Hemiarthroplasty and total hip arthroplasty for treating primary intracapsular fracture of the hip: a systematic review and cost-effectiveness analysis

No Difference in Revision Rates or Patient-Reported Outcome Measures Between Surgical Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture: An Analysis of 5,025 Primary Total Hip Arthroplasties From the New Zealand Joint Registry

BACKGROUND

Total hip arthroplasty (THA) for femoral neck fracture (FNF) can be performed through different surgical approaches. This study compared the revision rates and patient-reported outcome measures by surgical approach.

METHODS

Data from the New Zealand Joint Registry were analyzed for patients undergoing primary THA for FNF from January 2000 to December 2021. A total of 5,025 THAs were performed for FNF; the lateral approach was used in 2,499 (49.7%), the posterior in 2,255 (44.9%), and the anterior in 271 (4.3%). The primary outcome measure was the all-cause revision rate. Secondary outcome measures included revision rates for: dislocation, aseptic femoral component loosening, periprosthetic fracture, and infection. Oxford Hip Scores (OHS) were also collected. Age, sex, body mass index, American Society of Anesthesiologists score, femoral head size, dual mobility use, femoral fixation, and surgeon experience were assessed as potential confounding variables.

RESULTS

There was no difference in the revision rates between lateral and posterior (P = .156), lateral and anterior (P = .680), or posterior and anterior (P = .714) approaches. There was no difference in the reasons for revision between the lateral and posterior approaches or 6-month OHS (P = .712). There was insufficient data to compare the anterior approach.

CONCLUSIONS

There is no difference in the overall revision rates, reasons for revision, or OHS between the lateral and posterior surgical approaches for THA performed for FNF. Insufficient data on the anterior approach is available for an accurate comparison.

LEVEL OF EVIDENCE

Level III.

Comparative Interrupted Time Series Analysis of Direct Medical Expense and Length of Stay in Elderly Patients with Femoral Neck Fractures Who Underwent Total Hip Arthroplasty and Hemiarthroplasty: A Real World Nationwide Database Study

Background

The objective of our study was to analyze the postoperative direct medical expenses and hospital lengths of stay (LOS) of elderly patients who had undergone either hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fractures and to determine the indication of THA by comparing those variables between the 2 groups by time.

Methods

In this comparative large-sample cohort study, we analyzed data from the 2011 to 2018 Korean National Health Insurance Review and Assessment Service database. The included patients were defined as elderly individuals aged 60 years or older who underwent HA or THA for a femoral neck fracture. A 1:1 risk-set matching was performed on the propensity score, using a nearest-neighbor matching algorithm with a maximum caliper of 0.01 of the hazard components. In comparative interrupted time series analysis, time series were constructed using the time unit of one-quarter before and after 3 years from time zero. For the segmented regression analysis, we utilized a generalized linear model with a gamma distribution and logarithmic link function.

Results

A total of 4,246 patients who received THA were matched and included with 4,246 control patients who underwent HA. Although there was no statistically significant difference in direct medical expense and hospital LOS for the first 6 months after surgery, direct medical expenses and hospital LOS in THA were relatively reduced compared to the HA up to 24 months after surgery (p < 0.05). In the subgroup analysis, the THA group's hospital LOS decreased significantly compared to that of the HA group during the 7 to 36 months postoperative period in the 65 ≤ age < 80 age group (p < 0.05). Direct medical expenses of the THA group significantly decreased compared to those of the HA group during the period from 7 to 24 months after surgery in the men group (p < 0.05).

Conclusions

When performing THA in elderly patients with femoral neck fractures, the possibility of survival for at least 2 years should be considered from the perspective of medical expense and medical utilization. Additionally, in healthy and active male femoral neck fracture patients under the age of 80 years, THA may be more recommended than HA.

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.

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.

Cost effectiveness analyses of total hip arthroplasty for hip osteoarthritis: A PRISMA systematic review

BACKGROUND

Healthcare services are facing economic constraints globally with an increasingly elderly population, and greater burdens of osteoarthritis. Because of the chronic nature of osteoarthritis and the costs associated with surgery, arthroplasty is seen as potentially cost saving. There have been no systematic reviews conducted on cost effectiveness analysis (CEA) studies of total hip arthroplasty (THA) in the management of osteoarthritis. The aim of this systematic review was to evaluate CEAs conducted on THA for osteoarthritis to determine if THA is a cost-effective intervention.

MATERIALS AND METHODS

A systematic review was conducted using five databases to identify all clinical CEAs of THA for osteoarthritis conducted after 1 January 1997. Twenty-eight studies were identified that met the inclusion criteria. The Quality of Health Economic Analysis (QHES) checklist was employed to assess the quality of the studies.

RESULTS

The average QHES score was 86 indicating high quality studies. All studies reviewed concluded that THA was a cost-effective intervention. In younger patients, cementless THA and ceramic on polyethylene implants were found to be most cost effective. Hybrid THA and metal on polyethylene implants had the greatest cost utility in older patients. In patients with acetabular defects, cemented cup with impaction bone grafting was most cost effective, while dual mobility THA was most cost effective in patients with high risk of dislocation.

CONCLUSION

We have shown that THA is a cost-effective treatment for hip osteoarthritis. These findings should be implemented into clinical practice to improve cost utility in health services across the world.

The effect of gait training with low-intensity neuromuscular electrical stimulation of hip abductor muscles in two patients following surgery for hip fracture: Two case reports

Background: The rate of force development (RFD) is an indicator of muscle strength. A previous study reported that the RFD of hip abductor muscles was increased by neuromuscular electrical stimulation (NMES) to gluteus medius (GM) during gait in healthy adults. However, the effects for patients following femoral head replacement for hip fracture are unclear.Purpose: The aim of this case report was to investigate the effects of gait training with sub-motor threshold NMES on RFD of hip abductor muscles in two patients following femoral head replacement for hip fracture compared to gait training without NMES.Case description: Two elderly patients following femoral head replacement for hip fracture received both interventions of gait training with sub-motor threshold NMES to GM and without NMES. Intervention phases involved 14 sessions each, for 28 sessions total.Outcomes: The RFD of hip abductor muscles, maximum walking speed, six-minute walk distance (6MWD), Berg Balance Scale, one-leg standing time (OLST), functional independence measure, and Numeric Pain Rating Scale (NPRS) were used as outcome measures. In both patients, RFD, 6MWD, OLST, and NPRS were improved by gait training with NMES compared to without NMES.Conclusion: Our results suggest the potential of NMES as a treatment methodology for these two patients undergoing femoral head replacement for hip fracture.

