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.