Strong evidence supports arthroplasty for patients with unstable (displaced) femoral neck fractures.

Rationale
Six high strength (Davison et al 49, Keating et al 50, Johansson et al 51, Bray et al 52, Frihagen et al 53, and Sikorski et al 54) and 19 moderate-strength studies (Ravikumar et al 55, Rogmark et al 56, Tidermark et al 57, Chammout et al 58, Bacharach-Lindstrom et al 59, Calder et al 60, El-Abed et al 61, Johansson  et al 62, Johansson et al 63, Jonsson et al 64, Mouzopoulos et al 65, Neander et al 66, Parker et al 67, Parker et al 68, Parker et al 69, Roden et al 70, Skinner et al 71, Van Dortmont et al 72,  Waaler Bjornelv et al 73) directly compared arthroplasty (hemi- and/or total hip arthroplasty) to internal fixation for the treatment of unstable/displaced (Garden III and IV) femoral neck fractures in elderly patients. These studies consistently reported better outcomes (reoperation rate, pain scores, functional status, and/or complication rate) for patients in whom internal fixation was avoided as the treatment of choice.  A decreased rate of reoperation among patients treated with arthroplasty was the most consistent finding across the studies. A meta-analysis on patients treated with hemiarthroplasty demonstrated no statistically significant difference in mortality (Figure 4).
 
Risks and Harms of Implementing this Recommendation
The benefit of implementing this recommendation will be the avoidance of reoperations in this frail patient population.  This has implications on cost savings to society.

Future Research
Future studies should help to identify patient populations who may benefit from less invasive treatment.

 
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