Abstract
Background: Hemiarthroplasty and total hip arthroplasty are commonly
used to treat displaced intracapsular fractures of the femoral neck, but each
has disadvantages and the optimal treatment of these fractures remains
controversial.
Methods: In the present prospectively randomized study, eighty-one
patients who had been mobile and lived independently before they had sustained
a displaced fracture of the femoral neck were randomized to receive either a
total hip arthroplasty or a hemiarthroplasty. The mean age of the patients was
seventy-five years. Outcome was assessed with use of the Oxford hip score, and
final radiographs were assessed.
Results: After a mean duration of follow-up of three years, the mean
walking distance was 1.17 mi (1.9 km) for the hemiarthroplasty group and 2.23
mi (3.6 km) for the total hip arthroplasty group, and the mean Oxford hip
score was 22.3 for the hemiarthroplasty group and 18.8 for the total hip
arthroplasty group. Patients in the total hip arthroplasty group walked
farther (p = 0.039) and had a lower (better) Oxford hip score (p = 0.033) than
those in the hemiarthroplasty group. Twenty of thirty-two living patients in
the hemiarthroplasty group had radiographic evidence of acetabular erosion at
the time of the final follow-up. None of the hips in the hemiarthroplasty
group dislocated, whereas three hips in the total hip arthroplasty group
dislocated. In the hemiarthroplasty group, two hips were revised to total hip
arthroplasty and three additional hips had acetabular erosion severe enough to
indicate revision. In the total hip arthroplasty group, one hip was revised
because of subsidence of the femoral component.
Conclusions: Total hip arthroplasty conferred superior short-term
clinical results and fewer complications when compared with hemiarthroplasty
in this prospectively randomized study of mobile, independent patients who had
sustained a displaced fracture of the femoral neck.
Level of Evidence: Therapeutic Level I. See Instructions
to Authors for a complete description of levels of evidence.
The optimal treatment of mobile, independent patients who have sustained a
displaced intracapsular fracture of the femoral neck remains controversial.
Randomized, controlled trials that have compared internal fixation with either
total hip arthroplasty or hemiarthroplasty have demonstrated inferior results
for internal fixation, with reoperation rates ranging from 18% to
47%1-4.
The major long-term problem associated with hemiarthroplasty is painful
acetabular erosion. The reported rates of acetabular erosion have ranged from
0%5 to
26%6 for bipolar
designs and from
2.2%5 to
36%7 for unipolar
designs. In one
series7, 38% of the
hips with a unipolar prosthesis required revision because of acetabular
erosion. In contrast, the major early complication of total hip arthroplasty
is dislocation, the rate of which is increased in association with the use of
a posterior approach and a smaller prosthetic head
size8. The reported
rates of dislocation after total hip arthroplasty performed for the treatment
of a displaced intracapsular fracture of the femoral neck have ranged from 2%
to
20%9-14.
In a previous
publication7, we
suggested that hemiarthroplasty was inferior to total hip arthroplasty in
mobile, independent patients with a displaced intracapsular fracture of the
femoral neck. The weakness of that study, and the difficulty of trying to
determine which of these procedures is preferable for the management of
patients who have sustained this type of injury, is that it included
confounding variables such as different prosthetic designs, operative
approaches, and patient-selection criteria that precluded a meaningful
analysis of the two types of arthroplasty. In planning the present study, we
determined the required power needed to perform a randomized, prospective,
controlled trial and sought to answer the question of whether total hip
arthroplasty was indeed superior to hemiarthroplasty for the management of
mobile, independent patients who had sustained a displaced intracapsular
fracture of the femoral neck.
The present study was approved by all of the participating hospitals' local
research ethics committees (institutional review boards).
Patients who were admitted to one of three participating hospitals with a
diagnosis of a displaced fracture of the femoral neck were initially assessed
with use of the Abbreviated Mini Mental Test
score15, Oxford hip
score16, and Short
Form-36 physical and mental health summary
scales17. The
Oxford hip score is a validated twelve-item patient questionnaire on which
lower scores indicate superior function and lower pain in the affected hip
(best score, 12; worst score, 60) (see Appendix). In addition, we recorded the
self-reported prefracture walking distance of each patient in miles. The
patients were then prospectively randomized into one of two treatment arms.
Randomization was performed with use of sealed envelopes that were opened
before surgery.
The inclusion criteria were an age of more than sixty years, a normal
Abbreviated Mini Mental Test
score15, the
ability to walk =0.5 mi (=0.8 km), the ability to live independently
(without reliance on a caregiver), a nonpathological fracture, and a hip with
no or minimal osteoarthritic changes.
