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BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Comparison of Internal Fixation
with Total Hip Replacement for
Displaced Femoral Neck Fractures
RANDOMIZED, CONTROLLED TRIAL PERFORMED
AT
FOUR YEARS
BY RICHARD BLOMFELDT, MD, HANS TÖRNKVIST, MD, PHD, SARI PONZER, MD, PHD,
ANITA SÖDERQVIST, RN, AND JAN TIDERMARK, MD, PHD
Investigation performed at the Karolinska Institutet, Department of Orthopaedics, Stockholm Söder Hospital, Stockholm, Sweden
Background: Recent randomized, controlled trials performed at two years postoperatively have shown that a primary
total hip replacement is superior to internal fixation for the treatment of a displaced femoral neck fracture in a relatively healthy, mentally competent, elderly patient. The primary aim of the present study was to evaluate the outcomes at four years.
Methods: One hundred and two patients (mean age, eighty years) who had an acute displaced femoral neck fracture
were randomly allocated to be treated with total hip replacement or internal fixation. The inclusion criteria were an
age of at least seventy years, absence of severe cognitive dysfunction, an independent living status, and the ability to
walk independently. The main outcome measurements were hip complications, reoperations, hip function, and healthrelated quality of life.
Results: The mortality rate was 25% in both groups. At the forty-eight-month follow-up evaluation, the rate of hip complications was 4% in the patients treated with total hip replacement and 42% in those treated with internal fixation (p <
0.001) and the reoperation rates were 4% and 47%, respectively (p < 0.001). The arthroplasty group had no additional
hip complications or reoperations between the twenty-four and forty-eight-month follow-up visits. In the fixation group,
the percentage of hip complications increased from 36% to 42% and the percentage of reoperations increased from
42% to 47% during the same period. The hip function was significantly better and the decline in health-related quality of
life was less pronounced in the arthroplasty group than it was in the fixation group at the four, twelve, and twenty-fourmonth follow-up evaluations. Ninety-seven percent of the patients in the arthroplasty group and 57% of the patients in
the fixation group who were available for follow-up at forty-eight months had no hip complications (p < 0.001).
Conclusions: Compared with internal fixation, primary total hip replacement provides a better outcome for mentally
competent elderly patients with a displaced femoral neck fracture. The complication and reoperation rates were significantly lower and hip function and health-related quality of life were at least as good at four years after the surgery.
Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
T
he optimal treatment for an acute displaced femoral
neck fracture in an elderly patient is still under debate.
There is a growing opinion that the outcome would be
improved by a more patient-related, rather than a strictly
diagnosis-related, approach⎯that is, the treatment should be
based on the patient’s age, functional demands, and individual
risk profile1. The goal of future research should be to identify
selection criteria by which we can identify subgroups of patients that would be optimally treated by any of the surgical
methods available⎯i.e., internal fixation, hemiarthroplasty,
or total hip replacement2. The population of elderly patients
with femoral neck fracture comprises several subpopulations,
ranging from the mentally competent, relatively healthy, active
patient who is capable of living independently and has a long
life expectancy to the institutionalized, cognitively impaired,
bedridden patient. It is not likely that one method would be
optimal for all of the subpopulations.
A number of recent randomized, controlled trials have
shown that, for a relatively healthy, active, and lucid patient, a
primary total hip replacement is superior to internal fixation
regarding the need for secondary surgery, hip function3-8, and
the health-related quality of life3. The follow-up period in these
trials has been limited to two years except in the study by
Neander5 (which was partly randomized) and that by Raviku-
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mar and Marsh8, in which the durations of follow-up were four
and thirteen years, respectively. However, neither of those trials
included an assessment of the health-related quality of life.
It has often been claimed that hip function following
uneventful healing of a displaced femoral neck fracture will always be better than that following a hip arthroplasty. Since
this select group of relatively healthy elderly patients is likely
to have a longer life expectancy than the other elderly subgroups, it is important to evaluate the outcome, including
both hip function and health-related quality of life, after a
longer duration of follow-up.
