Orthopaedics & Traumatology: Surgery & Research 105 (2019) 985–990

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Orthopaedics & Traumatology: Surgery & Research

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Original article

Non-operative treatment is a reliable option in over two thirds of

patients with Garden I hip fractures. Rates and risk factors for failure
in 298 patients
Delphine Amsellem a,b , Sébastien Parratte a,b , Xavier Flecher a,b , Jean-Noël Argenson a,b ,
Matthieu Ollivier a,b,∗
a
CNRS, ISM UMR 7287, Aix-Marseille université, 13288 Marseille cedex 09, France
b
Department of orthopaedics and traumatology, institute of movement and locomotion, St. Marguerite hospital, 13009 Marseille, France

a r t i c l e i n f o a b s t r a c t

Article history: Background: Non-operative treatment for impacted femoral neck fractures is a now rarely used strategy
Received 10 October 2018 whose indications are controversial. No outcome predictors have been convincingly identified, in part
Accepted 4 April 2019 due to the small sizes of available studies. We conducted a large retrospective study with the following
objectives: (1) to evaluate the percentage of patients older than 65 years of age with non-operatively
Keywords: treated Garden I femoral neck fractures who experience secondary displacement, (2) to identify predictors
Femoral neck fracture of secondary displacement, and (3) to determine the frequency of non-operative treatment failure due
Garden I/non-displaced fracture
to any cause and requiring joint replacement surgery.
Age > 65 years
Non-operative treatment
Hypothesis: Non-operative treatment is reliable in patients older than 65 years of age with Garden I
femoral neck fractures.
Material and methods: Approval was obtained from the French data protection authority to conduct a ret-
rospective observational study of information in the Marseille university hospitals database. Consecutive
patients who were older than 65 years of age at traumatology department admission for Garden I femoral
neck fractures managed non-operatively between January 2007 and December 2017 were included. Non-
operative treatment consisted in a walking test on day 1 followed by radiographs on days 2, 7, 14, 21,
and 45 and after 3 and 12 months. Patients with secondary displacement underwent hip arthroplasty.
Demographic data, cognitive performance, and radiological parameters were collected for each patient.
We evaluated the rates of secondary displacement avascular necrosis, and non-union.
Results: We included 298 patients with a mean age of 82 years (range, 65–101). Mean follow-up was 5 ± 3
years. Secondary displacement occurred in 91 (30%) patients, at a mean of 16 days (range 2–45 days) after
the fracture. Avascular necrosis of the femoral head developed in 13 (4.3%) patients and non-union in 11
(3.7%) patients. Secondary displacement was significantly associated with hypnotic treatment (OR, 4.1;
95%CI, 2.2–7.5; p = 0.039), institutionalisation (OR, 6.7; 95%CI, 3.1–14.8; p = 0.028), a history of repeated
falls (OR, 13.5; 95%CI, 6.3–8.4; p < 0.0001), having three or more comorbidities (OR, 3.2; 95%CI, 1.7–5.8;
p = 0.046), and having dementia (OR, 3.5; 95%CI, 1.7–6.9; p = 0.0003). Secondary displacement occurred
in 18 (12%) of the 151 community-dwelling patients with normal cognition and no history of repeated
falls compared to 37 (75%) of the 50 institutionalised patients with dementia.
Discussion: Non-operative treatment was effective in 196 (66%) of 298 patients with Garden I femoral
neck fractures. Significant risk factors for secondary displacement were dementia, institutionalisation,
hypnotic treatment, multiple comorbidities, and a history of repeated falls. Of 151 community-dwelling
patients with normal cognition and no repeated falls, 133 (88%) achieved a full recovery with non-
operative treatment alone.
Level of evidence: IV, retrospective cohort study.
© 2019 Elsevier Masson SAS. All rights reserved.

