Orthopaedics & Traumatology: Surgery & Research (2010) 96, 228—234

ORIGINAL ARTICLE

Garden I femoral neck fractures in patients 65 years

old and older: Is conservative functional treatment a
viable option?
J.-M. Buord a,∗, X. Flecher a, S. Parratte a, L. Boyer b,
J.-M. Aubaniac a, J.-N. Argenson a

a
University Hospital Musculo-Skeletal Institute, Sainte-Marguerite Hospital, Orthopaedics surgery and
Traumatology Department, Marseille, France
b
Public Health Division, Public Health and Medical Information Department,
La Timone Hospital, Marseille, France

Accepted: 17 November 2009

KEYWORDS Summary
Functional Introduction: Internal fixation is the preferred treatment of Garden I femoral neck fractures in
treatment/non- the elderly. High re-operation rates have however been reported, and the results of arthroplasty
surgical treatment; performed following internal fixation failure are not as good as those of primary arthroplasty.
Femoral neck This is why we are advocating functional treatment. Our hypothesis is that this treatment leads
fracture/hip to fewer decubitus complications than strict orthopaedic treatment and no more mechanical
fracture; complications than internal fixation in a selected population sample. Therefore, the objective
Non-displaced of our prospective work was: (1) to assess the results of functional treatment of Garden I
fracture; femoral neck fractures in elderly subjects, and (2) to investigate predictive factors of secondary
Elderly subject displacement.
Patients and methods: All patients over age 65 years, admitted for a Garden I femoral neck frac-
ture between January 2006 and May 2008, were included in this prospective study representing
56 cases (57 fractures) with an average age of 82 years. Functional treatment was performed,
including early weight-bearing mobilisation, followed by radiographic evaluation at days 2, 7,
21 and 45, then at 3, 6 and 12 months. In the absence of displacement, discharge was planned
at day 5 (Non-Displaced [ND] group). Otherwise, arthroplasty was performed (Displaced [D]
group). Parker score and Harris Hip Score (HHS) were used for functional evaluation.

∗ Corresponding author at: Hôpital Sainte-Marguerite, BP 29, 13274 Marseille cedex 09, France. Tel.: +33 6 30 54 40 19;

fax: +33 4 91 74 56 25.

E-mail address: jmbuord@gmail.com (J.-M. Buord).

1877-0568/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2009.11.012
Garden 1 femoral neck fractures in patients 65 years old and older 229

Results: The observed displacement rate was 33.3% (19 patients) within an average period of
10 days. In the ND group, one case of osteonecrosis was observed and treated by arthroplasty.
The average Parker score was 6.9 and the HHS 82 in the ND group, and 7 and 85, respec-
tively, in the D group. None of the factors studied (age, gender, side, fracture type, inclination
angle, degree of outward displacement, sagittal displacement, general status) was statistically
predictive of final displacement.
Discussion: The medical complication rate was only 7% in our series, which seems to be lower
than that resulting from orthopaedic treatment. The observed secondary displacement rate
seemed to be higher than the rate found in the literature on surgical treatment (5.4 to 20%),
but the osteonecrosis rate appeared to be lower (11 to 25%). In addition, surgical treatment
was the purveyor of specific complications in over 10% of cases.
Conclusions: The present prospective study with minimum 1-year follow-up shows that func-
tional treatment results in fewer decubitus complications than orthopaedic treatment and a
rate of revision surgery comparable to internal fixation since 70% of included patients could
have been successfully treated without surgical intervention. However, the investigation of a
larger cohort would be necessary to identify predictive factors for the treatment’s failure.
Level of evidence: Level III prospective non-comparative cohort study.
© 2010 Elsevier Masson SAS. All rights reserved.

