At the Trauma III scientific session, Dr. Gerard Slobogean presented the results of a multicenter retrospective comparative study of 2,175 patients 50 years or older with minimally displaced femoral neck fractures from two prior large randomized controlled trials. They compared 734 patients from the FAITH trial, which compared cannulated screw versus sliding hip screw fixation, and 1,441 patients from the HEALTH trial, which compared total hip arthroplasty versus hemiarthroplasty.
The arthroplasty group was older and more medically complex than the internal fixation group. The overall 24-month mortality and reoperation rate was 15% and 11%. After adjusting for confounding factors, the arthroplasty group had a substantially lower 24-month mortality rate (Odds ratio (OR) 0.56, 95% confidence interval (CI) 0.44 to 0.72) and reoperation rate (OR 0.41, CI 0.32 to 0.55). The arthroplasty group had a higher 24-month SF-12 physical component score (2.7 points, CI 1.6 to 3.8) as well.
This study adds to the mounting evidence that minimally displaced femoral neck fractures in geriatric patients may be best served by arthroplasty. The results of this study were very similar to those reported in a recent large randomized control trial from Norway. Dolatowski et al. reported on elderly patients with nondisplaced (valgus) impacted femoral neck fractures randomized to screw fixation versus hemiarthroplasty. The arthroplasty group had better mobilization according to the timed “Up and Go” test, fewer reoperations (5% versus 20%), and a lower 24-month mortality rate (26% versus 36%). Cronin et al. demonstrated that even when these patients successfully heal after internal fixation up to 50% will experience fracture collapse of 10 mm or more, which could negatively affect physical function. In this fragile patient population, improving mobilization and reducing the risk of reoperation is paramount to optimize outcomes.
The above studies have impacted my practice. Fixation of these fractures is now the exception and not the rule to better mobilize, reduce reoperation rates, and lower mortality rates in this patient population. While the argument that a less invasive internal fixation procedure in these patients with significant medical comorbidities is a valid one, if these patients subsequently have more difficulty mobilizing, and have a higher risk of reoperation and death, then arthroplasty is the right call.
I would like to thank Dr. Slobogean and his many co-authors for their game-changing research and the AAOS for putting on their annual meeting in the face of the adversity of the COVID-19 pandemic to act as the forum for the exchanging of important ideas and research.
Dr. Parry is employed by Denver Health Medical Center. He is a paid consultant for Synthes Depuy and has received royalties from Macmillan Publishing.