A survey of the treatment of displaced intracapsular femoral neck fractures in the UK

Inconsistency of Bone Mineral Density Between Femoral Head and Proximal Femur After Femoral Neck Fracture Surgery Indicates Great Possibility of Femoral Head Necrosis

On clinical observation, it was found that the bone mineral density (BMD) of the femoral head and proximal femur was not consistent in some patients with femoral neck fracture after surgery. The current study was performed to explore whether this phenomenon was associated with femoral head necrosis after surgery for femoral neck fracture. Bone mineral density inconsistency is when the difference of the sum of pixel values on both sides of the fracture line has exceeded 30%. Statistical analysis was performed on the clinical characteristics of 271 patients who had received the operation for femoral neck fracture. Chi-square test, Spearman rank correlation, independent sample t test, Kaplan-Meier method, and log-rank test, as well as univariate Cox regression and multivariate Cox regression, were used to analyze the potential relationship among related factors. It was revealed that the incidence of inconsistency in BMD between the femoral head and proximal femur was significantly increased in patients with femoral head necrosis after surgery for femoral neck fracture, and that the consistency was considerably high between BMD inconsistency and femoral head necrosis. The inconsistent BMD occurred 11.1 months earlier than the necrosis of the femoral head. Cox multivariate regression analysis indicated that the inconsistency in BMD between the femoral head and proximal femur after surgery for femoral neck fracture was an independent prognostic factor affecting femoral head necrosis. The inconsistent changes in BMD between the femoral head and proximal femur after surgery for femoral neck fracture indicate a great possibility of femoral head necrosis. [Orthopedics. 2021;44(2):e223-e228.].

Cemented versus cementless bipolar hemiarthroplasty for femoral neck fractures in the elderly

The management of femoral neck fractures remains controversial. Treatment options include a wide variety of internal fixation methods, unipolar or bipolar hemiarthroplasty or total hip replacement.We carried out a systematic review of the available literature to detect differences between cemented and cementless fixation of bipolar prostheses in treating femoral neck fractures in patients aged 60 years or older.Thirteen studies involving a total of 1561 bipolar hemiarthroplasties (770 cemented and 791 uncemented) were identified. Uncemented hemiarthroplasty was associated with significantly lower blood loss (p < 0.0001), shorter operative time (p < 0.0001), less infection (p = 0.03) and lower risk of heterotopic ossification (p = 0.007). On the other hand, patients with cemented hemiarthroplasty suffered significantly less postoperative thigh pain than those with cementless implantation (p < 0.00001).The existing evidence indicates that uncemented bipolar hemiarthroplasty offers shorter operative time, less blood loss, lower local complications and a similar rate of systemic complications and reoperations as compared to cemented implantation. Cite this article: EFORT Open Rev 2021;6:380-386. DOI: 10.1302/2058-5241.6.200057.

Cemented versus uncemented hemi-arthroplasty for femoral neck fractures in elderly patients: A systematic review and meta-analysis of randomized controlled trials

AIM

To compare the efficacy and safety of cemented and uncemented hemiarthroplasty in elderly patients with femoral neck fracture.

MATERIALS AND METHODS

We searched PubMed, EMBASE, and Cochrane Library databases for published randomized clinical trials comparing cemented hemiarthroplasty with uncemented hemiarthroplasty in elderly patients with a femoral neck fracture. The search was not limited to language, time, or other factors. The quality of each study was assessed using the revised Jadad scale. Two researchers independently extracted data from all selected studies, including the following base line data: study period, fracture stage, number of patients, male female ratio, average age, and per-protocol (PP) or intent-to-treat (ITT), and the interest outcomes: the mortality at 12 months, operative time, hospital stay, common complications, prosthetic-related complications, blood loss and Harris Hip Score (HHS). Fixed-effects or random-effects models with mean differences and odds ratios were used to pool the continuous and dichotomous variables to determine heterogeneity of the included studies.

RESULTS

A total of 8 studies involving 1577 hips (782 uncemented and 795 cemented) were included in this meta-analysis. The meta-analysis is indicated that the operation time of cemented hemiarthroplasty was longer than uncemented hemiarthroplasty and there was statistical significance between two groups (OR = -7.30, 95%CI, -13.13, -1.46; P = .01). However, there was no significant difference between the two methods of fixation in mortality at 12 months (OR = 1.22, 95%CI, 0.94-1.59; P = .14), hospital stay (OR = 0.26, 95%CI, -0.41, 0.93; P = .44), blood loss (OR = -17.94, 95%CI, -65.83, 29.95; P = .46), and HHS score. There were significant differences in the common complications of pulmonary embolism between the two groups, but there were no differences in the other five common complications. The results showed that uncemented hemiarthroplasty could reduce the incidence of pulmonary embolism after operation. Moreover, the outcomes of prosthetic-related complications showed that there were significant differences between the two groups in periprosthetic fracture (OR = 8.32, 95%CI, 3.85-17.98; P < .00001) and prosthetic subsidence and loosening (OR = 5.33, 95%CI, 2.18-13.00; P = .0002).

CONCLUSIONS

Our study shows that uncemented prosthesis can shorten the operation time and reduce the incidence of pulmonary embolism, but it does not reduce mortality, blood loss, and hospital stay. Most importantly, the incidence of prosthetic-related complications was higher in uncemented patients.

Bone cement leaking into iliac vein during artificial femoral head replacement: A case report

RATIONALE

Leakage of bone cement from femoral medullary cavity is a rare complication after hip arthroplasty, and there is no report on the leaked bone cement entering into iliac vessels.

PATIENT CONCERNS

An 89-year-old woman presented with a fracture in the right femoral neck. She had well-fixed right femoral head replacement after careful preoperative examinations, and no adverse reactions appeared. She was able to get off bed to walk at the 2nd day after surgery.

DIAGNOSES

Postoperative radiograph showed leakage of bone cement into the joint through femoral medullary cavity entering into iliac vessels, but the patient complained no discomforts. She received a treatment with low-molecular weight heparin and rivaroxaban.

OUTCOMES

The patient was able to walk with normal gait, without swelling in both lower extremities and discomfort in the hip. There was no other complication concerning intravascular foreign bodies.

