Evidence based

management of
intracapsular neck of
femur fractures
Dr V V Vinay Vivek
Background
• With an ageing population, neck of femur fractures have become the
2nd leading cause of hospitalisation in the elderly.
• Females account for 80% of fractures and have an 11.4% lifetime risk
at age 50 years, which is comparable to that of breast cancer.
Although 1-month and 12-month mortality rates are high, they
strongly correlate with age
• Living independence, mobility and mental state.
• The mean age for patients sustaining this injury is 80 years.
Background
• Less than 5% of fractures occur in people below 60 years of age.
Premorbid cognitive impairment is present in up to 37% of patients.
Most (60%) patients are functionally independent prior to fracture,
often despite a heavy burden of medical comorbidities. At age 80, if
patients are independent at the time of injury, approximately 50% of
patients will survive 5 years, and 14% will survive 13 years. This
indicates the need for a durable surgical option in most patients.
• Approximately 50% of femoral neck fractures are intra- capsular, and
are routinely considered by their degree of displacement
 Goals
• To provide a single operation in a timely fashion, that allows the
patient to immediately comfortably weight-bear, and optimise the
chance to return to pre-injury functional status, with minimal
morbidity, mortality and likelihood of further surgery.
• Many patients do not have the capacity to withstand repeat surgery,
and the treatment given should be both clinically and cost effective in
the short- and long-term.
Options for surgical
management
• internal fixation
• hemiarthroplasty
• total hip arthroplasty (THA).
Displaced intracapsular fractures
Approximately 80% of intracapsular neck of femur fractures are
displaced
• Internal fixation
• For displaced fractures, internal fixation is outperformed by
arthroplasty options when considering
•reoperation rates
•functional performance
•quality of life
• After 17 years, functional outcome is still better following THA than internal
fixation. Internal fixation has a high reoperation rate, with nonunion and avascular
necrosis accounting for most treatment failures. Reoperation is almost 4 times
more likely after treatment by internal fixation than after treatment by arthroplasty.
• A lower rate of reoperation is seen with hemiarthroplasty in those with advancing
age, whereas the opposite occurs with internal fixation in the elderly (40).Within 4
months after surgery, reoperation can be as high as 25% of patients. A meta-
analysis calculated that 1 revision surgery could be avoided for every 5.6 people
treated with arthroplasty instead of internal fixation. Even when successful,
patients treated by internal fixation report more pain when walking and a reduction
in mobility.
• Mortality rate may be lower for internal fixation procedures, perhaps due to
shorter surgery and less blood loss. But because of the higher rate of reoperation,
internal fixation is suited more as either a palliative procedure for elderly frail
patients with undisplaced fractures, or conversely, in young active patients
following high energy trauma, where preservation of the femoral head is preferred
over arthroplasty.Patients aged 50-60 years treated by THA achieve better function
Arthroplasty:Displaced intracapsular neck of femur fractures in
the elderly are typically treated by hemiarthroplasty, and most
orthopaedic surgeons prefer this operation.
• Patients with little or no ambulatory capacity, poor mental
status, debilitating medical problems, and low life expectancy
are perhaps better treated by hemiarthroplasty as opposed to
THA.
• Monoblock hemiarthroplasty implants are associated with
poorer function, and higher levels of pain and revision surgery
than surgery using either modular hemiarthroplasty or THA.
This is perhaps partially because of the difficulty in restoring
femoral neck length and offset with monoblock prostheses
along with osseo incorporation and stem stability.
• Age is an important factor when considering which implant to
use.
5% of patients aged 75 years and over will require revision
surgery in the first 13 years following hemiarthroplasty.
• This figure more than doubles in those aged less than 75 years
treated by hemiarthroplasty
• For patients who are independent socially, and without
dementia, which arthroplasty option to choose has even
greater controversy.
• THA is typically only considered in the younger patient with a
longer life expectancy who can withstand a longer surgery
time, or alternatively in those with pre-existing degenerative
acetabular disease.
• Hemiarthroplasty is heavily preferred over THA in the USA,
with THA used in only 7.7% of cases.
• THA represents the best value for the treatment of displaced femoral neck
fractures in both the short and long term from a cost-effectiveness point of view.
