Methods of meta-analysis, a technique for the combination of data from multiple sources, were applied to analyze 106 reports of the treatment of displaced fractures of the femoral neck. Two years or less after primary internal fixation of a displaced fracture of the femoral neck, a non-union had developed in 33 per cent of the patients and avascular necrosis, in 16 per cent. The rate of performance of a second operation within two years ranged from 20 to 36 per cent after internal fixation and from 6 to 18 per cent after hemiarthroplasty (relative risk, 2.6; 95 per cent confidence interval, 1.4 to 4.6). Conversion to an arthroplasty was the most common reoperation after internal fixation and accounted for about two-thirds of these procedures. The remaining one-third of the reoperations were for removal of the implant or revision of the internal fixation. For the patients who had had a hemiarthroplasty, the most common reoperations were conversion to a total hip replacement, removal or revision of the prosthesis, and debridement of the wound. Although we observed an increase in the rate of mortality at thirty days after primary hemiarthroplasty compared with that after primary internal fixation, the difference was not significant (p = 0.22) and did not persist beyond three months. The absolute difference in perioperative mortality between the two groups was small. An anterior operative approach for arthroplasty consistently was associated with a lower rate of mortality at two months than was a posterior approach. Some reports showed promising results after total hip replacement for displaced fractures of the femoral neck; however, randomized clinical trials are still needed to establish the value of this treatment.

Outcomes after Displaced Fractures of the Femoral Neck. A Meta-Analysis of One Hundred and Six Published Reports.

In this prospective randomised trial we compare the mortality, morbidity and functional results of patients following each of the three principal methods of treatment for displaced subcapital fractures of the femur. Two hundred and ninety patients over the age of 65 years were included and randomly allocated to undergo closed reduction and internal fixation with a sliding compression screw plate or uncemented Austin Moore hemiarthroplasty or cemented Howse II total hip arthroplasty (THA). Nineteen patients were subsequently excluded. The 13 year results show that there was no statistical difference in the mortality between the three groups (81, 85 and 91% respectively). Internal fixation and hemiarthroplasty groups fared poorly with a revision rate of 33 and 24%, respectively, compared with 6.75% in the THA group. The dislocation rate was 13% following hemiarthroplasty and 20% following THA. Average Harris hip scores were 62, 55 and 80, respectively, for the internal fixation, hemiarthroplasty and THA groups. In the long term, both internal fixation and hemiarthroplasty resulted in a poor outcome with respect to pain and mobility. Despite high early complications, THA resulted in least pain and most mobility both in the short and long-term and was encouraging with a revision rate of only 6.25%. THA should be seriously considered in physiologically active patients with a displaced subcapital fracture of the femur.

Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur--13 year results of a prospective randomised study.

A prospective study of displaced femoral neck fractures was conducted with patients randomized into three groups: cemented total hip replacement (THR), cemented hemiarthroplasty (UHR-C), and noncemented hemiarthroplasty (UHR-NC). Eighty-nine patients were treated for displaced (Garden type 3 or 4) fracture with a prosthesis; 39 patients had THR, 37 had UHR-C, and 13 had UHR-NC. No difference was found in the level of pain, ambulation, or aids required between the THR group and the UHR-C group, except for active community ambulators, who demonstrated decreased endurance capability when treated with UHR-C. The patients treated with UHR-NC had increased pain and decreased ambulation and required assistive devices. The most significant complication was dislocation, which occurred in 7 patients with THR and 2 with UHR-C. The mortality rate at 2 years was 18%; all but two of the deaths were in patients with one of five different medical diseases: clinically significant cardiac or pulmonary disease, cancer, alcoholism, or psychosis. The mortality rate was insignificant in patients younger than 70 years of age. Roentgenographic review showed only 2 of 76 cemented stems with progressive cement-bone demarcation, with one patient requiring revision for a loose prosthesis. No evidence of protrusio was seen with the use of the bipolar cap. The uncemented hemiarthroplasties demonstrated lucency between the metal and bone in the proximal femur in 9 of 13 stems. The authors make recommendations regarding hip replacement.

Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty.

The results of stabilization of an intracapsular fracture of the femoral neck with cannulated screws placed in parallel in 141 patients between 1980 and 1985 were reviewed retrospectively. Fifty patients (35 per cent) had a non-displaced fracture (Garden Stage I or II) and ninety-one (65 per cent) had a displaced fracture (Garden Stage III or IV). The median age of the patients was sixty-eight years (range, twenty-four to ninety-five years). The mean duration of follow-up was eight years. No patient died or had a wound infection during the stay in the hospital. Twenty-nine patients, who had a median age of seventy-five years (range, fifty-six to ninety-five years), died within sixty months after treatment; eleven of them (median age, seventy-five years [range, sixty-five to eighty-six years]) died within the first twelve months. There was a loss of position or a non-union of the fracture in five patients (4 per cent) and healing of the fracture in 136 patients (96 per cent). Thirteen patients (11 +/- 3 per cent) had histological or roentgenographic evidence of osteonecrosis within twenty-four months after treatment. Ten of these patients had had a displaced fracture. Osteonecrosis developed in thirteen additional patients during the remaining period of follow-up. Eight of these patients had had a displaced fracture. The prevalence of osteonecrosis at the time of the most recent follow-up (mean duration, eight years) was 22 +/- 4 per cent. Osteonecrosis developed in eight of the forty-one patients who had had a Garden Stage-II fracture, in six of the thirty patients who had had a Garden Stage-III fracture, and in twelve of the forty patients who had had a Garden Stage-IV fracture. The fifty-five surviving patients in whom the fracture healed without complications were found to be functioning well more than sixty months after the fracture.

http://jbjs.org/content/jbjsam/76/12/1793.full.pdf

Intracapsular fractures of the femoral neck. Results of cannulated screw fixation.

We reviewed the long-term results of 126 consecutive total hip arthroplasties performed with cement in eighteen men and 108 women who had an acute fracture of the femoral neck. The patients had a mean age of seventy-five years (range, thirty-nine to eighty-nine years) at the time of the operation and were followed for a minimum of 10.1 years (or until the patient died or had a revision operation) and a maximum of 20.4 years. The median duration of follow-up was 8.8 years for all patients and 15.7 years for the twenty-two patients who were alive at the end of the study period. Six hips (5 per cent) were revised because of aseptic loosening. Survivorship analysis revealed that the probability of survival of the prosthesis without revision (with 95 per cent confidence intervals) was 95 per cent (91 to 99 per cent) at five years, 94 per cent (88 to 98 per cent) at ten years, 89 per cent (79 to 97 per cent) at fifteen years, and 84 per cent (66 to 97 per cent) at twenty years. Of the 118 patients who were alive at the one-year postoperative examination, 117 (99 per cent) had no pain or mild pain and eighty-one (69 per cent) had regained or had an improvement in the preoperative level of function. At the latest follow-up examination, eighty-seven (86 per cent) of the 102 patients who were available still had no pain or only mild pain. Twenty-six patients (21 per cent) had had perioperative medical complications, and twenty-one patients (17 per cent) had had operative complications, including thirteen patients (10 per cent) who had had a dislocation of the hip. Total hip arthroplasty performed in elderly patients for the treatment of an acute fracture of the femoral neck was associated with a higher rate of complications than usually is reported for hemiarthroplasty in such patients. However, the total hip arthroplasty provided good clinical results and was associated with long-term survival of the prosthesis.

Total Hip Arthroplasty for the Treatment of an Acute Fracture of the Femoral Neck. Long-term Results*

Primary total hip replacement for displaced subcapital fractures may be performed with an acceptable mortality. The majority of a series of patients who were reviewed after operation experienced few symptoms and 87 per cent were able to walk independently. These results compared favourably with other forms of management, and deterioration was seldom observed.

Paul Armour

Papers

Treatment of subcapital femoral fractures by primary total hip replacement.