A Retrospective Study on the Relationship Between Calcar Femorale Injury and Postoperative Complications of Femoral Neck Fracture in Young and Middle-Aged Patients Treated With Three Cannulated Screws

Abstract

Objectives: Given the critical biomechanical role of the calcar femorale in load transmission and fracture stability, understanding its relationship with postoperative complications is essential for optimizing surgical outcomes. Therefore, this study aimed to explore the relationship between calcar femorale injury and postoperative complications of femoral neck fracture in young and middle-aged patients.

Methods: A retrospective analysis was conducted on 350 femoral neck fracture patients (aged 18–65 years) treated with closed reduction and three cannulated screws fixation at a single institution from 2015 to 2020. Evaluate the clinical and imaging information of patients such as sex, age, body mass index, Garden classification, calcar femorale injury situation, computed tomography Hounsfield units (CT HUs), comorbidities (e.g., diabetes, hypertension etc.) and complications (femoral neck shortening, nonunion, and femoral head necrosis). CT-based 3D reconstruction was used to analyze calcar femorale morphology. Statistical analyses included univariate and multivariate logistic regression to identify independent risk factors.

Results: A total of 284 patients were included for analysis according to the inclusion and exclusion criteria. The results showed that Garden classification with displaced type (p < 0.001, OR = 4.615, 95% CI: 2.479–8.593), calcar femorale injury (p = 0.026, OR = 1.990, 95% CI: 1.087–3.645) and lower CT HUs (p = 0.002, OR = 0.989, 95% CI: 0.982–0.996) were independent risk factors for femoral neck shortening. Whether the patient has diabetes (p = 0.005, OR = 10.069, 95% CI: 2.043–49.628) was an independent risk factor for femoral neck nonunion. BMI (p = 0.030, OR = 1.154, 95% CI: 1.014–1.313) and Garden classification with displaced type (p < 0.001, OR = 10.000, 95% CI: 2.950–33.903) were independent risk factors for femoral head necrosis.

Conclusion: This study found that older patients with displaced type femoral neck fractures with calcar femorale injury are more likely to experience femoral neck shortening. Clinicians should pay close attention to the above risk factors to reduce the incidence of postoperative complications in young and middle-aged patients with femoral neck fractures.

Keywords

calcar femorale / femoral head necrosis / femoral neck fractures / femoral neck shortening / nonunion / postoperative complications

References

[1] Y. Z. Jin, B. H. Yin, L. Y. Shu, et al., “Morphological Characteristics of Femoral Neck Fractures in Young and Middle-Aged Population: A Retrospective Descriptive Study,” BMC Musculoskeletal Disorders 25, no. 1 (2024): 12.

[2] S. Johansson, “On the Operative Treatment of Medial Fractures of the Neck of the Femur,” Acta Orthopaedica Scandinavica 3, no. 3-4 (1932): 362-392.

[3] N. Ramadanov, I. Toma, H. Herkner, R. Klein, W. Behringer, and G. Matthes, “Factors That Influence the Complications and Outcomes of Femoral Neck Fractures Treated by Cannulated Screw Fixation,” Scientific Reports 10, no. 1 (2020): 758.

[4] M. Zlowodzki, O. Ayeni, B. A. Petrisor, et al., “Femoral Neck Shortening After Fracture Fixation With Multiple Cancellous Screws: Incidence and Effect on Function,” Journal of Trauma 64, no. 1 (2008): 163-169.

[5] G. P. Slobogean, S. A. Sprague, T. Scott, and M. Bhandari, “Complications Following Young Femoral Neck Fractures,” Injury 46, no. 3 (2015): 484-491.

[6] D. J. Stockton, K. A. Lefaivre, D. E. Deakin, et al., “Incidence, Magnitude, and Predictors of Shortening in Young Femoral Neck Fractures,” Journal of Orthopaedic Trauma 29, no. 9 (2015): e293-e298.

[7] N. Ramadanov, K. Jóźwiak, M. Hauptmann, et al., “Cannulated Screws Versus Dynamic Hip Screw Versus Hemiarthroplasty Versus Total Hip Arthroplasty in Patients With Displaced and Non-Displaced Femoral Neck Fractures: A Systematic Review and Frequentist Network Meta-Analysis of 5703 Patients,” Journal of Orthopaedic Surgery and Research 18, no. 1 (2023): 625.

