The growing number of femoral

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1 Displaced Femoral Neck Fractures in the Elderly: Hemiarthroplasty Versus Total Hip Arthroplasty William Macaulay, MD Michael R. Pagnotto, MD Richard Iorio, MD Michael A. Mont, MD Khaled J. Saleh, MD, Msc, FRCSC Abstract The incidence of femoral neck fracture among the elderly in the United States is expected to increase dramatically because of the anticipated explosion in the population aged 65 years and older, increased life expectancy, and the rising incidence of osteoporosis. The resulting public health implications may be significant, with annual hospital admissions resulting from hip fracture projected to increase to 700,000 by 2050, and with annual spending on hip fracture care expected to exceed $15 billion within a few years. The decision to perform internal fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA must be based on patient mental status, living arrangement, level of independence and activity, and bone and joint quality. Dr. Macaulay is Director, Center of Hip and Knee Replacement, and Associate Professor of Orthopaedic Surgery, Columbia University, New York, NY. Dr. Pagnotto is Resident, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. Dr. Iorio is Senior Attending Orthopaedic Surgeon, Lahey Clinic, Burlington, MA. Dr. Mont is Director, Center for Joint Preservation and Reconstruction, Rubin Institute for Advanced Orthopaedics, Sinai Hospital of Baltimore, Baltimore, MD. Dr. Saleh is Associate Professor, Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA. Reprint requests: Dr. Macaulay, Department of Orthopaedic Surgery, Columbia University, PH-1155, 622 W 168th Street, New York, NY J Am Acad Orthop Surg 2006;14: Copyright 2006 by the American Academy of Orthopaedic Surgeons. The growing number of femoral neck fractures in the United States population will have significant public health implications during the first half of the 21st century. 1 In 1994, the age-adjusted incidence was 63.3 per 100,000 person-years in women and 27.7 in men. 1 According to the American Academy of Orthopaedic Surgeons, each year 350,000 hospital admissions are the result of hip fractures; that number is expected to double by the year This dramatic rise in hip fractures may reach significant proportions in coming decades because of the expected explosion in the number of the US residents aged 65 years and older, the gradual increase in average life span, and the rising incidence of osteoporosis. Annual health care spending for hip fractures in the US alone will soon eclipse $15 billion. 3 Worldwide, surgical treatment of femoral neck fractures needs to be as cost-effective as possible. The 1-year mortality rate in the elderly for hip fractures is as high as 36%; 4,5 of those who survive hip fractures, only one third return to their prefracture living environment. 6-8 Many surgeons believe that preserving the femoral head is the ideal treatment for displaced femoral neck fracture. However, because of the high incidence of osteonecrosis, malunion, and nonunion, attempts to preserve the femoral head in most centers in North America are now generally reserved for the physiologically younger patient with good bone quality, a preserved joint space, a reducible fracture, and a low degree of comminution. 9,10 A generally accepted algorithm for managing displaced femoral neck fractures is depicted in Figure 1. Of the more than 500,000 hip fractures projected annually in the coming years, as few as 2% to 3% will occur in patients younger than age 50 years. 11 For hundreds of thousands of patients each year, a decision about best treatment Volume 14, Number 5, May

2 Displaced Femoral Neck Fractures in the Elderly Figure 1 Young patient (<65 yrs) with good bone stock, low degree of comminution ORIF Displaced femoral neck fracture (Garden III-IV) must be made: what should the surgeon recommend when he or she chooses not to attempt to retain the femoral head? Internal Fixation Versus Arthroplasty The optimal surgical treatment of the elderly patient with a displaced femoral neck fracture remains controversial. Current options are reduction with internal fixation, hemiarthroplasty, or total hip arthroplasty (THA). Rogmark et al 12 recently published the results of a large multicenter prospective randomized study comparing internal fixation with arthroplasty in patients older than age Hemiarthroplasty Poor bone quality, high degree of comminution, age >65 years Arthroplasty Patient factors OA or RA Groin pain Total hip arthroplasty Treatment algorithm for displaced femoral neck fractures in the elderly. OA = osteoarthritis, ORIF = open reduction and internal fixation, RA = rheumatoid arthritis No Yes 70 years who had displaced femoral neck fracture. At 2-year follow-up, the failure rate was 43% in the internal fixation group versus 6% in the arthroplasty group. 