Background

Treatment of displaced femoral neck fractures includes internal fixation and arthroplasty. However, whether arthroplasty or internal fixation is the primary treatment for displaced femoral neck fractures in elderly patients remains a subject for debate. The literature contains conflicting evidence regarding rates of mortality, revision surgery, major postoperative complications, and function in elderly patients with displaced femoral neck fractures treated either by internal fixation or arthroplasty (either hemiarthroplasty or THA).

Questions/purpose

We determined mortality, revision surgery rates, major surgical complications (which include infection, nonunion or early redisplacement, avascular necrosis, dislocation, loosening of the prosthesis, acetabular erosion, fracture below or around the implant, and other severe general complications such as deep vein thrombosis and pulmonary embolism), and function in patients treated with either internal fixation or arthroplasty for displaced femoral neck fractures in the elderly.

Methods

We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) comparing internal fixation and arthroplasty. We identified 20 RCTs with 4508 patients meeting all the criteria for eligibility. We performed a meta-analysis of the major complications, reoperations, function, pain, and mortality.

Results

Compared with internal fixation, arthroplasty reduced the risk of the major complications (95% CI, 0.21–0.54 for 1 year; 95% CI, 0.16–0.31 for 5 years) and the incidence of reoperation 1 to 5 years after surgery (95% CI, 0.15–0.34 for 1 year; 95% CI, 0.08–0.24 for 5 years), and provided better pain relief (95% CI, 0.34–0.72). Function was superior (RR = 0.59; 95% CI, 0.44–0.79) for patients treated with arthroplasty than for patients treated by internal fixation. However, mortality 1 to 3 years after surgery was similar (95% CI, 0.96–1.23, p = 0.20 for 1 year; 95% CI, 0.91–1.17, p = 0.63 for 3 years).

Conclusions

Arthroplasty can reduce the risk of major complications and the incidence of reoperation compared with internal fixation, and provide better pain relief and function, but it does not reduce mortality.

IORG Overview

Primary Arthroplasty should be primarily considered for elderly with femoral neck fracture. Again the query arises whether to use Total Hip Replacement or Hemiarthroplasty. Following are literature based observations

1.Total hip arthroplasty for displaced femoral neck fractures in the fit elderly may lead to higher patient-based outcomes but has higher dislocation rates compared with hemiarthroplasty. [1]

2. mortality and postoperative infection between HA and THA had no statistical differences

3.long-term reoperation rate of HA was higher than that of THA

4. medium-term dislocation rate of HA was lower than that of THA

5.pain rates of HA in short-term and long-term were both higher than THA

In summary: Treatment of THA for elderly displaced femoral neck fracture could provide better results of reduced reoperation rate and pain relief; however, HA yielded a lower incidence of postoperative dislocation [2]

1.Burgers PT, Van Geene AR, Van den Bekerom MP, Van Lieshout EM, Blom B, Aleem IS, Bhandari M, Poolman RW. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. Int Orthop. 2012 Aug;36(8):1549-60.

2.Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, Chang-Qing Z. Hemiarthroplasty vs primary total hip arthroplasty for displaced fractures of the femoral neck in the elderly: a meta-analysis. J Arthroplasty. 2012 Apr;27(4):583-90.

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