REGISTRY REVIEW: Hip Arthroplasty for Displaced Femoral Neck Fracture
The treatment of choice for a displaced femoral neck fracture is still a matter of debate, with the answer most likely hinging on patient age and activity level. In most cases, younger patients – generally those under age 60 – are offered open reduction and internal fixation (ORIF). Hemiarthroplasty and total hip arthroplasty (THA) are usually better options for older patients, [1-4] with recent studies suggesting that outcomes of the 2 procedures are about equal in this population. [5,6]
The literature emphasizes that the decision on whether to perform hemiarthroplasty or THA should be individualized to the patient, and that’s what appears to be happening in practice: In data reported to the American Joint Replacement Registry (AJRR), hemiarthroplasty has been the dominant procedure overall for displaced femoral neck fractures since 2012, although the percentage of hemiarthroplasties has decreased between 2012 and 2019 as the percentage of THAs has increased. (Note: AJRR does not collect data on ORIF, only arthroplasty procedures.)
Digging into the AJRR data, it’s clear that age plays a role in procedure choice. In patients up to age 59, THA was much more commonly performed than hemiarthroplasty, with the 2 switching places around age 60, as shown in the table below:
Note: Based on data from the AJRR’s 2020 Annual Report.
In elective primary THA for causes other than hip fracture, cementless fixation of the femoral stem is the norm in the US, although cement is making somewhat of a comeback in older patients with poor bone quality.  This trend appears to hold for patients with displaced femoral neck fractures as well: According to the AJRR data, the use of cemented femoral stems in this population decreased from 18.2% of THAs in 2012 to 12.6% in 2017 and then increased again to 15.8% in 2019, perhaps as a consequence of surgeons “rediscovering” cemented stems for elective primary THAs.
The use of cemented femoral stems is much more common in hemiarthroplasty, according to the AJRR data. More than half (51.2%) of hemiarthroplasties in 2012 were performed with a cemented femoral stem, dropping to 38.7% in 2016 and then increasing again to 44.8% in 2019. As expected, cement use increased by age group, from 29.2% of hemiarthroplasties performed in patients under age 50 to 49.2% of patients age 90 and above.
Interestingly, data from outside the US show higher use of cemented femoral stems for hemiarthroplasty. In the UK, about 78% of these procedures are done with cement,  with 98% of hemiarthroplasties performed with a cemented femoral stem in Sweden. 
The 2020 Annual Report from AJRR can be found here.
- Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P, Obremskey W, Koval KJ, Nork S, Sprague S, Schemitsch EH, Guyatt GH. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am. 2003 Sep;85(9):1673-81.
- Rogmark C, Leonardsson O. Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. Bone Joint J. 2016 Mar;98-B(3):291-7.
- Avery PP, Baker RP, Walton MJ, Rooker JC, Squires B, Gargan MF, Bannister GC. Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial. J Bone Joint Surg Br. 2011 Aug;93(8):1045-8.
- Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R, Törnkvist H, Ponzer S, Tidermark J. Comparison of bipolar hemiarthroplasty with total hip arthroplasty for displaced femoral neck fractures: a concise four-year follow-up of a randomized trial. J Bone Joint Surg Am. 2011 Mar 02;93(5):445-50.
- Ekhtiari S, Gormley J, Axelrod DE, Devji T, Bhandari M, Guyatt GH. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fracture: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2020 Sep 16;102(18):1638-1645. doi: 10.2106/JBJS.20.00226.
- Migliorini F, Trivellas A, Driessen A, et al. Hemiarthroplasty versus total arthroplasty for displaced femoral neck fractures in the elderly: meta-analysis of randomized clinical trials. Arch Orthop Trauma Surg. 2020 Nov;140(11):1695-1704. doi: 10.1007/s00402-020-03409-3. Epub 2020 Mar 13.
- Scanelli JA, Reiser GR, Sloboda JF, Moskal JT. Cemented femoral component use in hip arthroplasty. J Am Acad Orthop Surg. 2019 Feb 15;27(4):119-127. doi: 10.5435/JAAOS-D-17-00245.
- Swedish Knee Arthroplasty Register. Swedish Knee Arthroplasty Register 2018 Annual Report. Accessed January 29, 2021.
- National Joint Registry. 15th Annual Report National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Accessed January 29, 2021.