LESSONS

This case calls into the phenomenon of leakage of injected bone cement in femoral head replacement regardless of complete and nonfractured femur, which may be into the lower limb and pelvic veins, given that, dangerous consequences will not occur.

Historically, did Cemented Thompson perform better than uncemented Austin Moore hemiarthroplasty for femoral neck fractures? A meta-analysis of available evidence

INTRODUCTION

Thompson and Austin Moore prostheses have been commonly used in hemiarthroplasties for displaced femoral neck fractures. There has been considerable debate about which of these prostheses is preferred. The purpose of this meta-analysis was to compare historical data for clinical outcomes of cemented Thompson and uncemented Austin Moore hemiarthroplasty in displaced femoral neck fractures.

METHODS

We searched Medline via PubMed, Cochrane Central, Scopus, Ovid and Web of Science for relevant articles up to February 2019. The included outcomes measured were hip function, hip pain, implant-related complications, surgical complications, reoperation rate and hospital stay. The data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) between the two compared groups in a meta-analysis model.

RESULTS

Ten studies (four RCTs and six observational studies) with a total of 4378 patients were included in the final analysis. The pooled RR showed that the Thompson group was associated with a lower incidence of postoperative hip pain (RR = 0.66, 95% CI [0.54, 0.80]), lesser reoperation rate (RR = 0.46, 95% CI [0.24, 0.88]), lesser intraoperative fractures (RR = 0.15, 95% CI [0.09, 0.25]), but a longer operative time (MD = 12.04 min, 95% CI [2.08, 22.00]) in comparison to the Austin Moore group. The effect estimate did not favour either group in terms of hip function, periprosthetic fractures, prosthetic dislocations, wound infection, mortality and hospital stay.

CONCLUSION

Evidence shows that Thompson hemiarthroplasty is better than Austin Moore hemiarthroplasty in terms of hip pain, reoperation rate and intraoperative fractures. Whereas the postoperative hip function is equivalent, these results could be considered when assessing the outcomes in modern hips.

Uncemented Thompson's hemiarthroplasty: safe, palliative and cost-effective surgery in the infirm patient-a consecutive series of 1445 cases

BACKGROUND

Guidelines on the management of displaced intracapsular fractures recommend using an Orthopaedic Data Evaluation Panel-rated cemented implant. Prior to the National Institute for Health and Care Excellence guidelines, uncemented implants were commonly used in the UK.

METHODS

We retrospectively examined the outcomes of patients with uncemented Thompson's hemiarthroplasties at our unit, between April 2005 and December 2010. Patients who underwent revision surgery before December 2011 were identified. Implant survival calculation utilised the primary outcome of revision to total hip arthroplasty, revision hemiarthroplasty or excision arthroplasty. Patients who died post-operatively were identified and censored.

RESULTS

A total of 1445 patients received uncemented Thompson's implant. Patient mean age was 82 years with 76% female. Forty-six (3.2%) patients required revision with 15% performed within 30 days of surgery and 62% within 1 year. Reasons for revision were infection (0.83%), acetabular erosion (0.83%) and loosening (0.62%). Twenty-seven patients (59% of total revisions) underwent revision to THA, 14 (30%) to excision arthroplasty and 5 (11%) to revision hemiarthroplasty. Cumulative survival rate was 98% at 1 year and 95% at 5 years. Thirty-day mortality was 7.1%. One-year mortality was 28.1%.

CONCLUSION

Current guidelines strongly favour cemented hemiarthroplasty. Recognition that fractured hip patients are a non-homogeneous group is important. In patients with limited life expectancy, an uncemented Thompson is a quick, simple, palliative solution to early mobilisation. Correct surgical technique avoids using cement in this cohort, which is most vulnerable to bone cement implantation syndrome. Cost-effective resource utilisation with an increasingly elderly population remains a surgical responsibility.

Early acetabular cartilage wear following hemiarthroplasty: An ovine model

Objectives: Hemiarthroplasty induces degenerative changes in the hip joint, which are difficult to evaluate in vivo. Radiostereometric analysis (RSA) is a radiographic measurement technique that has recently been used to measure acetabular cartilage wear in vivo. The aim of the study was to measure acetabular cartilage wear, using this technique, in an ovine model during the first 14 weeks post-implantation.

Methods: Measurements of three-dimensional femoral head migration, combined with visual assessments at necropsy and safranin O staining for cartilage integrity, were undertaken.

Results: Mean femoral head migration during the first six weeks was 0.525 mm in the medial, 0.144 mm in the cranial, and 0.517 mm in the dorsal direction. The majority of this migration was confirmed to be cartilage wear in the medial and dorsal aspects of the acetabulum at necropsy and with subsequent histological evaluation depicting significant cartilage degeneration.

Clinical significance: Radiostereometric analysis is the current gold standard technique for in vivo assessment of implant migration following total hip replacement. This study has utilized RSA to quantify the amount of early cartilage wear in vivo, which was supported by ex vivo evaluations. Accurately measuring the amount of cartilage wear will allow future studies to compare component material and design characteristics prior to clinical use.

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.

Management of young femoral neck fractures: is there a consensus?

BACKGROUND

Femoral neck fractures in young adults (ages <60) are high-energy injuries that are associated with major fracture healing complications such as avascular necrosis, nonunion, and significant shortening. Historically, evidence from small trials has suggested multiple cannulated screws were the optimal implant; however, newer studies and implant designs warrant reevaluation of screws as the gold standard among surgeons. In addition, controversies surrounding reduction technique and urgency of surgical fixation have been previously identified. We aimed to survey surgeon treatment preferences for these challenging fractures.

METHODS

A 17-item survey was developed and tested for validity and reliability prior to administration. The questionnaire characterised surgeon demographics, treatment preferences for displaced and undisplaced fractures, and controversies for future clinical trials. The target population consisted of surgeons from the Canadian Orthopaedic Association, the Orthopaedic Trauma Association, and attendees at an international fracture course.

RESULTS

540 surgeons completed the survey, exceeding our sample size requirement. There was a similar proportion of respondents from academic and community hospitals. Most surgeons (61%) treat 1-5 young adult femoral neck fractures per year. For undisplaced fractures, 78% of respondents prefer to use multiple cannulated screws. For displaced fractures, equal preference for multiple screws (46%) and the sliding hip screw (SHS, 49%) was reported. The majority of surgeons perform an open reduction in less than 25% of cases, and the time to fixation was typically between 8 and 24h.

