Skip to main content
JDRS · Open access journal
Joint Diseases and
Related Surgery
Online manuscript submissionSubmit a manuscript e-ISSN 2687-4792

Original Article · Open access

Clinical efficacy and safety of closed reduction versus in situ internal fixation for valgus-impacted femoral neck fractures: A meta-analysis

PDF Cite this article

Duo Shan

Department of Orthopedics, Tianjin University Tianjin Hospital, Tianjin, China

ORCID: 0009-0001-8801-3951

Zhong-bo Deng

Department of Orthopedics, Tianjin University Tianjin Hospital, Tianjin, China

ORCID: 0009-0009-8431-9425

Qiang Dong

Department of Traumatology, Tianjin University Tianjin Hospital, Tianjin, China

ORCID: 0009-0009-1552-0969

Abstract

Objectives: In this meta-analysis, we discuss the clinical efficacy of closed reduction with in situ fixation for valgus-impacted femoral neck fractures (VIFNFs) by contrasting postoperative functional recovery and complication profiles.

Materials and methods: We performed a systematic literature search in PubMed, Embase, Web of Science, the Cochrane Library, and ScienceDirect for publications up to October 2025. The search targeted original studies which directly compared the surgical outcomes of closed reduction and in situ internal fixation for valgus-impacted femoral neck fractures. Search terms included combinations of: valgus-impacted (or valgus impaction), femoral neck fracture, in situ, reduction, and internal fixation. Pooled data were analyzed using mean differences (MD) with 95% confidence intervals (CIs) for continuous outcomes and risk differences (RD) with 95% CIs for dichotomous outcomes.

Results: The final analysis included a total of 447 patients extracted from five studies that met the predetermined inclusion criteria. The meta-analysis demonstrated that the closed reduction group exhibited a statistically significant reduction in postoperative femoral neck shortening (FNS) compared with the in situ fixation group (MD: 4.05; 95% CI: 2.68 ~ 5.42; p < 0.00001). For the caput-collum-diaphysis (CCD) angle, the closed reduction group showed a borderline significant improvement relative to the in situ fixation group (MD: 9.79; 95% CI: 0.19 ~ 19.39; p = 0.05). The in situ fixation group was associated with a substantially lower reoperation rate (RD: –0.08; 95% CI: –0.16 ~ –0.01; p = 0.04). No statistically significant intergroup differences were detected for the Harris Hip Score (HHS) (MD: –4.13; 95% CI: –9.37 ~ 1.11; p = 0.12), incidence of femoral head necrosis (RD: –0.05; 95% CI: –0.14 ~ 0.05; p = 0.36), or fixation failure rate (RD: –0.05; 95% CI: –0.17 ~ 0.06; p = 0.37).

Conclusion: Closed reduction yields a statistically significant advantage in reducing postoperative FNS and a borderline significant benefit in maintaining the CCD. In contrast, in situ fixation is associated with a lower reoperation rate. The two strategies show comparable outcomes for the HHS, femoral head necrosis incidence, and fixation failure rate. Thus, surgical approach should be individualized based on patient-specific profiles.

* These authors contributed equally to this work.

Citation: Shan D, Deng ZB, Dong Q. Clinical efficacy and safety of closed reduction versus in situ internal fixation for valgusimpacted femoral neck fractures: A meta-analysis. Jt Dis Relat Surg 2026;37(3):581-591. doi: 10.52312/jdrs.2026.2733.

Declarations

Author Contributions

D.S., Z.B.D.: Contributed equally to this work. Contributed to conception and design of this study, contributed to preparation of the manuscript; D.S., Z.B.D., Q.D.: Study selection and data extraction of the finally included studies, and independently assessed the methodological quality of each included study, the final version of the article was approved by all the authors.

Conflict of Interest

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Financial Disclosure

The authors received no financial support for the research and/or authorship of this article.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

AI Disclosure

The authors declare that artificial intelligence (AI) tools were not used, or were used solely for language editing, and had no role in data analysis, interpretation, or the formulation of conclusions. All scientific content, data interpretation, and conclusions are the sole responsibility of the authors. The authors further confirm that AI tools were not used to generate, fabricate, or ‘hallucinate’ references, and that all references have been carefully verified for accuracy.