In the present study, we examined the four-year followup results for elderly patients with a displaced femoral neck
fracture who had been included in a previously published randomized, controlled trial comparing internal fixation with total hip replacement3. The primary aim of the present study
was to determine whether the superior outcomes of primary
total hip replacement, as compared with the results of internal
fixation, in mentally competent elderly patients (at least seventy years old) with a displaced femoral neck fracture persisted at the time of a four-year follow-up. The secondary aim
was to describe the health-related quality of life for the two
treatment groups within the same period.
C O M P A R I S O N O F I N T E R N A L F I X A T I O N W I T H TO T A L H I P
R E P L A C E M E N T F O R D I S P L A C E D F E M O R A L N E C K F R A C T U RE S
Materials and Methods
he previously published randomized, controlled trial3 included 102 patients with an acute displaced femoral neck
fracture (Garden stage III or IV9). Eighty-two (80%) of the patients were female, and the mean age was eighty years (range,
seventy to ninety-six years). The inclusion criteria were an age
of at least seventy years, the absence of severe cognitive dysfunction (at least three correct answers on a ten-item mental
test [the Short Portable Mental Status Questionnaire10]), independent living status, and the ability to walk independently
with or without walking aids. Patients with a pathological fracture, a displaced fracture that had been sustained more than
twenty-four hours before presentation, or rheumatoid arthritis or osteoarthritis were not included. After clearance by
an anesthetist, the patients were randomized, with a sealedopaque-envelope technique, to be treated with internal fixation with two cannulated screws or to be treated with a primary
total hip replacement (Fig. 1).
Internal fixation was carried out with the patient on a
fracture table. The fractures were reduced with closed methods, with the aid of an image intensifier, and were fixed internally with two cannulated screws (Olmed; DePuy/Johnson
and Johnson, Sollentuna, Sweden). The goals for screw posi-
T
Fig. 1
Surgical outcomes for all 102 patients included in the study. THR = total hip replacement, IF = internal fixation, HA = hemiarthroplasty, fx = fracture,
and AVN = osteonecrosis.
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TABLE I Baseline Data for the One Hundred and Two Patients*
Characteristic†
Total Hip Replacement (N = 49)
Internal Fixation (N = 53)
79.2 ± 5.0
81.4 ± 6.6
9.0 ± 1.1
8.7 ± 1.6
0.80 ± 0.22
0.84 ± 0.13
40 (82)
42 (79)
Age‡ (yr)
Cognitive function (SPMSQ10) ‡
EQ-5D index score before fracture‡
Female§
No walking aid or just one cane§
45 (92)
46 (87)
ADL index13 of A or B§
48 (98)
51 (96)
Comorbidity grade14 of A or B§
40 (82)
44 (83)
*There were no significant differences between the treatment groups. †SPMSQ = Short Portable Mental Status Questionnaire, and ADL = activities of daily living. ‡The values are given as the mean and standard deviation. §The values are given as the number of patients with the
percentage in parentheses.
tioning were modified from the recommendations by Lindequist and Törnkvist11. The reduction was categorized as good
(displacement of <2 mm, a Garden angle of 160° to 175°, and
posterior angulation of <10°), fair (displacement of <5 mm, a
Garden angle of 160° to 175°, and posterior angulation of
<20°), or poor (displacement of >5 mm, a Garden angle of
<160° or >175°, and posterior angulation of >20°). The position of the screw was categorized as good if its tip was <5 mm
from the subchondral bone. As viewed in the anteroposterior
projection, the distal screw was aimed to be introduced at the
level of the lesser trochanter and to lie on the calcar femorale.
The proximal screw was introduced at least 2 cm from, and
parallel to, the distal screw, with an angle of <10° between the
two screws. As viewed in the lateral projection, the screws
were supposed to be parallel and positioned in the central or
posterior third of the femoral head and neck.
