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C OPYRIGHT Ó 2014 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

the
Orthopaedic
forum
Changing Trends in the Treatment of Femoral
Neck Fractures
A Review of the American Board of Orthopaedic Surgery Database
Benjamin J. Miller, MD, MS, John J. Callaghan, MD, Peter Cram, MD, MBA, Matthew Karam, MD,
J. Lawrence Marsh, MD, and Nicolas O. Noiseux, MD, MS

Background: The purpose of this study was to investigate the trends in operative management of femoral neck frac-
tures by orthopaedic surgeons applying for board certification.
Methods: We queried the American Board of Orthopaedic Surgery database to identify all femoral neck fractures that had been
treated and reported by candidates taking Part II of the licensing examination from 1999 to 2011 to determine the utilization of
internal fixation, hemiarthroplasty, and total hip arthroplasty. The longitudinal trends were then stratified by patient age (younger
than sixty-five, sixty-five to seventy-nine, eighty and older) and the declared subspecialty of the candidate.
Results: There were 19,541 femoral neck fractures that had been treated by 4450 board certification candidates. The
use of total hip arthroplasty increased over time (0.7% of fractures in 1999, 7.7% in 2011, p < 0.001); use of hemi-
arthroplasty (67.1% in 1999, 63.1% in 2011, p = 0.020) and internal fixation (32.2% in 1999, 29.2% in 2011, p =
0.064) declined slightly. All geographic regions showed an increase in utilization of total hip arthroplasty, with sub-
stantial variation between locations. The proportion of patients younger than age sixty-five who were managed with total
hip arthroplasty increased from 1.4% to 13.1% (p < 0.001). Candidates with a declared subspecialty of ‘‘adult re-
construction’’ showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from
2009 to 2011, p < 0.001), while ‘‘trauma’’ subspecialty candidates demonstrated decreasing utilization of internal
fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012). The percentage of candidates treating at
least one femoral neck fracture decreased from 54.8% from 1999 to 2002 to 46.3% from 2009 to 2011 (p < 0.001).
Conclusions: The most substantial changes in treatment of femoral neck fractures were seen in the younger group of
patients. Currently, a smaller percentage of board certification candidates are treating femoral neck fractures than those
in the past, possibly reflecting a trend toward specialty care.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed
by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication.
Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this
work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. In addition,
one or more of the authors has a patent or patents, planned, pending, or issued, that is broadly relevant to the work. Also, one or more of the authors has
had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this
work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

J Bone Joint Surg Am. 2014;96:e149(1-6) d http://dx.doi.org/10.2106/JBJS.M.01122

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Femoral neck fractures are common and typically require surgical
intervention. Numerous investigations have attempted to define
whether these fractures are best managed by internal fixation,
hemiarthroplasty, or total hip arthroplasty. Previous studies have
favored arthroplasty in older individuals without cognitive dys-
function1-14. A similar body of literature has attempted to deter-
mine the superiority of total hip arthroplasty compared with
hemiarthroplasty. Although the results have not allowed for a de-
finitive recommendation in a number of systematic reviews15-20,
most comparative trials have advocated for total hip arthroplasty in
healthy, active, and independent patients7,21-27. While fewer in num-
ber, there are investigations advocating for hemiarthroplasty over
total hip arthroplasty, favoring a simpler surgery with acceptable
functional outcomes in most patients28,29. Although there is no
consensus statement on the appropriateness of a specific surgical
procedure, the number of investigations and awareness of this
topic have dramatically increased in the last two decades.
Previous investigations have reported data from case lists
prepared for Part II (oral) of the certifying examination for the
American Board of Orthopaedic Surgery (ABOS)30-34. This data-
base is an interesting source of information for evaluating trends
in practice for surgeons who have recently completed training.
Our primary goal was to determine if there was a changing trend
in the surgical management of femoral neck fractures and if
there were differences in regional utilization. In addition, we
questioned if any changes in utilization were more pronounced
depending on patient age or the declared subspecialty of the
surgeon. Finally, we assessed changes over time in the proportion
of recently trained orthopaedic surgeons treating hip fractures.
