This review summarises the evidence for the treatment of displaced fractures of the femoral neck in elderly patients. Results from randomised clinical trials and national register studies are presented when available.

The advantages of arthroplasty compared with internal fixation are supported by several studies. A number of studies contribute to the discussions of total hip arthroplasty (THA) versus hemiarthroplasty and unipolar versus bipolar hemiarthroplasty, but no clear-cut evidence-based recommendation can be made. THA may be particularly advantageous for active, lucid patients with a relatively long life expectancy. For patients who are physiologically older, hemiarthoplasty is probably satisfactory, and for the oldest patients with more comorbidities, unipolar implants are considered to be sufficient. If the hospital can support emergency THA surgery in sufficient numbers and quality, there may be few patients who warrant bipolar hemiarthroplasty.

The direct lateral approach reduces the risk of dislocation compared with the posterior approach. Cemented implants lower the risk of periprosthetic fracture and its subsequent morbidity and mortality. As the risk of peri-operative death related to bone cement can be reduced by adequate measures, cemented implants are recommended in fracture cases.

Take home message: There remains a great variation in the surgical management of patients with a hip fracture, and an evidence-based approach should improve the outcomes for this vulnerable patient group.

Cite this article: Bone Joint J 2016;98-B:291–7.

Between 1999 and 2005, 10 264 patients who had undergone total hip replacement (THR) for subcapital fracture of the hip were compared with 76 520 in whom THR had been performed for other reasons. All the cases were identified through the Swedish Hip Arthroplasty Register. The THRs performed as primary treatment for fracture were also compared with those done after failure of internal fixation.

After seven years the rate of revision was higher in THR after fracture (4.4% vs 2.9%). Dislocation and periprosthetic fracture were the most common causes of revision. The risk was higher in men than in women. The type of femoral component and the surgical approach influenced the risk. After correction for gender, type of component and the surgical approach the revision rates were similar in the primary and secondary fracture THR groups.

Total hip replacement is therefore a safe method for both the primary and secondary management of fracture of the hip.