A Comparison of Internal Fixation and Hemiarthroplasty for Nondisplaced Femoral Neck Fractures: An Updated Systematic...

The optimal management of nondisplaced femoral neck fractures (FNFs) in elderly patients remains debated. Internal fixation (IF) offers shorter operative time and reduced blood loss but carries risks of nonunion and reoperation, whereas hemiarthroplasty (HA) may reduce these failures at the expense of greater operative burden. We conducted a systematic search of PubMed, MEDLINE, and Embase (completed in September 2025) to identify randomized controlled trials comparing IF and HA in patients aged ≥65 years with Garden I-II FNFs. Four RCTs were included, enrolling 454 patients (230 IF; 224 HA). Outcomes included implant-related complications, reoperation, mortality, functional outcomes, perioperative variables, and quality of life. IF was associated with significantly higher implant-related complications (19.1% vs. 3.1%; odds ratio (OR) = 4.12, 95% confidence interval (CI) = 2.12-8.00; P < 0.0001) and reoperations (OR = 4.10, 95% CI = 2.12-7.95; P < 0.0001). Osteonecrosis was more frequent following IF (OR = 5.97, 95% CI = 1.54-23.14; P = 0.01), as was nonunion/fixation failure (OR = 13.43, 95% CI = 3.66-49.33; P < 0.0001). Deep infection rates were comparable between the groups (OR = 0.52, 95% CI = 0.14-1.92; P = 0.33). In contrast, HA was associated with greater blood loss (mean difference (MD) = -143.11 mL, 95% CI = -204.53 to -81.69; P < 0.0001) and longer operative time (MD = -23.07 minutes, 95% CI = -41.14 to -4.99; P = 0.01). Mortality was comparable between the groups up to 36 months (risk ratio = 0.93, 95% CI = 0.50-1.73; P = 0.81). Early functional outcomes favored HA, although long-term scores were similar. This meta-analysis suggests that HA reduces complications and reoperations without increasing mortality and may represent a preferable option for many frail elderly patients, while treatment decisions should remain individualized based on operative risk and comorbidity.