Association of treatment method with mortality and functional outcome in patients with displaced femoral neck fracture: a cohort study of 60–69-year-old patients from the Swedish Hip Fracture Register
DOI:
https://doi.org/10.2340/17453674.2026.46368Keywords:
Arthroplasty, Fractures, HipAbstract
Background and purpose: Optimal treatment for displaced femoral neck fractures (FNF) in patients aged 60–69 years remains controversial. We aimed to compare mortality and short-term clinical outcomes after total hip arthroplasty (THA), hemiarthroplasty (HA), or internal fixation (IF) after displaced FNF.
Methods: We included 3,325 patients aged 60–69 years with displaced FNF recorded in the Swedish Hip Fracture Register. 1-year mortality and 4-month functional outcomes (maintenance of independent living and outdoor walking ability) were analyzed. Analyses were stratified by American Society of Anesthesiologists (ASA) class (I–II vs III–IV).
Results: Overall, 1-year mortality was 8.3%. Adjusted analyses showed higher 1-year mortality after HA (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.7–3.6) and IF (OR 2.3, CI 1.6–3.3) compared with THA. Survival analyses demonstrated lower survival probabilities after HA and IF compared with THA in ASA III–IV but not in ASA I–II patients. THA was associated with higher odds of maintaining independent living (IF: OR 0.40, CI 0.20–0.86; HA: OR 0.09, CI 0.04–0.17) and maintaining outdoor walking ability (IF: OR 0.35, CI 0.24–0.50; HA: OR 0.26, CI 0.16–0.43) in ASA I–II patients. In ASA III–IV patients, estimates were closer to unity.
Conclusion: THA was associated with lower mortality in ASA III–IV and better functional outcomes in ASA I–II.
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Blomfeldt R, Törnkvist H, Ponzer S, Söderqvist A, Tidermark J. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures: randomized, controlled trial performed at four years. J Bone Joint Surg Am 2005; 87(8): 1680-8. doi: 10.2106/JBJS.D.02655. DOI: https://doi.org/10.2106/00004623-200508000-00003
Leonardsson O, Sernbo I, Carlsson A, Åkesson K, Rogmark C. Long-term follow-up of replacement compared with internal fixation for displaced femoral neck fractures: results at ten years in a randomised study of 450 patients. J Bone Joint Surg Br 2010; 92(3): 406-12. doi: 10.1302/0301-620X.92B3.23036. DOI: https://doi.org/10.1302/0301-620X.92B3.23036
Parker M J, Pryor G, Gurusamy K. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures: long-term follow-up of a randomised trial. Injury 2010; 41(4): 370-3. doi: 10.1016/j.injury.2009.10.003. DOI: https://doi.org/10.1016/j.injury.2009.10.003
Lewis D P, Wæver D, Thorninger R, Donnelly W J. Hemiarthroplasty vs total hip arthroplasty for displaced femoral neck fractures: a systematic review and meta-analysis. J Arthroplasty 2019; 34(8): 1837-43.e2. doi: 10.1016/j.arth.2019.03.070. DOI: https://doi.org/10.1016/j.arth.2019.03.070
Guyen O. Hemiarthroplasty or total hip arthroplasty in recent femoral neck fractures? Orthop Traumatol Surg Res 2019; 105(1 Suppl). doi: 10.1016/j.otsr.2018.04.034. DOI: https://doi.org/10.1016/j.otsr.2018.04.034
Rogmark C, Viberg B, Wolf O, Mukka S, Costa M, Gjertsen J E. An Acta Orthopaedica educational article: Femoral neck fractures in adults with emphasis on surgical treatment. Acta Orthop 2025; 96: 632-9. doi: 10.2340/17453674.2025.44354. DOI: https://doi.org/10.2340/17453674.2025.44354
Hong G, Zhong H, Illescas A, Reisinger L, Cozowicz C, Poeran J, et al. Trends in hip fracture surgery in the United States from 2016 to 2021: patient characteristics, clinical management, and outcomes. Br J Anaesth 2024; 133(5): 955-64. doi: 10.1016/j.bja.2024.07.022. DOI: https://doi.org/10.1016/j.bja.2024.07.022
Rikshöft. The Swedish National Hip Fracture Registry. Slutrapport 1988–2025 [Internet]. Lund: Registercentrum Syd; 2026 [cited 2026 Aug 3]. Available from: https://rcsyd.se/rikshoft/wp-content/uploads/sites/24/2026/03/Slutrapport-Rikshoft-1988%E2%80%932025.pdf.
