Hip fracture evaluation with alternatives of total hip arthroplasty versus hemiarthroplasty (HEALTH): protocol for a multicentre randomised trial

The use of uncemented stems in femoral neck fractures in elderly patients: A comparative study of 671 cases

INTRODUCTION

The use of cemented stems in elderly patients is associated with the risk of intraoperative embolic complications. Uncemented stems eliminate this risk, but their use is controversial because of the risk of mechanical complications, with estimated subsidence between 3.6 and 30% and periprosthetic fractures between 2.1 and 11% at 6 weeks. A retrospective multicenter comparative study was conducted using a propensity score analysis to evaluate mechanical performances of uncemented stems in femoral neck fractures in elderly patients to (1) compare the risk of mechanical complications and (2) assess the use of metaphyseal-anchored stems for this indication.

HYPOTHESIS

There is no difference in the risk of mechanical complications, intraoperatively or postoperatively, between these stems.

MATERIALS AND METHODS

We conducted a multicenter retrospective comparative study including 358 uncemented and 313 cemented stems. The mean age was 84.5 years [83.9-85.1]. The inclusion criteria were patients 70 years and older and a follow-up of at least 6 weeks. The primary endpoint was a composite endpoint comprised of stem subsidence≥2mm or periprosthetic fracture (up to 3 months postoperatively). The secondary endpoints were infection, stem subsidence≥2mm, and operative time. These endpoints were analyzed using a propensity score to control confounding factors. A secondary analysis used the same endpoints to compare metaphyseal-anchored (short stems) versus Corail-like stems.

RESULTS

After adjusting for the propensity score, we found 11.17% mechanical complications in the uncemented group (n=40, 5.59% subsidence, and 5.59% fractures) versus 13.42% for the cemented group (n=42, 7.99% subsidence, and 5.43% fractures). There was no statistically significant difference between the 2 values (Odds Ratio [OR]=0.64 [95% Confidence Interval [CI]: 0.14-2.85] [p=0.7]). The mortality rate due to cement embolism was 1%. There was no difference in the rate of subsidence (OR=0.55 [95% CI: 0.02-12.5] [p=0.7]), periprosthetic fracture (OR=0.65 [95% CI: 0.13-3.12] [p=0.7]) or infection (OR=0.71 [95% CI: 0.32-1.55] [p=0.4]). However, the operative times were longer in the cemented group (p=0.03 for hemiarthroplasties [mean additional time 16minutes] and p=0.02 for total hip arthroplasties [mean additional time 22minutes]). No difference was observed between the metaphyseal-anchored (short stems) and Corail-like stems regarding operative time, rate of infection, and rate of stem subsidence or periprosthetic fractures.

DISCUSSION

This is one of the first studies to highlight cemented stem subsidence when used for femoral neck fractures in elderly patients. Using uncemented stems in this indication is still warranted, especially since they do not bring about more mechanical complications in the first few months. Metaphyseal-anchored short stems seem to give the same results as "standard" stems. However, these findings need to be assessed in the longer term.

LEVEL OF EVIDENCE

III; retrospective comparative study.

High Rates of Imminent Subsequent Fracture After Femoral Neck Fracture in the Elderly

BACKGROUND

Fragility fractures of the hip are known to be followed frequently by subsequent fragility fractures, including second hip fractures. Data on subsequent fractures are available for aggregated index femoral neck and intertrochanteric femoral fractures, grouped generically as hip fractures, but not specifically for femoral neck fractures. There is increasing recognition that a subsequent fracture often occurs early after a hip fracture in the elderly, creating an emphasis on the concept of "imminent fracture risk." Since 2000, there have been many reports on the care gap in interventions after a fragility fracture, with concern regarding the slow uptake of appropriate systemic treatments designed to prevent a subsequent fracture in high-risk patients.

METHODS

As planned a priori, we performed an analysis of subsequent fractures after an index femoral neck fracture in 2 prospective clinical trials involving 2,520 patients from 90 sites on 5 continents. We recorded the incidence and time of occurrence of all secondary fragility fractures as well as the reported use of bone-protective medication in all subjects.

RESULTS

In the 24 months following the index femoral neck fracture, 226 (9.0%) of 2,520 patients sustained at least 1 subsequent fragility fracture, including 113 hip fractures (4.5%). The median interval from the index fracture to a subsequent fracture was approximately 9.0 months. Only 25.2% (634) of the 2,520 patients reported using bone-protective medications at any time during follow-up. Female patients, those with nondisplaced index fractures, and those treated with arthroplasty, were more likely to have received protective medication.

CONCLUSIONS

Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. Interventions to prevent a subsequent fracture were instituted in only 1 of 4 patients, even though a focused directive was included in both study protocols.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Who, if anyone, may benefit from a total hip arthroplasty after a displaced femoral neck fracture?

Aims

The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

Methods

We performed a post hoc exploratory analysis of a fitter cohort of patients from the HEALTH trial. Participants were aged over 50 years and had sustained a low-energy displaced femoral neck fracture (FNF). The fittest participant cohort was defined as participants aged 70 years or younger, classified as American Society of Anesthesiologists grade I or II, independent walkers prior to fracture, and living at home prior to fracture. Multilevel models were used to estimate the effect of THA versus HA on functional outcomes. In addition, a sensitivity analysis of the definition of the fittest participant cohort was performed.

Results

There were 143 patients included in the fittest cohort. Mean age was 66 years (SD 4.5) and 103 were female (72%). No clinically relevant differences were found between the treatment groups in the primary and sensitivity analyses.

Conclusion

This analysis found no differences in functional outcomes between HA and THA within two years of displaced low-energy FNF in a subgroup analysis of the fittest HEALTH patients. These findings suggest that very few patients above 50 years of age benefit in a clinically meaningful way from a THA versus a HA early after injury.

Cite this article: Bone Jt Open 2022;3(8):611–617.

Does Garden type I incomplete femoral neck fracture really exist in older adults? To evaluate the stability and consistency of Garden classification

Background

Accurate classification of femoral neck fracture (FNF) is crucial for treatment plan and therapeutic outcomes. Garden classification is commonly used in the clinic, but its stability and consistency remain controversial. The aim of this study was to evaluate the stability and consistency of Garden classification based on X and CT images, and to analyze whether it is valid for Garden I in the elderly.

Methods

X-ray and CT images from 886 elderly patients with FNF were collected, four orthopaedic surgeons and four radiologists evaluated these images independently, and determined the fracture type based on Garden classification. Three months later, The exercise was repeated and the results were compared based on 4 types Garden classification (I, II, III and IV) and 3 types Garden classification (I + II, III and IV). Kappa was used to measure inter- and intraobserver agreement. The patients with Garden I incomplete FNF confirmed by 8 observers together based on images combined with medical history were compared with the intraoperative results.

Results

Four types Garden classification, there was little consistency inter- and intraobservers (Kappa from 0.18 to 0.43) based on X-ray images, while professors consistency (0.56 to 0.76) was higher than residents (0.28 to 0.35) based on CT. 3 types Garden classification showed almost perfect agreement inter- and intraobservers, which ranged from 0.76 to 0.90. Totally 52 patients were diagnosed as Garden I, 38 of whom underwent arthroplasty. All surgical cases showed complete fracture during operation.

Conclusions

There was low consistency and repeatability in 4 types Garden classification (I, II, III and IV), while 3 types Garden classification (I + II, III and IV) had high consistency among observers. In the elderly, all undisplaced femoral neck fracture may be Garden II, no Garden I.

