Hemiarthroplasty or total hip arthroplasty for the treatment of a displaced intracapsular fracture in active elderly patients

Safety and efficacy in the management of older patients with displaced intracapsular hip fractures

The management of the older person with a displaced intracapsular hip fracture is one of the most significant aspects of musculoskeletal trauma. These patients require prompt, integrated pathway delivered care. The care delivered outside of the operating theatre and that performed within, are intertwined. Traditionally, surgeons have focussed predominantly only on the operative elements. In modern trauma care for older people, this focus must broaden. We provide for the first time a comprehensive overview of all elements of care for this important patient group. This brings together pathway elements from the National Hip Fracture Database Key Performance Indicators and NICE guidance alongside a synthesis of all current research output for intracapsular hip fracture.

Does total hip arthroplasty in elderly patients with femoral neck fractures reduce complications?: A Japanese DPC study

BACKGROUND

The global increase in femoral neck fractures due to aging and osteoporosis is a major clinical challenge. The debate on the optimal surgical intervention for femoral neck fractures remains unresolved. This large-scale study explores femoral neck fractures among the elderly, focusing on the comparative outcomes of Total Hip Arthroplasty (THA) versus Bipolar Hemiarthroplasty (BHA) in Japanese patients.

METHODS

Using the Japanese National Administrative Diagnosis Procedure Combination (DPC) database, we studied cases of femoral neck fracture from April 2016 to March 2023, and after propensity score matching by age, sex, and comorbidities, we examined the association between THA, complications, and clinical outcomes, and the usefulness of THA for elderly patients with femoral neck fracture.

RESULTS

One-to-one propensity score matching identified 7741 pairs of THA and BHA cases. There was no difference in length of stay between the THA and BHA groups. Significantly more blood transfusions were required in the THA group. There was no significant difference in mortality between the THA and BHA groups, but there was a reduced risk of pneumonia in the THA group, with a ratio of 0.547 (95% CI: 0.418-0.715). On the other hand, the THA group had a higher risk of pulmonary embolism, with a ratio of 1.607 (95% CI: 1.379-1.874). The THA group shows improved discharge rates directly home from the facility where the operation was performed, with a ratio of 1.798 (95% CI: 1.675-1.929).

CONCLUSION

The findings of this research indicate that THA is more effective than BHA in enabling elderly Japanese patients with femoral neck fractures to be discharged directly home and in preventing pneumonia, despite concerns about pulmonary embolism. These findings suggest that THA may improve functional prognosis in elderly patients with femoral neck fractures, although there is a trade-off with an increased risk of pulmonary embolism.

Age-Based Heuristics Bias Treatment of Displaced Femoral Neck Fractures in the Elderly

Background

Surgeons performing arthroplasty for femoral neck fractures may rely on mental shortcuts (heuristics) when choosing total hip arthroplasty (THA) vs hemiarthroplasty (HA). We sought to quantify the extent to which age-based heuristics drive decision-making.

Methods

We identified all Medicare beneficiaries from 2017-2018 with femoral neck fractures who underwent THA or HA. We compared the likelihood of THA vs HA among patients admitted within 4 weeks before vs 4 weeks after their birthday for each age under the hypothesis that these cohorts would be similar except for numerical age. We controlled for race/ethnicity, sex, comorbidities, poverty status, and hospital census region in a multivariable regression that included facility-level cluster effects. We generated predicted/adjusted probabilities for THA vs HA for different age transition points.

Results

Thirteen thousand three hundred sixty-six elderly patients were included. One thousand eight hundred sixty-five (14%) received THA and 11,501 (86%) received HA. The likelihood of THA decreased from 50.3% among patients almost 67 to 8% among those ≥85 (P < .001). We found significant decreases in likelihood of THA across age transitions. The largest decrement was at age transition 69 (THA likelihood 28.7% for newly 69 vs 43.3% for almost 69, 33.7% relative change). Female gender, Black race, higher comorbidity burden, and lower socioeconomic status were also associated with a lower likelihood of THA.

Conclusions

Our data demonstrate that patient age transitions seem to influence the choice of THA vs HA. Further research is needed to develop data-driven surgical decision aids for this population.

The increasing complexity of femoral fragility fractures: incidence, fracture patterns and management over a 10-year period

INTRODUCTION

The purpose of this study was to determine whether there have been changes in the numbers and complexity of femoral fragility fractures presenting to our department over a period of 10 years.

METHODS

Patients >60 years presenting with femoral fragility fractures to our institution in 2018-2019 (397 fractures) were compared with respect to demographic data, incidence rates, fracture classification and surgical management with a historical cohort from 2009-2010 (335 fractures). Pathological and high velocity fractures were excluded.

RESULTS

The gender proportion and average age (83.1 vs. 82.7 years) was unchanged. The number of femoral fractures increased by 19% but the overall incidence in people >60 years fell by 6% (p = 0.41). The proportion of unstable trochanteric fractures (31A2 and A3) increased from 22% to 55% (p < 0.001). The proportion of displaced intracapsular fractures increased from 53% to 72% (p < 0.001). The incidence of stable trochanteric fractures fell from 12.4 to 7.3/10,000 patients>60 years (p = 0.0006) while the incidence of unstable trochanteric fractures (31A2 and 31A3) increased from 3.5 to 8.9/10,000 patients >60 years (p < 0.0001). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 9% to 35% (p = 0.0001). The number of shaft and distal femoral fractures increased by 41% although the incidence did not change significantly. Periprosthetic fractures comprised 70% of femoral shaft fractures in both cohorts.

CONCLUSIONS

The increasing number and complexity of femoral fragility fractures, especially unstable trochanteric fractures and periprosthetic fractures, is likely to have an impact on implant use, theatre time and cost.

Hemiarthroplasty Versus Total Hip Arthroplasty for Femoral Neck Fracture in Elderly Patients: Twelve-Month Risk of Revision and Dislocation in an Instrumental Variable Analysis of Medicare Data

BACKGROUND

There is practice variation in the selection of a total hip arthroplasty (THA) or a hemiarthroplasty (HA) for the treatment of displaced femoral neck fractures in elderly patients. Large data sets are needed to compare the rates of rare complications following these procedures. We sought to examine the relationship between surgery type and secondary hip surgery (revision or conversion arthroplasty) at 12 months following the index arthroplasty, and that between surgery type and dislocation at 12 months, among elderly Medicare beneficiaries who underwent THA or HA for a femoral neck fracture, taking into account the potential for selection bias.

METHODS

We performed a population-based, retrospective study of elderly (>65 years of age) Medicare beneficiaries who underwent THA or HA following a femoral neck fracture. Two-stage, instrumental variable regression models were applied to nationally representative Medicare medical claims data from 2017 to 2019.

RESULTS

Of the 61,695 elderly patients who met the inclusion criteria, of whom 74.1% were female and 92.2% were non-Hispanic White, 10,268 patients (16.6%) underwent THA and 51,427 (83.4%) underwent HA. The findings from the multivariable, instrumental variable analyses indicated that treatment of displaced femoral neck fractures with THA was associated with a significantly higher risk of dislocation at 12 months compared with treatment with HA (2.9% for the THA group versus 1.9% for the HA group; p = 0.001). There was no significant difference in the likelihood of 12-month revision/conversion between THA and HA.

CONCLUSIONS

The use of THA to treat femoral neck fractures in elderly patients is associated with a significantly higher risk of 12-month dislocation, as compared with the use of HA, although the difference may not be clinically important. A low overall rate of dislocation was found in both groups. The risk of revision/conversion at 12 months did not differ between the groups.

LEVEL OF EVIDENCE

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

Total hip arthroplasty versus hemiarthroplasty in the treatment of active elderly patients over 75 years with displaced femoral neck fractures: a retrospective study

BACKGROUND

Femoral neck fractures are associated with substantial morbidity and mortality for older adults. Total hip arthroplasty (THA) and hemiarthroplasty (HA) are widely used in elderly patients with displaced femoral neck fractures (DFNF), but there is still controversy refering to the optimal chose for the management of DFNF in active elderly patients.

METHODS

This is a retrospective cohort study that incorporates medical record review with an outcomes management database. 73 patients who underwent HA and 66 patients who underwent THA were identified from January 2015 to December 2017. Data of age, gender, BMI, comorbidity status, operation time, blood loss, hospitalization time, in-hospital complication were collected and analyzed. Clinical follow-up and radiographic examinations were performed at approximately five years, and hip complications, Harris Hip Score (HHS) and EuroQol-5 Dimensions (EQ-5D) were assessed.

RESULTS

Preoperative general data of sex, age, BMI and charlson comorbidity score of THA group(n=55) has no statistically significant difference with that of HA group. Patients treated by THA had significantly longer operation time (105.5 vs 76.7 minutes; P < 0.001), more blood loss (524.1 vs 350.1 ml; P < 0.001) and longer hospitalization time (15.8 vs 13.8 days; P < 0.001). There was no significant differences between two groups in complications (32.7% vs 25.8%, P=0.432). No patients died during the hospitalization. After five years, only 33 patients in the THA group and 34 patents in the HA group were still alive, and the fraction surviving were not statistically significant between two groups (60.0% vs 54.8%, P> 0.05). The differences in hip function in favor of THA appeared to increase after the five-year follow-up, and the difference was significant in terms of the total Harris hip score (81.3 vs 73.1, P < 0.001) as well as in the dimensions of pain (38.9 vs 35.9, P=0.033), function (33.7 vs 29.2, P=0.001), absence of deformity (4.0 vs 3.9, P=0.023) and range of motion (4.6 vs 4.2, P=0.008). There was no significant differences between groups in hip dislocation rate (6.1% vs 0.0%, P=0.239). The erosion rate of hip joint in the THA group was significantly lower than that of the HA group (0.0% vs 26.5%, P=0.002). The health-related quality of life, according to EQ-5D index score, was found to be higher (0.69 vs 0.63, P= 0.001) in the THA group than the HA group after five years.

