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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.

Campenfeldt P, Hedström M, et al. • Acta orthopaedica • 2026

Cohort PubMed 42690129 DOI 10.2340/17453674.2026.46368
TL;DR

THA was associated with lower mortality in ASA III-IV and better functional outcomes in ASA I-II patients aged 60-69 years with displaced femoral neck fracture compared with hemiarthroplasty or internal fixation.

Key Findings

Results

Overall 1-year mortality among 60-69-year-old patients with displaced femoral neck fracture was 8.3%.

  • Study included 3,325 patients aged 60-69 years with displaced FNF recorded in the Swedish Hip Fracture Register.
  • Three treatment groups were compared: total hip arthroplasty (THA), hemiarthroplasty (HA), and internal fixation (IF).
  • Analyses were stratified by ASA class (I-II vs III-IV).
  • 1-year mortality and 4-month functional outcomes were the primary endpoints.
Results

Adjusted analyses showed significantly higher 1-year mortality after hemiarthroplasty and internal fixation compared with THA.

  • HA was associated with higher 1-year mortality compared with THA (OR 2.5, 95% CI 1.7-3.6).
  • IF was associated with higher 1-year mortality compared with THA (OR 2.3, 95% CI 1.6-3.3).
  • These odds ratios were derived from adjusted analyses accounting for confounding factors.
Results

Survival analyses demonstrated lower survival probabilities after HA and IF compared with THA specifically in ASA III-IV patients, but not in ASA I-II patients.

  • The mortality difference between treatment methods was stratified by ASA class.
  • In ASA I-II patients, survival probabilities did not differ meaningfully between treatment groups.
  • In ASA III-IV patients, both HA and IF showed lower survival probabilities compared with THA.
  • This suggests the mortality benefit of THA was concentrated in higher-risk patients.
Results

THA was associated with significantly higher odds of maintaining independent living at 4 months in ASA I-II patients compared with both IF and HA.

  • Compared with THA, IF was associated with lower odds of maintaining independent living (OR 0.40, 95% CI 0.20-0.86) in ASA I-II patients.
  • Compared with THA, HA was associated with substantially lower odds of maintaining independent living (OR 0.09, 95% CI 0.04-0.17) in ASA I-II patients.
  • Functional outcomes were assessed at 4 months post-surgery.
  • In ASA III-IV patients, estimates for independent living were closer to unity, suggesting smaller differences between treatment groups.
Results

THA was associated with significantly higher odds of maintaining outdoor walking ability at 4 months in ASA I-II patients compared with both IF and HA.

  • Compared with THA, IF was associated with lower odds of maintaining outdoor walking ability (OR 0.35, 95% CI 0.24-0.50) in ASA I-II patients.
  • Compared with THA, HA was associated with lower odds of maintaining outdoor walking ability (OR 0.26, 95% CI 0.16-0.43) in ASA I-II patients.
  • In ASA III-IV patients, estimates for outdoor walking ability were closer to unity, indicating smaller differences between treatment groups.
  • Outdoor walking ability was one of two functional outcomes assessed at 4 months.
Results

The functional outcome advantage of THA over HA and IF was most pronounced in ASA I-II patients, while in ASA III-IV patients the differences between treatment groups were attenuated.

  • For both independent living and outdoor walking ability, odds ratio estimates in ASA III-IV patients were described as 'closer to unity' compared with ASA I-II patients.
  • This pattern suggests that health status (ASA class) modifies the relationship between treatment type and functional outcome.
  • The differential effect by ASA class was observed consistently across both functional outcome measures.

What This Means

This research studied 3,325 patients aged 60-69 years in Sweden who suffered a displaced hip fracture (specifically a femoral neck fracture) and compared three surgical treatment options: total hip replacement (THA), partial hip replacement (hemiarthroplasty, HA), and internal fixation with screws or pins (IF). The researchers tracked whether patients survived to one year and whether they could still live independently and walk outdoors four months after surgery. Overall, about 8% of patients died within one year, and patients who received total hip replacement fared better on nearly all measures compared to those receiving partial hip replacement or internal fixation. The benefits of total hip replacement varied depending on how healthy patients were before surgery, as measured by the ASA physical status classification. In healthier patients (ASA I-II), total hip replacement was strongly associated with better ability to maintain independent living and outdoor walking ability after surgery. In sicker patients (ASA III-IV), total hip replacement was associated with better survival compared to the other two treatments, though the functional outcome differences between treatment types were smaller in this group. This research suggests that for patients in their 60s with a displaced hip fracture, total hip replacement may offer advantages over partial hip replacement or internal fixation in terms of both survival and function, with the specific benefits depending on the patient's overall health status. These findings are relevant to ongoing debates about the best surgical approach for this age group, as current practice varies and there is no universal consensus on optimal treatment.

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Citation

Campenfeldt P, Hedström M, Olofsson O, Modig K, Al-Ani A. (2026). 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.. Acta orthopaedica. https://doi.org/10.2340/17453674.2026.46368