of interest relating to the topic of
this study: Walter Virkus receives royalties from GLW Orthopedics,
Frank Liporace, Daniel Horwitz, and S. Andrew Sems receives royalties
from Zimmer Biomet; Paul Tornetta III receives royalties from Smith &
Nephew.
Reprints: Cory A. Collinge MD, Department of Orthopedic Trauma, Harris
Methodist Fort Worth Hospital, 800 5th Ave, Suite 500, Fort Worth, TX
76104 (e-mail: ccollinge@msn.com)
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DOI: 10.1097/BOT.0000000000002562
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,
displaced fractures (39% vs. 53%, P , 0.001). Although TE(s) in
nondisplaced fractures increased the risk of treatment failure and/or
major reconstructive surgery (22% vs. 9%, P , 0.001), they were less
frequently associated with treatment failure when compared with dis-
placed fractures with a TE (22% vs. 69% P , 0.001).
Conclusions: TEs were found in half of all femoral neck fractures
in young adults undergoing operative repair. Both the occurrence
and number of TEs were associated with an increased risk for failure
of treatment. Preoperative planning for thoughtful and well-executed
reduction and fixation techniques should lead to improved outcomes
for young patients with femoral neck fractures. This study should
also highlight the need for educational forums to address this subject.
Key Words: young, femoral neck, Fracture, vertical, Pauwels, tech-
nical, surgical, error, Failure, outcome, outcomes, errors, technical
errors, mistake
Level of Evidence: Therapeutic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2023;37:214–221)
INTRODUCTION
Femoral neck fractures in young adults (,50 years) are a
relatively uncommon injury with management strategies and
clinical outcomes that differ substantially from geriatric counter-
parts.1–5 Although surgical reduction and fixation is the preferred
treatment in younger patient populations, it is associated with a
high complication rate6,7 signaling the need for an analysis of the
factors contributing to complications: the goal being to improve
outcomes and minimize the need for subsequent surgery.
Fried et al previously noted that “.a major determinant
of a patient’s safety and outcome is the skill and judgment of
the surgeon.“8 In 1976, Protzman and Burkhalter1 reported
nonunion in 59% and osteonecrosis in 86% of operatively
treated femoral neck fractures in a series of 22 young military
personnel 20 to 40 years of age. The authors noted that “treat-
ments varied widely as the surgeons involved were also
young, their experience mostly included Vietnam War
injuries, and likely no single surgeon treated more than one
of the patients studied.” (Personal communication, October
2016). Almost 5 decades after those experiences, the literature
J Orthop Trauma  Volume 37, Number 5, May 2023
J Orthop Trauma  Volume 37, Number 5, May 2023
is populated mostly by a few noncomparative clinical series
describing mixed results and offering few conclusions regard-
ing optimal treatment.2–8
Just recently conducted large multicenter study involving
26 North American Level 1 trauma centers found that the failure
rate of surgical treatment for femoral neck fractures in adults less
than 50 years of age was 45% (failed fixation, nonunion,
osteonecrosis, or shortening .10 mm).9 There was no clear
explanation for failure rates of this magnitude, and the relation-
ship between surgical technique and patient outcomes have not
specifically been previously evaluated in the orthopaedic litera-
ture. In some cases, technical errors (TEs) may cause a compli-
cation but not all TEs necessarily lead to a complication.
Complications also have varied contributions from patient co-
morbidities, injury characteristics, as well as compliance. These
effects can directly affect patient outcomes to varying degrees,
from no impairment to permanent disability.
Studies evaluating TEs in orthopaedic surgery are rare,
in large part, because validated standards for orthopaedic
implant choice and technique are lacking. However, there are
a number of publications citing optimal implant positioning in
hip fracture repairs, and these benchmark studies provide an
objective way to evaluate surgical technique.10–15 Therefore,
the aim of this study was to use these validated measures to
evaluate the impact of TE on the outcomes of the surgical
treatment of femoral neck fractures in young adults. Our
hypothesis was that TE in the treatment of femoral neck
fractures in young patients would be associated with
increased risk of treatment failure.
METHODS
For purposes of this study, a TE was defined radio-
graphically as:
