Fractures of the neck of femur constitute a significant orthopaedic challenge and are associated with considerable morbidity, functional disability, and socioeconomic burden. Hip fractures account for approximately 20% of the operative workload in orthopaedic trauma, with femoral neck fractures representing nearly 50% of all fractures around the hip. The lifetime risk of sustaining a hip fracture is substantially higher among females than males. With increasing life expectancy and progressive population ageing, the global incidence of hip fractures continues to rise, placing an additional burden on healthcare systems [1].Femoral neck fractures commonly occur following low-energy trauma in elderly individuals with osteoporosis, whereas younger patients usually sustain these injuries following high-energy trauma, particularly road traffic accidents and falls from height [2,3]. The worldwide incidence of hip fractures has increased considerably, with approximately 1.3 million cases reported in 1990 and projections suggesting a substantial increase by 2050. Femoral neck fractures in young adults are particularly concerning because of their potential to compromise the vascular supply to the femoral head, resulting in serious complications such as nonunion and avascular necrosis [4-8].The primary objective of treatment is to achieve fracture union, preserve femoral head viability, and restore pre-injury functional status. Anatomical reduction followed by stable internal fixation remains the preferred treatment for most young patients, whereas arthroplasty is frequently recommended for displaced fractures in elderly individuals. Successful management depends on several factors, including fracture displacement, quality of reduction, stability of fixation, and preservation of the femoral head blood supply [9,10].The optimal timing of surgical intervention in displaced femoral neck fractures remains controversial. Early reduction and fixation have traditionally been advocated to minimize vascular compromise and reduce the risk of complications. Some authors recommend surgical intervention within 6–12 hours of injury, particularly in young adults, while others favour fixation within 24 hours. However, the evidence regarding the independent influence of surgical timing on fracture healing and femoral head viability remains inconclusive [1,11].The degree of fracture displacement and disruption of the retinacular vessels may significantly influence femoral head perfusion. Anatomical reduction is therefore considered essential for restoring alignment, minimizing further vascular injury, and facilitating fracture healing. Internal fixation using cannulated cancellous screws is commonly preferred because it provides stable fixation with relatively limited soft-tissue disruption, reduced blood loss, and shorter operative duration [12]. The present study aimed to evaluate the effect of timing of surgical intervention on the quality of reduction in patients with displaced femoral neck fractures, with particular emphasis on the interval between injury and surgery.

The present study was an observational descriptive study conducted in the Department of Orthopaedics, Ballari Medical College and Research Centre, Ballari, Karnataka, India. The study was undertaken to evaluate the effect of timing of surgical intervention on the quality of reduction in patients with displaced fractures of the neck of femur.The study was conducted over a period of two years, from 1st August 2022 to 31st July 2024. Study Population The study included patients aged 18–60 years who presented to the Orthopaedics Outpatient Department (OPD) or emergency services of Ballari Medical College and Research Centre, Ballari, with a diagnosis of displaced fracture neck of femur. Patients fulfilling the predefined inclusion and exclusion criteria were enrolled in the study. Sample Size The minimum required sample size was calculated using the formula for estimating a population proportion. The calculated minimum sample size was approximately 28 patients. However, the original study protocol specified a minimum sample size of 25 patients. A total of 36 patients fulfilling the eligibility criteria were included in the study. Eligibility Criteria Inclusion Criteria Patients aged between 18 and 60 years who were diagnosed with displaced fractures of the neck of femur were included in the study. Exclusion Criteria Patients meeting any of the following criteria were excluded: 1. Pathological fractures of the neck of femur associated with malignant conditions. 2. Fractures of the neck of femur associated with ipsilateral femoral shaft fractures. 3. Established nonunion of fractures of the neck of femur. Preoperative Assessment and Investigations All enrolled patients underwent detailed clinical evaluation, including assessment of the mechanism of injury, duration since injury, clinical presentation, and associated medical conditions. A comprehensive pre-anaesthetic evaluation was performed to determine fitness for surgery.Radiological investigations included an anteroposterior (AP) radiograph of the pelvis with both hips, an AP radiograph of the affected hip with gentle traction and 15° internal rotation, and a lateral radiograph of the affected hip. A chest radiograph was also obtained as part of the preoperative assessment.Routine laboratory investigations included complete blood count, renal function tests, liver function tests, random blood glucose, and serological screening. Electrocardiography was performed as part of the pre-anaesthetic evaluation.Written informed consent for the surgical procedure and anaesthesia was obtained from all patients before surgery. Surgical Procedure All patients who were declared fit for surgery following preoperative assessment underwent