Medicine
Femoral Neck Fracture Fixation Versus Arthroplasty in Elderly Patients
Quick fact
In displaced femoral neck fractures, total hip arthroplasty halves the reoperation rate compared to internal fixation, but about 4% of arthroplasties require revision within 10 years, and 6% dislocate.
Why this is interesting
You've just fallen and broken your hip at age 80. The surgeon offers you two very different operations, but why does there even need to be a choice?
Read the full explanation
Understanding Femoral Neck Fracture Fixation Versus Arthroplasty in Elderly Patients
Imagine a crack in the neck of the femur—the bridge between the ball of the hip joint and the shaft of the thigh bone. When this crack is displaced, the blood supply to the ball may be torn, and that ball can die. In an elderly patient, two main surgical strategies exist: internal fixation (screws or pins) aims to hold the bone together so it heals naturally, while arthroplasty removes the damaged ball and replaces it with a metal or ceramic one, essentially rebuilding the joint. Which one is better isn't straightforward—it depends on how much the fracture is displaced, the patient's age and activity level, and the quality of the bone. Fixation preserves the native hip but carries a high risk of the bone not healing or the joint dying (avascular necrosis). Arthroplasty removes that risk but is a bigger operation and may later fail by dislocation or loosening.
A deeper explanation
The core issue is blood supply. The femoral head receives most of its blood from vessels entering at the fracture site; a displaced fracture can cut off this supply, leading to avascular necrosis and collapse. Internal fixation relies on healing, which requires intact blood supply and good bone quality—both often poor in the elderly. If the bone can't heal, fixation fails, and the patient needs a second operation. Arthroplasty bypasses healing entirely by removing the femoral head, but it introduces new risks: surgical dislocation, infection, and loosening over time. Evidence from randomized trials shows that for displaced fractures in active, older adults, arthroplasty—especially total hip arthroplasty—produces better functional outcomes and lower reoperation rates than fixation. However, for undisplaced fractures, where the blood supply is usually preserved, fixation remains a good option with lower surgical risk. The decision reflects a trade-off: preserve the hip but risk failure, or replace the hip but risk surgical complications.