1. “Inadequate reduction” (graded fair or poor) according to
the system of Haidukewych4
2. Fixed-angled devices (eg, sliding hip screw [SHS]) with a
tip-apex distance (TAD) . 25 mm10
3. Multiple cannulated screw constructs with any of the
following:11–15
a. “Inadequate buttress screw”- Inferior calcar screw $
4 mm away from the intramedullary cortical border of
the intact inferomedial cortex of the shaft fragment (ie,
medial cortical support for the distal screw)
b. “Inadequate screw depth” in the femoral head (inferior
and posterior screws .15 mm from the articular surface
on AP and lateral hip radiographs)
c. “Inadequate screw spread” in the femoral head
(,15 mm between screw shafts) on AP and lateral
hip radiographs
To further identify the relationship between TEs and
surgical outcomes, data were reviewed for the occurrence of
any treatment failure. If a patient had a treatment failure by
any one or more mechanism(s), that hip was included as a
treatment failure only once.
Treatment failures were defined as:9
1. Nonunion and/or failed fixation was defined as a lack of
healing at .6 months and/or loss of implant integrity and
reduction.9
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Technical Errors in Repair of Young Femoral Neck Fractures
2. Osteonecrosis was defined and stratified by the Ficat system.25
Types 2b or greater were considered treatment failures.
3. Malunion: vertical or femoral neck shortening greater than
15 mm.9,22,24
Subsequent major reconstructive surgery was defined as
secondary conversion to a proximal femoral osteotomy, hip
arthroplasty, or early revision fixation.
Exclusion criteria included follow-up of less than 6
months (unless treatment failed), lack of adequate records or
radiographic images, initial treatment with arthroplasty,
follow-up less than 6 months (unless failed), skeletally
immature, lack of a native contralateral hip, ballistic injury,
or associated acetabular, femoral head, or peritrochanteric
fractures or hip dislocations.
Health records from all institutions provided 492
patients fulfilling the inclusion criteria treated between 2005
and 2017 were identified and retrospectively studied. Medical
record and radiographic review were performed, and data
collection included patient demographic details and injury
characteristics. Patients were stratified into 1 of 2 study
groups: those with technical error (TE+) and without (TE2),
and the demographics of the 2 groups are presented in
Table 1.
Medical conditions associated with diminished bone
metabolism were identified9,17,18 and included smoking, diabetes
mellitus type 1, alcohol misuse, chronic steroid use, end-stage
renal disease, and other metabolic diseases. All available radio-
graphs of the hip, pelvis, and femur from before (“injury”),
during (“intraoperative”), and after surgery, including follow-
up were evaluated by 2 independent fellowship-trained ortho-
paedic trauma surgeons. Disagreements were adjudicated by a
third orthopaedic trauma surgeon. Injury factors assessed
included initial displacement (modified Garden classification)19,
modified Pauwels classification,20 and the Orthopaedic Trauma
Association’s fracture classification.16 Surgery details included
approach (open vs. closed reduction), reduction quality as mea-
sured on AP and lateral perioperative radiography using
Haidukewych system4 and implant(s) type. All measurements
were determined by comparing known implant geometry (ie,
screw head or SHS barrel diameter) and radiographic implant
measures while controlling for magnification. The greatest
absolute value for “shortening” was defined as (1) loss of height
as measured along a line parallel to the femoral shaft comparing
the center of the femoral head to the tip of the greater trochan-
ter9,21,22 or (2) loss of femoral neck length using an overlay
method.9,23,24 An outline of the contralateral femoral head, neck,
and trochanter was created as reference radiograph, then su-
perimposed onto the radiograph being evaluated for femoral
neck shortening. Displacement of the head between the outline
and the femoral head in the radiograph were measured and used
to calculate the shortening of the femoral neck.
Statistical Analysis
Descriptive statistics of frequency and percent for
categorical variables and mean 6 standard deviation for con-
tinuous variables is reported, stratified by patients with and
without TE during surgery, and with and without treatment
failure. The x2 test was used to assess whether categorical
data were likely to be from a specific theoretical distribution.
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Collinge et al J Orthop Trauma  Volume 37, Number 5, May 2023