∗ Corresponding author. UMR CNRS 787/AMU, centre hospitalo-universitaire Sud, institut du mouvement et de l’appareil locomoteur, hôpital Sainte Marguerite, 270,
boulevard de Sainte-Marguerite, 13009 Marseille, France.
E-mail address: [email protected] (M. Ollivier).

https://doi.org/10.1016/j.otsr.2019.04.021
1877-0568/© 2019 Elsevier Masson SAS. All rights reserved.
986 D. Amsellem et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) 985–990

1. Introduction

Garden I fractures (Fig. 1) [1], which account for 15% to 20% of all
femoral neck fractures [2], are incomplete fractures characterised
by limited displacement and continuity of the posterior capsule.
The mechanism of injury is excessive external rotation responsi-
ble for valgus and retroversion of the femoral head [3]. There is
probably little or no loss of blood supply to the femoral head, and
the fracture is stable due to impaction of the two fragments (Fig. 2).
Secondary displacement may occur, however, as a result of femoral
head retroversion or of poor cortical and cancellous bone quality
[4] combined with comminution [5]. Secondary displacement may
lead to delayed avascular necrosis by compromising the blood sup-
ply to the femoral head and increasing the pressure within the joint
capsule via the production of a haematoma around the fracture site
[6]. In published studies, the frequency of secondary displacement
ranged from 33% [7] to 44.3% [8]. Fig. 2. Kaplan-Meier curve of survival without secondary displacement.
Despite an abundant literature, no consensus exists regard-
ing the optimal management of Garden I hip fractures. Treatment 2. Material and methods
strategies include non-operative management, internal fixation,
and arthroplasty. Non-operative treatment has been proven effec- 2.1. Patients
tive in some cases of impacted fractures. Failure of non-operative
treatment may require secondary arthroplasty. A 2017 study by A multicentre retrospective cohort study was conducted in con-
Reina et al. [9] found no differences in mortality or functional out- secutive patients older than 65 years of age who were admitted
comes between internal fixation and arthroplasty used to treat to traumatology departments in the university hospital network
non-displaced femoral neck fractures in patients older than 80 in Marseille, France, between January 2007 and December 2017
years of age. Non-operative treatment of impacted femoral neck and who received non-operative management of a true Garden I
fractures is now rarely used and has controversial indications. No femoral neck fracture. Approval was first obtained from the French
strong predictors of non-operative treatment outcomes have been data protection authority (Commission de l’Informatique et des Lib-
identified to date, in part due to the often small size of available ertés, CNIL).
studies. Inclusion criteria were age older than 65 years; true, initially
We conducted a large retrospective study with the following impacted, Garden I femoral neck fracture visible on antero-
objectives: posterior and lateral pelvic radiographs; and non-operative
management. Exclusion criteria were age younger than 65 years
• to evaluate the percentage of patients older than 65 years of at the time of the fracture; pathological fracture; non-displaced
age with non-operatively treated Garden I femoral neck fractures Garden II or displaced Garden, III or IV fracture; pertrochanteric or
who experience secondary displacement; subtrochanteric fracture; and peri-prosthetic fracture. We included
• to identify predictors of secondary displacement; the 298 patients who met all the inclusion criteria and none of the
• to determine the frequency of non-operative treatment failure exclusion criteria.
due to any cause and requiring joint replacement surgery.
2.2. Methods
The working hypothesis was that non-operative treatment is
reliable in patients older than 65 years of age with Garden I femoral Non-operative management involved early ambulation in a
neck fractures. walking frame to decrease weight-bearing on the affected side and

Fig. 1. Radiographs taken at admission then 1 and 5 years later in a 77-year-old woman with a Garden I fracture on the left hip.
 D. Amsellem et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) 985–990 987

Table 1 correlation coefficient (R2 ). Values of p lower than 0.05 were taken
Main demographic and radiographic features in the overall population.
to indicate significant differences.
Features n of patients or mean (range)