12 In a meta-analysis examining the results of 14 prospective, randomized trials comparing internal fixation with arthroplasty, Bhandari et al 13 concluded that 17 conversion surgeries can be avoided for every 100 patients treated with arthroplasty rather than internal fixation. In a prospective randomized controlled trial comparing internal fixation with THA, Johansson et al 14 concluded that THA should be considered for a displaced femoral neck fracture in the elderly (age, 75 years or older) patient with normal mental function. Similarly, Keating et al 15 recently compared open reduction and internal fixation (ORIF) with hemiarthroplasty and THA. (They also compared ORIF with hemiarthroplasty alone.) Patients older than age 60 years with displaced femoral neck fractures were studied. At 2-year follow-up, a secondary surgery rate of 39% in the ORIF group was observed (compared with 5% and 9% in the hemiarthroplasty and THA groups, respectively). Additionally, the ORIF group had worse functional and quality of life outcome scores compared with the THA group at 24 months. Cost analysis also proved fixation to be significantly more expensive. Ultimately, the best arthroplasty treatment method (hemiarthroplasty vs THA) could not be concluded from this study (larger randomized clinical trials are needed), but investigators decisively determined that arthroplasty was superior to ORIF for displaced femoral neck fractures for the over-60 patient population. Once the decision is made to replace the femoral head, there are three treatment options: unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA. Each option has both proven and potential risks and benefits as well as evidence that supports treatment decisions. To determine the best management option, the surgeon should consider evidence-based decision-making, in addition to the cost effectiveness and economic impact of each option. Hemiarthroplasty Although by choosing hemiarthroplasty over internal fixation the surgeon effectively eliminates the risks of nonunion, malunion, and osteonecrosis, a new set of risks is in- None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Macaulay, Dr. Pagnotto, Dr. Iorio, and Dr. Mont. Dr. Saleh or the department with which he is affiliated has received research or institutional support from Smith & Nephew and Stryker. Dr. Saleh or the department with which he is affiliated has received royalties from Smith & Nephew. Dr. Saleh or the department with which he is affiliated serves as a consultant to or is an employee of Smith & Nephew and Stryker. 288 Journal of the American Academy of Orthopaedic Surgeons

3 William Macaulay, MD, et al troduced, such as those of increased infection, prosthetic hip dislocation, femoral stem loosening, and onset of buttock or groin pain caused by either acetabular protrusio or acetabular cartilage erosion (so-called prosthetic arthritis). Unipolar hemiarthroplasty has been used for managing femoral neck fractures for more than 50 years. In the short term (2 to 5 years postoperatively), patients treated with unipolar hemiarthroplasty do well, with low rates of infection and dislocation. With the appropriate use of polymethylmethacrylate cement for implant fixation, the most important mid- to long-term (5 to >20 years postoperatively) complication of unipolar prostheses is the high rate of acetabular cartilage erosion. This erosion often necessitates conversion to THA. In one study of 106 consecutive patients who underwent unipolar hemiarthroplasty, 37% of the 71 patients followed up at 2 years needed or had undergone THA; of those who were living independently, 55% required THA because of the development of pain. 16 Young age, high activity level, and length of followup are generally accepted as the most important factors leading to acetabular erosion. 17,18 D Arcy and Devas 19 reported that 26% of patients younger than age 70 years had evidence of acetabular erosion, compared with only 1.5% of patients older than age 80 years. Bipolar prostheses, consisting of a prosthesis-acetabular articulation and a femoral head polyethylene articulation, were introduced in the 1970s in an effort to avoid prosthetic arthritis. The prosthesis-prosthesis articulation theoretically decreases acetabular wear by shifting some hip movement away from the acetabulum to the internal prosthesisprosthesis articulation. Whether prosthesis-prosthesis motion is important is still unclear. Drinker and Murray 20 reported that young patients experienced only a minor amount of motion at the inner surface. However, Phillips 21 showed that of 76 patients with preexisting arthritis who received a Bateman bipolar prosthesis, 80% had motion primarily at the inner surface. Reports have been mixed regarding the efficacy of bipolar prostheses for managing displaced femoral neck fractures. Malhotra et al 22 suggested that bipolar hemiarthroplasty led to greater range of motion, less pain, andalowerrevisionratethandidunipolar hemiarthroplasty. In 2003, however, Raia et al 23 reported on 115 patients older than age 65 years randomized to either unipolar or bipolar hemiarthroplasty for a displaced femoral neck fracture. At 1-year follow-up, the authors found no statistically significant difference between the two groups, using quality of life and functional outcome measures. The authors concluded that bipolar endoprostheses provide no advantage in managing displaced femoral neck fractures in noninstitutionalized, cognitively or physically impaired patients older than age 65 years. 