TABLE 1. Patient, Injury, and Treatment Overall and According to the Occurrence of a Technical Error and Displaced and
Nondisplaced Fractures
Variables All Repairs without Technical Error(s) Repairs with Technical Error(s) P
Number of patients 492 247 245 NA
Mean age, y (SD) 36.8 6 8.8 38.1 6 8.7 36.2 6 8.8 0.040
Gender (% female) 172 (35.0%) 64 (25.9%) 108 (44.0%) 0.002
Mean body mass index 27.1 6 6.9 27.1 6 7.5 27.2 6 6.6 0.980
Patients with medical problems associated 236 (48.0%) 113 (40.5%) 123 (50.2%) 0.950
with bone metabolism
Mean Pauwels angle 53.2 6 11.4 51.8 6 14.0 54.1 6 13.5 0.060
Displacement (modified Garden) 0.005
Nondisplaced 115 (23.4%) 70 (60.9%) 45 (39.1%)
Displaced 377 (76.6%) 173 (45.9%) 204 (53.1%)
Pauwels classification for displaced fractures ,0.001
(n = 377)
Type I (,30 degrees) 7 (1.8%) 4 (57.1%) 3 (42.9%)
Type II (308–50 degrees) 124 (32.9%) 36 (27.8%) 88 (71.0%)
Type III (.50 degrees) 246 (65.3%) 38 (15.4%) 208 (84.6%)
OTA/AO classification (type 31B_._) 66 38 (63.3%) 22 (36.7%) ,0.001
1.1 42 37 (67.3%) 18 (32.7%)
1.2 38 22 (59.5%) 15 (40.5%)
1.3 29 13 (52.0%) 12 (48.0%)
2.1 120 49 (40.5%) 72 (59.5%)
2.2 162 70 (44.3%) 88 (55.7%)
2.3 35 22 (61.1%) 14 (38.9%)
3 NA NA NA
Reduction method 0.312
Open 249 131 128
Closed 243 116 127
Fixation construct ,0.001
Multiple cannulated screws 286 (58.1%) 102 (35.7%) 184 (64.3%)
Fixed angled device 206 (41.8%) 146 (70.9%) 60 (29.1%)

