Symptomatic Acetabular Erosion After Hip Hemiarthroplasty: Is It a Major Concern? A Retrospective Analysis of 2477 Hemiarthroplasty Cases

Background/Objectives: Acetabular erosion is a postoperative condition that can occur after hip hemiarthroplasty (HA), potentially leading to pain and requiring conversion to total hip arthroplasty (THA). Given the discrepancy in its incidence and impact in the literature, this study aims to report the incidence of symptomatic acetabular erosion and the subsequent conversion to THA in all HA cases performed in a single health system. Methods: A total of 2477 HA cases had their clinical notes and serial radiographs examined for this retrospective study. Outcome measures included any records of hip or groin pain and conversion to THA that were attributed to acetabular erosion as documented in the clinical notes. Results: Two thousand four hundred and seventy-seven HA cases were reviewed in this study. The mean age for all patients in the study was 81.5 years and the mean follow up was 3.7 years. Out of the 2477 HA cases, only 12 HA cases (0.48%) in 12 patients had data records of chronic hip pain, attributable to acetabular wear in the clinical notes, of variable severity and presentations. The mean duration until the clinical documentation of acetabular wear-induced pain was 25.6 months (range, 1.4-146.4 months), with most symptomatic hip erosion cases presented within the first year (50% presented within the first 6 months) after the index HA surgery. Despite that, only five cases underwent conversion to THA (0.2%) while seven patients received conservative management. Conclusions: In patients older than 65 years of age who are candidates for HA, the incidence of symptomatic hip erosion and the subsequent conversion to THA is low and hence HA remains a viable treatment option. Based on the duration until clinical presentation of acetabular erosion, this study suggests that the state of acetabular cartilage during surgery may influence the development of early acetabular wear in most symptomatic patients. On the other hand, hip hemiarthroplasty is a rare treatment option for displaced femoral neck fractures in patients younger than 65 years of age, and its use in this patient subset depends on conditional and patient-related factors such as the activity level, cognitive function, and medical comorbidities.

Is the use of bipolar hemiarthroplasty over monopolar hemiarthroplasty justified? A propensity score-weighted analysis of a multicentre randomized controlled trial

Aims

Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA).

Methods

This study is a secondary analysis of patients aged 50 years or older with a displaced femoral neck fracture who were enrolled in the HEALTH trial and underwent monopolar and bipolar HA. Scores from the Western Ontario and McMaster University Arthritis Index (WOMAC) and 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and (MCS) were compared between the two HA groups using a propensity score-weighted analysis.

Results

Of 746 HAs performed in the HEALTH trial, 404 were bipolar prostheses and 342 were unipolar. After propensity score weighting, adequate balance between the bipolar and unipolar groups was obtained as shown by standardized mean differences less than 0.1 for each covariable. A total of 24 months after HA, the total WOMAC score and its subcomponents showed no statistically significant difference between the unipolar and bipolar groups. Similarly, no statistically significant difference was found in the PCS and MCS scores of the SF-12 questionnaire. In participants aged 70 years and younger, no difference was found in any of the functional outcomes.

Conclusion

From the results of this study, the use of bipolar HA over unipolar design does not provide superior functional outcomes at 24 months postoperatively. The theoretical advantage of reduced acetabular wear with bipolar designs does not appear to influence functional outcomes in the first two years postoperatively.

Total hip arthroplasty compared to bipolar and unipolar hemiarthroplasty for displaced hip fractures in the elderly: a Bayesian network meta-analysis

PURPOSE

Displaced femoral neck fractures (FNF) usually require surgical treatment with either a total hip arthroplasty (THA), unipolar hemiarthroplasty (U-HHA), or bipolar hemiarthroplasty (B-HHA). However, there is still controversy regarding the optimal implant. This network meta-analysis compared the outcomes and complication rates of THA versus B-HHA and versus U-HHA in elderly patients with FNF.

MATERIAL AND METHODS

This study was conducted according to the PRISMA extension statement for reporting of systematic reviews, and incorporated network meta-analyses of health care interventions. The literature search was performed in September 2020. All randomized clinical trials comparing two or more of the index surgical interventions for displaced FNF in the elderly were eligible for inclusion. For the Bayesian network meta-analysis, the standardized mean difference (SMD) and Log Odd Ratio (LOR) were used.

RESULTS

Data from 24 RCTs (2808 procedures) were analysed. The mean follow-up was 33.8 months. The THA group had the longest surgical time (SMD 85.74) and the greatest Harris Hip Score (SMD - 17.31). THA scored similarly in terms of mortality (LOR 3.89), but had lower rates of revision surgeries (LOR 2.24), higher rates of dislocations (LOR 2.60), and lower rates of acetabular erosion (LOR - 0.02). Cementless implants required a shorter surgical duration (- 18.05 min; P = 0.03). Mortality was positively associated with acetabular erosion (P = 0.006), female gender (P = 0.007), revision (P < 0.0001).

CONCLUSION

THA led to the highest Harris Hip scores and lowest rate of revision surgery compared to B-HHA and U-HHA. However, B-HHA had the lowest dislocation rate when compared with U-HHA and THA. No significant differences in functional outcomes and complication rates were found between cemented and uncemented implants; however, a tendency for lower mortality, revision and dislocation rates in cemented implants was evidenced.

LEVEL OF EVIDENCE

I, Bayesian network meta-analysis of RCTs.