CONCLUSIONS

Multiple cannulated screws remain the preferred treatment for most surgeons treating undisplaced fractures; however, there is an equal divide in preference between multiple screws and the SHS for displaced fractures. This increased preference for the SHS contradicts previous survey and small trial data recommending multiple screws for all fracture patterns. The lack of surgeon consensus and the high rates of fracture complications associated with fixation of young femoral neck fractures supports the need for definitive clinical trials to optimise patient important outcomes.

Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Whether bipolar hemiarthroplasty (BH) for displaced femoral neck fractures has benefit over unipolar hemiarthroplasty (UH) remains controversial. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the relative effects between BH and UH.

METHODS

A systematic literature search (up to April, 2014) was conducted to include RCTs comparing BH with UH for displaced femoral neck fractures. Two authors independently assessed methodological quality of the included studies and extracted data. Surgical information and postoperative outcomes were analyzed.

RESULTS

A total of 10 RCTs including 1,190 patients were indentified. Our results demonstrated that BH was associated with similar or better outcomes in hip function, hip pain, and quality of life while with a higher cost compared with UH. Moreover, there were no significant differences between BH and UH with regard to operation time, blood loss, blood transfusion, hospital stay, mortality, reoperation, dislocation, and complications. BH could significantly decrease the incidence of acetabular erosion at 1 year follow-up compared with UH (RR = 0.24, 95% confidence interval (CI) = 0.06 to 0.89, P = 0.03), but no significant difference was observed at 4 months, 2 years, and 4 years follow-ups.

CONCLUSIONS

Based on the current evidence, BH is not superior to UH in terms of surgical information and postoperative results. Despite similar or better clinical outcomes compared with UH, BH with a higher cost could not decrease long-term acetabular erosion rate.

Cemented Thompson's hemiarthroplasty in patients with intracapsular neck of femur fractures: survival analysis of 1,670 procedures

Cemented Thompson's prostheses have been used to treat elderly patients with displaced intracapsular hip fractures at our two units for the last 15 years, amid growing support for the use of newer implant designs for hip hemiarthroplasty. This provided us with an opportunity to investigate survival of the Thompson's stem in our patients. A retrospective cohort study was set up to review previously collected data on patients who underwent Thompson's hemiarthroplasty over a 7-year period. These were linked to surgical notes, clinical letters and radiographs to record post-operative course and subsequent admissions and procedures. The identifiers were then linked to mortality data from the Office of 'National Statistics. Kaplan-Meier survival analyses were done for implants and patients. A total of 1,632 patients (mean age 82.7 years) underwent 1,670 procedures. Five-year implant survival was 95.4 %. A total of 36 stems were revised, including 14 revisions to total hip arthroplasty and 22 excision arthroplasties. Reasons for revision included infection (2.1 %), dislocation (1.1 %) and aseptic loosening (0.5 %). Symptomatic aseptic loosening and acetabular erosion occurred late (mean time 3.2 and 5.7 years, respectively following surgery). Aseptic loosening and erosion following hemiarthroplasty are relatively late complications.

Current trends of stem use in hemiarthroplasty for femoral neck fracture in South Korea

Background

Hemiarthroplasty is a common operation to treat femoral neck fracture in elderly patients. The choice of whether to use cemented stem or cementless stem in hemiarthroplasty has been controversial in clinical practice. However, recent trends regarding stem choice in South Korea are not known or documented. In this study, we assessed the trends of stem fixation in hemiarthroplasty for femoral neck fractures in South Korea.

Methods

Data of patients with femoral neck fractures, who were operated on between the years of 2007 and 2011 and were ≥ 50 years old at the time of operation, were obtained from the Health Insurance Review and Assessment Service. All new visits or admissions to clinics or hospitals for femoral neck fractures were identified using the International Classification of Disease Tenth Revision diagnostic code (S720). The trends in the utilization of cemented and cementless hemiarthroplasty were then analyzed.

Results

The proportion of cementless hemiarthroplasty increased from 42.7% of all surgical procedures in 2007 to 61.4% of all surgical procedures in 2011 (p < 0.001), while the use of cemented hemiarthroplasty demonstrated a corresponding decrease.

Conclusions

There was a current trends towards using cementless stems in hemiarthroplasty for femoral neck fractures in South Korea.

Effect of depression on femoral head avascular necrosis from femoral neck fracture in patients younger than 60 years

The purpose of this study was to determine the effect of depression on femoral head avascular necrosis (AVN) from femoral neck fracture in patients younger than 60 years and the relationship between depression and postoperative quality of life. The Beck Depression Inventory-II (BDI-II) was completed by 641 patients (352 men and 289 women; average age, 41.7±10.2 years; range, 20-60 years) postoperatively. Patients were divided into groups according to BDI-II score: a depressed group (BDI-II score of 14 or higher) and a nondepressed group (BDI-II score lower than 14). They were followed for an average of 28 months (range, 24-37 months). The postoperative diagnosis was confirmed by typical radiographs and single photon-emission computed tomography. Quality of life among patients was assessed using the Short Form-36 (SF-36) questionnaire. The overall incidences of depression and AVN were 30.6% (196 of 641) and 20.9% (134 of 641), respectively. Ninety-four (48.0%) patients in the depressed group and 40 (9.0%) patients in the nondepressed group ultimately developed AVN. Symptoms of depression significantly affected AVN. In addition, depression predicted patients' quality of life, as did sex, partner status, employment status, living alone, frequency of exercise, severity of fractures, and length of hospital stay. In a multiple linear regression model analyzing all of these variables, depression was the best independent predictor of quality of life. Depression in patients younger than 60 years with femoral neck fractures may increase postoperative femoral head AVN risk and greatly affect patients' quality of life.

Clinical implication of subgrouping in valgus femoral neck fractures: comparison of 31-B1.1 with 31-B1.2 fractures using the OTA/AO classification

OBJECTIVES

This study aimed to identify the clinical implications of valgus-impacted femoral neck fractures and compare fractures with >15-degree angle of impaction (31-B1.1) against fractures with <15-degree angle of impaction (31-B1.2).

