Johansson (2014) — Internal fixation compared with total hip replacement for displaced femoral neck fractures: a minimum fifteen-year follow-up study of a previously reported randomized trial.

Internal Fixation Compared with Total Hip Replacement for Displaced Femoral Neck Fractures: a Minimum Fifteen-Year Follow-Up Study of a Previously Reported Randomized Trial.

Johansson·J Bone Joint Surg Am·2014·80 citations·Trauma

Minimum 15-year follow-up of an RCT (n=143 patients, 146 hips) comparing closed reduction with two cannulated screws versus cemented total hip replacement for displaced femoral neck fractures in patients aged 75+ (mean age 84). Asks whether the short-term advantage of arthroplasty holds over the long term and whether cognitive status modifies the treatment effect.

Study Snapshot

Design

Single-center RCT

Blinding: Open-label

Setting: Single center, Linköping, Sweden

Funding: None

Objective

Determine whether total hip replacement outperforms internal fixation for displaced femoral neck fractures long-term

Outcome(s)

Treatment failure rate at minimum 15-year follow-up

Subjects

143 patients (146 hips); IF n=78, THR n=68

78Closed reduction + 2-screw internal fixation
68Cemented total hip replacement, posterolateral approach

Inclusion

Age ≥75 years
Ambulatory prior to fracture
No rheumatic joint disease

Exclusion

Contraindication to major surgery
Randomized twice (analyzed as separate cases)

Follow-up

Minimum 15 years (data through March 2013)

Statistics

Student t-testChi-square testFisher's exact test

Key Findings

In cognitively intact patients, internal fixation failed in 55% of hips versus only 5% after cemented THA — a tenfold difference persisting at 15+ years
In mentally impaired patients, failure rates were identical at 16% regardless of treatment, suggesting cognitive status fundamentally changes the treatment calculus
Overall failure rate across both groups was 27% (40/146 hips); reoperation after internal fixation clustered early, with 94% of reoperations occurring within the first two postoperative years
Dislocation occurred in 18% of primary THA patients and was significantly more common in mentally impaired patients (p = 0.03), implicating cognitive status as a dislocation risk factor
No aseptic loosening and no periprosthetic fractures were detected in the primary THA group at final follow-up, refuting the concern that long-term implant failure would erode arthroplasty's advantage

Clinical Relevance

When an elderly cognitively intact patient presents with a displaced femoral neck fracture, this data supports cemented THA as the default — the 55% vs. 5% failure gap at 15 years is too large to ignore.

For mentally impaired patients, both treatments fail at equal rates, so surgical risk, anesthesia burden, and dislocation risk (higher with THA in this group) should drive the decision rather than anticipated fracture healing.

Supplemental

Internal Fixation Compared with Total Hip Replacement for Displaced Femoral Neck Fractures: a Minimum Fifteen-Year Follow-Up Study of a Previously Reported Randomized Trial.

Internal Fixation Compared with Total Hip Replacement for Displaced Femoral Neck Fractures: a Minimum Fifteen-Year Follow-Up Study of a Previously Reported Randomized Trial.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Internal Fixation Compared with Total Hip Replacement for Displaced Femoral Neck Fractures: a Minimum Fifteen-Year Follow-Up Study of a Previously Reported Randomized Trial.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Internal Fixation Compared with Total Hip Replacement for Displaced Femoral Neck Fractures: a Minimum Fifteen-Year Follow-Up Study of a Previously Reported Randomized Trial.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Internal Fixation Compared with Total Hip Replacement for Displaced Femoral Neck Fractures: a Minimum Fifteen-Year Follow-Up Study of a Previously Reported Randomized Trial.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles