From Pages to Practice
Published November 20, 2019
Each year, more than 300,000 hip replacement procedures are performed in the United States. A large proportion of these are due to neck of femur fractures that are associated with significant morbidity and mortality in elderly patients.
Surgical repair in this population has typically involved either hemiarthroplasty (replacement of the femoral head with a prosthesis) or total hip arthroplasty (replacement of both the femoral head and the acetabulum).
Hemiarthroplasties are more common in current practice, given shorter operative times, reduced procedure complexity, and lower dislocation rates. In contrast, total hip arthroplasties offer better functional outcomes and lower risk of reoperation, but with the tradeoff of higher cost, longer operative times, and a higher dislocation rate.
The multicenter, international, randomized Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty (HEALTH) trial recently published in NEJM compared these two procedures. The investigators reported no significant difference between hemiarthroplasty and total hip arthroplasty in the primary outcome of the incidence of secondary hip procedures after 2 years of follow up.
The following NEJM Journal Watch summary explains the study in more detail.
Allan S. Brett, MD reviewing The HEALTH Investigators. N Engl J Med 2019 Sep 26
Hemiarthroplasty (replacement of only the femoral head) and total hip arthroplasty (replacement of both the femoral head and acetabulum) are both options for patients with displaced fractures of the femoral neck; each approach has certain advantages and disadvantages. In this international randomized trial, researchers compared the two procedures in 1495 patients.
The primary endpoint — another hip procedure required and performed within 24 months — occurred in 8% of patients in both groups. Nonsignificant trends suggested more adverse events and more hip-related complications with total hip arthroplasty than with hemiarthroplasty. Conversely, some measures of pain and function favored total hip arthroplasty compared with hemiarthroplasty, but differences were small and did not meet standard thresholds for clinical importance.
Comment: A guideline from the American Academy of Orthopaedic Surgeons (J Am Acad Orthop Surg 2015; 23:131) states that “moderate evidence supports a benefit to total hip arthroplasty in properly selected patients with unstable (displaced) femoral neck fractures.” However, the authors of the current study conclude that “the advantages of total hip arthroplasty may not be compelling.” Their results support current U.S. practice, in which the less complicated procedure — hemiarthroplasty — is done more commonly than total hip arthroplasty for displaced femoral neck fractures.