CORR Insights^®: Randomized Trial of Hemiarthroplasty versus Internal Fixation for Femoral Neck Fractures: No Differences at 6 Years

Excerpt

Treating displaced femoral neck fractures is an orthopaedic cruise between Scylla and Charybdis, navigating the tenuous passage between a fracture’s poor chances to heal and the (often elderly) patient’s ability to tolerate extensive surgery. Choosing internal fixation because the surgical procedure is minimally invasive will lead to failure in 40% to 50% of the treated hips. In the current study by Støen and colleagues, only 12 of 31 patients with internal fixation retained their native hip 6 years after surgery. The alternative, avoiding problems related to fracture healing by selecting immediate replacement of the injured hip with an arthroplasty, has the offsetting risk of increased perioperative strain on an already-frail individual. As shown in the most recent meta-analysis [6], based on a number of randomized trials [2, 5, 9, 11], hip replacement appears preferable in the elderly population based on a lower likelihood of hip-related complications, better cost-effectiveness, better functional recovery, improved health-related quality-of-life, and less pain—at least in the short-term. However, a recent national register study of 12,313 patients [13] found a higher early mortality after hemiarthroplasty compared to internal fixation, a difference that has not been detected in smaller clinical trials. Weighing this potential risk against the benefits of a hip replacement is in many ways an ethical issue. Currently, the orthopaedic community agrees that a “typical patient” (often a frail woman 80 years of age or older), will benefit from an arthroplasty. Any advantages in using hemiarthroplasty compared to internal fixation will diminish or disappear after a couple of years, according to the current study. On the other hand, only 48% of the women and 31% of the men live 5 years after hip fracture [14]. For a majority of patients, the short-term results are most important. …