Bipolar Hemiarthroplasty Does Not Result in a Higher Risk of Revision Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures: An Instrumental Variable Analysis of 36,118 Procedures from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Previous randomized studies have suggested that there is no short-term difference between the risk of revision following total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fracture in elderly patients. The aim of the present study was to compare the long-term revision rates of primary THA and HA for femoral neck fracture in order to determine whether unipolar or bipolar HA increases the all-cause risk of revision in patients 50 to 79 years old.

METHODS

Data for 36,188 patients who underwent primary arthroplasty, including 13,035 unipolar and 8,220 bipolar HAs and 14,863 THAs, from September 1, 1999, to December 31, 2019, were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Unadjusted analyses were performed, as well as analyses adjusted for age, sex, femoral cement, and procedure year. The primary outcome was time to first revision for any cause. Secondary analyses were performed for the reason for revision (i.e., infection, dislocation, and periprosthetic fracture). Instrumental variable analysis of hospital preference (for either HA or THA) was performed in order to mitigate the effect of any unmeasured confounding. All analyses were restricted to hospitals performing at least 10 procedures in the prior year.

RESULTS

A total of 18,955 procedures were available for the comparison of modular unipolar HA to THA. Both the adjusted analysis performed with use of Cox proportional hazards (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.64 to 2.31; p < 0.001) and the instrumental variable analysis (HR, 2.82; 95% CI, 1.89 to 4.22; p < 0.001) demonstrated a higher risk of revision following modular unipolar HA compared with THA from 3 months postoperatively. A total of 13,168 procedures were available for the comparison of bipolar HA to THA. The adjusted analysis performed with use of Cox proportional hazards showed a significantly higher risk of revision for bipolar HA (HR, 1.29; 95% CI, 1.08 to 1.54; p = 0.01). The instrumental variable analysis showed a similar effect size that was not significant (HR, 1.27; 95% CI, 0.91 to 1.78; p = 0.16).

CONCLUSIONS

Bipolar HA and THA demonstrated no significant difference in revision risk at long-term follow-up. Unipolar HA demonstrated higher risk of revision from 3 months postoperatively compared to THA. The higher risk of revision for dislocation observed following THA may be offset by the higher risk of revision for acetabular erosion or pain following bipolar HA, resulting in more equivalent revision risk.

LEVEL OF EVIDENCE

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

Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study

Importance

Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population.

Objective

To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy.

Design, Setting, and Participants

This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category ≤2).

Exposures

Shared decision-making (SDM) followed by nonoperative or operative fracture management.

Main Outcomes and Measures

The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire).

Results

Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8.

Conclusions and Relevance

Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.

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.

A pilot multicenter randomized controlled trial comparing Bankart repair and remplissage with the Latarjet procedure in patients with subcritical bone loss (STABLE): study protocol

Introduction

Anterior dislocations, the most common type of shoulder dislocation, are often complicated by subsequent instability. With recurrent dislocations there often is attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management remains unknown and current clinical practice is highly varied.

Methods and analysis

The Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multi-centre, pilot randomized controlled trial of 82 patients who have been diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss. Patients are randomized to either soft tissue repair (Bankart + Remplissage) or bony augmentation (Latarjet procedure). The primary outcome for this pilot is to assess trial feasibility and secondary outcomes include recurrent instability as well as functional outcomes up to two years post-operatively.

Conclusions

This trial will help to identify the optimal treatment for patients with recurrent shoulder instability with a focus on determining which treatment option results in reduced risk of recurrent dislocation and improved patient outcomes. Findings from this trial will guide clinical practice and improve care for patients with shoulder instability.

Trial registration

This study has been registered on http://www.ClinicalTrials.gov with the following identifier: ClinicalTrials.gov Identifier: NCT03585491, registered 13 July 2018, https://www.clinicaltrials.gov/ct2/show/NCT03585491?term=NCT03585491&draw=2&rank=1.

Ethics and dissemination

This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB) (approval #4942). Successful completion will significantly impact the global management of patients with recurrent instability. This trial will develop a network of collaboration for future high-quality trials in shoulder instability.

Expertise-based design in surgical trials: a narrative review

Randomized controlled trials (RCTs) are the most robust study design for evaluating the safety and efficacy of a therapeutic intervention. However, their internal validity are at risk when evaluating surgical interventions. This review summarizes existing expertise- based trials in surgery and related methodological concepts to guide surgeons performing this work. We provide caseloads required to reach the learning curve for various surgical interventions and report criteria for expertise from published and unpublished expertise-based trials. In addition, we review design and implementation concepts of expertise-based trials, including recruitment of surgeons, crossover, ethics, generalizability, sample size and definitions for learning curve. Several RCTs have used an expertise-based design. We found that the majority of definitions used for expertise were vague, heterogeneous, and inconsistent across trials evaluating the same surgical intervention. Statistical methods exist to adjust for the learning curve; however, there is limited guidance. We developed the following criteria for surgical expertise for future trials: 1) decide on the proxy to be used for the learning curve, and 2) assess eligible surgeons by comparing their performance to the previously defined expertise criteria.

Curriculum learning for improved femur fracture classification: Scheduling data with prior knowledge and uncertainty

An adequate classification of proximal femur fractures from X-ray images is crucial for the treatment choice and the patients' clinical outcome. We rely on the commonly used AO system, which describes a hierarchical knowledge tree classifying the images into types and subtypes according to the fracture's location and complexity. In this paper, we propose a method for the automatic classification of proximal femur fractures into 3 and 7 AO classes based on a Convolutional Neural Network (CNN). As it is known, CNNs need large and representative datasets with reliable labels, which are hard to collect for the application at hand. In this paper, we design a curriculum learning (CL) approach that improves over the basic CNNs performance under such conditions. Our novel formulation reunites three curriculum strategies: individually weighting training samples, reordering the training set, and sampling subsets of data. The core of these strategies is a scoring function ranking the training samples. We define two novel scoring functions: one from domain-specific prior knowledge and an original self-paced uncertainty score. We perform experiments on a clinical dataset of proximal femur radiographs. The curriculum improves proximal femur fracture classification up to the performance of experienced trauma surgeons. The best curriculum method reorders the training set based on prior knowledge resulting into a classification improvement of 15%. Using the publicly available MNIST dataset, we further discuss and demonstrate the benefits of our unified CL formulation for three controlled and challenging digit recognition scenarios: with limited amounts of data, under class-imbalance, and in the presence of label noise. The code of our work is available at: https://github.com/ameliajimenez/curriculum-learning-prior-uncertainty.

Cementless Fixation Is Associated With Increased Risk of Early and All-Time Revision After Hemiarthroplasty But Not After THA for Femoral Neck Fracture: Results From the American Joint Replacement Registry

BACKGROUND

Despite ample evidence supporting cemented femoral fixation for both hemiarthroplasty and THA for surgical treatment of displaced femoral neck fractures, cementless fixation is the preferred fixation method in the United States. To our knowledge, no nationally representative registry from the United States has compared revision rates by fixation for this surgical treatment.

QUESTION/PURPOSE

After controlling for relevant confounding variables, is femoral fixation method (cemented or cementless) in hemiarthroplasty or THA for femoral neck fracture associated with a greater risk of (1) all-cause revision or (2) revision for periprosthetic fracture?

