Expert Consensus on Vascular Assessment and Treatment Strategies for Adult Femoral Neck Fractures

This article presents an expert consensus on vascular assessment and management strategies for adult femoral neck fractures, based on a narrative review of current evidence and the collective clinical experience of a multidisciplinary panel of orthopaedic and reconstructive surgeons. To assist clinicians in accurately evaluating the vascular status of the femoral head and formulating individualized treatment plans, based on anatomic understanding of its blood supply, current vascular assessment techniques, and the establishment of a novel classification system. The ultimate goal is to reduce postoperative complications and improve patient outcomes. Femoral neck fractures in adults are associated with high rates of avascular necrosis (AVN) and nonunion, largely due to disruption of the femoral head's vascular supply. This expert consensus contains an updated vascular-based classification system and corresponding treatment strategies to improve outcomes in femoral neck fracture management. It integrates anatomic insights into femoral head blood supply, mechanisms of vascular injury, and advanced imaging assessments-especially digital subtraction angiography (DSA)-which may be used to evaluate perfusion status. A novel vascular classification system incorporating CT and DSA findings is proposed to stratify fractures into 4 types based on vascular involvement. Treatment recommendations are made accordingly, ranging from conservative management to internal fixation using bidirectional porous tantalum screws, femoral neck system, or hip arthroplasty. Emphasis is placed on preserving the epiphyseal arterial network by minimizing invasive maneuvers and controlling screw depth. For patients with complete vascular disruption, open reduction combined with microvascular reconstruction and vascularized bone grafting may be considered as an advanced option based on expert consensus. In addition, a scoring system based on patient age, fracture displacement, and vascular injury is proposed to predict complications. This consensus supports a shift from mechanically focused treatment toward a combined biomechanical-biological approach, highlighting the central role of vascular preservation in femoral head-saving strategies.