A Rare Case Report of Spontaneous Disassembly of Bipolar Hip Prosthesis in Elderly Patient

Introduction

Hip fracture is an established health problem, especially in the elderly population and, its incidence is dramatically rising in the globe. The standard protocol of management in the elderly population for end-stage hip diseases and unstable femur fracture is bipolar hemiarthroplasty. Common complications of hip replacement include infection, fracture, dislocation, venous thrombosis, nerve palsy, chronic pain, and implant failure. In the literature, there are very few reported cases of disassembly of the implant in hemi replacement arthroplasty.

Case Report

We, hereby, present a case of the spontaneous disassembly of the bipolar hip prosthesis, which was timely recognized and treated adequately in an elderly patient.

Conclusion

The use of the cemented bipolar prosthesis can also lead to disassembly of the implant components and thereby the need for open reduction. Identification of the distinction between dislocation of head and disassembly of the prosthetic components is vital for favorable patient prognosis.

Effect of referral systems on costs and outcomes after hip fracture surgery in Taiwan

OBJECTIVE

To explore the economic burdens of hip fracture surgery in patients referred to lower-level medical institutions and to evaluate how referral systems affect costs and outcomes of hip fracture surgery.

DESIGN

A nationwide population-based retrospective cohort study.

SETTING

All hospitals in Taiwan.

PARTICIPANTS

A total of 7500 patients who had received hip fracture surgery (International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes 820.0 ∼ 820.9 and procedure codes 79.15, 79.35, 81.52, 81.53) performed in 1997 to 2013.

MAIN OUTCOME MEASURES

Total costs including outpatient costs, inpatient costs and total medical costs and medical outcomes including 30-day readmission, 90-day readmission, infection, dislocation, revision and mortality.

RESULTS

The patients were referred to a lower medical institution after hip fracture surgery (downward referral group) and 3034 patients continued treatment at the same medical institution (non-referral group). Demographic characteristics, clinical characteristics and institutional characteristics were significantly associated with postoperative costs and outcomes (P < 0.05). On average, the annual healthcare cost was New Taiwan Dollars (NT$)2262 per patient lower in the downward referral group compared with the non-referral group. The annual economic burdens of the downward referral group approximated NT$241 million (2019 exchange rate, NT$30.5 = US$1).

CONCLUSIONS

Postoperative costs and outcomes of hip fracture surgery are related not only to demographic and clinical characteristics, but also to institutional characteristics. The advantages of downward referral after hip fracture surgery can save huge medical costs and provide a useful reference for healthcare authorities when drafting policies for the referral system.

Neck of femur fracture: who gets a total hip replacement? A review of 230 eligible patients

PURPOSE

To investigate patient-specific factors that predict Total Hip Replacement (THR) in patients with fracture neck of femur (NOF), fulfilling the National Institute of Health and Care Excellence (NICE) criteria.

METHODS

Hip fracture database from a district general hospital and university hospital was retrospectively reviewed to identify patients fulfilling NICE criteria for THR after fracture NOF. Patient demographics, Nottingham Hip Fracture score (NHFS), complications, re-operations, revision, 30 days and one-year mortality was obtained from patient-records. Independent predictors correlating with the outcome of surgery were identified. A logistic regression analysis was used to predict the type of surgery in these patients.

RESULTS

A total of 230 (114 WMH and 116 MH) were identified; 133 (57.8 per-cent) received hip hemiarthroplasty (HA), and 97 (42.2 per-cent) received THR. Patients receiving THR (mean 73.5 years, 95% CI 72-74.8) were significantly younger in comparison to patients receiving HA (mean 81.7 years, 95% CI 80.5-82.8). A negative correlation is noted between NHFS and type of surgery (Pearson's correlation - 0.537, p < 0.01), implying higher NHFS decreased the likelihood of receiving THR. Regression analysis showed NHFS (p-0.001) and walking ability (p-0.001) as significant predictors for the type of surgery (Nagelkerke R2-0.472). A log-rank test showed higher estimated survival time in patients with THR in comparison to HA (p-value 0.002).

CONCLUSIONS

NHFS and walking ability can be used as an adjunct to the NICE criteria for selecting patients for THR after fracture NOF. Carefully selected patients treated with THR survive longer and have a better outcome in comparison to HA.

Use of a Dual mobility cup to prevent hip early arthroplasty dislocation in patients at high falls risk

INTRODUCTION

Hip fracture is a common serious injury that occurs mainly in elderly. Dual-mobility hip arthroplasty or bipolar emiarthroplasty for its treatment remains a controversial decision. Co-morbidities and risk of fall represent additional aspects to be considered. The aim of our study was to determine the rate of mechanical complications for these two types of implants related to fall risk status of patients.

PATIENTS AND METHODS

Our study is a retrospective clinical trial of patients operated with a biarticular hemiarthroplasty or a dual-mobility total hip arthroplasty. Primary outcome was dislocation rate and need for any revision procedure. Patients were treated in a single center from January 2013 to March 2017. In all cases Morse Fall Scale (MSF) was calculated at patient admission to evaluate the risk of postoperative fall. Inclusion criteria to the study were: subcapital or femoral neck fracture of non-pathologic nature, patients with neuromuscular disorders or cognitive dysfunction, age > 75 years with MFS ≥ 45. The patients were reviewed postoperatively at 8 weeks, 6 months, 12 months, and then annually. Patients had clinical (Harris hip score) and radiological assessment.

RESULTS

The mean duration of the follow-up was 283 months. There were five dislocations in Group A (5,6%) and no dislocations in Group B (0%). All dislocations occurred within the first 6 months after surgery. The mean Harris Hip score was 81,7 in Group A patients and 79, 8 in Group B patients.

DISCUSSION

Treatment of hip fractures on non-cooperative patients still represents a dilemma. Falls and runaway motions represent high risk factors of dislocation. Use of dual-mobility cup has been found to be associated with a not statistically proved decrease of dislocation compared to traditional cups.

CONCLUSION

Dual-mobility cups might be considered a valuable option to prevent postoperative dislocation but further study is needed before extending the indications for dual-mobility following a fracture of the femoral neck, to assess the potential cost and complications of a longer procedure. So far, despite a lower dislocation risk, the authors actually cannot recommend widely use of a dual-motility cup instead of emiarthroplasty in high falls risk patients.

Low dislocation rate of Saturne®/Avantage® dual-mobility THA after displaced femoral neck fracture: a cohort study of 966 hips with a minimum 1.6-year follow-up

INTRODUCTION

Dislocation is a serious and common complication and a great concern with the use of total hip arthroplasty (THA) when treating displaced femoral neck fracture (FNF). Dual-mobility (DM) THA might reduce the dislocation risk. We aim to report the dislocation and revision rate of primary DM THA in patients with displaced FNF.