METHODS

Patients with Medicare insurance who had femoral neck fractures treated with hemiarthroplasty or THA reported in the American Joint Replacement Registry database from 2012 to 2017 and Centers for Medicare and Medicaid Services claims data from 2012 to 2017 were analyzed in this retrospective, large-database study. Of the 37,201 hemiarthroplasties, 42% (15,748) used cemented fixation and 58% (21,453) used cementless fixation. Of the 7732 THAs, 20% (1511) used cemented stem fixation and 80% (6221) used cementless stem fixation. For both the hemiarthroplasty and THA cohorts, most patients were women and had cementless femoral fixation. Early revision was defined as a procedure that occurred less than 90 days from the index procedure. All patients submitted to the registry were included in the analysis. Patient follow-up was limited to the study period. No patients were lost to follow-up. Due to inherent limitations with the registry, we did not compare medical complications, including deaths attributed directly to cemented fixation. A logistic regression model including the index arthroplasty, age, gender, stem fixation method, hospital size, hospital teaching affiliation, and Charlson comorbidity index score was used to determine associations between the index procedure and revision rates.

RESULTS

For the hemiarthroplasty cohort, risk factors for any revision were cementless stem fixation (odds ratio 1.42 [95% confidence interval 1.20 to 1.68]; p < 0.001), younger age (OR 0.96 [95% CI 0.95 to 0.97]; p < 0.001), and higher Charlson comorbidity index (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.004). Risk factors for early revision were cementless stem fixation (OR 1.77 [95% CI 1.43 to 2.20]; p < 0.001), younger age (OR 0.98 [95% CI 0.97 to 0.99]; p < 0.001), and higher Charlson comorbidity index (OR 1.09 [95% CI 1.04 to 1.15]; p < 0.001). Risk factors for revision due to periprosthetic fracture were cementless fixation (OR 6.19 [95% CI 3.08 to 12.42]; p < 0.001) and higher Charlson comorbidity index (OR 1.16 [95% CI 1.06 to 1.28]; p = 0.002). Risk factors for early revision due to periprosthetic fracture were cementless fixation (OR 7.38 [95% CI 3.17 to 17.17]; p < 0.001), major teaching hospital (OR 2.10 [95% CI 1.08 to 4.10]; p = 0.03), and higher Charlson comorbidity index (OR 1.20 [95% CI 1.09 to 1.33]; p < 0.001). For the THA cohort, there were no associations.

CONCLUSION

These data suggest that cemented fixation should be the preferred technique for most patients with displaced femoral neck fractures treated with hemiarthroplasty. The fact that stem fixation method did not affect revision rates for those patients with displaced femoral neck fractures treated with THA may be due to current practice patterns in the United States.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Comparison of functional outcome of cemented total hip replacement versus cemented dual-mobility cup total hip replacement for the management of displaced femoral neck fractures in the active elderly patients

INTRODUCTION

Current guidelines recommend treating displaced femoral neck fractures with a total hip replacement in fit and active elderly patients. Dislocation remains the main complication. Dual-mobility cup (DMC) hip replacements maybe a solution to decrease dislocation, with the benefit of increasing stability, achieving better range of motion and functional outcomes.

PATIENTS AND METHODS

This is a prospective randomised controlled trial which included 62 patients with Garden III and IV femoral neck fractures. The mean age was 67.2 years. 30 males and 32 females were included, randomised and allocated to 2 treatment groups; a cemented DMC replacement group, or a cemented 32-mm head total hip replacement (THR). The posterior approach was used in all patients. Postoperative functional outcome was assessed using Harris Hip Score (HHS). Health-related quality of life (HRQoL) was assessed using the SF-36 questionnaire.

RESULTS

The mean HHS for the DMC group at 4, 6 and 12 months were higher than mean HHS scores for the THR group (p < 0.001). The range of motion at 1 year was statistically better in the DMC group compared to the THR group (p < 0.001). The DMC showed a statistically better effect on the HRQoL measurements as compared to the THR group. There were no dislocations in both groups.

CONCLUSIONS

DMC hip replacements provide better functional, patient reported outcomes, and range of motion than the conventional THR. Combined with its stability, DMC replacements are a useful solution in managing femoral neck fractures in active elderly patients.Trial serial number 020841 (IRB Number 00007555).

Heterotopic Ossification Following Arthroplasty for Femoral Neck Fracture

BACKGROUND

Heterotopic ossification (HO) is a frequent complication following hip surgery. Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we aimed to (1) determine the prevalence of HO following total hip arthroplasty (THA) for femoral neck fracture in patients ≥50 years of age, (2) identify whether HO is associated with an increased risk of revision surgery within 24 months after the fracture, and (3) determine the impact of HO on functional outcomes.

METHODS

We performed a multivariable Cox regression analysis using revision surgery as the dependent variable and HO as the independent variable. We compared Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between participants with and those without HO at 24 months.

RESULTS

Of 1,441 participants in the study, 287 (19.9%) developed HO within 24 months. HO was not associated with subsequent revision surgery. Grade-III HO was associated with statistically significant and clinically relevant deterioration in the total WOMAC score, which was mainly related to the function component of the score, compared with grade I or II.

CONCLUSIONS

The impact of grade-III HO on the functional outcomes and quality of life after THA for hip fracture is clinically important, and HO prophylaxis for selected high-risk patients may be appropriate.

LEVEL OF EVIDENCE

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

The management of displaced femoral neck fractures: a narrative review

This article serves to review the existing clinical guidelines, and highlight the most recent medical and surgical recommendations, for the management of displaced femoral neck fractures (FNFs). It stresses the need for multi-disciplinary intervention to potentially improve mortality rates, limit adverse events and prevent further economic liability.Globally, the incidence of FNFs continues to rise as the general population ages and becomes more active. The annual number of FNFs is expected to exceed six million by 2050. The increased burden of FNFs exacerbates the demand on all services associated with treating these injuries.The management of FNFs may serve as an indicator of the quality of care of the geriatric population. However, despite escalating health costs, a significant 30-day and one-year mortality rate, increased rate of peri-operative adverse events and sub-optimal functional clinical outcomes, continued controversy exists over optimal patient care.Much debate exists over the type of surgery, implant selection and peri-operative clinical care and rehabilitation. FNF care models, systematized clinical pathways, formal geriatrics consultation and specialized wards within an established interdisciplinary care framework may improve outcomes, mitigate adverse events and limit unnecessary costs. Cite this article: EFORT Open Rev 2021;6:139-144. DOI: 10.1302/2058-5241.6.200036.

Predictors of Medical Serious Adverse Events in Hip Fracture Patients Treated With Arthroplasty

AIM

Patients with hip fractures are often frail with multiple comorbidities and at risk of medical serious adverse events (SAEs). We investigated the HEALTH trial patient population to ascertain predictors of SAEs.

METHODS

We performed a multivariable Cox regression analysis. Occurrence of SAEs was included as the dependent variable with 31 potential prognostic factors being included as independent variables.

RESULTS

One thousand four hundred forty-one patients were included in this analysis. Three hundred seventy (25.6%) patients suffered from an SAE. The most common events were cardiac (38.4%, n = 105), respiratory (20.8%, n = 77), and neurological (14.1%, n = 77). The majority of SAEs (50.8%, n = 188) occurred in the first 90 days after hip fracture with 35.4% occurring in the first 30 days (n = 131). Body mass index (BMI) between 18.5 and 24.9 compared with BMI between 25 and 29.9 [hazard ratio (HR) 1.32, P = 0.03] and receiving a total hip arthroplasty compared with a bipolar hemiarthroplasty (HR 1.36, P = 0.03) were associated with a higher risk of a medical SAE within 24 months of femoral neck fracture. Age (P = 0.09), use of femoral cement (P = 0.59), and use of canal pressurization (P = 0.37) were not associated with a medical SAE.