Patients with femoral neck fractures treated by bipolar hemiarthroplasty have superior to unipolar hip function and lower erosion rates and pain: a systematic review and meta-analysis of randomized controlled studies

PURPOSE

We assessed acetabular erosion, hip function, quality of life (QoL), pain, deep infection, mortality, re-operation and dislocation rates in patients with displaced femoral neck fractures (dFNFs) treated with unipolar versus bipolar hemiarthroplasty at different postoperative time points.

METHODS

Relevant Randomized Controlled Trials (RCTs) were identified, following comprehensive literature research in Medline, Cochrane Central and Scopus databases, from conception until August 31th, 2021 and analyzed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Database research retrieved 120 studies; sixteen met eligibility criteria, providing 1813 (1814 hips) evaluable patients. Acetabular erosion was significantly higher for unipolar group at 6 and 12 months (p = 0.02 and p = 0.01 respectively). Patients in the bipolar group presented significantly better hip function at 12 and 24 months (p = 0.02 and p = 0.04 respectively). Postoperative pain was significantly less in the bipolar group at 12, 24 and 48 months (p = 0.01). No statistically significant differences were found regarding the postoperative rates of deep infection, mortality, re-operation and dislocation.

CONCLUSION

This study showed that patients with dFNFs treated with bipolar hemiarthroplasty have lower acetabular erosion rates at 6 and 12 months postoperatively, better hip function at 12 and 24 months, better QoL and less pain, when compared with unipolar. No statistically significant difference could be established regarding deep infection, mortality, re-operation and dislocation rates.

Should We Use Bipolar Hemiarthroplasty in Patients ≥70 Years Old With a Femoral Neck Fracture? A Review of Literature and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Bipolar (BHA) and unipolar hemiarthroplasties (UHA) are interchangeably used in elderly patients with a displaced femoral neck fracture. We ask if there is a difference between BHA and UHA with regards to hip function, in elderly patients.

METHODS

Systematic review and meta-analysis was conducted of randomized controlled trials comparing BHA to UHA. The primary outcome was postoperative hip function scores. Secondary outcomes were overall health-related quality of life patient-reported outcomes, acetabular erosion, and postoperative complications. Data sources, last searched on June 1, 2020, were MEDLINE, EMBASE, Cochrane Library, and Web of Science.

RESULTS

Fourteen randomized controlled trials were eligible for meta-analysis. There was no difference in hip function scores between BHA and UHA (standardized mean difference 0.32, 95% confidence interval [CI] -0.06 to 0.71, n = 1084, I² = 87%). Patients with BHA with more than 2-year follow-up had better hip function scores (standardized mean difference 0.68, 95% CI 0.18-1.18, n = 700, I² = 87%). There was no difference in European Quality of life- five dimensions scores with BHA (mean difference 0.08, 95% CI -0.01 to 0.17, n = 967, I² = 82%). The use of BHA decreased the risk of acetabular erosion (relative risk 0.38, 95% CI 0.17-0.83, n = 1239, I² = 0%). There was no difference for revision, mortality, infection, and dislocation (I² = 0%).

CONCLUSION

There seems to be no difference between BHA and UHA with regards to hip function at 2 years. BHA might decrease the risk of acetabular erosion. There is a need for a large randomized controlled trial with a follow-up >2 years and better measurement tools to assess clinical benefits.

LEVEL OF EVIDENCE

II.

Surgical interventions for treating intracapsular hip fractures in older adults: a network meta-analysis

BACKGROUND

Hip fractures are a major healthcare problem, presenting a considerable challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising rapidly. The majority of intracapsular hip fractures are treated surgically.

OBJECTIVES

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of intracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, and five other databases in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility intracapsular hip fractures in older adults. We included total hip arthroplasties (THAs), hemiarthroplasties (HAs), internal fixation, and non-operative treatments. We excluded studies of people with hip fracture with specific pathologies other than osteoporosis or resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months, and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

MAIN RESULTS

We included 119 studies (102 RCTS, 17 quasi-RCTs) with 17,653 participants with 17,669 intracapsular fractures in the review; 83% of fractures were displaced. The mean participant age ranged from 60 to 87 years and 73% were women.  After discussion with clinical experts, we selected 12 nodes that represented the best balance between clinical plausibility and efficiency of the networks: cemented modern unipolar HA, dynamic fixed angle plate, uncemented first-generation bipolar HA, uncemented modern bipolar HA, cemented modern bipolar HA, uncemented first-generation unipolar HA, uncemented modern unipolar HA, THA with single articulation, dual-mobility THA, pins, screws, and non-operative treatment. Seventy-five studies (with 11,855 participants) with data for at least two of these treatments contributed to the NMA. We selected cemented modern unipolar HA as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison. In order to provide a concise summary of the results, we report only network estimates when there was evidence of difference between treatments. We downgraded the certainty of the evidence for serious and very serious risks of bias and when estimates included possible transitivity, particularly for internal fixation which included more undisplaced fractures. We also downgraded for incoherence, or inconsistency in indirect estimates, although this affected few estimates. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.  We found that cemented modern unipolar HA, dynamic fixed angle plate and pins seemed to have the greatest likelihood of reducing mortality at 12 months. Overall, 23.5% of participants who received the reference treatment died within 12 months of surgery. Uncemented modern bipolar HA had higher mortality than the reference treatment (RR 1.37, 95% CI 1.02 to 1.85; derived only from indirect evidence; low-certainty evidence), and THA with single articulation also had higher mortality (network estimate RR 1.62, 95% CI 1.13 to 2.32; derived from direct evidence from 2 studies with 225 participants, and indirect evidence; very low-certainty evidence). In the remaining treatments, the certainty of the evidence ranged from low to very low, and we noted no evidence of any differences in mortality at 12 months.  We found that THA (single articulation), cemented modern bipolar HA and uncemented modern bipolar HA seemed to have the greatest likelihood of improving HRQoL at 12 months. This network was comparatively sparse compared to other outcomes and the certainty of the evidence of differences between treatments was very low. We noted no evidence of any differences in HRQoL at 12 months, although estimates were imprecise. We found that arthroplasty treatments seemed to have a greater likelihood of reducing unplanned return to theatre than internal fixation and non-operative treatment. We estimated that 4.3% of participants who received the reference treatment returned to theatre during the study follow-up. Compared to this treatment, we found low-certainty evidence that more participants returned to theatre if they were treated with a dynamic fixed angle plate (network estimate RR 4.63, 95% CI 2.94 to 7.30; from direct evidence from 1 study with 190 participants, and indirect evidence). We found very low-certainty evidence that more participants returned to theatre when treated with pins (RR 4.16, 95% CI 2.53 to 6.84; only from indirect evidence), screws (network estimate RR 5.04, 95% CI 3.25 to 7.82; from direct evidence from 2 studies with 278 participants, and indirect evidence), and non-operative treatment (RR 5.41, 95% CI 1.80 to 16.26; only from indirect evidence). There was very low-certainty evidence of a tendency for an increased risk of unplanned return to theatre for all of the arthroplasty treatments, and in particular for THA, compared with cemented modern unipolar HA, with little evidence to suggest the size of this difference varied strongly between the arthroplasty treatments.