[8] X. J. Wang, Z. H. Zhang, L. Li, Y. X. Su, and L. Wei, “Quadratus Femoris Muscle Pedicle Bone Flap Transplantation in the Treatment of Femoral Neck Fracture for Chinese Young and Middle-Aged Patients: A Systematic Review and Meta-Analysis,” Chinese Journal of Traumatology = Zhonghua Chuang Shang Za Zhi 20, no. 6 (2017): 347-351.

[9] A. Upadhyay, P. Jain, P. Mishra, L. Maini, V. K. Gautum, and B. K. Dhaon, “Delayed Internal Fixation of Fractures of the Neck of the Femur in Young Adults. A Prospective, Randomised Study Comparing Closed and Open Reduction,” Journal of Bone and Joint Surgery. British Volume (London) 86, no. 7 (2004): 1035-1040.

[10] W. Konarski, T. Poboży, A. Kotela, et al., “The Risk of Avascular Necrosis Following the Stabilization of Femoral Neck Fractures: A Systematic Review and Meta-Analysis,” International Journal of Environmental Research and Public Health 19, no. 16 (2022): 10050.

[11] F. Zhao, L. Guo, X. Wang, and Y. Zhang, “Analysis on Risk Factors for Neck Shortening After Internal Fixation for Pauwels II Femoral Neck Fracture in Young Patients,” European Journal of Medical Research 26, no. 1 (2021): 59.

[12] A. Hammer, “The Calcar Femorale: A New Perspective,” Journal of Orthopaedic Surgery 27, no. 2 (2019): 2309499019848778.

[13] Q. Zhang, W. Chen, H. J. Liu, et al., “The Role of the Calcar Femorale in Stress Distribution in the Proximal Femur,” Orthopaedic Surgery 1, no. 4 (2009): 311-316.

[14] J. Mei, L. Pang, and Z. Jiang, “Strategies for Managing the Destruction of Calcar Femorale,” BMC Musculoskeletal Disorders 22, no. 1 (2021): 460.

[15] M. Harty, “The Calcar Femorale and the Femoral Neck,” Journal of Bone and Joint Surgery (American Volume) 39-a, no. 3 (1957): 625-630.

[16] J. D. Lowell, “Results and Complications of Femoral Neck Fractures,” Clinical Orthopaedics and Related Research 152 (1980): 162-172.

[17] K. Zhang, Z. Teng, A. Li, et al., “Real Experience of Young and Middle-Aged Hemodialysis Patients: A Qualitative Meta-Synthesis,” Frontiers in Medicine 12 (2025): 1530465.

[18] F. Randelli, M. Viganò, A. Liccardi, et al., “Femoral Neck Fractures: Key Points to Consider for Fixation or Replacement a Narrative Review of Recent Literature,” Injury 54, no. S1 (2023): S70-S77.

[19] B. P. Cunningham, S. Brazina, S. Morshed, et al., “Fracture Healing: A Review of Clinical, Imaging and Laboratory Diagnostic Options,” Injury 48, no. S1 (2017): S69-S75.

[20] R. P. Ficat, “Idiopathic Bone Necrosis of the Femoral Head. Early Diagnosis and Treatment,” Journal of Bone and Joint Surgery (British Volume) 67, no. 1 (1985): 3-9.

[21] X. Zhou, J. Jia, and K. Lian, “Structural Characteristics, Biomechanics and Clinical Significance of Calcar Femorale: A Review,” Medicine (Baltimore) 103, no. 21 (2024): e38323.

[22] Y. Li, Y. Wang, B. Dong, et al., “Comparison of Rehabilitation Outcomes Between Robot-Assisted and Freehand Screw Placement in Treatment of Femoral Neck Fractures: A Systematic Review and Meta-Analysis,” BMC Musculoskeletal Disorders 25, no. 1 (2024): 208.

[23] L. Mcgarry, J. Rotaru, R. Gunaratne, et al., “Medial Buttress Plate Use in Neck of Femur Fracture Fixations: A Systematic Review,” Injury 56, no. 2 (2025): 112160.