CONCLUSION

Total hip arthroplasty is associated with more SAEs in the immediate postoperative period, and care should be taken in selecting patients for this treatment compared with a hemiarthroplasty. A higher BMI may be protective in hip fracture patients while age alone does not predict SAEs and neither does the use of femoral cement and/or pressurization.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

What Predicts Health-Related Quality of Life for Patients With Displaced Femoral Neck Fractures Managed With Arthroplasty? A Secondary Analysis of the HEALTH Trial

BACKGROUND

Total hip arthroplasty (THA) has been argued to improve health-related quality of life (HRQoL) and function in femoral neck fracture patients compared with hemiarthroplasty (HA). The HEALTH trial showed no clinically important functional advantages of THA over HA. The current analysis explores factors associated with HRQoL and function in this population.

METHODS

Using repeated measures regression, we estimated the association between HRQoL and function [Short Form-12 (SF-12) physical component score (PCS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score] and 23 variables.

RESULTS

THA as compared to monopolar HA, but not bipolar HA, was more likely to improve PCS scores (adjusted mean difference [AMD] 1.88 points, P = 0.02), whereas higher American Society of Anesthesiologists score (AMD -2.64, P < 0.01), preoperative use of an aid (AMD -2.66, P < 0.01), and partial weight-bearing status postoperatively (AMD -1.38, P = 0.04) demonstrated less improvement of PCS scores over time. THA improved WOMAC function scores over time compared with monopolar HA (but not bipolar HA) (AMD -2.40, P < 0.01), whereas higher American Society of Anesthesiologists classification (AMD 1.99, P = 0.01) and preoperative use of an aid (AMD 5.39, P < 0.01) were associated with lower WOMAC function scores. Preoperative treatment for depression was associated with lower functional scores (AMD 7.73, P < 0.01).

CONCLUSION

Patients receiving THA are likely to receive small and clinically unimportant improvements in health utility and function compared with those receiving monopolar HA and little improvement compared with those receiving bipolar HA. Patient-specific characteristics seem to play a larger role in predicting functional improvement among femoral neck fracture patients.

LEVEL OF EVIDENCE

Prognostic Level II.

Precise proximal femur fracture classification for interactive training and surgical planning

PURPOSE

Demonstrate the feasibility of a fully automatic computer-aided diagnosis (CAD) tool, based on deep learning, that localizes and classifies proximal femur fractures on X-ray images according to the AO classification. The proposed framework aims to improve patient treatment planning and provide support for the training of trauma surgeon residents.

MATERIAL AND METHODS

A database of 1347 clinical radiographic studies was collected. Radiologists and trauma surgeons annotated all fractures with bounding boxes and provided a classification according to the AO standard. In all experiments, the dataset was split patient-wise in three with the ratio 70%:10%:20% to build the training, validation and test sets, respectively. ResNet-50 and AlexNet architectures were implemented as deep learning classification and localization models, respectively. Accuracy, precision, recall and [Formula: see text]-score were reported as classification metrics. Retrieval of similar cases was evaluated in terms of precision and recall.

RESULTS

The proposed CAD tool for the classification of radiographs into types "A," "B" and "not-fractured" reaches a [Formula: see text]-score of 87% and AUC of 0.95. When classifying fractures versus not-fractured cases it improves up to 94% and 0.98. Prior localization of the fracture results in an improvement with respect to full-image classification. In total, 100% of the predicted centers of the region of interest are contained in the manually provided bounding boxes. The system retrieves on average 9 relevant images (from the same class) out of 10 cases.

CONCLUSION

Our CAD scheme localizes, detects and further classifies proximal femur fractures achieving results comparable to expert-level and state-of-the-art performance. Our auxiliary localization model was highly accurate predicting the region of interest in the radiograph. We further investigated several strategies of verification for its adoption into the daily clinical routine. A sensitivity analysis of the size of the ROI and image retrieval as a clinical use case were presented.

Randomized Controlled Trials for Geriatric Hip Fracture Are Rare and Underpowered: A Systematic Review and a Call for Greater Collaboration

BACKGROUND

Geriatric hip fracture is a common condition, and there are many open questions regarding patient management. Among the various types of medical evidence, the prospective randomized controlled trial (RCT) is considered the best. Our primary hypothesis was that small sample size would be seen frequently among RCTs involving geriatric patients with hip fracture. A related hypothesis was that studies from the United States would have particularly large deficits in sample size. Therefore, we asked the following research questions: (1) What is the mean sample size of RCTs involving geriatric patients with hip fracture? (2) How do sample sizes for studies from the U.S. differ from those performed elsewhere?

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, a systematic review of hip fracture RCTs was conducted. The Embase and MEDLINE databases were searched. Additional data included the country of origin, the power of the study, and whether sample size calculations were performed. One hundred and forty-seven RCTs were identified.

RESULTS

The mean sample size of the 147 RCTs was 134.9. The mean sample size for the 7 American trials was 110.3, and the mean sample size for all trials conducted outside of the United States was 136.1. A sample size that was sufficient to ensure 80% power was used in only 31.3% of the RCTs.

CONCLUSIONS

RCTs for hip fracture are small and underpowered. Moreover, <5% of the RCT studies have been conducted in the U.S., and they were smaller than those conducted elsewhere. The shortage of American trials may be a feature of the dispersion of geriatric hip fracture care across many hospitals in the United States. If so, better clinical research might require more centralized care (e.g., in specialized geriatric hip fracture centers) or greater collaboration among the many hospitals that provide care.

Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture

BACKGROUND

Globally, hip fractures are among the top 10 causes of disability in adults. For displaced femoral neck fractures, there remains uncertainty regarding the effect of a total hip arthroplasty as compared with hemiarthroplasty.

METHODS

We randomly assigned 1495 patients who were 50 years of age or older and had a displaced femoral neck fracture to undergo either total hip arthroplasty or hemiarthroplasty. All enrolled patients had been able to ambulate without the assistance of another person before the fracture occurred. The trial was conducted in 80 centers in 10 countries. The primary end point was a secondary hip procedure within 24 months of follow-up. Secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points.

RESULTS

The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to total hip arthroplasty and 60 of 723 patients (8.3%) who were randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P = 0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored total hip arthroplasty over hemiarthroplasty. Mortality was similar in the two treatment groups (14.3% among the patients assigned to total hip arthroplasty and 13.1% among those assigned to hemiarthroplasty, P = 0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to total hip arthroplasty and in 265 patients (36.7%) assigned to hemiarthroplasty.

CONCLUSIONS

Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00556842.).

Preliminary experience with EBA ONE intramedullary nail for the treatment of pertrochanteric fractures

BACKGROUND AND AIM OF THE STUDY

The Authors report their preliminary experience with a new fixation device for treatment of pertrochanteric fractures. The EBA ONE nail, produced by Citieffe in Bologna - Italy.

MATERIALS

Between April 2019 and August 2019 in Orthopedics and Traumatology Department of  Piacenza,  11 patients (all female) with stable and unstable pattern of fractures, were treated with the EBA ONE intramedullary nail.

RESULTS

Despite the limited number of cases and the assence of a complete follow-up, the initial results are very encouraging. None of the reported complications were linked to the fixation device or to the surgical technique.

CONCLUSIONS

The minimal, simple and intuitive instrumentation set and the simplicity of the surgical procedure make this fixation device valuable for use in stable fractures. The possibility to distal locking the nail, either statically or dynamically, and the availability of a longer nail make this device also effective in more complex fractures.

