Review Question - QID 5808

THA is the best long term solution for displaced femoral neck fractures (FNF) in active elderly patients.

The aims of surgery for FNF in elderly patients are immediate pain relief, rapid mobilization, and low complications and revision. THA has best pain relief, fewer reoperations, best survivorship and is most cost-effective but has longer operative/anesthetic time, blood loss, higher infection rate, and potential instability compared with HA.

Healy and Iorio examined the optimal treatment for elderly FNF. They compared internal fixation (120 patients) with arthroplasty (HA, 43 patients; THA, 23 patients). There was no different in reoperation or mortality rates between the 2 groups, but arthroplasty was more cost effective, had independent living, and longer interval to reoperation/death. THA had less pain, better function, and lower rates of reoperation than HA, and was most cost-effective. They concluded that THA was the best treatment.

Yu et al. performed a meta-analysis of randomized controlled trials to determine whether THA or hemiarthroplasty (HA) was superior. They found that THA had lower risk of reoperation (RR = 0.53), higher risk of dislocation (RR = 1.99), and higher functional scores at 1 and 4 years. There was no difference in mortality, infection and complication rates.

Figure A shows a displaced left femoral neck fracture.

Incorrect Answers:
Answer 1: Cannulated screws may be indicated for nondisplaced fractures (CRIF) or displaced fractures (ORIF) in young patients. But internal fixation is not predictable/ reproducible in all patients (especially elderly patients) because of variations in the condition of articular cartilage, bone stock, fracture angle, comminution, reduction, fixation, comorbidities, nonunion, osteonecrosis, reoperation, mortality, and postoperative rehabilitation.
Answer 2: Valgus intertrochanteric osteotomy (or sliding hip screw) is indicated for displaced fractures with high Pauwel's angle in young patients where it is desirable to avoid arthroplasty.
Answer 3: Unipolar HA is reserved for low demand elderly patients, and is associated with groin pain, hip stiffness, cartilage erosion from oversized / undersized femoral head and protrusio.
Answer 4: Bipolar HA may be indicated for patients at risk for instability (neuromuscular/Parkinson’s disease, dementia). It is is associated with groin pain, acetabular cartilage deterioration, osteolysis from PE wear at the femoral head/mobile acetabular component, implant loosening, and early revision surgery.