Exploratory univariate logistic regression models with a ran-
dom effect for hospitals were conducted to examine the asso-
ciation between each factor on treatment failure. All variables
that were significant at a P , 0.05 level were retained. An
exploratory multivariate logistic regression model with a ran-
dom effect for facility was conducted to examine the associ-
ation between each factor and treatment failure, adjusting for
all other factors in the model. Statistical significance was set
at P , 0.05 for the multivariate regression model.
RESULTS
Four hundred ninety-two femoral neck fractures in
young adults managed with operative repair were evaluated.
The mean duration of follow-up was 22.4 months (range, 2
weeks [early failure] to 141 months). Patient, injury, and
treatment characteristics are shown in Table 1, grouped by TE
+ or TE2. Comparatively, the TE2 group was older (38 vs.
36 years, P = 0.040), included more men (74% vs. 56%, P =
0.002), were less frequently displaced (46% vs. 53%, P ,
0.005), included a lower proportion of Pauwels type III frac-
tures (15% vs. 85%, P , 0.001), and more OTA/AO Types
31B2.2 and 31B2.3 fractures (P , 0.001). There was a trend
toward a lesser mean vertical Pauwels angle (52 degrees vs.
54 degrees, P = 0.060) in TE2 compared with TE+ fractures.
Overall, a total of 284 TEs were identified in 245
fractures, associating to a TE rate of 50% (245/492). Failure
of treatment occurred in 45% of fractures (219/492). Most
TEs (82%) were found in patients presenting with displaced
fractures. More than one TE was identified in 8% (41/492) of
the entire patient cohort and 90% of these occurred in
displaced fractures (37/41).
Treatment failures for the entire cohort, as well as for
displaced and nondisplaced fractures, are seen in Table 2.
TE+ patients had a significantly higher failure rate than those
TE2, with more than half of the patients with TE(s) experi-
encing treatment failure (60% vs. 29%, P , 0.001). More
specifically, nonunion +/- failed fixation and the need for
major reconstructive surgery occurred more commonly in
TE+ patients (60% vs. 9%, P , 0.001, and 47% vs. 17%, P ,
0.001, respectively).
TE+ patients with displaced fractures demonstrated the
worst outcomes with a treatment failure rate of 69%, signif-
icantly higher than the failure rates for TE2 patients with
displaced fractures (32%, P , 0.001), TE+ patients with non-
displaced fractures (22%, P, 0.001), and TE- patients with
nondisplaced fractures (20%, P , 0.001). Failure of treatment
for TE+ patients with displaced fractures occurred primarily
in the form of failed fixation and/or nonunion (43%). An

