Comparative efficacy and safety of three internal fixation strategies for femoral neck fractures: a network meta-analysis

Background: Currently, the most common internal fixation devices for femoral neck fractures are cannulated compression screws (CCS), dynamic hip screws (DHS), and femoral neck systems (FNS). However, no clear consensus exists regarding which device offers superior clinical efficacy and safety. Methods: We systematically searched three databases (PubMed, Embase, and Cochrane Library) for clinical studies published from their inception until March 12, 2025. We included studies that directly compared the three internal fixation methods: FNS, DHS, and CCS. Outcomes of interest were analyzed using pairwise and network meta-analyses. Results: This network meta-analysis included 23 studies comprising 55,910 patients. FNS demonstrated a statistically significant higher Harris Hip Score (MD 3.79, 95% CI 1.44-6.13) and a shorter fracture healing time (MD -1.00 months, 95% CI -1.53 to -0.48) compared to CCS. Both FNS and CCS were associated with lower rates of femoral head necrosis than DHS. CCS was superior to both FNS and DHS, showing significantly less intraoperative blood loss. Conclusion: This network meta-analysis indicates that FNS may have advantages over CCS and DHS in fracture healing time and reduced risk of femoral head necrosis. Regarding Harris Hip Score, FNS was statistically superior to CCS, but the improvement did not reach the minimal clinically important difference, suggesting limited clinical meaningfulness. However, its definitive clinical superiority and optimal indications remain uncertain, necessitating further high-quality studies to validate its clinical value and guide practice. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251014243, identifier CRD420251014243.