Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials

Paul T P W Burgers, Arnoud R Van Geene, Michel P J Van den Bekerom, Esther M M Van Lieshout, Bastiaan Blom, Ilyas S Aleem, M Bhandari, Rudolf W Poolman, Paul T P W Burgers, Arnoud R Van Geene, Michel P J Van den Bekerom, Esther M M Van Lieshout, Bastiaan Blom, Ilyas S Aleem, M Bhandari, Rudolf W Poolman

Abstract

Purpose: Displaced femoral neck fractures in healthy elderly patients have traditionally been managed with hemiarthroplasty (HA). Recent data suggest that total hip arthroplasty (THA) may be a better alternative.

Methods: A systematic review of the English literature was conducted. Randomized controlled trials comparing all forms of THA with HA were included. Three authors independently extracted articles and predefined data. Results were pooled using a random effects model.

Results: Eight trials totalling 986 patients were retrieved. After THA 4 % underwent revision surgery versus 7 % after HA. The one-year mortality was equal in both groups: 13 % (THA) versus 15 % (HA). Dislocation rates were 9 % after THA versus 3 % after HA. Equal rates were found for major (25 % in THA versus 24 % in HA) and minor complications (13 % THA versus 14 % HA). The weighted mean of the Harris hip score was 81 points after THA versus 77 after HA. The subdomain pain of the HHS (weighted mean score after THA was 42 versus 39 points for HA), the rate of patients reporting mild to no pain (75 % after THA versus 56 % after HA) and the score of WOMAC (94 points for THA versus 78 for HA) all favored THA. Quality of life measured with the EQ-5D favored THA (0.69 versus 0.57).

Conclusions: Total hip arthroplasty for displaced femoral neck fractures in the fit elderly may lead to higher patient-based outcomes but has higher dislocation rates compared with hemiarthroplasty. Further high-quality randomized clinical trails are needed to provide robust evidence and to definitively answer this clinical question.

Figures

Fig. 1
Fig. 1
Flow chart of article selection process
Fig. 2
Fig. 2
Revision surgery. Forest plot comparing risk ratios of revision and planned revision surgery after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Mantel-Haenszel statistical method was used with the ‘random effects’ analysis method for dichotomous data. M-H Mantel-Haenszel, THA total hip arthroplasty, HA hemiarthroplasty
Fig. 3
Fig. 3
One year mortality. Forest plot comparing risk ratios of one-year mortality after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Mantel-Haenszel statistical method was used with the ‘random effects’ analysis method for dichotomous data. M-H Mantel-Haenszel, THA total hip arthroplasty, HA hemiarthroplasty
Fig. 4
Fig. 4
Dislocation. Forest plot comparing risk ratios of dislocation after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Mantel-Haenszel statistical method was used with the ‘random effects’ analysis method for dichotomous data. M-H Mantel-Haenszel, THA total hip arthroplasty, HA hemiarthroplasty
Fig. 5
Fig. 5
Major complications. Forest plot comparing risk ratios of minor complications (as defined in Appendix 2) after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Mantel-Haenszel statistical method was used with the ‘random effects’ analysis method for dichotomous data. M-H Mantel-Haenszel, THA total hip arthroplasty, HA hemiarthroplasty
Fig. 6
Fig. 6
Minor complications. Forest plot comparing risk ratios of major complications (as defined in Appendix 2) after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Mantel-Haenszel statistical method was used with the ‘random effects’ analysis method for dichotomous data. M-H Mantel-Haenszel, THA total hip arthroplasty, HA hemiarthroplasty
Fig. 7
Fig. 7
Harris hip score. Forest plot comparing risk ratios of total Harris hip score after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Inverse variance statistical method was used with the ‘random effects’ analysis method for continuous data. IV inverse variance,THA total hip arthroplasty, HA hemiarthroplasty
Fig. 8
Fig. 8
Harris hip score subdomain pain. Forest plot comparing risk ratios of Harris hip score pain section after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Inverse variance statistical method was used with the ‘random effects’ analysis method for continuous data. IV inverse variance,THA total hip arthroplasty, HA hemiarthroplasty
Fig. 9
Fig. 9
No to mild pain. Forest plot comparing risk ratios of no-to-mild pain after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Mantel-Haenszel statistical method was used with the ‘random effects’ analysis method for dichotomous data. M-H Mantel-Haenszel, THA total hip arthroplasty, HA hemiarthroplasty
Fig. 10
Fig. 10
WOMAC subdomain pain. Forest plot comparing risk ratios of the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire (WOMAC) pain score after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Inverse variance statistical method was used with the ‘random effects’ analysis method for continuous data. IV inverse variance,THA total hip arthroplasty, HA hemiarthroplasty
Fig. 11
Fig. 11
Quality of Life EQ5D. Forest plot comparing risk ratios of quality of life derived from the EuroQol-5 Dimensions (EQ-5D) after total hip arthroplasty versus hemiarthroplasty in displaced femoral neck fractures in the healthy elderly. Inverse variance statistical method was used with the ‘random effects’ analysis method for continuous data. IV inverse variance,THA total hip arthroplasty, HA hemiarthroplasty

