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Comparison of Internal Fixation with Total Hip Replacement for Displaced Femoral Neck FracturesRandomized, Controlled Trial Performed at Four Years
Richard Blomfeldt, MD1; Hans Törnkvist, MD, PhD1; Sari Ponzer, MD, PhD1; Anita Söderqvist, RN1; Jan Tidermark, MD, PhD1
1 Karolinska Institutet, Department of Orthopaedics, Stockholm Söder Hospital, S-118 83 Stockholm, Sweden. E-mail address for J. Tidermark: jan.tidermark@ortoped.sos.sll.se
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Trygg-Hansa Insurance Company, the Swedish Society for Medical Research, the Swedish Orthopaedic Association, and the Stockholm County Council. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Karolinska Institutet, Department of Orthopaedics, Stockholm Söder Hospital, Stockholm, Sweden

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Aug 01;87(8):1680-1688. doi: 10.2106/JBJS.D.02655
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Background: Recent randomized, controlled trials performed at two years postoperatively have shown that a primary total hip replacement is superior to internal fixation for the treatment of a displaced femoral neck fracture in a relatively healthy, mentally competent, elderly patient. The primary aim of the present study was to evaluate the outcomes at four years.

Methods: One hundred and two patients (mean age, eighty years) who had an acute displaced femoral neck fracture were randomly allocated to be treated with total hip replacement or internal fixation. The inclusion criteria were an age of at least seventy years, absence of severe cognitive dysfunction, an independent living status, and the ability to walk independently. The main outcome measurements were hip complications, reoperations, hip function, and health-related quality of life.

Results: The mortality rate was 25% in both groups. At the forty-eight-month follow-up evaluation, the rate of hip complications was 4% in the patients treated with total hip replacement and 42% in those treated with internal fixation (p < 0.001) and the reoperation rates were 4% and 47%, respectively (p < 0.001). The arthroplasty group had no additional hip complications or reoperations between the twenty-four and forty-eight-month follow-up visits. In the fixation group, the percentage of hip complications increased from 36% to 42% and the percentage of reoperations increased from 42% to 47% during the same period. The hip function was significantly better and the decline in health-related quality of life was less pronounced in the arthroplasty group than it was in the fixation group at the four, twelve, and twenty-four-month follow-up evaluations. Ninety-seven percent of the patients in the arthroplasty group and 57% of the patients in the fixation group who were available for follow-up at forty-eight months had no hip complications (p < 0.001).

Conclusions: Compared with internal fixation, primary total hip replacement provides a better outcome for mentally competent elderly patients with a displaced femoral neck fracture. The complication and reoperation rates were significantly lower and hip function and health-related quality of life were at least as good at four years after the surgery.

Level of Evidence: Therapeutic Level I. See Instructions to 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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    Jan Tidermark
    Posted on December 06, 2005
    Dr Tidermark responds to Dr. Berry's Commentary
    Dept. of Orthopaedics, Karolinska Institutet at Stockholm Soder Hospital, Stockholm, Sweden

    I wish to thank Dr. Berry for his excellent Commentary & Perspective regarding our paper. We fully share his overall conclusions but we would like to clarify one point. Besides our “intention to treat” analysis, we did, in fact, subanalyze the functional results of those patients treated with internal fixation who had no further operations and retained their femoral head. Table IV in the paper displays the outcomes for all patients without a hip complication at the 48-month follow-up. Among patients available at this follow-up, 34 out of 35 patients (97%) in the THR group and 21 out of 37 patients (57%) in the IF group remained without any hip complication. The absolute figures for hip function (Charnley score) and HRQoL (EQ-5D index score) were in favor of the THR group, although not statistically significant. Our interpretation was that a primary THR seems to provide at least as good hip function and HRQoL after four years even when compared to patients with uneventfully healed fractures after IF.

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