Femoral neck fractures. Aspects on treatment and outcome

Abstract: Hip fractures are a common cause of morbidity and mortality in elderly patients, with a high risk of functional impairment and institutionalization. The incidence and number of hip fractures have increased during the recent decades and hip fractures consume considerable health-care resources. The incidence of hip fractures in Malmö, Sweden, 1992–95, is described in Paper I. The annual incidence per 10,000 inhabitants in women and men over 50 years were 85 and 36, respectively. For women and men over 80 years, the corresponding numbers were 297 and 170. When comparing it to earlier Malmö studies, we found that the incidence is no longer increasing. An update on the incidence, covering 1999–2001, support this finding. In Paper II, a randomized, prospective, multicenter study, 450 patients with displaced femoral neck fractures were randomized to either internal fixation or primary arthroplasty. Criteria for inclusion were age over 70 years, living in own home, mentally unimpaired. Patients who had undergone arthroplasty had significantly better functional results, less pain and lower rates of failure and re-operation after two years. After five years the significant difference in failure rate remained. There were no difference in mortality between the groups. In Paper III the costs for each method were compared. The mean two-year cost for internal fixation was 210 000 SEK (21 000 USD) and for primary arthroplasty 150 000 SEK (15 000 USD), but the difference was not significant. In Paper IV, 103 demented and/or institutionalized patients, 80 years and older, with displaced femoral neck fractures, were treated with primary hemi-arthroplasty. They had a failure rate of 6% after one year, significantly lower than a control group treated with internal fixation, and good functional outcome. The results of a new treatment protocol are described in Paper V. When a majority of the displaced femoral neck fractures in patients over 70 years are treated with primary arthroplasty, the overall failure rate is reduced to 5% compared to earlier results of 42%, when all fractures were treated with internal fixation. The new protocol proved to be feasible in clinical use. The results of this thesis emphasize the need of a paradigm shift for the treatment of displaced femoral neck fractures in Sweden. There is an evidence-based rationale supporting both the use of total hip arthroplasty in vital patients, 70–80 years old, and the use of hemi-arthroplasty in the more frail, elderly patients.