CONCLUSION

THA may be a preferred management option for active elderly patients over 75 years. The more extensive surgery of THA is not associated with higher in-hospital complication rate or mortality rate. These patients can benefit from THA in terms of hip function and quality of life.

TRIAL REGISTRATION

No.

Bone Cement Implantation Syndrome: A Rare Disaster Following Cemented Hip Arthroplasties-Clinical Considerations Supported by Case Studies

Severe symptoms such as hypoxemia, hypotension, and unexpected loss of consciousness may develop during surgical interventions that use polymethyl methacrylate (PMMA), or as it is commonly known, bone cement. Physicians recognize this amalgam of clinical manifestations more and more as a distinct entity that bears the name of bone cement implantation syndrome (BCIS). Trauma cases, especially hip fractures, are seen to have a higher incidence of developing this complication compared to orthopedic elective ones. This research aims to present a detailed description of six severe BCIS cases in order to raise awareness and to emphasize its importance. Five of them had fatal outcomes, which demonstrate the necessity of future research on this topic, as little is known about it presently. In the Discussion section, a narrative overview from the scientific literature is performed on potential risk factors, prevention measures, and management strategies. The experience gathered through this case series may aid medical staff in the development of diagnostic and therapeutic protocols, thus improving safety when cemented surgical techniques are used on a high-risk group of patients.

Clinical Effectiveness of Total Hip Arthroplasty Compared With Hemiarthroplasty in Adults Undergoing Surgery for Displaced Intracapsular Hip Fracture: A Single-Centre Retrospective Cohort Study

BACKGROUND

The National Institute for Health and Care Excellence (NICE) recommends offering total hip arthroplasty (THA) over hemiarthroplasty (HA) for displaced intracapsular hip fractures, taking the premorbid functionality, present co-morbidities, and functional benefit beyond two years into account. Concerns remain whether the higher surgical burden and incidence of complications in THA would outweigh the potential benefits in the elderly.

METHOD

This retrospective cohort study evaluates the differences in surgical outcomes of THA vs HA in 85 patients with displaced intracapsular fractures, based on the time taken for patients to ambulate to walking frame/crutches and wheelchair post-operatively and the incidence of post-operative complications.

RESULTS

 Patients who received HA were significantly older (p<0.0001, <0.05) and had poorer pre-operative ambulatory function (p=0.032, p<0.05) than those of the THA group. HA patients had a significantly faster recovery to walking frame/crutches (20.2 days) compared to THA patients (47.3 days) (Mann-Whitney U=447.500, n=46, p=0.043, <0.05 two-tailed). While no significant differences were found in deep vein thrombosis (DVT), infected prosthesis, or dislocation incidence, hospital-acquired pneumonia (HAP) was more prevalent in THA patients (p=0.044, <0.05). Time to the walking frame had a significant effect on DVT/PE (p<0.001,

CONCLUSION

HA patients showed favourable outcomes in time to ambulate post-operatively and incidence of HAP among patients with advanced age and those with poorer pre-operative ambulatory function.

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Key Words

• geriatrics and internal medicine
• hemiarthroplasty
• hip fracture
• orthopaedic arthroplasty
• total hip arthroplasty

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MESH Headings Collapse

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Affiliation(s)

Dhanushan Gnanendran Trauma and Orthopaedics, York General Hospital, York, USA
Yanamrigesh Yanaganasar Geriatrics, Lincoln County Hospital, Lincoln, GBR
Jayagautham M Rajan Trauma and Orthopaedics, Bronglais General Hospital, Aberystwyth, GBR
Zulkifli B Hassan Trauma and Orthopaedics, Hospital Sultan Ismail, Johor Bahru, MYS
Neshvinder Balbir Singh Trauma and Orthopaedics, Newcastle University Medicine Malaysia, Johor Bahru, MYS
Lau Min Yi Trauma and Orthopaedics, Hospital Sultan Ismail, Johor Bahru, MYS
Mohamed F Nadzree Trauma and Orthopaedics, Hospital Sultan Ismail, Johor Bahru, MYS

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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).

A long term follow-up for a randomised trial of total hip arthroplasty versus hemiarthroplasty for displaced intracapsular fractures

104 patients with a displaced intracapsular fracture were randomised to surgical treatment with either a cemented hemiarthroplasty or a cemented total hip arthroplasty. All surviving patients were followed up for five years from injury by a blinded observer. No differences in outcome between groups was seen for the degree of residual pain or regain of function or independence. There was a tendency to more complications and re-operations for those treated with the total hip arthroplasty. We continue to recommend that caution should be exercised regarding the increased promotion of THR for intracapsular hip fractures until further studies with long term follow up are completed.

Total hip arthroplasty for displaced femoral neck fracture: Survey of orthopaedic surgeons in Ontario, Canada

BACKGROUND

Total hip arthroplasty (THA) for displaced femoral neck fractures in older patients remains a controversial topic. This study describes patient and surgeon factors that are associated with surgeons' recommendation of THA for this patient population. Furthermore, this study explores surgeon perceptions on why most patients are treated with hemiarthroplasty over THA.

METHODS

In October 2019, a cross-sectional survey was mailed to practicing orthopaedic surgeons in Ontario, Canada. The questionnaire included paper patient cases to capture surgical practice variation using a full factorial, vignette-based experimental design. Multilevel linear regression and multivariable linear regression were used to determine patient and surgeon factors that are associated with treatment recommendations.

RESULTS

Of a target population of 494 practicing surgeons, 302 (61.1%) responded. Sixty percent of respondents worked in the community, and most respondents (89.4%) had fellowship training. Surgeon-level predictors of treatment with THA included higher volume of THA for fracture in the last 12 months, having an elective THA practice, and increasing years in practice. Pre-existing hip arthritis increased likelihood to recommend THA, while increasing patient age and comorbidity burden decreased likelihood to recommend THA. There are medical, institutional, financial, and historic reasons why most patients are treated with hemiarthroplasty over THA.

INTERPRETATION

This survey identified several patient and surgeon-level factors that were associated with treatment recommendation for THA. Hemiarthroplasty remains the more common treatment for this patient population for multiple reasons. There is potential for differential access to care when the factors driving treatment decisions are unrelated to the patient.

Total Hip Arthroplasty in fracture neck of femur: A review of the literature

Fracture Neck of Femur (FnF) is a major cause of loss of independence, morbidity and mortality in a vulnerable group of elderly patients; as well as a substantial economic burden on healthcare systems across the world. An increasingly ageing population has resulted in a rise in incidence and prevalence of FnF. Over 76,000 patients were admitted with FnF in the United Kingdom in 2018, with the resulting health and social costs estimated to be in excess of £2 billion. It is therefore important that the outcomes of all management options be evaluated to ensure constant improvement as well as allocation of resources as appropriate. It is widely agreed that patients presenting with displaced intracapsular FnF injuries are managed operatively; with options including internal fixation, hemiarthroplasty or Total Hip Arthroplasty (THA). The volume of THA performed for FnF has significantly increased in recent years. However, compliance with national guidelines on FnF patient selection for THA has been shown to be inconsistent. The aim of this study was to review current literature with regards to the use of THA in management of FnF patients. The literature describes managing FnF in ambulant and independent patients by THA with dual-mobility acetabular cup and cemented femoral component via the anterolateral approach. There is scope for further research in assessing the outcomes of different prosthetic femoral head sizes and choice of bearing surfaces (tribiology) used for THA as well as cementation of the acetabular cup component specifically in FnF patients.

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.

Albumin is an Independent Predictor of up to 9-Year Mortality for Intracapsular Femoral Neck Fractures Aiding in Decision-Making for Total Hip Arthroplasty or Hemiarthroplasty

BACKGROUND

Intracapsular femoral neck fractures in the geriatric population are usually treated with hemiarthroplasty or total hip arthroplasty. The patients' medium-term to long-term mortality is a consideration to help decide which procedure to perform. The aim of this study is to examine whether easily identifiable serum investigations and patient identifiable factors on admission are associated with medium-term and long-term mortality.

METHODS

A consecutive series of 331 patients who sustained intracapsular femoral neck fractures and were over the age of 55 years were identified and retrospectively reviewed. American Society of Anesthesiologists (ASA) grade, cognitive function, gender, age, mobility status, and admission serum investigations were considered.

RESULTS

Low albumin levels, advanced age, men, and a combination of high ASA with lower mobility status were independent predictors of mean 5-year mortality. Similarly, low albumin levels and a combination of high ASA with lower mobility status were found to be independent predictors of longer term mortality (7-9 years). The optimal albumin cut-off to identify patient survival was >42 g/L with an area under the curve of 0.71.

CONCLUSION

We suggest that serum albumin on admission can be utilized as a factor to identify patients who are likely to survive at up to 9-year mean follow-up, to guide decision for total hip arthroplasty over hemiarthroplasty.