MATERIALS AND METHODS

Between 2005 and 2015, 966 consecutive patients (676 women) at mean age 80.5 years (range 42-104) with displaced FNF were operated with DM articulation THA by posterolateral approach (PLA). Patient files and radiographs were evaluated for dislocations, revisions, and other complications until death of the patient or August 1st, 2017. Data were crosschecked with the National Patient Registry. Patient's mental state was tested upon admissions. Surgeon's educational level was noted and post-operative cup position was measured.

RESULTS

At minimum 1.6-year follow-up, there were 45 (4.7%) dislocations and eight (0.8%) cup revisions. The 30-day mortality was 9.2% and 533 patients (55.2%) were dead at the time of last follow-up. We observed eight intraprosthetic dislocations (IPD); six occurred in relation to closed reduction. Cementless stem fixation was associated with higher dislocation risk (p = 0.04) and higher rate of stem complications (p = 0.002). There was no significant association between cognitive impairment and dislocation (OR 2.0, 95% CI 0.96-4.34, p = 0.06).

CONCLUSION

Overall, DM THA inserted via PLA results in an acceptable dislocation risk and low revision rate in fragile, old patients with acute FNF fracture, regardless of mental status. A unique complication in DM THA is IPD, which requires an immediate open reduction surgery.

Risk of bias and the reporting of surgeons' experience in randomized controlled trials of total hip and total knee arthroplasty: A systematic review

RATIONALE, AIMS, AND OBJECTIVES

The potential bias introduced by surgeons' lack of comparable, relevant experience when performing the procedures in different arms of randomized controlled trials (RCTs) is arguably not well-managed or reported. The aim of this work was to review the frequency and nature with which surgeons' relevant experience is reported in RCTs of total hip (THA) and total knee arthroplasty (TKA), and to relate this to other risk of bias domains for this study design.

METHODS

A systematic review of RCTs comparing different minimally invasive procedures for TKA and comparisons of THA and hemiarthroplasty (HA). We searched MEDLINE, EMBASE, Science Citation Index, The Cochrane Library, Conference Proceedings Citation Index-Science (CPCI-S), Current Controlled Trials, and Clinical Trials.gov.

RESULTS

Seventy-five relevant RCTs were identified, 65 RCTs comparing minimally invasive with standard or other minimally invasive approaches to TKA, and 10 for THA compared with HA. Risk of bias based on the reported details of surgeons' relevant experience was categorized as low, high, or unclear. There was a clear distinction before and after 2009, with a substantial decrease in trials at high or unclear risk of bias after this date. There were no strong associations between this domain and other, standard risk of bias domains for RCTs.

CONCLUSION

The surgeons' relevant experience in an evaluated procedure is often poorly reported but has improved since 2009. The variable is not adequately captured by any other risk of bias domain. Future work should concentrate on conducting research on a much larger sample of studies and in procedures other than knee and hip arthroplasty.

The effect of time to surgery on outcomes and complication rates following total hip arthroplasty for fractured neck of femur

INTRODUCTION

Total hip arthroplasty is recommended for elderly patients with fractured neck of femur who are independently mobile, have few co-morbidities and are not cognitively impaired. Providing a daily total hip arthroplasty service is challenging for some units in the UK and considering that these patients may be physiologically distinct from the average hip fracture patient, loss of the best practice tariff as a result of surgical delay may be unjustified. The aim of this study was to determine whether time to surgical intervention for patients eligible for total hip arthroplasty had a negative impact on patient complications, length of stay and functional outcomes.

METHODS

All patients undergoing total hip arthroplasty for fractured neck of femur at our institution over a ten-year period were identified. Complications and functional outcomes were compared between patients receiving total hip arthroplasty before and after 36 hours.

RESULTS

Of 112 consecutive patients undergoing total hip arthroplasty, 70 responded to a questionnaire or telephone consultation. Four patients were excluded owing to delayed presentation, the presence of advanced rheumatoid arthritis or a pathological fracture. Two-thirds (64%) of the remaining 66 patients underwent surgery within 36 hours of presentation. There were no significant differences between the groups of patients receiving surgery before or after 36 hours with regard to postoperative length of stay, complications, Oxford hip scores or visual analogue scale scores for state of health.

CONCLUSIONS

Delaying surgery for patients eligible for total hip arthroplasty as per the National Institute for Health and Care Excellence guidelines is justified and should not incur loss of the best practice tariff.

Risk factors for early readmission due to surgical complications after treatment of proximal femoral fractures - A Finnish National Database study of 68,800 patients

INTRODUCTION

Hip fracture surgery is associated with a considerable amount medical and surgical complications, which adversely impacts the patient's outcome and/or increases costs. We evaluated what risk factors were associated with the occurrence of early readmission due to surgical complications after hip fracture surgery.

MATERIAL AND METHODS

A nationwide database with 68,800 hip fracture patients treated between 1999 and 2011 was studied to uncover the association of readmissions with co-morbidities, fracture types, different hospital types and treatment methods using the Cox proportional hazards model.

RESULTS

Early readmission within three months due to hip fracture surgery complications occurred at a rate of 4.6%. Increased occurrence of readmission was found among patients with: heavy alcoholism (HR 1.38; 95% CI: 1.23-1.53); Parkinson's disease (PD; HR 1.22; 95% CI: 1.05-1.42); pre-existing osteoarthritis (HR 2.02; 95% CI: 1.83-2.23); rheumatic disease (HR 1.44; 95% CI: 1.27-1.65); as well as those with a fracture of the femur neck, depression, presence of a psychotic disorder, an operative delay of at least three days, or previous treatment with total hip arthroplasty.

CONCLUSION

Our results indicate that there are several factors associated with an increased risk of early readmission. We suggest that in the presence of these factors, the surgical treatment method and postoperative protocol should be carefully planned and performed.

Hip hemi-arthroplasty for neck of femur fracture: What is the current evidence?

