Comparative Effectiveness of Internal Fixation Versus Hemiarthroplasty and Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Patients Aged ≥65 Years: A Network Meta-Analysis

The ideal surgical approach for treating displaced femoral neck fractures (FNFs) in elderly patients is a clinical debate. While internal fixation (IF), hemiarthroplasty (HA), and total hip arthroplasty (THA) represent the established treatment methods, their relative hierarchy regarding safety and efficacy has not been fully established. This study aimed to evaluate and rank these interventions using a network meta-analysis (NMA) framework. MEDLINE, Embase, CENTRAL, Web of Science, and Scopus were searched for randomized controlled trials (RCTs) comparing IF, HA, and THA in patients aged ≥65 years with acute displaced FNFs. The primary outcomes were reoperation rate and all-cause mortality. Secondary outcomes included functional scores (Harris Hip Score (HHS)), quality of life, and dislocations. A frequentist, multivariate, random-effects NMA with Hartung-Knapp-Sidik-Jonkman (HKSJ) adjustment was performed. The required information size (RIS) and evidence conclusiveness were evaluated using trial sequential analysis (TSA). A treatment hierarchy was established using the surface under the cumulative ranking (SUCRA) curve analysis. Seventeen RCTs (3,223 patients) were included. Arthroplasty significantly reduced the risk of reoperation compared to IF (THA: RR 0.18, 95% CI 0.07-0.44; HA: RR 0.35, 95% CI 0.16-0.76). TSA confirmed that the cumulative evidence for the superiority of THA over IF in reducing reoperation has reached conclusive thresholds. THA achieved the highest functional recovery at 24 months compared to IF (MD 9.73, 95% CI 6.67-12.79), surpassing the minimal clinically important difference (MCID). SUCRA rankings identified THA as the superior intervention for both reoperation prevention (97.2%) and functional efficacy (99.5%). No significant differences were observed in all-cause mortality across the network. Arthroplasty is superior to IF for displaced FNFs in older adults. THA provides the most robust reduction in reoperation risk and superior functional restoration. Although HA remains a viable alternative, IF should be avoided as a primary treatment in this population because of its high failure rate.