Treating displaced femoral neck fractures: total hip arthroplasty (THA) found superior to open-reduction internal fixation (ORIF)

Image: PD/NIH

Key Study Points:

1)      THA produced better hip function than ORIF at all time-points as indicated by higher Harris Hip Scores.

2)      Patients in the ORIF group experience complications earlier and required a major reoperation more frequently than THA patients.

3)      THA patients had less pain in the involved hip throughout the study period than ORIF patients.

Primer: For patients with displaced femoral neck fractures, the predominant surgical treatment modalities include Open Reduction and Internal Fixation (ORIF) and Total Hip Arthroplasty (THA).  ORIF utilizes open surgery to set the fracture followed by the use of plates, pins, and screws to hold the bones in place.  THA involves surgically removing both the femoral head and acetabular cartilage, and replacing them with an artificial femoral head and acetabular cup.  The treatment of choice varies by age with ORIF preferred in patients under 65 due to the risk of failure of THA in a more active younger patient population.  Short and medium-term follow up of THA has shown excellent outcomes in patients over 65, although a lack of long-term outcomes has allowed for concern for possible late-failure in this population.  This study addresses this concern by detailing the positive long-term outcomes and low failure rate of THA.

Background reading:

  1. Hip Fractures: I. Overview and Evaluation and Treatment of Femoral-Neck Fractures (JAAOS)
  2. Comparison of Internal Fixationwith Total Hip Replacement for Displaced Femoral Neck Fractures (JBJS)

This [randomized controlled] study enrolled 100 patients (mean age 78) who presented with an acute displaced femoral neck fracture and no history of joint disease, previous fracture, or lower limb trauma.  Patients were randomly assigned to either ORIF (n=57) or THA (n=43) and evaluated at three months and one, two, four, eleven, and seventeen years.  The primary outcome of hip function was evaluated using the Harris Hip Score and secondary outcomes included mortality, hip complications, reoperations, and gait velocity.  The Harris Hip Score is a validated Health Related Quality of Life(HRQoL) questionnaire given to patients to assess their hip-related pain and ability to move and ambulate. Pain was evaluated using the Visual Analog Scale.

The Harris Hip Score was higher in the THA group throughout the study period with a mean difference of 14.7 points (95% CI, 9.2-20.1 points).  At 11 and 17 year follow-up, mortality rates similar between the treatment groups.  Although gait velocity was initially faster in THA patients, no difference was found at later follow-up evaluations.  THA patients experienced less pain than ORIF patients with an average difference of 1.2.

In Sum:  In a previously healthy elderly population with acute displaced femoral neck fractures, THA provided superior hip function with lower rates of complication, reoperation, and pain at both short and long-term follow-up.  These results help to quell concerns regarding the risk of late-failure of THA in this population.

The randomization methodology is a possible limitation of the study.  Although the first 20 subjects were randomized using a standard sealed-envelope system, the following 80 were allocated based upon the day of the week they were admitted.  This may have introduced bias as weekend surgeries are more likely to be conducted by less experienced surgeons.  That said, improvements in THA implants have yielded superior results than those used in this study which further supports the superiority of THA.

Click to read the study in The Journal of Bone and Joint Surgery

Click to read an accompanying editorial in The Journal of Bone and Joint Surgery

By [CC] and [AH]

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