Total hip arthroplasty versus hemiarthroplasty for management of hip fractures

1. In this randomized controlled trial, the incidence of secondary procedures within 2 years did not differ significantly between patients that received a total hip arthroplasty versus a hemiarthroplasty.

2. There was a minimal clinically significant difference in function among the total hip arthroplasty group, but also a higher incidence of hip-related complications.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Total hip arthroplasty involves prosthetic replacement of the femoral head and acetabulum, while hemiarthroplasty involves prosthetic replacement of only the femoral head. This international randomized controlled study assigned patients to receive either a total hip arthroplasty or hemiarthroplasty with 2 years of follow-up to determine if an unplanned secondary procedure was needed, as well as exploring adverse outcomes and quality of life. There was no significant difference in secondary hip procedures between the two groups. If they did require revisions, total hip arthroplasty revisions occurred most commonly in the first year, while hemiarthroplasty revisions occurred most commonly in the second year. Hip-related complications were more common among the total hip arthroplasty group. There was a minimal clinically important difference in functional improvement among the total hip arthroplasty group. Mortality and adverse events were similar between the two groups. Due to the possibility of bias in this study with unblinded evaluators and loss of follow-up, more research should be done to evaluate long term outcomes of surgical management for hip fractures.

Click to read the study in NEJM

Relevant Reading: Hemiarthroplasty vs Total Hip Arthroplasty for the Management of Displaced Neck of Femur Fractures: A Systematic Review and Meta-Analysis

In-Depth [randomized controlled trial]: This randomized controlled trial conducted from January 2009 to May 2019 included 1495 patients from 10 different countries, with 1441 patients included in the final analysis. 85.1% of the participants had 2 year follow up data available for analysis. Patients that were 50 years or older, had a displaced fracture of the femoral head, and able to ambulate without assistance before the fracture were candidates for this trial. Most of the participants were female, greater than 70 years old, and able to ambulate without an assistive device before their fracture. 7.9% of the total hip arthroplasty group received a secondary hip procedure, as compared to 8.3% of the hemiarthroplasty group (hazard ratio, 0.95; 95% CI, 0.64 to 1.40; P-0.79). The risk of a secondary hip procedure was higher in the first year for the total hip group, including open or closed reductions for hip dislocations. The risk of a secondary hip procedure in the hemiarthroplasty group was higher in the second year, including implant revisions most commonly. Hip-related complications occurred more commonly in the total hip group (4.7%) as compared to the hemiarthroplasty group (2.4%) (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function and quality of life was measured using the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and there was minimal clinically significant difference found between the groups (range, 9 to 22 points). Serious adverse events occurred in 41.8% of the total hip group and 36.7% of the hemiarthroplasty group (hazard ratio, 1.16; 99% CI, 0.90 to 1.51). Mortality did not differ significantly between the groups.

Image: PD

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