Bone quality and thickness of femoral cortices in hip fractures
Abstract
Background. Hip osteoarthritis and femoral neck fractures are two of the most prevalent orthopedic disorders afflicting the elderly, and both have major impact on overall health and quality of life. The thickness of femoral cortices appears to be of different dimensions in patients with osteoarthritis and femoral neck fracture.
Sources of data. This study was conducted at the San Francesco D’Assisi Hospital in Oliveto Citra (SA) from September 2023 to September 2024. Forty patients over 65 years of age were selected, divided into two groups of 20 patients each, respectively with femoral neck fracture and advanced hip osteoarthritis.
Areas of agreement. An important role in femoral neck fracture seems to be played by the thickness of the femoral cortices. This difference in thickness could be linked to greater fragility and susceptibility to fracture.
Areas of controversy. It is not yet possible to determine a certain relationship between the thickness of the femoral cortices and which of them has a greater impact on the possibility of fracture.
Growing points. In the analyzed patients who had a fracture of the femoral neck, it was seen that the thickness of the posterior cortex was significantly reduced.
Areas timely for developing research. To date, due to the lack of specific screening protocols, it is not possible to ascertain a direct relationship between thickness of the femoral cortices and the probability of femoral neck fracture in the elderly.
Introduction
Hip osteoarthritis and femoral neck fractures are two of the most prevalent orthopedic disorders afflicting the elderly, and both have major impact on overall health and quality of life 1. Particularly frequent among the elderly is femoral neck fracture, which can occur following even minor falls especially in individuals with bone fragility or osteoporosis 2. This type of fracture frequently leads to a loss of autonomy, immobility, and, in many cases, severe complications that can include infections, thromboembolism, and cardiovascular complications. Femoral neck fractures and hip osteoarthritis are two of the main orthopedic problems in the elderly, with important repercussions on the quality of life and general health 3. A femoral neck fracture, in particular, is a common traumatic event in the elderly, often caused by even minor falls, especially in the presence of bone fragility or osteoporosis 4. This kind of fracture often results in losing the ability to do things on your own, being unable to move, and, in many cases, serious complications such as infections, thromboembolism, and heart problems. These problems have a major impact on people’s lives and require them to stay in the hospital for an extended period 5.
Degenerative hip osteoarthritis is a gradual condition that compromises the hip joint gradually, resulting in pain and restrictions in mobility. Joint stiffness and discomfort severely limit routine activities and individual autonomy in advanced instances, resulting in an adverse impact on mental and physical health. However, the type of prosthesis chosen and how the patient is cared for after surgery are very different depending on how the femoral neck is shaped 6.
The stability of the hip prosthesis and recovery after surgery depend on the thickness of the cortices of the femoral neck 7. Nevertheless, cortices in fracture patients usually appear thinner and less robust, which raises the likelihood of complications and compromises the prosthesis’ stability 8. This study aims to compare the cortical characteristics of the femoral neck in patients with advanced osteoarthritis and patients with a femoral neck fracture, analyzing how these differences can guide the choice of prosthesis and improve postoperative management 9.
Osteoarthritis of the hip is a degenerative joint disease that worsens over time, resulting in restricted motion and chronic discomfort 10. Hip stiffness and pain significantly restrict routine activities and individual autonomy in advanced cases, resulting in a detrimental impact on mental and physical health. In both instances, hip prosthesis constitutes one of the most prevalent surgical interventions to restore joint functionality and enhance quality of life; however, the selection of the prosthesis type and the management of the postoperative period differ markedly depending on the anatomical configuration of the femoral neck 11. The stability of the hip prosthesis and post-operative recovery are influenced, in particular, by the thickness of the cortices of the femoral neck, and the outermost sections of the bone, which provide the main structural resistance 12. In patients with osteoarthritis, the cortices tend to be thicker and firmer, providing a stable base for the prosthesis 13. In patients with fractures, however, the cortices are often thinner and less resistant, which can compromise the stability of the prosthesis and increase the risk of complications 8. This study aims to compare the cortical characteristics of the femoral neck in patients with advanced osteoarthritis and patients with a femoral neck fracture, analyzing how these differences can guide the choice of prosthesis and improve post-operative management 14.
Materials and methods
The study was conducted at the San Francesco D’Assisi Hospital in Oliveto Citra (SA) from September 2023 to September 2024. The observational, retrospective and comparative design focused on the analysis of the structural characteristics of the femoral neck, collecting preoperative data through imaging, direct intraoperative measurements and postoperative observations (Fig. 1). Forty patients over 65 years of age were selected, divided into two groups of 20 patients each, respectively with femoral neck fracture and advanced hip osteoarthritis (Tabs. I-II).