AUTHORS' CONCLUSIONS

There was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, cemented modern arthroplasties tended to more often yield better outcomes than alternative treatments and may be a more successful approach than internal fixation. There is no evidence of a difference between THA (single articulation) and cemented modern unipolar HA in the outcomes measured in this review. THA may be an appropriate treatment for a subset of people with intracapsular fracture but we have not explored this further.

Arthroplasties for hip fracture in adults

BACKGROUND

Hip fractures are a major healthcare problem, presenting a huge challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising rapidly. The majority of hip fractures are treated surgically. This review evaluates evidence for types of arthroplasty: hemiarthroplasties (HAs), which replace part of the hip joint; and total hip arthroplasties (THAs), which replace all of it.

OBJECTIVES

To determine the effects of different designs, articulations, and fixation techniques of arthroplasties for treating hip fractures in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, seven other databases and one trials register in July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different arthroplasties for treating fragility intracapsular hip fractures in older adults. We included THAs and HAs inserted with or without cement, and comparisons between different articulations, sizes, and types of prostheses. We excluded studies of people with specific pathologies other than osteoporosis and with hip fractures resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for seven outcomes: activities of daily living, functional status, health-related quality of life, mobility (all early: within four months of surgery), early mortality and at 12 months after surgery, delirium, and unplanned return to theatre at the end of follow-up.

MAIN RESULTS

We included 58 studies (50 RCTs, 8 quasi-RCTs) with 10,654 participants with 10,662 fractures. All studies reported intracapsular fractures, except one study of extracapsular fractures. The mean age of participants in the studies ranged from 63 years to 87 years, and 71% were women. We report here the findings of three comparisons that represent the most substantial body of evidence in the review. Other comparisons were also reported, but with many fewer participants. All studies had unclear risks of bias in at least one domain and were at high risk of detection bias. We downgraded the certainty of many outcomes for imprecision, and for risks of bias where sensitivity analysis indicated that bias sometimes influenced the size or direction of the effect estimate. HA: cemented versus uncemented (17 studies, 3644 participants) There was moderate-certainty evidence of a benefit with cemented HA consistent with clinically small to large differences in health-related quality of life (HRQoL) (standardised mean difference (SMD) 0.20, 95% CI 0.07 to 0.34; 3 studies, 1122 participants), and reduction in the risk of mortality at 12 months (RR 0.86, 95% CI 0.78 to 0.96; 15 studies, 3727 participants). We found moderate-certainty evidence of little or no difference in performance of activities of daily living (ADL) (SMD -0.03, 95% CI -0.21 to 0.16; 4 studies, 1275 participants), and independent mobility (RR 1.04, 95% CI 0.95 to 1.14; 3 studies, 980 participants). We found low-certainty evidence of little or no difference in delirium (RR 1.06, 95% CI 0.55 to 2.06; 2 studies, 800 participants), early mortality (RR 0.95, 95% CI 0.80 to 1.13; 12 studies, 3136 participants) or unplanned return to theatre (RR 0.70, 95% CI 0.45 to 1.10; 6 studies, 2336 participants). For functional status, there was very low-certainty evidence showing no clinically important differences. The risks of most adverse events were similar. However, cemented HAs led to less periprosthetic fractures intraoperatively (RR 0.20, 95% CI 0.08 to 0.46; 7 studies, 1669 participants) and postoperatively (RR 0.29, 95% CI 0.14 to 0.57; 6 studies, 2819 participants), but had a higher risk of pulmonary embolus (RR 3.56, 95% CI 1.26 to 10.11, 6 studies, 2499 participants). Bipolar HA versus unipolar HA (13 studies, 1499 participants) We found low-certainty evidence of little or no difference between bipolar and unipolar HAs in early mortality (RR 0.94, 95% CI 0.54 to 1.64; 4 studies, 573 participants) and 12-month mortality (RR 1.17, 95% CI 0.89 to 1.53; 8 studies, 839 participants). We are unsure of the effect for delirium, HRQoL, and unplanned return to theatre, which all indicated little or no difference between articulation, because the certainty of the evidence was very low. No studies reported on early ADL, functional status and mobility. The overall risk of adverse events was similar. The absolute risk of dislocation was low (approximately 1.6%) and there was no evidence of any difference between treatments. THA versus HA (17 studies, 3232 participants) The difference in the risk of mortality at 12 months was consistent with clinically relevant benefits and harms (RR 1.00, 95% CI 0.83 to 1.22; 11 studies, 2667 participants; moderate-certainty evidence). There was no evidence of a difference in unplanned return to theatre, but this effect estimate includes clinically relevant benefits of THA (RR 0.63, 95% CI 0.37 to 1.07, favours THA; 10 studies, 2594 participants; low-certainty evidence). We found low-certainty evidence of little or no difference between THA and HA in delirium (RR 1.41, 95% CI 0.60 to 3.33; 2 studies, 357 participants), and mobility (MD -0.40, 95% CI -0.96 to 0.16, favours THA; 1 study, 83 participants). We are unsure of the effect for early functional status, ADL, HRQoL, and mortality, which indicated little or no difference between interventions, because the certainty of the evidence was very low.  The overall risks of adverse events were similar. There was an increased risk of dislocation with THA (RR 1.96, 95% CI 1.17 to 3.27; 12 studies, 2719 participants) and no evidence of a difference in deep infection.

