The indication for THA (vs. ORIF or Hemi) after a displaced femoral neck fracture is becoming more widely accepted. The indication for THA is associated with the trend of prioritizing “activity age” over “chronologic age”.
Chronoloigc age. The success of ORIF decreases with increased chronologic age regardless of patient activity due to diminished blood supply. A femoral neck fracture cannot heal when poor or disrupted blood flow. Elderly are more susceptible to disruptions in blow flow following femoral neck fractures. Therefore, Arthroplasty demonstrated superior functional outcome and decreased revision surgery in the elderly population [1-9]. Thus the debate for treating displaced femoral neck fractures in patients > 60 years old recognizes the inferior results of ORIF and focuses on Hemi vs. THA ... and herein lies the importance of activity age.
Activity age. Hemi is shown to provide inferior functional scores and persistent pain in patients that place high demands on their hip. THA is considered a superior operation in the independent elderly (young activity age). There are trade offs. There is a higher reported risk of hip instability in THA after femoral neck fracture. The soft tissue surrounding the hip becomes tight and contracted during the gradual process of osteoarthritis and acts as a stabilizing force after THA. In contrast, the acute event of a fracture does not allow the soft tissue to stiffen and these patients have demonstrated a higher rate of dislocation with THA from the posterior approach, although direct anterior THA or anterolateral approach may reduce this risk [10].
REFERENCES
1. Stoen, R.O., et al., Randomized trial of hemiarthroplasty versus internal fixation for femoral neck fractures: no differences at 6 years. Clin Orthop Relat Res, 2014. 472(1): p. 360-7.
2. Rogmark, C., CORR Insights (R): Randomized trial of hemiarthroplasty versus internal fixation for femoral neck fractures: no differences at 6 years. Clin Orthop Relat Res, 2014. 472(1): p. 368-9.
3. Rogmark, C. and O. Johnell, Primary arthroplasty is better than internal fixation of displaced femoral neck fractures: a meta-analysis of 14 randomized studies with 2,289 patients. Acta Orthop, 2006. 77(3): p. 359-67.
4. Blomfeldt, R., et al., A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br, 2007. 89(2): p. 160-5.
5. Blomfeldt, R., et al., Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am, 2005. 87(8): p. 1680-8.
6. Hedbeck, C.J., et al., Comparison of bipolar hemiarthroplasty with total hip arthroplasty for displaced femoral neck fractures: a concise four-year follow-up of a randomized trial. J Bone Joint Surg Am, 2011. 93(5): p. 445-50.
7. Baker, R.P., et al., Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg Am, 2006. 88(12): p. 2583-9.
8. Macaulay, W., et al., Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty. J Am Acad Orthop Surg, 2006. 14(5): p. 287-93.
9. Macaulay, W., et al., Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. J Arthroplasty, 2008. 23(6 Suppl 1): p. 2-8.
10. Skoldenberg, O., et al., Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing from posterolateral to anterolateral approach. Acta Orthop, 2010. 81(5): p. 583-7.