[24] J. Felton, G. P. Slobogean, S. S. Jackson, et al., “Femoral Neck Shortening After Hip Fracture Fixation Is Associated With Inferior Hip Function: Results From the FAITH Trial,” Journal of Orthopaedic Trauma 33, no. 10 (2019): 487-496.

[25] A. Polat, A. Misir, M. O. Buyukkuscu, S. Basilgan, and H. Basar, “Factors Associated With Femoral Neck Shortening After Closed or Open Reduction and Screw Fixation,” Indian Journal of Orthopaedics 56, no. 2 (2022): 303-311.

[26] E. J. Lim, H. C. Shon, J. W. Cho, J.-K. Oh, J. Kim, and C.-H. Kim, “Dynamic Hip Screw Versus Cannulated Cancellous Screw in Pauwels Type II or Type III Femoral Neck Fracture: A Systematic Review and Meta-Analysis,” Journal of Personalized Medicine 11, no. 10 (2021): 1017.

[27] J. R. Andresen, G. Schröder, T. Haider, H.-C. Schober, and R. Andresen, “Osteoporosis Assessment Using Bone Density Measurement in Hounsfield Units in the Femoral Native CT Cross-Section: A Comparison With Computed Tomography X-Ray Absorptiometry of the Hip,” Diagnostics 15, no. 8 (2025): 1014.

[28] A. G. Abdallatif, A. Sharma, T. Mahmood, et al., “Complications and Outcomes of the Internal Fixation of Non-Displaced Femoral Neck Fracture in Old Patients: A Two-Year Follow-Up,” Cureus 15, no. 7 (2023): e41391.

[29] G. Zhao, M. Liu, B. Li, H. Sun, and B. Wei, “Clinical Observation and Finite Element Analysis of Cannulated Screw Internal Fixation in the Treatment of Femoral Neck Fracture Based on Different Reduction Quality,” Journal of Orthopaedic Surgery and Research 16, no. 1 (2021): 450.

[30] M. Tanios, B. Brickman, E. Cage, et al., “Diabetes and Impaired Fracture Healing: A Narrative Review of Recent Literature,” Current Osteoporosis Reports 20, no. 5 (2022): 229-239.

[31] N. Sheng, F. Xing, J. Wang, et al., “Recent Progress in Bone-Repair Strategies in Diabetic Conditions,” Materials Today Bio 23 (2023): 100835.

[32] Y. Shen, Y. Zhang, Z. Zhou, et al., “Dysfunction of Macrophages Leads to Diabetic Bone Regeneration Deficiency,” Frontiers in Immunology 13 (2022): 990457.

[33] F. X. Ju, L. F. Tang, J. F. Wang, et al., “Age is Not the Most Important Factor in the Prognosis of Femoral Neck Fracture: An Analysis of Long-Term Clinical Follow-Up,” Alternative Therapies in Health and Medicine 29, no. 6 (2023): 430-435.

[34] F. Pei, R. Zhao, F. Li, X. Chen, K. J. Guo, and L. Zhu, “Osteonecrosis of Femoral Head in Young Patients With Femoral Neck Fracture: A Retrospective Study of 250 Patients Followed for Average of 7.5 Years,” Journal of Orthopaedic Surgery and Research 15, no. 1 (2020): 238.

[35] B. C. Liu, C. Sun, Y. Xing, et al., “Analysis of Risk Factors for Necrosis of Femoral Head After Internal Fixation Surgery in Young and Mid-Aged Patients With Femoral Neck Fracture,” Beijing Da Xue Xue Bao Yi Xue Ban = Journal of Peking University Health Sciences 52, no. 2 (2020): 290-297.

[36] M. S. Hamdy, A. O. Sabry, M. Abdelazim, et al., “Does Capsulotomy in Closed Reduction of Garden Type 3 Femoral Neck Fractures Decrease Incidence of Avascular Necrosis? A Randomized Controlled Trial,” European Journal of Orthopaedic Surgery & Traumatology 35, no. 1 (2025): 155.

[37] H. Chen, G. Wu, S. Cao, et al., “Clinical Outcomes of Open Reduction and Internal Fixation Combined With Sartorius Muscle Iliac Bone Graft Transplantation for Displaced Femoral Neck Fractures in Middle-Aged and Young Adults: A Retrospective Analysis of 24 Cases,” BMC Musculoskeletal Disorders 25, no. 1 (2024): 1011.

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.