Total hip replacement was carried out with use of the
modified Hardinge approach12, with the patient in the lateral
decubitus position. An Exeter modular stem (Howmedica,
Malmö, Sweden) with a 28-mm head and an Ogee acetabular
component (DePuy/Johnson and Johnson, Sollentuna, Sweden) were implanted.
The patients in both groups were allowed to walk with
full weight-bearing as tolerated. The patients who were treated
with the total hip replacement were informed about mobilization techniques and were allowed to sit on a high chair immediately after the surgery and to stop using crutches at their
own convenience. After six weeks, there were no restrictions.
All operations were performed by one of two surgeons (J.T. or
H.T.) who were experienced with both procedures.
The perioperative details and the results at the four,
twelve, and twenty-four-month follow-up evaluations have
been reported previously3. There were no significant preoperative differences between the groups regarding age, gender,
cognitive function10, ability to carry out activities of daily
living13, walking ability, or comorbidities14 (Table I).
The present study included clinical and radiographic examination at approximately forty-eight months (mean [and
standard deviation], 48.8 ± 1.6 months). Fracture-healing, hip
complications, ability to carry out activities of daily living,
ability to live independently, new fractures of the lower extremity, hip function, and health-related quality of life were
assessed. All clinical variables except hip motion were assessed
by an unbiased observer (a research nurse who was not involved in the surgery or clinical decisions). That observer was
not blinded with regard to the type of surgical intervention.
Comorbidity14 was graded as A (healthy), B (another illness not affecting rehabilitation), or C (another illness that affected rehabilitation).
The ADL (activities of daily living) index described by
Katz et al.13 was used to evaluate the functional independence
or dependence of patients with regard to bathing, dressing, using the toilet, transferring, continence, and feeding. An ADL
index of A indicates independence in all six functions; an index of B indicates independence in all but one of the six functions; and indices of C through G indicate dependence on
another for bathing and at least one more function.
Living conditions were categorized as independent (living in one’s own home or in housing for the elderly) or as institutionalized (living in a care group for demented patients or
in a nursing home).
Hip complications in the fixation group were defined as
nonunion, osteonecrosis, or peri-implant fracture. Local pain
from protruding screws was not defined as a hip complication.
The fracture was defined as healed if there were visible trabeculations across the fracture line and no signs of osteonecrosis.
Nonunion was defined as an absence of radiographically visible trabeculations across the fracture line and included early
redisplacement or progressive displacement. Hip complications in the arthroplasty group were recorded as dislocation,
periprosthetic fracture, or radiographic signs of loosening of
the femoral15 or acetabular16 component.
Charnley’s numerical classification17 defines the clinical
state of the affected hip joint in terms of pain, movement, and
walking ability. Each dimension is graded on a scale of 1 to 6,
with 1 indicating total disability and 6 indicating a normal
state. The mean value and the percentage of patients with the
best scores (5 and 6) for each dimension were determined.
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The health-related quality of life was rated with use of
the EuroQol-5D (EQ-5D) index18. An EQ-5D index score of 0
indicates the worst possible health state, and a value of 1 indicates full health.
In the outcome analysis, all patients who had been included in the study remained in their primary randomization
group according to the intention-to-treat principle, regardless
of secondary procedures. The patients who were lost to followup had been followed for as long as possible, and their results
are presented separately.
The study was performed according to the Helsinki
Declaration. All patients gave informed consent to participate,
and the protocol was approved by the local ethics committee.
Statistical Methods
The analyses were performed with SPSS 12.0.1 for Windows
(SPSS, Chicago, Illinois) statistical software. All scale variables
were tested for normality with the Kolmogorov-Smirnov test.
