Unstable Femoral Neck Fractures - Arthroplasty vs Fixation

Six high quality (Frihagen 2007, Johansson 2001, Keating 2005, Lu 2017, Parker 2010, Stoen 2014) and 22 moderate quality studies (Bachrach-Lindstrom 2000, Calder 1995, Cao 2014, Channout 2012, Davison 2001, Desteli 2015, Dolatowski 2019, El-Abed 2005, Johansson 2014, Johansson 2006, Johansson 2000, Jolly 2019, Mouzopoulos 2008, Parker 2002, Ravikumar 2000, Roden 2003, Shi 2018, Sikorski 1981, Skinner 1989, Tidermark 2003, Waaler 2012) 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. These studies consistently reported better outcomes (reoperation rate, pain scores, functional status, and/or complication rate) for patients in who were treated with arthroplasty. A decreased rate of reoperation among patients treated with arthroplasty was the most consistent finding across the studies. Composite analysis of these studies shows no statistically significant difference in mortality between arthroplasty and internal fixation. 

Benefits/Harms of Implementation

Implementing this recommendation does not result in additional harm to the patient beyond that conferred by usual surgical risk. Arthroplasty may be associated with somewhat higher initial charges compared with internal fixation due to more costly implants and higher procedural and professional fees, however this is likely offset by the decrease in reoperations expenses avoided by arthroplasty versus internal fixation. 

Future Research 

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