This editorial reviews and summarises the current evidence (meta-analyses and Cochrane reviews) relating to the use of hip hemi-arthroplasty for neck of femur fractures. Regarding the optimal surgical approach, two recent meta-analyses have found that posterior approaches are associated with: higher rates of dislocation compared to lateral and anterior approaches; and higher rates of re-operation compared to lateral approaches. Posterior approaches should therefore be avoided when performing hip hemi-arthroplasty procedures. Assessing the optimal prosthesis head component, three recent meta-analyses and one Cochrane review have found that while unipolar hemi-arthroplasty can be associated with increased rates of acetabular erosion at short-term follow-up (up to 1 year), there is no significant difference between the unipolar hemi-arthroplasty and bipolar hemi-arthroplasty for surgical outcome, complication profile, functional outcome and acetabular erosion rates at longer-term follow-up (2 to 4 years). With bipolar hemi-arthroplasty being the more expensive prosthesis, unipolar hemi-arthroplasty is the recommended option. With regards to the optimal femoral stem insertion technique, three recent meta-analyses and one Cochrane Review have found that, while cemented hip hemi-arthroplasties are associated with a longer operative time compared to uncemented Hip Hemi-arthroplasties, cemented prostheses have lower rates of implant-related complications (particularly peri-prosthetic femoral fracture) and improved post-operative outcome regarding residual thigh pain and mobility. With no significant difference found between the two techniques for medical complications and mortality, cemented hip hemi-arthroplasty would appear to be the superior technique. On the topic of wound closure, one recent meta-analysis has found that, while staples can result in a quicker closure time, there is no significant difference in post-operative infections rates or wound healing outcomes when comparing staples to sutures. Therefore, either suture or staple wound closure techniques appear equally appropriate for hip hemi-arthroplasty procedures.

A New Approach for Sampling Ordered Parameters in Probabilistic Sensitivity Analysis

BACKGROUND

Probabilistic sensitivity analysis (PSA) in cost-effectiveness analysis involves sampling a large number of realisations of an economic model. For some parameters, we may be uncertain around the true mean values of the variables, but the ordering of the values is known. Typical sampling approaches lack either statistical or clinical validity. For example, sampling using a common number generator results in extreme dependence, and independent sampling can lead to realisations with incorrect ordering.

METHODS

We propose a new sampling approach for ordered parameters, the difference method (DM) approach, which samples the parameters of interest via a difference parameter. If the parameters of interest are bounded, it involves transforming the variables so that they are unbounded and then sampling via the difference parameter. We have provided a Microsoft Excel workbook to implement the method. The proposed approach is illustrated with an example sampling ordered parameters for utility and cost.

RESULTS

The DM approach has a number of advantages when comparing with the typical approaches used in practice. It generates PSA samples that have similar summary statistics as the given values in our examples, while maintaining the constraint that one value was greater than another. The method also implies plausible positive correlation between the two ordered variables.

CONCLUSIONS

Both clinical and statistical validity should be checked when producing PSA samples. The DM approach should be considered as a solution to potential problems in generating PSA samples for ordered parameters.

Reduced risk of reoperation after treatment of femoral neck fractures with total hip arthroplasty

Background and purpose - Femoral neck fractures (FNFs) are commonly treated with some kind of arthroplasty, but evidence on whether to use hemiarthroplasty (HA) or total hip arthroplasty (THA) is lacking. HA reduces the risk of dislocation, but may lead to acetabular erosion. THA implies longer surgery and increased bleeding. THA may result in better function and health-related quality of life, but evidence is contradictory. We compared HA and THA and in terms of revision, reoperation and death. Patients and methods - Data were extracted from the Swedish Hip Arthroplasty Register for 11,253 patients with acute FNF receiving cemented HA or THA during 2008-2012. 2,902 patients with THA were matched by propensity score matching with as many patients with HA based on age, sex, BMI, and ASA classification. We used competing risks survival regression with reoperation or death and revision or death as endpoints. Results - THA patients had significantly reduced risk of revision (absolute risk reduction 0.51; 95% CI 0.39-0.67) and reoperation (0.58; 0.46-0.74). THA was associated with an almost 50% reduced mortality (risk ratio as competing risk for reoperation 0.51; 0.46-0.57). Interpretation - In our national register study of femoral neck fractures, THA had a lower risk than HA for further surgical procedures related to the hip. The reasons for lower mortality after THA are not known. Despite matching, there might be a selection of more healthy patients for this procedure, and other factors unknown to us, with or without relation to the choice of implant.

Evidence based management of intracapsular neck of femur fractures

Neck of femur fractures are occurring at an increased incidence. Functionally independent patients without cognitive impairment can expect reasonable life expectancy. This indicates the need for a durable surgical option that optimises the chance to return to pre-injury functional status, with minimal risk of complications and reoperation. Most fractures are displaced. Surgical options include internal fixation, hemiarthroplasty or total hip arthroplasty (THA). Evidence is conclusive that arthroplasty options outperform internal fixation in terms of function, quality of life and reoperation rates. In anyone other than young patients where head preserving surgery is required, arthroplasty is the standard of care. Hemiarthroplasty is the heavily favoured arthroplasty option for surgeons. However, in patients other than the extreme elderly, medically infirm, neurologically impaired, or with little or no ambulatory capacity, the evidence to support hemiarthroplasty is lacking. In functionally independent patients without cognitive impairment, THA should be considered the gold standard, producing better functional and quality of life outcomes, lower reoperation rates and better cost effectiveness, with no difference in complications or mortality. An increased risk of dislocation does exist. This may be reduced with modern surgical technique and implant options. Low amounts of research have been afforded to undisplaced fractures. For this fracture type, surgery is the standard of care. Despite a higher risk of reoperation, internal fixation is the preferred option for all age groups. Further study is required to identify the difference between internal fixation and THA, in particular, for unstable fracture patterns in elderly patients.

Arthroplasty versus Internal Fixation for Displaced Intracapsular Femoral Neck Fracture in the Elderly: Systematic Review and Meta-analysis of Short- and Long-term Effectiveness

BACKGROUND

There is conflicting evidence as to whether the femoral head should be preserved or replaced in elderly patients with displaced intracapsular femoral neck fractures. In this article, we performed a systematic review and meta-analysis to compare the short- and long-term effectiveness of arthroplasty (AR) and internal fixation (IF).

METHODS

PubMed, Embase, and the Cochrane Library were searched systematically up to January 2016. All randomized controlled trials directly comparing the effectiveness of AR and IF for displaced intracapsular fracture were retrieved with no limitation on language or publication year.

RESULTS

In total, eight prospective randomized studies involving 2206 patients were included. The results of our study showed that patients in the AR group reported significantly lower complication (risk ratio: 0.56, 95% confidence interval [CI] = 0.38-0.80), re-operation (risk ratio: 0.17, 95% CI = 0.13-0.22), revision rates (risk ratio: 0.11, 95% CI: 0.08-0.16), and better function compared with their IF counterparts, and they were less likely to suffer postoperative pain. No statistically significant differences for the rates of mortality, infection, and/or deep vein thrombosis between AR and IF were found.