The Student t test was used for parametric scale variables in independent groups. The Mann-Whitney U test was used for
nonparametric scale variables and ordinal variables in independent groups. Nominal variables were tested with the chisquare test or the Fisher exact test. All tests were two-sided. The
results were considered significant at p < 0.05. Trend values
(0.05 ≤ p < 0.1) are displayed in this paper, and all other values
are reported as not significant. In order to maximize the power
of the statistical tests, we did not apply any correction factor
(such as Bonferroni correction) to the p values, which may increase the possibility of a Type-I error.
Fig. 2
Percentage of patients who were still alive and had not undergone a reoperation (among all 102 patients who had been included in the study)
in relation to time. THR = total hip replacement, and IF = internal fixation.
C O M P A R I S O N O F I N T E R N A L F I X A T I O N W I T H TO T A L H I P
R E P L A C E M E N T F O R D I S P L A C E D F E M O R A L N E C K F R A C T U RE S
Results
n our previously published two-year-follow-up study3, the
fracture reduction was considered to be good in forty-six
(87%) of the fifty-three patients in the fixation group and fair
in the remaining seven. The screw position was thought to be
good in fifty-one (96%) of the fifty-three patients. The stem
position was considered to be good in forty-eight (98%) of the
forty-nine patients in the arthroplasty group, and the stem
was in 8° of varus in one patient. The acetabular component
was in a good position in forty-four (90%) of the forty-nine
patients. The lateral opening was increased by 5° to 8° in the
five remaining patients, one of whom also demonstrated 6° of
retroversion. The operatively treated limb was lengthened by a
mean of 6 mm (range, −10 to +24 mm). There were two superficial infections in the arthroplasty group but no deep infections. The failure rate, with regard to hip complications
and the number of patients undergoing a reoperation, was
higher in the fixation group than in the arthroplasty group.
I
Surgical Outcome for All Patients
The surgical outcomes after forty-eight months are shown in
Figure 1. In the entire study population, including the patients
who later died (25% of the population) or were lost to followup (5%), the rate of hip complications was 4% (two of fortynine) in the arthroplasty group and 42% (twenty-two of fiftythree) in the fixation group (p < 0.001); nonunion occurred in
23% of the patients in the fixation group and osteonecrosis, in
19%. The rate of reoperations was significantly higher in the
fixation group (47% [twenty-five of fifty-three]), with 34%
having a subsequent arthroplasty and 13%, screw removal)
than it was in the arthroplasty group (4% [two of forty-nine])
(p < 0.001). Three of the patients in the fixation group who
underwent a total hip replacement had had a previous operation for screw removal, which was not included among the reoperations for the analysis. The differences between the
groups regarding reoperations were still significant if only the
major reoperations (the arthroplasties) were counted in the
fixation group (p < 0.001).
The mortality rate was 24% (twelve of forty-nine) in the
arthroplasty group and 25% (thirteen of fifty-three) in the fixation group (difference not significant). A life-table analysis of
the percentage of surviving patients who had not had a reoperation is displayed in Figure 2.
Eight patients (16%) in the arthroplasty group and ten
(19%) in the fixation group had a new fracture involving the
lower extremities during the four-year follow-up period (difference not significant). There were four femoral neck fractures, three trochanteric fractures, and one periprosthetic
fracture in the arthroplasty group and eight femoral neck fractures, one pubic ramus fracture, and one tibial condylar fracture in the fixation group. There were no ipsilateral periimplant fractures in the fixation group.