Lagergren J, Strøm Rönnquist S, Wolf O, Mukka S, Möller M, Nåtman J, et al. The different strategies in treating displaced femoral neck fractures: mid-term surgical outcome in a register-based cohort of 1,283 patients aged 60-69 years. Acta Orthop 2023; 94: 505-10. doi: 10.2340/17453674.2023.20284. DOI: https://doi.org/10.2340/17453674.2023.20284
Ekhtiari S, Gormley J, Axelrod D E, Devji T, Bhandari M, Guyatt G H. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fracture: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am 2020; 102(18): 1638-45. doi: 10.2106/JBJS.20.00226. DOI: https://doi.org/10.2106/JBJS.20.00226
Garden R S. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br. 1961; 43(4): 647-63. doi: 10.1302/0301-620X.43B4.647. DOI: https://doi.org/10.1302/0301-620X.43B4.647
National Board of Health and Welfare. The Swedish National Patient Register [Internet]. Stockholm: National Board of Health and Welfare; 2020 [cited 2026 Aug 1]. Available from: https://www.socialstyrelsen.se/statistik-och-data/register/patientregistret/.
Meyer A C, Hedström M, Modig K. The Swedish Hip Fracture Register and National Patient Register were valuable for research on hip fractures: comparison of two registers. J Clin Epidemiol 2020; 125: 91-9. doi: 10.1016/j.jclinepi.2020.06.003. DOI: https://doi.org/10.1016/j.jclinepi.2020.06.003
Rikshöft. Four-month follow-up questionnaire [Internet]. Lund: Registercentrum Syd; 2021 [cited 2026 Aug 3]. Available from: https://rcsyd.se/rikshoft/wp-content/uploads/sites/24/2025/10/Fyramanaders-uppfoljningsformular.pdf.
von Elm E, Altman D G, Egger M, Pocock S J, Gøtzsche P C, Vandenbroucke J P; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147(8): 573-7. doi: 10.7326/0003-4819-147-8-200710160-00010. DOI: https://doi.org/10.7326/0003-4819-147-8-200710160-00010
American Society of Anesthesiologists. ASA Physical Status Classification System [Internet]. Schaumburg, IL: American Society of Anesthesiologists; 2020 [cited 2026 Aug 3]. Available from: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system.
World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013; 310(20): 2191-4. doi: 10.1001/jama.2013.281053. DOI: https://doi.org/10.1001/jama.2013.281053
Lagergren J, Möller M, Rogmark C. Displaced femoral neck fractures in patients 60–69 years old: treatment and patient-reported outcomes in a register cohort. Injury 2020; 51(11): 2652-7. doi: 10.1016/j.injury.2020.08.004. DOI: https://doi.org/10.1016/j.injury.2020.08.004
Bartels S, Gjertsen J E, Frihagen F, Rogmark C, Utvåg S E. High failure rate after internal fixation and beneficial outcome after arthroplasty for displaced femoral neck fractures in patients 55–70 years. Acta Orthop 2018; 89(1): 53-8. doi: 10.1080/17453674.2017.1376514. DOI: https://doi.org/10.1080/17453674.2017.1376514
Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med 2001; 33(5): 337-43. doi: 10.3109/07853890109002087. DOI: https://doi.org/10.3109/07853890109002087
Ponzer S, Skoog A, Bergström G. The Short Musculoskeletal Function Assessment Questionnaire (SMFA): cross-cultural adaptation, validity, reliability and responsiveness of the Swedish SMFA (SMFA-Swe). Acta Orthop Scand 2003; 74(6): 756-63. doi: 10.1080/00016470310018324. DOI: https://doi.org/10.1080/00016470310018324
Nationellt programområde rörelseorganens sjukdomar. Nationellt vårdprogram för höftfraktur [Internet] 2024 [cited 2026 Aug 5]. Available from: https://vardpersonal.1177.se/globalassets/nkk/nationell/media/dokument/kunskapsstod/vardprogram/nationellt-vardprogram-for-hoftfraktur.pdf.
Ek S, Al-Ani H, Greve K, Modig K, Hedström M. Internal fixation or hip replacement for undisplaced femoral neck fractures? Pre-fracture health differences reflect survival and functional outcome. Acta Orthop 2022; 93: 643-51. doi: 10.2340/17453674.2022.3974. DOI: https://doi.org/10.2340/17453674.2022.3974
HEALTH Investigators. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med 2019; 381: 2199-208. doi: 10.1056/NEJMoa1906190. DOI: https://doi.org/10.1056/NEJMoa1906190
Hailer P, Garland A, Rogmark C, Garellick G, Kärrholm J. Early mortality and morbidity after total hip arthroplasty in patients with femoral neck fracture. Acta Orthop 2016; 87(6): 560-6. doi: 10.1080/17453674.2016.1234869. DOI: https://doi.org/10.1080/17453674.2016.1234869
Heetveld M J, Rogmark C, Frihagen F, Keating J. Internal fixation versus arthroplasty for displaced femoral neck fractures: what is the evidence? J Orthop Trauma 2009; 23(6): 395-402. doi: 10.1097/BOT.0b013e318176147d. DOI: https://doi.org/10.1097/BOT.0b013e318176147d
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Copyright (c) 2026 Pierre Campenfeldt, Margareta Hedström, Olle Olofsson, Karin Modig, Amer Al-Ani
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