Total number of patients 298 3. Results

Age (years) 81 (65–101)
Females/males 245/53
3.1. Secondary displacement rate
Body mass index (kg/m2 ) 25 (15–36)
Left hip/right hip 144/154
Institutionalised 57 Over the 11-year study period, 298 patients met our selection
Dementia 66 criteria, including 245 (86%) women. Mean age was 81.5 years
Parker score 7 (3–9) (range, 65-101 years) and 183 (61%) patients were older than 80
Hypnotic agents 106
History of falls 86
years. Mean follow-up was 5 ± 3 years. The right hip was fractured
Three or more comorbidities 139 in 154 (51%) patients.
Pauwel’s angle Secondary displacement occurred in 91 (30%) patients, at a mean
I 18 of 16 days (range, 2–45 days) after the fracture, and was consis-
II 241
tently managed by arthroplasty. Times to secondary displacement
III 38
Valgus,◦ 23 (2–49) were as follows: ≤ 2 days, n = 2; 3–5 days, n = 17; 6–8 days, n = 14;
Femoral head retroversion,◦ 13.4 (0–42) 9–10 days, n = 7; 11–15 days, n = 14; 16–20 days, n = 5; 21–30 days,
n = 21; and 31–45 days, n = 11.

a walking test on the day after the fracture (day 1) conducted by a

3.2. Non-operative treatment failure rate
physiotherapist under medical supervision. Follow-up radiographs
consisting of an antero-posterior view of the pelvis and antero-
Avascular necrosis of the femoral head occurred in 13 (4.3%)
posterior and lateral views of the affected hip were scheduled on
patients. Surgery was required in 11 (3.7%) patients for non-union
days 2, 7, 14, 21, and 45; after 3 and 12 months; and annually there-
or pain. Mean hospital stay length was 8 days (range, 2–34 days)
after (Fig. 1). Patients were informed that secondary displacement
overall, 7 days (range, 2–20 days) in the group without secondary
might occur and would require arthroplasty.
displacement, and 13 days (range, 5–34 days) in the group with
secondary displacement. Of our 298 patients, 26 (9%) died during
2.3. Assessment methods
follow-up, at a mean of 19 months (range, 0.3–96 months) after the
fracture. Mean 5-year survival without secondary surgery (for any
For each patient, we recorded the following information from
cause) was 70% ± 26% and mean 5-year survival without secondary
the electronic patient files in the hospital databases: age, sex, body
displacement was 68.8% ± 27.4% (Fig. 2).
mass index, institutionalisation at the time of the fall, use of hyp-
notic agents, comorbidities, and the Parker score (Table 1). The
radiographs were reviewed by two different physicians, one of 3.3. Predictors of secondary displacement
whom was a senior surgeon (MO). The following were measured
on the radiographs obtained at admission: Pauwel’s angle (1, 2, or Age, sex, and body mass index were not significantly associ-
3), degree of valgus on the antero-posterior radiograph of the hip, ated with secondary displacement. Six factors were significantly
and degree of femoral head retroversion on the lateral radiograph associated with secondary displacement, namely, institutionalisa-
of the hip. During follow-up, the radiographs were evaluated for tion, dementia, use of hypnotics, a history of falls, three or more
evidence of secondary displacement, which was defined as varus comorbidities, and a smaller angle of valgus displacement (Table 2).
displacement and classified as Garden III or IV. The multivariate logistic regression analysis identified five fac-
The primary outcome measure was the occurrence of secondary tors independently associated with a higher risk of secondary
displacement during follow-up. The secondary outcome measures displacement (Table 3), i.e., use of hypnotic agents (OR, 4.1; 95%CI,
were time to secondary displacement, hospital stay length, type of 2.2–7.5; p = 0.039), institutionalisation (OR, 6.7; 95%CI, 3.1–14.8;
surgery, and morbidity and mortality associated with secondary p = 0.028), a history of repeated falls (OR, 13.5; 95%CI, 6.3–8.46;
displacement. Arthroplasty during follow-up was recorded as a p < 0.0001), three or more comorbidities (OR, 3.2; 95%CI, 1.7–5.8;
marker for failure of non-operative management due to any cause p = 0.046), and dementia (OR, 3.5; 95%CI, 1.7–6.9; p = 0.0003). The
(avascular necrosis, pain, or non-union). angle of valgus displacement, in contrast, correlated with a lower
risk of non-operative treatment failure (R2 = 0.43 and p < 0.0001).
2.4. Statistical analysis Thus, impaction in valgus protected against secondary displace-
ment.
We compared the groups with and without secondary displace- Of the 50 institutionalised patients with dementia, 37 (75%)
ment (primary outcome measure). Distribution of each variable experienced secondary displacement. In contrast, of the 151 self-
was assessed to guide the choice between parametric and non- sufficient community-dwelling patients without repeated falls or
parametric tests for comparing quantitative and qualitative criteria. cognitive disorders, only 18 (12%) experienced secondary displace-
Kaplan-Meier curves were plotted to assess survival without ment.
delayed surgery for any reason and for secondary displacement.
There were no missing data. 4. Discussion
A multivariate logistic regression analysis was performed to
identify predictors of secondary displacement. First, univariate To date, no consensus exists about the optimal management
analyses were done to identify variables whose distribution dif- of Garden I fractures. Available treatment options include arthro-
fered between the groups with and without displacement, with plasty, internal fixation, and non-operative treatment. Fixation
p values < 0.20). These variables were then entered into the mul- using three percutaneously inserted screws is another alternative
tivariate model. The adjusted odds ratios (ORs) were computed to arthroplasty that decreases the risk of secondary displacement
with their 95% confidence intervals (95%CIs). Correlations between while allowing early ambulation. However, a secondary displace-
quantitative parameters were assessed by computing Spearman’s ment rate of 5.4% has been reported with this technique [10], which
988 D. Amsellem et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) 985–990