To maintain the homogeneity of the sample, only patients who did not present other concomitant bone diseases, such as severe forms of osteoporosis or metabolic bone diseases, and who had not undergone prosthetic revisions or previous hip interventions were included. In this way, we wanted to avoid the introduction of confounding variables and focus exclusively on cortical differences caused by fracture or osteoarthritis, ensuring a targeted analysis.
Each patient underwent standard radiographs and for patients with uncertain fractures computed tomography (CT) of the joint was performed. CT was essential to obtain detailed and precise assessments of the anterior, posterior and medial cortices, providing crucial information for planning the surgery and choosing the type of prosthesis. During surgery, direct measurements of the cortices were performed using calipers to confirm the data obtained in the case of fractures, via imaging and to evaluate bone structure in real time, in order to ensure optimal adaptation of the prosthesis.
After surgery, patients underwent post-operative radiographic checks and complications were studied in the immediate post-operative period during hospital stay to evaluate some complications, such as anemia and infections, which were recorded and treated according to the hospital’s standard protocols. Depending on the anatomical characteristics found, in patients with osteoarthritis, total hip replacement (THA) was preferred, which proved suitable to support more robust cortices, while in patients with fracture, endoprosthesis was chosen, which is more suitable to compensate for the lower cortical density and reduced functional demands in older patients. We followed the indications of the literature for the choice of the type of implant, endoprosthesis or THA, based on the age and characteristics of the patient.
Results
Data analysis revealed significant differences in bone characteristics, need for postoperative transfusion support, and early ambulation ability between patients with proximal femoral fracture (Group A) and those with osteoarthritis (Group B). Patients in Group A exhibited a mean anterior cortical thickness of 4.5 mm, which was inferior to the mean of 5.15 mm observed in Group B. The disparity was particularly evident in posterior cortical thickness, with Group A exhibiting a mean value of 1.075 mm, in contrast to 2.6 mm in Group B, showing increased structural vulnerability in individuals with fractures.
Although medial cortical thickness was similar between the groups (6.55 mm for Group A and 6.9 mm for Group B), the difference in anterior and posterior thicknesses suggests a variation in bone characteristics depending on the pathology, with Group A presenting a pattern of greater cortical deterioration.
Regarding post-operative transfusion support, 30% of patients in Group A required transfusions for anemia, compared to 20% of patients in Group B. The increased need for transfusions in Group A could be attributable to the characteristics of femoral fracture, which typically induces significant blood loss, and to the greater vulnerability of patients with fracture, who often have comorbidities and more compromised preoperative conditions. This finding may indicate disparities in bone integrity and blood regeneration capacity, which are diminished in individuals with traumatic pathologies compared to those with osteoarthritis.
A notable distinction was noted in early ambulation. Only 35% of patients in Group A commenced ambulation in the early postoperative phase, whereas 95% of patients in Group B did so. This research indicates that patients with osteoarthritis who are undergoing elective total hip replacement (THA) are typically in situations conducive to prompt mobilization.
In contrast, the presence of a femoral fracture appears to negatively affect the ability to recover in the short term, probably due to the greater invasiveness of the procedure and the potential for tissue trauma associated with these procedures.
Finally, the choice of the type of prosthesis used in the two groups followed criteria specific to the underlying pathology. In Group A, 75% of patients underwent endoprosthesis implantation, whereas merely 25% were subjected to total hip arthroplasty (THA). Conversely, all patients in Group B underwent THA treatment. Patients with osteoarthritis often have higher functional demands than patients with femoral fractures, for whom endoprosthesis is preferred, allowing for a less complex surgical procedure with quicker execution.
Diverse prostheses may impact postoperative quality of life, and delay complications and functional outcomes over time.
In summary, the data collected indicate that the presence of a proximal femoral fracture involves greater structural bone fragility, a higher probability of postoperative transfusions and slower early functional recovery compared to patients with osteoarthritis. These results support the importance of a differentiated approach in the perioperative management and in the choice of prosthetic solutions for patients with traumatic pathologies compared to those with degenerative pathologies. The results also suggest that a targeted prosthetic intervention and an intensive postoperative management could be fundamental to optimize recovery times and reduce complications in patients with proximal femoral fracture. Degenerative hip osteoarthritis is a gradual condition that compromises the hip joint gradually, resulting in pain and restrictions in mobility. Joint stiffness and discomfort severely limit routine activities and individual autonomy in advanced instances, resulting in an adverse impact on mental and physical health. However, the type of prosthesis chosen and how the patient is cared for after surgery are very different depending on how the femoral neck is shaped 4.