Study protocol: design and rationale for an exploratory phase II randomized controlled trial to determine optimal vitamin D3 supplementation strategies for acute fracture healing

Background

Observational studies have found that 75% of healthy adult fracture patients (ages 18-50) have serum 25-hydroxyvitamin D (25(OH)D) levels < 30 ng/mL. Although lower serum 25(OH)D levels have yet to be correlated to fracture healing complications or poor fracture outcomes, many orthopedic surgeons are routinely prescribing vitamin D supplements to improve fracture healing in healthy non-osteoporotic patients. To address this gap in the literature, we propose a phase II exploratory randomized controlled trial comparing three vitamin D₃ dosing regimens for early surrogate treatment response.

Methods

We will conduct a 4-arm blinded exploratory phase II trial in 96 adults aged 18-50 years with a closed or low-grade open (Gustilo type I or II) tibial or femoral shaft fracture. Eligible patients will be randomized in equal allocation ratio of 1:1:1:1 to one of the treatment groups: (1) 150,000 IU loading dose vitamin D₃ plus daily dose placebo; (2) loading dose placebo plus 4000 IU vitamin D₃ per day, (3) loading dose placebo plus 600 IU vitamin D₃ per day, or (4) loading dose placebo plus daily dose placebo. The primary outcome is fracture healing, assessed as follows: (1) clinical fracture healing measured using the Function IndeX for Trauma, (2) radiographic fracture healing measured using the Radiographic Union Score for Tibial fractures, and (3) biological fracture healing measured using serum levels of cross-linked C-terminal telopeptides of type I collagen and amino-terminal procollagen propeptides of collagen type I. The main secondary outcome will be assessed by measuring serum 25(OH)D levels. All outcome analyses will be exploratory and adhere to the intention-to-treat principle. Per-protocol sensitivity analyses will also be conducted.

Discussion

Study results will be disseminated through a publication in an academic journal and presentations at orthopedic conferences. Study results will inform dose selection for a large definitive randomized controlled trial and provide preliminary clinical data on which dose may improve acute fracture healing outcomes in healthy adult patients (18-50 years) at 3 months.

Trial registration

Vita-Shock (A Blinded Exploratory Randomized Controlled Trial to Determine Optimal Vitamin D₃ Supplementation Strategies for Acute Fracture Healing) was registered at ClinicalTrials.gov (identifier NCT02786498) prior to enrollment of participants.

Treatment of the displaced intracapsular fracture for the 'fitter' elderly patients: A randomised trial of total hip arthroplasty versus hemiarthroplasty for 105 patients

Controversy exists for the optimum method of surgical treatment for the 'fitter' elderly patient with a displaced intracapsular fracture. 105 patients were randomised to treatment with either a cemented polished tapered stem hemiarthroplasty or a cemented total hip arthroplasty (THR) with a cemented acetabular cup. All patients were followed up for a minimum of one year using a blinded assessment of functional outcome. Those patients treated with a THR had a tendency to a longer hospital stay and increased medical (12 versus 62) and surgical complications (4 versus 2) in comparison to those treated by hemiarthroplasty. Mean operative times (842 versus 52 min) and operative blood loss (335mls versus 244mls) were increased for THR. Final outcome measures of residual pain and regain of function were similar for both methods of treatment. We recommend that caution should be exercised regarding the increased promotion of THR for intracapsular hip fractures until further studies are completed.

Fixation using alternative implants for the treatment of hip fractures (FAITH-2): design and rationale for a pilot multi-centre 2 × 2 factorial randomized controlled trial in young femoral neck fracture patients

Background

Femoral neck fractures in patients ≤ 60 years of age are often very different injuries compared to low-energy, hip fractures in elderly patients and are difficult to manage because of inherent problems associated with high-energy trauma mechanisms and increased functional demands for recovery. Internal fixation, with multiple cancellous screws or a sliding hip screw (SHS), is the most common treatment for this injury in young patients. However, there is no clinical consensus regarding which surgical technique is optimal. Additionally, there is compelling rationale to use vitamin D supplementation to nutritionally optimize bone healing in young patients. This pilot trial will determine feasibility and provide preliminary clinical data for a larger definitive trial.

Methods

We will conduct a multicenter, concealed randomized controlled pilot study, using a 2 × 2 factorial design in 60 patients aged 18–60 years with a femoral neck fracture. Eligible patients will be randomized in equal proportions to one of four groups: 1) SHS and vitamin D supplementation (4000 international units (IU) daily dose) for 6 months, 2) cancellous screws and vitamin D supplementation (4000 IU daily dose) for 6 months, 3) SHS and placebo, and 4) cancellous screws and placebo. Participants will be followed for 12 months post-fracture. Feasibility outcomes include initiation of clinical sites, recruitment, follow-up, data quality, and protocol adherence. Clinical outcomes, for both the pilot and planned definitive trials, include a composite of patient-important outcomes (re-operation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion), health-related quality of life and patient-reported function, fracture healing complications, and radiographic fracture healing. A priori success criteria have been established. If the pilot study is deemed successful, study participants will be included in the definitive trial and clinical outcomes for the pilot will not be analyzed. If the pilot study is not deemed successful, clinical outcome data will be analyzed.

Discussion

Results of this study will inform the feasibility of a definitive trial. If clinical outcome data are analyzed, they will be disseminated through a publication and presentations.

Trial registration

The FAITH-2 trial, described as a definitive trial, was registered at ClinicalTrials.gov (NCT01908751) prior to enrollment of the first participant.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0458-x) contains supplementary material, which is available to authorized users.

Total hip arthroplasty versus hemiarthroplasty for independently mobile older adults with intracapsular hip fractures

Background

Displaced intracapsular hip fractures are typically treated with hemiarthroplasty (HA) or total hip arthroplasty (THA). A number of professional bodies recommend considering THA for patients that were independently mobile and cognitively intact before injury. The aim of this study was to compare the outcomes between HA and THA for independently mobile older adults with hip fractures.

Methods

A systematic review and meta-analysis of RCTs was undertaken alongside analysis of a propensity score matched national cohort of older adults (aged > 60) with hip fractures. Participants were identified for the propensity score matched cohort from the National Hip Fracture Database (NHFD), which was linked to Hospital Episode Statistics (HES) and civil death registration data. The primary outcomes were 12-month dislocation, revision, and mortality. The secondary outcomes were length of stay, discharge home, unplanned re-admission, functional outcomes, and health-related quality of life.

Results

Five RCTs reported higher THA dislocation but this was not statistically significant (THA risk ratio [RR] 2.77, 95% CI 0.81 to 9.48). However, THA dislocation was significantly higher in the national observational dataset (sub-distribution hazard ratio [SHR] 1.73, 95% CI 1.24 to 2.41). Meta-analysis of data from four RCTs did not identify a significant difference in terms of revision (RR 1.52, 95% CI 0.56 to 4.14). However, THA revision was significantly lower in the national dataset (SHR 0.66, 95% CI 0.48 to 0.90). Meta-analysis of data from 5 RCTs suggested higher mortality amongst patients undergoing HA (RR 0.63, 95% CI 0.38 to 1.04), which was also observed within the national registry dataset (hazard ratio 0.45, 95% CI 0.37 to 0.54).

Conclusions

National clinical registries can provide important context when interpreting RCT data, which may alone be inadequate for comparing the safety profile of surgical interventions. These data suggest that THA is at significantly higher risk of dislocation but lower risk of revision within 12 months. The finding from both RCT and clinical registry data that THA is associated with lower 12-month mortality amongst the fittest patients with hip fractures requires urgent further study to determine whether or not this can be replicated in other balanced populations.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2590-4) contains supplementary material, which is available to authorized users.