23 In an attempt to settle the debate regarding managing displaced femoral neck fractures with unipolar versus bipolar hemiarthroplasty, a 2004 Cochrane Review examined seven prospective randomized trials with a total of 857 subjects. 24 The authors of this review concluded that there was no significant difference between treatment with unipolar and bipolar hemiarthroplasty for dislocation, acetabular cartilage erosion, deep wound sepsis, reoperations, deep vein thrombosis, or mortality. The two primary limitations of these randomized trials were small sample size and short-term followup. The small sample sizes (48 to 250 patients, with four of the six studies enrolling <100 patients) decrease the power of the studies and makes it more difficult to statistically prove differences. The relatively short follow-up (approximately 2 years) also makes it difficult to identify differences because the foremost theoretical advantage of the bipolar prosthesis (ie, less acetabular wear) occurs during mid to late follow-up. With a >50% mortality rate within 5 years of the injury in patients older than age 70 years, 25 it is difficult to attain information to achieve adequate power in clinical studies. Based on the literature, there is no consensus either supporting or rejecting the use of bipolar rather than unipolar hemiarthroplasty. Because the most important factors leading to acetabular cartilage erosion are age, activity level, and length of follow-up, unipolar hemiarthroplasty is generally recommended in older patients who are less active and have a shorter life expectancy. 21,26 These patients would benefit least from the potential advantage of the more expensive bipolar prostheses. Considering the increased cost of bipolar prostheses, the potential consequences of polyethylene wear debris, and the increased chance of a dislocation requiring open reduction, some authors discourage the use of bipolar prostheses for managing displaced femoral neck fractures in the elderly. 20,27 Total Hip Arthroplasty THA is currently an accepted treatment option for the elderly patient with a displaced femoral neck fracture. 28 Historically, THA has been recommended only for patients with concurrent acetabular disease (eg, osteoarthritis, rheumatoid arthritis, Paget s disease). Previous studies have demonstrated that patients treated with THA for femoral neck fracture will dislocate at a higher rate than patients treated electively with THA for arthritis. 29 The increased dislocation rate has been attributed to increased range of motion in the fracture group. 30 When patients with a single, early (within 4 months after surgery) hip dislocation are excluded from dislocation statistics, unipolar hemiarthroplasty, bipolar hemiarthroplasty, and THA have similar Volume 14, Number 5, May

4 Displaced Femoral Neck Fractures in the Elderly long-term dislocation rates. 29 In addition, prospective data comparing hemiarthroplasty with THA indicate comparable rates of dislocation at 1 year postoperatively. 30 More recently, Abboud et al 31 retrospectively compared 30 consecutive patients treated with THA for femoral neck fractures with 30 patients treated with THA for degenerative joint disease. At a mean follow-up of 36 months (range, 26 to 52 months), the authors found no significant difference between the two groups in terms of perioperative morbidity, Harris Hip Score, strength during physical examination, or radiographic evidence of loosening. 31 The longevity of THA, especially in younger, more active patients, has been questioned. In a frequently cited study, Greenough and Jones 32 reviewed 37 patients (average age, 70 years or younger) with no evidence of acetabular disease who were treated with primary THA for subcapital femoral neck fracture. Of these 37 patients, 18 (49%) had undergone or were awaiting revision surgery at a mean follow-up of 56 months (range, 12 to 112 months). The authors recommended against primary THA for displaced femoral neck fracture in the younger patient without preexisting hip disease. Other retrospective studies have demonstrated far better results. Delamarter and Moreland 33 reported on 27 patients with acute femoral neck fracture treated with THA. At average follow-up of 3.8 years, the authors reported complication rates to be less than in their elective THA series. They reported no revision surgeries. Nineteen of the 27 patients had no pain; 4 more had only mild pain. 33 Taine and Armour 34 reported a series of 163 independently mobile patients older than age 65 years who were treated with THA for displaced femoral neck fracture. The