The Journal of Arthroplasty 28 (2013) 18391841

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The Journal of Arthroplasty

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Trends of Surgical Treatment in Femoral Neck Fracture

A Nationwide Study Based on Claim Registry
Young-Kyun Lee, MD a, Yong-Chan Ha, MD b, Chanmi Park c, Kyung-Hoi Koo, MD a
a
b
c

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, South Korea
Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Dongjak-gu, Seoul, South Korea
Health Insurance Review and Assessment Service, Seocho-gu, Seoul, South Korea

a r t i c l e

i n f o

Article history:
Received 30 August 2012
Accepted 5 January 2013
Keywords:
trends
femoral neck fracture
surgical treatment
internal xation
arthroplasty
registry

a b s t r a c t
We evaluated current trends of surgical treatment, such as internal xation and hip arthroplasty, in femoral
neck fracture. We assessed annual proportion of the each procedure in patients aged 50 years or more from
2006 to 2011, using the data of Health Insurance Review and Assessment Service (HIRA), which is a
national claim registry. The proportion of hip arthroplasty increased while that of internal xation
decreased annually during the 5 years. The proportion of total hip arthroplasty increased in patients aged
65 years, and that of hemiarthroplasty increased in patients aged 65 years. The proportional increase of
hip arthroplasty seemed to conform to the recent evidence regarding the outcomes of surgical treatments
for the femoral neck fracture.
2013 Elsevier Inc. All rights reserved.

The incidence of femoral neck fracture is increasing annually

worldwide due to the proportional increase of aged population.
Femoral neck fractures generally require surgical management, which
includes internal xation (IF), hemiarthroplasty (HA), and total hip
arthroplasty (THA) [13].
The optimal treatment for femoral neck fractures in older patients
has been controversial. However, recent studies have reported that
arthroplasty has better outcomes than other surgical options [37].
Although some surgeon-derived surveys in the United States and
Europe showed that this recent evidence is reected in clinical practice
[810], no epidemiologic study has been conducted in East Asia.
The purpose of this study was to evaluate whether trends in
surgical treatment of femoral neck fractures changed currently in
South Korean, using national claim registry.

No benets in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article. This study was supported
by Grant No. 02-2012-066 from the Seoul National University Bundang Hospital
Research Fund.
The Conict of Interest statement associated with this article can be found at http://
dx.doi.org/10.1016/j.arth.2013.01.015.
Reprint requests: Yong-Chan Ha, MD, Department of Orthopaedic Surgery, ChungAng University College of Medicine, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755,
South Korea.
0883-5403/2810-0029$36.00/0 see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.arth.2013.01.015

Materials and Methods

Subjects
We analyzed data from a nationwide claim database, the Korean
Health Insurance Review and Assessment Service (HIRA), which
contains adjusted medical and pharmacy claims for all Korean
citizens, for the years 2006 to 2011. In Korea, 97.0% of the population
is legally obliged to enroll in the Korea National Health Insurance
Program. Patients pay on average 30% of total medical costs to clinics
or hospitals that manage almost all diseases, and National Health
Insurance Corporation pays for the remainder, except for procedures
not covered by insurance, such as cosmetic surgery and some
unproven therapies. All clinics and hospitals then submit claims
data for inpatients and outpatients care, including diagnoses (coded
according to the International Classication of Diseases, Tenth Revision
[ICD-10]), procedures, prescription records, demographic information, and direct medical costs, to HIRA to obtain 70% reimbursement of
the total medical costs from the government. Those constituting the
remaining 3% of the population not insured by the Korean National
Health Insurance Program are either covered by a Medical Aid
Program or are temporary or illegal residents. Claims data covered by
Medical Aid programs are also reviewed by HIRA, and thus, virtually
all information about patients and their medical records is available
from the HIRA database, which has been used on several occasions for
epidemiological studies [1113]. All new visits or admissions to
Korean hospitals for a femoral neck fracture were recorded

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Y.-K. Lee et al. / The Journal of Arthroplasty 28 (2013) 18391841

increased steadily during the study period (from 64.3% to 66.8% for
patients 65 to 79 years [P b .001], and from 69.5% to 72.8% in patients
aged 80 years [P b .001]). Furthermore, we observed an overall trend
of a declining proportion of patients undergoing IF with time across all
age groups (Fig. 2).

