European Journal of Trauma and Emergency Surgery

https://doi.org/10.1007/s00068-020-01358-5

ORIGINAL ARTICLE

Neck of femur fracture: who gets a total hip replacement? A review

of 230 eligible patients
Atanu Bhattacharjee1,6 · Owen Richards2 · Chris Marusza3 · Claire J. Topliss4 · Ian Wilson5 · Stephen Phillips5 ·
Ian Starks5

Received: 29 November 2019 / Accepted: 30 March 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose  To investigate patient-specific factors that predict Total Hip Replacement (THR) in patients with fracture neck of
femur (NOF), fulfilling the National Institute of Health and Care Excellence (NICE) criteria.
Methods  Hip fracture database from a district general hospital and university hospital was retrospectively reviewed to
identify patients fulfilling NICE criteria for THR after fracture NOF. Patient demographics, Nottingham Hip Fracture score
(NHFS), complications, re-operations, revision, 30 days and one-year mortality was obtained from patient-records. Inde-
pendent predictors correlating with the outcome of surgery were identified. A logistic regression analysis was used to predict
the type of surgery in these patients.
Results  A total of 230 (114 WMH and 116 MH) were identified; 133 (57.8 per-cent) received hip hemiarthroplasty (HA), and
97 (42.2 per-cent) received THR. Patients receiving THR (mean 73.5 years, 95% CI 72–74.8) were significantly younger in
comparison to patients receiving HA (mean 81.7 years, 95% CI 80.5–82.8). A negative correlation is noted between NHFS
and type of surgery (Pearson’s correlation − 0.537, p < 0.01), implying higher NHFS decreased the likelihood of receiving
THR. Regression analysis showed NHFS (p-0.001) and walking ability (p-0.001) as significant predictors for the type of
surgery (Nagelkerke R2-0.472). A log-rank test showed higher estimated survival time in patients with THR in comparison
to HA (p-value 0.002).
Conclusions  NHFS and walking ability can be used as an adjunct to the NICE criteria for selecting patients for THR after
fracture NOF. Carefully selected patients treated with THR survive longer and have a better outcome in comparison to HA.

Keywords  Hip fracture · Total hip replacement · Neck of femur fracture · Nottingham hip fracture score (NHFS)

Introduction

NICE first published clinical guidance on hip fracture man-

* Atanu Bhattacharjee agement in June 2011. They recommended that patients with
atanu_bhattacharjee@yahoo.co.in a displaced intra-capsular neck of femur fracture (NOF)
should be offered a total hip replacement (THR) [1] if they
1
Speciality Trainee, Orthopaedics, Morriston Hospital, Wales fulfilled the following criteria:
Deanery, Swansea SA6 6NL, UK
2
Orthopaedic Registrar, Wrexham Maeloar Hospital, • were able to walk independently outdoors with no more
Wrexham LL13 7TD, UK
than the use of a stick and
3
Core Trainee, Morriston Hospital, Wales Deanery, • are not cognitively impaired and
Swansea SA6 6NL, UK
• are medically fit for anaesthesia and the procedure.
4
Consultant Orthopaedics Surgeon, Morriston Hospital,
Swansea SA6 6NL, UK
A recent review of these guidelines in 2017 reaffirmed the
5
Consultant Orthopaedics Surgeon, Wrexham Maeloar same indications for consideration of THR after NOF [1].
Hospital, Wrexham LL13 7TD, UK
This has led to the paradigm shift of ‘offering THR rather
6
Speciality Trainee, Orthopaedics, Wrexham Maeloar than HA’ in patients fulfilling the above criteria [1, 2].
Hospital, Wrexham LL13 7TD, UK

