Hemiarthroplasty compared to total hip arthroplasty for the treatment of femoral neck fractures: a systematic review and meta-analysis

Comparison of acute outcomes from elective total hip replacements and after fragility femoral neck fractures in nonagenarians

BACKGROUND

Hip hemiarthroplasty has traditionally been used to treat displaced femoral neck fractures in older, frailer patients whilst total hip replacements (THR) have been reserved for younger and fitter patients. However, not all elderly patients are frail, and some may be able to tolerate and benefit from an acute THR. Nonagenarians are a particularly heterogenous subpopulation of the elderly, with varying degrees of independence. Since THRs are performed electively as a routine treatment for osteoarthritis in the elderly, its safety is well established in the older patient. The aim of this study was to compare the safety of emergency THR to elective THR in nonagenarians.

METHODS

A retrospective 10-year cohort study was conducted using data submitted to the National Hip Fracture Database (NHFD) across three hospitals in one large NHS Trust. Data was collected from 126 nonagenarians who underwent THRs between 1st January 2010 - 31st December 2020 and was categorised into emergency THR and elective THR groups. Mortality rates were compared between the two groups. Secondary outcomes were also compared including postoperative complications (dislocations, revision surgeries, and periprosthetic fracture), length of stay in hospital, and discharge destination.

RESULTS

There was no significant difference in mortality between the two groups, with 1-year mortality rates of 11.4% and 12.1% reported for emergency and elective patients respectively (p = 0.848). There were no significant differences in postoperative complication rate and discharge destination. Patients who had emergency THR spent 5.56 days longer in hospital compared to elective patients (p = 0.015).

CONCLUSION

There is no increased risk of 1-year mortality in emergency THR compared to elective THR, in a nonagenarian population. Therefore, nonagenarians presenting with a hip fracture who would have been considered for a THR if presenting on an elective basis should not be precluded from an emergency THR on safety grounds.

TRIAL REGISTRATION

Not necessary as this was deemed not to be clinical research, and was considered to be a service evaluation.

Comparison of rehabilitation outcomes between robot-assisted and freehand screw placement in treatment of femoral neck fractures: a systematic review and meta-analysis

PURPOSE

To compare the postoperative rehabilitation of femoral neck fractures treated with robot-assisted nailing and freehand nailing.

METHODS

We systematically searched the PubMed, EMBASE, Cochrane, China National Knowledge Infrastructure(CNKI), WanFang database, China Science and Technology Journal Database (VIP) and Web of Science databases to identify potentially eligible articles. Indispensable data such as the year of publication, country, study type, robot type, age, number of patients, sex distribution, study design, and outcome indicators were extracted. The outcome indicators of interest included healing rate, length of healing time, Harris score, operation time, frequency of X-ray fluoroscopy, frequency of guide pin insertion, and intraoperative blood loss. RevMan 5.4.1 was used for the meta-analysis.

RESULTS

Fourteen studies with 908 participants were included in this meta-analysis. The results showed that in terms of healing rate (SMD = 2.75, 95% CI, 1.03 to 7.32, P = 0.04) and Harris score (SMD = 2.27, 95% CI, 0.79 to 3.75, P = 0.003), robot-assisted screw placement technique scores were higher than the traditional freehand technique. Additionally, operative time (SMD = -12.72, 95% CI, -19.74 to -5.70, P = 0.0004), healing time (SMD = -13.63, 95% CI, -20.18 to -7.08, P < 0.0001), frequency of X-ray fluoroscopy (SMD = - 13.64, 95% CI, - 18.32 to - 8.95, P < 0.00001), frequency of guide pin insertion (SMD = - 7.95, 95% CI, - 10.13 to - 5.76, P < 0.00001), and intraoperative blood loss (SMD = - 17.33, 95% CI, - 23.66 to - 11.00, P < 0.00001) were lower for patients who underwent robotic-assisted screw placement than those for patients who underwent the conventional freehand technique.

CONCLUSION

Compared to the freehand nailing technique, robot-assisted nailing helps improve postoperative healing rates in patients with femoral neck fractures; shortens healing times; better restores hip function; reduces the number of intraoperative fluoroscopies, guides pin placements; reduces intraoperative bleeding; and increases perioperative safety.