Discussion

Fig. 1. The proportions of internal xation, total hip arthroplasty, and hemiarthroplasty
for patients with femoral neck fracture over 50 years old from 2006 to 2011.

prospectively in the above-described system using ICD-10 codes

and procedures. To identify femoral neck fractures, we selected ICD-10
codes (S72.0) and a cut-off of 50 years [1416]. We divided the cohort
into three groups, that is, an IF group (open reduction of fractured
extremity-femur, closed pinning-femur, closed reduction of fractured
extremity-pelvis/femur), an HA group, and a THA group. Data were
retrospectively evaluated to determine trends in the surgical
treatment of femoral neck fractures, in men and women aged
50 years treated between 2006 and 2011. The study protocol was
approved by the institutional review board.
Statistical Analysis
To determine the trends of surgical treatment for femoral neck
fractures, patients were stratied by age (5064, 6579, and
80 years) and gender. The chi-square test of independence was
used to evaluate whether the frequencies of each procedures had
changed between 2006 and 2011. Statistical analyses were conducted
using SPSS for Windows (version 15.0; SPSS, Chicago, IL) and statistical signicance was accepted for P-values of b .05.
Results
Overall, the proportion of patients undergoing IF diminished from
34.2% in 2006 to 29.9% in 2011, whereas, the proportion of patients
undergoing HA and THA increased from 62.2% and 3.6% in 2006 to
65.1% and 5.0% in 2011, respectively (P b .001 for both) (Fig. 1). When
stratied by age, although the majority of patients younger than 65
underwent IF, the proportion of the patients undergoing IF decreased.
However, the proportion of patients who underwent THA increased
with time in this age group (Fig. 2). The HA was performed in the
majority of patients aged 65 to 79 years (62.2% to 65.4%) and in
patients aged 80 years (69.2% to 72.8) during the study period
(Fig. 2), and the proportion of these patients who underwent HA

The optimal surgical treatment of femoral neck fractures is controversial. In the present study, we determined trends in proportions
of femoral neck fractures treated by IF, HA, and THA in patients aged
50 years in South Korea from 2006 to 2011.
Our study shows an increase in the proportion of THA over the
study period in patients younger than 65 years, and an increase in the
proportion of HA in patients 65 to 79 years old and 80 years old.
On the other hand, we observed a decrease in the proportion treated
by IF in all age groups.
These trends conrm the evidence recently published that supports the use of arthroplasty for the treatment of femoral neck
fractures [37]. Furthermore, reports about the higher risk of
dislocation after THA in older patients may explain the increase in
the proportion treated by HA rather than THA, among patients aged
65 years [17,18].
On the other hand, these ndings do not concur with the results
of a recent national epidemiologic study conducted in the United
States [19], in which it was demonstrated that the proportion of
patients treated by THA decreased with time across all age groups
during the previous decade. As they pointed out, their study was
performed before the publication of recent evidence supporting the
use of arthroplasty for femoral neck fractures. However, the present
study conrmed recent published evidence. Overall, arthroplasty for
femoral neck fracture was found to increase across all age groups. In
those younger than 65 years, THA might be preferred to achieve
better functional recovery [37], and, in those 65 years, HA might
be preferred because it is a less technical demanding procedure and
has a lower risk of dislocation after arthroplasty [17,18].
Although the present study has the benet of a large sample size
from a nationwide database, it also has some limitations. First, other
important decision-making factors, such as radiographic ndings
(degree of displacement, the presence of osteoporosis, and the
extent of hip osteoarthritis) and demographic characteristics (preinjury ambulatory state and instability risk), were unavailable,
because data were obtained from National Claim Registry. For
example, IF should be considered as the procedure of choice in
patients with non-displaced femoral neck fracture [1]. Second,
patients who were not hospitalized may not have been included,
though the numbers involved are likely to be negligible, because
femoral neck fractures ultimately require surgical treatment. Third,
our study was limited in terms of duration, because HIRA limited the
study period to a maximum of 6 years.

Fig. 2. The age-specic proportions of internal xation, total hip arthroplasty, and hemiarthroplasty for patients with femoral neck fracture over 50 years old from 2006 to 2011.

