Arthroplasty versus internal fixation for displaced femoral neck fractures in older patients with dementia: a target trial emulation study
Acta Orthopaedica · 26 Oct 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.
Why it matters
It challenges the standard teaching that arthroplasty beats fixation for displaced femoral neck fractures, but mostly shows how registry outcomes can mislead in patients with dementia.
The evidence
Using Danish national registry data, this study compared arthroplasty with internal fixation (screws or similar) for displaced femoral neck fractures in 3,161 patients aged 70 or older with dementia, analysed as if it were a randomised trial. Within one year, recorded hip reoperations were less common after internal fixation (7.6%) than after arthroplasty (13%), an adjusted difference of -5.8 percentage points. The authors warn that this likely reflects uncemented stems, posterior approaches, and missed fixation failures in patients who cannot report symptoms, rather than a true advantage of fixation.
A coherent primary effect estimate is unavailable. Clinical relevance does not estimate treatment benefit.
Why this rigour score?
Target trial emulationDesign starting point: 47.8
Raised the score
- Target trial protocol specified+4.3
- Post-adjustment balance demonstrated+4.3
Lowered the score
- Control arm not optimally delivered−4.3
Methods at a glance
Recorded assessment- Confounding adjustmentInverse-probability weighting / doubly robust
- Covariate balance confirmedMet
- Outcome assessors blindedNot reported
- Comparable start of follow-upMet
- Adequate statistical powerNot reported
- Prospective registrationNot reported
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
See the full score breakdown
- Study design starting point
- 47.8
- Target trial protocol specified
- +4.3
- New-user design
- +3.4
- Post-adjustment balance demonstrated
- +4.3
- Aligned time zero
- +2.5
- Compared against an accepted alternative
- +1.7
- Control arm not optimally delivered
- −4.3
- 0% loss to follow-up
- +1.7
- Competing risks handled
- +4.3
- Journal prior (not an observed method)
- +0.6
- Final rigour score rounded
- 66 / 100
Study design sets the starting point and a ceiling of 90. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
For journal club
1.For a patient with advanced dementia and a displaced femoral neck fracture, how should expected survival, ambulatory status, and goals of care shape the choice between cemented hemiarthroplasty and internal fixation?
2.Since failures after internal fixation may go unrecognized in patients with dementia, what follow-up plan should surgeons arrange to detect nonunion or avascular necrosis in these patients?
Original publication title
Arthroplasty versus internal fixation for displaced femoral neck fractures in older patients with dementia: a target trial emulation study