Current Trends in the Evaluation and Management of Nondisplaced Femoral Neck Fractures in the Elderly

Kanu Okike, MD, MPH; Ian G. Hasegawa, MD


J Am Acad Orthop Surg. 2021;29(4):e154-e164. 

In This Article


As noted above, high rates of conversion arthroplasty have been documented after fixation of nondisplaced FN fractures in the elderly. When the conversion arthroplasty procedure is performed, the outcomes are often worse than when the arthroplasty procedure is performed acutely for a FN fracture.[39,40] As a result, some have begun to consider primary arthroplasty as an initial treatment of nondisplaced FN fractures in the elderly.

The results from two randomized clinical trials and one systematic review with meta-analysis have suggested that hemiarthroplasty may result in a lower risk of revision surgery, without any added mortality. In particular, Dolatowski et al[7] randomized 219 patients aged 70 years and older who had sustained a nondisplaced FN fracture to either hemiarthroplasty or cannulated screw fixation. Hemiarthroplasty was associated with a 5% major revision surgery rate as compared to 20% for multiple cannulated screw fixation (P = 0.002). In another randomized clinical trial, Lu et al[5] also found a lower revision surgery rate after hemiarthroplasty as compared to cannulated screw fixation (5.4% versus 21.4%, respectively, P < 0.05). In a recent systematic review and meta-analysis comprising 579 patients (343 treated with internal fixation and 236 treated with hemiarthroplasty) taken from the two randomized controlled trials described above and two additional retrospective cohorts, hemiarthroplasty was associated with a 70% reduction in revision surgery as compared to internal fixation.[41] Hemiarthroplasty was associated with higher surgical blood losses, more blood transfusions, more deep infections, and a longer hospital stay but was not associated with any greater mortality at one-year (16.9% versus 13%, respectively, P = 0.36). In addition, no differences were observed in patient-reported functional outcomes between the two groups.

Although internal fixation is currently considered the standard of care in treating nondisplaced FN fractures in the elderly, evidence in support of primary arthroplasty is growing. Further research is required to evaluate the outcomes associated with the novel fixation devices described above and to confirm early findings that hemiarthroplasty is not associated with any increase in mortality as compared to fixation. The answers to these questions may help to determine whether the most effective treatment of nondisplaced FN fractures involves internal fixation or arthroplasty or perhaps a protocol whereby Garden I and II fractures with favorable characteristics are fixed, whereas those at high risk of failure are replaced (similar to Garden III and IV FN fractures today).