Question: In patients with fractures of the femoral neck, is internal fixation or arthroplasty more effective for improving functional outcome and reducing mortality and complications?
Design: Randomized (allocation concealed), unblinded, controlled trial with 2-year follow-up.
Setting: 12 hospitals in Sweden.
Patients: 450 patients who were =70 years of age and had fractures of the hip graded as Garden 3 or 4. Patients with confusion, rheumatoid arthritis, or fractures older than 2 days and patients who were bedridden or confined to a nursing home were excluded. 409 patients (91%; mean age, 82 years; 79% women) were assessed at 1 year. 383 patients (85%) were assessed at 2 years.
Intervention: Patients were allocated to primary arthroplasty ( n = 192; 103 total arthroplasty and 89 hemiarthroplasty) or internal fixation with use of Hansson hook-pins or Olmed screws ( n = 217).
Main outcome measures: Failure (=2 dislocations, loosening, deep infection, or femoral fracture adjacent to the prosthesis in the arthroplasty group; early redisplacement of the fracture, nonunion, segmental collapse of the femoral head, or deep infection in the internal fixation group), mortality, function (standardized questionnaire), and complications.
Main results: Analysis was by intention to treat. Arthroplasty led to fewer failures and more complications than did internal fixation ( table ). Mortality rates did not differ between groups (table). More patients in the internal fixation group than in the arthroplasty group reported reduced mobility because of hip symptoms (36% vs 25%, P < 0.05) and an inability to walk up stairs (46% vs 33%, P = 0.03) at 2 years.
Conclusions: In patients with fractures of the femoral neck, arthroplasty led to fewer treatment failures and better function than did internal fixation. More patients in the arthroplasty group had complications. Mortality rates did not differ between the two treatment groups.