Introduction • to investigate predictive factors of secondary displace-

ment.
Femoral neck fractures, as a consequence of osteoporosis,
are becoming a real public health problem with ageing of Patients and methods
the population in industrialized countries. These fractures
are predicted to double by 2050 [1,2], reaching a worldwide Patients
incidence of over six million a year [3]. Though arthroplasty
has proven superiority for displaced fractures [4,5] and
A prospective monocentric cohort study, aiming to assess the
osteosynthesis has become essential for non-displaced frac-
functional treatment of impacted femoral neck fractures in
tures in young subjects [6], the treatment of non-displaced
elderly subjects, was conducted over a continuous 30-month
or impacted fractures in the elderly remains without consen-
period.
sus. Historically, the treatment of Garden I femoral neck
The inclusion criteria were:
fractures [7] in the elderly pits orthopaedic treatment [8]
against classic osteosynthesis using triple screwing or the
• Garden I femoral neck fracture [7];
compression plate and screw method [9—16]. Nonetheless,
• recent injury (< 24 hours);
high rates of mechanical complications, mainly osteonecro-
• age 65 years or over;
sis and secondary displacement or pseudoarthrosis, have
• follow-up longer than 12 months.
been observed in the literature with a frequency rang-
ing from 24 to 50% [17,18]. In addition, in this context,
The exclusion criteria were:
arthroplasty results after osteosynthesis failure appear to
be clearly not as good as first-line arthroplasty in terms of
• age under 65 years;
survival, complications and functional results [19,20], lead-
• pathological fracture;
ing some authors to consider first-line arthroplasty for these
• a history of fracture in the studied hip.
fractures [21,22]. Functional treatment with early mobil-
isation and protected weight-bearing is another option,
but seems to increase the risk of secondary displacement. The variables assessed included age, sex, general state
This modality has already been the subject of a study by (ASA score [23], chronic diseases, dementia if MMS < 24),
SOFCOT [15], but follow-up lasted only 3 months, and no functional state (Parker score [24], Harris Hip Score (HHS)
predictive factor of secondary displacement was indicated. [25]) and the side injured. Initial X-rays were analyzed by
Our hypothesis is that functional treatment leads to fewer two different observers, including a senior department sur-
decubitus complications than orthopaedic treatment and geon, noting (1) fracture type; (2) subcapital or transcervical
a rate of mechanical complications comparable to that of location; (3) inclination angle of the fracture line based on
osteosynthesis. The purpose of our prospective study was Pauwels classification [26]; (4) valgisation degree (Fig. 1);
therefore: and (5) inclination angle on lateral X-rays (Fig. 2).