AUTHORS' CONCLUSIONS

For people undergoing HA for intracapsular hip fracture, it is likely that a cemented prosthesis will yield an improved global outcome, particularly in terms of HRQoL and mortality. There is no evidence to suggest a bipolar HA is superior to a unipolar prosthesis. Any benefit of THA compared with hemiarthroplasty is likely to be small and not clinically appreciable. We encourage researchers to focus on alternative implants in current clinical practice, such as dual-mobility bearings, for which there is limited available evidence.

Hip Hemiarthroplasty for Fractured Neck of Femur Revised to Total Hip Arthroplasty: Outcomes Are Influenced by Patient Age Not Articulation Options

BACKGROUND

Hip hemiarthroplasty is the most common arthroplasty option for fractured neck of femur (FNOF). Revision to total hip arthroplasty (THA) is occasionally required. This study aimed to assess the outcome of hemiarthroplasty revised to THA and to assess the impact of femoral head size, dual mobility (DM), and constrained liners.

METHODS

All aseptic 1^st revisions reported to the Australian Joint Replacement Registry after hemiarthroplasty performed for FNOF when a THA was used as the revision procedure were included from September 1999 to December 2019. The primary outcome measure was the cumulative percent revision for all-causes and dislocation. The impact of prosthesis factors on revision THA was assessed: standard head THA (≤32 mm), large head THA (≥36 mm), DM, and constrained liners. Outcomes were compared using Kaplan Meyer and competing risk.

RESULTS

There were 96,861 hemiarthroplasties performed, with 985 revised to THA. The most common reasons for 1^st revision were loosening (49.3%), fracture (17.7%), and dislocation (11.0%). Of the hemiarthroplasty procedures revised to THA, 76 had a 2^nd revision. The most common reasons for 2^nd revision were fracture (27.6%), dislocation (26.3%), loosening (23.7%), and infection (18.4%). Femoral head size, DM, or constrained liner use did not alter the incidence of all-cause 2^nd revision. This did not change when solely looking at patients still alive. A 2^nd revision was more likely in patients aged <75 years.

CONCLUSION

The outcome of hemiarthroplasty performed for FNOF revised to THA is influenced by patient age, not by the articulation used.

Revision Risk After Unipolar or Bipolar Hemiarthroplasty for Femoral Neck Fractures: An Instrumental Variable Analysis of 62,875 Procedures from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

There remains much international practice variation regarding the choice of a unipolar or bipolar prosthesis design for displaced femoral neck fractures that are treated with hemiarthroplasty. The purpose of the present study was to compare revision rates following primary hemiarthroplasty for femoral neck fracture to determine if the unipolar hemiarthroplasty design increases the risk of revision arthroplasty for all causes.

METHODS

Instrumental variable analysis was performed with use of data that had been entered into the Australian Orthopaedic Association National Joint Replacement Registry from September 1, 1999, to December 31, 2018. Sixty-two thousand, eight hundred and seventy-five patients with femoral neck fractures that were treated with primary modular unipolar or bipolar hemiarthroplasty procedure were analyzed. Hospital preference for prosthesis design in the 12 months prior to the index procedure was used as an instrument to adjust for unmeasured confounding. The primary outcome was time to first revision for any cause. Secondary analyses were performed on the reason for revision (infection, dislocation, periprosthetic fracture, or acetabular erosion), the use of cement femoral stem fixation, and the type of stem (polished or matte).

RESULTS

Modular unipolar hemiarthroplasty was associated with a higher rate of revision at >2.5 years (hazard ratio [HR], 1.86; 95% confidence interval [CI], 1.46 to 2.36; p < 0.001), but there was no difference between the groups before 2.5 years (HR, 0.98; 95% CI, 0.85 to 1.13; p = 0.79). Protective factors for revision included female sex (HR, 0.82; 95% CI, 0.74 to 0.9), use of cemented fixation (HR, 0.69; 95% CI, 0.62 to 0.77), and surgery performed in a public hospital setting (HR 0.79; 95% CI, 0.70 to 0.89). Modular unipolar prostheses had a greater risk of revision for acetabular erosion, particularly in later time periods (HR at ≥5.5 years, 5.10; 95% CI, 2.40 to 10.83; p < 0.001), while being protective against periprosthetic fractures (HR, 0.72; 95% CI, 0.59 to 0.87; p < 0.001) at all time points. There was no difference in terms of the risk of revision for infection, dislocation, or stem type.

