Hemiarthroplasty in worst cases is better than internal fixation in best cases of displaced femoral neck fractures: A prospective study of 683 patients treated with hemiarthroplasty or internal fixation

Abstract

Background Studies have shown that the degree of initial displacement and also comminution of the femoral calcar, size of the head and varus angulation are prognostic of failure in displaced femoral neck fracture. We have applied these radiographic criteria in order to select patients who would benefit from internal fixation as opposed to primary hemiarthroplasty, and this prospective study was conducted in order to monitor the results of this strategy.Methods 683 displaced fractures of the femoral neck were treated with internal fixation or primary hemiarthroplasty based on the proposed radiographic criteria in a prospective consecutive study, and the patients were followed for 1-6 years. We treated 228 fractures with internal fixation and 455 by bipolar hemiprosthesis. The choice of operation was based on clinical evaluation of the patient and assessment of the assumed healing potential of the fracture, as determined by radiographic evaluation. Revision and mortality were primary endpoints.Results 54 (24%) of the patients originally treated by osteosynthesis were revised, whereas 9 (2%) of the patients treated with hemiarthroplasty had revision surgery. There were no significant differences in mortality between the groups at 30, 120 or 365 days.Interpretation Even when treating only the fractures with the assumed best healing potential with internal fixation, the results are inferior to hemiarthroplasty.

Influence of Internal Fixation and Cemented Hemiarthroplasty on 1-Year Mortality in Geriatric Hip Fracture Patients

“…Results of our multivariate Cox-regression analysis are in contrast to the vast majority of trails [8][9][10][11][16][17][18]26] . Several studies reported higher one year mortality rates for HA than IF [18,26,27] .…”

“…Moreover, cognitive impairment which was demonstrated to be a risk factor for higher mortality in hip fracture patients [4,31] was ignored. Similarly, other RCTs [10,11,32] and non-randomised studies did not respect patients who were confused or had neurologic impairment [17,18] as well as patients incapable of independent walking or who were bed-ridden [9,10] . Subsequently, at least one third of hip fracture patients are disobeyed according to our study cohort.…”

“…Strikingly, recruitment of most patients in recent studies comparing IF with arthroplasty in hip fracture patients date back a decade or even longer [8][9][10][11]17,18,27,[21][22][23][24][25][26][27][28][29][30][31][32][33][34] . In this regard, improved anaesthesia and modern cementing techniques might explain the difference of our results compared to earlier studies.…”

“…This is confirmed by Frihagen et al [8] who also identified approximately one third of femoral neck fracture patients suffering from cognitive impairment. Another factor potentially influencing mortality which is time to surgery or patients referred to surgery beyond 48 h are not addressed in all recent randomised and nonrandomised trials [8][9][10][11][16][17][18][32][33][34] . In our study timing of surgery was associated with significantly higher one year mortality.…”

“…Beyond study design, the time period of patient recruitment should be considered which in most of the studies comparing IF with cemented HA date back almost 10 years or even longer [8][9][10][11][16][17][18] . This is of importance, since Schneppendahl and colleagues [19] reported a decreasing mortality after femoral neck fractures treated with bipolar HA over the last twenty years with the most pronounced effect seen after 2006.…”