Femoral neck fracture

Speaker :
Modular :

Patient profile

Name XX
Gender Female
Age 59 years old
Chart number 02766663

Chief complaint

Right hip painful deformity

Present illness

The 59 year-old female was a victim of hypertension

before.
On 95.3.7, she suffered from slipped down and felt
right hip pain and cant walk.
She was brought to our OPD for help.
Severe pain with limited ROM was noted.

Physical examination

Tenderness, swelling of the right hip

ROM limitation (+), severe pain when moving

Past history

Diabetes mellitus (-)

Hypertension (+)
Drug allergy denied
Medication history (-)
Operation history (-)
Admission history (-)

Tentative diagnosis

Right femoral neck fracture, Garden type III

Plan

Arrange open reduction and internal fixation

with three cannulated screws

EBM Discussion

Evidence-Based Medicine

Patient :

A 59 y/o female was a case of femoral neck displaced

fracture, right hip
Intervention :
Open reduction and internal fixation
Comparison :
Arrangement of arthroplasty
Outcome :
Open reduction and internal fixation was better than
arthroplasty of the outcome

Evidence-Based Medicine

One Question Sentence:

Can open reduction and internal fixation be better than
arthroplasty for the patient with femoral neck displaced
fracture?
Type of Question:
Therapy
Ideal Study type:
SR of RCT or High-Quality RCT
Feasible Study type:
SR of RCT or High-Quality RCT
Search Strategy Design :
Database : PubMed
Key words and search tactics: PCL + Avulsion fracture

JAAOS 2005;13
P 220-229

Search Strategy Design

Abstract 1

Internal fixation versus arthroplasty

for intracapsular proximal femoral
fractures in adults. [Systematic Review]

Cochrane Database of Systematic Reviews. 1,

2006.
This version 1st published online: 22 April
2003 in Issue 2, 2003.

Abstract 1

Search strategy: MEDLINE (1966 to January 2002),

EMBASE (1988 to 2002, Week 2), Current Contents
(1993 to 2002, Week 4), PREMEDLINE (January
2002) and selected orthopaedic journals and
conference proceedings, and reference lists of
relevant articles.
Selection criteria: All randomised and quasirandomised trials comparing internal fixation with
arthroplasty for intracapsular hip fractures in adults

Abstract 1

Thirteen trials involving 2091 patients were included

Main results :

Internal fixation had a reduced length of surgery,

operative blood loss, need for blood transfusion
and risk of deep wound infection.
Arthroplasty had a lower re-operation rate and
total cost in comparison with fixation.
No definite differences for hospital stay, mortality,
degree of residual pain, regain of mobility or
regain of same residential state were found
Hip and other composite scores :
ORIF v.s Hemiarthroplasty No difference
ORIF v.s THR Better in the THR group

Abstract 1

Conclusions:
Internal fixation is associated with less
initial operative trauma but has an increased
risk of re-operation on the hip
Definite conclusions cannot be made for
differences in pain and residual disability
between the two groups.
The attending physician should choose the
method which they feel is most appropriate
for each individual patient.

Abstract 2

Internal fixation compared with

arthroplasty for displaced fractures of the
femoral neck: a meta-analysis (Structured
abstract)
Centre for Reviews and Dissemination
University of York, York, U.K.
This version 1st published online:

Journal of Bone and Joint Surgery. American volume,

2003;85-A(9):1673-1681.

Abstract 2

Outcomes assessment :
Mortality, revision surgery, pain, function,
complications (wound infection, hip
dislocation, nonunion, avascular necrosis and
post-operative confusion), blood loss and
surgical time taken

Abstract 2

Search strategy: MEDLINE (1969 to June 2002);

Science Citation Index and the Cochrane Controlled
Trials Register; Four orthopaedic journals were
handsearched (1998 to June 2002); bibliographies of
two orthopaedic textbooks, and poster presentations
of three orthopaedic societies (1996 to 2002).
Selection criteria: Randomised or quasi-randomised
trials study; Patients aged 65 years or older who had a
displaced femoral neck fracture

Abstract 2

Twelve studies and two abstracts were eligible for

inclusion (n=1,933)
Result :
Mortality No significant difference
Revision surgery Arthroplasty significantly
reduced the risk
Pain & function No significant difference
Infection Arthroplasty was significantly increased
Blood loss & surgical time Arthroplasty was
significantly increased

Abstract 2

Conclusions :
Arthroplasty significantly reduces the risk of
revision surgery at the cost of greater infection
rates, blood loss and operative time.

Abstract 3

Comparison of internal fixation

with total hip replacement for
displaced femoral neck fractures:
randomized, controlled trial
performed at four years
The Journal of Bone and Joint Surgery, American volume
Volume 87-A(8), August 2005, p 16801688

Abstract 3

Methods : 102 patients (mean age, eighty years) were

randomly allocated to be treated with total hip
replacement or internal fixation.
Inclusion criteria : an age of at least seventy years,
absence of severe cognitive dysfunction, an
independent living status, and the ability to walk
independently.
The main outcome measurements were hip
complications, reoperations, hip function, and healthrelated quality of life.
Forty-eight-month follow-up evaluation

Abstract 3
Results:
THA : ORIF at the forty-eight-month follow -up evaluation
Mortality rate 25% in both groups. No significant
difference
Rate of hip complications 4% : 42% (p < 0.001)
Reoperation rates 4% and 47%, respectively (p <
0.001)
The arthroplasty group had no additional hip
complications or reoperations between the 24 ~48 month
follow-up visits. In the fixation group, the percentage of
hip complications increased from 36% to 42% and the
percentage of reoperations increased from 42% to 47%
during the same period.

Abstract 3

The hip function was significantly better and

the decline in health-related quality of life was
less pronounced in the arthroplasty group than
it was in the fixation group at the 4, 12, and 24month follow-up evaluations.

97% of the patients in the arthroplasty group

and 57% of the patients in the fixation group
who were available for follow-up at forty-eight
months had no hip complications (p < 0.001).

Abstract 3

Conclusions:
Compared with internal fixation, primary total
hip replacement provides a better outcome for
mentally competent elderly patients with a
displaced femoral neck fracture.
The complication and reoperation rates were
significantly lower and hip function and
health-related quality of life were at least as
good at four years after the surgery.

Applicability

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