operative management under spinal or epidural anaesthesia. The procedures were performed on a fracture table under image intensifier guidance. Initially, closed reduction of the fracture was attempted using gentle longitudinal traction and internal rotation of the affected limb. In most patients, satisfactory reduction was achieved using this technique. In selected cases, additional abduction or adduction of the limb, as described in Whitman's technique, was required to obtain adequate reduction.The adequacy of fracture reduction was assessed intraoperatively using an image intensifier in both anteroposterior and lateral projections. Particular attention was given to restoration of anatomical alignment and the continuity of Lowell's S-shaped curve. In two patients in whom satisfactory reduction could not initially be achieved, fracture disimpaction was performed in flexion using Flynn's method, followed by reduction with traction.Following satisfactory reduction, the operative site was prepared using standard antiseptic painting and sterile draping. A lateral surgical approach was used to expose the proximal femur. Under fluoroscopic guidance, three parallel guidewires were introduced across the fracture site into the subchondral region of the femoral head.A 3.2-mm cannulated drill was passed over the guidewires, followed by insertion of 6.5-mm cannulated cancellous screws to stabilize the fracture. Screw lengths were determined using a reference guidewire and confirmed fluoroscopically. Washers were used as required to secure fixation.Care was taken to ensure appropriate screw positioning within the femoral head, with central placement on the lateral view and distribution across the superior, central, and inferior regions on the anteroposterior view. Final fracture reduction and implant positioning were confirmed under fluoroscopic guidance, and the surgical wound was closed in layers. Perioperative Antibiotic Prophylaxis All patients received one dose of intravenous antibiotics before surgery, followed by two postoperative intravenous doses. Subsequently, patients were switched to oral antibiotics for an additional three days according to the institutional treatment protocol. Postoperative Management and Rehabilitation Postoperative rehabilitation was initiated as soon as patients recovered from anaesthesia. Active quadriceps strengthening exercises and knee range-of-motion exercises were encouraged during the immediate postoperative period. Patients were advised to sit and perform gentle hip and knee movements on the first postoperative day. Mobilization with walker support was initiated on the second postoperative day, with strict non-weight-bearing ambulation maintained for a minimum of three months.Sutures were removed between the 10th and 12th postoperative days. Weight-bearing activities were permitted only after satisfactory radiological evidence of fracture union was observed. Radiological union was noted between 14 and 18 weeks in the study series. Partial weight bearing was initiated initially and gradually progressed to full weight bearing over approximately one month. Assessment of Fracture Reduction The quality of fracture reduction was assessed intraoperatively using anteroposterior and lateral fluoroscopic images. Restoration of anatomical alignment, correction of displacement, and continuity of Lowell's S-shaped curve were considered important indicators of satisfactory reduction.The interval between injury and surgical intervention was documented to evaluate its association with the quality of fracture reduction. The relationship between surgical timing and reduction quality was assessed to determine whether earlier surgical intervention was associated with more favourable anatomical alignment. Follow-up and Outcome Assessment All patients were followed up monthly until radiological union was achieved. Subsequently, follow-up assessments were conducted at six-month intervals for up to two years.During follow-up, patients underwent clinical and radiological evaluation to assess fracture healing, maintenance of reduction, implant position, and postoperative complications. Radiographs were reviewed to determine progression of fracture union and identify complications such as nonunion, avascular necrosis of the femoral head, or implant-related problems.The primary outcome of the study was the quality of fracture reduction in relation to the interval between injury and surgical fixation. Data Collection Data were collected using a structured study proforma that included demographic characteristics, clinical presentation, mechanism of injury, radiological findings, interval between injury and surgery, intraoperative reduction characteristics, fixation details, and postoperative outcomes.All relevant clinical and radiological findings were documented and entered into a Microsoft Excel spreadsheet for subsequent statistical analysis. Statistical Analysis The collected data were entered into Microsoft Excel and analysed using IBM SPSS Statistics, version 24.0 (IBM Corp., USA). Qualitative variables were expressed as frequencies and percentages, whereas quantitative variables were presented as mean ± standard deviation (SD). Standard errors of the mean were calculated where appropriate.Associations between categorical variables were assessed using the Chi-square test or Fisher's exact test, depending on the expected cell frequencies. Comparisons of continuous variables between two independent groups were performed using the unpaired Student's t-test when the assumptions of the test were satisfied.All statistical tests were considered two-tailed. A p-value of less than 0.05 was considered statistically significant, whereas a p-value of less than 0.001 was considered highly statistically significant.