Materials and Methods
We queried the database of the ABOS for all cases of femoral neck fracture from
1999 to 2011. The database contains cases from a nationwide population of
surgeons across all orthopaedic subspecialties, and most are at the same point in
their career. Because the contributing surgeons are primarily recent graduates
of residency training programs, their treatment decisions are likely to reflect
knowledge gained from scientific reports and the opinions of multiple experts,
compared with established orthopaedic surgeons who may rely heavily on prior
C H A N G I N G T R E N D S I N T H E T R E AT M E N T OF
FEMORAL NECK FRACTURES
personal experience. Therefore, exploration of the practice patterns of recently
trained orthopaedic surgeons may be an effective means to investigate changes
due to new knowledge, new technologies, or changes in reimbursement.
The credentialing process for orthopaedic surgeons in the United States
involves two sequential examinations that are created and administered by the
ABOS. The first is a written test, most commonly taken immediately after the
completion of residency. The second part is an oral examination that is admin-
istered after the candidate has been in practice for twenty-two months. Prep-
aration for Part II requires all candidates to record complete case lists for a
defined six-month period prior to the examination. The case lists are confirmed
and notarized by medical administrators at each candidate’s institution.
Candidates may request an examiner panel based on the subspecialty of
their fellowship. This assignment is optional and is not inclusive. For our re-
view, we recorded the declared subspecialty of the candidate as ‘‘adult recon-
struction,’’ ‘‘trauma,’’ or ‘‘other.’’
The individual case records include de-identified patient demographic
data (age, sex), International Classification of Diseases, Ninth Revision (ICD-9)
codes, and Current Procedural Terminology (CPT) codes. The data do not
include any medical comorbidities or validated functional outcomes. Recorded
patient follow-up is limited to the collection period, and ranges from zero to six
months. Each candidate’s practice location was classified into one of six geo-
graphic regions, as in a previous study .
34
We limited our investigation to closed femoral neck fractures (ICD-9
820.0, 820.00, 820.01, 820.02, and 820.09). Basicervical fractures (ICD-9 820.03)
were excluded because the treatment considerations are often different from other
fractures of the femoral neck. We were not able to distinguish between displaced
and nondisplaced fractures. We classified the surgery performed as internal fixation
(CPT 27235, 27269, and 27187), hemiarthroplasty (CPT 27125), and total hip
arthroplasty (CPT 27130). The majority of cases were assigned CPT 27236, ‘‘open
treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic
replacement.’’ Because this code does not distinguish between arthroplasty and
internal fixation, we performed an additional search based upon descriptive com-
ments entered by the surgeon. If we still were not able to determine which type of
surgery had been performed, the entry was excluded.
In addition to a global trend analysis, we stratified the results into
groups based on age (younger than sixty-five, sixty-five to seventy-nine, eighty
and older) and the declared subspecialty of the candidate (adult reconstruction,
trauma, or other). We chose the youngest grouping to represent a cohort of
femoral neck fractures outside of the traditional Medicare population. Eighty
years old was the age cutoff that previously had been used to reflect an ‘‘older’’
35
cohort of patients with femoral neck fractures . Our results were analyzed
separately to determine if the tendencies differed relative to patient age or
examinee subspecialty.
Fig. 1
The trends in utilization of hemiarthroplasty (HA),
internal fixation (IF), and total hip arthroplasty
(THA) in the ABOS database from 1999 to 2011.
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All candidates for the Part II examination are aware, and sign a release,
that any data they submit for the voluntary certification process may be used for
research. The identities of the individual candidates were not known to the
research team. This study proposal was reviewed by the ABOS Research Com-
mittee as well as our institutional review board.
Statistical Analysis
We used bivariate methods for trend analysis and comparisons between inter-
nal fixation, hemiarthroplasty, and total hip arthroplasty. We performed two-
tailed t tests for continuous variables and chi-square testing for categorical
variables. The statistical calculations were performed with SAS version 9.3
(SAS Institute, Cary, North Carolina).
Source of Funding
Departmental funds were used to acquire data from the ABOS.