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J Orthop Trauma  Volume 37, Number 5, May 2023 Technical Errors in Repair of Young Femoral Neck Fractures

TABLE 2. Relationship of Technical Errors With Complications in all Fracture and Nondisplaced and Displaced Fractures
All Fractures (492) Nondisplaced Fractures (115) Displaced Fractures (377)
Repairs Repairs Repairs
Failed Treatment without TE(s) Repairs with without TE(s) Repairs with without TE(s) Repairs with
Outcome (247) TE(s) (245) P (70) TE(s) (45) P (177) TE(s) (200) P
Repairs with major 219 71 (28.7%) 148 (60.4%) ,0.001 14 (20.0%) 10 (22.2%) 0.849 57 (32.2%) 138 (69.0%) ,0.001
complications and/or
major reconstructive
surgery
Nonunion and/or failed 112 24 (9.3%) 88 (59.5%) ,0.001 3 (4.3%) 4 (8.9%) 0.367 19 (10.7%) 86 (43.5%) ,0.001
fixation
Osteonecrosis (stages 57 25 (10.1%) 32 (13.1%) 0.198 4 (5.7%) 3 (6.7%) 0.585 21 (11.9%) 29 (14.5%) 0.381
2b–4)
Malunion 74 31 (12.6%) 43 (17.6%) 0.238 5 (7.1) 5 (11.1%) 0.291 26 (14.7%) 38 (19.0%) 0.470
Required major 158 43 (17.4%) 115 (46.9%) ,0.001 8 (11.4%) 4 (8.9%) 0.411 35 (19.7%) 111 (55.5%) ,0.001
reconstructive surgery

increasing number of TEs (2 or greater) was also associated
with an increasing risk of treatment failure: 57% failure rate
with 1 TE, 84% failure rate with 2 TEs, and 100% failure rate
with 3 TEs (P , 0.001).
Further analysis of specific TEs revealed that treatment
failure was incrementally higher with decreasing quality of
reduction. Failure rates in displaced fractures were 34% with
“excellent” reductions, 57% with “good” reductions, 56%
with “fair” reductions, and 86% with “poor” reductions (P
, 0.001; Table 3). Of the excellent reductions that failed,
71% had an associated TE. The treatment failure rate was
also higher when implants were positioned inappropriately.
For fractures treated with cannulated screws, the failure rate
was 52% (71/136) when screws were well-positioned,

TABLE 3. Impact of Technical error(s) on Outcomes in 377 Displaced Fractures

Factors All Fractures without Failed Treatment Fractures with Failed Treatment P
Number of patients (n) 377 182 (48.3%) 195 (51.8%) —
Presence of technical error(s) ,0.001
Repairs without technical errors 177 130 (73.4%) 47 (26.6%)
Repairs with technical error 200 76 (38.0%) 124 (62.0%)
1 technical error 163 71 (43.6%) 92 (56.4%)
2 technical errors 32 5 (15.6%) 27 (84.4%)
3 technical errors 5 0 5 (100%)
Reduction method 0.096
Closed 128 (34.0%) 57 (31.3%) 71 (36.4%)
Open 249 (66.0%) 125 (68.7%) 124 (63.4%)
Reduction quality ,0.001
Excellent 99 65 (65.7%) 34 (34.3%)
Good 197 85 (43.1%) 112 (56.9%)
Fair 68 30 (44.1%) 38 (55.9%)
Poor 13 2 (15.4%) 11 (85.6%)
Construct type
Multiple cannulated screws 95 107
Inadequate buttress screw* 202 68 (44.7%) 81 (54.0%) 0.070
Inadequate screw lengths† 150 2 (14.3%) 12 (85.7%) 0.026
Inadequate screw spread‡ 14 1 (20.0%) 4 (80.0%) 0.199
Mean position of “buttress screw” from 5 5.42 mm 7.51 mm 0.004
inferomedial cortex
Fixed angled devices (no. of fractures) 111 64
Tip apex distance (TAD) . 25 mm 175 10 (30.3%) 23 (69.7%) ,0.001
Mean TAD 33 18.3 6 5.2 mm 21.7 6 6.1 mm ,0.001
*Inadequate buttress screw = screw inferior screw .4 mm from intact inferomedial buttress.
†Inadequate screw spread = screws .1 cm from subchondral bone femoral head.
‡Inadequate screw spread #10 mm caudal to posterior screw.