CONCLUSIONS

Based on our analysis, we recommend that AR should be used as the primary treatment for displaced intracapsular femoral neck fractures in the elderly. However, IF may be appropriate for those who are very frail.

A randomised feasibility study comparing total hip arthroplasty with and without dual mobility acetabular component in the treatment of displaced intracapsular fractures of the proximal femur : The Warwick Hip Trauma Evaluation Two : WHiTE Two

AIMS

The optimal treatment for independent patients with a displaced intracapsular fracture of the hip remains controversial. The recognised alternatives are hemiarthroplasty and total hip arthroplasty. At present there is no established standard of care, with both types of arthroplasty being used in many centres.

PATIENTS AND METHODS

We conducted a feasibility study comparing the clinical effectiveness of a dual mobility acetabular component compared with standard polyethylene component in total hip arthroplasty for independent patients with a displaced intracapsular fracture of the hip, for a 12-month period beginning in June 2013. The primary outcome was the risk of dislocation one year post-operatively. Secondary outcome measures were EuroQol 5 Dimensions, ICEpop CAPability measure for Older people, Oxford hip score, mortality and re-operation.

RESULTS

Only 20 patients were recruited during this time. The baseline demographics were similar in the two groups and no patient suffered a dislocation. Differences in secondary outcomes were not analysed due to the small sample.

CONCLUSION

This feasibility study suggests that any trial investigating the effectiveness of total hip arthroplasty for fracture of the hip might not be deliverable within the constraints of current systems of care in the United Kingdom. Cite this article: Bone Joint J 2016;98-B:1431-5.

A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS?

Objectives

The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS?

Methods

We performed a contemporaneous process evaluation that provides a context for the interpretation of the findings of WHiTE Two – a randomised study of THA for hip fracture. We developed a mixed methods approach to situate the trial centre within the context of wider United Kingdom clinical practice. We focused on fidelity, implementation, acceptability and feasibility of both the trial processes and interventions to stakeholder groups, such as healthcare providers and patients.

Results

We have shown that patients are willing to participate in this type of research and that surgeons value being part of a team that has a strong research ethos. However, surgical practice does not currently reflect NICE guidance. Current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients.

Conclusions

Further observational research should be conducted to define the population of interest before future interventional studies are performed.

Cite this article: C. Huxley, J. Achten, M. L. Costa, F. Griffiths, X. L. Griffin. A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS? Bone Joint Res 2016;5:444–452. DOI: 10.1302/2046-3758.510.BJR-2015-0008.R1.

Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients

This review summarises the evidence for the treatment of displaced fractures of the femoral neck in elderly patients. Results from randomised clinical trials and national register studies are presented when available.

The advantages of arthroplasty compared with internal fixation are supported by several studies. A number of studies contribute to the discussions of total hip arthroplasty (THA) versus hemiarthroplasty and unipolar versus bipolar hemiarthroplasty, but no clear-cut evidence-based recommendation can be made. THA may be particularly advantageous for active, lucid patients with a relatively long life expectancy. For patients who are physiologically older, hemiarthoplasty is probably satisfactory, and for the oldest patients with more comorbidities, unipolar implants are considered to be sufficient. If the hospital can support emergency THA surgery in sufficient numbers and quality, there may be few patients who warrant bipolar hemiarthroplasty.

The direct lateral approach reduces the risk of dislocation compared with the posterior approach. Cemented implants lower the risk of periprosthetic fracture and its subsequent morbidity and mortality. As the risk of peri-operative death related to bone cement can be reduced by adequate measures, cemented implants are recommended in fracture cases.

Take home message: There remains a great variation in the surgical management of patients with a hip fracture, and an evidence-based approach should improve the outcomes for this vulnerable patient group.

Cite this article: Bone Joint J 2016;98-B:291–7.

Meta-Analysis of a Complex Network of Non-Pharmacological Interventions: The Example of Femoral Neck Fracture

Background

Surgical interventions raise specific methodological issues in network meta-analysis (NMA). They are usually multi-component interventions resulting in complex networks of randomized controlled trials (RCTs), with multiple groups and sparse connections.

Purpose

To illustrate the applicability of the NMA in a complex network of surgical interventions and to prioritize the available interventions according to a clinically relevant outcome.

Methods

We considered RCTs of treatments for femoral neck fracture in adults. We searched CENTRAL, MEDLINE, EMBASE and ClinicalTrials.gov up to November 2015. Two reviewers independently selected trials, extracted data and used the Cochrane Collaboration’s tool for assessing the risk of bias. A group of orthopedic surgeons grouped similar but not identical interventions under the same node. We synthesized the network using a Bayesian network meta-analysis model. We derived posterior odds ratios (ORs) and 95% credible intervals (95% CrIs) for all possible pairwise comparisons. The primary outcome was all-cause revision surgery.

Results

Data from 27 trials were combined, for 4,186 participants (72% women, mean age 80 years, 95% displaced fractures). The median follow-up was 2 years. With hemiarthroplasty (HA) and total hip arthroplasty (THA) as a comparison, risk of surgical revision was significantly higher with the treatments unthreaded cervical osteosynthesis (OR 8.0 [95% CrI 3.6–15.5] and 5.9 [2.4–12.0], respectively), screw (9.4 [6.0–16.5] and 6.7 [3.9–13.6]) and plate (12.5 [5.8–23.8] and 7.8 [3.8–19.4]).

Conclusions

In older women with displaced femoral neck fractures, arthroplasty (HA and THA) is the most effective treatment in terms of risk of revision surgery.

Systematic Review Registration

PROSPERO no. CRD42013004218.

Level of Evidence

Network Meta-Analysis, Level 1.

Heterogeneity of the definition of elderly age in current orthopaedic research

Medical research often defines a person as elderly when they are 65 years of age or above, however defining elderly age by chronology alone has its limitations. Moreover, potential variability in definitions of elderly age can make interpretation of the collective body of evidence within a particular field of research confusing. Our research goals were to (1) evaluate published orthopaedic research and determine whether there is variability in proposed definitions of an elderly person, and (2) to determine whether variability exists within the important research sub-group of hip fractures. A defined search protocol was used within PubMed, EMBASE and the Cochrane Library that identified orthopaedic research articles published in 2012 that stated within their objective, intent to examine an intervention in an elderly population. 80 studies that included 271,470 patients were identified and subject to analysis. Four (5 %) studies failed to define their elderly population. The remaining 76 (95 %) studies all defined elderly age by chronology alone. Definitions of an elderly person ranged from 50 to 80 years and above. The most commonly used age to define an elderly person was 65, however this accounted for only 38 (47.5 %) of studies. Orthopedic research appears to favor defining elderly age by chronology alone, and there is considerable heterogeneity amongst these definitions. This may confuse interpretation of the evidence base in areas of orthopaedic research that focus on elderly patients. The findings of this study underline the importance of future research in orthopaedics adopting validated frailty index measures so that population descriptions in older patients are more uniform and clinically relevant.