reported revision rate was only 4% (7 of 163 hips). The authors of both studies concluded that THA is the best treatment option for active patients with a longer life expectancy. Lee et al 35 published the results of 126 consecutive patients treated with THA for acute femoral neck fracture. Patient mean age was 75 years (range, 39 to 89 years), with a median follow-up of 8.8 years. Ninety-nine percent of the patients living 1 year after surgery reported mild or no pain; 69% reported that they regained or improved their level of function compared with their preoperative status. However, of the 126 patients, 10% dislocated. The authors concluded that THA was associated with a higher rate of complications than is usually reported for hemiarthroplasty, although it provided good clinical results and was associated with high long-term prosthesis survival. The conclusions of Lee et al 35 highlight the crux of the debate between proponents of hemiarthroplasty versus THA as options for managing displaced femoral neck fracture. THA seems to offer a more lasting treatment with better functional outcomes but with a higher rate of complications, such as dislocation. Balancing the benefits of improved function (with fewer conversion surgeries) versus the cost of a higher number of perioperative complications remains challenging. Yetto-be-defined patient subpopulations may benefit from THA, whereas other groups may carry a higher risk of complications. Another variable, which is difficult to measure, is that the surgical technique used for THA after femoral neck fracture undoubtedly affects the likelihood of success. Surgical approach, recreation of appropriate hip biomechanics, application of large head-to-neck ratios, quality of capsular closure, and surgical experience are all variables that can affect dislocation risk in patients with femoral neck fracture treated with THA. The only scientifically rigorous way to compare these two treatment options is with larger, well-designed, prospective randomized clinical trials. Hemiarthroplasty Versus Total Hip Arthroplasty Ravikumar and Marsh 36 performed the most comprehensive study to date concerning management options for displaced femoral neck fracture. From 1984 to 1986, 271 patients older than age 65 years with Garden stage III and IV femoral neck fractures were randomized into one of three treatment groups: internal fixation, hemiarthroplasty, or THA. Patients with old fractures, pathologic fractures, or rheumatoid arthritis were excluded. After 1 year, 27% of the hemiarthroplasty patients reported persistent severe pain in the hip compared with none of the THA patients (0/89). This trend continued throughout follow-up. At 13 years, 45% of the nine remaining hemiarthroplasty patients reported pain severe enough to warrant analgesia, whereas only 6% of the remaining 17 THA patients reported a similar level of pain. Because they had a higher level of pain, the hemiarthroplasty group required further revisions. At 13 years, 24% of the initial 91 hemiarthroplasty patients had undergone revision surgery, mostly to THA, whereas only 6.8% of all THA patients required additional surgery. In the internal fixation group, outcomes were less than optimal for both level of pain and the need for additional surgery compared with the arthroplasty groups. The authors reported a 20% rate of dislocation for the THA patients (compared with 13% in the hemiarthroplasty group). Even with the high dislocation rate, Ravikumar and Marsh 36 concluded that THA is the optimal management option for displaced femoral neck fractures in active patients. Dorr et al 37 randomized 89 patients with displaced femoral neck fractures to one of three treatment groups: cementless hemiarthroplasty, cemented hemiarthroplasty, or THA. At 2-year follow-up, no differences 290 Journal of the American Academy of Orthopaedic Surgeons

5 William Macaulay, MD, et al were found in the level of pain, ambulation, or assistive devices between the THA and the cemented hemiarthroplasty groups. However, active community ambulators demonstrated decreased ambulatory endurance after cemented hemiarthroplasty. Additionally, patients treated with cementless hemiarthroplasty had both increased pain and decreased ambulatory capacity. An 18% THA dislocation rate (compared with 5% for hemiarthroplasty) was reported. However, five of the seven dislocations in the THA group (n = 39) were early (2 weeks to 3 months) and occurred during a noncompliant sit-to-stand maneuver. Skinner et al 30 randomized 278 patients older than age 65 years to receive internal fixation, Moore hemiarthroplasty, or a cemented Howse THA for a displaced femoral neck fracture. At 1 year, there was no statistically significant difference in either the mortality or rate of complications among the three groups. The THA group showed the greatest ambulatory capacity and least pain at 1 year, whereas the hemiarthroplasty group had the most pain and the least ambulatory capacity of the three options. The