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Operative Management of Displaced Femoral Neck Fractures in Elderly Patients: An International Survey

The International Hip Fracture Research Collaborative; Bhandari, Mohit MD, MSc; Devereaux, P.J. MD; Tornetta, Paul III MD; Swiontkowski, Marc F. MD; Berry, Daniel J. MD; Haidukewych, George MD; Schemitsch, Emil H. MD; Hanson, Beate P. MD; Koval, Kenneth MD; Dirschl, Douglas MD; Leece, Pamela BSc; Keel, Marius MD; Petrisor, Brad MD; Heetveld, Martin MD; Guyatt, Gordon H. MD, MSc

Journal of Bone & Joint Surgery - American Volume: September 2005 - Volume 87 - Issue 9 - p 2122–2130
doi: 10.2106/JBJS.E.00535
The Orthopaedic Forum

Background: Hip fractures occur in 280,000 North Americans each year. Although surgeons have reached consensus with regard to the treatment of undisplaced fractures of the hip, the surgical treatment of displaced fractures remains controversial. Identifying surgeons' preferences in techniques, and the rationale for their choices, may aid in focusing educational activities to the orthopaedic community as well as planning future clinical trials. Our objective was to clarify current opinion with regard to the operative treatment of displaced fractures of the femoral neck.

Methods: We used a cross-sectional survey design and a sample-to-redundancy strategy to examine surgeons' preferences in the treatment of displaced femoral neck fractures. We mailed this survey to members of the Orthopaedic Trauma Association and European-AO International-affiliated trauma centers.

Results: Of 442 surgeons who received the questionnaire, 298 (67%) responded. The typical respondent was a North American man over the age of forty years who was in academic practice, supervised residents, had fellowship training in trauma, and worked in a low-volume center (<100 hip fractures per year), treating an equal proportion of displaced and undisplaced femoral neck fractures. Most surgeons believed that internal fixation was the procedure of choice in younger patients (those who are less than sixty years old) with a displaced fracture (Garden type III or IV). For patients over eighty years old with Garden type-III or IV fractures, almost all surgeons preferred arthroplasty. Respondents varied widely in their preferences for the treatment of patients who were sixty to eighty years old with a displaced fracture (Garden type III or IV) or active patients with a Garden type-III fracture. Many surgeons believed there was no difference between arthroplasty and internal fixation when considering mortality (45%), infection rates (30%), and quality of life (37%). Surgeons also revealed variable preferences in their choice of the optimal approach to arthroplasty for patients between sixty and eighty years old with a type-IV fracture (32% preferred unipolar; 41%, bipolar; and 17%, total hip arthroplasty) and in the optimal choice of implant for internal fixation.

Conclusions: While surgeons prefer internal fixation for younger patients and arthroplasty for older patients, they disagree about the optimal approach to the management of patients between sixty and eighty years old with a displaced fracture and active patients with a Garden type-III fracture. Surgeons also disagree on the optimal implants for internal fixation or arthroplasty.

1 Departments of Surgery and Clinical Epidemiology and Biostatistics, Hamilton Health Sciences-General Hospital, 237 Barton Street East, 7 North, Suite 727, Hamilton, ON L8L 2X2, Canada. E-mail address for M. Bhandari: bhandam@mcmaster.ca

2 Department of Orthopaedic Surgery, Boston Medical Center, 818 Harrison Avenue, Dowling 2 North, Boston, MA 02118-2393

3 Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, Minneapolis, MN 55454

4 Mayo Clinic, 200 First Street S.W., Rochester, MN 55905

5 Florida Orthopaedic Institute, 13020 North Telecom Parkway, Temple Terrace, FL 33637

6 St. Michael's Hospital, 55 Queen Street East, #800, Toronto, ON M5C 1R6, Canada

7 MPH AO Clinical Investigation and Doc, Clavadelerstrasse, 7270 Davos Platz, Switzerland

8 Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756

9 Department of Orthopaedics, University of North Carolina at Chapel Hill, 3147 Bioinformatics, CB #7055, Chapel Hill, NC 27599-7055

10 Division of Trauma Surgery, University of Zurich Hospital, Sternwartstrasse 14, 8091 Zurich, Switzerland

11 Department of General Surgery—Trauma, Erasmus Medical Center, P.O. Box 2040, 300 CA Rotterdam, The Netherlands

Copyright 2005 by The Journal of Bone and Joint Surgery, Incorporated
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