Is the Revision Rate for Femoral Neck Fracture Lower for Total Hip Arthroplasty Than for Hemiarthroplasty?: A Comparison of Registry Data for Contemporary Surgical Options

BACKGROUND

When arthroplasty is indicated for a femoral neck fracture (FNF), it is unclear whether total hip arthroplasty (THA) or hemiarthroplasty (HA) is best. This study compares data from the Australian Orthopaedic Association National Joint Replacement Registry using contemporary surgical options.

METHODS

Patients from 60 to 85 years old who were treated with arthroplasty for FNF, between September 1999 and December 2019, were included if the femoral stems were cemented. Only THAs with femoral heads of ≥36 mm or dual-mobility articulations were included. Patients who had monoblock HA were excluded. Rates of revision for all aseptic failures and dislocation were compared. Competing risks of revision and death were considered using the cumulative incidence function. Subdistribution hazard ratios (HRs) for revision or death from a Fine-Gray regression model were used to compare THA and HA. Interactions of procedure with age group and sex were considered. Secondary analysis adjusting for body mass index (BMI) and American Society of Anesthesiologists (ASA) classification was also considered.

RESULTS

There were 4,551 THA and 29,714 HA procedures included. The rate of revision for THA was lower for women from 60 to 69 years old (HR = 0.58 [95% confidence interval (CI), 0.39 to 0.85]) and from 70 to 74 years old (HR = 0.65 [95% CI, 0.43 to 0.98]) compared with HA. However, women from 80 to 85 years old (HR = 1.56 [95% CI, 1.03 to 2.35]) and men from 75 to 79 years old (HR = 1.61 [95% CI, 1.05 to 2.46]) and 80 to 85 years old (HR = 2.73 [95% CI, 1.89 to 3.95]) had an increased rate of revision when THA was undertaken compared with HA. There was no difference in the rate of revision for dislocation between THA and HA for either sex or age categories.

CONCLUSIONS

When contemporary surgical options for FNF are used, there is a benefit with respect to revision outcomes for THA in women who are <75 years old and a benefit for HA in women who are ≥80 years old and men who are ≥75 years old. There is no difference in dislocation rates.

LEVEL OF EVIDENCE

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

Amyloidosis of the Femoral Neck: An Unusual Cause of Pathologic Fracture

The deposition of amyloid within human tissue can be detrimental to the proper functioning of multiple organ systems. While the infiltration of the amyloid protein within the musculoskeletal soft tissues can lead to compressive neuropathies, tendon irritation or rupture, and joint stiffness, pathologic fracture as a result of amyloid deposition in bone is a rare manifestation of amyloidosis. We present a case of pathologic fracture of the femoral neck from amyloid deposition in a 59-year-old male on chronic hemodialysis who was found to have lytic lesions in his proximal femur. At the time of hemiarthroplasty, histopathologic analysis of a femoral head sample revealed apple-green birefringence of the deposits under polarized light, consistent with amyloid deposition. Clinicians should have a high index of suspicion for the atypical presentation of amyloidosis in a patient on chronic hemodialysis with lytic bone lesions.

Bipolar Hemiarthroplasty Does Not Result in a Higher Risk of Revision Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures: An Instrumental Variable Analysis of 36,118 Procedures from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Previous randomized studies have suggested that there is no short-term difference between the risk of revision following total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fracture in elderly patients. The aim of the present study was to compare the long-term revision rates of primary THA and HA for femoral neck fracture in order to determine whether unipolar or bipolar HA increases the all-cause risk of revision in patients 50 to 79 years old.

METHODS

Data for 36,188 patients who underwent primary arthroplasty, including 13,035 unipolar and 8,220 bipolar HAs and 14,863 THAs, from September 1, 1999, to December 31, 2019, were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Unadjusted analyses were performed, as well as analyses adjusted for age, sex, femoral cement, and procedure year. The primary outcome was time to first revision for any cause. Secondary analyses were performed for the reason for revision (i.e., infection, dislocation, and periprosthetic fracture). Instrumental variable analysis of hospital preference (for either HA or THA) was performed in order to mitigate the effect of any unmeasured confounding. All analyses were restricted to hospitals performing at least 10 procedures in the prior year.

RESULTS

A total of 18,955 procedures were available for the comparison of modular unipolar HA to THA. Both the adjusted analysis performed with use of Cox proportional hazards (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.64 to 2.31; p < 0.001) and the instrumental variable analysis (HR, 2.82; 95% CI, 1.89 to 4.22; p < 0.001) demonstrated a higher risk of revision following modular unipolar HA compared with THA from 3 months postoperatively. A total of 13,168 procedures were available for the comparison of bipolar HA to THA. The adjusted analysis performed with use of Cox proportional hazards showed a significantly higher risk of revision for bipolar HA (HR, 1.29; 95% CI, 1.08 to 1.54; p = 0.01). The instrumental variable analysis showed a similar effect size that was not significant (HR, 1.27; 95% CI, 0.91 to 1.78; p = 0.16).

CONCLUSIONS

Bipolar HA and THA demonstrated no significant difference in revision risk at long-term follow-up. Unipolar HA demonstrated higher risk of revision from 3 months postoperatively compared to THA. The higher risk of revision for dislocation observed following THA may be offset by the higher risk of revision for acetabular erosion or pain following bipolar HA, resulting in more equivalent revision risk.

LEVEL OF EVIDENCE

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

Is Dual Mobility Total Hip Arthroplasty Surgery More Aggressive than Hemiarthroplasty when Treating Femoral Neck Fracture in the Elderly? A Multicentric Retrospective Study on 302 Hips

Introduction

Bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) are validated treatments for displaced femoral neck fractures (DFNFs). BHA seldomly needs conversion to THA, but the latter has higher dislocation rate in FNFs. Dual Mobility THA offers a reduced dislocation rate and eliminates the risk of conversion. This study looks for differences between BHA and DMTHA in terms of surgical time, blood loss and transfusion, dislocation rate, mortality, and thromboembolic events.

Material and Methods

All patients were ≥75yo. Recorded data included use of anticoagulant/antiplatelet drugs, ASA, operative time, intra-operative complications, pre/post-operative hemoglobin values, transfusions, hospitalization time, DVT/PE, glomerular filtration rate, Charlson Comorbidity Index (CCI), dislocation at 60 days, and mortality at 30 days and 6 months. A secondary analysis compared the subgroups in different age range (75–85 and ≥ 86yo).

Results

In the cohort of 302 DFNF (93 BHA and 209 DMTHA) differences in mean age, CCI, and ASA score were significant. Once divided by age, the subgroups resulted comparable in terms of age and CCI, with no significant difference. A significant difference in surgical times showed DMTHA being an average 12 minutes longer than BHA. Significant was the ΔHB in the DMTHA subgroup which resulted lower compared to the BHA one. Difference in mean number of post-operative transfusion were not statistically significant.

Conclusions

From our data, DMTHA did not lead to an increase in mortality, morbidity, bleeding, or dislocation rate when compared to BHA and could be considered as treatment of choice for DFNFs especially in healthy and active patients.

Surgical interventions for treating intracapsular hip fractures in older adults: a network meta-analysis

BACKGROUND

Hip fractures are a major healthcare problem, presenting a considerable challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising rapidly. The majority of intracapsular hip fractures are treated surgically.

OBJECTIVES

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of intracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, and five other databases in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility intracapsular hip fractures in older adults. We included total hip arthroplasties (THAs), hemiarthroplasties (HAs), internal fixation, and non-operative treatments. We excluded studies of people with hip fracture with specific pathologies other than osteoporosis or resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months, and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

MAIN RESULTS

We included 119 studies (102 RCTS, 17 quasi-RCTs) with 17,653 participants with 17,669 intracapsular fractures in the review; 83% of fractures were displaced. The mean participant age ranged from 60 to 87 years and 73% were women.  After discussion with clinical experts, we selected 12 nodes that represented the best balance between clinical plausibility and efficiency of the networks: cemented modern unipolar HA, dynamic fixed angle plate, uncemented first-generation bipolar HA, uncemented modern bipolar HA, cemented modern bipolar HA, uncemented first-generation unipolar HA, uncemented modern unipolar HA, THA with single articulation, dual-mobility THA, pins, screws, and non-operative treatment. Seventy-five studies (with 11,855 participants) with data for at least two of these treatments contributed to the NMA. We selected cemented modern unipolar HA as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison. In order to provide a concise summary of the results, we report only network estimates when there was evidence of difference between treatments. We downgraded the certainty of the evidence for serious and very serious risks of bias and when estimates included possible transitivity, particularly for internal fixation which included more undisplaced fractures. We also downgraded for incoherence, or inconsistency in indirect estimates, although this affected few estimates. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.  We found that cemented modern unipolar HA, dynamic fixed angle plate and pins seemed to have the greatest likelihood of reducing mortality at 12 months. Overall, 23.5% of participants who received the reference treatment died within 12 months of surgery. Uncemented modern bipolar HA had higher mortality than the reference treatment (RR 1.37, 95% CI 1.02 to 1.85; derived only from indirect evidence; low-certainty evidence), and THA with single articulation also had higher mortality (network estimate RR 1.62, 95% CI 1.13 to 2.32; derived from direct evidence from 2 studies with 225 participants, and indirect evidence; very low-certainty evidence). In the remaining treatments, the certainty of the evidence ranged from low to very low, and we noted no evidence of any differences in mortality at 12 months.  We found that THA (single articulation), cemented modern bipolar HA and uncemented modern bipolar HA seemed to have the greatest likelihood of improving HRQoL at 12 months. This network was comparatively sparse compared to other outcomes and the certainty of the evidence of differences between treatments was very low. We noted no evidence of any differences in HRQoL at 12 months, although estimates were imprecise. We found that arthroplasty treatments seemed to have a greater likelihood of reducing unplanned return to theatre than internal fixation and non-operative treatment. We estimated that 4.3% of participants who received the reference treatment returned to theatre during the study follow-up. Compared to this treatment, we found low-certainty evidence that more participants returned to theatre if they were treated with a dynamic fixed angle plate (network estimate RR 4.63, 95% CI 2.94 to 7.30; from direct evidence from 1 study with 190 participants, and indirect evidence). We found very low-certainty evidence that more participants returned to theatre when treated with pins (RR 4.16, 95% CI 2.53 to 6.84; only from indirect evidence), screws (network estimate RR 5.04, 95% CI 3.25 to 7.82; from direct evidence from 2 studies with 278 participants, and indirect evidence), and non-operative treatment (RR 5.41, 95% CI 1.80 to 16.26; only from indirect evidence). There was very low-certainty evidence of a tendency for an increased risk of unplanned return to theatre for all of the arthroplasty treatments, and in particular for THA, compared with cemented modern unipolar HA, with little evidence to suggest the size of this difference varied strongly between the arthroplasty treatments.