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Collinge et al J Orthop Trauma  Volume 37, Number 5, May 2023

compared with 86% (12/14) when screws were malpositioned
(P , 0.001). The most common error in screw placement was
positioning the inferior calcar screw greater than 4 mm from
intact inferomedial cortex. For fractures treated with a fixed-
angle device, the failure rate was 57% for those with a poorly
positioned screw (TAD . 25 mm), compared with 18% with
an appropriately positioned screw (P , 0.001).
Of the entire cohort of 492 patients, 175 displaced
fractures were treated with a fixed-angle device and 202 were
treated with multiple cannulated screws (Table 4); the failure
rates were 37% (n = 64) and 53% (n = 107), respectively (P ,
0.001). Overall, 79% (n = 122) of the TEs experienced treat-
ment failure after a displaced fracture were related to improper
implant positioning, and this occurred much more frequently
with multiple cannulated screws (80% of cases) than with a
SHS (19% of cases). For example, the mean positioning of the
inferior calcar screw from the medial cortex was 5.4 mm in
those cases that healed in acceptable alignment, compared with
7.5 mm in those that failed (P = 0.004). Only 21% (n = 33) of
the TEs were felt to be related to an inadequate reduction.
Further analysis showed an odds ratio for failure of
5.1· when the occurrence of any TE was identified in dis-
placed fractures (95% confidence interval = 3.25–7.96).
Additional odds ratios for failure in this group included
9.0· for a poor reduction, 4.0· for multiple cannulated screw
constructs with inadequate screw lengths, and 1.1· for a fixed
angled device with TAD .25 mm. After adjusting for quality
of reduction, the odds of failure were still 2.5 times higher
(95% confidence interval = 1.31–4.86) when TE occurred.
The odds ratios of TEs are reported in Table 5.
DISCUSSION
In this analysis of 492 femoral neck fractures in young
adult patients treated with operative reduction and fixation at
26 Level 1 North American trauma centers, failures occurred
in 45% of all patients including 53% of displaced and 21% of
nondisplaced femoral neck fractures. Importantly, this study
demonstrated that TEs occurred in 50% of cases and that the
presence of a TE was found to have significant additive
effects on the outcomes of treatment, particularly for dis-
placed fractures—irrespective of the form of fixation chosen.
For example, only 27% of displaced fractures failed treatment
in the absence of a TE, compared with failure rates of 56%
with 1 TE, 84% with 2 TEs, and 100% with 3 TEs. These data
highlight the vital relationship between TEs and treatment
outcomes in young patients with displaced femoral neck frac-
tures. These TEs seem to be clearly measurable factors that
emphasize the importance of maintaining standards during
surgical repair of these fractures. The consequences of TEs
were not as clearly defined in nondisplaced fractures where
the rate of treatment failure was higher in the presence of TE,
but not as noteworthy.
This study also showed that the incidence of treatment
failure was incrementally worse with decreasing quality of
reduction in displaced fractures, as failed treatment
occurred in 34% of fractures with an “excellent” reduction,
compared with 57% with a “good” reduction, 56% of fair
reductions, and 86% of “poor” reductions. Although this
may be intuitive, in fact, a paucity of literature to support
this assertion, Haidukewych et al4 evaluated 51 patients less
than 50 years old with displaced femoral neck fractures and
found that nonunion or osteonecrosis developed in 28%
with a good or excellent reduction compared with 80% with
a fair or poor reduction. Upadhyay et al reported on a sim-
ilar group of young displaced femoral neck fractures treated
with multiple cannulated screw fixation and found that none
of the patients with a high-quality reduction developed a
nonunion, compared with 33% of those with a poor-quality
reduction.