Table 2
Comparison of the groups with and without secondary displacement.

Featuresn of patients or mean (range) No displacement Displacement p value

Number of patients 207 91 (30%) –

Age (years) 78 (65–97) 80 (65–101) 0.058
Females/males 176/31 76/15 0.764
Body mass index (kg/m2 ) 24.8 (17–32) 25.3 (15–36) 0.311
Left side/right side 108/190 47/44 –
Institutionalisation 15 42 < 0.0001
Dementia 26 40 0.0003
Parker score 7 (4–9) 6 (3–9) 0.061
Hypnotic agents 45 59 < 0.0001
History of falls 21 65 < 0.0001
Three or more comorbidities 68 71 < 0.0001
Pauwel’s angle 0.173
I 16 2
II 166 75
III 24 14
Valgus,◦ 24.3 (3–43) 20.1 (2–49) 0.0046
Femoral head retroversion,◦ 14.5 (0–35) 12.5 (0–42) 0.384

Table 3
Multivariate analysis of factors potential independent predictors of secondary displacement.

Featuresn of patients or mean (range) No displacement Displacement Odds Ratio p value

Age (years) 78 (65–97) 80 (65–101) NS

Females/males 176/31 76/15 NS
Body mass index (kg/m2 ) 24.8 (17–32) 25.3 (15–36) NS
Left side/right side 108/190 47/44 NS
Institutionalised 15 42 6.7 (3.1–14.8) 0.028
Dementia 26 40 3.5 (1.7–6.9) 0.0003
Parker score 7 (4–9) 6 (3–9) 1.5 (0.9–2.3)
Hypnotic agents 45 59 4.1 (2.2–7.5) 0.039
History of falls 21 65 13.5 (6.3–28.4) < 0.0001
Three or more comorbidities 68 71 3.2 (1.7–5.8) 0.046
Valgus,◦ 24.3 (3–43) 20.1 (2–49) NS
Femoral head retroversion,◦ 14.5 (0–35) 12.5 (0–42) NS

NS: non-significant.