Of the 102 patients, five (5%) were lost to follow-up before forty-eight months postoperatively; three of these patients
were in the fixation group, and two were in the arthroplasty
group. Of the three patients in the fixation group, one had un-
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TABLE II Hip Function According to the Charnley Score for All Patients Available at Each Follow-up Evaluation*
Total Hip Replacement
Pain
4 mo
Internal Fixation
Mean Score†
(points)
Percentage with Score
of 5 or 6 Points
Mean Score†
(points)
Percentage with Score
of 5 or 6 Points
P Value‡
5.7
85%
4.7
55%
<0.001
12 mo
24 mo
5.3
5.6
76%
84%
4.5
4.7
50%
54%
<0.005
<0.005
48 mo
5.5
80%
5.2
70%
0.088
Movement
4 mo
5.0
65%
4.7
49%
NS
12 mo
24 mo
5.0
4.9
70%
67%
4.6
4.5
44%
46%
<0.01
<0.05
48 mo
4.7
57%
4.5
46%
NS
Walking
4 mo
4.3
33%
3.5
15%
<0.001
12 mo
24 mo
4.6
4.5
50%
51%
3.9
3.8
24%
32%
<0.01
<0.05
48 mo
3.8
23%
3.5
24%
NS
*N = 95 at four months, n = 92 at twelve months, n = 84 at twenty-four months, and n = 72 at forty-eight months. †1 = total disability, and
6 = normal state. ‡The p values are given for the differences between the treatment groups. NS = not significant.
dergone a hemiarthroplasty to treat a nonunion at twenty-two
months and was seen at the two-year follow-up evaluation, one
patient was lost to follow-up after the two-year visit, and one
was lost to follow-up after a four-month visit. In the arthroplasty group, one of the patients lost to follow-up had a dislocation and underwent a revision of the acetabular component and
lengthening of the neck of the prosthesis at six months, after
which the dislocation did not recur. The patient had good hip
function at the twelve-month follow-up evaluation and then refused to return for additional examinations; however, he reported satisfactory hip function in a telephone interview at
forty-eight months after the primary surgery. The other patient
in the arthroplasty group who was lost to follow-up had a good
outcome at the two-year follow-up visit.
Surgical Outcome for Patients Available
for Follow-up at Forty-Eight Months
In the arthroplasty group, one (3%) of thirty-five patients
available for follow-up at forty-eight months had had a hip
complication and a reoperation. This patient sustained a
periprosthetic fracture in a fall six weeks after the primary operation and was treated with internal fixation of the fracture,
with an uneventful outcome. One additional patient in the arthroplasty group had a reoperation⎯a revision arthroplasty
due to dislocations six months after the primary surgery. This
patient was later lost to follow-up, as mentioned above. There
were no hip complications in the arthroplasty group between
twenty-four and forty-eight months, and there were no radiographic signs of loosening of the components in any of the patients at the four-year follow-up evaluation.
In the group treated with internal fixation, sixteen (43%)
of the thirty-seven patients available for follow-up at forty-eight
months had had a fracture-healing complication. Twelve (32%)
of the thirty-seven had undergone an arthroplasty (a total hip
replacement in eleven of them), and seven (19%) had had the
fixation screws removed. All patients with a nonunion but only
five of the nine patients with osteonecrosis underwent an arthroplasty. Two of the patients with osteonecrosis had screw removal only. Between the twenty-four and forty-eight-month
follow-up evaluations, the percentage of fracture-healing complications increased from 36% to 42% and the percentage of reoperations increased from 42% to 47%.
Functional Outcome and
Health-Related Quality of Life
There were no differences in the ADL index between the
groups at the four, twelve, and twenty-four-month follow-up
evaluations. At forty-eight months, 81% of the patients in the
arthroplasty group and 70% in the fixation group had an ADL
index of A or B (difference not significant). This finding reflected a deterioration compared with the twenty-four-month
ADL indices, which were A or B in 90% and 88%, respectively.
The Charnley hip scores are presented in Table II. The
hip function was generally better in the arthroplasty group at
the four, twelve, and twenty-four-month follow-up evaluations, but there was no significant difference between the
groups with regard to hip function at forty-eight months.
Both groups had a marked reduction in walking ability at
forty-eight months compared with the ability at twelve and
twenty-four months.
The health-related quality of life according to the EQ5D index score was better in the arthroplasty group at each
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follow-up point, but the differences were significant only at
four months (p < 0.005) and twelve months (p < 0.05) (Fig.
