Fractured neck of femur in the mobile independent elderly patient: should we treat with total hip replacement?

Journal of Orthopaedic Surgery, Dec 2003 by Pai, V S, Arden, D, Wilson, N

Previous studies9,10,12 have shown that, despite a high rate of early complications, the durability of a total hip replacement for the treatment of acute femoral neck fracture in the elderly is good. The revision rate in these studies was below 5% at 10 years. This is in contrast to the findings of Greenough and Jones,24 who reported a 49% revision rate in 37 patients followed for a mean of 56 months.

Our results are consistent with other reported series8-10,12-19 and indicate that total hip arthroplasty has a definite place in selected patients with acute femoral neck fractures. We believe this procedure is best reserved for active elderly patients who have fractures and thus standard internal fixation has a high potential for failure (for example, the high displaced subcapital fracture), or for patients who have significant preexisting hip disease. Cost-benefit analysis of surgical treatment has shown that total hip replacement is the most cost-effective treatment when complication rate, mortality, re-operation rate, and function are evaluated over a 2-year postoperative period.25

This study reports a relatively small patient series. If similar results were obtained in a larger, prospective, randomised trial, this would confirm our belief that the gold standard treatment for displaced subcapital fractures of the femur in previously independent, active elderly patients is primary total hip arthroplasty via the modified Hardinge approach.

ACKNOWLEDGMENTS

The authors are grateful to Mr G Curtis, Mr D Atkinson, Mr Elliott, Mr DA Lawson, and Mr S Bentall, consultant orthopaedic surgeons, Health Care Hawkes Bay, for allowing us to study their patients. We are also grateful to Dr Peter Lloyd for his help in preparing the manuscript, and to the medical records department, Health Care Hawkes Bay, for their assistance.

No benefit in any form have been received or will be received from any commercial party related directly or indirectly to the subject of this article.

REFERENCES

1. Koval KJ, Zuckerman JD. Functional recovery after fracture of the hip. J Bone Joint Surg Am 1994:76;751-8.

2. Walker N, Norton R, Vander Hoorn S, Rodgers A, MacMahon S, Clark T, et al. Mortality after hip frature: regional variations in New Zealand. NZ Med J 1999:112;269-71.

3. Scott J, Sommerville R, Jeffery K. Treatment of the displaced subcapital fractured neck of femur in New Zealand: A national survey. 48th New Zealand Orthopaedic Association Annual Scientific Meeting; 1999 Oct 3-6; Welligton, New Zealand. Wellington: New Zealand Orthopaedic Association; 1999.

4. Beadel G, Rowan R, Brougham D. A prospective study of displaced subcapital femoral neck fractures managed with primary arlhroplasty. 48th New Zealand Orthopaedic Association Annual Scientific Meeting; 1999 Oct 3-6; Welligton, New Zealand. Wellington: New Zealand Orthopaedic Association; 1999.

5. Blessed G, Tomlinson BE, Roth M. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Br J Psychiatry 1968;114:797-811.