Comparison of young femoral neck fractures treated by femoral neck system, multiple cancellous screws and dynamic hip screws: a retrospectively comparison study

BACKGROUND

Implant choice for the fixation of femoral neck fracture is one of the most important management controversies. This study aims to evaluate and compare the short-term outcomes associated with the use of the Femoral Neck System (FNS), Multiple Cancellous Screws (MCS), and Dynamic Hip Screws (DHS) in treating femoral neck fractures in a young patient population.

METHODS

From June 2018 to June 2021, a total of 120 surgeries for a primary femoral neck fracture were retrospectively analyzed. This review encompassed demographic details of the patients and the mechanisms behind the injuries. Key surgical parameters such as operation duration, intraoperative blood loss, fluoroscopy duration, and hospital stay were meticulously documented. The employed surgical technique was described. All patients were followed up at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Avascular necrosis of the femoral head (AVN), nonunion, malreduction, implant failure or other complications were noted. The functional status at the last follow-up was assessed using the Harris functional scoring criteria.

RESULTS

There were 90 males and 30 females, with a mean age of 40.4 years. As to patient characteristics, there were no significant differences between the three groups. DHS group showed longer operation time(52.15 ± 4.80 min), more blood loss(59.05 ± 5.87 ml) and longer time of hospitalization(7.6 ± 0.90 d) than FNS group (39.65 ± 2.84 min, 45.33 ± 9.63 ml and 4.87 ± 0.48 d) and MCS group (39.45 ± 3.10 min, 48.15 ± 7.88 ml and 5.04 ± 0.49 d) (p < 0.05). In addition, the time of fluoroscopy in FNS group (15.45 ± 3.67) was less than that in MCS group (26.3 ± 4.76) and DHS group (27.1 ± 5.67) (p < 0.05). The cost of FNS group(44.51 ± 2.99 thousand RMB) was significantly higher than the MCS and DHS groups. The FNS, MCS and DHS groups showed a similar mean length of femoral neck shortening (LFNS) and Harris score. The FNS, MCS and DHS groups showed a similar mean rate of AVN and internal fixation failure.

CONCLUSIONS

Following successful fracture reduction, FNS, MCS, and DHS are effective for in the young femoral neck fractures. No difference was found in complications between the three groups. However, the reduced fluoroscopy time associated with FNS contributes to shorter operation durations. The adoption of minimally invasive techniques correlates with decreased blood loss and shorter hospital stays. Nevertheless, these advantages may be offset by the potential economic burden they impose.

Analysis of the effects of intraoperative warming devices on surgical site infection in elective hip arthroplasty using a large nationwide database

INTRODUCTION

The aim of our study is to analyze the association of usage and type of warming device with the risk of surgical site infection (SSI) in patients who underwent hip arthroplasty, and to analyze the factors that increase the risk of SSI if the warming device is not used.

MATERIALS AND METHODS

This retrospective cross-sectional study identified subjects from data of "Evaluation of the Appropriate Use of Prophylactic Antibiotics". Included patients were defined as those who underwent elective unilateral hip hemiarthroplasty or total hip arthroplasty (THA). Patients were classified into no intraoperative warming device, forced air warming devices, and devices using conduction. Multiple logistic regression analysis was conducted to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to assess the association between warming devices and SSI.

RESULTS

A total of 3945 patients met the inclusion criteria. Compared to those who received an intraoperative warming device, the odds of developing SSI were 1.9 times higher in those who did not receive intraoperative warming devices (aOR 1.9; 95% CI 1.1-3.6). The risk of SSI was 2.2 times higher with forced air warming devices compared to devices using conduction but this difference was not statistically significant (aOR 2.2; 95% CI 0.7-6.8). The risk of SSI increased in males (aOR 2.8; 95% CI 1.1-7.2), in patients under 70 years of age (aOR 4.4; 95% CI 1.6-10.4), in patients with a Charlson`s comorbidity index of 2 or higher (aOR 3.3; 95% CI 1.3-8.7), and in patients who underwent THA (aOR 3.8; 95% CI 1.7-8.3) when intraoperative warming devices were not used.

CONCLUSIONS

The use of intraoperative active warming devices is highly recommended to prevent SSI during elective hip arthroplasty. In particular, male patients younger than 70 years, those with a high CCI, and those undergoing THA are at significantly increased risk of SSI if intraoperative active warming devices are not used. Intraoperative warming device using conduction is likely superior to forced air warming device, but further studies are needed to confirm this.