References

    1. Bhandari M, Devereaux PJ, Tornetta P, Swiontkowski MF, Berry DJ, Haidukewych G, Schemitsch EH, Hanson BP, Koval K, Dirschl D, Leece P, Keel M, Petrisor B, Heetveld M, Guyatt GH. Operative management of displaced femoral neck fractures in elderly patients. An international survey. J Bone Joint Surg Am. 2005;87(9):2122–2130. doi: 10.2106/JBJS.E.00535.
    1. Parker MJ, Gurusamy KS, Azegami S (2010) Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 6:CD001706
    1. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17(12):1726–1733. doi: 10.1007/s00198-006-0172-4.
    1. De Laet CE, Pols HA. Fractures in the elderly: epidemiology and demography. Baillieres Best Pract Res Clin Endocrinol Metab. 2000;14(2):171–179. doi: 10.1053/beem.2000.0067.
    1. Bergstrom U, Jonsson H, Gustafson Y, Pettersson U, Stenlund H, Svensson O. The hip fracture incidence curve is shifting to the right. Acta Orthop. 2009;80(5):520–524. doi: 10.3109/17453670903278282.
    1. Hagino H, Nakamura T, Fujiwara S, Oeki M, Okano T, Teshima R. Sequential change in quality of life for patients with incident clinical fractures: a prospective study. Osteoporos Int. 2009;20(5):695–702. doi: 10.1007/s00198-008-0761-5.
    1. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: an evidence-based review of the literature. I: femoral neck fractures. J Am Acad Orthop Surg. 2008;16(10):596–607.
    1. Haentjens P, Autier P, Barette M, Boonen S. The economic cost of hip fractures among elderly women. A one-year, prospective, observational cohort study with matched-pair analysis. Belgian Hip Fracture Study Group. J Bone Joint Surg Am. 2001;83-A(4):493–500.
    1. Harvey N, Dennison E, Cooper C. Osteoporosis: impact on health and economics. Nat Rev Rheumatol. 2010;6(20125177):99–9105. doi: 10.1038/nrrheum.2009.260.
    1. Keating JF, Grant A, Masson M, Scott NW, Forbes JF (2005) Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty. Health Technol Assess 9(41):iii–iv, ix–x, 1–65
    1. Raaymakers ELFB. Fractures of the femoral neck: a review and personal statement. Acta Chir Orthop Traumatol Cech. 2006;73(1):45–59.
    1. Tanous T, Stephenson KW, Grecula MJ. Hip hemiarthroplasty after displaced femoral neck fracture: a survivorship analysis. Orthopedics. 2010;33(6):385–385.
    1. van den Bekerom MPJ, Hilverdink EF, Sierevelt IN, Reuling EMBP, Schnater JM, Bonke H, Goslings JC, van Dijk CN, Raaymakers ELFB. A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: a randomised controlled multicentre trial in patients aged 70 years and over. J Bone Joint Surg Br. 2010;92(10):1422–1428. doi: 10.1302/0301-620X.92B10.24899.
    1. Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg Am. 2006;88(12):2583–2589. doi: 10.2106/JBJS.E.01373.
    1. Blomfeldt R, Tornkvist H, Eriksson K, Soderqvist A, Ponzer S, Tidermark J. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br. 2007;89(2):160–165. doi: 10.1302/0301-620X.89B2.18576.
    1. Macaulay W, Nellans KW, Garvin KL, Iorio R, Healy WL, Rosenwasser MP. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. J Arthroplasty. 2008;23(6 Suppl 1):2–8. doi: 10.1016/j.arth.2008.05.013.
    1. Mouzopoulos G, Stamatakos M, Arabatzi H, Vasiliadis G, Batanis G, Tsembeli A, Tzurbakis M, Safioleas M. The four-year functional result after a displaced subcapital hip fracture treated with three different surgical options. Int Orthop. 2008;32(3):367–373. doi: 10.1007/s00264-007-0321-1.
    1. Cho M-R, Lee H-S, Lee S-W, Choi C-H, Kim S-K, Ko S-B. Results after total hip arthroplasty with a large head and bipolar arthroplasty in patients with displaced femoral neck fractures. J Arthroplasty. 2011;26(6):893–896. doi: 10.1016/j.arth.2010.01.001.
    1. Rodriguez-Merchan EC. Displaced intracapsular hip fractures: hemiarthroplasty or total arthroplasty? Clin Orthop Relat Res. 2002;399:72–77. doi: 10.1097/00003086-200206000-00010.
    1. Schmidt AH, Leighton R, Parvizi J, Sems A, Berry DJ. Optimal arthroplasty for femoral neck fractures: is total hip arthroplasty the answer? J Orthop Trauma. 2009;23(6):428–433. doi: 10.1097/BOT.0b013e3181761490.
    1. Hopley C, Stengel D, Ekkernkamp A, Wich M (2010) Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review. BMJ 340:c2332
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):1–34. doi: 10.1016/j.jclinepi.2009.06.006.
    1. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c332. doi: 10.1136/bmj.c332.
    1. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, Hill S, Jaeschke R, Leng G, Liberati A, Magrini N, Mason J, Middleton P, Mrukowicz J, O'Connell D, Oxman AD, Phillips B, Schunemann HJ, Edejer TT-T, Varonen H, Vist GE, Williams JW, Zaza S. Grading quality of evidence and strength of recommendations. BMJ. 2004;328(15205295):1490.
    1. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006;88(2):249–260. doi: 10.2106/JBJS.E.00215.
    1. Macaulay W, Nellans KW, Iorio R, Garvin KL, Healy WL, Rosenwasser MP. Total hip arthroplasty is less painful at 12 months compared with hemiarthroplasty in treatment of displaced femoral neck fracture. HSS J. 2008;4(1):48–54. doi: 10.1007/s11420-007-9061-4.
    1. Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur—13 year results of a prospective randomised study. Injury. 2000;31(10):793–797. doi: 10.1016/S0020-1383(00)00125-X.
    1. Skinner P, Riley D, Ellery J, Beaumont A, Coumine R, Shafighian B. Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement. Injury. 1989;20(5):291–293. doi: 10.1016/0020-1383(89)90171-X.
    1. Dorr LD, Glousman R, Hoy AL, Vanis R, Chandler R. Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty. J Arthroplasty. 1986;1(1):21–28. doi: 10.1016/S0883-5403(86)80006-7.
    1. Goh S-K, Samuel M, Su DHC, Chan ES-Y, Yeo S-J. Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced neck of femur fracture. J Arthroplasty. 2009;24(3):400–406. doi: 10.1016/j.arth.2007.12.009.
    1. Bhandari M, Sprague S, Schemitsch EH. Resolving controversies in hip fracture care: the need for large collaborative trials in hip fractures. J Orthop Trauma. 2009;23(6):479–484. doi: 10.1097/BOT.0b013e3181a772e3.
    1. Dijkman BG, Kooistra BW, Pemberton J, Sprague S, Hanson BP, Bhandari M. Can orthopedic trials change practice? Acta Orthop. 2010;81(1):122–125. doi: 10.3109/17453671003587093.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa