Dylan McCreary BA, Brian P. Cunningham MD, and Marc Swiontkowski MD Department of Surgery, University of Minnesota, Minneapolis, MN, USA Maintaining the patient’s original hip with a fixation device versus removing the femoral head and replacing the hip with a prosthesis has important implications for outcome and function. Current opinion is highly divergent among orthopedic surgeons on whether to fix or replace the hip. The disability adjusted life‐years lost as a result of hip fractures ranks in the top 10 of all cause disability globally. Over 4.5 million persons sustain hip fractures around the world each year. By the year 2040, the number of people aged 65 or older will increase from 34.8 million to 77.2 million. The number of hip fractures is likely to exceed 500 000 annually in the United States and 88 000 in Canada over the next 40 years.1–4 Hip fractures are associated with a 21% mortality rate at one year and profound temporary, and sometimes permanent, impairment of independence, and quality of life.5 Furthermore, approximately 30% of surgically treated hip fractures require revision surgery.6 These revisions are associated with a large burden of morbidity and mortality. Arthroplasty has the potential to achieve reduced re‐operation and mortality. Multiple randomized controlled trials (RCTs) have investigated the difference in mortality and re‐operation rate between internal fixation and arthroplasty for displaced femoral neck fractures in patients over the age of 65. The most relevant literature consisted of a systematic review of the literature and meta‐analysis (level I evidence). In 2003, Bhandari et al. reported the results of a meta‐analysis of 14 randomized trials comparing outcomes of internal fixation and arthroplasty (level I).7 Nine trials (n = 1162 patients) provided postoperative mortality data at four months or less, twelve trials (n = 1767) provided one‐year mortality data, and all 14 trials (n = 1901) provided information on revision surgeries. They found no difference in the risk of mortality between arthroplasty and internal fixation, but did find that arthroplasty was associated with significantly lower risk of revision and the results were consistent study to study (risk ratio [RR] = 0.23; 95% confidence interval [CI]: 0.13–0.42). Information on secondary outcomes of pain, function, and infection rate was available for some studies. Information on secondary outcomes was available for six studies (n = 1153 patients) reporting on pain relief and 12 on function (n = 1179 patients). Pain relief and function were similar in patients treated with arthroplasty or internal fixation (RR of no/little pain 1.12; 95% CI: 0.88–1.35 and good function 0.99; 95% CI: 0.90–1.10). Arthroplasty significantly increased the risk of infection (12 studies, n = 1822) compared to internal fixation (RR = 1.81; 95% CI: 1.16–2.85, p = 0.009, homogeneity p = 0.16). The risk difference between the two treatments was 3.4%. This meant that for every 29 patients treated with internal fixation one infection could be prevented (number needed to treat [NNT] = 1/0.034 = 29.4). Relatively fewer data were available for secondary outcomes of blood loss and surgical time. Four studies (n = 343 patients) reported on estimated blood loss, and five (n = 447 patients) and surgical time. Patients who underwent arthroplasty experienced greater blood loss than those who were treated with internal fixation (weighted mean difference = 176.4 mL; 95% CI: 132.4–220.4, p <0.05). Similarly, surgical time in the arthroplasty‐treated patients was greater than the patients treated with internal fixation (weighted mean difference = 29.0 minutes; 95% CI: 23.2–34.8, p <0.05). Overall, level I evidence suggests that arthroplasty is associated with significantly lower risk of re‐operation compared to internal fixation, but there is no difference in risk or mortality.7 Additionally, arthroplasty was associated with significantly greater blood loss, operative time, and risk of infection. There are limitations to these data though as they lacked the power to demonstrate whether there was an increased risk of mortality with arthroplasty. The review did raise a possible concern for increased risk of early mortality (relative risk of death at four months 1.27); however, this was not statistically significant.
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Femoral Neck Fractures in the Elderly
Clinical scenario
Top three questions
Question 1: In patients over the age of 65 undergoing treatment of a displaced femoral neck fracture, does arthroplasty result in decreased mortality and re‐operation rates compared to internal fixation?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
Resolution of clinical scenario
Question 2: In patients over the age of 65 undergoing internal fixation for a displaced femoral neck fracture, does use of cancellous screws result in reduced risk of complications and re‐operation compared to sliding hip screws (SHSs)?
Rationale
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