Displaced Geriatric Femoral Neck Fractures: A Retrospective Comparison of Total Hip Arthroplasties Versus Hemiarthroplasty

Introduction

Controversary exists around the best surgical management for traumatic geriatric displaced femoral neck fractures. The study objective was to compare outcomes among those managed with a total hip arthroplasty (THA) to those managed with a hemiarthroplasty (HA).

Methods

This retrospective matched cohort study included geriatric hip fractures (≥65 y/o) admitted 7/1/16-3/31/20. Patients were matched on having an advanced directive, pre-existing dementia, and age. Outcomes included: time to surgery, length of stay (LOS), blood loss volume, and discharge destination. THAs were compared to HAs; an alpha of <.05 indicated statistical significance.

Results

There were 191 patients: 86% were treated with HA and 14% with THA. Most (40%) were 80-89 years old, 66% were female, and 92% were white. After matching, the groups were well balanced on demographics and baseline characteristics with 27 patients/arm. The median time to surgery was 23 hours for both arms, P = .38. The LOS was significantly longer for those managed with a HA when compared to those managed with a THA, 5.6 vs 4.0 days, P = .001. The median blood loss volume was significantly lower for HAs than for THAs, but the difference was small, 100 vs 120 mL, P = .02. Patients managed with a HA were less likely to be discharged home than those managed with a THA, 22% vs 70%, P = .005.

Conclusions

While patients managed with a THA had significantly more blood loss than those managed with a HA, the difference in blood loss was small and not clinically relevant. Those managed with a THA experienced a significantly shorter LOS and were more likely to be discharged home than patients managed with a HA. Among a healthier, younger geriatric population, THA may lead to shortened LOS and improved discharge destinations when compared to HA for treatment of femoral neck fractures.

Cannulated screws versus dynamic hip screw versus hemiarthroplasty versus total hip arthroplasty in patients with displaced and non-displaced femoral neck fractures: a systematic review and frequentist network meta-analysis of 5703 patients

BACKGROUND

Our aim was to determine the best operative procedure in human participants with a displaced or non-displaced femoral neck fracture comparing cannulated screw (CS) fixation, dynamic hip screw (DHS) fixation, hemiarthroplasty (HA), and total hip arthroplasty (THA) in terms of surgical and functional outcomes, reoperation and postoperative complications.

METHODS

We searched PubMed, The Cochrane Library, Clinical trials, CINAHL, and Embase for randomized controlled trials (RCTs) or quasi-RCTs up to 31 July 2022. A frequentist network meta-analysis was performed to assess the comparative effects of the four operative procedures, using fixed-effects and random-effects models. Mean differences (MDs) with 95% confidence intervals (CIs) were estimated for continuous variables and odds ratios (ORs) with 95% CIs were estimated for binary variables.

RESULTS

A total of 33 RCTs with 5703 patients were included in our network meta-analysis. CS fixation was best in terms of operation time (CS: MD = - 57.70, 95% CI - 72.78; - 42.62; DHS: MD = - 53.56, 95% CI - 76.17; - 30.95; HA: MD = - 20.90, 95% CI - 30.65; - 11.15; THA: MD = 1.00 reference) and intraoperative blood loss (CS: MD = - 3.67, 95% CI - 4.44; - 2.90; DHS: MD = - 3.20, 95% CI - 4.97; - 1.43; HA: MD = - 1.20, 95% CI - 1.73; - 0.67; THA: MD = 1.00 reference). In life quality and functional outcome, measured at different time points with EQ-5D and the Harris Hip Score (HHS), THA ranked first and HA second (e.g. EQ-5D 2 years postoperatively: CS: MD = - 0.20, 95% CI - 0.29; - 0.11; HA: MD = - 0.09, 95% CI - 0.17; - 0.02; THA: MD = 1.00 reference; HHS 2 years postoperatively: CS: MD = - 5.50, 95% CI - 9.98; - 1.03; DHS: MD = - 8.93, 95% CI - 15.08; - 2.78; HA: MD = - 3.65, 95% CI - 6.74; - 0.57; THA: MD = 1.00 reference). CS fixation had the highest reoperation risk, followed by DHS fixation, HA, and THA (CS: OR = 9.98, 95% CI 4.60; 21.63; DHS: OR = 5.07, 95% CI 2.15; 11.96; HA: OR = 1.60, 95% CI 0.89; 2.89; THA: OR = 1.00 reference).