Short-term outcomes of hip fractures in patients aged 90 years old and over receiving surgical intervention

Background

The knowledge about short-term outcomes of nonagenarians undergoing surgery for hip fracture in Asian is limited.

Methods

The patients with hip fractures who underwent hip hemiarthroplasty and open reduction with internal fixation (ORIF) for management during the period from 2008 to 2012 were identified and their medical record was retrospectively reviewed.

Results

During the study period, a total of 101 patients underwent surgery for management of hip fractures, and the age of patients ranged from 90 to 96 years. The sites of hip fracture were intertrochanteric (n = 57, 56.4%) and the neck of the femur (n = 44, 43.6%). Most of the patients had American Society of Anesthesiologists scores of 3(n = 55) or 4 (in 44 patients). 80.2% (n = 81) underwent the operation within one day after admission; however, there were 13 patients (12.9%) that underwent surgery 48 or more hours later. ORIF and hemiarthroplasty were performed for 63 (62.4%) and 38 (37.6%) patients, respectively. Overall, the 30-day and 1-year mortality rates were 9.9% (10/101) and 17.3% (13/75), respectively. Multivariate analysis showed that the 30-day mortality was significantly associated only with end-stage renal disease (ESRD) (Odds ratio, 11.13, 95% confidence interval, 1.275–97.881, P = .029).

Conclusions

The short-term outcome of surgical management for Asian nonagenarians with hip fractures is favorable in selected patients.

The orthopaedic research scene and strategies to improve it

Trauma and orthopaedics is the largest of the surgical specialties and yet attracts a disproportionately small fraction of available national and international funding for health research. With the burden of musculoskeletal disease increasing, high-quality research is required to improve the evidence base for orthopaedic practice. Using the current research landscape in the United Kingdom as an example, but also addressing the international perspective, we highlight the issues surrounding poor levels of research funding in trauma and orthopaedics and indicate avenues for improving the impact and success of surgical musculoskeletal research.

Femoral neck fractures: current management

Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.

Clinical outcomes of total hip arthroplasty for fractured neck of femur in patients over 75 years

To date, there has been little research into the clinical outcomes of total hip arthroplasty (THA) for intracapsular neck of femur (NOF) fracture in the very elderly. 44 patients over 75years underwent THA for an intracapsular NOF fracture over a two year period. Oxford Hip Scores were obtained from 37 patients with a mean score of 39.7 (range 11-47). Katz Index Scores were collected from 36 patients with a mean pre-operative score of 5.9 and post operative score of 5.7. THA in this population gives patients the best opportunity to return to premorbid function. When complications occur there is a catastrophic effect on independence. Therefore it is important to select these patients' appropriately and to optimise their medical condition peri-operatively.

Decreasing incidence of femoral neck fractures in the Medicare population

This study was designed to evaluate trends in incidence and treatment patterns for intracapsular hip fractures and to evaluate risk factors for complications and mortality. Patients with an intracapsular hip fracture who underwent internal fixation, hemiarthroplasty, or total hip arthroplasty (THA) were identified from a 5% nationwide sample of Medicare data (1998-2007). The authors identified 41,053 patients with intracapsular hip fractures between 1998 and 2007. The number of intracapsular hip fractures treated with internal fixation, hemiarthroplasty, or THA decreased by 21.8%, from 4602 in 1998 to 3601 in 2007. In 2007, 54.3% of patients with an intracapsular hip fracture were treated with hemiarthroplasty, compared with 41.2% who were treated with internal fixation and 4.5% who were treated with THA. Compared with internal fixation, hemiarthroplasty had higher adjusted risks of dislocation (+98%) and infection (+53%) at 90 days and higher rates of death (+8%) and reoperation (+33%) at 1 year. Patients who underwent THA had a higher risk of complications at 90 days compared with those who underwent hemiarthroplasty, with 114%, 39%, and 123% greater risk of dislocation, deep venous thrombosis, and mechanical complications, respectively. At 1 year, patients treated with THA had a 42% lower mortality risk and an 85% lower risk of reoperation compared with those who underwent internal fixation. Primary THA is performed more often in younger patients with fewer comorbidities. The incidence of intracapsular hip fracture decreased by 21.8% over the past decade. This decrease is likely the result of multiple factors, most significantly increased awareness and medical management of osteoporosis.

Changing trends in the treatment of femoral neck fractures: a review of the american board of orthopaedic surgery database

BACKGROUND

The purpose of this study was to investigate the trends in operative management of femoral neck fractures by orthopaedic surgeons applying for board certification.

METHODS

We queried the American Board of Orthopaedic Surgery database to identify all femoral neck fractures that had been treated and reported by candidates taking Part II of the licensing examination from 1999 to 2011 to determine the utilization of internal fixation, hemiarthroplasty, and total hip arthroplasty. The longitudinal trends were then stratified by patient age (younger than sixty-five, sixty-five to seventy-nine, eighty and older) and the declared subspecialty of the candidate.

RESULTS

There were 19,541 femoral neck fractures that had been treated by 4450 board certification candidates. The use of total hip arthroplasty increased over time (0.7% of fractures in 1999, 7.7% in 2011, p < 0.001); use of hemiarthroplasty (67.1% in 1999, 63.1% in 2011, p = 0.020) and internal fixation (32.2% in 1999, 29.2% in 2011, p = 0.064) declined slightly. All geographic regions showed an increase in utilization of total hip arthroplasty, with substantial variation between locations. The proportion of patients younger than age sixty-five who were managed with total hip arthroplasty increased from 1.4% to 13.1% (p < 0.001). Candidates with a declared subspecialty of "adult reconstruction" showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from 2009 to 2011, p < 0.001), while "trauma" subspecialty candidates demonstrated decreasing utilization of internal fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012). The percentage of candidates treating at least one femoral neck fracture decreased from 54.8% from 1999 to 2002 to 46.3% from 2009 to 2011 (p < 0.001).

CONCLUSIONS

The most substantial changes in treatment of femoral neck fractures were seen in the younger group of patients. Currently, a smaller percentage of board certification candidates are treating femoral neck fractures than those in the past, possibly reflecting a trend toward specialty care.