The use of THA for the management of neck of femur fractures is supported by
National Institute for Health and Care Excellence (NICE) clinical guidelines, which
recommend that a patient should be offered THA in a displaced intracapsular hip
fracture if they were able to walk independently with only 1 stick, are not
cognitively impaired and are medically fit for anaesthesia and the procedure.
• Studies comparing hemiarthroplasty to THA are problematic with confounding
variables between different prosthetic designs, operative approaches, and
patient-selection criteria. Cohort studies inherently have a selection bias.
Randomised controlled trials are limited by their end points and may take up to
25 years to complete if adequately powered. The difficulty of performing
adequately powered RCTs may not be feasible in public health systems, and for
this reason, data from registries may also assist in any decision-making process.
• Surgical time and blood loss
• The surgical time of hemiarthroplasty (59-82 minutes) is shorter than
THA (80-102 minutes) (22, 26-28). The increased
• surgical time and more complex operation (26) correlates with
increased blood loss of 140 ml (22).
• Complications
• Despite the longer operative time and higher blood loss, no randomised
controlled trial has found a difference in other complications between
hemiarthroplasty and total hip arthroplasty at up to 1 year (11, 22, 24, 28). In a
study of patients undergoing hip arthroplasty, there was no difference in the 90-
day complication risk over an 11-year period (66). Systematic reviews have found
no difference in complication rates for major (25% THA/24% hemiarthroplasty)
and minor surgical complications (13% THA/14% hemiarthroplasty) (67). Some
series have found complications to be higher following hip hemiarthroplasty than
THA (10), although this is likely to be due to selection bias and it is why it might
be difficult to use this study design to compare this outcome.
• Mortality
• No increased mortality has been shown by performing THA instead of
hemiarthroplasty (11, 23, 26, 28). Differences in mortality following
hemiarthroplasty and THA have been
• shown at various time points (16, 27), but in a recent meta- analysis the 12-
month mortality was equal in both groups (13% THA/15% hemiarthroplasty) (67).
Function and quality of life
• THA has consistently been shown to have better function,
mobility and quality of life outcomes than
hemiarthroplasty.Studies including monoblock
hemiarthroplasty should perhaps be omitted from comparison
given the poorer results of these prostheses.
• Some studies showed little difference, or no early difference,
however, a difference becomes apparent over time and
prolonged follow-up.
• This is particularly evident by the 2- to 4-year mark. Function
and quality of life outcomes are more pronounced in patients
aged 60-75, and functional outcomes correlate with age .
• 2 out of 3 patients who had THA managed to regain pre-fracture function,
whereas only half of patients with hemiarthroplasty did, with this decreasing to
close to 1 in 3 by 4 years
Dislocation
• Despite the significant improved function and quality of life
following THA, fear of dislocation is the main concern following
THA for neck of femur fracture.
• Dislocation rates are higher for THA following neck of femur
fracture than for osteoarthritis, with an estimated 1.8-fold
increased hazard dislocation risk. However, dislocation can still
occur following hemiarthroplasty.
• Cause of dislocation is multifactorial, comprising patient and
surgical factors. Patient factors include inadequate soft tissues,
abductor insufficiency and medical comorbidities such as
dementia, Parkinson’s disease and cerebrovascular accidents
• In this patient population, evidence to support a higher dislocation rate and
revision requirement for instability for THA is surprisingly weak. Although it is
apparent that THA has a higher risk of dislocation, this has not translated into
reoperation for instability.
• Dislocations rates after THA to be 9% and 3% after hemiarthroplasty.
• However, other studies have found that after the early post- operative period,
THA may have similar long-term dislocation rates to hemiarthroplasty.
• Surgical factors can also play an important role in dislocation
and instability.
• Large head THA (head size ≥36 mm) is an option to help
mitigate the risk of dislocation, and this has become more
accepted following the advent of highly-crosslinked
polyethylene. These larger head options have not been
included in RCTs or most published series.
• constrained captive acetabular components
• dual-mobility cups.
 Constrained acetabular component use has been reported in revision arthroplasty
and as a salvage option for recurrent hemiarthroplasty dislocation. Concerns exist
regarding use of constraint with concern that force that would otherwise cause
dislocation being transferred to liner-shell and shell-bone interfaces. This may
cause dislocation, being difficult to manage (81), head dissociation from the stem,
liner dissociation from the acetabulum and long term, component loosening,
osteolysis and periprosthetic fracture. The use of constrained liners following neck
of femur fracture has rarely been discussed in orthopaedic literature.