13
Vol.:(0123456789)

The NICE guidelines are based upon a growing body
of evidence demonstrating that fit and active patients
with a fracture NOF achieve a better functional outcome
with lower revision rates after THR in comparison to HA
[3–5]. Moreover, patients satisfying the recommended
criteria also have lower mortality following THR com-
pared to HA [6]. Interestingly, however, significantly
worse mortality is evident following THR in patients
failing to satisfy these parameters [6]. This is a particu-
lar concern when it is considered that a recent review of
the National Hip Fracture Database (NHFD) from 2011
to 2015 revealed that not only 32 per cent of the eligible
21,193 patients received THR [7], but also that 42 per
cent of the total 11,683 patients treated with THR during
this period failed to meet the criteria set out by NICE [7].
Despite the updated guidelines [1], the most recent
reports from the NHFD demonstrate a minimal rise in
the number of THRs performed for these eligible patients
(30.14 per cent in 2016–31.4 per cent in 2017 and 33.1
per cent in June 2018 [8]). Also, there remains a wide and
unexplained variation in the provision of THR across dif-
ferent NHS trusts in England (ranging from 0 to 62.5%)
[8]. The reasons for such variation in compliance is mul-
tifactorial, but there is a general belief that the guidelines
are simply too broad and thus result in the inclusion of a
group of patients not suitable for THR.
While current literature suggests that fit and high func-
tioning patients with NOF will clearly benefit from THR
in comparison to HA, both functionally and clinically, the
procedure also demands higher skillset than undertak-
ing HA [2, 9, 10]. Therefore it is imperative not only to
adhere to the recommendations set out by NICE but to try
to devise an effective clinical assessment tool to ascertain
the pre-injury physiological performance of these patients
and thus identify the subset of patients better suited to
THR. The NHFS is an objective assessment tool that has
been widely validated in patients with fracture NOF to
predict mortality and outcome, its use therefore as an
adjunct to reliably define the premorbid state in patients
eligible for THR would seem logical [11–13].
The purpose of this study was to investigate patient-
specific factors predicting THR in a patient cohort ful-
filling the NICE criteria for THR after NOF. The NHFS,
American Society of Anesthesiologists physical status
classification (ASA grade) and abbreviated mental test
score (AMTS) at admission were used as surrogates of
patients’ pre-morbid status. Complications, discharge
destination, 30 day and 1-year mortality in this group of
patients treated with either THR or HA, despite their eli-
gibility for a total joint replacement, were also recorded.
13
A. Bhattacharjee et al.
Methods
Patient data were retrieved from the Hip Fracture Database
of both a district general hospital (WMH) and a university
hospital (MH) in Wales. Patients fulfilling the NICE crite-
ria for THR after fracture NOF were included in the study.
The AMTS of ≥ 8 for the absence of cognitive impairment
and ASA score of ≤ 2 for medical fitness was used for pre-
cise patient selection [7].
The overall inclusion criteria for patient selection were:
(a) Displaced intracapsular hip fracture treated with HA or
THR
(b) Independently mobile outdoors (requiring no more than
one stick)
(c) Medically fit for anaesthesia and the surgery (ASA ≤ 2)
(d) Cognitively not impaired (AMTS of ≥ 8).
Exclusion criteria for the study were:
(a) Undisplaced fracture or fractures treated with operative
fixation (i.e., Cannulated screws or Compression hip
screws).
(b) Pathological fractures.
The NHFS was collected from the hip fracture care
pathway used in both hospitals. Complications, re-opera-
tions and revision of primary surgery were collected from
individual patient notes.The 30 day and one-year mortal-
ity data were also obtained from the case notes and death
registry office.
Statistical methods
The two groups of patients receiving THR and hemiar-
throplasty of the hip (HA) were statistically compared by
using Pearson’s chi-square test for pre-operative mobil-
ity (without aids: with one stick), medical fitness for the
operation (ASA grade) and cognitive impairment (AMTS
score). An independent sample t-test was undertaken to
identify the difference in the age of the two cohorts of
patients. Pearson’s chi-square test was used to ascertain
the difference in NHFS-categorised as 3 & below and 4
& above, based on predicted 30-day mortality of 3.8%
vs ≥ 6.2% and the significant dichotomy of the overall per-
formance of these patients with scores higher than 4 [11].
Furthermore, logistic regression analysis with backward
likelihood ratio was used to predict the type of surgery (i.e.
THR or HA) using age, NHFS, ASA grade, AMTS, pre-
operative mobility and source of admission as covariates.
Neck of femur fracture: who gets a total hip replacement? A review of 230 eligible patients