conversion rate was 13% in the hemiarthroplasty group versus a 4% revision rate in the THA group. The authors concluded that THA was an acceptable option for treating elderly patients with displaced femoral neck fractures. Rodriguez-Merchan 38 published preliminary results from a prospective trial comparing THA with hemiarthroplasty for managing displaced femoral neck fractures. Between 1993 and 1997, 46 patients with displaced femoral neck fractures were treated with either a cemented Thompson hemiarthroplasty or a cemented Charnley THA. All patients were 65 to 75 years of age, had no preexisting acetabular disease, and were ambulatory before injury. At an average follow-up of 5 years, 61% of the hemiarthroplasty group reported good results, using Table 1 Rogmark Preoperative Scoring System for Patients With Femoral Neck Fractures Patient Variables Points* Age (years) 70 to 80 5 >80 2 Habitat Own home 5 Sheltered home 2 Walking aids One cane or none 5 Canes, walking frame 2 Mental status Alert 5 Slight confusion 2 * A total score 15 points indicates treatment required with total hip arthroplasty. Adapted with permission from Rogmark C, Carlsson A, Johnell O, Sernbo I: A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur: Functional outcomes for 450 patients at two years. J Bone Joint Surg Br 2002;84: the Harris Hip Score, versus 83% of the THA group. The hemiarthroplasty group had an overall higher rate of complications: 3 of 23 were converted to THA and 2 of 23 dislocated. No patients in the THA group dislocated or were revised. In their multicenter prospective randomized study comparing internal fixation with arthroplasty, Rogmark et al 12 assigned treatment within the arthroplasty group to either hemiarthroplasty or THA, based on the scoring system shown in Table 1. Patients receiving a total score 15 were treated with THA. The scoring system favored THA in younger (aged 70 to 80 years), alert, more independent, ambulatory patients. No significant difference in complication rates between hemiarthroplasty and THA groups was identified, and an overall dislocation rate of 8% for all arthroplasty patients was reported. The authors Table 2 Cumulative 2-Year Costs* Following Femoral Neck Fracture Procedure concluded that the lower dislocation rate and good functional outcomes demonstrated that the point scoring system was useful for choosing between treatment options. Cost Iorio et al 39 reviewed the use of reduction with internal fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty, and THA for managing displaced femoral neck fractures in the elderly. They did a costeffectiveness analysis during a 2-year postoperative period. Taking into account complication rates, mortality, revision rates, and function, they concluded that THA was more costeffective than internal fixation, unipolar hemiarthroplasty, and bipolar hemiarthroplasty (Table 2). Summary Cost Internal fixation $24,606 Unipolar $21,597 hemiarthroplasty Bipolar $22,043 hemiarthroplasty Hybrid total hip $21,066 arthroplasty Cemented total hip $20,670 arthroplasty * Includes hospital, rehabilitation, and probability-adjusted revision costs Reproduced with permission from Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ: Displaced femoral neck fractures in the elderly: Outcomes and cost effectiveness. Clin Orthop Relat Res 2001;383: Strong evidence indicates that primary arthroplasty is superior to internal fixation for treating the elderly patient with a displaced femoral neck fracture. However, there is no consensus regarding a besttreatment prosthetic option when the surgeon chooses to replace the Volume 14, Number 5, May

6 Displaced Femoral Neck Fractures in the Elderly femoral head. Compared with hemiarthroplasty, THA appears to offer a more durable result with better functional outcomes but with an increased risk of complications, such as dislocation. Finding a balance between the benefits of improved function (with fewer conversion surgeries) and the cost of a higher number of perioperative complications remains challenging. Yet-to-be-defined patient subpopulations may benefit from THA after femoral neck fractures, whereas other groups are likely to do better with hemiarthroplasty. Nonambulatory patients and those with very poor mental status are best treated with hemiarthroplasty. THA is indicated for the patient with severe concurrent acetabular disease, such as osteoarthritis or rheumatoid arthritis. For most patients with displaced femoral neck fracture who do not meet the aforementioned criteria, the decision between hemiarthroplasty and THA remains controversial. The surgeon may take into account the patient s mental status, living arrangement (ie, home versus care facility), levels of independence and activity, and bone and joint quality when choosing between hemiarthroplasty and THA. THA likely offers some patients more predictable pain relief and more consistent return to prefracture level of ambulation than does hemiarthroplasty. Younger, more active patients