AUTHORS' CONCLUSIONS

There was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, cemented modern arthroplasties tended to more often yield better outcomes than alternative treatments and may be a more successful approach than internal fixation. There is no evidence of a difference between THA (single articulation) and cemented modern unipolar HA in the outcomes measured in this review. THA may be an appropriate treatment for a subset of people with intracapsular fracture but we have not explored this further.

Arthroplasties for hip fracture in adults

BACKGROUND

Hip fractures are a major healthcare problem, presenting a huge challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising rapidly. The majority of hip fractures are treated surgically. This review evaluates evidence for types of arthroplasty: hemiarthroplasties (HAs), which replace part of the hip joint; and total hip arthroplasties (THAs), which replace all of it.

OBJECTIVES

To determine the effects of different designs, articulations, and fixation techniques of arthroplasties for treating hip fractures in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, seven other databases and one trials register in July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different arthroplasties for treating fragility intracapsular hip fractures in older adults. We included THAs and HAs inserted with or without cement, and comparisons between different articulations, sizes, and types of prostheses. We excluded studies of people with specific pathologies other than osteoporosis and with hip fractures resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for seven outcomes: activities of daily living, functional status, health-related quality of life, mobility (all early: within four months of surgery), early mortality and at 12 months after surgery, delirium, and unplanned return to theatre at the end of follow-up.

MAIN RESULTS

We included 58 studies (50 RCTs, 8 quasi-RCTs) with 10,654 participants with 10,662 fractures. All studies reported intracapsular fractures, except one study of extracapsular fractures. The mean age of participants in the studies ranged from 63 years to 87 years, and 71% were women. We report here the findings of three comparisons that represent the most substantial body of evidence in the review. Other comparisons were also reported, but with many fewer participants. All studies had unclear risks of bias in at least one domain and were at high risk of detection bias. We downgraded the certainty of many outcomes for imprecision, and for risks of bias where sensitivity analysis indicated that bias sometimes influenced the size or direction of the effect estimate. HA: cemented versus uncemented (17 studies, 3644 participants) There was moderate-certainty evidence of a benefit with cemented HA consistent with clinically small to large differences in health-related quality of life (HRQoL) (standardised mean difference (SMD) 0.20, 95% CI 0.07 to 0.34; 3 studies, 1122 participants), and reduction in the risk of mortality at 12 months (RR 0.86, 95% CI 0.78 to 0.96; 15 studies, 3727 participants). We found moderate-certainty evidence of little or no difference in performance of activities of daily living (ADL) (SMD -0.03, 95% CI -0.21 to 0.16; 4 studies, 1275 participants), and independent mobility (RR 1.04, 95% CI 0.95 to 1.14; 3 studies, 980 participants). We found low-certainty evidence of little or no difference in delirium (RR 1.06, 95% CI 0.55 to 2.06; 2 studies, 800 participants), early mortality (RR 0.95, 95% CI 0.80 to 1.13; 12 studies, 3136 participants) or unplanned return to theatre (RR 0.70, 95% CI 0.45 to 1.10; 6 studies, 2336 participants). For functional status, there was very low-certainty evidence showing no clinically important differences. The risks of most adverse events were similar. However, cemented HAs led to less periprosthetic fractures intraoperatively (RR 0.20, 95% CI 0.08 to 0.46; 7 studies, 1669 participants) and postoperatively (RR 0.29, 95% CI 0.14 to 0.57; 6 studies, 2819 participants), but had a higher risk of pulmonary embolus (RR 3.56, 95% CI 1.26 to 10.11, 6 studies, 2499 participants). Bipolar HA versus unipolar HA (13 studies, 1499 participants) We found low-certainty evidence of little or no difference between bipolar and unipolar HAs in early mortality (RR 0.94, 95% CI 0.54 to 1.64; 4 studies, 573 participants) and 12-month mortality (RR 1.17, 95% CI 0.89 to 1.53; 8 studies, 839 participants). We are unsure of the effect for delirium, HRQoL, and unplanned return to theatre, which all indicated little or no difference between articulation, because the certainty of the evidence was very low. No studies reported on early ADL, functional status and mobility. The overall risk of adverse events was similar. The absolute risk of dislocation was low (approximately 1.6%) and there was no evidence of any difference between treatments. THA versus HA (17 studies, 3232 participants) The difference in the risk of mortality at 12 months was consistent with clinically relevant benefits and harms (RR 1.00, 95% CI 0.83 to 1.22; 11 studies, 2667 participants; moderate-certainty evidence). There was no evidence of a difference in unplanned return to theatre, but this effect estimate includes clinically relevant benefits of THA (RR 0.63, 95% CI 0.37 to 1.07, favours THA; 10 studies, 2594 participants; low-certainty evidence). We found low-certainty evidence of little or no difference between THA and HA in delirium (RR 1.41, 95% CI 0.60 to 3.33; 2 studies, 357 participants), and mobility (MD -0.40, 95% CI -0.96 to 0.16, favours THA; 1 study, 83 participants). We are unsure of the effect for early functional status, ADL, HRQoL, and mortality, which indicated little or no difference between interventions, because the certainty of the evidence was very low.  The overall risks of adverse events were similar. There was an increased risk of dislocation with THA (RR 1.96, 95% CI 1.17 to 3.27; 12 studies, 2719 participants) and no evidence of a difference in deep infection.

AUTHORS' CONCLUSIONS

For people undergoing HA for intracapsular hip fracture, it is likely that a cemented prosthesis will yield an improved global outcome, particularly in terms of HRQoL and mortality. There is no evidence to suggest a bipolar HA is superior to a unipolar prosthesis. Any benefit of THA compared with hemiarthroplasty is likely to be small and not clinically appreciable. We encourage researchers to focus on alternative implants in current clinical practice, such as dual-mobility bearings, for which there is limited available evidence.

Clinical Outcomes for Hemiarthroplasty Versus Total Hip Arthroplasty in Patients With Femoral Neck Fracture Who Meet Published National Criteria for Total Hip Arthroplasty

OBJECTIVES

To examine outcome for patients with hip fracture treated by a hemiarthroplasty (HA) but who actually met the United Kingdom, National Institute for Health and Care Excellence (NICE) criteria for receiving a total hip arthroplasty (THA).

DESIGN

Match cohort study.

SETTING

Level 1, Academic Trauma Centre (UK Major Trauma Centre).

PATIENTS/PARTICIPANTS

Three hundred ninety-eight patients underwent either a HA or THA for a nonpathological displaced intracapsular fractured neck of the femur [OTA/AO 31 B3 (garden 3-4)], having met the NICE criteria for THA.

INTERVENTION

HA versus THA. Two analyses were performed, the first comparing the outcome in a cohort of patients who either received a THA or HA but who all had met the NICE criteria to receive a THA (n = 398). The second analysis assessed the outcome of THA versus HA, in a matched cohort of patients who all met the NICE criteria for a THA (n = 44 matched pairs). All patients in the matched cohort were able to walk independently outdoors (WIOs) before injury.

MAIN OUTCOME

Mobility and functional outcome, 1 year after surgery.

RESULTS

Of the 398 patients who met the criteria for THA, only 78 (19.6%) patients actually received a THA. Within the matched cohort, significantly more THA patients (92.9%, 39/42) maintained the ability to WIOs at 1-year compared with patients with HA (56.4%, 22/39; P = 0.001). There was no difference in mortality, reoperation, or complication rates for our matched population at 1 year.

CONCLUSIONS

Patients who meet the NICE criteria for THA and are able to WIOs preinjury are more likely to have a higher level of independent mobility and a better functional outcome at 1-year if they receive a THA, as opposed to receiving a HA.

LEVEL OF EVIDENCE

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

Cost-effectiveness of dual-mobility components in patients with displaced femoral neck fractures

AIMS

Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA.

METHODS

Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer's perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions.