DESIGN

Retrospective study.

PATIENTS/PARTICIPANTS

We enrolled 78 patients with 31-B1 femoral neck fractures who were treated by screw osteosynthesis.

MAIN OUTCOME MEASUREMENTS

We evaluated the clinical and radiographic outcomes.

RESULTS

Thirty-six patients sustained 31-B1.1 fractures, and 42 patients sustained 31-B1.2 fractures. The average follow-up period was 15 months, and bony union occurred in all cases. The mean femur neck shortening was 8.88 mm for B1.1 and 3.70 mm for B1.2 fractures (P < 0.001). The mean sliding distance of the screw was 3.36 mm for B1.1 fractures and 1.38 mm for B1.2 fractures (P < 0.001). The mean Harris hip score was 82.0 for B1.1 and 88.8 for B1.2 fractures (P = 0.029). Avascular necrosis (AVN) of the femoral head occurred in 4 patients with B1.1 fractures, and none with B1.2 fractures (P = 0.041). Eighteen of the 78 patients required a second operation, and 15 of them were included in 31-B1.1 fracture (P = 0.003). Three patients underwent arthroplasty due to AVN, and 15 patients required hardware removal due to pain after bony union.

CONCLUSIONS

More femoral neck shortening and less functional recovery should be expected in valgus-impacted femoral neck fracture patients based on the severity of the initial deformity. Even though we obtained bony union in all of the cases, the risk of AVN and second operation after bony union was higher with greater initial deformity.

LEVEL OF EVIDENCE

Therapeutic level III.

Comparative pooled survival and revision rate of Austin-Moore hip arthroplasty in published literature and arthroplasty register data

The aim was to evaluate the pooled survival and revision rate of Austin-Moore hip arthroplasty (AMHA) in published literature and arthroplasty register data. A comprehensive literature analysis of clinical publications and register reports was conducted with the main endpoints revision surgery and revision rate. Sixteen relevant clinical studies have been found to significantly underestimate revision rates by a ratio of 2.15 compared to register data sets. The medium-term outcome of AMHA showed significantly worse outcomes than the use of other bipolar implants, or modular cervicocephalic prostheses and data of journal publications on revision rates deviate significantly from data of arthroplasty registers.

Cemented versus uncemented hemiarthroplasty for femoral neck fractures in elderly patients: a meta-analysis

Objective

Controversy still exists regarding using cemented or uncemented hemiarthroplasty for femoral neck fractures in elderly patients. The aim of this study is to compare the effectiveness and safety of the two surgical techniques in femoral neck fracture patients over 70 years old.

Methods

We searched PUBMED, EMBASE, Cochrane Library, CNKI and VIP Database from inception to December 2012 for relevant randomized controlled trials (RCTs). Outcomes of interest include postoperative hip function, residue pain, complication rates, mortality, reoperation rate, operation time and intraoperative blood loss. Odds ratios (OR) and weighted mean differences (WMD) from each trial were pooled using random-effects model or fixed-effects model given on the heterogeneity of the included studies.

Results

7 RCTs involving 1,125 patients (1,125 hips) were eligible for meta-analysis. Our results demonstrate that cemented hemiarthroplasty is associated with better postoperative hip function (OR = 0.48, 95% CI, 0.31–0.76; P = 0.002), lower residual pain (OR = 0.43, 95%CI, 0.29–0.64; P<0.0001), less implant-related complications (OR = 0.15, 95%CI, 0.09–0.26; P<0.00001) and longer operation time (WMD = 7.43 min, 95% CI, 5.37–9.49 min; P<0.00001). No significant difference was observed between the two groups in mortality, cardiovascular and cerebrovascular complications, local complications, general complications, reoperation rate and intraoperative blood loss.

Conclusions

Compared with uncemented hemiarthroplasty, the existing evidence indicates that cemented hemiarthroplasty can achieve better hip function, lower residual pain and less implant-related complications with no increased risk of mortality, cardiovascular and cerebrovascular complications, general complications, local complications and reoperation rate in treating elderly patients with femoral neck fractures.

Cemented versus cementless hemiarthroplasty for intracapsular neck of femur fracture--a comparison of 60,848 matched patients using national data

National guidelines recommend cemented hemiarthroplasty for intracapsular fractured neck of femur (NOF), based on evidence of less pain, better mobility and lower costs. We aimed to compare complications following cemented and cementless implants, using the national hospital episode statistics (HES) database in England. Dislocation, revision, return to theatre and medical complications were extracted for all patients with NOF fracture who underwent hemiarthroplasty between January 2005 and December 2008. To make a 'like for like' comparison all 30,424 patients with a cementless implant were matched to 30,424 cemented implants (from a total of 42,838) in terms of age, sex and Charlson co-morbidity score. In the cementless group, 18-month revision (1.62% versus 0.57% (OR 2.90, p<0.001)), 4-year revision (2.45% versus 1.11% (OR 2.28, p<0.001)) and 30-day chest infection (8.14% versus 7.23% (OR 1.14, p=0.028)) were significantly higher. Four-year dislocation rate was higher in cemented implants (0.60% versus 0.26% (OR 0.45, p<0.001)). No significant differences were seen in return to theatre or other medical complications. In this national analysis of matched patients mid-term revision and perioperative chest infection was significantly higher in the cementless group. This supports the published evidence and national guidelines recommending cement fixation of hemiarthroplasty.

Adherence to a femoral neck fracture treatment guideline

PURPOSE

In 2007 the Dutch Surgical Society published a clinical practice guideline for the treatment of hip fracture patients, based on the best available international evidence at that time. We investigated to what extent treatment of femoral neck fracture patients in the Netherlands corresponded with these guidelines, and determined differences in patient characteristics between the treatment groups.

METHODS

All femoral neck fracture patients treated in 14 hospitals between February 2008 and August 2009 were included. Patient characteristics, X-rays, and treatment data were collected retrospectively.

RESULTS

From a total of 1,250 patients 59% had been treated with arthroplasty, 39% with internal fixation, and 2% with a non-operative treatment. While 74% of the treatment choices complied with the guideline, 12% did not. In 14% adherence could not be determined from the available data. Arthroplasty was preferred over internal fixation in elderly patients with severe comorbidity, pre-fracture osteoporosis and a displaced fracture, who were ambulatory with aids pre-fracture (odds ratio, OR 2.2-58.1). Sliding hip screws were preferred over cancellous screws in displaced fractures (OR 1.9).