may benefit more from THA than older, less active patients. Acknowledgment We gratefully acknowledge the ongoing, invaluable contributions of the Displaced Femoral (neck fracture) Arthroplasty Consortium for Treatment and Outcomes (DFACTO) Consortium. The consortium members thoughtful comments and ideas have not only led to the completion of this work but also greatly influenced the initiation and continuation of the DFACTO prospective, multicenter, randomized clinical trial comparing total hip arthroplasty with hemiarthroplasty. The DFACTO Consortium consists of the following members: Brian S. Parsley, Catherine A. Compito, Justin Greisberg, Howard A. Kiernan,WilliamB.Macaulay,Christopher B. Michelson, Ohannes A. Nercessian, Melvin P. Rosenwasser, William L. Healy, Richard Iorio, Bernard A. Pfeifer, Anthony H. Presutti, Lawrence M. Specht, Michael S. Thompson, John F. Tilzey, Michael P. Clare, Edward V. Fehringer, Kevin L. Garvin, Matthew A. Mormino, James R. Neff, Erik T. Otterberg, Todd Sekundiak, Julian S. Arroyo, Dale L. Hirz, Steven M. Teeny, Alan B. Thomas, John B. Sledge III, Robert M. Wood, William Dowling, Robert Goldman, Paul M. Lombardi, Michael D. Ries, Kevin J. Bozic, Jonathon P. Garino, Craig L. Israelite, David G. Nazarian, and Charles L. Nelson. Finally, the authors would also like to acknowledge the support of Richard S. Yoon, whose assistance was integral in the completion of this manuscript. 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7 William Macaulay, MD, et al 16. Kofoed H, Kofod J: Moore prothesis in the treatment of fresh femoral neck fractures: A critical review with special attention to secondary acetabular degeneration. Injury 1983;14: Phillips TW: Thompson hemiarthroplasty and acetabular erosion. J Bone Joint Surg Am 1989;71: Warwick D, Hubble M, Sarris I, Strange J: Revision of failed hemiarthroplasty for fractures at the hip. Int Orthop 1998;22: D Arcy J, Devas M: Treatment of fractures of the femoral neck by replacement with the Thompson prosthesis. J Bone Joint Surg Br 1976;58: Drinker H, Murray WR: The universal proximal femoral endoprosthesis: A short-term comparison with conventional hemiarthroplasty. J Bone Joint Surg Am 1979;61: Phillips TW: The Bateman bipolar femoral head replacement: A fluoroscopic study of movement over a fouryear period. J Bone Joint Surg Br 1987;69: Malhotra R, Arya R, Bhan S: Bipolar hemiarthroplasty in femoral neck fractures. Arch Orthop Trauma Surg 1995;114: Raia FJ, Chapman CB, Herrera M, Schweppe MW, Michelsen CB, Rosenwasser MP: Unipolar or bipolar hemiarthroplasty for femoral neck fractures in the elderly? Clin Orthop Relat Res 2003;414: Parker MJ, Gurusamy K: Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2004;2:CD Nilsson LT, Strömquist B, Thorngren KG: Nailing of femoral neck fracture: Clinical and sociologic 5-year followup of 510 consecutive hips. Acta Orthop Scand 1988;59: Baumgaertner MR, Higgins TF: Femoral neck fractures, in Heckman JD, Bucholz RW: Rockwood and Green s Fractures in Adults, ed 5. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp Giliberty RP: Hemiarthroplasty of the hip using a low-friction bipolar endoprosthesis. Clin Orthop Relat Res 1983;175: Healy WL, Iorio R: Total hip arthroplasty: Optimal treatment for displaced femoral neck fractures in elderly patients. Clin Orthop Relat Res 2004;429: Papandrea RF, Froimson MI: Total hip arthroplasty after acute displaced femoral neck fractures. Am J Orthop 1996;25: Skinner P, Riley D, Ellery J, Beaumont A, Coumine R, Shafighian B: Displaced subcapital fractures of the femur: A prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement. Injury 1989; 20: Abboud JA, Patel RV, Booth RE Jr, Nazarian DG: Outcomes of total hip arthroplasty are similar for patients with displaced femoral neck fractures and osteoarthritis. Clin Orthop Relat Res 2004;421: Greenough CG, Jones JR: Primary total hip replacement for displaced subcapital fracture of the femur. J Bone Joint Surg Br 1988;70: Delamarter R, Moreland JR: Treatment of acute femoral neck fractures with total hip arthroplasty. Clin Orthop Relat Res 1987;218: Taine WH, Armour PC: Primary total hip replacement for displaced subcapital fractures of the femur. J Bone Joint Surg Br 1985;67: Lee BP, Berry DJ, Harmsen WS, Sim FH: Total hip arthroplasty for the treatment of an acute fracture of the femoral neck: Long-term results. J Bone Joint Surg Am 1998;80: Ravikumar KJ, Marsh G: Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur 13 year results of a prospective randomized study. Injury 2000;31: Dorr LD, Glousman R, Hoy AL, Vanis R, Chandler R: Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty. J Arthroplasty 1986;1: Rodriguez-Merchan EC: Displaced intracapsular hip fractures: Hemiarthroplasty or total arthroplasty? Clin Orthop Relat Res 2002;399: Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ: Displaced femoral neck fractures in the elderly: Outcomes and cost effectiveness. Clin Orthop Relat Res 2001; 383: Volume 14, Number 5, May