Comparing Complications and Costs of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fractures: A Propensity Score-Matched, Population-Based Study

BACKGROUND

Although the prevalence of displaced femoral neck fractures in the elderly population is increasing worldwide, there remains controversy as to whether these injuries should be managed with hemiarthroplasty or total hip arthroplasty. Although total hip arthroplasties result in better function, they are more expensive and may have higher complication rates. Our objective was to compare the complication rates and health-care costs between hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the elderly population.

METHODS

A population-based, retrospective cohort study was performed on adults (≥60 years of age) undergoing either hemiarthroplasty or total hip arthroplasty for hip fracture between April 1, 2004, and March 31, 2014. We excluded patients who resided in long-term care facilities prior to the injury and those who were discharged to these facilities after the surgical procedure. Patients who underwent a hemiarthroplasty and those who underwent a total hip arthroplasty were matched using a propensity score encompassing patient demographic characteristics, patient comorbidities, and provider factors. After matching, we compared the rates of medical and surgical complications, as well as the perioperative and postoperative health-care costs in the year following the surgical procedure. The primary outcome was the occurrence of a medical complication (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, ileus, pneumonia, renal failure) within 90 days or a surgical complication (dislocation, infection, revision surgical procedure) within 1 year. Additionally, we examined the change in health-care costs in the year following the surgical procedure, including costs associated with the index admission, relative to the year before the surgical procedure.

RESULTS

Among 29,121 eligible patients, 2,713 (9.3%) underwent a total hip arthroplasty. After successfully matching 2,689 patients who underwent a total hip arthroplasty with those who underwent a hemiarthroplasty, the patients who underwent a total hip arthroplasty were at an increased risk for dislocation (1.7% compared with 1.0%; p = 0.02), but were at a decreased risk for revision (0.2% compared with 1.8%; p < 0.0001), relative to patients who underwent a hemiarthroplasty. Furthermore, the overall increase in the annual health-care expenditure in the year following the surgical procedure was approximately $2,700 in Canadian dollars lower in patients who underwent a total hip arthroplasty (p < 0.001).

CONCLUSIONS

Among elderly patients with displaced femoral neck fractures, total hip arthroplasty was associated with lower rates of revision surgical procedures and reduced health-care costs during the index admission and in the year following the surgical procedure, relative to hemiarthroplasty.

LEVEL OF EVIDENCE

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

Radiographic evaluation of linear wear of bipolar hemiarthroplasty devices in vivo

BACKGROUND

The indications for bipolar hemiarthroplasty (BHA) have been narrowing as those for total hip arthroplasty (THA) have been expanding in cases of femoral neck fracture and initial stages of osteonecrosis of femoral head (ONFH). It is difficult to measure wear in vivo after BHA because the equipment used has a dual bearing system with an inner head inside a metal outer cup. The present study aimed to (1) use a roentgenograph to measure linear wear in vivo after BHA with different acetabular conditions around the bipolar cup, and (2) compare the linear wear of polyethylene between integral bipolar cup (IBC) and Centrax prostheses.

METHODS

From among patients who had undergone BHA in our department after 1996, we analyzed 48 joints with osteoarthritis (OA) and without acetabular cartilage, as well as 25 joints with ONFH of stage 3 or less, in which the acetabular cartilage remains. Two types of bipolar cup prostheses were used: the IBC, which was gamma-sterilized in air using 2-Mrad irradiation, and the Centrax, which was gamma-sterilized in nitrogen using 3-Mrad irradiation. To image the inner head in vivo, we used high-pressure X-ray photography; we measured linear wear of the polyethylene with software using Martell Method 1.

RESULTS

Comparing mean annual linear wear between the OA and ONFH groups, using IBC prostheses in both groups, there was a significant difference (0.213 mm vs. 0.096 mm, respectively; P = 0.0177). There was a significant difference between the Centrax and IBC prostheses in OA patients in terms of linear wear (0.04 mm vs. 0.213 mm; P = 0.0181).

CONCLUSION

The linear wear of polyethylene in BHA implants can be affected by the material used to manufacture the bipolar cup. Such implants should only be used for appropriate indications.

Hip fracture-great steps forward but we still need better evidence. A commentary on NICE CG124 and QS16 on fractured neck of femur

The National Institute for Health and Care Excellence (NICE) updated its Clinical Guideline and its Quality Standard on hip fracture in 2017. Three quality statements relate to the organisation of care-having a multidisciplinary hip fracture programme, and both operating and starting rehabilitation without delay-while three relate to surgical aspects, the most recent being the requirement to offer total hip replacement rather than hemiarthroplasty for those with displaced intracapsular fractures who could mobilise outdoors with a stick. Some evidence exists to support this, but the timely provision of this more complex and specialised operation presents a logistical challenge to many units. The evidence for many more general aspects of the care of hip fracture patients is still extrapolated from other populations, and more research is needed to guide the care of this specific group.

Functional outcome and health related quality of life after dual mobility cup total hip replacement for displaced femoral neck fractures in middle aged Egyptian patients

AIM

This study was done to assess the functional and clinical results after one year of cemented THR with dual mobility cup for the treatment of fracture neck femur in active middle-aged patients in Egypt (Middle Eastern population).

PATIENTS AND METHODS

This study included 31 patients (32 hips) with displaced femoral neck fractures that were admitted to El Hadara University Hospital, Alexandria, Egypt. Their mean age was 66.4 ± 5.9 years. Fifteen patients were females. All the patients were treated with total hip replacement using a cemented dual mobility cup (Ecofit^® 2 M, Implantcast GmbH, Germany) total hip replacement through the standard posterior approach. Functional assessment was done using Harris Hip Score (HHS), SF-36 questionnaire for health related quality of life (HRQoL) with assistance of a physiotherapist.

RESULTS

The mean HHS improved over the follow up period from 79.04 ± 7.9 at 12 weeks to an average of 92.8 ± 11.1 at 1 year follow up. HRQoL measures showed a pattern of initial drop at 3 months postoperatively, then a steady rise to be restored at 1 year as compared to the preoperative baseline measures. There were no dislocations encountered in this series over one year follow up. The following complications were encountered; 1 deep infection, 2 deep vein thrombosis, 2 heterotopic ossifications, and 1 patient died within one year after surgery.

CONCLUSIONS

Dual mobility cup total hip replacement is an acceptable method for treatment of displaced femoral neck fracture in active middle aged patients in Egypt as it provides pain relief and good function without compromising the stability.

A Missed Opportunity in Bone Health: Vitamin D and Calcium Use in Elderly Femoral Neck Fracture Patients Following Arthroplasty

INTRODUCTION

Introduction: Adequate calcium and vitamin D from diet and supplementation is recommended for elderly hip fracture patients. Using data from the multinational hip fracture arthroplasty trial (HEALTH), we determined the proportion of patients who consistently took vitamin D and calcium and which characteristics/prescribing practices were associated with consistency of supplement use.

METHODS

HEALTH is a multicenter randomized trial of elderly hip fracture patients treated with hemi-arthroplasty and total hip arthroplasty. Patients were categorized as consistent users, inconsistent users, or nonusers of calcium and vitamin D. We used multinomial regression to determine the characteristics associated with calcium and vitamin D use.

RESULTS

603 HEALTH participants were included in the analysis. 34.7% of patients never took vitamin D within 12 months after surgery, 26.2% took vitamin D inconsistently, and 39.1% took vitamin D consistently. 36.0% of patients never took calcium within 12 months after surgery, 28.4% took calcium inconsistently, and 35.7% took calcium consistently. There was great variation in prescribed/recommended doses. Compared to nonusers, consistent users of the supplements were more likely to be female, North American, prescribed/recommended vitamin D and/or calcium postoperatively, and presented to a facility with comprehensive fragility fracture protocols.