Kaplan-Meir survival analysis with a log-rank test (Man-
tel–Cox) was used to evaluate the potential difference in
survival of the two groups of patients. A p-value of 0.05
was considered to be statistically significant. All analysis
performed in IBM SPSS 25 Inc. software.
Results
Patient characteristics
A total of 991 patients from WMH (2011–15) and 982
patients from MH (2016–17) with fracture NOF were iden-
tified. Inclusion criteria were met by 230 patients (114
patients from WMH and 116 from MH). A total of 97 (42.2
per-cent) received THR, and 133 (57.8 per-cent) patients
received HA.
A detailed sub-group analysis (Table 1) revealed patients
receiving THR (mean 73.5 years, 95% CI 72–74.8 years)
were significantly younger in comparison to patients
receiving HA (mean 81.7 years, 95% CI 80.5–82.8 years)
with conspicuously fewer patients being treated with THR
above the age of eighty years (p < 0.01). A significant
negative correlation is also noted between NHFS and the
type of surgery in this group of patients (Pearson’s corre-
lation – 0.537, p < 0.01), implying higher NHFS decreases
the likelihood of patients receiving THR. It also revealed
that a high proportion of patients treated with THR after
hip fracture are ASA grade 1 (p = 0.018) with higher AMTS
value (p = 0.002) in comparison to patients receiving HA.
Additionally, a significantly higher proportion of patients
receiving THR were walking independently without any
aids, both indoors and outdoors, in comparison to patients
receiving HA (p = 0.001).
Further analysis of the patient cohorts from the two hospi-
tals revealed comparable demographic data (Table 2). How-
ever, a statistically significant difference of age in patients
receiving HA in two hospital sites is noted (WMH-mean
80.4 years and MH- mean 83 years) although this was not the
case for patients receiving THR (WMH-mean 72.9 years and

Table 1  Patient characteristics Table 2  Comparison of patient characteristics in two hospitals

THR HA p-value WMH MH p-value
Total number 97 133 0.001* Total number
Age (avg.years ± SD) 73 ± 6.8 81.7 ± 6.9  THR 50 47 0.7
Sex  HA 64 69
 Male 20 35 0.3** Mean age (years)
 Female 77 98  THR 72.9 73.9 0.5
ASA grade  HA 80.4 83 0.02*
 1 14 2 0.018** Sex (F:M)
 2 83 131  THR 37:13 40:7 0.17
AMTS  HA 47:17 51:18 0.9
 8 4 16 0.002** ASA Grade -1:2
 9 9 29  THR 9:41 5:42 0.3
 10 84 88  HA 0:64 2:67 0.17
Nottingham hip fracture score AMTS-8:9:10
  <  = 3 69 25 0.001**  THR 2:5:43 2:4:41 0.96
  >  = 4 28 108  HA 9:13:42 7:16:46 0.7
Mobility Nottingham Hip Fracture Score (3 & below: 4 & above)
 Without aids 93 97 0.001**  THR 30:20 39:8 0.006*
 With 1 × stick 4 36  HA 8:56 17:42 0.3
Admission source Mobility (without aids:with one stick)
 Home /sheltered accomodation 97 130 0.26  THR 48:2 45:2 0.9
 Institutional care 0 3  HA 51:13 46:23 0.12
Discharge destination Admission source (home or sheltered accomodation:institutional
 Home /sheltered accomodation 92 108 0.008** care)
 Institutional care 4 14  THR 50:0 47:0 NA
 Not available 1 11  HA 63:1 67:2 1

