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Total Hip Replacement Versus Open Reduction and Internal Fixation of Displaced Femoral Neck FracturesA Randomized Long-Term Follow-up Study
Ghazi Khalil Chammout, MD1; Sebastian Simon Mukka, MD2; Thomas Carlsson, MD1; Gustaf Fredrik Neander, MD, PhD1; André Wilhelm Helge Stark, MD, PhD1; Olof Gustaf Sköldenberg, MD, PhD1
1 Division of Orthopaedics, Department of Clinical Sciences at Danderyd Hospital, Karolinska Institute, Stockholm, Sweden. E-mail address for G.K. Chammout: ghazi.chammout@ds.se. E-mail address for T. Carlsson: thomas.carlsson@ds.se. E-mail address for G.F. Neander: gustaf.neander@ds.se. E-mail address for A.W.H. Stark: andreas.stark@ds.se. E-mail address for O.G. Sköldenberg: olof.skoldenberg@ki.se
2 Department of Surgical and Perioperative Sciences, Sundsvall Hospital, Umeå universitet, SE-901 87, Umeå, Sweden. E-mail address: sebastian.mukka@gmail.com
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Investigation performed at the Division of Orthopaedics, Department of Clinical Sciences at Danderyd Hospital, Karolinska Institute, Stockholm, Sweden

This article was chosen to appear electronically on September 26, 2012, in advance of publication in a regularly scheduled issue.

A commentary by J.L. Marsh, MD, is linked to the online version of this article at jbjs.org.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Nov 07;94(21):1921-1928. doi: 10.2106/JBJS.K.01615
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Clinical trials with short and intermediate-term follow-up have demonstrated superior results for total hip replacement as compared with internal fixation with regard to hip function and the need for secondary surgery in elderly patients with a displaced intracapsular femoral neck fracture. The aim of the present study was to compare the results of total hip replacement with those of internal fixation over a long-term follow-up period of seventeen years.


We enrolled 100 patients who had sustained a femoral neck fracture in a single-center, randomized controlled trial; all patients had had a healthy hip before the injury. The study group included seventy-nine women and twenty-one men with a mean age of seventy-eight years (range, sixty-five to ninety years). The subjects were randomly assigned to either total hip replacement (the arthroplasty group) (n = 43) or internal fixation (the control group) (n = 57). The primary end point was hip function, evaluated with use of the Harris hip score. Secondary end points included mortality, reoperations, gait speed, and activities of daily life. Follow-up evaluations were performed at three months and at one, two, four, eleven, and seventeen years.


The Harris hip score was higher in the total hip arthroplasty group, with a mean difference of 14.7 points (95% confidence interval, 9.2 to 20.1 points; p < 0.001 [analysis of covariance]) during the study period. We found no difference in mortality between the two groups. Four patients (9%) in the total hip replacement group and twenty-two patients (39%) in the internal fixation group had undergone a major reoperation (relative risk, 0.24; 95% confidence interval, 0.09 to 0.64). The overall reoperation rate was 23% (ten of forty-three) in the total hip replacement group and 53% (thirty of fifty-seven) in the internal fixation group (relative risk, 0.44; 95% confidence interval, 0.24 to 0.80). The results related to gait speed and activities of daily living favored the arthroplasty group during the first year.


Over a period of seventeen years in a group of healthy, elderly patients with a displaced femoral neck fracture, total hip replacement provided better hip function and significantly fewer reoperations compared with internal fixation without increasing mortality.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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