Historical implant or current best standard? Minimum five year follow-up outcomes of cemented Thompson hemiarthroplasties

UK NICE guidelines recommend abandoning the Thompson hemiarthroplasty (TH) in favour of a 'proven prosthesis' such as the Exeter Trauma Stem. The aim of this study was to assess the hip fracture treatment with the TH. Between 2002 and 2006, 430 cemented THs were performed (minimum 5 year follow-up). Death rates at 1 year and 5 years were 26.6% and 67.4% with low complication (Dislocation 1.4%) and revision rate (1.2%). The TH remains a reliable and proven implant in appropriate patients (over the age of 80, with low activity levels, low ambulatory status and who maybe cognitively impaired), due to low complication and revision rates. Modern implants may provide better function or longevity, but there is little evidence to support abandoning the TH.

In-Hospital Outcomes after Hemiarthroplasty versus Total Hip Arthroplasty for Isolated Femoral Neck Fractures

BACKGROUND

Previous studies suggest total hip arthroplasty may have some benefits compared to hemi-arthroplasty for displaced intracapsular femoral neck fractures in patients more than 60 years of age. The primary research question of our study was whether in-hospital adverse events, post-operative length of stay (LOS) and mortality in patients 60 year of age or older differed between total hip and hemi-arthroplasty for femoral neck fracture.

METHODS

We obtained data on 82951 patients more than 60 years of age with an isolated femoral neck fracture treated with either hemi-arthroplasty or total hip arthroplasty in 2009 or 2010 from the National Hospital Discharge Survey (NHDS) database. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9, CM) was used to code diagnoses, comorbidities, complications, and procedures.

RESULTS

Controlling for demographics and comorbidities, patients treated with hemi-arthroplasty had a 40% (95% CI 1.4-1.5) higher risk of adverse events compared to patients treated with a total hip arthroplasty. Length of stay and in-hospital mortality did not differ between these groups.

CONCLUSIONS

The observed advantage for total hip arthroplasty might reflect greater infirmity in hemi-arthroplasty patients that was not accounted for by ICD-9 codes alone.

The results of total hip arthroplasty for fractured neck of femur in octogenarians

The role of total hip arthroplasty (THA) for fracture in octogenarians remains unclear. Over a two-year period, 354 patients aged > 80 years were admitted with a displaced intracapsular hip fracture. Using defined clinical guidelines, 38 patients underwent THA with a median age of 84 years, mean follow-up of 20 months. Primary outcomes were dislocation, 30-day and one-year mortality, revision surgery and periprosthetic fracture. There were no dislocations or periprosthetic fractures and patient survival was 97% at 30 days and 87% at one year. There was one revision for deep infection. This study demonstrates that THA for selected octogenarians can be performed safely, allows the majority of patients to return to independent living and has a low complication rate.

Dual mobility cup reduces dislocation and re-operation when used to treat displaced femoral neck fractures

PURPOSE

Total hip arthroplasty (THA) as primary treatment for displaced femoral neck fractures is controversial as THA is associated with higher rates of dislocation but lower rates of re-operation compared to hemiarthroplasty (HA). A dual mobility cup (DMC) design is associated with lower dislocation and re-operation rates in elective surgery. Is this also the case when used to treat displaced femoral neck fractures? The aim of this study is to compare rates of dislocation and re-operation of any kind following treatment for displaced femoral neck fractures with either bipolar HA or THA with DMC.

METHODS

Two consecutive groups of patients treated for displaced femoral neck fractures at the Regional Hospital in Viborg in Denmark were included. In 2007-2008 171 patients (mean age 84.1 years) were treated with bipolar HA. In 2009-2010 175 patients (mean age 75.2 years) were treated with THA with DMC. Data regarding rates of dislocation and re-operation were obtained by retrospective review of medical records.

RESULTS

We found a statistically significant difference regarding rates of dislocation and re-operation of any kind in favour of THA with DMC. Dislocation occurred in 25/171 patients [95 % confidence interval (CI) 9.3-19.9 %] treated with bipolar HA and 8/175 patients (95 % CI 1.5-7.7 %) treated with THA with DMC (p = 0.002). Re-operations were required in 32/171 patients (95 % CI 12.9-24.6 %) treated with bipolar HA and 16/175 patients (95 % CI 4.8-13.4 %) treated with THA with DMC (p = 0.01).

CONCLUSIONS

Our findings indicate that THA with DMC is superior to bipolar HA following treatment for displaced femoral neck fractures in regard to rates of dislocation and re-operation.

Randomized trial of hemiarthroplasty versus internal fixation for femoral neck fractures: no differences at 6 years

BACKGROUND

Hemiarthroplasty has been shown superior to internal fixation for displaced femoral neck fractures (FNF) in the first 2 years. However, there are unanswered questions about the performance of hemiarthroplasty over the longer term compared with internal fixation.

QUESTIONS/PURPOSES

We sought to compare hemiarthroplasty with internal fixation in terms of (1) outcomes scores for pain, hip function, and quality of life at a minimum of 5 years after surgery in a randomized trial. A secondary purpose was to compare (2) patient survival and (3) frequency of reoperation in the two groups.

METHODS

A total of 222 consecutive patients older than 60 years, including those cognitively impaired, with FNF were randomized to either internal fixation with two parallel screws or bipolar hemiarthroplasty. At a minimum followup of 4.9 years (mean, 5.9 years; range, 4.9-7.2 years), 68 of the 70 surviving patients were examined by a study nurse and study physiotherapist blinded to initial treatment. Questionnaires on hip function (Harris hip score), quality of life (Eq5D), and activity of daily living function (Barthel ADL) were administered. The Barthel ADL index score was split into good function (score 95 or 100) and reduced function (score below 95).

RESULTS

The mean survival of the groups was similar with 66.4% (73 of 110) of the patients undergoing hemiarthroplasty and 70.5% (79 of 112) of the patients undergoing internal fixation having died since surgery (p = 0.51). Only 12 of 31 living patients in the internal fixation group had retained their native hips at a mean of 6 years. Between 2 and 6 years, there were two new major reoperations (both in the internal fixation group, for avascular necrosis and deep wound infection). The mean Harris hip score was 66 (SD 19) and 67 (SD 20) in the internal fixation and hemiarthroplasty groups, respectively (p = 0.96). The mean Eq5D index was 0.50 (SD 0.40) in the internal fixation group and 0.34 (SD 0.36) in the hemiarthroplasty group (p = 0.10). Function in terms of ADLs was comparable between the groups; of the patients in the internal fixation group, 42% reported good function on the Barthel ADL index, and the corresponding number in the hemiarthroplasty group was 51% (p = 0.44).