*Independent sample t-test *Independent sample t-test

**Pearson’s chi-square test **Pearson’s chi-square test
*** Fisher’s exact test *** Fisher’s exact test

13

Fig. 1  Distribution of NHFS in patients receiving total hip replace-
ment (THR)
Fig. 2  Distribution of NHFS in patients receiving hemiarthroplasty of
the hip (HA)
MH-mean 73.9 years). A statistically significant difference is
also noted in the proportion of patients with NHFS <  = 3 in
the THR group in WMH (30/50 patients) with respect to MH
(39/48 patients). Nevertheless, the median NHFS score of all
patients treated with THR was 3 (with upper quartile being
4, noted only in WMH, Fig. 1) and 4 for patients receiving
HA (interquartile range 4–5, Fig. 2).
A binary logistic regression analysis (backward likeli-
hood ratio) showed age (p-0.001), NHFS (p-0.001), AMTS
(p-0.01) and walking ability (p-0.001) as significant pre-
dictors for the type of surgery after NOF (Nagelkerke
R2-0.624). Since age and AMTS of the patient are part of
NHFS; the analysis was performed without these param-
eters. The results still showed NHFS (p-0.001) and walking
13
A. Bhattacharjee et al.
ability (p-0.001) as significant predictors for the type of sur-
gery after NOF (Nagelkerke R2-0.472). The other covariates
which failed to achieve statistical significance in the regres-
sion analysis were ASA grade (p-0.076) and patients source
of admission at the time of injury (p-0.795).
Survival analysis
There was no mortality in either cohort at 30 days. However,
nine patients treated with HA and one patient receiving THR
died at one year. The total reported mortality of patients
receiving HA was 25 (18.4 per cent) at mean 2.5 ± 1.5 years,
and THR was 5 (5.3 per cent) at 2.9 ± 1.6 years, with no
statistical significance in the difference of follow up for
the type of surgery (p-value 0.13). Kaplan–Meier survival
analysis showed an estimated mean survival time for the
whole cohort was 5.3 years (95% CI 5.0–5.6). A log-rank
test (Mantel and Cox) showed a statistically significant
higher estimated survival time in patients treated with THR
(estimated mean 5.9 years, 95% CI 5.6–6.20) in comparison
to HA (estimated mean 4.9 years,95% CI 4.5–5.4) (p-value
0.002) (Fig. 3).
Complications
Three patients receiving THR (two patients from WMH and
one patient from MH) and one patient treated with HA (from
WMH) had per-operative peri-prosthetic fractures requiring
revision surgeries within 30 days of the index surgery. Three
patients (one patient from WMH and two patients from MH)
treated with THR had a dislocation of the hip within 30 days
of the surgery which required a closed reduction in theatre.
However, no revision surgery was required for these patients.
Two patients in MH had dislocation after HA which had
to be revised to THR within 30 days of index surgery. One
patient treated with HA (WMH) had a leg-length discrep-
ancy which led to symptoms related to the sciatic nerve and
subsequently had to undergo revision to THR. Two patients
in MH had an infection after HA, one deep infection requir-
ing excision arthroplasty, and one superficial infection man-
aged non-operatively. Complications from both the group are
illustrated in Table 3.
Discharge destination
The discharge destination was identified in 218 patients
with 12 being not available. A significantly higher propor-
tion of patients receiving THR (92 out of 97) in comparison
to HA (108 out of 133) returned to their pre-injury place of
residence (p-0.008). There was no correlation between the
