Little debate surrounds the treatment of displaced fractures of the femoral neck in very young, high-demand patients (generally treated with fixation) and very old, low-demand patients (generally treated with arthroplasty). However, defining the boundaries for these extremes and the treatment for patients in the middle is controversial. The study by Rogmark et al. used an age of =70 years as a surrogate for bone quality and demand, with no upper age limit. In order to recruit a sufficient number of patients, a multicenter study was required; however, no attempt was made to standardize surgical technique or choice of implant. Moreover, after random allocation to "arthroplasty," this group was further subdivided to receive either total hip replacement or hemiarthroplasty on the rather arbitrary basis of patient age, mental status, and life situation. Surgeons from 12 hospitals implanted 2 types of pins and more than 10 different types of arthroplasty components (using the operative approach of their choice). Details regarding quality of reduction, type of anesthetic, and prophylaxis against deep-vein thrombosis were not provided.
Although "failure" was chosen as the primary outcome, pain and function probably represent more relevant end points. No specific protocol was used to manage nonunions and other "failures," and validated instruments for the assessment of functional outcome were not used. Although patients in the arthroplasty group had better pain relief and mobility than did those in the internal fixation group, arthroplasty was associated with a longer operative time, an increased length of hospital stay, and more complications (but not higher mortality).
Results were not stratified by age, but all patients were =70 years of age, with an overall mean age of >80 years. In this population, arthroplasty seems to be superior to internal fixation for the treatment of displaced fractures of the femoral neck. One must be careful not to extrapolate this conclusion to younger, higher-demand patients. Further work is required to better define the best management of displaced subcapital hip fractures in a given population on the basis of bone quality, medical status, physical demands, and expectations.