CONCLUSIONS

Overall guideline adherence was good. Most deviations concerned treatment of elderly patients with a displaced fracture and implant use in internal fixation. Additional data on these issues, preferably at a higher scientific level of evidence, is needed in order to improve the guideline and to reinforce a more uniform treatment of these patients.

Logistic regression analysis of factors associated with avascular necrosis of the femoral head following femoral neck fractures in middle-aged and elderly patients

BACKGROUND

Risk factors for femoral neck fracture-induced avascular necrosis of the femoral head have not been elucidated clearly in middle-aged and elderly patients. Moreover, the high incidence of screw removal in China and its effect on the fate of the involved femoral head require statistical methods to reflect their intrinsic relationship.

METHODS

Ninety-nine patients older than 45 years with femoral neck fracture were treated by internal fixation between May 1999 and April 2004. Descriptive analysis, interaction analysis between associated factors, single factor logistic regression, multivariate logistic regression, and detailed interaction analysis were employed to explore potential relationships among associated factors.

RESULTS

Avascular necrosis of the femoral head was found in 15 cases (15.2 %). Age × the status of implants (removal vs. maintenance) and gender × the timing of reduction were interactive according to two-factor interactive analysis. Age, the displacement of fractures, the quality of reduction, and the status of implants were found to be significant factors in single factor logistic regression analysis. Age, age × the status of implants, and the quality of reduction were found to be significant factors in multivariate logistic regression analysis. In fine interaction analysis after multivariate logistic regression analysis, implant removal was the most important risk factor for avascular necrosis in 56-to-85-year-old patients, with a risk ratio of 26.00 (95 % CI = 3.076-219.747).

CONCLUSION

The middle-aged and elderly have less incidence of avascular necrosis of the femoral head following femoral neck fractures treated by cannulated screws. The removal of cannulated screws can induce a significantly high incidence of avascular necrosis of the femoral head in elderly patients, while a high-quality reduction is helpful to reduce avascular necrosis.

Survival of patients aged over 80 years after Austin-Moore hemiarthroplasty and bipolar hemiarthroplasty for femoral neck fractures

OBJECTIVES

Hemiarthroplasty is recommended for treatment of displaced femoral neck fractures in physically compromised elderly patients. The objective of this study was to analyze survival of patients aged >80 years after the implantation of either an Austin-Moore type prosthesis or a bipolar bearing prosthesis.

METHODS

An Austin-Moore or bipolar hemiarthroplasty was implanted into 120 patients aged >80 years. Demographic data were collected. Survival rate at 5 years and factors related to mortality were analyzed.

RESULTS

Sixty-two patients received Austin-Moore hemiarthroplasty, and 58 received bipolar hemiarthroplasty. No significant differences in gender, comorbid conditions, ASA scores, duration of hospitalization, intraoperative blood loss, duration from injury to operation, or postoperative morbidity between the two groups were found. However, patients who received the Austin-Moore hemiarthroplasty were older and had shorter operation time than those who received bipolar hemiarthroplasty. Kaplan-Meier estimates of 5 years survival were 40.0% for patients who received Austin-Moore hemiarthroplasty, and 62.9% for patients who received bipolar hemiarthroplasty. Cox proportional hazard regression analysis of risks factors of death revealed that patients who underwent Austin-Moore hemiarthroplasty were 2.0-fold more likely to die when compared to those who received bipolar hemiarthroplasty.

CONCLUSIONS

Elderly patients who receive bipolar hemiarthroplasty may have a more favorable survival outcome when compared to those who receive unipolar hemiarthroplasty.

Monoblock hemiarthroplasties for femoral neck fractures--a part of orthopaedic history? Analysis of national registration of hemiarthroplasties 2005-2009

This study from the Swedish Hip Arthroplasty Register (SHAR) compares cemented (Thompson(®), Exeter Trauma Stem (ETS)(®)) and uncemented (Austin-Moore(®)) monoblock hemiarthroplasties (n=1116 and 616, respectively) with modular ones (n=18,659). Austin-Moore(®) prostheses lead to more re-operations (6.7%) compared to modular implants (3.5%) and Thompson(®)/ETS(®) (2.4%). A Cox regression analysis, adjusting for other risk factors, shows twice the risk of re-operation for Austin-Moore(®) implants (CI 1.5-2.8), in particular, due to periprosthetic fracture (5.4; CI 3.2-9.1) and dislocation (1.9; CI 1.3-3.0). The Thompson(®)/ETS(®) implants do not influence the overall risk of re-operation (0.7; CI 0.5-1.2) compared to modular implants and decrease the risk of re-operation due to infection (0.2;CI 0.04-0.7). An increased risk of re-operation is also seen in men, age groups 75-85 years and <75 years and after secondary fracture surgery. Both Swedish and Australian orthopaedic surgeons have decreased their use of Austin-Moore(®) implants after reports from their national arthroplasty registers identifying inferior outcome for this implant. Due to the increased risk of re-operations, it should not be used in modern orthopaedic care. Cemented Thompson(®) or ETS(®) implants could still be suitable for the oldest, low-activity patients. To finally decide if there is a place for them, patient-reported outcome must be analysed as well.

Cemented versus uncemented hemiarthroplasty for hip fractures: a systematic review of randomised controlled trials

We performed a systematic review of randomised controlled trials in order to identify the best available evidence to compare the outcome between cemented and uncemented hemiarthroplasty for treatment of intracapsular hip fractures. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, MEDLINE and the National Research Register (UK) to retrieve all of the published randomised controlled trials designed to address these issues, in order to perform a meta-analysis. Eight studies involving 1169 patients were determined to be appropriate for meta-analysis. The following statistically significant differences were found between the cemented and uncemented prostheses: (1) longer operative time for cemented prosthesis; (2) lower reduction in mobility score for those treated with cemented prosthesis; (3) fewer patients with residual pain in the hip and lower pain score (signifying less pain) for those treated with a cemented prosthesis. Our meta-analysis has shown that there is good evidence that the use of cement during hemiarthroplasty will reduce the amount of residual hip pain and also allow better restoration of function. There is no evidence of significant adverse effects of cement on mortality or other complications encountered. These observations apply to older designs, and there is a need for randomised trials comparing hydroxyapatite-coated modern stems with cemented prostheses.