original place of residence (p = 0.14), NHFS (p = 0.39) and
discharge destination.
Neck of femur fracture: who gets a total hip replacement? A review of 230 eligible patients
Fig. 3  Survival function curve
of the patients receiving hemi-
arthroplasty of the hip (HA) and
total hip replacement (THR)
Table 3  Complications in patients receiving THR and HA
THR HA Comments
Fracture 3 1 All of them required revision surgery
Dislocation 3 2 2 HA revised to constrained THR
Infection 0 2 1 excision arthroplsty
Other 0 1 Revised to THR
Discussion
This study demonstrates that in patients fulfilling NICE
criteria for THR, those patients who received THR exhib-
ited very different characteristics from those undergo-
ing HA. Younger age, low NHFS (score-3), high AMTS
(score-10) and independent unaided mobility significantly
increased the likelihood of undergoing THR. In addition,
the cohort of patients undergoing THR had a significantly
longer post-operative survival in comparison to patients
with HA. The results also show that a significantly high
proportion of patients receiving THR were discharged to
their original residence. While there was a higher inci-
dence of fracture and dislocation in patients receiving
THR in comparison to HA, the numbers were low, and
there was no reported incidence of infection in patients
being treated with THR.
Our results support the previously published retrospec-
tive study across eight trauma units in the North of Eng-
land. In this study, the authors observed that age, ASA
grade, AMTS and independent walking ability were sig-
nificantly different in patients receiving THR as opposed
to HA when all patients fulfilled the NICE criteria for
THR [4]. The results of our study concur with similar find-
ings of a unique subset of NICE eligible patients treated
with THR who are both high performing and young and fit.
Furthermore, our findings indicate that NHFS significantly
correlates with the likelihood of undergoing THR. The
NHFS is already established as a powerful validated tool
to define pre-morbid status for patients sustaining frac-
ture NOF. We, therefore, believe that this objective tool
can be used as a surrogate to define fitness to determine
the type of surgery (THR/HA) in this particular group of
patients. This is the first study to date, attempting to use
a scoring tool to help more accurately define the subset
of patients deemed “medically fit for the procedure”. A
cut off of 3 was chosen as the predicted 30-day mortality
(3.8%) increases dramatically with an NHFS of 4 (6.2%),
in addition to the significant difference in the overall out-
come in those patients over the score of 4 [11, 13]. Our
study benefits from a large sample size with patient data
obtained from two different hospitals representing wider
demographic characteristics. Our results show that a low
NHFS score (3 interquartile range 3–4), based on patients
pre-morbid status, increases the likelihood of receiving
THR. Such an approach of objectively defining patients
with a scoring tool will potentially eliminate the more
subjective assessment used pragmatically in a day to day
practice.
Previous publications on THR for NOF have used ASA
grade as an indicator of fitness for surgery with an ASA ≤ 2
often qualifying patients for THR [7, 14]. Although ASA
can help to quantify the physical fitness of these patients,
it has the inherent weakness of poor intra and interob-
server reliability in clinical practice [7, 15]. Moreover,
not only has the NHFS been validated as a predictive tool
13