CONCLUSION

In our cohort of patients with displaced and non-displaced femoral neck fractures, HHS, EQ-5D, and reoperation risk showed an advantage of THA and HA compared with CS and DHS fixation. Based on these findings, we recommend that hip arthroplasty should be preferred and internal fixation of femoral neck fractures should only be considered in individual cases.

LEVEL OF EVIDENCE I

a systematic review of randomized controlled trials.

TRIAL REGISTRATION

PROSPERO on 10 August 2022 (CRD42022350293).

Risk factors for hypoxaemia following hip fracture surgery in elderly patients who recovered from COVID-19: a multicentre retrospective study

Objectives

To explore the risk factors associated with postoperative hypoxaemia in elderly patients who have recovered from coronavirus disease (COVID-19) and underwent hip fracture surgery in the short term.

Design

Multicentre retrospective study.

Setting

The study was performed in three first 3A-grade hospitals in China.

Participants

A sequential sampling method was applied to select study participants. Medical records of 392 patients aged ≥65 years who had recovered from COVID-19 and underwent hip fracture surgery at three hospitals in China between 1 November, 2022, and 15 February, 2023, were reviewed.

Interventions

Patients were assigned to hypoxaemia or non-hypoxaemia groups, according to whether hypoxaemia occurred after surgery. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for postoperative hypoxaemia.

Results

The incidence of postoperative hypoxaemia was 38.01%. Statistically significant differences were found between the two groups in terms of age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, presence of expectoration symptoms, preoperative hypoxaemia, chronic obstructive pulmonary disease, pulmonary inflammation, time between recovery from COVID-19 and surgery, anaesthetic mode, surgical procedure, intraoperative blood loss, intraoperative infusion, duration of surgery, and length of hospital stay (p < 0.05). Furthermore, patients with BMI ≥28.0 kg/m², expectoration symptoms, presence of preoperative hypoxaemia, ASA classification III, time between recovery from COVID-19 and surgery ≤2 weeks, and general anaesthesia were potential risk factors for postoperative hypoxaemia.

Conclusion

Obesity, expectoration symptoms, preoperative hypoxaemia, ASA classification III, time between recovery from COVID-19 and surgery ≤2 weeks, and general anaesthesia were potential risk factors for postoperative hypoxaemia in elderly patients who recovered from COVID-19 and underwent hip fracture surgery in the short term.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Gamma Nail Combined with One Cannulated Compression Screw Fixation for Treating Pauwels Type III Femoral Neck Fractures in Young and Middle-Aged Adults: Clinical Follow-Up and Biomechanical Studies

OBJECTIVE

Recently, some clinical studies have reported the use of an intramedullary nailing system for treating unstable femoral neck fractures or femoral neck fractures combined with femoral shaft fractures in young adults, and the results have indicated certain advantages. However, no study has investigated the mechanical properties of this method. We aimed to evaluate the mechanical stability and clinical efficacy of the Gamma nail combined with one cannulated compression screw (CCS) fixation for treating Pauwels type III femoral neck fracture in young and middle-aged adults.

METHODS

This study consists of two parts: a clinical retrospective study and randomized controlled biomechanical test. Twelve adult cadaver femora were used to test and compare the biomechanical properties among three fixation methods: three parallel CCS (group A), Gamma nail (group B), and Gamma nail combined with one cannulated compression screw (group C). The single continuous compression test, cyclic load test, and ultimate vertical load test were used to evaluate the biomechanical performance of the three fixation methods. We also conducted a retrospective study of 31 patients with Pauwels type III femoral neck fractures, including 16 patients with fractures fixed with three parallel CCS (CCS group) and 15 patients with fractures fixed with Gamma nail combined with one CCS (Gamma nail + CCS group). The patients were followed up for at least 3 years, and all were evaluated for surgical time (from skin incision to closure), surgical blood loss, hospital stay, and the Harris hip score.