Results
We identified 19,686 cases of femoral neck fracture that met our
inclusion criteria. We excluded 145 cases for which we were un-
able to determine the precise type of surgery that had been per-
formed, leaving a cohort of 19,541 entries for analysis. Out of 8897
total candidates for the Part II examination, 4450 (50%) had
C H A N G I N G T R E N D S I N T H E T R E AT M E N T OF
FEMORAL NECK FRACTURES
Fig. 2
The regional variation in the percentage of total
hip arthroplasty cases performed for femoral
neck fractures in the ABOS database from 1999
to 2011.
treated at least one femoral neck fracture surgically (median, three
femoral neck fractures treated surgically; range, one to thirty-six).
There were 13,081 cases of hemiarthroplasty, 5990 cases of inter-
nal fixation, and 470 cases of total hip arthroplasty in the database.
Throughout the study period, the proportion of femoral
neck fractures treated with internal fixation (32.2% in 1999,
29.2% in 2011, p = 0.064) and hemiarthroplasty (67.1% in 1999,
63.1% in 2011, p = 0.020) decreased slightly, while total hip arthro-
plasty increased (0.7% in 1999, 7.7% in 2011, p < 0.001) (Fig. 1).
The percentage of total hip arthroplasty cases, rather than
hemiarthroplasty cases, increased over time in all locations (Fig. 2).
However, the magnitude of increase was not consistent. For instance,
from 2009 to 2011, total hip arthroplasty represented 9.4% of arthro-
plasty cases in the Northeast versus 3.4% in the South (p < 0.001).
Stratification of the data based on patient age (younger
than sixty-five, sixty-five to seventy-nine, or eighty and older)
demonstrated differences in procedure utilization. The youngest
age group (younger than sixty-five) had the greatest increase in
the use of total hip arthroplasty (1.4% from 1999 to 2002, 13.1%
from 2009 to 2011, p < 0.001) (Fig. 3). The use of internal
Fig. 3
The trends in utilization of hemiarthroplasty (HA),
internal fixation (IF), and total hip arthroplasty
(THA) in patients younger than sixty-five years old
in the ABOS database from 1999 to 2011.
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Fig. 4
The percentage of examinees in the ABOS database who surgically treated at least one femoral neck fracture from 1999 to 2011.
fixation showed a minimal decline (62.7% from 1999 to 2002,
59.4% from 2009 to 2011, p = 0.205) and was the dominant
form of treatment in patients younger than sixty-five years old.
Hemiarthroplasty decreased in all age groups except for patients
older than age eighty, where it was slightly increased (74.5%
from 1999 to 2002, 76.4% from 2009 to 2011, p = 0.098).
We found additional differences when the declared subspe-
cialty of the examinee was categorized. Specifically, examinees
with the subspecialty of adult reconstruction demonstrated a dra-
matic increase in the utilization of total hip arthroplasty (4.3%
from 1999 to 2002, 21.1% from 2009 to 2011, p < 0.001). Al-
though examinees with the subspecialty of trauma treated a
greater proportion of fractures with internal fixation compared
with the rest of the cohort, this utilization diminished over time
(40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012).
The number of examinees who treated at least one fem-
oral neck fracture in the six-month board collection period
decreased over time (54.8% from 1999 to 2002, 46.3% from
2009 to 2011, p < 0.001) (Fig. 4).
Discussion
On review of the ABOS database from 1999 to 2011, we found a
longitudinal trend of increasing use of total hip arthroplasty
and small decreases in the use of hemiarthroplasty and internal
fixation in the treatment of femoral neck fractures. Our de-
termination that the proportion of total hip arthroplasties
increased throughout the study period is a new finding that
differs from prior investigations. Jain et al. found that total
hip arthroplasty utilization for femoral neck fractures de-
creased in the Nationwide Inpatient Sample databases from
1990 to 200136. The differences may be partially explained be-
cause we investigated a more recent time period, which had a
larger number of comparative trials in the literature advocating
for total hip arthroplasty. A recent trend analysis of Medicare
C H A N G I N G T R E N D S I N T H E T R E AT M E N T OF
FEMORAL NECK FRACTURES
Part A data did not find substantial differences in the utilization
of total hip arthroplasty for femoral neck fractures from 1991
to 200837. This earlier study did not include patients younger
than sixty-five years old, which is the population with the most
dramatic change in our study. Additionally, the ABOS database
is uniquely focused on recent trainees and may not be reflective
of orthopaedic decision-making in general. We cannot com-
ment specifically on the reasons for the change or differentiate
further based upon patient factors because detailed demo-
graphic and medical information for individual patients was
not available. Regardless of the causes, there has clearly been a
definable change in actual clinical practice over time.