RESULTS

DM-THA was found to be cost-effective, with an estimated incremental cost-effectiveness ratio (ICER) of CAD $46,556 (£27,074) per quality-adjusted life year (QALY). Sensitivity analysis revealed DM-THA was not cost-effective across all age groups in the first two years. DM-THA becomes cost-effective for those aged under 80 years at time periods from five to 15 years, but was not cost-effective for those aged 80 years and over at any timepoint. To be cost-effective at ten years in the base case, DM-THA must reduce the risk of dislocation compared to SB-THA by at least 62%. Probabilistic sensitivity analysis showed DM-THA was 58% likely to be cost-effective in the base case.

CONCLUSION

Treating patients with a displaced femoral neck fracture using DM-THA components may be cost-effective compared to SB-THA in patients aged under 80 years. However, future research will help determine if the modelled rates of adverse events hold true. Surgeons should continue to use clinical judgement and consider individual patients' physiological age and risk factors for dislocation. Cite this article: Bone Joint J 2021;103-B(12):1783-1790.

Comparison of Mortality, Length of Hospital Stay and Transfusion between Hemiarthroplasty and Total Hip Arthroplasty in Octo- and Nonagenarian Patients with Femoral Neck Fracture: a Nationwide Study in Korea

BACKGROUND

The purpose of this study was to compare the mortality rate between patients undergoing hemiarthroplasty (HA) and those undergoing total hip arthroplasty (THA) in two age groups: patients aged 65-79 years (non-octogenerian) and patients aged ≥ 80 years (octogenarian).

METHODS

We identified elderly (aged ≥ 65 years) femoral neck fracture patients who underwent primary THA or HA from January 1, 2005 to December 31, 2015 in South Korea using the Health Insurance and Review and Assessment database; the nationwide medical claim system of South Korea. We separately compared the mortality rate between the HA group and THA group in two age groups. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to calculate the adjusted risk ratio (aRR) of death according to the type of surgery.

RESULTS

The 3,015 HA patients and 213 THA patients in younger elderly group, and 2,989 HA patients and 96 THA patients in older elderly group were included. In the younger elderly group, the mortality rates were similar between the two groups. In older elderly group, the aRR of death in the THA group compared to the HA group was 2.16 (95% confidence interval [CI], 1.20-3.87; P = 0.010) within the in-hospital period, 3.57 (95% CI, 2.00-6.40; P < 0.001) within 30-days, and 1.96 (95% CI, 1.21-3.18; P = 0.006) within 60-days.

CONCLUSIONS

In patients older than 80 years, THA was associated with higher postoperative mortality compared to HA. We recommend the use of HA rather than THA in these patients.

Intracapsular Femoral Neck Fractures-A Surgical Management Algorithm

Background and Objectives: Femoral neck fractures are common and constitute one of the largest healthcare burdens of the modern age. Fractures within the joint capsule (intracapsular) provide a specific surgical challenge due to the difficulty in predicting rates of bony union and whether the blood supply to the femoral head has been disrupted in a way that would lead to avascular necrosis. Most femoral neck fractures are treated surgically, aiming to maintain mobility, whilst reducing pain and complications associated with prolonged bedrest. Materials and Methods: We performed a narrative review of intracapsular hip fracture management, highlighting the latest advancements in fixation techniques, generating an evidence-based algorithm for their management. Results: Multiple different fracture configurations are encountered within the category of intracapsular hip fractures, with each pattern having different optimal surgical strategies. Additionally, these injuries typically occur in patients where further procedures due to operative complications are associated with a considerable increase in mortality, highlighting the need for choosing the correct index operation. Conclusions: Factors such as pathological causes for the fracture, pre-existing symptomatic osteoarthritis, patient’s physiological age and fracture displacement all need to be considered when choosing optimal management.

Intramedullary hemostasis further reduces postoperative anemia in patients over 70 years old undergoing total hip arthroplasty

PURPOSE

Postoperative anemia has been a threat to total hip arthroplasty patients. We introduced a novel medullary cavity hemostasis (MCH) technique and combined it with tranexamic acid (TXA) to prevent postoperative anemia in elder patients. This trial was conducted to evaluate the effectiveness and safety of this technique.

METHODS

In this retrospective consecutive study, each group has 88 patients who were all over 70 years old. In the control group, patients were given TXA. In the experimental group, the MCH technique and same TXA application were used.

RESULTS

The average of total blood loss, drainage volume, and hidden blood loss were significantly less in the experimental group. The postoperative hemoglobin (Hb) level was significantly higher in the experimental group (100.6 g/dL) than it is in the control group (81.4 g/dL). None of the patient has shown signs of prosthesis subsidence, periprosthetical osteolysis, or stem loosening during follow-ups in the average follow-up time of 3 years.

CONCLUSION

We discovered that application of TXA alone is not sufficient to prevent postoperative moderate anemia in patients over 70 years old. Combination of TXA and MCH is an effective and safe way to alleviate the severity of postoperative anemia.

Initial femoral stem position in cementless bipolar hemiarthroplasty for femoral neck fracture in elderly patients is associated with early implant subsidence: A radiographic analysis

BACKGROUND

Bipolar hemiarthroplasty is a well-established treatment for displaced femoral neck fracture in elderly patients. Implant subsidence is a potential complication with cementless femoral stems, and smaller canal fill ratio has been reported as a radiographic risk factor. We aimed to determine the risk factors for subsidence, particularly the initial implant position relative to the resected medial calcar of proximal femur.

METHODS

We retrospectively reviewed all cementless bipolar hemiarthroplasties performed using a single proximally hydroxyapatite-coated femoral stem in patients with a minimum radiographic follow-up of 12 weeks between January 2017 and December 2018. The amount of subsidence (significant subsidence defined as ≥ 5 mm), canal fill ratio, and implant position relative to the point of resected medial calcar (position A: medial and superior to calcar; position B: lateral and superior to calcar; position C: lateral and inferior to calcar) were measured and analyzed.

RESULTS

One-hundred eighty patients were identified (mean age: 80.9 years). Significant subsidence was observed in 52 patients (28.9%). On multivariate analysis, older age, lower canal fill ratio, implant position B, C, and less medial overhang of stem were independent risk factors for early implant subsidence. The risk ratio of position B and C to position A was 5.13 (95% confidence interval, 2.23-11.80).

CONCLUSION

In our analysis, older age and lower canal fill ratio were associated with increased risk of subsidence, whereas implant with position A and more medial overhang were less prone to subsidence with the tapered proximally hydroxyapatite-coated implant.

Place of residence before and place of discharge after femoral neck fracture surgery are associated with mortality: A study of 1238 patients with at least three years' follow-up

BACKGROUND

Femoral neck fractures constitute a major public health challenge. The risk of death after surgery depends chiefly on the patient's general health and comorbidities. No studies assessing place of residence are available. The objectives of this study were to determine whether mortality differed according to the patient's previous place of residence and to the place of discharge, and to describe the complications occurring after femoral neck fracture surgery.

HYPOTHESIS

After femoral neck fracture surgery, the place of discharge is associated with the risk of death, and the complication rate is high.

METHODS

This single-centre retrospective study included 1241 adults who sustained a true femoral neck fracture between 2006 and 2016 and were followed up for at least 3 years. The following data were collected: age at the time of the fracture, sex, hospital stay length, place of residence before and after the fracture, characteristics of the fracture, type of treatment, time from the fracture to surgery, and whether anticoagulant therapy was given. We then recorded data on mortality and complications.

RESULTS

The 3-year mortality rate was 36.0±1.4% (95%CI, 33.3-38.7). Place of residence before the fracture was strongly associated with mortality: the risk of death was higher in patients who lived in care homes (hazard ratio [HR], 2.18) or were hospitalised (HR, 1.78) and lower in patients who lived at home (HR, 0.46). The risk of death was also higher in patients discharged to care homes (HR, 1.82) or to hospitals (HR, 1.90) and lower in patients discharged home (HR, 0.30). All these differences were statistically significant (p<0.0001).

CONCLUSION

Place of residence and likely place of discharge should be evaluated as soon as the patient is admitted to the emergency department, in order to provide the best information possible to the patient and family and to establish the most appropriate treatment strategy. Patient self-sufficiency is a major parameter that should be preserved to the extent possible.

LEVEL OF EVIDENCE

IV.

Stratified cost-utility analysis of total hip arthroplasty in displaced femoral neck fracture

OBJECTIVE

To conduct a stratified cost-utility analysis of total versus partial hip arthroplasty as a function of clinical subtype.

METHOD

All cases of this type of intervention were analysed between 2010 and 2016 in the Basque Health Service, gathering data on clinical outcomes and resource use to calculate the cost and utility in quality-adjusted life years (QALYs) at individual level. The statistical analysis included applying the propensity score to balance the groups, and seemingly unrelated regression models to calculate the incremental cost-utility ratio and plot the cost-effectiveness plane. The interaction between age group and American Society of Anesthesiologists (ASA) risk class was assessed in the multivariate analysis.

RESULTS

The study identified 5867 patients diagnosed with femoral neck fracture, of whom 1307 and 4560 were treated with total and partial hip arthroplasty, respectively. In the cost-utility analysis based on the seemingly unrelated regression, total hip arthroplasty was found to have a higher cost and higher utility (2465€ and 0.42 QALYs). Considering a willingness-to-pay threshold of €22,000 per QALY, total hip arthroplasty was cost-effective in the under-80-year-old subgroup. Among patients above this age, hemiarthroplasty was cost-effective in ASA class I-II patients and dominant in ASA class III-IV patients.