More intramedullary nails and arthroplasties for treatment of hip fractures in Sweden

BACKGROUND AND PURPOSE

The surgical methods for treatment of femoral neck fractures and trochanteric hip fractures vary. We describe the changes in Sweden over the period 1998–2007 and the regional differences in treatment. Patients and methods Data on 144,607 patients were drawn from the National Patient Register.

RESULTS

The proportion of femoral neck fractures treated with arthroplasty increased from 10% in 1998 to 52% in 2007. The use of intramedullary (IM) nails for pertrochanteric fractures increased from 5% to 20%, at the expense of the use of different sliding hip screws. In subtrochanteric fractures, the use of IM nails increased from 32% to 72%. Re-admissions within 180 days due to hip complications were more common after internal fixation for femoral neck fractures than after arthroplasty, and more common after intramedullary nailing of pertrochanteric fractures than after use of sliding hip screws. Treatment varied substantially within Sweden, particularly regarding the use of IM nails.

INTERPRETATION

An increase in arthroplasties reflects an evidence-based treatment rationale for femoral neck fractures, whereas the increase in use of IM nails in pertrochanteric fractures lacks scientific support. The geographic variations call for national treatment guidelines. Further clinical trials are needed to solve the treatment issues regarding per- and subtrochanteric fractures.

Cemented Thompson versus cemented bipolar prostheses for femoral neck fractures

PURPOSE

To compare early functional outcomes, complications, and mortality in elderly patients treated with the less costly, cemented Thompson prosthesis or the cemented bipolar prosthesis in order to identify factors affecting outcomes.

METHODS

Records of 303 patients with femoral neck fractures treated with the cemented Thompson monoblock prosthesis (n=206) or the cemented bipolar prosthesis (n=97) were reviewed. The choice of prosthesis was solely determined by surgeon's preference. Data relating to patient demographics, clinical and residential status, mobility, mental function, mortality, and complications during hospitalisation and rehabilitation were collected.

RESULTS

After adjusting for confounding variables, independent postoperative indoor mobility was associated with preoperative indoor mobility (p=0.002) and mental function (p=0.001), whereas postoperative outdoor mobility was associated with preoperative outdoor mobility (p=0.003), daily living activity (p=0.02), and mental function (p=0.02). Mortality within 6 months was only associated with poor mental function (p=0.009). At 6-month follow-up, there was no significant difference between the 2 types of prosthesis in terms of functional outcomes, mortality and complication rates.

CONCLUSION

In elderly patients with limited mobility, treatment with the bipolar prosthesis was not associated with better short-term outcomes than those receiving the Thompson prosthesis.

Effect of a prostaglandin EP4 receptor agonist on early fixation of hydroxyapatite/titanium composite- and titanium-coated rough-surfaced implants in ovariectomized rats

The agonist of the prostaglandin EP4 receptor can increase bone density in osteoporosis. Using ovariectomized (OVX) and sham-operated (SO) rats, the effects of the EP4 receptor agonist, ONO-4819, and hydroxyapatite (HA) on implant-bone fixation in implants with a rough surface were investigated. Female Wistar rats (12 weeks old) were divided into either SO or bilateral OVX groups. Twenty four weeks later, either hydroxyapatite/titanium (HA/Ti) composite-coated or Ti-coated implants were implanted into the femora, and the animals were treated with either ONO-4819 or saline for 4 weeks. The fixation strength of the HA/Ti-coated implants was higher than that of the Ti-coated implants in the saline-treated OVX rats. In the OVX rats, ONO-4819 enhanced fixation of the rough Ti-coated implants to levels similar to that of HA/Ti-coated implants. These data suggest that a combination of treatment with an EP4 receptor agonist and a rough-surfaced implant might be useful in increasing the early fixation of cement-less arthroplasty, particularly in elderly patients with osteoporosis.

Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures: a long-term follow-up of a randomised trial

In a prospective randomised trial, 455 patients presenting to one hospital with a displaced intracapsular fracture were randomised to either closed reduction and internal fixation with three cancellous screws or replacement with an uncemented hemiarthroplasty. Follow-up of surviving patients was for between 9 and 15 years to determine the long-term outcome for the two treatment methods. 93% of patients died during this follow-up period. There was no difference in mortality between the two procedures. The need for revision surgery to the hip was increased for those treated by internal fixation (93% versus 62% implant survival rate; hazard ratio: 0.14, 95% CI 0.08-0.24). 91% of revision's operations occurred within 2 years from injury. There was no difference in the degree of residual pain between groups neither was there any difference in the number of patients requiring institutional care. These results demonstrate that both treatment methods produce comparable final outcomes but internal fixation is associated with an increased re-operation rate.

Internal screw fixation compared with bipolar hemiarthroplasty for treatment of displaced femoral neck fractures in elderly patients

BACKGROUND

Internal fixation and arthroplasty are the two main options for the treatment of displaced femoral neck fractures in the elderly. The optimal treatment remains controversial. Using data from the Norwegian Hip Fracture Register, we compared the results of hemiarthroplasty and internal screw fixation in displaced femoral neck fractures.

METHODS

Data from 4335 patients over seventy years of age who had internal fixation (1823 patients) or hemiarthroplasty (2512 patients) to treat a displaced femoral neck fracture were compared at a minimum follow-up interval of twelve months. One-year mortality, the number of reoperations, and patient self-assessment of pain, satisfaction, and quality of life at four and twelve months were analyzed. Subanalyses of patients with cognitive impairment and reduced walking ability were done.

RESULTS

In the arthroplasty group, only contemporary bipolar prostheses were used and uncemented prostheses with modern stems and hydroxyapatite coating accounted for 20.8% (522) of the implants. There were no differences in one-year mortality (27% in the osteosynthesis group and 25% in the arthroplasty group; p = 0.76). There were 412 reoperations (22.6%) performed in the osteosynthesis group and seventy-two (2.9%) in the hemiarthroplasty group during the follow-up period. After twelve months, the osteosynthesis group reported more pain (mean score, 29.9 compared with 19.2), higher dissatisfaction with the operation result (mean score, 38.9 compared with 25.7), and a lower quality of life (mean score, 0.51 compared with 0.60) than the arthroplasty group. All differences were significant (p < 0.001). For patients with cognitive impairment, hemiarthroplasty provided a better functional outcome (less pain, higher satisfaction with the result of the operation, and higher quality of life as measured on the EuroQol visual analog scale) at twelve months (p < 0.05).