also exposes patients to complications related to the anaesthesia displacement rate of 46% in a retrospective review of patients with
and to the surgery itself (e.g., surgical-site infections) [11], as well Garden I fractures managed non-operatively with partial weight
as to a need for material removal [12]. To the best of our knowledge, bearing. Of their 110 patients, 5 were excluded when a review of
no previous study has demonstrated associations linking secondary their radiographs showed that they had Garden II or III fractures. In
displacement to institutionalisation, hypnotic agent use, or a his- our study, the rate of avascular necrosis was 4.3% (13 patients). This
tory of repeated falls. Assessments of these potential risk factors complication is classified among treatment failures, as it requires
are not usually performed, as they would require splitting small arthroplasty. In a study of 319 patients managed non-operatively,
patient groups, thereby reducing statistical power. The large num- Raaymakers et al. [18] found an 11% rate of avascular necrosis after
ber of patients in our study combined with the in-depth evaluation 2 years of follow-up.
that older patients receive at admission in our hospital network A 2002 study by Raaymakers [21] (Table 5) demonstrated that
allowed us to demonstrate significant associations linking the non- the risk of secondary displacement was higher in patients older
operative treatment success rate to institutionalisation, dementia, than 70 years. In a SoFCOT symposium multicentre study reported
medication use, and a history of repeated falls, rather than to older by Simon et al. in 2008 [22], secondary displacement occurred in
age at the time of the fall. Our findings confirm our working hypoth- 31% of patients and correlated with age. In contrast, age was not
esis that non-operative treatment is reliable in patients older than significantly associated with secondary displacement in our pop-
65 years admitted for Garden I femoral neck fractures. Among the ulation. This apparent discrepancy may be ascribable to the many
entire population of patients older than 65 years and admitted confounding factors, such as cognitive function, use of hypnotic
to university hospitals in Marseille between 2007 and 2017, 70% agents, and place of residence, which were identified in our study:
achieved a full recovery with non-operative treatment alone. The we suggest that these factors, rather than older age, were associ-
risk of secondary displacement was not associated with age, sex, ated with a higher risk of secondary displacement. In studies of
or body mass index [13,14]. Significant risk factors for secondary impacted femoral neck fractures conducted by Hansen and Sol-
displacement were institutionalisation, dementia, hypnotic agent gaard [17] and Otremski et al. [23], secondary displacement was
use, three or more comorbidities, and a history of repeated falls. not associated with Pauwel’s angle, valgus displacement, or femoral
In previous studies, the proportion of patients with secondary head retroversion. In our population, in contrast, valgus impaction
displacement ranged from 20% [15] to 66% [16] (Table 4). A prospec- protected against secondary displacement (24.3◦ in the group with-
tive study by Buord et al. [7] of 56 patients older than 65 years and out vs. 20.1◦ in the group with secondary displacement), and the
treated by unrestricted mobilisation starting 48 h after the frac- difference was statistically significant (p = 0.0046).
ture showed a secondary displacement rate of 33%. In their work Our retrospective cohort design was a hybrid of an epidemi-
reported 1978, Hansen et al. [17] described a 28% secondary dis- ological study and a descriptive analysis. We therefore obtained
placement rate after weight bearing resumption, similar to that data over a short period in a specific population. Furthermore,
found in our study. Verheyen et al. [13] observed a high secondary our study relied entirely on the Garden classification, which has a
 D. Amsellem et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) 985–990 989

Table 4
Previous studies of outcomes of non-operative management for Garden I fractures.

Authors n of patients Age, years Follow-up Secondary Treatment method

displacement

Hansen and Solgaard [17] 46 47–93 > 3 months 29% Immediate partial weight bearing with canes
Cserhati et al. [15] 122 Mean, 72 – 20% 7-10 days of bedrest, weight bearing after 8 weeks
Raaymakers and Marti [18] 167 14–94 6 months–10 years 14% 7 days of bedrest then partial weight bearing with canes
Bel et al. [16] 23 65–100 > 2 years 66% 7-10 days of bedrest, weight bearing after 6 weeks
Tanaka et al. [19] 38 68–92 6 months–7 years 63% 14 days of bed rest, weight bearing after 6 weeks
Verheyen et al. [13] 105 17–97 3 months–4 years 46% Immediate partial weight bearing
Shuqiang et al. [20] 115 60–80 2 months–5 years 48% Immobilisation for 6 weeks
Buord et al. [7] 56 65–99 12–28 months 23% Bed rest for 48 h then partial weight bearing with canes
Taha et al. [8] 61 37–96 3 months–5 years 55% Immediate partial weight bearing with canes

Table 5
Potential predictors of secondary displacement evaluated in previous studies.

n of patients (n) Factors studied

Significant Not significant

Hansen and 46 – Pauwel’s angle, amount of valgus,

Solgaard [17] femoral head retroversion
Raaymakers [21] 167 Age > 70 years (p = 0.0002) Valgus > 20◦ ,
Comorbidities (p < 0.001) early weight bearing,
Femoral head break in anterior cortex
retroversion > 20◦ (p = 0.009)
Pauwel’s III (p = 0.012)
Tanaka et al. [19] 38 Bed rest < 14 days (p < 0.01) Age, sex, amount of valgus, femoral
Dementia (p < 0.05) head retroversion
Bel et al. [16] 23 – Age, comorbidities, place of residence,
Parker, ASA, femoral head retroversion
Verheyen et al. [13] 105 Age, Pauwel’s, ASA
Shuqiang et al. [20] 115 Age 60–80 years (p = 0.03) ASA, Pauwel’s
Buord et al. [7] 56 – Age, sex, dementia, comorbidities,
Pauwel’s angle, amount of valgus
Taha et al. [8] 61 Garden II (p < 0.001) Age, sex, BMI, ASA, history of fracture,
Osteoporosis (p = 0.028) contralateral THA
Our study, 2018 298 ≥ 3 comorbidities, dementia, Age, sex, BMI, Parker score, amount of
institutionalisation, hypnotic valgus, femoral head retroversion,
agents, repeated falls Pauwel’s angle

ASA: American Society of Anesthesiology score; BMI: body mass index; THA: total hip arthroplasty.

number of limitations, as pointed out by Van Embden et al. [24]. The these criteria can help to select patients for non-operative treat-
Garden types can be simplified into displaced and non-displaced ment: thus, among self-sufficient community-dwelling patients
fractures. For rare potential risk factors of secondary displacement, with no history of repeated falls, only 14% experienced secondary
the number of patients may have been too small to provide suf- displacement.
ficient statistical power to detect significant associations. In our
daily practice, we do not obtain computed tomography scans in Disclosure of interest
patients with impacted femoral neck fractures. Our study therefore
relied on radiographic criteria, which were both qualitative (type None of the authors has any conflicts of interest to declare in
of fracture) and quantitative (displacement, change in trabecular relation to this work.
orientation). Determining the exact value of Pauwel’s angle [25] Delphine Amsellem declares he has no competing interest.
requires a true antero-posterior radiograph, which may be difficult Sébastien Parratte is an educational consultant for Zimmer,
to obtain in older patients with pain from a fracture [26]. Zhang et al. Adler, Arthrex, and Newclip.
[27] described a new angle that was measured more reliably than Xavier Flecher is an educational consultant for Zimmer and
Pauwel’s angle in patients with early failure of femoral neck fracture Adler.
fixation using three compression screws. Femoral head retrover- Matthieu Ollivier is an educational consultant for Stryker,
sion can be measured only on a true lateral radiograph of the hip, Arthrex, and Newclip.
whose acquisition requires sedation in hip fracture patients [28]. Jean-Noel Argenson is a consultant for Symbios, Zimmer, and
Finally, our study does not provide data on important points such Adler and receives royalties from Symbios and Zimmer.
as quality of life and medical and surgical complications associ-
ated with non-operative treatment alone and with non-operative Funding
treatment followed by delayed surgery.
This research did not receive any specific grant from funding
5. Conclusion agencies in the public, commercial, or not-for-profit sectors.

Non-operative treatment alone provided a full recovery in about Contributions of each author
70% of elderly patients with Garden I fractures followed up for a
mean of 5 years. Dementia, institutionalisation, hypnotic agent use, Delphine Amsellem and Matthieu Ollivier conceived the project,
multiple comorbidities, and a history of repealed falls were asso- designed the protocol, processed the study data, performed the
ciated with a higher risk of secondary displacement. Awareness of statistical analysis, and wrote the manuscript.
990 D. Amsellem et al. / Orthopaedics & Traumatology: Surgery & Research 105 (2019) 985–990

Sébastien Parratte, Jean-Noel Argenson, and Xavier Flecher [13] Verheyen CCPM, Smulders TC, van Walsum ADP. High secondary displacement
revised the manuscript for important intellectual content. rate in the conservative treatment of impacted femoral neck fractures in 105
patients. Arch Orthop Trauma Surg 2005;125:166–8.
[14] Helbig L, Werner M, Schneider S, Simank HG. Garden I femoral neck fractures:
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