To Fix or Replace: Options for Femoral Neck Fractures

Why It Matters

The choice between fixation and arthroplasty directly influences surgical success, recovery speed, and long‑term healthcare costs for a growing elderly demographic.

Key Takeaways

• 300k US hip fractures yearly; half are femoral neck
• Fixation failure ~30% in older displaced fractures
• Arthroplasty offers faster mobilization, lower re‑operation risk
• Choice hinges on displacement, bone quality, activity level
• FASTER HIP trial comparing fixation vs arthroplasty

Pulse Analysis

The demographic shift toward an older population is inflating the burden of femoral neck fractures, a subset that now accounts for roughly 150,000 cases each year in the United States. These injuries are not only common but also costly, as they frequently require hospitalization, surgery, and extensive rehabilitation. With bone density declining and fall risk rising, clinicians are under pressure to adopt treatment pathways that minimize complications while preserving function, making the fixation‑versus‑replacement debate a focal point of orthopedic care.

Clinical decision‑making has evolved beyond simple age thresholds. Surgeons assess radiographic features—such as displacement, comminution, and posterior neck involvement—alongside patient‑specific factors like bone quality, pre‑injury activity level, and overall health status. Internal fixation, once the default for many fractures, now shows a re‑operation rate near 30 % in older adults, largely due to non‑union, avascular necrosis, and hardware failure. By contrast, hemiarthroplasty or total hip arthroplasty can provide more reliable early weight‑bearing, especially in displaced or comminuted fractures, though they introduce concerns about infection, dislocation, and long‑term wear.

Research is catching up with practice. The multi‑center FASTER HIP trial, funded by PCORI, is enrolling 600 patients aged 60 and above with minimally displaced femoral neck fractures to directly compare arthroplasty and internal fixation on mortality, ambulation, and days spent at home. Early results could reshape guidelines, offering evidence‑based clarity on when to bypass fixation in favor of replacement. Meanwhile, the orthopedic community continues to emphasize rapid postoperative mobilization, recognizing that getting patients upright and moving within hours—not days—significantly improves outcomes and reduces hospital stays.