The different strategies in treating displaced femoral neck fractures: mid-term surgical outcome in a register-based cohort of 1,283 patients aged 60-69 years.

BACKGROUND AND PURPOSE: In patients around retirement age controversy exists as to whether to treat displaced femoral neck fracture (dFNF) with internal fixation (IF) or arthroplasty. An arthroplasty in this age group may need revision due to a long expected remaining lifetime. IF carries a higher risk of early failure but a maintained native hip if healing occurs. We aimed to determine the cumulative 5-year rate of conversion to arthroplasty after IF and implant revision after primary total hip arthroplasty (THA), respectively. PATIENTS AND METHODS: In this longitudinal cohort study, patients aged 60-69 years registered with a dFNF in the Swedish Fracture Register (SFR) 2012-2018 were cross-referenced with available data from the Swedish Arthroplasty Register (SAR) until December 31, 2019. Conversion to arthroplasty or revision were analyzed utilizing competing risk, with death as competing event. RESULTS: At 5 years, the cumulative rate of conversion to arthroplasty after IF was 31% (95% confidence interval [CI] 26-37). For primary THA, the 5-year rate of revision was 4.0% (CI 2.8-5.8). The 5-year mortality did not differ, being 20% (CI 16-27) and 23% (CI 20-28) after IF and THA, respectively. Regression analyses did not identify any risk factors for conversion arthroplasty based on the variables in the register. CONCLUSION: A follow-up of 5 years catches most reoperations after IF, resulting in a 31% conversion rate. The 4% revision rate at 5 years after primary THA should be seen as an intermediate result, as late complications may occur.

Rate of conversion to secondary arthroplasty after femoral neck fractures in 796 younger patients treated with internal fixation: a Swedish national register-based study.

BACKGROUND AND PURPOSE: In younger patients with a femoral neck fracture (FNF), internal fixation is the recommended treatment regardless of displacement. Healing complications are often treated with arthroplasty. We determined the rate of conversion to arthroplasty up to 5 years after fixation of either undisplaced FNFs (uFNFs) or displaced FNFs (dFNFs). PATIENTS AND METHODS: The study was based on prospectively collected data from the Swedish Fracture Register (SFR) and the Swedish Arthroplasty Register (SAR). FNFs in patients aged < 60 treated with parallel pins/screws or sliding hip screws (SHS) registered in SFR 2012-2018 were cross-referenced with conversions to arthroplasty registered in SAR until 2019. The cumulative conversion and mortality rates were determined by Kaplan-Meier analyses and patient- and surgery-dependent risk factors for conversion by Cox regression analyses. RESULTS: We included 407 uFNFs and 389 dFNFs (median age 52, 59% men). The 1-year conversion rate was 3% (95% CI 1-5) for uFNFs and 9% (CI 6-12) for dFNFs. Corresponding results at 5 years were 8% (CI 5-11) and 25% (CI 20-30). Besides a displaced fracture, age 50-59 was associated with an increased rate of conversion in uFNFs. This older group also had a higher mortality rate, compared with patients aged < 50. There was no sex difference for mortality. INTERPRETATION: Adults aged under 60 with uFNFs and dFNFs face an 8-25% risk, respectively, of conversion to arthroplasty within 5 years after internal fixation. This is new and pertinent information for surgeons as well as patients.

Conversion to Arthroplasty After Internal Fixation of Nondisplaced Femoral Neck Fractures: Results from a Swedish Register Cohort of 5,428 Individuals 60 Years of Age or Older.