TABLE 4. Fixation Construct’s Relationship to Technical error(s) and Treatment Failure in displaced Fractures
Fixed Angled Devices (175) Independent Screws (202)
F Factors Fractures without Failure Fractures with Failure Fractures without Failure Fractures with Failure P
All patients’ fractures 111 (63.7%) 64 (36.8%) 96 (47.5%) 106 (52.5%) 0.001
Repairs with no technical errors 90 (81.1%) 28 (44.3%) 41 (41.1%) 19 (18.5%) 0.077
Repairs with 1 technical error 21 (17.1%) 27 (44.3%) 50 (53.3%) 65 (63.9%) 0.555
Repairs with $2 technical errors 0 9 (100%) 5 (5.4%) 23 (21.3%) 0.225
Technical errors (all occurrences) 23 (46.9%) 26 (53.1%) 59 (41.6%) 83 (58.4%) 0.087
Poor reduction 1 (33.3%) 2 (66.7%) 0 (4.3%) 8 (100%) 0.511
Fair or poor reduction 4 (23.5%) 13 (76.5%) 5 (18.5%) 22 (81.5%) 0.688
Construct type
Multiple cannulated screws
Inadequate buttress screw*
Inadequate screw lengths† NA NA 64 (42.7%) 86 (57.3%) NA
Inadequate screw spread‡ NA NA 2 (14.3%) 12 (85.7%) NA
Fixed angled devices NA NA 1 (20%) 4 (80%) NA
Inadequate tip apex distance (.25 mm) 11 (33.3%) 22 (66.7%) NA NA NA
*Inadequate buttress screw = screw inferior screw .4 mm from intact inferomedial buttress.
†Inadequate screw lengths = screws .1 cm from subchondral bone femoral head.
‡Inadequate screw spread = independent multiple screw construct #10 mm between screws.

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J Orthop Trauma  Volume 37, Number 5, May 2023 Technical Errors in Repair of Young Femoral Neck Fractures

TABLE 5. Regression Analysis of displaced Fractures

Univariate Regression Models Multivariate Regression Model
Odds Lower Control Upper Control Odds Lower Control Upper Control
Technical Errors Ratio P Unit Unit Ratio P Unit Unit
Occurrence of any technical error 5.05 ,0 0.001 3.25 7.96 2.51 0.006 1.31 4.86
Quality of reduction
Good and excellent versus fair 2.44 ,0 0.001 1.56 3.84 1.86 0.04 1.02 3.43
and poor
Good and excellent versus poor 9.00 ,0.001 3.97 23.24 6.08 0.005 1.86 23.76
Fixed angled devices
Inadequate tip apex distance 1.12 ,0.001 1.05 1.19
(.25 mm)
Multiple cannulated screws
Quality buttress screw 0.70 0.24 0.39 1.26
Inadequate buttress screw* 1.05 0.27 0.98 1.12
Inadequate screw lengths† 3.96 0.03 1.23 17.66
Inadequate screw spread‡ NA NA NA NA
*Inadequate buttress screw = screw inferior screw .4 mm from intact inferomedial buttress.
†Inadequate screw lengths = screws .1 cm from subchondral bone femoral head.
‡Inadequate screw spread group too small for analysis.

TEs as they pertain to implant choice and positioning
also exerted a profound effect on treatment results: for
example, the use of a fixed-angle device construct was
associated with fewer TEs (30%) compared with the use of
multiple cannulated screws (64%) and treatment failures
occurred less often for fixed-angled devices (37%) than
multiple cannulated screw constructs (53%). These findings
are consistent with numerous biomechanical and clinical
studies that show superior fixation with fixed angled devices
when compared with multiple cannulated screws. Gardner
et al26 reported failure rates of 3% and 21% for fixed angle
devices and multiple cannulated screws, respectively, for
patients ,60 year old with a displaced femoral neck fracture.
A subsequent analysis in similar patients by Hoshino et al27
also favored fixed angle devices over multiple cannulated
screw reporting overall rates of treatment failure to 21% v
for SHS and 60% for multiple cannulated screws. The com-
parative misapplication of these implants relative to quality of
reduction and the presence or absence of displacement, how-
ever, has not been previously studied.
It seems logical in the context of our findings that even
a superior fixation construct will have shortcomings if not
properly applied. This study showed that fractures stabilized
with a fixed angled device and a TAD of .25 mm failed two-
thirds of the time (67%) compared with a quarter of the time
(28%) with a TAD #25 mm. Baumgaertner et al described
the TAD as a summation measurement indicating a “central
and deep” lag screw position for a single screw fixed angled
device and attributed an appropriate TAD to fixation strength
suitable to achieve union in most geriatric peritrochanteric
fractures.10 This is the first study in young adult femoral neck
fractures where certain parameters of fixed-angle fixation
such as TAD have been assessed relative to achieving union
and success with treatment.
Similar benchmarks representing “optimal fixation”
exist for multiple cannulated screw constructs, with the
recognized importance of placing the inferior “buttress” screw
within 3 to 4 millimeters of the inferomedial cortex along the
calcar.11,22 Most authors have recommended placing the
screws to a depth of 5–10 mm from the subchondral articular
surface, keeping them .1 cm from one another with the
thoughtful use of multiplanar imaging to prevent inadvertent
screw penetration.12,13 In the context of displaced femoral
neck fractures in young patients, there are 2 potential pitfalls
with this fixation technique: screws being malpositioned
remote from an intact medial cortex, or use of the construct
in a fracture pattern that does not allow for the placement of
an inferior buttress screw, as in some vertical neck fractures.
Although not objectively studied, both causes were observed
here, and treatment failures occurred in 57% of all multiple
cannulated screw constructs with a malpositioned inferior
buttress screw. Our findings corroborate existing literature
showing an average distance of 7.6 mm for the inferomedial
buttress screws from the cortex for the cases that went on to
fail treatment. We also found that 7% of multiple cannulated
screw constructs had screws that were of “inadequate length”
and 2% had “inadequate spread”.
The parameters of placing multiple cannulated screws
are expected to allow for “best case” repair strength by rely-
ing in dense subchondral bone with otherwise optimal
mechanics. Similarly, effectiveness of a SHS depends on
screw placement deep and central in the femoral head.
Although it is true that anatomic fracture reduction can, in
some cases, be quite difficult to achieve (with or without an
open reduction), errors in placement of implants and fixation
are usually related to impatience or lack of attention to detail.
Surgeons would be advised to pay close attention to implant
placement in these difficult cases as this study has shown a
significant correlation between failure of treatment with sub-
optimal implant positioning. Relevant educational forums
should continue to push these principles of treatment. To date,
research addressing the relationship between TEs and