for mortality and patient outcome after NOF [11–13, 17,
18], it has also been shown to outperform the other co-
morbidity indices. The use of NHFS as an adjunct to NICE
criteria by surgeons will help to reduce the ambiguity in
clinical decision making about the choice of surgery and
promote reproducibility of the selection criteria.
Pre-injury functional level denoted by the independ-
ent outdoor walking ability with a low NHFS is strongly
associated with THR in our study. Furthermore, the sig-
nificantly younger age of patients receiving THR in com-
parison to HA, with THR being done to patients < 80 years
of age (average age 73  years) remains consistent with
previous recommendations based on the NJR data and
observational studies [14, 19]. These features explain the
high physiological resilience amongst the patients selected
for THR on top of their fulfilment of the NICE criteria.
Such patient characteristics can be potentially related to
them being discharged back to their admission source and
longer survival in comparison to the HA group. Longer
survival time along with good functional outcome and
consequently, better patient satisfaction is also reported
after THR in patients with NOF [5, 6, 20, 21].
Complications of THR, specifically fracture and disloca-
tion, were marginally higher in comparison to HA. Similar
findings of high dislocation rate and peri-prosthetic frac-
tures are reported in the literature [22, 23]. However recent
evidence suggests that units performing a higher volume of
THR after NOF can improve the outcome of their surgery
[24]. Despite the critical findings, the current report has its
limitation of being a retrospective case series with poten-
tial selection bias. The study also has not accounted for the
day of the week and the sub-speciality interest of the admit-
ting specialist on the choice of surgery. Moreover, previous
reports have already demonstrated the impact of the lack of
experienced arthroplasty surgeon during the weekend leads
to a significant reduction in the number of THR’s for NICE
eligible patients after fracture NOF [7]. While Wales is not
subject to the BPT; this has not impacted on the use of the
NICE guidance and the provision of best practice to our
patient population [25].
In summary, our results indicate that NHFS and inde-
pendent walking ability are significant predictors for the
provision of THR in patients fulfilling NICE criteria for con-
sideration of THR after fracture NOF. These patients have
a significantly higher probability of being discharged back
to their admitting destination and longer survival in com-
parison to patients receiving HA. We propose that NHFS
should be used as an adjunct to provide an objective measure
when assessing “fitness for the procedure” in this patient
cohort. Future studies should focus on the use of NHFS as a
comorbidity index on a national scale to ascertain its validity
for selecting patients for THR after NOF and relate it to the
outcome in these patients.
13
A. Bhattacharjee et al.
Funding  No benefits in any form has been received or will be received
from any parties related directly or indirectly to the article.
Compliance with ethical standards 
Conflict of interest  Atanu Bhattacharjee declares that there is no con-
flict of interest. Owen Richards declares that there is no conflict of
interest. Chris Marusza declares that there is no conflict of interest.
Claire J Topliss declares that there is no conflict of interest. Ian Wilson
declares that there is no conflict of interest. Stepehen Phillips declares
that there is no conflict of interest. Ian Starks declares that there is no
conflict of interest.
Ethical statement  The study respected all ethical standards valid for a
retrospective departmental service evaluation.
Ethical comitte approval  None required
References
1. NICE National Institute for Health and Care Excellence. Clini-
cal guideline CG124. Hip fracture: management.London: NICE,
2017. www.nice.org.uk/Guidan​ ce/CG124.​ Accessed 27 June 2017
2. Jay RH, Hipps D. Hip fracture-great steps forward but we still
need better evidence. A commentary on NICE CG124 and QS16
on fractured neck of femur. Age Ageing. 2018;47(5):630–2.
3. Carroll C, Stevenson M, Scope A, Evans P. Buckley S Hemiar-
throplasty and total hip arthroplasty for treating primary intraca-
psular fracture of the hip: a systematic review and cost-effective-
ness analysis. Health Technol Assess. 2011;15(36):1–74.
4. Collaborative, Orthopaedic, Research, Network. The provision