CONCLUSIONS

Subgroup analysis supports current daily clinical practice in displaced femoral neck fractures, namely, using partial replacement in most patients and reserving total replacement for younger patients.

The management of displaced femoral neck fractures: a narrative review

This article serves to review the existing clinical guidelines, and highlight the most recent medical and surgical recommendations, for the management of displaced femoral neck fractures (FNFs). It stresses the need for multi-disciplinary intervention to potentially improve mortality rates, limit adverse events and prevent further economic liability.Globally, the incidence of FNFs continues to rise as the general population ages and becomes more active. The annual number of FNFs is expected to exceed six million by 2050. The increased burden of FNFs exacerbates the demand on all services associated with treating these injuries.The management of FNFs may serve as an indicator of the quality of care of the geriatric population. However, despite escalating health costs, a significant 30-day and one-year mortality rate, increased rate of peri-operative adverse events and sub-optimal functional clinical outcomes, continued controversy exists over optimal patient care.Much debate exists over the type of surgery, implant selection and peri-operative clinical care and rehabilitation. FNF care models, systematized clinical pathways, formal geriatrics consultation and specialized wards within an established interdisciplinary care framework may improve outcomes, mitigate adverse events and limit unnecessary costs. Cite this article: EFORT Open Rev 2021;6:139-144. DOI: 10.1302/2058-5241.6.200036.

Differences of hemiarthroplasty and total hip replacement in orthogeriatric treated elderly patients: a retrospective analysis of the Registry for Geriatric Trauma DGU®

PURPOSE

Medial femoral neck fractures are typically managed with hemiarthroplasty (HA) or total hip arthroplasty (THA) in elderly patients. There is a debate as to which treatment predominates. The literatures have reported better outcomes for those patients with proximal femur fracture who were treated in an orthogeriatric centres compared to standard orthopaedic hospitals. Therefore, we have analysed the differences of outcome between HA and THA on patients, exclusively treated in orthogeriatric co-management and compared the results with the available literature.

METHODS

We conducted a retrospective registry analysis of the Registry for Geriatric Trauma DGU^®. Between 2016 and 2018, data for 16,236 patients from 78 different hospitals were available: they were analysed univariably, and differences between HA and THA were examined using propensity score matching, according to the American Society of Anesthesiologists (ASA) grade, Identification-of-Seniors-At-Risk (ISAR) Score, anticoagulation level, sex, age, and walking ability prefracture.

RESULTS

There were 4,662 patients treated with HA and 892 with THA, meeting inclusion criteria. Patients in the HA group were older (84 years (IQR 80-89) vs. 79 years (IQR 75-83); p < 0.001), with more severe preexisting conditions, with an ASA grade ≥ 3 in 79% vs. 57% in the THA group (p < 0.001). After matching, the mortality rate, in-house revision rate, and quality of life (QoL) 7 days postoperatively were not significantly different by group. After 120 days, the HA group presented a lower rate of surgical complications (4% vs. 10%; p = 0.006), while the THA group had a higher rate of independent walking (18% vs. 28%; p = 0.001) and a higher QoL, measured by the EQ-5D-3L (0.81 (IQR 0.7-1.0) vs. 0.9 (IQR 0.72-1.0); p = 0.01).

CONCLUSIONS

Due to better walking ability and QoL, THA might be the better choice in healthier and more mobile patients, while HA would be better for multimorbid patients to avoid additional complication-associated treatments. Not the age of the patient but the preoperative condition might be important for the choice between THA and HA.

THA for a Fractured Femoral Neck: Comparing the Revision and Dislocation Rates of Standard-head, Large-head, Dual-mobility, and Constrained Liners

BACKGROUND

THA is a reasonable surgical option for some patients with fragility fractures of the femoral neck, but it has the risk of prosthesis dislocation. The prosthesis combination that reduces the risk of dislocation and the rate of revision surgery is not known.

QUESTIONS/PURPOSES

In patients receiving primary THA for a femoral neck fracture, does (1) the rate of all-cause revision or (2) the reason for revision and rate of revision for dislocation differ among THA with a standard head size, large head size, dual mobility (DM), or constrained liner? (3) Is there a difference in the revision risk when patients are stratified by age at the time of surgery?

METHODS

Data were analyzed for 16,692 THAs performed to treat fractures of the femoral neck reported in the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from January 2008 to December 2018, as this included the first use of DM prostheses. The AOANJRR includes information on more than 98% of arthroplasty procedures performed in Australia. Most patients were female (72%) and the mean age was 74 years ± 11. There were 8582 standard-head prostheses, 5820 large-head prostheses, 1778 DM prostheses, and 512 constrained prostheses identified. The cumulative percent revision (CPR) was determined for all causes as well as CPR for dislocation. The time to the first revision was described using Kaplan-Meier estimates of survivorship, with right censoring for death or closure of the database at the time of analysis. The unadjusted CPR was estimated each year of the first 10 years for standard heads, 10 years for large heads, 8 years for constrained liners, and 7 years for DM prostheses, with 95% confidence intervals using unadjusted pointwise Greenwood estimates. The results were adjusted for age, sex, femoral fixation, and head size where appropriate and were considered by age groups < 70 and ≥ 70 years.

RESULTS

When adjusted for age, sex, femoral fixation and head size, there was no difference in the rate of all-cause revision at 7 years for any of the four groups. There was no difference in the rate of all-cause revision when patients were stratified by < 70 or ≥ 70 years of age. Dislocation was the most common reason for revision (32%). When analyzing revision for dislocation alone, large-head THA had a lower rate of revision for dislocation compared with standard head (HR 0.6 [95% CI 0.4 to 0.8]; p < 0.001) and DM prostheses had a lower rate of revision for dislocation than standard head for the first 3 months (HR 0.3 [95% CI 0.1 to 0.7]; p < 0.004) but not after this time point.

CONCLUSION

The Australian registry shows that there is no difference in the rate of all-cause revision for standard-head, large-head, DM prostheses or constrained liner THA after femoral neck fractures for all patients or for patients stratified into younger than 70 years and at least 70 years of age groups. Dislocation is the most common cause of revision. Large-head prostheses are associated with a lower revision risk for dislocation and DM prostheses have a lower rate of revision for dislocation than standard heads for the first 3 months only. Surgeons treating a femoral neck fracture with THA might consider a large head size if the diameter of the acetabulum will allow it and a DM prosthesis if a large head size is not possible. The age, life expectancy and level of function of patients with femoral neck fractures minimizes the potential long-term consequences of these prostheses. The lack of significant differences in survival between most prosthesis combinations means surgeons should continue to look for factors beyond head size and prosthesis to minimize dislocation and revision surgery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Hemiarthroplasty versus total hip arthroplasty for displaced femoral neck fracture in patients older than 80 years: A randomized trial protocol

BACKGROUND

The forms of treatment which are available for these patients include internal fixation, hemiarthroplasty (HA), or total hip arthroplasty (THA). Both HA and THA are widely used methods of hip replacement after displaced femoral neck fracture (DFNF). Our purpose is to analyze the long-term outcomes of these 2 different forms of treatment, which are suitable for active patients with femoral neck intracapsular fractures ≥80 years of age without advanced osteoarthritis or rheumatoid arthritis.

METHODS

This study is designed as a single-center randomized controlled trial. The participants will be randomly assigned to either the THA group or the HA group. Information will be collected from all participants after obtaining written informed consent in accordance with the Declaration of Helsinki and ethical board approval. Inclusion criteria include: displaced intracapsular femoral neck fracture, capability to obtain informed consent, no known metastatic disease, no contraindications to anesthesia, age ≥80 years, and ability to understand written Chinese. Patients will be evaluated at 3 months, 6 months, 1 year, and 3 years after surgery. At the time of the final follow-up, patients were assessed with use of the Harris hip score (HHS) and walking distance. Secondary outcomes of interest include postoperative complications, including 90-day medical complications (acute myocardial infarction, deep vein thrombosis, pulmonary embolism, intestinal obstruction, renal failure, and pneumonia) and surgical complications within 1 year (dislocation, infection, and revision replacement).

RESULTS

This trial is expected to be the largest randomized trial assessing the efficacy of THA and HA and powered to detect a potential difference in the primary outcome.

TRIAL REGISTRATION

This study protocol has been registered in Research Registry (researchregistry6203).

The comparison between total hip arthroplasty and hemiarthroplasty in patients with femoral neck fractures: a systematic review and meta-analysis based on 25 randomized controlled trials

Background

We performed an updated systematic review and meta-analysis which enrolled 25 prospective randomized controlled trials (RCTs) to compare the outcomes between total hip arthroplasty (THA) and hemiarthroplasty (HA) in patients with femoral neck fractures (FNFs).

Methods

We searched English databases which included PubMed, Embase (vis OvidSP), The Cochrane Library, and Web of Science, and Chinese databases Chinese National Knowledge Infrastructure (CNKI), VIP, Wang Fang, and China Biology Medicine Disc (CBM) in July 2020. The quality of each study was assessed according to the Cochrane Collaboration’s Risk of Bias. Risk ratios (RRs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were pooled with random-effects models. Data regarding baseline characteristics, hospital and surgery outcomes, clinical outcomes, patients’ quality of life, common complications, prothesis-related complications, mortality, and costs were reported.