CONCLUSIONS

A low proportion of elderly hip fracture patients are consistently taking vitamin D and calcium, which may contribute to poorer bone health. Surgeons should be educated to prescribe/ recommend vitamin D and calcium, institutions should develop comprehensive fragility fracture protocols and patient education strategies to ensure that patients with osteoporosis receive bone health management beyond fracture care.

Proximal femoral fractures in elderly people: time to surgery. The experience of Milan's "ASST Pini/CTO"

Proximal femoral fractures in elderly patients represent a rapidly increasing socio-economic problem. The functional recovery and the mortality rate are influenced by a substantial quantity of variables, including the waiting time for surgical treatment ("time to surgery"). This study aims at investigating the average waiting time, and ascertaining the causes and effects, together with other non-modifiable variables, on the outcome for patients admitted to Milan's Istituto Ortopedico Gaetano Pini (Gaetano Pini Orthopaedic Institute) with a proximal femoral fracture. Data have been collected from 234 patients, between May and November 2015. Parameters recorded and analysed included fracture type, presence of comorbidities (Charlson Index (CCI)), the ASA (American Society of Anesthesiology) score, day of the week presenting to hospital, the type of treatment received, the functional recovery, and the patient's condition on discharge. In 46.4% of cases, the duration of preoperative stay prior to surgery was found to be in line with what is recommended in the literature (<48 h). In 20% of cases, the time to surgery was found to exceed 96 hours. The data collected that pertain to the distribution of the sample and the comorbidities were shown to be in line with the literature. A statistical significant difference was found between day of the week that the patient was admitted to hospital and the waiting time for surgery.

Outcomes of Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fracture: A Medicare Cohort Study

OBJECTIVES

For patients with femoral neck fractures, total hip arthroplasty (THA) demonstrates superior outcomes compared with hemiarthroplasty. However, hemiarthroplasty remains a common treatment for femoral neck fractures and the conversion rates are unknown. We compared the results of the 2 procedures using a Medicare database.

METHODS

We assembled a cohort of 70,242 patients 65 to 90 years of age with an ICD9 diagnosis and matching Current Procedure Terminology code for femoral neck fracture between 2008 and 2012. Patients were followed forward for 2 years minimum. Incidences of dislocation and mortality were measured. Reoperation for revision of THA or conversion of hemiarthroplasty to THA was assessed by Current Procedure Terminology code. Groups were compared through proportional hazard models controlling for age, race, sex, and comorbidity index.

RESULTS

Hemiarthroplasty represented 95% of the patients treated using arthroplasty for femoral neck fracture. The proportional hazard of reoperation and dislocation were significantly lower for hemiarthroplasty than THA (P < 0.0001 for both). At 2 years, fewer than 2% of hemiarthroplasty patients underwent conversion to total hip replacement. Patients treated with THA were more likely to be alive for 2 years (adjusted hazard ratio = 1.67, 95% confidence interval: 1.59-1.92).

CONCLUSION

Patients treated with hemiarthroplasty after femoral neck fractures had significantly lower proportional hazard of reoperation than those treated with THA. THA may be associated with lower mortality.

LEVEL OF EVIDENCE

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

Hemiarthroplasty or total hip arthroplasty for the treatment of a displaced intracapsular fracture in active elderly patients

Aims

Our aim was to analyse the long-term functional outcome of two forms of surgical treatment for active patients aged > 70 years with a displaced intracapsular fracture of the femoral neck. Patients were randomised to be treated with either a hemiarthroplasty or a total hip arthroplasty (THA). The outcome five years post-operatively for this cohort has previously been reported. We present the outcome at 12 years post-operatively.

Patients and Methods

Initially 252 patients with a mean age of 81.1 years (70.2 to 95.6) were included, of whom 205 (81%) were women. A total of 137 were treated with a cemented hemiarthroplasty and 115 with a cemented THA. At long-term follow-up we analysed the modified Harris Hip Score (HHS), post-operative complications and intra-operative data of the patients who were still alive.

Results

At a mean follow-up of 12 years (8.23 to 16.17, standard deviation 2.24), 50 patients (20%), 32 in the hemiarthroplasty group and 18 in the THA group, were still alive, of which 47 (94%) were women. There were no significant differences in the mean modified HHS (p = 0.85), mortality (p = 0.13), complications (p = 0.93) or rate of revision surgery (p = 1.0) between the two groups.

Conclusion

In the treatment of active elderly patients with an intracapsular fracture of the hip there is no difference in the functional outcome between hemiarthroplasty and THA treatments at 12 years post-operatively. Cite this article: Bone Joint J 2017;99-B:250–4.

Trends in Operative and Nonoperative Hip Fracture Management 1990-2014: A Longitudinal Analysis of Manitoba Administrative Data

OBJECTIVES

To evaluate longitudinal trends in the use of total hip arthroplasty (THA), hemiarthroplasty (HA), internal fixation (IF), and nonoperative management and to identify individual-level factors associated with nonoperative treatment of hip fracture (HF).

DESIGN

Longitudinal analysis of administrative data.

SETTING

Manitoba, Canada.

PARTICIPANTS

All adults who experienced nontraumatic hip fractures between 1990 and 2014 (N = 19,626; mean age 80.6, 72.3% female).

MEASUREMENTS

Billing codes were used to identify surgical treatment, and trends in treatment over time were examined. Regression models were developed to identify individual factors associated with receiving nonoperative management.

RESULTS

Use of THA increased from 0.6% for all HFs in 1990-94 to 5.3% in 2010-14, use of HA increased from 19.3% to 29.7%, and use of IF declined from 71.8% to 59.9% (P < .001 for all); increase in THA and HA were largest in individuals with femoral neck fracture. Nonoperative management declined from 8.3% in 1990-94 to 5.1% in 2010-14 (P < .001). Factors associated with nonoperative management included aged 90 and older, male sex, residing in a care facility before fracture, and rural residence.

CONCLUSION

HF is increasingly treated with THA and HA, whereas rates of nonoperative management and IF are declining. Future efforts should focus on ensuring that all individuals are optimally triaged to the best procedure for them, with nonoperative management considered for individuals with extremely poor prefracture health.

Total hip replacement for neck of femur fracture: Comparing outcomes with matched elective cohort

INTRODUCTION

Current literature suggests that total hip replacement (THR) is superior to hemiarthroplasty (HA) for neck of femur fracture in selected group of patients. The outcomes of THR undertaken for trauma setting remain unclear when comparing with elective THR. We compared the outcomes of THR trauma cohort with best-matched elective cohort.

METHODS

We retrospectively reviewed 102 patients that underwent THR due to trauma from 2011 to 2013. We had access to 90 cases with complete records. Another 90 matched elective cases were obtained from local arthroplasty database. The elective cases were matched for gender, surgical approaches, surgeon's grade, types of implant, patient's age at operation date of ±5 years and operation date of ±60days. Subsequently, the selection criteria were relaxed to patient's age at operation date of ±10 years and operation date of ±60days. Unmatched cases were excluded. Complications and death rate were compared.