The stability of the hip prosthesis and recovery after surgery depend on the thickness of the cortices of the femoral neck. Nevertheless, cortices in fracture patients usually appear thinner and less robust, which raises the likelihood of complications and compromises the prosthesis’ stability 8. This study aims to compare the cortical characteristics of the femoral neck in patients with advanced osteoarthritis and patients with a femoral neck fracture, analysing how these differences can guide the choice of prosthesis and improve postoperative management 5.
Osteoarthritis of the hip is a degenerative joint disease that worsens over time, resulting in restricted motion and chronic discomfort. Hip stiffness and pain significantly restrict routine activities and individual autonomy in advanced cases, resulting in a detrimental impact on mental and physical health. In both instances, hip prosthesis constitutes one of the most prevalent surgical interventions to restore joint functionality and enhance quality of life; however, the selection of the prosthesis type and the management of the postoperative period differ markedly depending on the anatomical configuration of the femoral neck 4.
The stability of the hip prosthesis and post-operative recovery are influenced, in particular, by the thickness of the cortices of the femoral neck, and the outermost sections of the bone, which provide the main structural resistance. In patients with osteoarthritis, the cortices tend to be thicker and firmer, providing a stable base for the prosthesis 13. In patients with fractures, however, the cortices are often thinner and less resistant, which can compromise the stability of the prosthesis and increase the risk of complications 8. This study aims to compare the cortical characteristics of the femoral neck in patients with advanced osteoarthritis and patients with a femoral neck fracture, analysing how these differences can guide the choice of prosthesis and improve post-operative management.
Discussion
The results of the present study highlight significant differences between patients with proximal femoral fracture and those with osteoarthritis in terms of bone characteristics, need for transfusion support and these differences, related both to the nature of pathology and to the type of surgical intervention, emphasize the need for a targeted and personalized therapeutic approach for these two categories of patients.
The differences in cortical thickness, especially in the anterior and posterior values, suggest that proximal femoral fracture involves greater bone fragility compared to osteoarthritis. Reduction of cortical thickness, particularly posterior cortical thickness, may contribute to fracture susceptibility in Group A patients. Previous studies have highlighted that cortical deterioration is a key indicator of bone fragility and a risk factor for proximal femoral fractures 15,16, making these patients particularly vulnerable to traumatic events; patients with osteoarthritis tend to have higher bone density due to mechanical adaptation, which may explain the higher values in cortical thickness observed in Group B. The different incidence of postoperative transfusions observed between the two groups reflects not only the greater blood loss typical of fracture surgery, but also a different general preoperative health status. In patients with femoral fracture, trauma and the frequent presence of comorbidities increase the likelihood of postsurgical anemia. This finding is supported by literature 17, where patients with fractures are described as more susceptible to hematological complications than those with osteoarthritis, in whom the surgical course is often planned and characterized by less physiological stress. A useful finding concerns early ambulation, which is significantly higher in patients with osteoarthritis. This finding is consistent with the elective approach of these interventions, which allows for optimal preoperative preparation and usually ensures a better starting functional status. Early mobilization is widely documented as a crucial factor in reducing postoperative complications and improving functional recovery, with positive impacts on both the general well-being of the patient and the length of hospital stay 13,18. In patients with femoral fracture, the complexity of the operation and the more critical conditions at admission slow down immediate recovery, indicating that they could benefit from intensive assisted mobilization protocols 19.
The choice of prostheses in the two groups was differentiated to meet specific clinical needs, following the guidelines of the Italian Society of Orthopedics and Traumatology 20.
In patients with femoral fractures, the common application of hemiarthroplasty indicates a preference for a minimally invasive operation focused on functional stabilization rather than complete joint restoration. This methodology is evident in the literature, indicating that hemiarthroplasty is frequently favored for elderly and weak patients to mitigate problems and facilitate safe recovery 20.
On the contrary, in patients with coxarthrosis, total hip replacement is chosen as a long-term solution to improve joint function and relieve chronic pain, with positive effects on the patient’s quality of life in the long term 20,21.
In summary, our results support the hypothesis that a personalized approach is essential in the surgical and post-operative management of patients with femoral fracture compared to those with osteoarthritis. Understanding the anatomical and functional differences between these two groups can guide the choice of prosthesis, optimize postoperative protocols and improve clinical outcomes. Future studies should aim to confirm these results with larger samples and evaluate the effectiveness of specific rehabilitation protocols for each group.
Conclusions
The morphological and anatomic variations of the femoral neck between patients with advanced osteoarthritis and those with non-traumatic fractures were observed in this study. Fracture patients are found to have substantially decreased bone quality, which is associated with higher fragility.
