Fixation versus primary replacement of displaced femoral neck fractures in the elderly

Hip fractures are among the most common debilitating injuries in the elderly and are a significant cause of morbidity and mortality worldwide. Despite the ever-increasing literature on the topic of hip fractures, optimal treatment remains uncertain. Trials with small sizes, methodological limitations, strict inclusion criteria and wide confidence intervals leave the optimal approach to treating hip fractures unknown and controversial. In 2005, the International Hip Fracture Research Collaborative was officially established with the mandate of resolving controversies in hip fracture management. Presently, two multicenter randomized trials, FAITH and HEALTH, are underway. The FAITH trial (Fixation Using Alternative Implants for the Treatment of Hip Fractures) will compare Sliding Hip Screws and Cancellous Screws; the HEALTH trial (Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty) will compare total hip arthroplasty and hemi-arthroplasty. The present paper reviews current controversies in hip fracture care. Ultimately, only large randomized trials, such as FAITH and HEALTH, will resolve the longstanding controversy of whether primary replacement or fixation is the preferred treatment modality in this common fracture. Subsequent trials need to focus on surgical strategies in the cognitively impaired patient.