Which is the best alternative for displaced femoral neck fractures in the elderly?: A meta-analysis

Abstract

Background: Treatment of displaced femoral neck fractures includes internal fixation and arthroplasty. However, whether arthroplasty or internal fixation is the primary treatment for displaced femoral neck fractures in elderly patients remains a subject for debate. The literature contains conflicting evidence regarding rates of mortality, revision surgery, major postoperative complications, and function in elderly patients with displaced femoral neck fractures treated either by internal fixation or arthroplasty (either hemiarthroplasty or THA).

Questions/purpose: We determined mortality, revision surgery rates, major surgical complications (which include infection, nonunion or early redisplacement, avascular necrosis, dislocation, loosening of the prosthesis, acetabular erosion, fracture below or around the implant, and other severe general complications such as deep vein thrombosis and pulmonary embolism), and function in patients treated with either internal fixation or arthroplasty for displaced femoral neck fractures in the elderly.

Methods: We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) comparing internal fixation and arthroplasty. We identified 20 RCTs with 4508 patients meeting all the criteria for eligibility. We performed a meta-analysis of the major complications, reoperations, function, pain, and mortality.

Results: Compared with internal fixation, arthroplasty reduced the risk of the major complications (95% CI, 0.21-0.54 for 1 year; 95% CI, 0.16-0.31 for 5 years) and the incidence of reoperation 1 to 5 years after surgery (95% CI, 0.15-0.34 for 1 year; 95% CI, 0.08-0.24 for 5 years), and provided better pain relief (95% CI, 0.34-0.72). Function was superior (RR = 0.59; 95% CI, 0.44-0.79) for patients treated with arthroplasty than for patients treated by internal fixation. However, mortality 1 to 3 years after surgery was similar (95% CI, 0.96-1.23, p = 0.20 for 1 year; 95% CI, 0.91-1.17, p = 0.63 for 3 years).

Conclusions: Arthroplasty can reduce the risk of major complications and the incidence of reoperation compared with internal fixation, and provide better pain relief and function, but it does not reduce mortality.

Level of evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

The selection of RCTs comparing arthroplasty with internal fixation for displaced femoral neck fractures in elderly patients is shown.

Fig. 2

We used a funnel plot to analyze publication bias of three RCTs that included 789 patients. The major complication at 5 years postoperative showed no evidence of asymmetry, suggesting that there was no statistically significant publication bias.

Fig. 3

This funnel plot of three RCTs with 655 patients for reoperation at 5 years postoperative shows no evidence of asymmetry suggesting there was no statistically significant publication bias.

Fig. 4

This funnel plot shows publication bias of 19 RCTs including 4237 patients for mortality at 1 year postoperative. There is no evidence of asymmetry, suggesting there was no statistically significant publication bias in 19 RCTs for mortality at 1 year postoperative.

Fig. 5

This forest plot shows pooling of RRs of the major complication at 1 year postoperative. It has 16 RCTs including 3221 patients. The 95% CI of the pooled RR is 0.21 to 0.54. This result showed a lower risk of major surgical complications at 1 year for arthroplasty compared with internal fixation. M-H = Mantzel-Haenzel method; df = degrees of freedom; IF = internal fixation.

Fig. 6

The forest plot compares three RCTs including 789 patients for the major complication at 5 years postoperative. The 95% CI of the pooled RR is 0.16 to 0.31. It showed there was also a lower risk of major surgical complications for arthroplasty at 5 years postoperatively. M-H = Mantzel-Haenzel method; df = degrees of freedom; IF = internal fixation.

Fig. 7

This forest plot shows pooling of RRs for reoperation at 1 year postoperative. Seventeen RCTs are included with 3830 patients. The 95% CI of the pooled RR is 0.15 to 0.34, suggesting there were fewer reoperations in patients treated by arthroplasty than by internal fixation. M-H = Mantzel-Haenzel method; df = degrees of freedom; IF = internal fixation.

Fig. 8

This forest plot shows pooling of RRs for reoperation at 5 years postoperative. The three RCTs include 655 patients. The 95% CI of the pooled RR is 0.08 to 0.24 suggesting there also were fewer reoperations in patients treated by arthroplasty at 5 years. M-H = Mantzel-Haenzel method; df = degrees of freedom; IF = internal fixation.

Fig. 9

Eight RCTs including 1982 patients were compared for postoperative function. The 95% CI of the pooled RR is 0.44 to 0.79, suggesting function was better for patients treated with arthroplasty than for patients treated by internal fixation. M-H = Mantzel-Haenzel method; df = degrees of freedom; IF = internal fixation.

Fig. 10

Nine RCTs including 2121 patients were compared for postoperative pain. The 95% CI of the pooled RR is 0.34 to 0.72 showing patients treated with arthroplasty reported less pain than patients treated with internal fixation. M-H = Mantzel-Haenzel method; df = degrees of freedom; IF = internal fixation.

Fig. 11

Pooling of RRs for mortality at 1 year postoperative is shown in this forest plot. Nineteen RCTs including 4237 patients were compared. The 95% CI of the pooled RR is 0.96 to 1.23. The result showed these studies did not significantly change the overall pooled effect of internal fixation compared with arthroplasty. M-H = Mantzel-Haenzel method; df = degrees of freedom; IF = internal fixation.

Fig. 12

This forest plot shows pooling of RRs for mortality at 5 years postoperative. Nine RCTs were included with 2170 patients. The 95% CI of the pooled RR is 0.91 to 1.17 suggesting there still was no difference in mortality after internal fixation and arthroplasty. M-H = Mantzel-Haenzel method; df = degrees of freedom; IF = internal fixation.