Surgical treatment of patients with displaced femoral neck fractures : : aspects on outcome and selection criteria

Abstract: The optimal treatment for elderly patients with femoral neck fractures, i.e. internal fixation (IF), hemiarthroplasty (HA) or total hip replacement (THR), should be based on the individual patient's age, functional demands and risk profile. IF is uncontroversial in the treatment of undisplaced (Garden I and II) femoral neck fractures and good results regarding fracture healing, function and the health-related quality of life (HRQoL) can be expected. IF is also the method of choice in young patients with displaced fractures (Garden III and IV) and in patients not medically fit for an arthroplasty. Recent randomised controlled trials (RCTs) have shown that a primary THR is superior to IF in the relatively healthy, luci d elderly patient with a displaced femoral neck fracture during the first two years after the operation. There are few published reports on the outcome in a longer time perspective. Despite the good results for THR in this patient group, a vast majority of orthopaedic surgeons prefer HA instead of THR. Furthermore, in spite of the high failure rate for IF, the method is still recommended for this patient cohort by some authors. One argument is that if IF fails, there is always the possibility of performing a secondary salvage THR. Patients with severe cognitive dysfunction pose significant challenges to the treating surgeon in several respects, e.g. lack of compliance, problems in assimilating rehabilitation regimens and frequent co-morbidities, so the optimal treatment for this patient cohort is still controversial. In an RCT with a four-year follow-up period, lucid, elderly patients with an acute displaced femoral neck fracture were randomly allocated to THR or IF. The results confirm that a primary THR, compared to IF, provides a better outcome. The complication and reoperation rates were significantly lower and the outcome regarding hip function and HRQoL were at least as good, even in this longer time perspective. In a prospective trial with a two-year follow-up period lucid, elderly patients treated for an acute displaced femoral neck fracture were included. The outcome for patients with a primary THR was compared with the outcome for patients treated with a secondary THR after failed IF. Hip function was significantly better in the primary THR group and patients with failed IF later undergoing a secondary THR experienced a significant decrease in HRQoL during the first year of treatment compared with patients in the primary THR group. In an RCT with a one-year follow-up period, lucid, elderly patients with an acute displaced femoral neck fracture were randomised to a bipolar HA or THR. The results indicate that a THR provides better hip function than a bipolar HA as soon as after one year without increasing the complication rate. There are good reasons to assume that this difference will increase with time. In an RCT with a two-year follow-up period, patients with severe cognitive impairment and a displaced femoral neck fracture were randomly allocated to treatment by either IF or a unipolar HA (uncemented Austin Moore HA). The mortality rate was very high and the deterioration in ADL function, walking ability and HRQoL was pronounced in both randomisation groups, reflecting the major impact of the severe cognitive dysfunction. The results imply that there does not seem to be any advantage in performing an uncemented Austin Moore RA compared to IF in this selected patient cohort. The overall conclusion of the thesis is that THR can be recommended as the primary treatment for the relatively healthy, active and lucid elderly patient with a displaced femoral neck fracture. Bipolar HA can be recommended for the most elderly patients with lower functional demands. The optimal treatment for patients with severe cognitive impairment and a displaced femoral neck fracture needs to be further evaluated.