References

  1. Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int 1997;7:407-13. DOI: 10.1007/pl00004148.
  2. Zhang C, Chen Y, Zhang J. Non-coding RNAs in osteoarthritis and osteoporosis-related hip fractures: Molecular biomarkers for precision diagnosis and prognosis. Front Endocrinol (Lausanne) 2025;16:1653831. DOI: 10.3389/fendo.2025.1653831.
  3. Yoon PW, Shin YH, Yoo JJ, Yoon KS, Kim HJ. Progression of a fracture site impaction as a prognostic indicator of impacted femoral neck fracture treated with multiple pinning. Clin Orthop Surg 2012;4:66-71. DOI: 10.4055/cios.2012.4.1.66.
  4. Lucenti L, Sodano A, Panvini FMC, Vescio A, Papotto G, Testa G, et al. Does preoperative CT improve outcomes in femoral neck fracture fixation? A retrospective study. J Clin Med 2025;14:5917. DOI: 10.3390/jcm14165917.
  5. Huang Y, Lin D, Shangguan S, Lin F. Complications and risk factors after internal fixation of femoral neck fractures in young and middle-aged patients. Eur J Trauma Emerg Surg 2025;51:304. DOI: 10.1007/s00068-025-02991-8.
  6. Lewis SR, Macey R, Stokes J, Cook JA, Eardley WG, Griffin XL. Surgical interventions for treating intracapsular hip fractures in older adults: A network meta-analysis. Cochrane Database Syst Rev 2022;2:CD013404. DOI: 10.1002/14651858.CD013404.pub2.
  7. Heu JY, Kim JY, Lee SW. Outcomes of reduction and fixation versus in-situ fixation for valgus-impacted femoral neck fractures: A systematic review. Hip Pelvis 2025;37:178- 86. DOI: 10.5371/hp.2025.37.3.178.
  8. Vidakovic H, Kieser D, Hooper G, Frampton C, Wyatt M. Valgus-impacted subcapital neck of femur fractures: A systematic review, meta-analysis with cost analysis of fixation in-situ versus nonoperative management. Hip Int 2024;34:260-9. DOI: 10.1177/11207000231210240.
  9. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021;372:n71. DOI: 10.1136/bmj.n71.
  10. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): Development and validation of a new instrument. ANZ J Surg 2003;73:712-6. DOI: 10.1046/j.1445-2197.2003.02748.x.
  11. Jang BW, Park JW, Nho JH, Kim J, Kim TY, Lee YK, et al. Comparison between in situ fixation and fixation after closed reduction in valgus-impacted femoral neck fractures: A multicenter study. J Orthop Trauma 2025;39:127-31. DOI: 10.1097/BOT.0000000000002942.
  12. Kweon SH, Song JH, Park HW, Kang M, Lim YW, Lee SW, et al. Simple minimally invasive method to reduce valgus-impacted and tilted femoral neck fractures without soft tissue or cartilage injury: Radiological and clinical results. Orthop Surg 2023;15:2591-601. DOI: 10.1111/os.13841.
  13. Nobori T, Takegami Y, Tokutake K, Nakashima H, Mishima K, Okamoto M, et al. Comparative outcomes of in-situ fixation and fixation after reduction in geriatric patients with severe valgus-impacted femoral neck fractures: A retrospective multicenter (TRON group) study. Nagoya J Med Sci 2025;87:295-304. DOI: 10.18999/nagjms.87.2.295.
  14. Park YC, Um KS, Kim DJ, Byun J, Yang KH. Comparison of femoral neck shortening and outcomes between in situ fixation and fixation after reduction for severe valgusimpacted femoral neck fractures. Injury 2021;52:569-74. DOI: 10.1016/j.injury.2020.10.028.
  15. Yu T, Liu J, Ying J, Zhuang Y. “In-Out-In” percutaneous reduction technique for treatment of valgus-impacted femoral neck fractures: A technical trick and case series. Orthop Surg 2023;15:214-22. DOI: 10.1111/os.13582.
  16. Kamara E, Zvi YS, Vail TP. Treatment of valgus-impacted and nondisplaced femoral neck fragility fractures in the elderly. J Am Acad Orthop Surg 2021;29:470-7. DOI: 10.5435/JAAOS-D-19-00866.