The present study included 36 patients with femoral neck fractures. The demographic distribution showed that the highest proportion of patients belonged to the age group of 41–50 years (33.33%), followed by 51–60 years (30.56%), 18–30 years (25.00%), and 31–40 years (11.11%). Male patients constituted 55.56% (n = 20) of the study population, while females accounted for 44.44% (n = 16), indicating a slight male predominance (Table 1).According to Garden's classification, Type III femoral neck fractures were the most frequently observed, accounting for 50.00% (n = 18) of cases. Type II and Type IV fractures were equally distributed, each representing 25.00% (n = 9) of the study population (Table 2 and Figure 1).Regarding the injury-to-surgery interval, the majority of patients (55.56%, n = 20) underwent surgical intervention within 1–2 days of injury (Group 1). Approximately 27.78% (n = 10) underwent surgery between 3 and 7 days (Group 2), while 16.67% (n = 6) were operated on more than 7 days after injury (Group 3) (Table 3 and Figure 2).The quality of fracture reduction varied considerably according to the injury-to-surgery interval. In Group 1, excellent reduction was achieved in 80.00% (n = 16) of patients, while the remaining 20.00% (n = 4) had good reduction, with no cases of poor reduction. In Group 2, excellent, good, and poor reductions were observed in 20.00%, 60.00%, and 20.00% of patients, respectively. In Group 3, none of the patients achieved excellent reduction, while 66.67% (n = 4) had good reduction and 33.33% (n = 2) had poor reduction. Overall, excellent reduction was achieved in 50.00% of patients, good reduction in 38.89%, and poor reduction in 11.11%. These findings demonstrated a descriptive trend toward better fracture reduction with earlier surgical intervention (Table 4).Radiological union was achieved within 3 months in 25.00% (n = 9) of patients and within 4 months in 38.89% (n = 14). An additional 13.89% (n = 5) achieved union at 5 months, while 13.89% (n = 5) required more than 5 months for union. Nonunion was observed in 8.33% (n = 3) of patients. Thus, the largest proportion of patients achieved radiological union at 4 months following surgical intervention (Table 5 and Figure 3).Postoperative complications were reported in 11.11% (n = 4) of patients. Nonunion was the most frequent complication, occurring in 8.33% (n = 3), followed by surgical site infection in 2.78% (n = 1). The majority of patients (88.89%, n = 32) experienced no reported postoperative complications during the study period (Table 6). Table 1. Distribution of Study Participants According to Age and Gender (N = 36) Parameters Frequency (n) Percentage (%) Age group (years) 18–30 9 25.00 31–40 4 11.11 41–50 12 33.33 51–60 11 30.56 Gender Male 20 55.56 Female 16 44.44 Total participants 36 100.00 Table 2. Distribution of Study Participants According to Garden's Classification of Femoral Neck Fractures (N = 36) Garden's classification Frequency (n) Percentage (%) Type II 9 25.00 Type III 18 50.00 Type IV 9 25.00 Total 36 100.00 Figure 1 Distribution of Study Participants According to Garden's Classification of Femoral Neck Fractures (N = 36) Table 3. Distribution of Study Participants According to Injury-to-Surgery Interval (N = 36) Injury-to-surgery interval Study group Frequency (n) Percentage (%) 1–2 days Group 1 20 55.56 3–7 days Group 2 10 27.78 More than 7 days Group 3 6 16.67 Total 36 100.00 Figure 2 Distribution of Study Participants According to Injury-to-Surgery Interval (N = 36) Table 4. Association Between Injury-to-Surgery Interval and Quality of Fracture Reduction (N = 36) Injury-to-surgery interval Excellent n (%) Good n (%) Poor n (%) Total (n) 1–2 days (Group 1) 16 (80.00) 4 (20.00) 0 (0.00) 20 3–7 days (Group 2) 2 (20.00) 6 (60.00) 2 (20.00) 10 More than 7 days (Group 3) 0 (0.00) 4 (66.67) 2 (33.33) 6 Total 18 (50.00) 14 (38.89) 4 (11.11) 36 Table 5. Distribution of Study Participants According to Time Taken for Radiological Union (N = 36) Time taken for union Frequency (n) Percentage (%) 3 months 9 25.00 4 months 14 38.89 5 months 5 13.89 More than 5 months 5 13.89 Nonunion 3 8.33 Total 36 100.00 Figure 3 Distribution of Study Participants According to Time Taken for Radiological Union (N = 36) Table 6. Distribution of Postoperative Complications Among Study Participants (N = 36) Postoperative complications Frequency (n) Percentage (%) Nonunion 3 8.33 Surgical site infection 1 2.78 No complications reported 32 88.89 Total 36 100.00