The analysis that was stratified by patient age adds some
insight into the details of the observed changes in utilization. The
majority of comparative investigations limit conclusions for a
potential benefit of total hip arthroplasty to younger, healthier
individuals with a femoral neck fracture7,21-27. While we did see
an increase in total hip utilization in every age group, the most
dramatic shift was clearly in patients younger than sixty-five years
old. The proportion of internal fixation use in this group re-
mained around 60%, which was double the rate of the older age
groups. This observation is not surprising since many experts
advocate for internal fixation of displaced femoral neck fractures
in younger individuals38-40. There has been some interest in use of
total hip arthroplasty in younger patients with femoral neck frac-
tures, citing decreased reoperation rates and better function, but
overall, the results have been conflicting and inconclusive41,42. In-
creasingly, younger patients with a total hip arthroplasty for ar-
thritis have demonstrated acceptable long-term function and wear
rates with modern cementless fixation and polyethelene compo-
nents43, suggesting that this could potentially be a viable option for
fracture treatment in younger individuals.
To our knowledge, no investigation has prospectively
compared total hip arthroplasty with internal fixation for
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displaced femoral neck fractures in patients younger than sixty-
five years old. While we clearly found differences in treatment
trends over time in nearly every group and subgroup, the im-
plications of these changes are not clear. Although they are
measureable and significant, there is no context to decide
whether or not the magnitude of the changes is appropriate
or clinically important. The incidence of hip fractures is ap-
proximately nine in 1000 women and four in 1000 men over
the age of sixty-five44, making even small changes in treatment
of this condition potentially significant in the public health
arena. Perhaps the orthopaedic community should be per-
forming a greater number of total hip arthroplasties to give
more patients better long-term function. Alternatively, total
hip arthroplasty may be best used conservatively, and only in
the healthiest patients, to avoid higher initial costs and com-
plication rates whenever possible. The optimal utilization of
total hip arthroplasty for femoral neck fractures is unquestion-
ably a complex topic depending on a combination of factors,
including patient health, avoidance of complications, costs of
implants, surgeon comfort and skill, procedural reimburse-
ment, informed consent and patient decision-making, and
eventual quality and duration of life.
A smaller percentage of candidates taking the Part II ex-
amination reported that they were treating femoral neck frac-
tures over time (54.8% from 1999 to 2002, 46.3% from 2009 to
2011, p < 0.001). This is potentially a reflection of increased
specialization at the level of the surgeon, the orthopaedic prac-
tice, or the hospital. Perhaps a surgeon who is not specifically
trained in trauma or joint arthroplasty is less likely to treat a
femoral neck fracture today compared with ten years ago. Sim-
ilarly, as orthopaedic groups become larger, there may be spe-
cialists within the groups with a clinical interest or responsibility
to handle femoral neck fractures. Alternatively, as hospitals
evolve, surgeons may find themselves practicing at institutions
where orthopaedic trauma volumes are low or where emergency
call is covered by salaried, hospital-employed orthopaedic sur-
geons. To date, there has not been evidence of regionalization of
femoral neck fracture treatment to specific centers37. However, it
is possible that these injuries are clustered at an individual, rather
than an institutional, level. Femoral neck fractures have been
classically considered a ‘‘general’’ orthopaedic condition, and
whether this remains the case deserves additional follow-up.
This investigation has several limitations that warrant
more discussion. First, the ABOS database does not provide
any patient-level data other than age and sex, negating any
analysis investigating procedural choices in relation to comor-
bidities or functional status. Next, the candidates reflect a na-
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NOTE: The authors thank Annunziato Amendola, MD, for his assistance in working with the ABOS
research committee. We also thank John Harrast for his assistance with data acquisition and
statistical analysis.
Benjamin J. Miller, MD, MS
John J. Callaghan, MD
Peter Cram, MD, MBA
Matthew Karam, MD
J. Lawrence Marsh, MD
Nicolas O. Noiseux, MD, MS
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J.L.M., and N.O.N.) and Internal Medicine (P.C.),
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