BACKGROUND: Although most nondisplaced or minimally displaced femoral neck fractures are routinely treated with internal fixation, high rates of secondary surgical procedures are common, especially in the elderly population. Primary arthroplasty in elderly patients has been proposed as an alternative treatment to reduce the need for a secondary surgical procedure. The objective of this study was to describe the rate of conversion to arthroplasty within 5 years after internal fixation of nondisplaced femoral neck fractures in patients ≥60 years of age. METHODS: In this observational cohort study of prospectively collected data from the Swedish Fracture Register (SFR) between 2012 and 2018, cross-matched with the Swedish Arthroplasty Register (SAR), 5,428 nondisplaced femoral neck fractures in patients ≥60 years of age were included. Competing risk analysis was used to estimate conversion rates to arthroplasty and mortality in various age groups at 1, 2, and 5 years. RESULTS: The cumulative incidence function (CIF) for conversion to arthroplasty was 6.3% at 1 year, 8.1% at 2 years, and 10.1% at 5 years. The conversion rates within 2 years were 6.5% in 60 to 69-year-olds, 9.6% in 70 to 79-year-olds, and 7.8% in ≥80-year-olds. Women had a higher risk of conversion; the hazard ratio (HR) was 1.49 (95% confidence interval [CI], 1.19 to 1.87). The cumulative mortality was 21.3% (95% CI, 20.3% to 22.5%) at 1 year, 31.3% (95% CI, 30.0% to 32.6%) at 2 years, and 54.9% (95% CI, 53.1% to 56.7%) at 5 years. Mortality was higher in men at all time points, and the adjusted 1-year HR was 1.79 (95% CI, 1.61 to 2.00). CONCLUSIONS: One in 10 patients ≥60 years of age treated with internal fixation for a nondisplaced femoral neck fracture underwent conversion to arthroplasty within 5 years, and more than one-half of the conversions occurred within the first year. The risk of conversion was highest in women and in patients 70 to 79 years of age. These data warrant further studies in this frail patient group to identify subgroups of patients who would benefit from primary arthroplasty for nondisplaced femoral neck fractures. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

No Difference in Conversion Rate to Hip Arthroplasty After Intramedullary Nail or Sliding Hip Screw for Extracapsular Hip Fractures: An Observational Cohort Study of 19,604 Individuals.

BACKGROUND: The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures. METHODS: In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years. RESULTS: We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants. CONCLUSIONS: Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Displaced femoral neck fractures in patients 60-69 years old - treatment and patient reported outcomes in a register cohort.

BACKGROUND: Several randomized studies have compared arthroplasty and internal fixation (IF) and found better patient reported outcome measure (PROM) and fewer reoperations for arthroplasty. But consensus is lacking regarding which method to use in the "young elderly" patients aged 60-69; IF tend to fail in up to 1/3 of the cases but can offer the benefits of a biologically intact hip if successful. To add to this, revision of failed IF with secondary arthroplasty has increased risk for complications. This register study aims to describe current treatment and mortality rates for displaced hip fractures based on register data, with focus on young elderly. A secondary aim is to compare changes in PROM between treatments. METHODS: Data was retrieved from the Swedish Fracture Register, SFR. We found 9,564 femoral neck fractures classified as displaced (AO/OTA 31-B3) in patients 60 years or older. 883 patients were aged 60-69 years. In the final analysis of treatment allocation and PROM mean differences, 723 of these met the inclusion criteria. We adjusted for age, sex and baseline PROM, in patients treated with either IF or total hip arthroplasty (THA) in a regression model. RESULTS: In the 60-69 years group, THA was used in 512 (58%), IF 211 (24%) and hemi arthroplasty (HA) 160 (18%) of the patients. As HA patients differed from those selected to THA and IF in regards to baseline characteristics and response rates, we omitted them from the PROM-analysis. When comparing only THA and IF we found no significant differences in mortality nor PROM means one year after injury. Treatment with THA was more common in women. CONCLUSIONS: In young elderly patients THA is a common treatment for displaced FNF in Sweden. Patients in this segment treated with HA differ from patients treated with THA and IF, with baseline results in PROM indicating poorer health and function, as well as higher mortality and lower response rates. We found no differences in crude mortality between IF and THA treatment, and no significant influence from treatment on PROM outcome comparing THA and IF.