1. Femoral Neck Fractures
Evidence Review
Where is the Evidence Leading Us?

2. Burden of Hip Fractures
The disability adjusted life-years
lost as a result of hip fractures
ranks in the top 10 of all cause
disability globally
Cooper et al, 2002

3. Current Practice?
Operative management of displaced femoral neck fractures in
elderly patients. An international survey
Bhandari M, Devereaux PJ, Tornetta P 3rd, Swiontkowski MF,
Berry DJ, Haidukewych G, Schemitsch EH, Hanson BP, Koval K,
Dirschl D, Leece P, Keel M, Petrisor B, Heetveld M, Guyatt GH.
J Bone Joint Surg Am. 2005;87:2122-30

4. Characteristics of Surgeons
• Age (41-50yr) 45.0%
• Gender (male) 98.2%
• Type of Practice (Academic) 76.5%
• Supervise Residents 84.0%
• Trauma fellowship 73.3%
• Reconstructive fellowship 26.0%
• Volume of hip #(>100) 53.0%

5. Displaced Fractures
• Age<60 yrs
• 80% Internal Fixation
• 80% Multiple Screws
• Age:60-80 yrs
• 89% arthroplasty
• 33% unipolar
• Age>80 years
• 94% arthroplasty
• 60% unipolar

6. Cannulated Screws
• Surgeon Preferences:
• Inverted Triangle- 51%
• Capsulotomy- 20%
• Aspiration of Intracapsular
Hematoma- 10%
• 3 Cannulated Screws- 73%

7. Arthroplasty
• Surgeon Preferences:
• Posterior Approach 44%
• Capsular Repair- 60%
• Cemented- 69%
• No drains- 66%

8. Hierarchy of Evidence
Randomized Trials
Prospective Cohort Studies
Retrospective Case Series
Case Control Studies
Opinion
Meta-
analysis
Level 1
Level 2
Level 3
Level 4
Level 5

9. Internal Fixation OR Arthroplasty?

10. Internal Fixation Versus Arthroplasty for Displaced Fractures of the
Femoral Neck: A Meta-Analysis
Mohit Bhandari MD, MSc*, Philip J Devereaux MD*, Marc F. Swiontkowski MD^,
Paul Tornetta III MD#, William Obremskey MD, MPH**, Kenneth J. Koval MD^,
Sean Nork MD#, Sheila Sprague, BSc*, Emil H. Schemitsch MD
and Gordon H. Guyatt MD, MSc*
From the *Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario and the Departments of
Orthopaedics, Hospital for Joint Diseases, New York, New York, ^University of Minnesota, Minneapolis, **University of North
Carolina, Raleigh, North Carolina, # Harborview Medical Centre, Seattle, Washington, #Boston Medical Centre, Boston,
Massachusetts, and St. Michael’s Hospital, University of Toronto, Toronto, Ontario.
Journal of Bone and Joint Surgery 2003:85A:1673-81.
Internal Fixation or Arthroplasty for
Displaced Femoral Neck Fractures?
Level I Evidence?

11. IF vs Arthroplasty
• Early decrease in Mortality risk with IF
• No difference in Mortality at 1 yr
• Reduction in Revisions with Arthroplasty
• Pain and Functional Outcomes Similar
• More Blood Loss and O.R time with
Arthroplasty
• Increased infection risk with Arthroplasty

12. < 4 Month Mortality
• Internal Fixation may reduce risk of
mortality by 22% (48% RRR, 19% RRI)
• Unadjusted crude rates:
9% Arthroplasty vs 6% Internal Fixation
• Underpowered for the comparison with
1162 patients

13. Revision Surgery
All Arthroplasty vs IF
• N=1901 patients
• 11% rate Arthroplasty
• 35% rate in Internal Fixation
• Relative Risk: 0.23, 95%CI: 0.13-0.42
P<0.0003
Arthroplasty reduced risk of revision by
77% (58%-87%)

14. Favours Arthroplasty Favours Internal Fixation
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Davison (2001)n=280 patients
Ravikumar (2000)n=271patients
VanVugt (1993)n=43 patients
Parker(2001)n=208 patients
VanDortmont (2000)n=60 patients
Tidermark(1999)n=39 patients
Sikorski (1981)n=218 patients
Soreide(1976)n=104 patients
Johansson(2000)n=100 patients
Neander(1997)n=20 patients
Jonsson (1996)n=47 patients
Rogmark(2002)n=408 patients
Puolakka (2001)n=32 patients
Jensen (1984)n=102 patients
Pooled estimate n=1901 patients
0.001 0.01 0.1 1 10
Relative Risk (95%Confidence Interval)
Revision Rates
Revision Rates

15. Revision Surgery
• Revisions following internal fixation:
• Nonunions (weighted mean=18.5%, range
5-28%)
• AVN (weighted mean=9.7%, range 5-18%)

16. Revision Surgery
• Revisions following arthroplasty
• Dislocations
• Overall weighted mean=0.82%, range 0-22%
• THA- weighted mean=6.9%, range 0-
22%

17. Pain and Function
• Pain relief and function were similar in
patients treated with arthroplasty or internal
fixation, RR no/little pain 1.12, 95% CI 0.88-1.35,
RR good function 0.99, 95% CI 0.90-1.10
• Arthroplasty significantly increased the risk of
infection (12 studies, n=1822) compared to
internal fixation
RR: 1.81, 95% CI 1.16-2.85, p = 0.009

19. Argument for IF of Displaced
Fractures
• Less Blood loss, O.R Time
• Significantly less infection rates
• No difference in Pain and Function
• Possible decrease in mortality risk by as
much as 48%
• Although high revision rates 65%
patients may never need a re-op!

20. Screws or SHS for Displaced
Fractures?

21. Subgroup Analysis (Meta-analysis)
• Screw and side plate constructs
performed significantly (five-
fold) better than multiple screws
in reducing the risk of revision
surgery
Level II evidence

22. Multiple Screws or SHS?
• Meta-analysis (Parker MJ, Cochrane Review)
• N=27studies involving 5269 participants
(5274 fractures) were included in the
study
• “No difference among various implants”SHS versus 3 or more screws (4 trials, n=414 patients ) on
fracture healing complications suggested a trend in favour
of compression screw and side plate fixation
25% Reduction in Risk of
Complications!
Level II evidence

23. Total Vs Hemi-Arthroplasty?

24. Direct Comparisons
• 2 RCTs
• N=180 patients
• Keating
• Ravikumar
Level II

25. Primary Outcome: Rel. Risk
Reoperation 13% 0.86 P=0.63
Mortality 21.8% 0.71 P=0.13
Dislocation 7.4% 1.54 P=0.17
Wound Infection 5.4% 0.69 P=0.46
DVT 6% 2.95 P=0.29
Pain and Function:
Hip pain 42.1% 0.76 P=0.03
Functional Limit 53.5% 0.90 P=0.13

26. What Hemiarthroplasty?
Unipolar Vs Bipolar

27. Cochrane Meta-analysis .
Parker (2005)
• N=7 RCTs, 857 participants
• No differences in complications,
mortality or function
Level II

28. Summary
• Evidence suggests arthroplasty for
displaced (Garden IV) femoral neck
fractures is currently the best
alternative
• The optimal arthroplasty for treated
displaced femoral neck fractures
remains unknown

29. Summary
• The role of internal fixation remains
unclear
• Earlier studies may have used the
wrong comparison group
• The optimal internal fixation device
may not be the current standard
“multiple screws”