3). The change in the EQ-5D index score between the time
that the patient was included in the study and each follow-up
evaluation (four, twelve, twenty-four, and forty-eight months)
is shown in Table III. The decline in the score was more pronounced in the fixation group, but, with the numbers available, the difference between the groups at the forty-eightmonth follow-up evaluation was not significant.
Among the patients available for follow-up at fortyeight months, thirty-four (97%) of the thirty-five in the arthroplasty group and twenty-one (57%) of the thirty-seven
patients in the fixation group remained without a hip complication (p < 0.001). The hip function and health-related quality of life of these patients are shown in Table IV.
At forty-eight-months, there was a trend toward a higher
percentage of patients living independently in the arthroplasty
group (89%; thirty-one of thirty-five) than in the fixation group
(70%; twenty-six of thirty-seven) (p = 0.082).
Discussion
he benefit of primary total hip replacement compared
with internal fixation for the treatment of a displaced femoral neck fracture in a relatively healthy, cognitively intact, elderly patient is apparent even at four years postoperatively. The
rate of hip complications and the need for secondary surgery
are lower, and hip function and health-related quality of life are
as good.
The rate of hip complications in the fixation group con-
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tinued to increase, from 36% at twenty-four months to 42% at
forty-eight months, and the reoperation rate increased from
42% to 47%. The increase in hip complications was due to detection of osteonecrosis in a number of patients after the
twenty-four-month follow-up evaluation; the total rate of osteonecrosis was 19% at forty-eight months, and the rate of
nonunions was 23%. This increase was in contrast to the
outcome in the arthroplasty group, in which the rate of hip
complications and the rate of reoperations each remained unchanged at 4%. According to the current state of the art, the
fracture reduction and screw position were optimal in the vast
majority of the patients in the fixation group, and the outcomes in that group at twenty-four months were equal to or
better than those reported in most other studies. This is confirmed by the meta-analysis by Lu-Yao et al.19, in which the hip
complication rate was 49%, with a 33% rate of nonunion and
a 16% rate of osteonecrosis. In a large meta-analysis focusing
on the choice of implant in almost 5000 patients20, screws (as
used in our study) appeared to be superior to pins, but there is
no clinical evidence that the use of three or more screws is superior to the use of two screws.
There were no additional complications in our arthroplasty group between the twenty-four and forty-eight-month
follow-up evaluations. The dislocation rate remained low at 2%
and was on par with what can be expected after an elective total
hip replacement in patients with osteoarthritis or rheumatoid
arthritis. This low rate compares favorably with the dislocation
rates (range, 9% to 22%) in other randomized, controlled trials
of primary total hip replacement in patients with a femoral
Fig. 3
Health-related quality of life (EQ-5D index score) for all patients available at each follow-up interval (n = 102 before the fracture, {n = 94 at four
months, n = 92 at twelve months, n = 84 at twenty-four months, and n = 72 at forty-eight months). The p values are given for differences between
the treatment groups. 0 = worst possible health state, and 1 = full health. THR = total hip replacement, IF = internal fixation, fx = fracture, and NS =
not significant.
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TABLE III Change in EQ-5D Score Between Baseline and Each Follow-up Evaluation
Change in EQ-5D Score Compared with Baseline (points)
Follow-up Time*
Total Hip Replacement†
Internal Fixation†
P Value‡
4 mo
−0.09 ± 0.24
−0.25 ± 0.25
<0.005
12 mo
−0.09 ± 0.27
−0.23 ± 0.26
<0.05
24 mo
−0.11 ± 0.28
−0.22 ± 0.24
<0.05
48 mo
−0.21 ± 0.36
−0.32 ± 0.38
NS
*N = 94 at four months, n = 92 at twelve months, n = 84 at twenty-four months, and n = 72 at forty-eight months. †The values are given as the
mean and standard deviation. ‡The p values are given for the differences between the treatment groups. NS = not significant.