RESULTS

In mechanical experiments, we have found that the mechanical advantages of Gamma nail fixation are not as good as those of conventional CCS fixation. However, the mechanical properties of Gamma nail fixation combined with one cannulated screw perpendicular to the fracture line are much better than those of Gamma nail fixation and CCS fixation. No significant difference was found in the incidence of femoral head necrosis and nonunion between the CCS and Gamma nail + CCS groups. Moreover, there was no statistically significant difference in the Harris hip scores between the two groups. One patient in the CCS group showed significant withdrawal of cannulated screws at 5 months after surgery, whereas in the Gamma nail + CCS group, all patients, including those with femoral neck necrosis, showed no loss of stability of the fixation.

CONCLUSION

Among the two fixation methods evaluated in this study, Gamma nail combined with one CCS fixation showed better biomechanical properties and may reduce complications associated with unstable fixation devices.

Comparative Effectiveness of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fracture: A Propensity-Score-Matched Cohort Study

BACKGROUND

The optimal treatment of older patients with a displaced femoral neck fracture remains a controversial topic. This study aimed to compare clinical outcomes across a matched group of patients with a femoral neck fracture treated with either hemiarthroplasty or total hip arthroplasty (THA).

METHODS

Routinely collected health-care databases were linked to create a population-based cohort of 49,597 patients ≥60 years old from Ontario, Canada, who underwent hemiarthroplasty or THA for a femoral neck fracture between 2002 and 2017. A propensity-score-matched cohort was created using relevant and available predictors of treatment assignment and outcomes of interest. Clinical outcomes consisting of hip dislocation, revision surgery, hospital readmission, and death were compared in the matched cohort using survival analysis.

RESULTS

Over 99% of THA patients (4,612) were adequately matched 1:1 to hemiarthroplasty patients (total matched cohort = 9,224). Patients treated with THA were at higher risk for hip dislocation at 30 days and 1 and 2 years postoperatively (2-year risk, 1.8% for THA versus 0.8% for hemiarthroplasty; p < 0.001). There was no difference in the short-term (30-day) or long-term (up to 10-year) risk of revision surgery between treatment groups. There was no significant difference in the risk of 30-day hospital readmission between groups. The risk of death at 1 year and 2 years postoperatively was lower for patients treated with THA.

CONCLUSIONS

For patients with a hip fracture, shared decision-making should involve discussion of the potential higher risk of short-term hip dislocation after THA compared with hemiarthroplasty. The risk of revision surgery was similar between treatment groups at up to 10 years of follow-up.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparative Study of Proximal Femur Bone Tumor Patients Undergoing Hemiarthroplasty versus Total Hip Arthroplasty: A Meta-Analysis

Hemiarthroplasty and total hip arthroplasty are routinely performed procedures. A comparison of these procedures in tumor patients can be performed based on complications and functional outcomes. To weigh the advantages and disadvantages of both procedures, a comparative study is indeed required to decide which procedure is more beneficial for primary bone tumor patients. The outcomes of proximal femur tumor-resected patients were collected from research reports from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 30 December 2022. Differences between these two operative procedures in primary bone tumors patients were analyzed based on dislocation, infection, local recurrence, MSTS, and HHS. Six articles were included according to the selection criteria with a total of 360 patients. Our results showed that there was a significant difference in our primary outcome as hemiarthroplasty participants encountered less dislocation than those with total hip arthroplasty. Moreover, the secondary outcomes of our study were similar. Proximal femur bone tumors, when resected, tend to produce more complications and decrease functional ability due to extensive tumor extension and soft tissue involvement. The lower dislocation rate in hemiarthroplasty participants emphasizes the importance of preserving the acetabular head in hemiarthroplasty as a key to preventing dislocation.

Complications following total hip arthroplasty and hemiarthroplasty for femoral neck fractures in patients with a history of lumbar spinal fusion

INTRODUCTION

The purpose of this study was to examine whether previous lumbar spinal fusion (LSF) was an independent risk factor for complications in patients undergoing total hip arthroplasty (THA) or hemiarthroplasty for displaced femoral neck fractures.

METHODS AND MATERIALS

An administrative database was queried from 2010 to Q2 of 2019 to analyze and compare complications in patients undergoing either THA or hemiarthroplasty for femoral neck fracture with a history of LSF versus no history of LSF. Joint complications including periprosthetic fracture, prosthetic joint infection (PJI), prosthetic joint dislocation (PJD), aseptic loosening, and prosthetic revision were examined at 90 days and 1 year post-operatively.

