What Is the Optimal Approach for Treating a Displaced Femoral Neck Fracture?
Hip fractures continue to be a serious health issue for older adults, with more than 300,000 people age 65 and older hospitalized in the US each year for treatment of a hip fracture.  Sequelae of hip fracture include increased morbidity, reduced life quality, and premature mortality. [2,3]
Guidelines from the American Academy of Orthopaedic Surgeons in the US and the National Institute for Health and Care Excellence in Europe recommend total hip arthroplasty (THA) to treat displaced femoral neck fractures in all independent ambulators. [4,5] However, there have been concerns that this approach can also be associated with an increased risk of dislocation requiring a revision procedure, as well as a higher risk of complications.
Is there a better option for the surgical management of displaced femoral neck fractures?
Maybe not better, but at least as good, according to the findings of a large clinical study published in the New England Journal of Medicine. The study – a head-to-head comparison of THA and hemiarthroplasty to treat displaced femoral head fractures – included nearly 1500 patients at 80 institutions in 10 countries.
The optimum surgery for patients with a displaced femoral neck fracture is unknown. Advocates of THA claim better improvement in patient function and quality of life, while proponents of hemiarthroplasty point to reduced rates of dislocation and deep vein thrombosis, shorter operating times, less blood loss, and a technically less-demanding surgical procedure. 
To gain clarity on the issue, researchers randomly assigned 1495 patients who presented between January 2009 and May 2017 with a displaced femoral neck fracture to undergo either THA or hemiarthroplasty. Surgery was performed within 72 hours of the patient being medically cleared for the procedure. All patients in the study were over age 50 and had been able to walk before sustaining the hip fracture, either independently or with the use of a walking aid.
The study’s primary outcome measure was unplanned revision surgery within 2 years of the index procedure. Secondary outcome measures included:
- Serious adverse events
- Hip-related complications
- Quality of life
- Overall health
The researchers conducted follow-up assessments at 1 and 10 weeks and 6, 9, 12, 18, and 24 months after surgery. These assessments, done by phone or in person, included questionnaires and interviews on health status, hip function, pain, functional mobility, and revision surgery. Some in-person assessments also included radiographs of the affected hip.
The researchers found that the type of surgery had no significant influence on whether patients needed a revision procedure in the 2 years after the index surgery, with 7.9% of THA patients (57/718) and 83% of hemiarthroplasty patients (60/723) requiring revision surgery (P=0.79). The same was true of the mortality rate: 14.3% for THA patients and 13.1% for hemiarthroplasty patients (P=0.48).
Serious complications occurred in 42% of THA patients (300 patients), compared with 37% of hemiarthroplasty patients (265 patients). More THA patients experienced hip instability or dislocation (4.7%; 34 patients) than hemiarthroplasty patients (2.4%; 17 patients). The THA patients reported better function and less pain and stiffness than hemiarthroplasty patients, but the difference was not statistically significant.
The study findings suggest that the advantages of THA in managing displaced femoral neck fractures may not be as compelling as previously thought, and that patients who undergo hemiarthroplasty can expect equally good results.
“This is a big change [that] will have impact on clinical care,” said Mohit Bhandari, MD, PhD, FRCSC, principal investigator of the study and professor of surgery at McMaster University’s Michael G. DeGroote School of Medicine.
His co-principal investigator, Thomas A. Einhorn, MD, of New York University, added: “The economic impact of these findings could be substantial and lead to more appropriate use of valuable health care resources.”
HEALTH Investigators, Bhandari M, Einhorn TA, et al. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med. 2019 Sep 26. doi: 10.1056/NEJMoa1906190. [Epub ahead of print]
- Centers for Disease Control and Prevention. Hip Fractures Among Older Adults. Accessed November 15, 2019.
- Haleem S, Lutchman L, Mayahi R, Grice JE, Parker MJ. Mortality following hip fracture: trends and geographical variations over the last 40 years. Injury. 2008;39(10):1157–1163.
- Hall SE, Williams JA, Senior JA, Goldswain PRT, Criddle RA. Hip fracture outcomes: quality of life and functional status in older adults living in the community. Australian and New Zealand Journal of Medicine. 2000;30(3):327–332.
- American Academy of Orthopaedic Surgeons. Management of Hip Fractures in the Elderly: Evidence-Based Clinical Practice Guideline. 2014. Accessed November 15, 2019.
- National Institute for Health and Care Excellence. The Management of Hip Fracture in Adults. 2011; updated 2017. Accessed November 15, 2019.
- Bhandari M, Einhorn TA. Comparing total hip arthroplasty and hemi-arthroplasty on secondary procedures and quality of life in adults with displaced hip fractures (HEALTH). ClinicalTrials.gov Identifier NCT00556842. Accessed November 18, 2019.