Do Computerized Tomography Images Influence Surgeons' Estimates of Posterior Tilt Angle or Treatment Preference for Minimally Displaced Femoral Neck Fractures?

Abstract

To determine if axial computerized tomography (CT) images compared with radiographs of minimally displaced femoral neck fractures in older adults change surgeons' estimates of posterior tilt or treatment preference for internal fixation versus arthroplasty. A survey was developed from the clinical vignettes, injury radiographs of anteroposterior (AP) pelvis and lateral hip, and CT pelvis axial images of 10 patients randomly selected from 50 patients with minimally displaced femoral neck fractures enrolled in a clinical trial. Survey respondents estimated femoral neck fracture posterior tilt angle (0-90 degrees) and stated their treatment preference on a scale of 100% for internal fixation to 100% for arthroplasty based on the radiographs, then again after viewing the CT images of the same patient. The survey was administered electronically using REDCap and distributed by email between 15 June and 15 July 2025. The survey was distributed to a convenience sample of attending orthopaedic surgeons with hip fracture call experience nonrandomly selected from email contacts of colleagues, acquaintances, and extramural research collaborators located in North America, South America, and Europe. Neither fellowship training nor practice setting were requirements for participation. The mean differences in posterior tilt estimates and treatment preferences between radiographs and CT were estimated using linear mixed-effects models. Complete survey responses were received from 69 of 98 participants (70.4% response rate). Posterior tilt estimates were 6 degrees greater based on CT versus radiographs (95% confidence interval [CI], 4-7 degrees; P < 0.0001). CT images significantly changed treatment preferences by 20% more in favor of arthroplasty (95% CI, 14%-26%; P < 0.0001). Axial CT images significantly changed orthopaedic surgeons' estimates of posterior tilt and treatment preferences in favor of arthroplasty for minimally displaced femoral neck fractures compared with radiographs. Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.