Displaced fracture of the intracapsular proximal femur has been termed the “unsolved fracture” because it is unclear whether it should be treated by internal fixation or by replacement of the femoral head with an artificial hip (arthroplasty).1 More than a third of fixed fractures will require revision surgery for either redisplacement (a complication of fracture healing), fracture non-union, or avascular necrosis of the femoral head. Arthroplasty, however, is a more extensive surgical procedure and may cause dislocation, loosening, and peri-prosthetic fracture, which together have an overall incidence of 5-15%. In their randomised controlled trial in this week’s BMJ, Frihagen and colleagues compare the effects of internal fixation or bipolar hemiarthroplasty after displaced fracture of the femoral neck.

Numerous reports of case series and some methodologically weak randomised controlled trials have failed …