Bone assessment is frequently neglected in male participants, yet osteoporosis screening is routine amid postmenopausal women.
The implementation of systematic and early screening programs, aimed at diagnosing osteoporosis also among men and elderly patients, emerges as a key strategy to reduce the incidence of non-traumatic fractures.
This research emphasizes that precise and focused bone screening, utilizing sophisticated technologies like CT and three-dimensional examination of bone tissue, can early identify individuals at risk of bone fragility. The discovery of reduced cortical thickness in patients with non-traumatic fractures, in contrast to those with osteoarthritis, underscores the necessity for intervention prior to the onset of permanent structural damage, particularly in underdiagnosed individuals.
In summary, the results of our study support the importance of modifying current clinical practices, integrating inclusive and systematic osteoporosis screening protocols, in order to prevent hip fractures and improve the quality of life of older adults. An integrated approach to bone health, including early diagnosis and targeted treatment of associated pathologies, is essential to address the challenges of longevity. With increasing life expectancy, the adoption of these prevention protocols could significantly reduce the number of fractures, improving not only the health but also the quality of life of the elderly population.
Conflict of interest statement
The authors declare no conflict of interest.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contributions
The Authors contribuited equally to the work.
Ethical consideration
The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki.
Written informed consent was obtained from each participant/patient for study participation and data publication.
History
Received: June 16, 2025
Accepted: September 7, 2025
Figures and tables
Figure 1.Intraoperative measurements of the femoral cortices.
| Patient | Sex | Walking before surgery | Anterior cortical thickness (mm) | Posterior cortical thickness (mm) | Medial cortical thickness (mm) | Transfusions for post-surgical anemia | Early walking ability | Type of prosthesis |
|---|---|---|---|---|---|---|---|---|
| Patient 1 | F | YES | 3 | 1 | 6 | NO | YES | THA |
| Patient 2 | M | YES | 4 | 1 | 7 | YES | NO | Endoprosthesis |
| Patient 3 | F | YES | 5 | 1 | 7 | NO | NO | Endoprosthesis |
| Patient 4 | F | NO | 3 | 1 | 6 | YES | NO | Endoprosthesis |
| Patient 5 | M | YES | 6 | 1,5 | 8 | NO | YES | THA |
| Patient 6 | M | YES | 5 | 1 | 6 | NO | NO | Endoprosthesis |
| Patient 7 | F | YES | 5 | 1 | 7 | NO | YES | Endoprosthesis |
| Patient 8 | M | NO | 3 | 1 | 6 | NO | YES | Endoprosthesis |
| Patient 9 | F | YES | 5 | 1 | 7 | YES | NO | THA |
| Patient 10 | F | NO | 3 | 1 | 6 | NO | NO | Endoprosthesis |
| Patient 11 | F | YES | 5 | 1 | 6 | YES | YES | Endoprosthesis |
| Patient 12 | M | YES | 6 | 1,5 | 8 | NO | NO | Endoprosthesis |
| Patient 13 | M | YES | 5 | 1 | 6 | NO | NO | Endoprosthesis |
| Patient 14 | F | YES | 6 | 1,5 | 7 | NO | NO | Endoprosthesis |
| Patient 15 | F | YES | 4 | 1 | 6 | NO | YES | THA |
| Patient 16 | M | YES | 5 | 1 | 6 | YES | NO | Endoprosthesis |
| Patient 17 | M | YES | 5 | 1 | 7 | NO | NO | Endoprosthesis |
| Patient 18 | F | NO | 3 | 1 | 6 | NO | NO | Endoprosthesis |
| Patient 19 | F | YES | 4 | 1 | 6 | YES | NO | THA |
| Patient 20 | F | YES | 5 | 1 | 7 | NO | YES | Endoprosthesis |
| Patient | Sex | Walking before surgery | Anterior cortical thickness (mm) | Posterior cortical thickness (mm) | Medial cortical thickness (mm) | Transfusions for post-surgical anemia | Early walking ability | Type of prosthesis |
|---|---|---|---|---|---|---|---|---|
| Patient 1 | F | YES | 5 | 3 | 7 | NO | YES | THA |
| Patient 2 | M | YES | 4 | 2 | 6 | NO | YES | THA |
| Patient 3 | F | YES | 5 | 3 | 8 | YES | NO | THA |
| Patient 4 | M | YES | 5 | 3 | 7 | NO | YES | THA |
| Patient 5 | M | YES | 5 | 3 | 7 | NO | YES | THA |
