Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Internal Screw Fixation Compared with Bipolar Hemiarthroplasty for Treatment of Displaced Femoral Neck Fractures in Elderly Patients"
by J.-E. Gjertsen, MD, PhD, et al.

Commentary & Perspective by
Richard F. Kyle, MD*,
Hennepin County Medical Center, Minneapolis, Minnesota

Posted March 2010

This is a well-written paper that has good data collected from the Norwegian Hip Fracture Register, which was initiated in 2005. The paper analyzes 4335 patients who were seventy years of age or older and had a displaced fracture of the femoral neck. The patients fell into two treatment groups: osteosynthesis and hemiarthroplasty. The analysis looked at a four-month and one-year follow-up and made use of well-recognized instruments to measure functional outcomes and quality of life. Unfortunately, there is no radiographic analysis or report of physical-examination findings. The response rates to questionnaires describing pain, function, and satisfaction on analog scales were 55% at the four-month period and just over 70% for the one-year period. The number of patients analyzed at one year was 455 in the osteosynthesis group and 711 in the arthroplasty group. This was not a randomized prospective study, and this fact was noted at the beginning of the paper. The rigorous statistical analysis, however, does give the reader confidence that the information delivered in the paper is credible.

The conclusion of the paper is that displaced femoral neck fractures in the elderly should be treated with hemiarthroplasty. This is based on the fact that the level of function and level of patient satisfaction were superior in the arthroplasty group. Death rates at one year were essentially the same.

The major concern that I have with this paper is that the conclusion does not allow for the option of total hip arthroplasty and there is little comment about patient selection for various modes of treatment. There is a comment that more men than women received osteosynthesis despite the authors' comments later in the paper that there were no differences in baseline characteristics between the patient groups. This may indicate that some selection did occur but was not recognized by the authors. Previous studies1 in the literature have supported the use of an algorithm based on the patient's preoperative mobility, cognition, degree of osteoporosis, and comorbidities in the selection of patients to receive fracture fixation or an arthroplasty. In the study of Robinson et al.1, the use of such an algorithm substantially improved the results of osteosynthesis and decreased complications. This may mitigate the author's recommendation for the use of arthroplasty in all patients with displaced femoral neck fractures. Another concern is that recent randomized prospective studies2,3 looking at osteosynthesis compared with hemiarthroplasty compared with total joint replacement have clearly indicated superior results for total joint replacement compared with osteosynthesis or hemiarthroplasty at longer-term follow-up. The select group of patients described as "the active elderly" with displaced femoral neck fractures who are good candidates for total hip replacement would fall outside of the recommended conclusion by the authors for the use of hemiarthroplasty in all patients with displaced femoral neck fractures.

In their randomized prospective trial on displaced femoral neck fractures with a longer term follow-up, Keating et al.3 found that the patients undergoing osteosynthesis improve their function as well as their satisfaction beyond one-year follow-up and catch up with hemiarthroplasty patients by two years. The length of follow-up in the current paper from Norway is too short to evaluate intermediate term results. The authors address this concern by stating that the patients have a short life expectancy. This may not be true for all patients who are seventy years of age or older.

There is also a concern about the technique of osteosynthesis in this paper because two screws are routinely used rather than three screws as recommended in most studies of osteosynthesis of femoral neck fractures. This was addressed in the body of the paper, with the results of the two-screw technique used in Scandinavian countries being described as comparable with the three-screw technique used in North America. The reoperation rate with osteosynthesis in this study is certainly consistent with the current literature and remains quite high at 22%.

I find the paper valuable and the findings consistent with the rest of the recent literature comparing arthroplasty and osteosynthesis in displaced femoral neck fractures. I am concerned that the authors do not discuss the use of total joint arthroplasty in the active elderly and did not address a patient-selection process when looking at factors that predict a successful result with use of osteosynthesis. The patient's activity level, the severity of the osteoporosis, the quality of fracture reduction, the amount of comminution, the Pawel angle, and patient preference are all important factors in selecting the proper procedure for the patient. I disagree with the authors' ultimate conclusion that displaced femoral neck fractures should all be treated with hemiarthroplasty. I believe that their paper shows that, given the two treatment options, hemiarthroplasty showed results superior to osteosynthesis. Unfortunately, the paper did not address other options, such as total joint replacement and the importance of patient selection in deciding the proper procedure for the patient. These factors must be taken into account when deciding if a patient is a candidate for osteosynthesis, hemiarthroplasty, or total joint replacement.

*The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of his immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (DePuy).

References

1. Robinson CM, Saran D, Annan IH. Intracapsular hip fractures. Results of management adopting a treatment protocol. Clin Orthop Relat Res. 1994;302:83-91.
2. Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ: Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness. Clin Orthop Relat Res. 2001;383:229-42.
3. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006;88:249-60.