For many years the displaced intracapsular fracture has been termed the ‘unsolved fracture’, because of this continuing controversy between internal fixation and arthroplasty.1-3 The reason for this was that both treatments appeared acceptable and to produce similar outcomes. However in this era of evidence based medicine the patient rightly expects more. It is not good enough to provide treatment that appears to be acceptable, the patients want and should be given the best treatment. So which is best internal fixation or arthroplasty?
The only way to resolve the issue is with good quality randomised controlled trials. The key aspects of such a study should include:
1. Sufficient patient numbers.
2. Blinded allocation of patients.
3. Surgeons’ experience at both surgical procedures.
4. Results analysed on an intention to treat basis, such that once the patient is randomised they stay within the group to which they were allocated.
5. Blinded assessment of outcome.
6. Adequate follow-up.
7. Clear and full presentation of outcomes.
8. Minimal loss of patients to follow-up.
This multi-centre Swedish study fulfils all these criteria apart from number 5. The essential results of this study are:
1. Internal fixation leads to a 50% fixation failure rate requiring re-operation compared to that of approximately 10% after arthroplasty.
2. Dislocation is the main complication after arthroplasty.
3. Revisions procedures after two years are rare, regardless of the type of treatment used.
4. Both arthroplasty and internal fixation produce similar functional outcomes but there is a slight tendency towards better results after arthroplasty.
These findings have been confirmed in other recent studies and summarised in the Cochrane review on this subject.4 Therefore it now seems clear that for the majority of patients with a displaced intracapsular fracture the most appropriate method of treatment is a replacement arthroplasty. The arthroplasty should probably be cemented in place and total hip replacement may give better results that hemiarthroplasty, although further trials are needed to confirm this. 4
One should not, however, forget that there is still a place for internal fixation of an intracapsular fracture in the following situations:
1. Undisplaced and minimally displaced fractures
2. Intracapsular fractures in the younger patient in which the patient’s life expectancy exceeds that of an arthroplasty. Younger patients and male patients also have a lower risk of fracture healing complications.
3. Those in which there is a specific contraindication or increased risk from arthroplasty, such as pre-existing sepsis.
4. The very frail who may not be able to tolerate the more extensive surgical procedure of replacement arthroplasty
So perhaps now the unsolved fracture has been ‘solved’, at least for the majority of such cases. But as is often the case, as one controversy is resolved, other questions are raised such as how young is a young patient for fixation and how displaced should a fracture be before arthroplasty is chosen.
1. Dickson JA. The unsolved fracture: a protest against defeatism. J Bone Joint Surg [Am] 1953;35-A:805-21.
2. Nicoll EA. The unsolved fracture. J Bone Joint Surg [Br] 1963;45-B:239-41.
3. Speed K. The unsolved fracture. Surg Gynaecol Obstet 1935;60:341-52.
4. Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2010;6:CD001706.
Parker M, Consultant Orthopaedic Surgeon
Peterborough District Hospital, Peterborough