neck fracture5-8,21. The surgical approach was through a trochanteric osteotomy in the study by Jonsson et al.7 and was posterolateral in all of the others5,6,8,21. The low rate of dislocation in our
series is probably explained by our inclusion criteria, which
were an ability to walk and live independently and, most importantly, no severe cognitive dysfunction. In the study by Johansson et al.6, the dislocation rate was 32% in patients with mental
dysfunction compared with 12% in lucid patients. Assessment
of cognitive function with a validated instrument, such as the
Short Portable Mental Status Questionnaire (SPMSQ)10 used in
our study, is advantageous, especially with regard to facilitating
the implementation of the findings in future treatment protocols. Additionally, we believe that the anterolateral surgical
approach has advantages over the posterolateral approach regarding stability of the hip joint, which is of crucial importance
in patients with this particular diagnosis5,6,8,21-23.
The four-year mortality rate of 25% in both groups in
our study was lower than the two-year mortality rate in most
series in which the patients were not selected on the basis of
walking ability, living conditions, and cognitive function1. The
25% rate is in sharp contrast to the finding of a study in which
patients were selected if they were able to walk independently
but had severe cognitive dysfunction (an SPMSQ score of
<3)24. In that study, in which the patients were randomized to
be treated with internal fixation or primary hemiarthroplasty,
the two-year mortality rate was 42%. The expected longer survival of the patients selected for our study emphasizes the importance of a primary procedure with durable results. Total
hip replacement seems to provide good long-lasting function.
According to the Swedish National Hip Arthroplasty Register,
98% of patients in whom a hip fracture was treated with total
hip replacement did not have a revision within eleven years25.
Given the expected mean duration of survival of a seventyyear-old Swedish woman and man (sixteen and thirteen years,
respectively)26, it appears that most primary total hip replacements in patients older than seventy years of age will last
throughout their remaining life span, provided that they do
not have an early complication. This contention is also supported by the four-year follow-up study by Neander5 and the
thirteen-year follow-up study by Ravikumar and Marsh8. In
the latter study, in which internal fixation, cementless hemiarthroplasty, and total hip replacement were compared, the
thirteen-year revision rates were 33%, 24%, and 7%, respectively. Hip function was best in the total hip replacement group
and worst in the hemiarthroplasty group. This unfavorable
outcome of cementless hemiarthroplasty was confirmed by
the 1986 study by Dorr et al.27.
In our study, hip function was significantly better and the
decline in health-related quality of life was less pronounced in
the arthroplasty group than in the fixation group at the four,
twelve, and twenty-four-month follow-up evaluations, but the
differences were no longer significant at the forty-eight-month
evaluation. The scores for hip pain in the fixation group were
markedly improved between the twenty-four and forty-eightmonth follow-up evaluations, probably reflecting the fact that
the majority of the patients with hip complications had undergone a reoperation. All patients with a nonunion and five of the
nine with osteonecrosis had an arthroplasty, and eleven of the
twelve patients who had an arthroplasty had a total hip replacement. Additionally, 19% of the patients had had the screws
TABLE IV Outcomes Regarding Hip Function (Charnley Score) and Health-Related Quality of Life (EQ-5D Index Score) for All
Patients without a Hip Complication at Forty-eight Months Postoperatively*
Total Hip Replacement (N = 34)
Internal Fixation (N = 21)
Charnley pain score
5.5 ± 1.1
5.3 ± 1.1
Charnley movement score
4.7 ± 0.8
4.7 ± 1.2
Charnley walking score
3.9 ± 1.3
3.3 ± 1.7
0.62 ± 0.31
0.52 ± 0.40
EQ-5D index score
*The values are given as the mean number of points and the standard deviation. Charnley score: 1 = total disability, and 6 = normal state.
EQ-5D index score: 0 = worst possible health state, and 1 = full health. There were no significant differences between the treatment groups.