CONCLUSIONS

Hemiarthroplasty has predictable and good long-term results after FNF and is the treatment of choice compared with internal fixation. Further studies will evaluate if total hip arthroplasty has advantages over hemiarthroplasty in patients with fracture with long life expectancy.

Association between estrogen receptor α gene (ESR1) PvuII (C/T) and XbaI (A/G) polymorphisms and hip fracture risk: evidence from a meta-analysis

Background and Objective

Genetic factors are important in the pathogenesis of fractures. Notably, estrogen receptor α (ESR1) has been suggested as a possible candidate gene for hip fractures; however, published studies of ESR1 gene polymorphisms have been hampered by small sample sizes and inconclusive or ambiguous results. The aim of this meta-analysis is to investigate the associations between two novel common ESR1 polymorphisms (intron 1 polymorphisms PvuII-rs2234693: C>T and XbaI-rs9340799: A>G) and hip fracture.

Methods

Crude odds ratios (ORs) with 95% confidence intervals (CIs) were used to evaluate the strength of the association.

Results

Five case-control and three cohort studies were assessed, including a total of 1,838 hip fracture cases and 14,972 healthy controls. This meta-analysis revealed that the PvuII T allele is a highly significant risk factor for hip fracture susceptibility, with an effect magnitude similar in male and pre-menopausal and post-menopausal female patients. In stratified analysis based on ethnicity, the PvuII T allele remained significantly correlated with increased risk of hip fracture in Caucasian populations; this correlation, however, was not found in Asian populations. Unlike the PvuII polymorphism, we did not find significant differences in the XbaI (A>G) polymorphism allele or genotype distributions of hip fracture patients and controls. We also found no obvious association between the XbaI polymorphism and hip fracture in any of the racial or gender subgroups.

Conclusion

Our findings show that the ESR1 PvuII T allele may increase the risk of hip fracture and that the XbaI polymorphism is not associated with hip fracture.

A case study of binary outcome data extraction across three systematic reviews of hip arthroplasty: errors and differences of selection

BACKGROUND

Data extraction is a key stage in systematic review, yet it is the subject of little research. The aim of the present research was to use a small case study to highlight some important issues affecting this fundamental process.

METHODS

The authors undertook an analysis of differences in the binary event data extracted and analysed by three systematic reviews on the same topic: a comparison of total hip arthroplasty and hemiarthroplasty. The following binary event data were extracted for three key outcomes, common to all three reviews, from those trials common to all three reviews: Dislocation rates, 1-year mortality, and revision rates. Differences between the data extracted by the three reviews were categorised as either errors or an issue of data selection. Meta-analysis was performed to assess whether these differences led to differences in summary estimates of effect.

RESULTS

Across the three outcomes, differences in selection accounted for between 8% and 42% of the data differences between reviews, and errors accounted for between 8% and 17%. No rationale was given in any of these former cases for the choice of event data being reported. These differences did lead to small differences in meta-analysed relative risks between the two treatments in the three reviews, but none was significant.

CONCLUSIONS

Systematic reviewers should use double-data extraction to minimise error and also make every effort to clarify or explain their choice of data, within the scope of their publication. Reviewers frequently exercise selection when faced with a choice of alternative but potentially equally appropriate data for an outcome. However, this selection is rarely made clear by review authors. Systematic review was developed as a method specifically to be both reproducible and transparent. This case study suggests that neither objective is always being achieved.

The Warwick Hip Trauma Evaluation Two -an abridged protocol for the WHiTE Two Study: An embedded randomised trial comparing the Dual-Mobility withpolyethylene cups in hip arthroplasty for fracture

Fractures of the proximal femur are one of the greatest challenges facing the medical community, constituting a heavy socioeconomic burden worldwide. Controversy exists regarding the optimal treatment for independent patients with displaced intracapsular fractures of the proximal femur. The recognised alternatives are hemiarthroplasty and total hip replacement. At present there is no established standard of care, with both types of arthroplasty being used in many centres. The principal advantages of total hip replacement are a functional benefit over hemiarthroplasty and a reduced risk of revision surgery. The principal criticism is the increased risk of dislocation. We believe that an alternative acetabular component may reduce the risk of dislocation but still provide the functional benefit of total hip replacement in these patients. We therefore propose to investigate the dislocation risk of a dual-mobility acetabular component compared with standard polyethylene component in total hip replacement for independent patients with displaced intracapsular fractures of the proximal femur within the framework of the larger WHiTE (Warwick Hip Trauma Evaluation) Comprehensive Cohort Study.

Cite this article: Bone Joint Res 2013;2:210–13.

Augmentation of implant fixation in osteoporotic bone

Osteoporosis presents a dilemma for the orthopedic surgeon. Screw fixation within the bone is crucial for mechanical stabilization, maintenance of reduction, and ultimately, fracture healing. For the patient, soft bones and physiological fragility usually benefit from immediate weight bearing and mobility to avoid further disuse osteoporosis, deconditioning, and immobility. For implant companies, traditional screws, plates, and nails function for simple fractures and compliant patients. Locked plating has improved screw purchase in osteoporotic bone and has expanded fracture fixation capabilities but is not the panacea for all fractures. For orthopedic surgeons, traditional surgical augmentation for osteoporosis consisting of dual plating, augmentation with polymethyl methacrylate, joint replacement, and now locked plating are beneficial. In order to advance orthopedic care in the expanding population of elderly osteoporotic patients, modern solutions utilizing the dual properties of secure fixation and relatively flexible implants are required. Endosteal substitution, extraosteal substitution, and combined nail/plate combinations are methods of utilizing traditional implants in a nontraditional way. Nonsurgical augmentation of fracture fixation is also paramount.

The Warwick Hip Trauma Evaluation - an abridged protocol for the WHiTE Study: A multiple embedded randomised controlled trial cohort study

Fractures of the proximal femur are one of the greatest challenges facing the medical community, constituting a heavy socioeconomic burden worldwide. The National Hip Fracture Audit currently provides a framework for service evaluation. This evaluation is based upon the assessment of process rather than assessment of patient-centred outcome and therefore it fails to provide meaningful data regarding the clinical effectiveness of treatments. This study aims to capture data from the cohort of patients who present with a fracture of the proximal femur at a single United Kingdom Major Trauma Centre. Patient-centred outcomes will be recorded and provide a baseline cohort within which to test the clinical effectiveness of experimental interventions.