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ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis

Swart, Eric MD; Roulette, Paulvalery MD; Leas, Daniel MD; Bozic, Kevin J. MD, MBA; Karunakar, Madhav MD

Journal of Bone & Joint Surgery - American Volume: 4 January 2017 - Volume 99 - Issue 1 - p 65–75
doi: 10.2106/JBJS.16.00406
Scientific Articles
Supplementary Content

Background: The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ≤65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario.

Methods: A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis.

Results: THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs.

Conclusions: Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group.

Level of Evidence: Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

1Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts

2Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina

3Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas

E-mail address for E. Swart:

Copyright 2017 by The Journal of Bone and Joint Surgery, Incorporated
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