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removed. Of the patients in whom the fracture healed uneventfully, 24% underwent screw removal. There was an obvious deterioration in walking ability and health-related quality of life
between the twenty-four and forty-eight-month follow-up evaluations in both groups, probably reflecting the natural course of
aging, the increased frequency of comorbidities, and new fractures of the lower extremity. Eighteen percent of all patients sustained a new fracture of the lower extremity, and the fractures
were predominately of the hip.
In a randomized, controlled trial comparing internal fixation with total hip replacement, it is inevitable that the difference in hip function and health-related quality of life between
the two groups will decrease with time (in an intention-to-treat
analysis) as a result of a substantial proportion of salvage arthroplasties being performed in the fixation group. Therefore, it
is important to evaluate the overall outcome⎯i.e., revision surgery, hip function, and health-related quality of life⎯during
this relatively long time period, rather than focusing exclusively
on the outcome at the time of the final follow-up. Four years
is a substantial period of the remaining lifetime of these elderly patients.
The opinion that the outcome following uneventful healing of a displaced femoral neck fracture treated with internal
fixation is better than that of an arthroplasty seems not to be
true when internal fixation is compared with primary total hip
replacement in a group of relatively healthy, mentally competent patients. In the group of patients with an uneventful outcome, those treated with arthroplasty had better absolute values
for hip function and health-related quality of life than those
treated with internal fixation, although this difference was not
significant at the forty-eight-month follow-up evaluation. Thus,
the hip function and health-related quality of life at four years
after the hip arthroplasties were at least as good as those following uneventful healing of internally fixed fractures.
The number of patients enrolled in this trial limited its
statistical power for detecting differences in hip function and
health-related quality of life, especially with the mortality rate
reducing the number of patients available for long-term
follow-up. However, the statistical power was adequate to confirm the difference in the rate of hip complications and reoperations and to support the conclusion that, at four years, the
hip function and health-related quality of life provided by to-
C O M P A R I S O N O F I N T E R N A L F I X A T I O N W I T H TO T A L H I P
R E P L A C E M E N T F O R D I S P L A C E D F E M O R A L N E C K F R A C T U RE S
tal hip replacement are similar to those provided by internal
fixation. The fact that the nurse who performed the follow-up
evaluations was not blinded to the type of surgical intervention is also a limitation. The questionnaires for most of the
outcome variables were mailed to the patients a week before
the scheduled follow-up visit. The questionnaires were filled
out by the patients, and the nurse’s task at the follow-up evaluation was to ensure that all questions had been completed. A
strength of the trial was that only 5% of the patients were lost
to follow-up less than the forty-eight-months postoperatively.
In summary, the results of this study confirm that, at
four years postoperatively, the outcomes of primary total hip
replacement are better than those of internal fixation in mentally competent elderly patients with a displaced femoral neck
fracture. The complication and reoperation rates were significantly lower following the hip arthroplasties, and the hip
function and the health-related quality of life were similar to
those following internal fixation. The criteria for selecting patients for treatment with total hip replacement are important,
and we recommend use of a validated instrument for assessing
cognitive function. Richard Blomfeldt, MD
Hans Törnkvist, MD, PhD
Sari Ponzer, MD, PhD
Anita Söderqvist, RN
Jan Tidermark, MD, PhD
Karolinska Institutet, Department of Orthopaedics, Stockholm Söder
Hospital, S -118 83 Stockholm, Sweden. E-mail address for J. Tidermark:
jan.tidermark@ortoped.sos.sll.se
In support of their research or preparation of this manuscript, one or
more of the authors received grants or outside funding from the TryggHansa Insurance Company, the Swedish Society for Medical Research,
the Swedish Orthopaedic Association, and the Stockholm County Council. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed to pay or direct, any
benefits to any research fund, foundation, educational institution, or
other charitable or nonprofit organization with which the authors are
affiliated or associated.
doi:10.2106/JBJS.D.02655
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