CONCLUSIONS

Bipolar hemiarthroplasty designs resulted in a lower risk of revision than unipolar designs. Unipolar hemiarthroplasties are justified for patients with femoral neck fracture and a shorter life expectancy (≤2.5 years).

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Geriatric Femoral Neck Fractures: Hemiarthroplasty Implant Trends Across a Health System From 2006 to 2018

Introduction:

Hemiarthroplasty is increasingly used for the treatment of geriatric femoral neck fractures in an effort to optimize value-based care. The current American Association of Orthopaedic Surgeons (AAOS) guidelines released in 2014 for the treatment of geriatric hip fractures recommend the utilization of monopolar cemented constructs. The purpose of this study was to evaluate hip hemiarthroplasty implant cost variability and implant selection trends from 2006 to 2018.

Materials and Methods:

A retrospective review of 940 geriatric hip fractures treated with hemiarthroplasty was conducted across 3 institutions from 2006 to 2018. Variables examined were construct type, surgeon, operative time, patient mortality, and implant cost. Statistical analysis consisted of multigroup comparative tests and multiple linear regression analyses to evaluate correlative measures.

Results:

The study population was 85.0 ± 7.9 years of age with a body mass index of 24.0 ± 5.5. A total of 33 (3.5%) patients were deceased at the 90-day postoperative mark and 45 (4.8%) patients at the 1-year mark. There was no statistical difference in terms of mortality between the 4 implant cohorts at the 90-day mark (P = .56) and 1-year mark (P = .24). The bipolar press-fit construct was the most expensive, US$3900.61 ± US$2607.54, and the monopolar cemented construct was the least expensive, US$2618.68 ± US$1834.16. The mean operative time was 6 minutes greater for press-fit implants, 93.6 ± 32.0, than cemented implants, 87.1 ± 33.6 (P = .02). The use of monopolar cemented implants increased from 12.1% to 83.3%, while bipolar press-fit decreased from 57.6% to 4.6% from 2013 to 2018.

Discussion:

The use of a bipolar and/or press-fit implant significantly increases construct cost despite little evidence in the literature of improved outcomes. Contrary to previous research, cemented implants do not increase the operative time.

Conclusions:

Encouragingly, selection of the most cost-conscience implant, monopolar cemented, has been increasing since 2014, which may reflect the influence of current AAOS guidelines.

Level of Evidence:

Diagnostic Level III.

Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: A pooled analysis of 30,250 participants data

PURPOSE

To assess the clinical outcomes of unipolar versus bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures in older patients and to report whether bipolar implants yield better long-term functional results.

METHODS

We searched PubMed, Scopus, EBSCO, and Cochrane Library for relevant randomized clinical trials (RCTs) and observational studies, comparing unipolar and bipolar hemiarthroplasty. Data were extracted from eligible studies and pooled as relative risk (RR) or mean difference (MD) with corresponding 95% confidence intervals (CI) using RevMan software for Windows.

RESULTS

A total of 30 studies were included (13 RCTs and 17 observational studies). Analyses included 30,250 patients with a mean age of 79 years and mean follow-up time of 24.6 months. The overall pooled estimates showed that bipolar was superior to unipolar hemiarthroplasty in terms of hip function, range of motion and reoperation rate, but at the expense of longer operative time. In the longer term the unipolar group had higher rates of acetabular erosion compared to the bipolar group. There was no significant difference in terms of hip pain, implant related complications, intraoperative blood loss, mortality, six-minute walk times, medical outcomes, and hospital stay and subsequently cost.

CONCLUSIONS

Bipolar hemiarthroplasty is associated with better range of motion, lower rates of acetabular erosion and lower reoperation rates compared to the unipolar hemiarthroplasty but at the expense of longer operative time. Both were similar in terms of mortality, and surgical or medical outcomes. Future large studies are recommended to compare both methods regarding the quality of life.

Comparison of Mid-term Survivorship and Clinical Outcomes between Bipolar Hemiarthroplasty and Total Hip Arthroplasty with Cementless Stem: A Multicenter Retrospective Study

Objectives

To compare the clinical outcome between bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) using a U2 HA cementless hip stem, and the results of elderly femoral neck fracture patients who underwent BHA with a cementless hip stem.

Methods

A multicenter retrospective study enrolled 96 BHA and 115 THA cases using U2 HA cementless hip stems with mean age (BHA: 67.9 years; THA: 64.1 years), body height (BHA: 160.4 cm; THA: 160.7 cm) and weight (BHA: 62.7 kg; THA: 64.5 kg) recorded. Mean follow‐up durations were, respectively, 7.1 (BHA) and 7.8 (THA) years. Survivorship analyses and Oxford hip scores were compared.

Results

Both the BHA and the THA groups revealed high survival rates at 5‐year (100%) and 10‐year (100.0% and 90.1%) follow‐up. The THA group achieved better joint performance and pain relief. The cementless HA stems had survived perfectly for 10 years for elderly femoral neck fracture patients following BHA.