Therapeutic method
• to evaluate the results of managing Garden I femoral neck
fractures in subjects over age 65 years with a minimum Unique, original functional treatment was administered to
1-year follow-up; patients admitted to emergency with an impacted femoral
230
Figure 1 On anterior hip X-ray, the valgisation angle (AV) is
formed by the intersection of two straight lines passing through
bone fracture sections in the femoral neck (A) and head (B).
This angle measures fracture impaction in the anterior plane.
neck fracture (Fig. 3). After an initial 48-hour period of bed
rest during which patients received analgesics without any
additional immobilisation device (traction, splints, etc.),
this treatment included a full mobilisation test supported
by a pair of crutches or a walker under strict guidance by a
physiotherapist, followed with routine anterior and lateral
X-rays. In the absence of fracture displacement, a second
test was performed under similar conditions within less than
48 hours. The onset of decubitus complications (bedsores,
venous thrombosis, respiratory and urinary complications)
during hospitalisation was recorded for each patient.
Depending on whether or not secondary displacement
had occurred during one of two mobilisation tests or
after initial hospitalisation, the patients were assigned to
the displaced group (D group) or the non-displaced group
(ND group), respectively. Based on functional demand and
osteoarthritic status, we performed hemi-arthroplasty or
total hip arthroplasty in D group patients. Each patient was
prescribed rehabilitation care with assistance to resume
Figure 3 Results of functional treatment. A. Anterior at day 0. B. Lateral at day 0. C. Follow-up at day 7. D. Follow-up at 1 year.
J.-M. Buord et al.
Figure 2 On virtual lateral surgical hip X-ray, the sagittal
inclination angle (IS) is formed by the intersection of a straight
line (A) passing through the axis of the neck and a straight line
(B) parallel to the cephalic bone span going through the cen-
tre of the head (C). This angle measures head impaction in the
sagittal plane and its possible retro- or anteversion.
walking and preventive anticoagulant treatment with low-
molecular-weight heparin for a period of 2 months. Length
of hospitalisation, the need for and duration of a second
hospitalisation as well as discharge destination (home or
convalescence and/or rehabilitation centre) were recorded.
Assessment method
Follow-up X-rays were all analyzed by two different
observers, including a senior department surgeon, who
reported secondary displacement defined as any displace-
ment in varus, allowing the classification of fractures as
Garden III or IV. Potential valgus impaction was neither con-
sidered as secondary displacement nor as a factor of surgical
indication. All patients were seen during a consultation to
ensure radioclinical follow-up at 1, 3 and 6 weeks, 3, 6 and
12 months, to monitor consolidation as well as possible onset
of secondary displacement, pseudoarthrosis or osteonecro-
sis of the femoral head.
Garden 1 femoral neck fractures in patients 65 years old and older
Table 1 Data on patient series.
ND Group
Fracture (n) 40
M/W 3/37
Average age (years) 81.8 ± 9.2
Side (right/left) 22/18
Location
Sub-cephalic 34
Transcervical 6 3
Pauwels
I 16
II 21
III 4 6
Valgisation angle (◦ ) 21.5
Sagittal inclination (◦ ) 5.75
Length of hospitalisation (days) 8±4
ND: non-displaced; D: displaced.
Statistical methods
The patients’ sociodemographic characteristics
(age > 80 years, sex), clinical characteristics (side frac-
tured, dementia, existence of two or more co-morbidities,
ASA score) and radiographic characteristics (location on
neck, Pauwells score, valgisation > 15◦ and > 20◦ , sagittal
inclination angle) as well as complications during hospital-
isation were compared between the D and ND groups. In
this univariate analysis, we used the Chi-square test, and
replaced it, if necessary, by Fisher’s exact probability test
to compare proportions, and Student’s t-test was replaced
by the Mann-Whitney test when the distribution was not
normal, to compare averages of the two groups. Multivari-
ate analysis was conducted with a logistic regression model
to identify factors independently associated with secondary
displacement. Variables independently introduced into the
model included those identified by univariate analysis with
a value of p < 0.20. Associations were estimated with odds
ratios and 95% confidence intervals.
The threshold of statistical significance was set at 5%.
Statistical analyses were conducted with statistical treat-
ment software (SPSS version 15.0).
Results
Descriptive results
Of the 357 cases admitted to our hospital emergency for
cervical femoral neck fractures during the study period,
56 patients with 57 valgus-impacted fractures (15.7%) meet-