CONCLUSIONS

Displaced femoral neck fractures in the elderly should be treated with hemiarthroplasty.

Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures: A randomised controlled trial in 400 patients

We undertook a prospective randomised controlled trial involving 400 patients with a displaced intracapsular fracture of the hip to determine whether there was any difference in outcome between treatment with a cemented Thompson hemiarthroplasty and an uncemented Austin-Moore prosthesis. The surviving patients were followed up for between two and five years by a nurse blinded to the type of prosthesis used. The mean age of the patients was 83 years (61 to 104) and 308 (77%) were women. The degree of residual pain was less in those treated with a cemented prosthesis (p < 0.0001) three months after surgery. Regaining mobility was better in those treated with a cemented implant (p = 0.005) at six months after operation. No statistically significant difference was found between the two groups with regard to mortality, implant-related complications, re-operations or post-operative medical complications. The use of a cemented Thompson hemiarthroplasty resulted in less pain and less deterioration in mobility than an uncemented Austin-Moore prosthesis with no increase in complications.

Femoral neck shortening after fracture fixation with multiple cancellous screws: incidence and effect on function

BACKGROUND

Shortening of the femoral neck after fracture fixation with multiple parallel screws decreases the moment arm for the abductor muscles of the hip. This study aimed to assess the incidence of femoral neck shortening quantitatively and qualitatively in patients with femoral neck fractures treated with multiple cannulated screws, and to investigate its influence on functional outcome.

METHODS

We conducted an observational study in a consecutive series of 56 patients with united fractures of the femoral neck treated with multiple cancellous screws. The latest anterior-posterior radiograph of the fractured hip was compared with that of the contralateral uninjured hip. After scanning and electronically overlapping those radiographs, femoral neck shortening was assessed. All identified patients were contacted and the Short Form-36 (SF-36) functional outcome questionnaire was administered.

RESULTS

The shortening rate was 31% for undisplaced (14 of 45) and 27% for displaced fractures (3 of 11). The average abductor moment arm shortening was 10 +/- 4 mm. The average femur length decrease was 8 +/- 5 mm. In all other patients, abductor moment arm as well as femur length measurements were within 3 mm of the contralateral side and considered not to be shortened. Thirteen patients completed the SF-36 questionnaire (12 of 13 undisplaced fractures; all 13 with good fracture reduction). Patients with shortened fractures (8 of 13) had significantly lower Physical Functioning (p = 0.01) and Role Physical (p = 0.04) SF-36 subscores.

CONCLUSIONS

Femoral neck shortening after femoral neck fracture fixation with multiple cancellous screws is common and it has a significant negative impact on physical functioning.

Shortening after femoral neck fracture fixation: is there a solution?

When using parallel screws for treatment of femoral neck fractures, shortening of the femoral neck might occur. Given the high revision surgery rates associated with parallel screws, we developed a questionnaire to explore (1) surgeons' viewpoints on difficulties in the fixation of femoral neck fractures, (2) their perception of the clinical importance of femoral neck shortening after internal fixation, and (3) their opinions regarding the ideal fixation device. Two hundred three surgeons responded. Eighty-three percent believed shortening of the femoral neck is common after screw fixation of femoral neck fractures; 89% believed shortening limits hip abductor function; and 69% believed shortening limits patients' physical function. When asked for features of the ideal implant for treatment of a femoral neck fracture, allowing compression across the fracture site on insertion and providing angular stability with a fixed-angle device to minimize shortening of the femoral neck were favored by 89% and 79% of the respondents, respectively. A plate with multiple nonparallel lag screws that can be locked into the plate might be a solution. However, the findings of this study are surgeons' opinions, which may or may not be confirmed by scientific evidence.

[Bilateral Moore hemiarthroplasty: 36 years of good tolerance without loosening or osteolysis]

We report an illustrative case of bilateral Moore arthroplasty with the clinical and radiographic results at 36 years follow-up. The femoral prostheses were implanted for necrosis of the femoral head when the patient was 46 years old. At implantation the patient's physical activity level was high (Devane 4) and remained so until retirement at age 65 years. His activity level remained high (Devane 3) to the age of 82 years when the patient suffered a Vancouver B1 periprosthetic fracture on the left. At this date, both arthroplasties were free of loosening an osteolysis. Plate fixation with wiring led to fracture healing. The Postel Merle d'Aubigné score was 17 before the fracture and 16 at healing (with a pain score of 6 both before and after). Radiographically, acetabular cartilage tolerance was excellent. This case illustrates the excellent clinical outcome obtained with the Moore hemiarthroplasty at more than 35 years despite less than satisfactory initial fixation and the absence of resurfacing. The fact that this prosthesis does not have a polyethylene element prevented the development of osteolysis which could have been expected with such a long postoperative period in this a highly active patient. Favorable factors (good abductor lever arm, adapted head diameter, resistance of the acetabular cartilage in a young subject with femoral head necrosis) may have played a role in this particular case since the excellent and sustained outcome was observed on both sides. This exceptional longevity provides useful information for better determining precise indications for head cups for the treatment of necrosis of the femoral head.

Prosthesis survivorship and clinical outcome of the Austin Moore hemiarthroplasty: An 8-year mean follow-up of a consecutive series of 500 patients

The results of a consecutive series of 500 patients treated with Austin Moore hemiarthroplasty prosthesis are reported. The range of follow-up was from 5-12 years and the mean was 8 years. Only 10 patients were lost to follow-up and 398 (81%) patients died within the follow-up period. The mean age of the patient population was 82 years, and 85% were women. The cumulative survivorship of the prosthesis was calculated at 94% (95% CI 90-96%) at 5 years and 83% (95% CI 65-94%) at 12 years. A total of 66 secondary operations of any type were required in 46 (9%) patients. Revision of the Austin Moore prosthesis was performed in 23 cases (5%). Of the long-term survivors contacted for follow-up, 66 (81%) had no pain or minimal pain, whilst 5 (6%) reported constant pain in the hip. The revision rates in our series were higher for younger patients, those from their own home and with good pre-fracture mobility and mental function. For the frail elderly with a displaced intracapsular fracture this prosthesis can still be recommended. This paper presents the largest consecutive series, with the longest follow-up, currently available.