Results

A total of 25 RCTs involving 3223 patients (1568 THA and 1655 HA) were included. THA had longer hospital length (WMD = 0.721, P < 0.0001) and surgery time (WMD = 20.044, P < 0.0001), and more blood loss compared with HA (WMD = 69.109, P < 0.0001). THA showed better ratings in the Harris Hip Score during follow-up periods between 1 and 5 years while no differences within 6 months and after 9 years. THA was associated with higher quality-of-life EuroQol-5 Dimension (EQ-5D) scores after 2 years of surgery but no difference within 1 year. There was no difference in common complications. THA had significant higher rate of dislocation (WMD = 1.897, P = 0.002) and lower acetabular erosion (WMD = 0.030, P = 0.001). For mortality, there was no difference during all the follow-up periods except for slightly higher 2-year mortality after surgery.

Conclusion

This meta-analysis demonstrates that THA has better medium-term functional results and quality of life and lower acetabular erosion rate, while HA shows better in reducing hospital stay, surgery time, and blood loss and also has lower dislocation rate.

Does total hip arthroplasty provide better outcomes than hemiarthroplasty for the femoral neck fracture? A systematic review and meta-analysis

PURPOSE

By comparing the outcomes of total hip arthroplasty with hemiarthroplasty in elderly patients with a femoral neck fracture to investigate the one-year mortality, dislocation, infection, reoperation rate, and thromboembolic event.

METHODS

The PubMed, EMBASE databases, and Cochrane library were systematically searched from the inception dates to April 1, 2020 for relevant randomized controlled trials in English language using the keywords: "total hip arthroplasty", "hemiarthroplasty" and "femoral neck fracture" to identify systematic reviews and meta-analyses. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration' stools, and discussed any disagreements. The third reviewer was consulted for any doubts or uncertainty. We derived risk ratios and 95% confidence intervals. Mortality was defined as the primary outcome. Secondary outcomes were other complications, dislocation, infection, reoperation rate, and thromboembolic event.

RESULTS

This meta-analysis included 10 studies with 1419 patients, which indicated that there were no significant differences between hemiarthroplasty and total hip arthroplasty in reoperation, infection rate, and thromboembolic event. However, there was a lower mortality and dislocation rate association with total hip arthroplasty at the one-year follow-up.

CONCLUSION

Based on our results, we found that total hip arthroplasty was better than hemiarthroplasty for a hip fracture at one-year follow-up.

Hemiarthroplasty versus total arthroplasty for displaced femoral neck fractures in the elderly: meta-analysis of randomized clinical trials

INTRODUCTION

Displaced femoral neck fractures (FNF) are complicated by high mortality rates and continue to represent an important cause of disability, having a negative impact on patient mobility and physical independence. The purpose of this study was to update and analyse current outcomes and evidence concerning hip hemiarthroplasty (HHA) versus total hip arthroplasty (THA) for displaced femoral neck fractures in the elderly. Thus, a meta-analysis of randomized clinical trials was conducted.

MATERIALS AND METHODS

This meta-analysis was conducted according to the PRISMA guidelines. In October 2019, the following databases were accessed: Embase, Google Scholar, Pubmed, Scopus. All randomized clinical trials (RCTs) comparing total hip arthroplasty versus hip hemiarthroplasty for displaced femoral neck fractures were included in the present study. For the statistical analysis and the methodological quality assessment, the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen) and STATA/MP Software 14.1 (StataCorp, College Station, TX) were used.

RESULTS

Data from 2325 (1171 HHA vs 1154 THA) patients were collected. The mean follow-up was 58.12 months. The HHA group reported lower values of the mean Harris hip score (EE 3.22; p = 0.2), surgical duration (EE 21.75; p < 0.0001), length of the hospitalization stay (EE 0.8; p = 0.4). The HHA group evidenced lower dislocations rate (OR 1.78; p = 0.01, Fig. 4), but higher rate of acetabular erosion (OR 0.08; p = 0.0006). At a mean of 58.12 ± 52.8 months follow-up, revisions rate scored reduced in the THA group (OR 0.76; p = 0.2). Subgroup analysis of RCTs < 5 years follow-up revealed reduced revision in favour of the HHA group (OR 2.19; p = 0.03), while subgroup analysis of RCTs > 5 years follow-up revealed reduced revision in favour of the THA group (OR 0.25; p = 0.0003). The Kaplan-Meier curve detected similarity of patients survivorship between the two groups (HR 1.06; p = 0.3).

CONCLUSION

For the elderly population, both HHA and THA are valid solutions to treat displaced femoral neck fractures, with comparable survivorship. HHA detected reduced dislocations, while for THA a lower risk of acetabular erosion and further revision surgeries were reported.

LEVEL OF EVIDENCE

Level I, meta-analysis of randomized clinical trials.

What Predicts Health-Related Quality of Life for Patients With Displaced Femoral Neck Fractures Managed With Arthroplasty? A Secondary Analysis of the HEALTH Trial

BACKGROUND

Total hip arthroplasty (THA) has been argued to improve health-related quality of life (HRQoL) and function in femoral neck fracture patients compared with hemiarthroplasty (HA). The HEALTH trial showed no clinically important functional advantages of THA over HA. The current analysis explores factors associated with HRQoL and function in this population.

METHODS

Using repeated measures regression, we estimated the association between HRQoL and function [Short Form-12 (SF-12) physical component score (PCS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score] and 23 variables.

RESULTS

THA as compared to monopolar HA, but not bipolar HA, was more likely to improve PCS scores (adjusted mean difference [AMD] 1.88 points, P = 0.02), whereas higher American Society of Anesthesiologists score (AMD -2.64, P < 0.01), preoperative use of an aid (AMD -2.66, P < 0.01), and partial weight-bearing status postoperatively (AMD -1.38, P = 0.04) demonstrated less improvement of PCS scores over time. THA improved WOMAC function scores over time compared with monopolar HA (but not bipolar HA) (AMD -2.40, P < 0.01), whereas higher American Society of Anesthesiologists classification (AMD 1.99, P = 0.01) and preoperative use of an aid (AMD 5.39, P < 0.01) were associated with lower WOMAC function scores. Preoperative treatment for depression was associated with lower functional scores (AMD 7.73, P < 0.01).

CONCLUSION

Patients receiving THA are likely to receive small and clinically unimportant improvements in health utility and function compared with those receiving monopolar HA and little improvement compared with those receiving bipolar HA. Patient-specific characteristics seem to play a larger role in predicting functional improvement among femoral neck fracture patients.

LEVEL OF EVIDENCE

Prognostic Level II.

Perioperative Outcomes of Hemiarthroplasty Versus Total Hip Arthroplasty for Geriatric Hip Fracture: The Importance of Studying Matched Populations

BACKGROUND

Geriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study.

METHODS

Patients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts.

RESULTS

In total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P < .001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation.

CONCLUSION

Geriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Total Hip Arthroplasty Versus Hemiarthroplasty for Displaced Femoral Neck Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Hip fractures are a leading cause of disability worldwide, with displaced femoral neck fractures being of particular concern. A recent meta-analysis reported that total hip arthroplasty (THA) was superior to hemiarthroplasty (HA) in terms of reoperations, but inferior in terms of dislocations. However, publication of 4 additional randomized controlled trials that enrolled nearly 1,780 additional patients merits an updated meta-analysis.

METHODS

We conducted a literature search of 4 databases to identify randomized controlled trials comparing THA and HA in patients with displaced femoral neck fractures. For patient-reported outcomes, the minimally important difference informed calculation of risk differences. We performed a subgroup analysis to address the possible impact of risk of bias and performed meta-regression to assess the possible impact of duration of follow-up.

RESULTS

Sixteen studies that enrolled 3,084 patients randomized to undergo THA (n = 1,521) or HA (n = 1,563) proved eligible. There were no significant differences between the 2 groups in terms of the revision rate at up to 5 years of follow-up or functional outcome at up to 3 years. Health-related quality of life was superior in the THA group (mean difference [MD] = 0.05, 95% confidence interval [CI] = 0.02 to 0.07, minimally important difference, 0.145). There was no significant difference between the groups in terms of dislocation or periprosthetic fracture incidence. Operative time was significantly shorter in the HA group (MD = 22 minutes, 95% CI = 9 to 35 minutes). Analyses addressing risk of bias and length of follow-up did not reveal subgroup differences. Certainty of evidence for all outcomes was rated as moderate.

CONCLUSIONS

The best evidence showed, with moderate certainty, that HA and THA likely result in similar revision rate, function, mortality, periprosthetic fracture, and dislocation at up to 5 years, with a small, possibly unimportant benefit in health-related quality of life with THA. More specifically, the improvements are well below established cutoffs for clinical importance. Almost half of all patients were from a single large randomized controlled trial, although the results were consistent across the studies. In addition, HA likely results in a clinically unimportant reduction in operative time.

LEVEL OF EVIDENCE

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

Comparing total hip arthroplasty and hemiarthroplasty for the treatment of displaced femoral neck fracture in the active elderly over 75 years old: a systematic review and meta-analysis of randomized control trials

BACKGROUND

Displaced femoral neck fractures (DFNF) are increasingly common in elderly patients. Hip arthroplasty, the recommended treatment of DFNF, consists of the total hip arthroplasty (THA) and hemiarthroplasty (HA). THA is superior to HA in younger patients. However, there are concerns whether the more substantial surgical trauma and higher dislocation rate would trade off the advantages of THA due to frailty and lower physical demands in the elderly over 75 years.