Dual-mobility cups
• combine a large articulation between the metal shell and mobile polyethylene
insert, with a small articulation between the insert and prosthetic head.
• Their use is more common in the treatment and prevention of instability in both
primary and revision THA.The overall dislocation rates in the literature for dual-
mobility cups follow- ing total hip arthroplasty is 2.7% at 9-24 month follow up
over 4 studies all using a posterior approach.
• Long-term results of constrained cups and dual-mobility liners remain
unknown. Given the life expectancy of a neck of femur fracture
patient compared to those receiving THA for osteoarthritis, midterm
data may be enough to accept these as valid options and the
theoretical long-term risks may be less important.
• NICE guidelines suggest considering using an anterolateral approach
in favour of a posterior approach for hemiarthroplasty surgery,
whilst the Scottish Intercollegiate Guidelines Network (SIGN) reports
that an approach with which the surgeon is familiar is most likely to
lead to lower complications
• Reoperation
• Despite a higher risk of dislocation with THA following
neck of femur fracture, the overall risk of reoperation
has been found to be higher for hemiarthroplasty in
recent meta-analyses.
• In RCTs at 1 year and 3 years, significant reoperation
rates have been found for hemiarthroplasty when
compared with THA (13% vs. 4%; and 14.6% vs. 2.5%).
• At 9 years in another study the reoperation rate was
9.8% vs. 2.5%
• Erosion
• Acetabular erosion following hip hemiarthroplasty is a unique
complication, that may mandate conversion to THA
• Erosion occurs with both unipolar and bipolar hemiarthroplasty, but
may be more of a problem with unipolar designs. Young age, activity
level, and length of follow-up are the most important factors.
• In an early study, 26% of patients younger than age 70 years had
evidence of acetabular erosion, compared with only 1.5% of patients
older than age 80 years (122).
Undisplaced fractures
• Nonoperative treatment has been suggested as an
option for undisplaced fractures (123). The few
studies that exist show that non-union can be high
with over half the patients requiring subsequent
surgery, and the 1-year mortality is also lower in the
surgical group.
• Internal fixation has historically been the most
popular treatment modality for undisplaced fracture
• Registry data comparing internal fixation with hemiarthroplasty at 12 months
shows a 22.6% vs. 2.9% reoperation rate, with internal fixation having significantly
higher pain, dissatisfaction and lower quality of life, with there being no
difference in mortality.
• Further investigation is warranted on undisplaced fracture patterns comparing
internal fixation with THA given the predictability and durability of THA following
neck of femur fracture, and also potential cost savings
Issues
• surgeons trained in hip arthroplasty are not routinely involved
in treating patients with acute fractures of the femoral neck.
• Criticism has also been made of available literature in that
THAs are performed by arthroplasty not trauma specialists, or
senior surgeons. However, several of the RCTs had registrars
performing these operations.
• The modern trauma surgeon should have hip arthroplasty skills
given the incidence of this fracture pattern.
• However, consideration should be given to management of
these fractures in trauma units with accompanying arthroplasty
specialists
Conclusions
• displaced neck of femur fracture, hemiarthroplasty is the preferred option for
elderly patients with little or no ambulatory capacity, who are neurologically
impaired or medically infirmed.
• In functionally independent elderly patients THA should be considered the gold
standard, with risk of persistent pain, acetabular erosion, poor function and
higher reoperation rates following hemiarthroplasty.
• THA offers a more functional, cost-effective and durable option in such patients,
with no higher risk of complications despite the complexity of the surgery.
• Concerns regarding dislocation may be reduced with modern surgical strategies
such as large heads, dual-mobility cups or constrained liners.
• Further research will identify a preferred strategy option.
• The greater acceptance of THA will optimise patient function, reduce risks of
reoperation and provide a short and long-term cost benefit to health care
systems.
Conclusions
• For patients with undisplaced neck of femur fracture, surgery is the
standard of care.
• Despite a higher risk of reoperation, internal fixation is the current
preferred choice.
• However, further study is required to identify the difference between
internal fixation and THA, in particular, unstable fracture patterns.
• In young patients, head preserving surgery should still be the gold
standard.