Conclusions

The U2 HA cementless hip stem provides an effective solution for both BHA and THA surgeries, and for elderly femoral neck fracture patients undergoing BHA. According to the findings of the current study, THA may be inadequate for addressing avascular necrosis, and pain control is a considerable concern for patients who have undergone BHA.

Higher cartilage wear in unipolar than bipolar hemiarthroplasties of the hip at 2 years: A randomized controlled radiostereometric study in 19 fit elderly patients with femoral neck fractures

Background and purpose - The use of unipolar hemi-arthroplasties for femoral neck fractures is increasing in some countries due to reports of higher reoperation rates in bipolar prostheses. On the other hand, it has been proposed that bipolar hemiarthroplasties have clinical advantages and less cartilage wear than unipolar hemiarthroplasties. We compared cartilage wear between bipolar and unipolar hemiarthroplasties using radiostereometric analyses (RSA), in patients aged 70 years or older. Patients and methods - 28 ambulatory, lucid patients were randomized to treatment with a unipolar or a bipolar hemiarthroplasty for an acute femoral neck fracture. Migration of the prosthetic head into the acetabulum was measured using RSA. Secondary outcomes were Harris Hip Score (HHS), and EQ-5D scores. Patients were assessed at 3, 12. and 24 months. Results - 19 patients were available for follow-up at 2 years: mean proximal penetration was 0.83 mm in the unipolar group and 0.24 mm in the bipolar group (p = 0.01). Mean total point movement was 1.3 mm in the unipolar group and 0.95 mm in the bipolar group (p = 0.3). Median HHS was 78 (62-96) in the unipolar group and 100 (70-100) in the bipolar group (p = 0.004). Median EQ-5D Index Score was 0.73 (0.52-1.00) in the unipolar group and 1.00 (0.74-1.00) in the bipolar group (p = 0.01). Median EQ-5D VAS was 70 (50-90) in the unipolar group and 89 (70-95) in the bipolar group (p = 0.03) Interpretation - Patients with unipolar hemiarthroplasties had higher proximal cartilage wear and lower functional outcomes. Unipolar hemiarthroplasties should be used with caution in ambulatory, lucid patients.

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.

Interventions for treating displaced intracapsular femoral neck fractures in the elderly: a Bayesian network meta-analysis of randomized controlled trials

Displaced intracapsular femoral neck (AO type 31 B2/3) fractures have various treatments, including internal fixation (IF), unipolar uncemented hemiarthroplasty (HA), bipolar uncemented HA, unipolar cemented HA, bipolar cemented HA, uncemented total hip replacement (THR), and cemented THR. Systematic literature retrieval was performed from the databases to compare them in a network meta-analysis. Forty studies (85 arms) containing 6141 patients were included. Overall, our network meta-analysis rank the orders of 7 procedures in reoperation, mortality, dislocation and infection, which indicates that IF may provide the highest reoperation incidence, unipolar cemented HA may provide the lowest reoperation incidence; uncemented THR contributes the highest dislocation incidence; and bipolar uncemented HA provides the lowest infection incidence. No differences in mortality were observed among the treatments. This conclusion is indirect; higher-quality direct comparisons are required.

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.

Steady state acetabular cartilage wear after bipolar hemiarthroplasty: a case series of 10 patients with radiostereometric analysis

INTRODUCTION

Cartilage wear is a concern after hemiarthroplasty. The precise pattern of the progression of wear has not been evaluated. We previously reported the application of radiostereonetric analysis (RSA) for the measurement of cartilage wear in patients. The purpose of this study was to report the amount and the orientation of the steady state wear of cartilage between 1 and 3 years after bipolar hemiarthroplasty.

METHODS

22 patients with a bipolar hemiarthroplasty for displaced femoral neck fracture were included. 10 patients completed the mean follow up of 37 months. The cartilage wear was evaluated by calculating the migration of the bipolar head in reference to the markers in the acetabulum using RSA.

RESULTS

The mean age of the patients at the final follow-up was 80 (range 67-91) years. The 3-D migration was -0.02 mm (SD 0.30) between 1 and 3 years. The migration in each direction was 0.03 mm (SD 0.49) in medial, 0.03 mm (SD 0.14) in proximal and 0.11 mm (SD 0.29) in posterior directions. 2 patients showed migration of more than 0.2 mm. The large initial migration seen in some patients up to 1 year did not progress further. Total wear after 37 months was 0.43 mm (SD 0.17).

CONCLUSIONS

Cartilage wear progressed slowly in 2 of 10 patients from 1 to 3 years. No pelvic penetration was seen. We believe that RSA will give a basic knowledge about the development and the progression of cartilage wear after hemiarthroplasty.

Unipolar Versus Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures in Elderly Patients

Hip replacement using hemiarthroplasty (HA) is a common surgical procedure in elderly patients with femoral neck fractures. However, questions remain regarding the choice of unipolar or bipolar HA. A meta-analysis of randomized, controlled trials (RCTs) was performed to determine whether bipolar HA was associated with lower rates of dislocation, reoperation, acetabular erosion, mortality, and general complications, as well as lower Harris Hip Scores, compared with unipolar HA. The authors searched PubMed and the Cochrane Register of Controlled Trials database, and 8 RCTs (including a total of 1100 patients) were selected for meta-analysis. Risk ratios (RRs) and weighted mean differences (WMDs) from each trial were pooled using random-effects or fixed-effects models depending on the heterogeneity of the included studies. There were no differences in dislocation (RR=1.20; 95% confidence interval [CI], 0.47 to 3.07), reoperation (RR=0.64; 95% CI, 0.33 to 1.26), acetabular erosion (RR=2.29; 95% CI, 0.85 to 6.12), mortality (RR=0.85; 95% CI, 0.63 to 1.13), and general complications (RR=1.05; 95% CI, 0.70 to 1.56). The authors found no difference in postoperative Harris Hip Scores between patients undergoing unipolar vs bipolar HA (WMD=-1.32; 95% CI, -3.29 to 0.65; P=.19). Unipolar and bipolar HA achieved similar clinical outcomes in patients with displaced femoral neck fractures.