METHODS

We conducted the literature search by searching PubMed, Embase, the Cochrane Library, ClinicalTrials.gov, and Web of Science from the inception dates to June 1, 2019. Randomized controlled trials (RCTs) were included according to the inclusion and exclusion criteria. Included studies were analyzed according to Cochrane review methods.

RESULTS

Nine studies met the inclusion criteria totaling 631 participants (301 THA and 330 HA). Four of the studies conducted were identical to a previous study but look at different follow-up periods. Our study revealed that THA was superior in terms of pain HHS, total HHS, EQ-5D, and acetabulum erosion, with a trend of a lower mortality rate within 6 months after surgery. However, the THA group had a longer average operative time and higher dislocation rate, with a trend towards a higher general complication rate. Moreover, there was no significant difference in terms of reoperation rate, postoperative infection, peri-prosthetic fracture, and VTE prevalence across the groups.

CONCLUSIONS

THA may be a preferred management option for active elderly patients over 75 years old, which can provide superior hip function and life quality with acceptable risks. Strict management should be followed to prevent dislocation following a THA, especially within the first 6 months.

TRIAL REGISTRATION

This study was registered at the International Prospective Register of Systematic Reviews (CRD42019139135).

Treatment of displaced intracapsular fractures of the femoral neck with total hip arthroplasty or hemiarthroplasty

AIMS

Despite few good-quality studies on the subject, total hip arthroplasty (THA) is increasingly being performed for displaced intracapsular fractures of the neck of femur. We compared outcomes of all patients with displacement of these fractures treated surgically over a ten-year period in one institution.

METHODS

A total of 2,721 patients with intracapsular fractures of the femoral neck treated with either a cemented hemiarthroplasty or a THA at a single centre were retrospectively reviewed. The primary outcomes analyzed were readmission for any reason and revision surgery. We secondarily looked at mortality rates.

RESULTS

We found no difference in the overall revision rate or rate of infection. However, the rates of readmission due to dislocation, pain, and trochanteric bursitis were significantly higher in the THA group (p = 0.001, p < 0.001, p < 0.001, and p = 0.001, respectively).

CONCLUSION

Our study, comparing the outcomes of neck of femur fractures treated with a cemented hemiarthroplasty and THA, revealed the perceived superiority of THA was not borne out by our results. This should be carefully considered before any radical change in practice regarding the use of THA for displaced intracapsular fractures of the femoral neck. Cite this article: Bone Joint J 2020;102-B(6):693-698.

Hemiarthroplasty vs Total Hip Arthroplasty for Femoral Neck Fractures: 2010-2017 Trends in Complication Rates

BACKGROUND

Optimal treatment of femoral neck fractures (FNFs) remains debated. Recent data suggest that total hip arthroplasty (THA) confers improved functional outcomes compared to hemiarthroplasty (HA) in active patients. However, temporal trends in complication rates between these treatments lack study.

METHODS

The National Surgical Quality Improvement Program database was retrospectively queried to compare differences between HA and THA over time (2010-2012, 2013-2015, and 2016-2017) in blood transfusions, operation time, major complications, minor complications, and 30-day readmission, among FNF patients aged ≥50 years. Analyses adjusted for age, gender, anesthesia type, smoking, body mass index, hypertension, bleeding disorder, steroid use, and American Society of Anesthesiologists classification.

RESULTS

In total, 16,213 patients were identified. THA was associated with higher transfusion rates in 2010-2012 (mean = 0.34 vs 0.28, P = .001) and 2013-2015 (mean = 0.21 vs 0.19, P = .002), but not in 2016-2017 (mean = 0.13 vs 0.14, P = .146). Operation time was significantly higher for THA across all periods (P's < .001), but declined over time. In recent years, THA was associated with less major (2016-2017: 5.4% vs 10.2%, P = .02; 2013-2015: 5.3% vs 10.3%, P < .001) and minor (2016-2017: 6.2% vs 9.8%, P = .02; 2013-2015: 7.2% vs 12.4%, P < .001) complications compared to 2010-2012 (major: 7.2% vs 10.6%, P = .87; minor: 12.6% vs 10.1%, P = .89). No differences in 30-day readmission were noted.

CONCLUSION

THA was associated with less major and minor complications in recent time periods compared to HA for the treatment of FNF, controlling for comorbidities. THA trends in transfusions and operation duration have improved over time compared to HA.

Psychometric Assessment of Modified Harris Hip Score for Femoral Neck Fracture in Indian Population

BACKGROUND

Objective of the study was to evaluate and compare psychometric properties such as validity, reliability, floor ceiling effects and interpretability of the modified Harris Hip Score (mHHS) and the Forgotten Joint Score (FJS) in patients undergoing bipolar hemiarthroplasty for femoral neck fracture in Indian patients, because this has not been done before.

METHODS

This observational study consisted of 40 consecutively operated patients. Construct validity and reliability were evaluated using correlation coefficient and Intraclass correlation coefficient (ICC), respectively. Interpretability was evaluated by describing mean and standard deviation of mHHS and FJS in five subgroups of patients based on their response to the global rating questions and assessment.

RESULTS

The mean follow-up duration was 15.7 months ± 10.4. There was very high correlation between mHHS and FJS (r = 0.92, p < 0.0001) suggesting convergent construct validity. The results of correlation coefficient were 100% and 66.7% in accordance with the pre-formulated hypotheses for mHHS and FJS, respectively. mHHS and FJS demonstrated adequate construct validity and inadequate construct validity, respectively. The ICC value for mHHS and FJS was 0.80 (p = 0.005) {adequate reliability} and 0.34 (p = 0.06) {inadequate reliability}, respectively. Both mHHS and FJS-12 demonstrated acceptable level of floor (0% for mHHS and 14.3% for FJS) and ceiling effects (12.5% for both mHHS and FJS). There was significant difference in the mHHS and FJS in the five subgroups of patients suggesting adequate interpretability.

CONCLUSION

We recommend the use of the modified Harris Hip Score over the Forgotten Joint Score for functional outcome evaluation of Indian patients from rural setting undergoing bipolar hemiarthroplasty for femoral neck fracture.

Hemiarthroplasties: the choice of prosthetic material causes different levels of damage in the articular cartilage

BACKGROUND

Hemiarthroplasty has clear advantages over alternative procedures and is used in 20% of all shoulder joint replacements. Because of cartilage wear, the clinical outcome of hemiarthroplasty is unreliable and controversial. This paper suggests that the optimal choice of prosthetic material may reduce cartilage degeneration and improve the reliability of the procedure. The specific objectives were to assess 3 materials and assess how the severity of arthritis might affect the choice of prosthetic material.

METHODS

A CoCr alloy, an AL₂O₃ ceramic, and a polycarbonate urethane polymer (PCU) were mechanically tested against 5 levels of human osteoarthritic cartilage (from intact to severely arthritic, n = 45). A high friction coefficient, a decrease in Young's modulus, an increase in permeability, a decrease in relaxation time, an increase in surface roughness, and a disrupted appearance of the cartilage after testing were used as measures of cartilage damage. The biomaterial that caused minimal cartilage damage was defined as superior.

RESULTS

The CoCr caused the most damage. This was followed by the AL₂O₃ ceramic, whereas the PCU caused the least amount of damage. Although the degree of arthritis had an effect on the results, it did not change the trend that CoCr performed worst and PCU the best.

DISCUSSION AND CONCLUSION

This study indicates that ceramic implants may be a better choice than metals, and the articulating surface should be as smooth as possible. Although our results indicate that the degree of arthritis should not affect the choice of prosthetic material, this suggestion needs to be further investigated.

Radiological subsidence and acetabular erosion after tapered uncemented hemiarthroplasty in femoral neck fractures a 10- to 13- year follow-up study

BACKGROUND

Contemporary uncemented hemiarthroplasties are being used after displaced femoral neck fractures, however, their functional and radiological results remain controversial. The aim of this study was to evaluate the clinical and radiological results of a tapered uncemented stem combined with a uni- or bipolar hemiarthroplasty after a minimum follow-up of ten years.

PATIENTS AND METHODS

135 patients underwent uncemented hip hemiarthroplasty after a displaced femoral neck fracture between 2004 and 2007. Their mean age was 81.5 years old (range, 70 to 90). 38 patients were evaluated with a minimum follow-up of ten years. We analysed the complications and the postoperative clinical result according to the Merle D´Aubigné and Postel scale. Radiological femoral type according to Dorr et al., femoral canal filling and the appearance of stem loosening, subsidence and acetabular erosion according to Baker et al., were also assessed.

RESULTS

There were two early periprosthetic femoral fractures. The mean clinical score was 15.8 (range, 9 to 17). Six hips were converted to a total hip arthroplasty due to acetabular erosion, and three stems were revised due to an infection, a late periprosthetic fracture and one aseptic loosening. The survival rate for any cause was 85.4% (Confidence interval (CI) 76 - 92.4%). The survival rate for revision surgery on the acetabular side at 10 years was 92.6% (CI 85 - 100%) and on the femoral side was 97.6% (CI 94.4 - 100%). 14 hips showed non-progressive radiological subsidence and 9 acetabular erosion. Stem subsidence was related to a femoral canal filling < 80% (p = 0.035) and acetabular erosion to a cylindrical femur (p = 0.024).

CONCLUSION

Bone fixation can be obtained with a contemporary uncemented stem in hemiarthroplasty for patients over 70 years old with a femoral neck fracture. Acetabular erosion was frequent after ten years, however, the rate of revision surgery was low.