  17. Zhu XZ, Han CX, Ai ZS, Wang W, Wu SH, Zhao KY, et al. A quantitative study of bone defects in displaced femoral neck fractures based on virtual reduction techniques. Comput Methods Programs Biomed 2022;222:106958. DOI: 10.1016/j.cmpb.2022.106958.
  18. Gjertsen JE, Fevang JM, Matre K, Vinje T, Engesæter LB. Clinical outcome after undisplaced femoral neck fractures. Acta Orthop 2011;82:268-74. DOI: 10.3109/17453674.2011.588857.
  19. Kain MS, Marcantonio AJ, Iorio R. Revision surgery occurs frequently after percutaneous fixation of stable femoral neck fractures in elderly patients. Clin Orthop Relat Res 2014;472:4010-4. DOI: 10.1007/s11999-014-3957-3.
  20. Gautam VK, Anand S, Dhaon BK. Management of displaced femoral neck fractures in young adults (a group at risk). Injury 1998;29:215-8. DOI: 10.1016/s0020-1383(97)00184-8.
  21. Wang JG, Wu JX, Li YM, Xu YY. Biomechanical analysis of the closed reduction internal fixation with cannulated screw of femoral neck fractures. Medicine (Baltimore) 2021;100:e24834. DOI: 10.1097/MD.0000000000024834.
  22. Jiang D, Zhu H, Cao J, Cai Q, Wu F, Li X, et al. Contralateral neck-shaft angle lower than 130° is associated with clinical failure in nongeriatric individuals: Analysis of the National Femoral Neck Fracture Database of 1066 patients. Clin Orthop Relat Res 2024;482:1801-12. DOI: 10.1097/CORR.0000000000003071.
  23. Zlowodzki M, Brink O, Switzer J, Wingerter S, Woodall J Jr, Petrisor BA, et al. The effect of shortening and varus collapse of the femoral neck on function after fixation of intracapsular fracture of the hip: A multi-centre cohort study. J Bone Joint Surg Br 2008;90:1487-94. DOI: 10.1302/0301-620X.90B11.20582.
  24. Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am 2004;86:1711-6. DOI: 10.2106/00004623-200408000-00015.
  25. Stoffel K, Zderic I, Gras F, Sommer C, Eberli U, Mueller D, et al. Biomechanical evaluation of the femoral neck system in unstable Pauwels III femoral neck fractures: A comparison with the dynamic hip screw and cannulated screws. J Orthop Trauma 2017;31:131-7. DOI: 10.1097/BOT.0000000000000739.
  26. Okike K, Udogwu UN, Isaac M, Sprague S, Swiontkowski MF, Bhandari M, et al. Not all Garden-I and II Femoral neck fractures in the elderly should be fixed: Effect of posterior tilt on rates of subsequent arthroplasty. J Bone Joint Surg Am 2019;101:1852-9. DOI: 10.2106/JBJS.18.01256.
  27. Yin H, Zhang Y, Hou W, Wang L, Fu X, Liu J. Comparison of complications between total hip arthroplasty following failed internal fixation and primary total hip arthroplasty for femoral neck fractures: A metaanalysis. Jt Dis Relat Surg 2025;36:479-88. DOI: 10.52312/jdrs.2025.2230.
  28. Stegelmann SD, Butler JT, Mathews DJ, Ostlie HC, Boothby BC, Phillips SA. Survivability of the Femoral Neck System for the treatment of femoral neck fractures in adults. Eur J Orthop Surg Traumatol 2023;33:2555-63. DOI: 10.1007/s00590-023-03474-5.
  29. Ju FX, Hou RX, Xiong J, Shi HF, Chen YX, Wang JF. Outcomes of femoral neck fractures treated with cannulated internal fixation in elderly patients: A long-term follow-up study. Orthop Surg 2020;12:809-18. DOI: 10.1111/os.12683.
  30. Honkanen JS, Ekman EM, Huovinen VK, Mäkelä KT, Koivisto M, Karvonen MP, et al. Preoperative posterior tilt increases the risk of later conversion to arthroplasty after osteosynthesis for femoral neck fracture. J Arthroplasty 2021;36:3187-93. DOI: 10.1016/j.arth.2021.04.039.