of total hip replacement for displaced intracapsular hip fractures.
Ann R Coll Surg Engl. 2016;98(2):96–101.
5. Hansson S, Nemes S, Karrholm J, Rogmark C. Reduced risk of
reoperation after treatment of femoral neck fractures with total hip
arthroplasty. Acta Orthop. 2017;88(5):500–4.
6. Walker LC, Lee LH, Webb M, Walmsley J, O’Brien S, Krishnan
KM, et al. Provision of total hip replacement for displaced intraca-
psular hip fracture and the outcomes: audit of local practice based
on NICE guidelines. Hip Int. 2016;26(2):153–7.
7. Perry DC, Metcalfe D, Griffin XL, Costa ML. Inequalities in use
of total hip arthroplasty for hip fracture: population based study.
BMJ (Clinical research ed). 2016;353:i2021.
8. Royal College of Physicians. National Hip Fracture Database
annual report 2017. London: RCP; 2017. p. 2017.
9. Jameson SS, Lees D, James P, Johnson A, Nachtsheim C, McVie
JL, et al. Cemented hemiarthroplasty or hip replacement for intra-
capsular neck of femur fracture? A comparison of 7732 matched
patients using national data. Injury. 2013;44(12):1940–4.
10. Sharma V, Awasthi B, Kumar K, Kohli N, Katoch P. Outcome
analysis of hemiarthroplasty vs. total hip replacement in dis-
placed femoral neck fractures in the elderly. J Clin Diagnost Res.
2016;10(5):RC11–RC13.
11. Wiles MD, Moran CG, Sahota O, Moppett IK. Nottingham Hip
Fracture Score as a predictor of one year mortality in patients
undergoing surgical repair of fractured neck of femur. Br J
Anaesth. 2011;106(4):501–4.
12. Rushton PR, Reed MR, Pratt RK. Independent validation
of the Nottingham Hip Fracture Score and identification of
regional variation in patient risk within England. Bone Joint J.
2015;97-B(1):100–3.
Neck of femur fracture: who gets a total hip replacement? A review of 230 eligible patients
13. Moppett IK, Wiles MD, Moran CG, Sahota O. The Nottingham
Hip Fracture Score as a predictor of early discharge following
fractured neck of femur. Age Ageing. 2012;41(3):322–6.
14. Jameson SS, Kyle J, Baker PN, Mason J, Deehan DJ, McMur-
try IA, et al. Patient and implant survival following 4323 total
hip replacements for acute femoral neck fracture: a retrospective
cohort study using National Joint Registry data. J Bone Joint Surg
British Vol. 2012;94(11):1557–666.
15. Sankar A, Johnson SR, Beattie WS, Tait G, Wijeysundera DN.
Reliability of the American society of anesthesiologists physical
status scale in clinical practice. Br J Anaesth. 2014;113(3):424–32.
16. Moppett IK, Wiles MD, Moran CG, Sahota O. The Nottingham
Hip Fracture Score as a predictor of early discharge following
fracture neck of femur. Age Ageing. 2012;41:322–6.
17. Salar O, Baker PN, Forward DP, Ollivere BJ, Weerasuriya
N, Moppett IK, et al. Predictors of direct home discharge fol-
lowing fractured neck of femur. Ann R Coll Surg Engl.
2017;99(6):444–51.
18. Karres J, Heesakkers NA, Ultee JM, Vrouenraets BC. Predicting
30-day mortality following hip fracture surgery: evaluation of six
risk prediction models. Injury. 2015;46(2):371–7.
19. Hailer NP, Garland A, Rogmark C, Garellick G, Karrholm J. Early
mortality and morbidity after total hip arthroplasty in patients
with femoral neck fracture. Acta Orthop. 2016;87(6):560–6.
20. Tabori-Jensen S, Hansen TB, Bovling S, Aalund P, Homilius M,
Stilling M. Good function and high patient satisfaction at mean
2.8 years after dual mobility THA following femoral neck frac-
ture: a cross-sectional study of 124 patients. Clin Intervent Aging.
2018;13:615–21.
21. Leonardsson O, Rolfson O, Hommel A, Garellick G, Akesson
K, Rogmark C. Patient-reported outcome after displaced femoral
neck fracture: a national survey of 4467 patients. J Bone Joint
Surg Am Vol. 2013;95(18):1693–9.
22. Wang Z, Bhattacharyya T. Outcomes of hemiarthroplasty and
total hip arthroplasty for femoral neck fracture: a medicare cohort
study. J Orthop Trauma. 2017;31(5):260–3.
23. Wang F, Zhang H, Zhang Z, Ma C, Feng X. Comparison of bipolar
hemiarthroplasty and total hip arthroplasty for displaced femoral
neck fractures in the healthy elderly: a meta-analysis. BMC Mus-
culoskelet Disord. 2015;16:229.
24. Maceroli M, Nikkel LE, Mahmood B, Ketz JP, Qiu X, Ciminelli J,
et al. Total hip arthroplasty for femoral neck fractures: improved
outcomes with higher hospital volumes. J Orthop Trauma.
2016;30(11):597–604.
25. Horriat S, Hamilton PD, Sott AH. Financial aspects of arthroplasty
options for intra-capsular neck of femur fractures: a cost analy-
sis study to review the financial impacts of implementing NICE
guidelines in the NHS organisations. Injury. 2015;46(2):363–5.
13