RESULTS

The average age for both cohorts was 70 years. The trauma cohort had statistically significant lower BMI and longer hospital stay (p=0.001). The Functional Comorbidity Index (FCI) and Charlson Age Comorbidity Index (CACI) were the same for both cohorts, reflecting an active patient selection for THR in our centre. The trauma cohort had higher surgical complication rate (9% vs 4%), particularly higher dislocation rate (7% vs 1%); and higher medical complication rate (32% vs 6%). These were consistent with the literature. Contrary to literature, the trauma cohort had six dislocations that five of them were done via anterolateral approach. Among the eight trauma cases with surgical complications, six cases were performed by trainees. The cause of surgical complications remains unclear due to the nature of retrospective study. The trauma cohort had higher death rate than the elective cohort (14% vs 4%), with one post-operative cardiac arrest in the trauma cohort. The rest were non-orthopaedic related deaths, ranging between four months to four years.

CONCLUSION

A more robust way of selecting trauma patients for THR is warranted to reduce morbidity and mortality. Follow-up for the trauma cohort is warranted, as the patients are likely to outlive the implants.

Recent advances in the treatment of hip fractures in the elderly

The treatment of hip fractures in the elderly represents a major public health priority and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of these injuries are treated with surgery in an expedient fashion. From the surgical perspective, there are certain special considerations in this population including osteoporosis, pre-existing arthritis, age, activity level, and overall health that contribute to the type of surgical fixation performed. Open reduction and internal fixation versus arthroplasty remain the two major categories of treatment. While the indications and treatment algorithms still remain controversial, the overall goal for these patients is early mobilization and prevention of morbidity and mortality. The use of preoperative, regional anesthesia has aided in this effort. The purpose of this review article is to examine the various treatment modalities for hip fractures in the elderly and discuss the most recent evidence in the face of a rapidly aging population.

Reporting of planned statistical methods in published surgical randomised trial protocols: a protocol for a methodological systematic review

INTRODUCTION

Poor reporting can lead to inadequate presentation of data, confusion regarding research methodology used, selective reporting of results, and other misinformation regarding health research. One of the most recent attempts to improve quality of reporting comes from the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Group, which makes recommendations for the reporting of protocols. In this report, we present a protocol for a systematic review of published surgical randomised controlled trial (RCT) protocols, with the purpose of assessing the reporting quality and completeness of the statistical aspects.

METHODS

We will include all published protocols of randomised trials that investigate surgical interventions. We will search MEDLINE, EMBASE, and CENTRAL for relevant studies. Author pairs will independently review all titles, abstracts, and full texts identified by the literature search, and extract data using a structured data extraction form. We will extract the following: year of publication, country, sample size, description of study population, description of intervention and control, primary outcome, important methodological qualities, and quality of reporting of planned statistical methods based on the SPIRIT guidelines.

ETHICS AND DISSEMINATION

The results of this review will demonstrate the quality of statistical reporting of published surgical RCT protocols. This knowledge will inform recommendations to surgeons, researchers, journal editors and peer reviewers, and other knowledge users that focus on common deficiencies in reporting and how to rectify them. Ethics approval for this study is not required. We will disseminate the results of this review in peer-reviewed publications and conference presentations, and at a doctoral independent study of oral defence.

Inequalities in use of total hip arthroplasty for hip fracture: population based study

OBJECTIVES

To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there are systematic inequalities.

DESIGN

Observational cohort study using the National Hip Fracture Database (NHFD).

SETTING

All hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland.

PARTICIPANTS

Patients within the national database (all aged ≥60) who received operative treatment for a non-pathological displaced intracapsular hip fracture from 1 July 2011 to 31 April 2015.

MAIN OUTCOME MEASURES

Provision of THA to patients considered eligible under criteria published by the National Institute for Health and Care Excellence (NICE).

RESULTS

114 119 patients with hip fracture were included, 11 683 (10.2%) of whom underwent THA. Of those who satisfied the NICE criteria, 32% (6780) : received a THA. Of patients who underwent THA, 42% (4903) did not satisfy the NICE criteria. A recursive partitioning algorithm found that the NICE eligibility criteria did not optimally explain which patients underwent THA. A model with superior explanatory power drew distinctions that are not supported by NICE, which were an age cut off at 76 and a different ambulation cut off. Among patients who satisfied the NICE eligibility, the use of THA was less likely with higher age (odds ratio 0.88, 95% confidence interval 0.87 to 0.88), worsening abbreviated mental test scores (0.49 (0.41 to 0.58) for normal cognition v borderline cognitive impairment)), worsening American Society of Anesthesiologists score (0.74, 0.66 to 0.84), male sex (0.85, 0.77 to 0.93), worsening ambulatory status (0.32, 0.28 to 0.35 for walking with a stick v independent ambulation), and fifths of worsening socioeconomic area deprivation (0.76 (0.66 to 0.88) for least v most deprived fifth). Patients receiving treatment during the working week were more likely to receive THA than at the weekend (0.90, 0.83 to 0.98).

CONCLUSIONS

There are wide disparities in the use of THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those who require surgery at the weekend were less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimal treatment for older adults with hip fractures can depend on where and when they present to hospital.

Total hip arthroplasty after hip fracture

Practice is inconsistent and inequitable

Cemented Bipolar Hemiarthroplasty Provides Definitive Treatment for Femoral Neck Fractures at 20 Years and Beyond

BACKGROUND

Displaced femoral neck fractures frequently are treated with bipolar hemiarthroplasties. Despite the frequency with which bipolar hemiarthroplasty is used to treat these fractures, there are few long-term data.

QUESTIONS/PURPOSES

We sought to evaluate (1) the cumulative incidence of revision for any reason of bipolar hemiarthroplasties at 20 years, and the proportion of patients who lived more than 20 years who still have the prosthesis in situ from the index arthroplasty, (2) the cumulative incidence of aseptic loosening at 20 years, and (3) the Harris hip score of the surviving patients at long term.

METHODS

We performed 376 cemented bipolar hemiarthroplasties for displaced femoral neck fractures in 359 patients between 1976 and 1985. At a minimum of followup of 20 years (mean, 24 years; range, 20-31 years), 339 of 359 patients (94%) were deceased, leaving 20 patients in the study group. Of those, one patient was confirmed to be lost to followup and two others had radiographic followup only. Three hundred fifty-nine patients (99.2%) (376 of the original 379 hips) were followed until death, revision of the hemiarthroplasty, or for at least 20 years (of clinical followup). Bipolar hemiarthroplasty was performed for displaced femoral neck fractures. Cemented fixation was the standard of care between 1976 and 1985 at our institution. The mean age of the patients at the time of surgery was 79 years (range, 60-99 years). The cumulative incidence of revision, estimated with death as a competing risk, and radiographs were evaluated for signs of aseptic loosening by a surgeon not involved in the clinical care of the patients. Clinical function was evaluated with the Harris hip score. The mean age of the patients at the time of surgery was 79 years.

RESULTS

The 20-year cumulative incidence of revision for any reason was 3.5% (95% CI, 1.6%-5.3%). Of the 20 patients who survived more than 20 years, seven had the implant intact. The 20-year cumulative incidence of revision for aseptic loosening was 1.4% (95% CI, 0.2%-2.6%). The mean Harris hip score in patients who were still living and patient who did not have revision surgery was 63 ± 22, however 13 of the 20 patients had undergone revision surgery.

CONCLUSIONS

The long-term survivorship of bipolar hemiarthroplasty prostheses used to treat displaced femoral neck fractures in the elderly was high, and the procedure can be considered definitive for the majority of elderly patients with a femoral neck fracture. In this series, 6% (20 patients, 339 of 359) of the patients survived more than 20 years after treatment of a femoral neck fracture with a bipolar hemiarthroplasty. Of those, 35% (seven of 20) survived with their index prosthesis in situ.

LEVEL OF EVIDENCE

Level IV, therapeutic study.