RESULTS

In the THA cohort, patients with prior LSF had significantly higher likelihood of aseptic loosening at 90 days and 1 year post-operatively in comparison to those without prior LSF (90-day: OR 2.22; 1-year: OR 1.95). Patients in the hemiarthroplasty cohort with prior LSF had significantly higher likelihood of PJI (90-day: OR 2.18; 1-year: OR 2.37), aseptic loosening (90-day: OR 3.42; 1-year: OR 4.68), and prosthetic revision (90-day: OR 2.27; 1-year: OR 2.25) in both the 90-day and 1-year postoperative period in comparison to those without prior LSF. Additionally, for the same cohort, periprosthetic fracture (1-year: OR 2.32) and PJD (1-year: OR 2.31) were significantly higher at 1-year postoperative.

CONCLUSION

Presence of LSF was found to be an independent risk factor for increased joint complications in patients undergoing either a THA or hemiarthroplasty for displaced femoral neck fractures.

A comparison of different surgical approaches to hemiarthroplasty for the femoral neck fractures: A meta-analysis

There are three traditional surgical approaches to hemiarthroplasty (HA) for femoral neck fractures, respectively, the anterior approach (AA), the lateral approach (LA) and the posterior approach (PA). However, the optimum approach is still controversial, the purpose of this meta-analysis is to identify the merits and demerits of all three approaches. All clinical published studies in PubMed, Web of Science, Embase, and the Cochrane Library from January 2000 to April 2022 were searched which compared different surgical approaches and covered surgery-related outcomes and frequent complications. Five randomized controlled trials and 26 cohort studies for a total of 31 clinical trials were included in the meta-analysis. The dislocation of PA was significantly higher than LA (OR: 3.00 95% CI: 2.25-4.01 I ² = 27% P < 0.00001) and AA (OR: 6.61 95% CI: 2.28-19.13 I ² = 0% P = 0.0005); PA was substantially more than LA in terms of risk of postoperative reoperation (P < 0.05); meanwhile, AA has markedly shorter hospital length of stays than LA. The remaining items showed no significant differences in the results.The results of this meta-analysis demonstrated that the risk of PA dislocation and reoperation is higher with hemiarthroplasty, and AA has markedly shorter hospital length of stays than LA.

Total hip arthroplasty compared to bipolar and unipolar hemiarthroplasty for displaced hip fractures in the elderly: a Bayesian network meta-analysis

Purpose

Displaced femoral neck fractures (FNF) usually require surgical treatment with either a total hip arthroplasty (THA), unipolar hemiarthroplasty (U-HHA), or bipolar hemiarthroplasty (B-HHA). However, there is still controversy regarding the optimal implant. This network meta-analysis compared the outcomes and complication rates of THA versus B-HHA and versus U-HHA in elderly patients with FNF.

Material and methods

This study was conducted according to the PRISMA extension statement for reporting of systematic reviews, and incorporated network meta-analyses of health care interventions. The literature search was performed in September 2020. All randomized clinical trials comparing two or more of the index surgical interventions for displaced FNF in the elderly were eligible for inclusion. For the Bayesian network meta-analysis, the standardized mean difference (SMD) and Log Odd Ratio (LOR) were used.

Results

Data from 24 RCTs (2808 procedures) were analysed. The mean follow-up was 33.8 months. The THA group had the longest surgical time (SMD 85.74) and the greatest Harris Hip Score (SMD − 17.31). THA scored similarly in terms of mortality (LOR 3.89), but had lower rates of revision surgeries (LOR 2.24), higher rates of dislocations (LOR 2.60), and lower rates of acetabular erosion (LOR − 0.02). Cementless implants required a shorter surgical duration (− 18.05 min; P = 0.03). Mortality was positively associated with acetabular erosion (P = 0.006), female gender (P = 0.007), revision (P < 0.0001).

Conclusion

THA led to the highest Harris Hip scores and lowest rate of revision surgery compared to B-HHA and U-HHA. However, B-HHA had the lowest dislocation rate when compared with U-HHA and THA. No significant differences in functional outcomes and complication rates were found between cemented and uncemented implants; however, a tendency for lower mortality, revision and dislocation rates in cemented implants was evidenced.

Level of evidence

I, Bayesian network meta-analysis of RCTs.