We have read with interest the article by Miralles-Muñoz et al., entitled, “Screw configuration in femoral neck fracture osteosynthesis does not influence functional or mechanical outcomes,” published in the January–February 2024 issue. In this retrospective study, the authors compared the outcomes of 22 patients with femoral neck fractures treated with triangular screws and 31 with inverted triangle screws. This is a relevant topic, given the enormous controversy it still generates in the orthopedic community.
We would highlight the homogeneity of the baseline characteristics of the groups, which increases the internal validity of the study. For this same purpose, the authors excluded cases with open or imperfect reduction. We would have appreciated more information about the selection process, without which we cannot rule out the possibility that these exclusions constituted a source of bias. A more exhaustive description of the injuries would also have been useful. Fractures with vertical lines present a higher risk of failure, information not included in the Garden classification used in this study. These patterns (Pauwels III) may benefit from the use of support or angularly stable devices,1,2 no mention of which was made at any time by the authors. Similarly, posterior comminution and retroversion of the femoral neck, which is a risk factor for treatment failure that has become more established in recent years, was not described.3
We congratulate the authors’ efforts in collecting functional data. Patients in both groups experienced functional regression after the fracture. It would be helpful to know specifically the deterioration in those who presented complications, as they occurred in 17%. Overall, no statistically significant differences were found in the incidence of complications between the two treatment groups (p=.14). However, mechanical complications occurred at a four-fold higher incidence in the triangular group compared to the inverted triangular group (13.6% vs. 3.2%). The inverted triangular configuration places a greater volume of implants in areas with greater trabecular density, improving fixation strength.4 Furthermore, it reduces perforations in the lateral cortex, which increase the risk of subtrochanteric fracture. Studies with sufficient statistical power to perform a reliable multivariate analysis confirm that the triangular configuration is an independent risk factor for the development of non-union (OR=2.92).5 The absence of significant differences in the present study is attributable to the limited group size.
We congratulate the authors and the journal for circulating this study. However, we believe the message proclaimed in its title should be cautiously interpreted, since both the findings of this study and those of previously published studies suggest that the inverted triangle configuration offers more favorable results in the osteosynthesis of femoral neck fractures.
Level of evidenceLevel of evidence v.
AuthorshipThe first draft of the manuscript was written by DGM and JVAP, and all authors contributed to subsequent versions. All authors read and approved the final version.
FundingThis study received no external funding sources.
Conflict of interestsThe authors have conflicts of interest to declare with Smith & Nephew, Zimmer-Biomet, Link-Orthopaedics, Stryker, and MBA Surgical Empowerment.