| Patient 6 | F | YES | 6 | 2 | 7 | NO | YES | THA |
| Patient 7 | F | YES | 5 | 3 | 7 | NO | YES | THA |
| Patient 8 | M | YES | 6 | 2 | 8 | NO | YES | THA |
| Patient 9 | F | YES | 6 | 3 | 6 | YES | YES | THA |
| Patient 10 | M | YES | 5 | 2 | 7 | NO | YES | THA |
| Patient 11 | M | YES | 5 | 3 | 7 | NO | YES | THA |
| Patient 12 | F | YES | 5 | 3 | 8 | NO | YES | THA |
| Patient 13 | M | YES | 6 | 3 | 7 | NO | YES | THA |
| Patient 14 | F | YES | 4 | 2 | 6 | NO | YES | THA |
| Patient 15 | M | YES | 5 | 3 | 7 | YES | NO | THA |
| Patient 16 | F | YES | 5 | 2 | 6 | NO | YES | THA |
| Patient 17 | M | YES | 6 | 3 | 7 | NO | YES | THA |
| Patient 18 | F | YES | 5 | 2 | 6 | NO | YES | THA |
| Patient 19 | F | YES | 4 | 2 | 7 | YES | YES | THA |
| Patient 20 | F | YES | 6 | 3 | 7 | NO | YES | THA |
References
- Fernandez MA, Griffin XL, Costa ML. Management of hip fracture. Br Med Bull. 2015; 115:165-172. DOI
- Händel MN, Cardoso I, von Bülow C. Fracture risk reduction and safety by osteoporosis treatment compared with placebo or active comparator in postmenopausal women: systematic review, network meta-analysis, and meta-regression analysis of randomised clinical trials. BMJ. 2023; 381:E068033. DOI
- Liu P, Zhang Y, Sun B. Risk factors for femoral neck fracture in elderly population. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2021; 46:272-277. DOI
- Ganz R, Parvizi J, Beck M. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003; 417:112-120. DOI
- Barceló M, Torres OH, Mascaró J. Hip fracture and mortality: study of specific causes of death and risk factors. Arch Osteoporos. 2021; 16:15. DOI
- Petis S, Howard JL, Lanting BL. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg. 2015; 58:128-139. DOI
- Kanai H, Igarashi M, Yamamoto S. Spontaneous subcapital femoral neck fracture complicating a healed intertrochanteric fracture. Arch Orthop Trauma Surg. 1999; 119:271-275. DOI
- Peeters CMM, Visser E, Van de Ree CLP. Quality of life after hip fracture in the elderly: a systematic literature review. Injury. 2016; 47:1369-1382. DOI
- Jin Y, Yin B, Shu L. Morphological characteristics of femoral neck fractures in young and middle-aged population: a retrospective descriptive study. BMC Musculoskelet Disord. 2024; 25:100. DOI
- Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: etiopathogenesis and implications for management. Adv Ther. 2016; 33:1921-1946. DOI
- Gargano G, Poeta N, Oliva F. Zimmer natural nail and ELOS nails in pertrochanteric fractures. J Orthop Surg Res. 2021; 16:509. DOI
- Ajami S, Javaheri B, Chang YM. Spatial links between subchondral bone architectural features and cartilage degeneration in osteoarthritic joints. Sci Rep. 2022; 12:6694. DOI
- Bennell K. Physiotherapy management of hip osteoarthritis. J Physiother. 2013; 59:145-57. DOI
- Fischer H, Maleitzke T, Eder C. Management of proximal femur fractures in the elderly: current concepts and treatment options. Eur J Med Res. 2021; 26:86. DOI
- Haider IT, Schneider P, Michalski A. Influence of geometry on proximal femoral shaft strains: implications for atypical femoral fracture. Bone. 2018; 110:295-303. DOI
- Ehlinger M, Moser T, Adam P. Early prediction of femoral head avascular necrosis following neck fracture. Orthop Traumatol Surg Res. 2011; 97:79-88. DOI
- Bhandari M, Swiontkowski M. Management of acute hip fracture. N Engl J Med. 2017; 377:2053-2062. DOI
- Xu DF, Bi FG, Ma CY. A systematic review of undisplaced femoral neck fracture treatments for patients over 65 years of age, with a focus on union rates and avascular necrosis. J Orthop Surg Res. 2017; 12:28. DOI
- Boddaert J, Raux M, Khiami F. Perioperative management of elderly patients with hip fracture. Anesthesiology. 2014; 121:1336-1341. DOI
- Rivera F, Comba LC, Colombo M. Management of intracapsular hip fracture: current trends from a national survey. Injury. 2024; 55:111539. DOI
- Zagra L, Kjaersgaard-Andersen P. Advances in primary and revision total hip replacement. Hip Int. 2014; 24:S1. DOI
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