Which is the Best Alternative for Displaced Femoral Neck Fractures in the Elderly?: A Meta-analysis

Overview

Journal Clin Orthop Relat Res

Publisher Wolters Kluwer

Specialty Orthopedics

Date 2012 Jan 27

PMID 22278852

Citations 39

Authors

Hongwei Gao

Zhonghao Liu

Deguo Xing

Mingzhi Gong

Affiliations

Soon will be listed here.

Abstract

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.

Level Of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Citing Articles

Comparable results for the Femoral Neck System and three-screw fixation in femoral neck fracture treatment.

Honkanen J, Forsbacka N, Strengell I, Laaksonen I, Makela K, Koivisto M OTA Int. 2024; 8(1):e351.

PMID: 39737137 PMC: 11684558. DOI: 10.1097/OI9.0000000000000351.

Internal Fixation With Cannulated Screws for Stable Femoral Neck Fractures in High-Risk Patients: Good Clinical Outcomes and Evaluation of Postoperative Complications.

Giotis D, Konstantinidis C, Plakoutsis S, Kotsias C, Konstantinou A, Tsiampas D Cureus. 2024; 16(10):e71767.

PMID: 39559651 PMC: 11570436. DOI: 10.7759/cureus.71767.

[Correlation between combined deflection angle classification adduction typing and complications after internal fixation of adduction femoral neck fracture].

Dong Y, Luo C, Zhang N, You R, Yuan Q, Li W Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2024; 38(4):405-411.

PMID: 38632058 PMC: 11024535. DOI: 10.7507/1002-1892.202401063.

Does a hip fracture mean we should we operate on a concomitant proximal humerus fracture?.

Ganta A, Meltzer-Bruhn A, Esper G, Konda S, Egol K Eur J Orthop Surg Traumatol. 2023; 33(8):3435-3441.

PMID: 37184596 DOI: 10.1007/s00590-023-03529-7.

Combined Deflection Angle Classification: A Novel Typing System of Adult Femoral Neck Fracture.

Zhang Y, Yuan Q, Wei Q, Dong Y, Liu Y, He W Orthop Surg. 2022; 15(3):839-850.

PMID: 36573274 PMC: 9977581. DOI: 10.1111/os.13629.

References

Tidermark J, Ponzer S, Svensson O, Soderqvist A, Tornkvist H . Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br. 2003; 85(3):380-8. DOI: 10.1302/0301-620x.85b3.13609. View

Roden M, Schon M, Fredin H . Treatment of displaced femoral neck fractures: a randomized minimum 5-year follow-up study of screws and bipolar hemiprostheses in 100 patients. Acta Orthop Scand. 2003; 74(1):42-4. DOI: 10.1080/00016470310013635 . View

Svenningsen S, Benum P, Nesse O, Furset O . [Femoral neck fractures in the elderly--a comparison of 3 treatment methods]. Nord Med. 1985; 100(10):256-9. View

Guyatt G, Oxman A, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coello P . GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008; 336(7650):924-6. PMC: 2335261. DOI: 10.1136/bmj.39489.470347.AD. View

Juni P, Altman D, Egger M . Systematic reviews in health care: Assessing the quality of controlled clinical trials. BMJ. 2001; 323(7303):42-6. PMC: 1120670. DOI: 10.1136/bmj.323.7303.42. View

Parker M, Johansen A . Hip fracture. BMJ. 2006; 333(7557):27-30. PMC: 1488757. DOI: 10.1136/bmj.333.7557.27. View

Parker M, Khan R, Crawford J, Pryor G . Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. J Bone Joint Surg Br. 2002; 84(8):1150-5. DOI: 10.1302/0301-620x.84b8.13522. View

Davison J, Calder S, Anderson G, Ward G, Jagger C, Harper W . Treatment for displaced intracapsular fracture of the proximal femur. A prospective, randomised trial in patients aged 65 to 79 years. J Bone Joint Surg Br. 2001; 83(2):206-12. DOI: 10.1302/0301-620x.83b2.11128. View

Johansson T, Jacobsson S, Ivarsson I, Knutsson A, Wahlstrom O . Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips. Acta Orthop Scand. 2001; 71(6):597-602. DOI: 10.1080/000164700317362235 . View

10.

Keating J, Grant A, Masson M, Scott N, Forbes J . Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006; 88(2):249-60. DOI: 10.2106/JBJS.E.00215. View

11.

Leonardsson O, Sernbo I, Carlsson A, Akesson K, Rogmark C . Long-term follow-up of replacement compared with internal fixation for displaced femoral neck fractures: results at ten years in a randomised study of 450 patients. J Bone Joint Surg Br. 2010; 92(3):406-12. DOI: 10.1302/0301-620X.92B3.23036. View

12.

MAHONEY F, BARTHEL D . FUNCTIONAL EVALUATION: THE BARTHEL INDEX. Md State Med J. 1965; 14:61-5. View

13.

Hedlund R, Lindgren U, Ahlbom A . Age- and sex-specific incidence of femoral neck and trochanteric fractures. An analysis based on 20,538 fractures in Stockholm County, Sweden, 1972-1981. Clin Orthop Relat Res. 1987; (222):132-9. View

14.

Thomsen N, Jensen C, Skovgaard N, Pedersen M, Pallesen P, ROSENKLINT A . Observer variation in the radiographic classification of fractures of the neck of the femur using Garden's system. Int Orthop. 1996; 20(5):326-9. DOI: 10.1007/s002640050087. View

15.

Jonsson B, Sernbo I, Carlsson A, Fredin H, Johnell O . Social function after cervical hip fracture. A comparison of hook-pins and total hip replacement in 47 patients. Acta Orthop Scand. 1996; 67(5):431-4. DOI: 10.3109/17453679608996662. View

16.

Sikorski J, Barrington R . Internal fixation versus hemiarthroplasty for the displaced subcapital fracture of the femur. A prospective randomised study. J Bone Joint Surg Br. 1981; 63-B(3):357-61. DOI: 10.1302/0301-620X.63B3.7263746. View

17.

Rogmark C, Johnell O . Primary arthroplasty is better than internal fixation of displaced femoral neck fractures: a meta-analysis of 14 randomized studies with 2,289 patients. Acta Orthop. 2006; 77(3):359-67. DOI: 10.1080/17453670610046262. View

18.

Sierra R, Raposo J, Trousdale R, Cabanela M . Dislocation of primary THA done through a posterolateral approach in the elderly. Clin Orthop Relat Res. 2005; 441:262-7. DOI: 10.1097/01.blo.0000194308.23105.f4. View

19.

Schulz K, Chalmers I, Hayes R, Altman D . Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA. 1995; 273(5):408-12. DOI: 10.1001/jama.273.5.408. View

20.

Bjorgul K, Reikeras O . 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. Acta Orthop. 2006; 77(3):368-74. DOI: 10.1080/17453670610046271. View