Internal fixation remains the treatment of choice for non-displaced femoral neck fractures in elderly patients, whereas, arthroplasty is preferred for displaced fracture patterns. Given technological advancements in implant design and excellent long-term outcomes, arthroplasty may provide improved outcomes for the treatment of non-displaced femoral neck fractures. The aim of our study was to conduct a systematic review of the orthopaedic literature (1) to investigate the outcomes of internal fixation for the treatment of non-displaced and minimally displaced femoral neck fractures in elderly patients and (2) to compare the outcomes of patients treated with internal fixation to arthroplasty in this patient population.

Relevant articles were identified using PubMed, Embase, and CENTRAL databases. Manuscripts were included only if they contained (1) patients 60 years or older with (2) nondisplaced or minimally displaced (Garden I or II) femoral neck fractures (3) treated with internal fixation or arthroplasty or (4) separately reported outcomes in this patient population. The primary outcome was reoperation. Secondary outcomes included mortality, patient reported outcomes, length of hospital stay, infection, and transfusions. An a priori decision was made to classify studies into comparative or non-comparative groups. Comparative studies directly compared arthroplasty to internal fixation in the specific study population while the non-comparative studies included separate cohorts of patients treated with arthroplasty or internal fixation. A fixed-effects model was used to quantitatively pool study outcomes.

Twenty-five non-comparative studies were identified with a total of 22,020 patients, all of which were treated with internal fixation. The pooled incidence of reoperation after internal fixation was 14.4% (95% CI: 10.8 – 18.8). The incidence of mortality within one-year of injury was 14.4% (95% CI: 6.7 – 28.3), based on the reporting in 14 studies.

Three comparative studies were identified with a total of 360 patients (128 treated with arthroplasty and 232 treated with internal fixation). All three studies reported reoperation rates. The overall risk of reoperation was 3.1% in the arthroplasty group compared to 9.5% in the internal fixation group (relative risk: 0.30, 95% CI: 0.10 – 0.84, p= 0.02). Only two studies reported mortality. The relative risk of mortality in patients treated with arthroplasty compared to internal fixation was 2.54 (95% CI: 1.38 – 4.70, p= 0.003).

Internal fixation of minimally displaced femoral neck fractures in the elderly is associated with a risk of reoperation and mortality that exceeds 14%. Treatment with arthroplasty may reduce the risk of reoperation by 70%. However, this benefit maybe tempered by a potential increased risk of mortality associated with arthroplasty in this patient population.