ing the inclusion criteria were treated according to the study
protocol (Table 1), including seven men and 49 women, with
one female patient who was injured on both sides during two
separate events that occurred several months apart. Aver-
age age of the series was 82.8 ± 8.5 years (65 to 99 years
old). The right side was injured in 29 cases, and the left, in
28 cases. Twelve patients did not present with co-morbidity
factors and 11 patients had dementia. Based on ASA clas-
sification [23], 12 patients were in Class I, 24 in Class II,
20 in Class III, and one in Class IV. Average follow-up was
20 ± 8 months (12 to 28 months). One patient was excluded
231
D Group Total
17 57
4/13 7/50
85 ± 6.1 82.8 ± 8.5
7/10 29 /28
14 48
9
3 19
7 28
10
19.1 21
6.1 6
15 ± 8 10 ± 6
from the statistical analysis of research into the predictive
factors of secondary displacement due to another fall on
the hip 2 months after the first injury, causing a basicer-
vical fracture in the same hip, which was treated by the
compression plate and screw method; 10 patients were lost
to follow-up, and eight patients were already dead at the
time of follow-up.
Radiographic analysis found nine transcervical and
48 subcapital fractures. Inclination angle of the fracture was
Pauwels I (< 30◦ ) in 19 cases, Pauwels II (30—50◦ ) in 28 cases,
and Pauwels III (> 50◦ ) in 10 cases. Average valgisation was
21 ± 10.7◦ (5◦ to 40◦ ) and average sagittal inclination was
6 ± 7◦ (0◦ to 25◦ ).
During initial hospitalisation, we found only three
complications (5.2%): two cases of bronchial congestion and
one case of trophic problems related to bed rest. Deep
venous thrombosis was diagnosed during convalescence and
received ambulatory treatment, for an overall complication
rate of 7%. Twenty-five patients (44.6%) were able to return
home or to their former lifestyles, and 30 patients needed
to be placed in a convalescent home.
Nineteen patients (33.3%) presented with secondary dis-
placement, for an average of 10.1 ± 4.9 days (1 to 30 days):
10 patients during their initial hospitalisation, for an aver-
age of 6.3 ± 4 days (1 to 15 days), seven patients were
admitted for a second hospitalisation, for an average of
11.8 ± 3.9 days (8 to 17 days), and two patients showed sec-
ondary displacement during follow-up at 1 month. Average
duration of hospitalisation was 10 ± 6 days (4 to 30 days) for
the entire cohort, 8 ± 4 days (4 to 21 days) for the ND group
and 15 ± 8 days (8 to 30 days) for the D group. Arthroplasty
was performed in 17 patients (three total arthroplasties and
14 hemi-arthroplasties), and two patients refused any kind
of procedure. In the ND group, radioclinical follow-up iden-
tified only one aseptic osteonecrosis of the femoral head at
12 months, which required total arthroplasty.
Analytical results
At follow-up, the average Parker score was 7 and the
HHS was 85 points in the D group, and 6.9 and 82 points,
232
Table 2 Univariate statistical analyses (Mann-Whitney
test).
Demographic data
Age > 80 years p = 0.108
Sex p = 0.206
Side p = 0.256
Dementia p = 0.153
> 2 co-morbidities p = 0.099
ASA p = 0.103
Radiographic data
Location p = 0.341
Pauwels classification p = 0.105
Valgisation > 20◦ p=1
Valgisation > 15◦ p=1
Sagittal inclination p = 0.675
respectively, in the ND group. No mechanical or infectious
complications were noted in the D group at follow-up. Only
one significant difference (p = 0.03) was found between the
two groups concerning average age, with higher age in the D
group (85 vs 81.8 in the ND group). However, analysis of age
over or under 80 years, mentioned by some authors [21,22]
as a predictive factor, did not show a significant difference
(p = 0.108). Despite the distribution of male patients in the
two groups, statistical analysis did not discern any signifi-
cant difference (p = 0.206). Univariate analyses (Table 2) did
not indicate any significant difference between the D and
ND groups with respect to other demographic factors (side,
dementia, co-morbidity) or radiographic factors (location,
Pauwels classification, initial valgisation over 15◦ , initial val-
gisation over 20◦ , initial sagittal inclination). Multivariate
logistic regression analyses were conducted on the demo-
graphic and radiographic data but no significant differences
were ascertained. None of these factors was considered to
be predictive.
Discussion
Classic treatments of Garden I femoral neck fractures in the
elderly include bed rest with or without traction until conso-
lidation is achieved, so-called ‘‘functional’’ treatments and
osteosynthesis by triple screwing or the compression plate
and screw method. We suggest functional treatment of Gar-
den I femoral neck fractures, including early mobilisation
with immediate resumption of weight-bearing to avoid sur-
gical intervention while limiting decubitus complications.
