This prospective RCT enrolled 271 patients over age 65 with displaced Garden III/IV subcapital femoral neck fractures. Patients were randomized to internal fixation (Richards compression screw), uncemented Austin Moore hemiarthroplasty, or cemented Howse II THA via posterolateral approach. The study reports 13-year outcomes across mortality, revision rates, dislocation, pain, mobility, and Harris hip scores.
For decades, THA was withheld from most elderly femoral neck fracture patients out of concern for early complications — hemiarthroplasty was considered the safer default. This 13-year RCT dismantles that assumption: the short-term risk of THA (primarily dislocation) is outweighed by dramatically better long-term pain, function, and revision rates.
When you see a physiologically active patient over 65 with a displaced Garden III or IV subcapital fracture, THA is the strongest long-term option. But approach selection is critical. The 20% dislocation rate here reflects a posterolateral approach without documented posterior capsule repair; modern practice favors posterior soft tissue repair or anterior/direct lateral approaches to reduce instability.
Counsel patients explicitly: internal fixation offers a chance at a native hip, but one-third will need revision, most within 9 months, and two-thirds of survivors will still have significant pain at 13 years. And if revision becomes necessary for any reason, remind yourself that 80% of those patients will be dead within a year. The goal is to get the index operation right.
This prospective RCT enrolled 271 patients over age 65 with displaced Garden III/IV subcapital femoral neck fractures. Patients were randomized to internal fixation (Richards compression screw), uncemented Austin Moore hemiarthroplasty, or cemented Howse II THA via posterolateral approach. The study reports 13-year outcomes across mortality, revision rates, dislocation, pain, mobility, and Harris hip scores.
For decades, THA was withheld from most elderly femoral neck fracture patients out of concern for early complications — hemiarthroplasty was considered the safer default. This 13-year RCT dismantles that assumption: the short-term risk of THA (primarily dislocation) is outweighed by dramatically better long-term pain, function, and revision rates.
When you see a physiologically active patient over 65 with a displaced Garden III or IV subcapital fracture, THA is the strongest long-term option. But approach selection is critical. The 20% dislocation rate here reflects a posterolateral approach without documented posterior capsule repair; modern practice favors posterior soft tissue repair or anterior/direct lateral approaches to reduce instability.
Counsel patients explicitly: internal fixation offers a chance at a native hip, but one-third will need revision, most within 9 months, and two-thirds of survivors will still have significant pain at 13 years. And if revision becomes necessary for any reason, remind yourself that 80% of those patients will be dead within a year. The goal is to get the index operation right.