Clinical Pearls & Morning Reports
Published December 4, 2019
Despite the high frequency of hip fracture, the way in which displaced femoral neck fractures in elderly patients should be managed surgically remains uncertain. Bhandari et al. conducted a randomized, controlled trial that compared total hip arthroplasty to hemiarthroplasty in patients with a displaced femoral neck fracture. Read the Review Article here.
Q: What are some of the concerns regarding the choice of total hip arthroplasty for hip fracture?
A: Advocates of total hip arthroplasty perceive benefits with regard to patient function and quality of life as compared with hemiarthroplasty. There are concerns, however, that total hip arthroplasty has greater associated surgical morbidity than hemiarthroplasty and may increase the risk of dislocation, which often leads to a secondary procedure to reduce or revise the prosthesis.
Q: What were the eligibility criteria for participation in the trial by Bhandari et al.?
A: To be eligible for participation, patients had to be 50 years of age or older, had to have a low-energy displaced fracture of the femoral neck that was planned to be treated with surgery, and had to have been able to ambulate without the assistance of another person before the hip fracture occurred.
A: The primary end point of the trial was any unplanned secondary hip procedure within 24 months after the initial surgery. The authors found that the type of arthroplasty had no significant influence on the risk of unplanned secondary hip procedures over 24 months. A secondary hip procedure within 24 months of follow-up occurred in 57 of 718 patients (7.9%) who had been randomly assigned to total hip arthroplasty and in 60 of 723 patients (8.3%) who had been randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P=0.79). The authors note that the follow-up period in the trial may have been insufficient for understanding longer-term end points.
A: Mortality did not differ significantly between the treatment groups (14.3% in the total hip arthroplasty group and 13.1% in the hemiarthroplasty group, P=0.48). Serious adverse events occurred in 300 of 718 patients (41.8%) in the total hip arthroplasty group and in 265 of 723 patients (36.7%) in the hemiarthroplasty group (hazard ratio, 1.16; 99% CI, 0.90 to 1.51). Hip instability or dislocation occurred in 34 patients (4.7%) who were assigned to total hip arthroplasty and 17 patients (2.4%) who were assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09).