Factors limiting our study were the small number of cases
and differences in the number of subjects in the two groups.
The lack of power limited the statistical analysis. The second
factor limiting our study was the absence of osteoporo-
sis assessment. The only radiographic assessment tool for
osteoporosis found in the literature was the Singh index [27],
but recent studies have shown no correlation between the
degree of osteoporosis and this index [28—30]. As a result,
we did not investigate this factor.
The objective functional results of various treatments
are rarely assessed and often the measuring tools used can-
not be compared [31—35]. The average Parker score [24]
at follow-up in the ND group of our study was 6.9 and the
J.-M. Buord et al.
HHS [25] was 82 points. The SOFCOT series [15] obtained an
average Parker score of 5.5 in functionally-treated patients
at 3 months versus 5 in patients with osteosynthesis, which
did not seem to improve the results. Nikolopoulos et al. [36]
recorded HHS > 80 in 82.6% of patients after internal fixation.
In a study of non-displaced fracture treatment in patients
over age 60 years, Yih-Shiunn et al. [16] reported average
HHS of 84.2 ± 5.2 for DHS and 82.6 ± 5.1 for osteosynthe-
sis with cannulated screws. In a recent series involving
224 patients who had completed a self-evaluation question-
naire over 3 years after internal fixation, Rogmark et al.
[37] perceived 40% with average to severe pain on walk-
ing and 25% pain at rest, which led 4% of them to undergo
surgical material removal. The heterogeneity of these mea-
suring systems makes it difficult to compare different types
of treatment.
The displacement rate in our series was 33.3%, which
appears comparable to the data in the literature. At the
2008 SOFCOT symposium, Simon et al. [15] reported a
28% displacement rate for similar treatment in terms of
weight-bearing and early resumption of weight-bearing.
Raaymakers and Marti [22,38,39] observed displacement
rates of 14 to 31% with treatment similar to that in our study,
upon resumption of weight-bearing delayed by 1 week.
Verheyen et al. [26] noted a 46% displacement rate in a ret-
rospective series involving 105 patients aged 17 to 97 years,
after implementing partial weight-bearing, without a sig-
nificant difference between subgroups whose average age
was about 70 years. However, as Handoll and Parker [40]
point out, it is difficult to identify an exact trend in the
displacement rates of non-surgical treatments due to the
large variety of protocols found in the literature. With a
rate of 16 to 41% [13,35], prolonged bed rest with or without
traction — which theoretically has the advantage of delaying
surgery — does not consistently reduce the risk of secondary
displacement, while remaining a purveyor of decubitus
complications and cognitive deterioration [8,13,41]. These
high rates of decubitus complications have led numerous
authors to regard osteosynthesis as a first-line treatment
for postponing early weight-bearing to reduce secondary
displacements [9—11,13,14]. In a prospective series com-
paring 247 patients, Cserhati et al. [41] discerned 16% of
general complications with bed rest versus 3% for osteosyn-
thesis. In comparison to our study, prolonged bed rest did
not seem to offer benefits in terms of consolidation or
reduction of secondary displacements. We noted only 7% of
decubitus complications in our series, which was compara-
ble to the results of the SOFCOT series [15] that reported
4% of complications for the same protocol. We hypothesize
that mobilisation within 48 hours and authorisation of early
weight-bearing are certainly responsible for these low rates
of decubitus complications. In their retrospective, compar-
ative series, Jain et al. [42] had already shown a significant
decrease of mortality rates (2.5 times lower) than functional
treatment with early mobilisation or prolonged bed rest, the
mortality rate for early verticalisation approaching that of
surgical treatment by internal fixation.
The advantage of osteosynthesis would be to reduce
secondary displacement rates while authorizing early
weight-bearing. Rates may vary between 5.4% [43] and 20%
[17]. In addition, these techniques are associated with spe-
cific complications, such as infections at the operating site
Garden 1 femoral neck fractures in patients 65 years old and older
(10% according to Rodriguez-Merchan [44]), the need for
material ablation (4% according to Rogmark et al. [37]),
and the risk of anaesthesia. Osteosynthesis also does not
protect against aseptic osteonecrosis of the femoral head
and the possibility of arthroplasty. We found only one case
(2%) of osteonecrosis of the femoral head at 1 year in our
series, which is lower than the overall data in the litera-
ture on non-surgical treatments. The SOFCOT series [15] did
not have enough follow-up, and the osteonecrosis rate was
not indicated, whereas Raaymakers [39] ascertained 11%
of osteonecrosis in a 2-year follow-up of 319 functionally-
treated patients. It would appear that these rates are higher
with treatments by internal fixation, ranging from 11 to 25%
[17,36,44]. Chen et al. [43] reported 67% of radiological
signs of osteonecrosis at 1 year of surgical treatment, but
only 11% justified secondary arthroplasty.
The second objective of this work was to be able to make
a choice between functional treatment and first-line arthro-
plasty based on predictive criteria. However, we could not
identify predictive clinical factors of secondary displace-
ment on the basis of patient age, sex or general health (ASA
score [23], co-morbidity or dementia), thereby matching the
data in the literature. Heetveld et al. [32] have already
shown that physiological status cannot guide the therapy in
case of displaced femoral neck fractures among the elderly.
These criteria have been described as predictive by certain
authors: Raaymakers and Marti [22] as well as Hui et al. [21]
recommended first-line arthroplasty in women over 80 years
old. More recent studies involving larger series [12,14] have
revealed significant mortality with this option compared to
classic treatments, thus not endorsing this first-line treat-
ment [22,36]. Radiographic analysis has not disclosed a
significant difference with respect to fracture location, its
type according to Pauwels score, the degree of anterior val-
gisation or sagittal inclination of the femoral head, thereby
corroborating the literature [22,35,45]. A study involving
a larger population seems necessary to identify predictive
factors.
Conclusions
This investigation shows that functional treatment with
early mobilisation helps to successfully manage nearly 70%
of patients without exposing them to the risks of surgical
intervention. The secondary displacement rate is equiv-
alent to that of prolonged bed rest, with a decubitus
complication rate that is clearly lower. Osteosynthesis,
the currently-recommended treatment, presents a non-
negligible complication rate, without protecting against
secondary arthroplasty. Given that arthroplasty performed
after failure of functional treatment did not seem to evoke
a high complication rate in our study and that, on the other
hand, it was not possible to determine any predictive factors
of its failure, we believe that, as described in this investiga-
tion, functional treatment remains a valid option for Garden
I fractures among the elderly.
Conflict of interest statement
None.
233
References
[1] Brutel C, Omalek L. Demographic projections for France, its
regions and departments on the horizon in 2030. Résultats
INSEE 2003, insee.fr/fr/ffc/docs ffc/irsoc016.pdf.
[2] Cummings SR, Rubin SM, Black D. The future of hip fractures
in the United States. Numbers, costs, and potential effects of
postmenopausal estrogen. Clin Orthop 1990;252:163—6.
[3] Cooper C, Campion G, Melton 3rd LJ. Hip fractures
in the elderly: a world-wide projection. Osteoporos Int
1992;2:285—9.
[4] Bhandari M, Devereaux PJ, Swiontkowski MF, et al. Internal
fixation compared with arthroplasty for displaced fractures
of the femoral neck. A meta-analysis. J Bone Joint Surg Am
2003;85:1673—81.
[5] Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized
comparison of reduction and fixation, bipolar hemiarthro-
plasty, and total hip arthroplasty. Treatment of displaced
intracapsular hip fractures in healthy older patients. J Bone
Joint Surg Am 2006;88:249—60.
[6] Ly TV, Swiontkowski MF. Treatment of femoral neck fractures
in young adults. J Bone Joint Surg Am 2008;90:2254—66.
[7] Garden R. Low-angle fixation in fractures of femoral neck. J
Bone Joint Surg Br 1961;43:647—63.
[8] Heim M, Adunski A, Chechick A. Nonoperative treatment of
intracapsular fractures of the proximal femur. Clin Orthop
2002;399:35—41.
[9] Loizou CL, Parker MJ. Avascular necrosis after internal fixa-
tion of intracapsular hip fractures: a study of the outcome for
1023 patients. Injury 2009;40:1143—6.
[10] Nikolaou VS, Papathanasopoulos A, Giannoudis PV. What’s new
in the management of proximal femoral fractures? Injury
2008;39:1309—18.
[11] Parker MJ. The management of intracapsular fractures of the
proximal femur. J Bone Joint Surg Br 2000;82:937—41.
[12] Parker MJ, White A, Boyle A. Fixation versus hemiarthro-
plasty for undisplaced intracapsular hip fractures. Injury
2008;39:791—5.
[13] Shuqiang M, Kunzheng W, Zhichao T, Mingyu Z, Wei W. Out-
come of non-operative management in Garden I femoral neck
fractures. Injury 2006;37:974—8.
[14] Sikand M, Wenn R, Moran CG. Mortality following surgery
for undisplaced intracapsular hip fractures. Injury
2004;35:1015—9.
[15] Simon P, Gouin F, Veillard D, et al. Femoral neck frac-
tures in patients over 50 years old. Rev Chir Orthop
2008;94(Suppl.):S108—32.
[16] Yih-Shiunn L, Chien-Rae H, Wen-Yun L. Surgical treatment of
undisplaced femoral neck fractures in the elderly. Int Orthop
2007;31:677—82.
[17] Estrada LS, Volgas DA, Stannard JP, Alonso JE. Fixation failure
in femoral neck fractures. Clin Orthop 2002;399:110—8.
[18] Toh EM, Sahni V, Acharya A, Denton JS. Management of intra-
capsular femoral neck fractures in the elderly: is it time to
rethink our strategy? Injury 2004;35:125—9.
[19] Frihagen F, Madsen JE, Aksnes E, et al. Comparison of
re-operation rates following primary and secondary hemi-
arthroplasty of the hip. Injury 2007;38:815—9.
[20] McKinley JC, Robinson CM. Treatment of displaced intracap-
sular hip fractures with total hip arthroplasty: comparison
of primary arthroplasty with early salvage arthroplasty after
failed internal fixation. J Bone Joint Surg Am 2002;84:
2010—5.
[21] Hui AC, Anderson GH, Choudhry R, Boyle J, Gregg PJ. Inter-
nal fixation or hemiarthroplasty for undisplaced fractures of
the femoral neck in octogenarians. J Bone Joint Surg Br
1994;76:891—4.
234
[22] Raaymakers EL, Marti RK. Non-operative treatment of
impacted femoral neck fractures. A prospective study of
170 cases. J Bone Joint Surg Br 1991;73:950—4.
[23] Keats AS. The ASA classification of physical status — a recapit-
ulation. Anesthesiology 1978;49:233—6.
[24] Parker MJ, Palmer CR. A new mobility score for predicting mor-
tality after hip fracture. J Bone Joint Surg Br 1993;75:797—8.
[25] Harris WH. Traumatic arthritis of the hip after dislocation and
acetabular fractures: treatment by mold arthroplasty. An end-
result study using a new method of result evaluation. J Bone
Joint Surg Am 1969;51:737—55.
[26] Verheyen CC, Smulders TC, van Walsum AD. High secondary
displacement rate in the conservative treatment of impacted
femoral neck fractures in 105 patients. Arch Orthop Trauma
Surg 2005;125:166—8.
[27] Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern
of the upper end of the femur as an index of osteoporosis. J
Bone Joint Surg Am 1970;52:457—67.
[28] Hauschild O, Ghanem N, Oberst M, et al. Evaluation of Singh
index for assessment of osteoporosis using digital radiography.
Eur J Radiol 2008;71:152—8.
[29] Koot VC, Kesselaer SM, Clevers GJ, et al. Evaluation of the
Singh index for measuring osteoporosis. J Bone Joint Surg Br
1996;78:831—4.
[30] Soontrapa S, Soontrapa S, Srinakarin J, Chowchuen P. Singh
index screening for femoral neck osteoporosis. J Med Assoc
Thai 2005;88(Suppl. 5):S13—6.
[31] Eisler J, Cornwall R, Strauss E, et al. Outcomes of elderly
patients with nondisplaced femoral neck fractures, 2002. J
Orthop Trauma 2003;17:S31—7.
[32] Heetveld MJ, Raaymakers EL, Luitse JS, Nijhof M, Gouma
DJ. Femoral neck fractures: can physiologic status determine
treatment choice? Clin Orthop 2007;461:203—12.
[33] Jain R, Koo M, Kreder HJ, et al. Comparison of early
and delayed fixation of subcapital hip fractures in patients
J.-M. Buord et al.
sixty years of age or less. J Bone Joint Surg Am 2002;84:
1605—12.
[34] Parker MJ, Myles JW, Anand JK, Drewett R. Cost-benefit
analysis of hip fracture treatment. J Bone Joint Surg Br
1992;74:261—4.
[35] Tanaka J, Seki N, Tokimura F, Hayashi Y. Conservative treatment
of Garden stage I femoral neck fracture in elderly patients.
Arch Orthop Trauma Surg 2002;122:24—8.
[36] Nikolopoulos KE, Papadakis SA, Kateros KT, et al. Long-term
outcome of patients with avascular necrosis, after internal fix-
ation of femoral neck fractures. Injury 2003;34:525—8.
[37] Rogmark C, Flensburg L, Fredin H. Undisplaced femoral neck
fractures — no problems? A consecutive study of 224 patients
treated with internal fixation. Injury 2009;40:274—6.
[38] Raaymakers EL. Undisplaced femoral neck fracture. To operate
or not to operate? Acta Orthop Scand 1993;64:233—4.
[39] Raaymakers EL. The non-operative treatment of impacted
femoral neck fractures. Injury 2002;33(Suppl. 3):C8—14.
[40] Handoll HH, Parker MJ. Conservative versus operative treat-
ment for hip fractures in adults. Cochrane Database Syst Rev
2008;16:CD000337.
[41] Cserhati P, Kazar G, Manninger J, Fekete K, Frenyo S. Non-
operative or operative treatment for undisplaced femoral neck
fractures: a comparative study of 122 non-operative and 125
operatively treated cases. Injury 1996;27:583—8.
[42] Jain R, Basinski A, Kreder HJ. Nonoperative treatment of hip
fractures. Int Orthop 2003;27:11—7.
[43] Chen WC, Yu SW, Tseng IC, et al. Treatment of undis-
placed femoral neck fractures in the elderly. J Trauma
2005;58:1035—9.
[44] Rodriguez-Merchan EC. In situ fixation of nondisplaced intra-
capsular fractures of the proximal femur. Clin Orthop
2002;399:42—51.
[45] Parker MJ, Dynan Y. Is Pauwels classification still valid? Injury
1998;29:521—3.