Dissociation of bipolar hemiarthroplasty of the hip after dislocation. A report of five different cases and review of literature

Little information is available about the rare but serious disadvantage of dissociation of modular components during dislocation or after close reduction in the bipolar hemiarthroplasty of the hip. In most cases, simple dislocation after primary bipolar hemiarthroplasty can safely be reduced by close methods. Dissociation leads almost always to reoperation and possible revision of the prosthesis. To avoid this complication, strict adherence to the surgical technique during the initial procedure and extra precaution during close reduction are recommended, in order to provide enhanced security over component disassembly. In the five cases presented in this study, dissociation is reported at different circumstances, along with the different methods of treatment required in each patient.

Interprosthetic dislocations of the Charnley/Hastings hemiarthroplasty--report of 11 cases in 350 consecutive patients

We report 11 cases of interprosthetic dislocation of the Charnley/Hastings hemiarthroplasty in a retrospective study of 350 consecutive patients treated for an acute femoral neck fracture. We found a total of 14 dislocations (4.0%), 11 were interprosthetic. The median age of the 350 patients was 79 (36-99) years and the median age of the 11 patients with an interprosthetic dislocation was 85 years (82-94). The median time from surgery to radiologically acknowledged dislocation was 18 (4-64) days. These interprosthetic dislocations may be caused by either an assembly mistake perioperatively, by maximum angulation and impingement between the components, or by trauma.

The Value of Washers in Cannulated Screw Fixation of Femoral Neck Fractures

BACKGROUND

Given the limited evidence to support the technical aspects of screw placement for treatment of femoral neck fractures, we conducted an observational study to evaluate demographic and radiographic variables associated with fixation failure.

METHODS

Eligible patients with femoral neck fractures were treated with multiple cannulated screws across three academic centers during a 6-year period. The following variables were evaluated for their predictive value for fixation failure: age, gender, fracture type, presence of comminution, total number of screws, the absence of a washer, the screw configuration, reduction quality, the distance of the most inferior screw to the inferior neck, and screw alignment. Variables were evaluated separately and in a multivariable regression model.

RESULTS

Eighty patients were included in the study. The overall failure rate was 30%. We identified four variables associated with fixation failure. These included the lack of washers (odds ratio [OR], 11.2; p = 0.03), imperfect quality of reduction (OR, 9.7; p < 0.01), age greater than 75 years (OR, 5.1; p = 0.04), and displaced versus undisplaced fracture type (OR, 3.8; p < 0.01). These four variables accounted for 43% of the variability in fixation failure (R(2) = 0.43). All other variables including the distance of the most inferior screw to the inferior/medial neck were found to be not significant.

CONCLUSION

This study confirms previous findings in the literature that increased age, a displaced fracture type, and poor reduction increase the risk of fixation failure. Contradictory to current belief, there was no significant association between the distance of the inferior screw to the inferior/medial femoral neck cortex and fixation failure. A novel finding of the present study is that the use of washers significantly decreases the risk of fixation failure.

Critical radiological analysis after Austin Moore hemiarthroplasty

The aim of this study is to investigate the causes of prosthesis loosening in patients treated with Austin Moore hemiarthroplasty (AMA). The clinical and radiological outcomes were documented in a quantitative manner after 7 years follow-up of 144 patients. At the time of final follow-up, 52 patients had died and 48 patients were lost to follow-up, leaving a total of 44 patients for analysis. Immediate post-operative X-rays were studied for the initial alignment of prosthesis, the fit of the prosthesis and the degree of osteoporosis. X-rays on latest follow-up were studied for evidence of loosening. All patients were assessed clinically with the hip score of hospital for special surgery. It was found that hip pain was significantly related to subsidence and pivoting of the prosthesis (P = 0.014 and 0.035, respectively). Significant increase in subsidence was noted if the stem of prosthesis was not fitting well within the shaft of femur (P = 0.006). When the patient was younger than 73 years old at the time of operation, there was more subsidence of the prosthesis at the final follow-up (P = 0.001). It was concluded that the fill of AMA within the shaft of femur should be greater than 70% to avoid early loosening. Relatively younger patients with acute fracture of the neck of femur should be treated by methods other than cementless AMA.

Mortality following surgery for undisplaced intracapsular hip fractures

PURPOSE

The aim of the study was to evaluate the mortality following the operative treatment of undisplaced subcapital fracture of the hip by internal fixation (with three lag screws) or hemiarthroplasty.

METHODS

A prospective audit of all patients admitted with hip fracture was undertaken at the university hospital in Nottingham. An independent research assistant collected data on a standardised questionnaire. Mortality was calculated from data received from National office of Statistics allowing 100% 1-year follow up for mortality statistics.

RESULTS

One hundred and sixty patients were admitted with undisplaced intracapsular fracture of the hip. Twenty-one patients had non-operative management and were excluded from the results. One hundred and thirty-nine patients had surgical treatment. Mean age of patients was 78 years. Twenty-nine patients had hemiarthroplasty and 110 patients underwent internal fixation of their fractures. There was no significant difference between the two groups for age, sex, mobility, residential status, co-morbidity and cognitive state. There was a significant difference in mortality between the two operated groups at 1 month and 1 year after the operation. Six patients (21%) died after hemiarthroplasty in the first month while there were only two (2%) deaths in the internal fixation group (P < 0.001). At 1 year from operation, 11 patients (38%) from the hemiarthroplasty group and 17 patients (16%) from the internal fixation group died (P = 0.0072). The re-operation rate within 1 year was higher for the internal fixation group (n = 8; 7.2%) than the hemiarthroplasty group (n = 1; 3%).

CONCLUSIONS

There is significant increase in mortality when undisplaced intracapsular hip fractures are treated by hemiarthroplasty as compared to internal fixation and we would not recommend it for these fractures.