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Collinge et al
complications is lacking for fracture treatment. However, var-
iables such as lack of specialization, low hospital volume,
increased case complexity, trainee participation, communica-
tion breakdowns, fatigue, and time of day have all been cited
as potential risk factors.26–30 Regenbogen et al reported on
4310 fracture cases at a European level 1 center, reviewing
surgical errors related to osteosynthesis.26 Although only
1.8% of those cases demonstrated a TE, 85% of those cases
with an error required early revision surgery. The most cited
TEs were poor quality reduction (30%) and incorrect implant
positioning (30%), with the hip being the most frequently
affected anatomy. TEs and performance in nonorthopaedic
surgery have not been studied either.8,28–32 Karsh et al30 stud-
ied complications at a large academic surgery department
over a 1-year period and found that TEs were responsible
for 78% of major complications across all specialties: the
errors cited included surgical technique (64%), judgment
(30%), inattention to detail (29%), and incomplete under-
standing of the clinical situation (23%).
Although the operative goals in repairing a femoral
neck fracture in young adult patients are anatomic reduction
and stable internal fixation, the surgeons’ process may be
complicated by inadequate understanding of the injury, trep-
idation regarding outcomes, sense of urgency due to the
patient’s physiological condition, and confusion about “best”
practices. Attentive preoperative planning is a potential means
to address obstacles and focus the surgical team to the treat-
ment goals. In a recent survey, Wade et al reported that
although 94%–100% of orthopaedic surgeons acknowledged
that preoperative planning in these specific cases was impor-
tant, less than half acknowledged routinely planning these
cases.32 A lack of principled treatment is also highlighted
by Luttrell et al in a survey of active OTA “expert” members
regarding young adult femoral neck fractures.32,33 Half of
surgeons recommended multiple cannulated screws, with
the other half choosing fixed angled devices: interestingly,
almost 80% stated that their choice was based on mechanical
superiority.
There are limitations to this study. First, some of the
measures regarding technical importance are not absolutely
validated for femoral neck fractures in young patients (ie,
TAD), although these concepts are clearly accepted as repre-
senting femoral head-neck fixation and this seems to represent
reasonable equivalence. Second, the data collected are based
on radiographic interpretation, measurements, and estima-
tions. Difficulties and inconsistencies may exist with the
assessment and measurement of radiographic images. Third,
the authors did not address some of the decisions that are
likely to affect treatment outcomes, such as whether to use
open versus closed reduction techniques and implant choice.
These decisions, while clearly important, cannot be ade-
quately assessed in a retrospective study design but should
be more directly addressed in future research. Fourth, since
the study period ended, at least 3 manufacturers have released
fixed angled devices designed specifically for use in femoral
neck fractures, but no cases were reported from our centers.
We acknowledge that the future use of these implants might
affect TEs and clinical outcomes differently than seen here.
Finally, we did not quantify the experience or training of the
220 | www.jorthotrauma.com
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J Orthop Trauma  Volume 37, Number 5, May 2023
surgeons participating in these surgeries. There are many
strengths to this study as well. First, this study evaluates
TEs in the largest cohort of young femoral neck fractures ever
reported. This specific aspect of treatment has never been
broadly investigated. Second, the “young” population of this
study was defined relatively strictly to patients ,50 years old.
This is important as many studies have included older patients
to grow their study size, which unfortunately comprises
patients with bony and patient factors differing from those
that are truly young.
In summary, we found that half of patients ,50 years
of age with a femoral neck fracture experienced a technical in
their surgical repair despite being cared for at a Level 1
trauma center and established quality benchmarks for hip
fracture repair. Furthermore, TEs had profound and additive
effects toward treatment failure. Overall, displaced fractures
without a TE failed 27% of the time highlighting the potential
need for improved implants or different fixation constructs for
these difficult injuries. Yet, surgeries performed with a single
TE more than doubled the risk of failure and increased incre-
mentally with additional TEs. We expect that this study will
shine a light on this problem and direct educational interven-
tions to decrease the rate of TEs. After that, a thoughtful
evaluation and preoperative plan, careful decision-making,
and a well-executed technique should lead to improved out-
comes for patients with these complex injury patterns.
APPENDIX
The following individuals meet ICJME criteria for
authorship. Site affiliations are as of time of study unless
otherwise noted.
Young Femoral Neck Fracture Working Group includes:
University of South Florida, Tampa, FL: Ben Streufert, MD;
Duke University School of Medicine, Durham, NC: Patton
Robinette, MD; University of Texas Southwestern Medical
Center, Dallas, TX: David O’Neill, MD; Boston University
Medical Center, Boston, MA: Nathan Olszewski, MD; Mayo
Clinic, Rochester, MN: Andrew Sems, MD, William Rainer,
MD, Brandon Yuan, MD; Prisma Health-Upstate, Greenville,
SC; Kyle Jeray, MD, Stephanie Tanner, MS; Orlando Health,
Orlando, FL: Stefano Cardin Poza, MD, Frank Avilucea, MD;
University of Cincinnati, Cincinnati, OH; Adam Schumaier,
MD; University of Rochester, Rochester, NY: John Ketz,
MD, Jon Hedgecock, MD; Dalhousie University, Halifax,
Nova Scotia: Chad Coles, MD; Nova Scotia Health
Authority, Halifax, Nova Scotia: Kelly Trask, MSc, Shelley
Macdonald; University of California-Irvine, Orange, CA:
John Scolaro, MD, David Bustillo; University of Missouri,
Columbia, MO: Brett D. Crist, MD, Kevin Horner;
University of Mississippi, Jackson, MS: Patrick Bergin, MD,
Daniel T. Miles, MD; University of Alabama Birmingham,
Birmingham, AL: Clay Spitler, MD; University of
Pennsylvania, Philadelphia, PA: Jaimo Ahn, MD, Joshua T.
Bram, MD Tyler Morris, MD; Atrium Health Musculoskeletal
Institute, Charlotte, NC: Joseph Hsu, MD, J. Stewart Buck,
MD; Hennepin Healthcare, Minneapolis, MN Andrew
Schmidt, MD, JR Westberg; NYU Langone Orthopaedic
Hospital, New York, NY: Nirmal Tejwani, MD, Devan Mehta
MD; Indiana University Health Methodist Hospital,
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 37, Number 5, May 2023
Indianapolis, IN: Walter Virkus, MD, Justin Harrington, MD;
OrthoIndy Trauma, Indianapolis, Indiana: Timothy Weber,
MD, Kathy Flint; Indiana University Health, Indianapolis,
IN: Brian Mullis, MD, Alex Lancaster, MD; RWJBarnabas
Health, Jersey City, NJ: Frank Liporace, MD, Don Adams,
DO; Geisinger Medical Center, Danville, PA: Daniel
Horwitz, MD, Eyal Yaacobi, MD; Inova Fairfax Medical
Campus, Falls Church, VA: Robert Hymes, MD; Walter
Reed National Military Medical Center, Bethesda, MD:
Kelly Kilcoyne, MD; Saint Louis University, St. Louis, MO:
Dominic Lusk, MD.
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