Optimal arthroplasty for femoral neck fractures: is total hip arthroplasty the answer?

Although there is little doubt that arthroplasty of one form or another is appropriate treatment for many patients with a displaced femoral neck fracture, there is ongoing controversy about the relative merits of different types of arthroplasty among specific groups of patients. In particular, total hip arthroplasty is infrequently recommended because of concerns about the perceived high initial cost, increased risk of dislocation, and the anticipated low functional demands and life expectancy of the typical hip fracture patient. When viewed in this traditional context, the merits of total hip arthroplasty are not believed to outweigh the risks, except in the rare instance of a patient with preexisting symptomatic hip arthritis that sustains a hip fracture.Accumulating evidence suggests that a reevaluation of the role of total hip arthroplasty (THA) in patients with hip fracture is warranted. Recent comparative follow-up studies have documented superior and more durable function in a subset of patients with displaced femoral neck fractures after total hip replacement when compared to hemiarthroplasty or uncomplicated osteosynthesis. Economic analyses have suggested that the long-term cost of treatment favors total hip replacement because of the additional cost of treating failures of internal fixation and hemiarthroplasty in patients who survive 2 years or longer after their initial hip fracture. Finally, recent advances in the design of THA components such as the introduction of improved bearing surfaces allowing the use of larger femoral heads, combined with improved surgical techniques, may be making THA safer and less prone to dislocation and other mechanical complications.The purpose of this paper is to review the recent literature regarding the results of total hip replacement in patients with a displaced fracture of the femoral neck. Total hip replacement may have a larger role in the treatment of displaced femoral neck fractures than it has in the past.