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.

Bipolar versus unipolar hemiarthroplasty for displaced femoral neck fractures in the elder patient: a systematic review and meta-analysis of randomized trials

OBJECTIVE

To assess the safety and efficacy that compare bipolar hemiarthroplasty with unipolar hemiarthroplasty for the treatment of femoral neck fracture in the patient aged more than 65 years.

METHODS

We searched databases including PubMed Central, MEDLINE (from 1966), EMBASE (from 1980) and the Cochrane Central Register of Controlled Trials database. Only prospective randomized controlled trials (RCTs) that compare bipolar hemiarthroplasty with unipolar hemiarthroplasty for the treatment of femoral neck fracture in the elder patient were included. RevMan 5.2 from the Cochrane Collaboration was applied to perform the meta-analysis.

RESULTS

Six relevant RCTs with a total of 982 patients were retrieved. From this meta-analysis, mortality rates showed no statistical difference between two treatments, 14.7% for bipolar versus 13.8% for unipolar. The acetabular erosion rates were significantly different between two groups (P=0.01), 1.2% in bipolar versus 5.5% in unipolar group. Overall complication rates, dislocation rates, infection rates and reoperation rates between two groups showed no statistical difference (P>0.05). Neither of two treatments appeared to be superior regarding the clinical function assessed by Harris hip scores or return to pre-injury state rates (P>0.05).

CONCLUSIONS

Both bipolar and unipolar hemiarthroplasty for the treatment of elderly patient suffering displaced femoral neck fracture achieve similar and satisfy clinical outcome in short-term follow-up. Unipolar hemiarthroplasty seems to be a more cost-effectiveness option for elderly patient.

Unipolar hemiarthroplasty versus bipolar hemiarthroplasty in patients with displaced femoral neck fractures: a four-year follow-up of a randomised controlled trial

PURPOSE

The treatment of choice for a displaced femoral neck fracture in the most elderly patients is a cemented hemiarthroplasty (HA). The optimal design, unipolar or bipolar head, remains unclear. The possible advantages of a bipolar HA are a better range of motion and less acetabular wear. The aim of this study was to evaluate hip function, health related quality of life (HRQoL), surgical outcome and acetabular erosion in a medium-term follow-up.

METHODS

One hundred and twenty patients aged 80 or more with a displaced fracture of the femoral neck (Garden III and IV) were randomised to treatment with a cemented Exeter HA using a unipolar or a bipolar head. All patients were able to walk independently, with or without aids, before surgery. Follow-ups were performed at four, 12, 24 and 48 months postoperatively. Assessments included HRQoL (EQ-5D index score), hip function (Harris hip score [HHS]) and radiological acetabular erosion.

RESULTS

The mean EQ-5D index score was generally higher among the patients with bipolar hemiarthroplasties at the follow-ups with a significant difference at 48 months: unipolar HAs 0.59 and bipolar HAs 0.70 (p = 0.04). There was an increased rate of acetabular erosion among the patients with unipolar hemiarthroplasties at the early follow-ups with a significant difference at 12 months (unipolar HAs 20% and bipolar HAs 5%, p = 0.03). At the later follow-ups the incidence of acetabular erosion accelerated in the bipolar group, and there were no significant differences between the groups at the 24- and 48-month follow-ups. There was no difference in HHS or reoperation rate between the groups at any of the follow-ups.

CONCLUSION

The bipolar HAs seem to result in better HRQoL beyond the first two years after surgery compared to unipolar HAs. Bipolar HAs displayed a later onset of acetabular erosion compared to unipolar HAs.

Adherence of hip and knee arthroplasty studies to RSA standardization guidelines. A systematic review

BACKGROUND AND PURPOSE

Guidelines for standardization of radiostereometry (RSA) of implants were published in 2005 to facilitate comparison of outcomes between various research groups. In this systematic review, we determined how well studies have adhered to these guidelines.

METHODS

We carried out a literature search to identify all articles published between January 2000 and December 2011 that used RSA in the evaluation of hip or knee prosthesis migration. 2 investigators independently evaluated each of the studies for adherence to the 13 individual guideline items. Since some of the 13 points included more than 1 criterion, studies were assessed on whether each point was fully met, partially met, or not met.

RESULTS

153 studies that met our inclusion criteria were identified. 61 of these were published before the guidelines were introduced (2000-2005) and 92 after the guidelines were introduced (2006-2011). The methodological quality of RSA studies clearly improved from 2000 to 2011. None of the studies fully met all 13 guidelines. Nearly half (43) of the studies published after the guidelines demonstrated a high methodological quality and adhered at least partially to 10 of the 13 guidelines, whereas less than one-fifth (11) of the studies published before the guidelines had the same methodological quality. Commonly unaddressed guideline items were related to imaging methodology, determination of precision from double examinations, and also mean error of rigid-body fitting and condition number cutoff levels.

INTERPRETATION

The guidelines have improved methodological reporting in RSA studies, but adherence to these guidelines is still relatively low. There is a need to update and clarify the guidelines for clinical hip and knee arthroplasty RSA studies.