Y.-K. Lee et al. / The Journal of Arthroplasty 28 (2013) 18391841

In spite of these limitations, this study shows that the use of

arthroplasty (HA and THA) for treatment of femoral neck fractures
increased between 2006 and 2011, especially THA in patients younger
than 65 years, which concurs with the ndings of recent studies that
showed better outcomes for arthroplasty than for internal xation for
treatment of femoral neck fractures. This study provides contemporary data for surgeons to estimate trends for the surgical treatment of
femoral neck fractures.
References
1. Shah AK, Eissler J, Radomisli T. Algorithms for the treatment of femoral neck
fractures. Clin Orthop Relat Res 2002;399:28.
2. Haentjens P, Autier P, Barette M, et al. Costs of care after hospital discharge among
women with a femoral neck fracture. Clin Orthop Relat Res 2003;414:250.
3. Hopley C, Stengel D, Ekkernkamp A, et al. Primary total hip arthroplasty versus
hemiarthroplasty for displaced intracapsular hip fractures in older patients:
systematic review. BMJ 2010:c2332.
4. Keating JF, Grant A, Masson M, et al. Randomized comparison of reduction and
xation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am
2006;2:249.
5. Frihagen F, Nordsletten L, Madsen JE. Hemiarthroplasty or internal xation for
intracapsular displaced femoral neck fractures: randomised controlled trial. BMJ
2007;7632:1251.
6. Blomfeldt R, Tornkvist H, Ponzer S, et al. Comparison of internal xation with total
hip replacement for displaced femoral neck fractures. Randomized, controlled trial
performed at four years. J Bone Joint Surg Am 2005;8:1680.

1841

7. Leonardsson O, Sernbo I, Carlsson A, et al. Long-term follow-up of replacement

compared with internal xation for displaced femoral neck fractures: results at
ten years in a randomised study of 450 patients. J Bone Joint Surg Br 2010;3:406.
8. Pogrund H, Makin M, Robin G, et al. Osteoporosis in patients with fractured femoral
neck in Jerusalem. Clin Orthop Relat Res 1977;124:165.
9. Laursen JO. Treatment of intracapsular fractures of the femoral neck in Denmark:
trends in indications over the past decade. Acta Orthop Belg 1999;4:478.
10. Iorio R, Schwartz B, Macaulay W, et al. Surgical treatment of displaced femoral neck
fractures in the elderly: a survey of the American Association of Hip and Knee
Surgeons. J Arthroplasty 2006;8:1124.
11. Gong HS, Oh WS, Chung MS, et al. Patients with wrist fractures are less likely to be
evaluated and managed for osteoporosis. J Bone Joint Surg Am 2009;10:2376.
12. Park C, Ha YC, Jang S, et al. The incidence and residual lifetime risk of osteoporosisrelated fractures in Korea. J Bone Miner Metab 2011;6:744.
13. Yoon HK, Park C, Jang S, et al. Incidence and mortality following hip fracture in
Korea. J Korean Med Sci 2011;8:1087.
14. Kang HY, Yang KH, Kim YN, et al. Incidence and mortality of hip fracture among the
elderly population in South Korea: a population-based study using the national
health insurance claims data. BMC Public Health 2010:230.
15. Lim S, Koo BK, Lee EJ, et al. Incidence of hip fractures in Korea. J Bone Miner Metab
2008;4:400.
16. Lippuner K, Johansson H, Kanis JA, et al. Remaining lifetime and absolute 10-year
probabilities of osteoporotic fracture in Swiss men and women. Osteoporos Int
2009;7:1131.
17. van den Bekerom MP, Hilverdink EF, Sierevelt IN, et al. A comparison of
hemiarthroplasty with total hip replacement for displaced intracapsular fracture
of the femoral neck: a randomised controlled multicentre trial in patients aged
70 years and over. J Bone Joint Surg Br 2010;10:1422.
18. Morris AH, Zuckerman JD. National Consensus Conference on Improving the
Continuum of Care for Patients with Hip Fracture. J Bone Joint Surg Am 2002;4:670.
19. Jain NB, Losina E, Ward DM, et al. Trends in surgical management of femoral neck
fractures in the United States. Clin Orthop Relat Res 2008;12:3116.