In the present study, the majority of patients belonged to the 41–50-year age group (33.33%), followed by 51–60 years (30.56%). Male patients constituted 55.56% of the study population, while females accounted for 44.44% (Table 1). Huang et al. (2010)[12] studied displaced femoral neck fractures in patients aged 20–50 years, highlighting the occurrence of these injuries in younger adults. Duckworth et al. (2011)[13] evaluated 122 patients aged 60 years or younger and reported that patients older than 40 years had significantly higher rates of fixation failure (p=0.03). These findings emphasize the importance of age in determining treatment outcomes. In the present study, Garden type III fractures were the most common (50%), followed by type II (25%) and type IV (25%) fractures (Table 2). Huang et al. (2010)[12] investigated 122 patients with completely displaced femoral neck fractures treated using three cannulated screws and reported considerable rates of nonunion and avascular necrosis. Similarly, Duckworth et al. (2011)[13] emphasized the influence of fracture-related and patient-related factors on fixation failure. These observations highlight the importance of fracture severity and anatomical restoration in the management of femoral neck fractures. In the present study, 55.56% of patients underwent surgery within 1–2 days, 27.78% within 3–7 days, and 16.67% after seven days (Table 3). Excellent reduction was achieved in 80% of patients operated within two days, compared with 20% among those operated within 3–7 days and none among those operated after seven days. Poor reduction increased from 0% in Group 1 to 20% in Group 2 and 33.33% in Group 3 (Table 4).Thapa et al. (2021)[14] evaluated 50 patients and reported satisfactory reduction in 84% and poor reduction in 16%. Nonunion and functional outcomes were significantly associated with reduction quality (p=0.001 and p=0.004, respectively). However, the authors found no statistically significant difference in outcomes between surgery performed within and after 24 hours. Similarly, Huang et al. (2010)[12] reported no significant association between surgical delay and nonunion (p=0.196). These findings suggest that anatomical reduction may be more important than surgical timing alone, although the present study demonstrated better reduction quality with earlier intervention. In the present study, radiological union occurred within three months in 25%, four months in 38.89%, and five months in 13.89% of patients. Delayed union beyond five months was observed in 13.89%, while nonunion occurred in 8.33% (Table 5). Thapa et al. (2021)[14] reported nonunion in 8% of patients, closely corresponding to the present findings. Huang et al. (2010)[12] observed nonunion in 18.9% of 122 patients, whereas Duckworth et al. (2011)[13] reported nonunion in 7.4%. Differences in union rates may be attributed to fracture displacement, reduction quality, fixation stability, and patient characteristics. In the present study, nonunion occurred in 8.33% of patients, while surgical site infection was recorded in 2.78% (Table 6). Huang et al. (2010)[12] reported nonunion in 18.9%, fixation failure in 12.3%, and avascular necrosis in 17.2%. Duckworth et al. (2011)[13] observed complications in 32% of patients, including nonunion in 7.4% and avascular necrosis in 11.5%. Thapa et al. (2021)[14] reported osteonecrosis in 4% and nonunion in 8%. Collectively, these findings indicate that satisfactory anatomical reduction and stable fixation are important determinants of successful fracture healing. The present study suggests that early surgical intervention may facilitate improved reduction quality, although larger studies are required to establish its independent influence on long-term outcomes.

The present study demonstrated that early surgical intervention was associated with better anatomical reduction in patients with femoral neck fractures. Excellent reduction was achieved in 80% of patients operated within two days, whereas delayed surgery was associated with poorer reduction quality. Radiological union was achieved in 91.67% of patients, while nonunion occurred in 8.33%. These findings suggest that timely surgical fixation, anatomical reduction, and stable internal fixation are important for favourable outcomes. However, larger studies are required to establish the independent effect of surgical timing on fracture healing and long-term complications. LIMITATIONS The present study was limited by its small sample size of 36 patients and single-centre observational design, which restricted the generalizability of the findings. The unequal distribution of patients across surgical timing groups may have influenced the results. Potential confounding factors, including fracture severity, associated comorbidities, and bone quality, were not fully evaluated. Additionally, the absence of adjusted statistical analysis limited the ability to establish an independent association between surgical timing and fracture outcomes.

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