Meta-analysis of randomised controlled trials comparing unipolar with bipolar hemiarthroplasty for displaced femoral-neck fractures

PURPOSE

Unipolar and bipolar hemiarthroplasty (HA) are used to treat displaced femoral-neck fractures. However, which type is best for treating displaced femoral-neck fractures in elderly patients remains a subject for debate. Our aim was to review randomised controlled trials to establish which type provides superior clinical outcome for this patient population.

METHODS

We searched PubMed, Embase and Cochrane Register of Controlled Trials databases and Web of Science for randomised controlled trials (RCTs) comparing unipolar with bipolar HA to treat femoral-neck fracture in the elderly. Risk ratios (RRs) and mean differences (MDs) from each trial were pooled using random-effects or fixed-effects models depending on study heterogeneity. Analysis was performed using RevMan5.2 from the Cochrane Collaboration.

RESULTS

A total of 1,100 patients from nine studies were assessed in this meta-analysis. Results showed no significant differences in function score [MD = -0.14, 95% confidence interval (CI) -2.42-2.13], mortality (RR = 0.97, 95% CI 0.65-1.46), dislocation (RR = 1.33, 95% CI 0.53-3.34), deep infection (RR = 0.79, 95% CI 0.35-1.79), acetabular erosion (RR = 1.99, 95% CI 0.61-6.52), operating time (MD = 2.14, 95% CI -9.85 to14.14), blood loss (MD = 13.40, 95% CI -49.60 to 76.39) and length of hospital stay (MD = 0.12, 95% CI -0.49 to 0.73) between unipolar and bipolar HA.

CONCLUSIONS

Unipolar and bipolar HA achieved similar clinical outcomes in patients with displaced femoral-neck fractures.

Proximal femoral fractures: Principles of management and review of literature

The purpose of this study was to review the principles involved in the management of proximal femoral fractures as reported in the literature.

METHODS

A medical literature search in the MEDLINE (PubMed) and Cochrane database was undertaken to review strategies and principles in proximal femoral fracture treatment. Randomized control trials and meta analysis were given preference while case reports/small series were rejected.

RESULTS AND CONCLUSIONS

Early anatomical reduction and surgical fixation remains the best option to reduce the risk of complications like non-union and avascular necrosis in treating fracture neck femurs. Cancellous screws continue to be the preferred treatment for fixation of neck femur fractures in younger population until the benefit of using sliding hip screws is validated by large multicentric studies. In the geriatric age group, early prosthetic replacement brings down the mortality and morbidity associated with neck femur fractures. Sliding hip screw (DHS) is the best available option for stable inter trochanteric fractures. The use of intramedullary nails e.g. PFN is beneficial in treating inter trochanteric fractures with comminution and loss of lateral buttress. Intramedullary implants have been proven to have increased success rates in subtrochanteric fractures and should be preferred over extramedullary plate fixation systems.

Radiostereometric analysis of hemiarthroplasties of the hip--a highly precise method for measurements of cartilage wear

OBJECTIVE

Cartilage wear is a feature of osteoarthritis and rheumatoid arthritis. Precise measurements of wear have been difficult. Cartilage wear caused by an artificial articulating joint surface is a well-known feature of hemiarthroplasties. The aim of this study was to demonstrate that radiostereometric analysis (RSA) may be used for three-dimensional measurements of cartilage wear in hemiarthroplasties of the hip.

METHOD

We performed a phantom model study to assess the feasibility of a subsequent clinical trial. We showed that the motion of the prosthetic head relative to the pelvis was not influenced by the orientation of the prosthetic head. Twenty-two patients were randomised to treatment with a cemented or an uncemented hemiarthroplasty for an acute femoral neck fracture. Migration of the prosthetic head into the acetabulum was measured using RSA.

RESULTS

A mean migration of the prosthetic head into the acetabulum of 0.62 mm was found at 3 months [95% confidence interval (CI): 0.27-0.97] and a further migration of -0.07 mm at 12 months (95% CI: -0.16-0.32). There were no differences between the groups in prosthetic migration or functional outcome. Between three and 12 months, there was no detectable cartilage wear during the first postoperative year.

CONCLUSION

Whether the migration during the first 3 months represents a period of bedding in due to a harder opposite surface remains to be shown. RSA may be used for measurement of cartilage wear in hemiarthroplasties of the hip. This study demonstrates a highly precise method for measurements of cartilage wear.

Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial

We reviewed the seven- to ten-year results of our previously reported prospective randomised controlled trial comparing total hip replacement and hemiarthroplasty for the treatment of displaced intracapsular fracture of the femoral neck. Of our original study group of 81 patients, 47 were still alive. After a mean follow up of nine years (7 to 10) overall mortality was 32.5% and 51.2% after total hip replacement and hemiarthroplasty, respectively (p = 0.09). At 100 months postoperatively a significantly greater proportion of hemiarthroplasty patients had died (p = 0.026). Three hips dislocated following total hip replacement and none after hemiarthroplasty. In both the total hip replacement and hemiarthroplasty groups a deterioration had occurred in walking distance (p = 0.02 and p < 0.001, respectively). One total hip replacement required revision compared with four hemiarthroplasties which were revised to total hip replacements. All surviving patients with a total hip replacement demonstrated wear of the cemented polyethylene component and all hemiarthroplasties had produced acetabular erosion. There was lower mortality (p = 0.013) and a trend towards superior function in patients with a total hip replacement in the medium term.