Screw fixation versus hemiarthroplasty for undisplaced femoral neck fractures in the elderly: a meta-analysis.

Abstract

Screw fixation and hemiarthroplasty are commonly used surgical options for treating undisplaced femoral neck fractures in the elderly. While fixation preserves the native joint, arthroplasty offers immediate mechanical stability. The optimal treatment remains controversial. A systematic review and meta-analysis was conducted across PubMed, Scopus, Cochrane Library, and Google Scholar through June 2025. Twelve studies (including randomised controlled trials and observational cohorts) encompassing 2190 patients treated with screw fixation and 2606 with hemiarthroplasty were included. Outcomes assessed included intraoperative blood loss, transfusion rates, operation time, hospital stay, pain scores, Harris Hip Score, complication and reoperation rates, and mortality at 1 month and 1 year. Screw fixation was associated with significantly less intraoperative blood loss (MD =  - 162.79 mL), shorter surgery time (MD =  - 31.68 min), and reduced transfusion requirements (RR = 0.30). Hospital stay was shorter by 3.5 days on average. Pain scores at final follow-up were similar between groups (p = 0.55), while Harris Hip Scores were slightly higher with fixation (MD = 2.09), though of questionable clinical relevance. However, fixation carried a markedly higher risk of reoperation (RR = 3.54) and complications such as non-union and osteonecrosis. Mortality at 1 month and 1 year trended lower in the fixation group but did not reach statistical significance. Screw fixation provides notable perioperative advantages and comparable long-term functional outcomes in select elderly patients with undisplaced femoral neck fractures. However, it is offset by a significantly higher risk of failure and reoperation. Hemiarthroplasty, while more invasive, ensures greater mechanical reliability and lower revision rates. Treatment decisions should be individualized based on patient frailty, fracture characteristics, and mobility goals.