The exclusion criteria included age of less than sixty years (it is our
practice to perform internal fixation in this group), medical or physical
comorbidities that limited the walking distance to <0.5 mi (0.8 km), a
preexisting hip abnormality requiring total hip arthroplasty, or a
pathological fracture secondary to malignant disease.
With use of a power of 80% and a p value of 0.05, it was determined that
thirty-nine patients in each treatment arm were required to demonstrate a
difference, based on previous
results7. Eighty-one
patients were prospectively randomized into two groups: forty-one patients
were managed with hemiarthroplasty, and forty were managed with total hip
arthroplasty. The mean age of the patients was seventy-five years. There were
no significant differences between the two groups with regard to demographic
characteristics or mental and functional scores
(Table I). The operations were
equally distributed among the three participating hospitals.
The delay from the time of the fracture to the time of surgery was 1.95
days in the hemiarthroplasty group and 1.75 days in the total hip arthroplasty
group. The operations were performed by surgeons with similar levels of
training. Thirty-one hemiarthroplasties were performed by residents, seven
were performed by consultants, two were performed by senior house officers,
and one was not documented. Thirty-one total hip arthroplasties were performed
by residents, and nine were performed by consultants. There was no significant
difference between the groups with regard to the American Society of
Anesthesiologists
grades18 of the
patients (Table I).
All patients received the same cemented femoral component, the CPT
collarless polished tapered stem (Zimmer, Warsaw, Indiana). All operations
were performed through a transgluteal lateral approach. The femoral canal was
restricted distally with use of a Hardinge cement restrictor (DePuy
International, Leeds, United Kingdom). Palacos cement (Schering-Plough,
Hertfordshire, United Kingdom) impregnated with gentamicin was inserted with a
venting tube in place with use of a cement gun (Biomet Europe, Dordrecht,
Netherlands) and digital pressure.
The hemiarthroplasty group received an Endo Femoral Head (Zimmer). The
prosthetic head size was available in 2-mm increments that allowed accurate
reproduction of the patient's femoral head, which was measured
intraoperatively with a hemispherical template. The total hip arthroplasty
group received a 28-mm femoral head articulating with an all-polyethylene
Zimmer cemented acetabular cup without a long posterior wall (Zimmer).
The mean operative time was seventy-eight minutes (range, forty-five to 120
minutes) for the hemiarthroplasty group and ninety-three minutes (range, sixty
to 135 minutes) for the total hip arthroplasty group (p < 0.001).
The mean femoral head size in the hemiarthroplasty group was 48 mm (range,
43 to 59 mm). The mean outer diameter of the acetabular component in the total
hip arthroplasty group was 47 mm (range, 44 to 55 mm).
Postoperatively, patients were mobilized with full weight-bearing on the
second postoperative day and graduated from a walker to a cane prior to
discharge.
Patients were evaluated at three months, one year, and three years after
surgery. At the time of the final follow-up, patients were assessed with use
of the Oxford hip
score16 and the
Short Form-3617.
The walking distance at the time of the final follow-up was reported by the
patients themselves. Anteroposterior and lateral radiographs of the involved
hip were made.
Initial postoperative radiographs were reviewed to determine the cementing
grade according to the criteria of Barrack et
al.19. In addition,
femoral component alignment was assessed in the anteroposterior and lateral
planes.
Final radiographs were analyzed with regard to acetabular erosion,
polyethylene wear, femoral stem subsidence, and component migration.
Acetabular erosion was graded on the basis of its radiographic appearance as
grade 0 (no erosion), grade 1 (narrowing of articular cartilage, no bone
erosion), grade 2 (acetabular bone erosion and early migration), and grade 3
(protrusio acetabuli) (Fig.
1).
Statistical Analysis
Statistical analysis was performed by a medical statistician with use of
the Statistical Package for the Social Sciences package (SPSS, Chicago,
Illinois). The Mann-Whitney test was used to compare groups with regard to the
delay to surgery, stem size, Oxford hip score, and physical and mental Short
Form-36 component scores at three years. The Wilcoxon rank test was used to
compare Oxford hip scores, Short Form-36 scores, and walking distances in each
individual after three years. The time-to-discharge and walking-distance
comparisons required log transformation, and then the Student t test was
performed. Chi-square analysis was used to assess Barrack cement grading and
anteroposterior and lateral femoral stem alignment; the Fisher exact test was
used to assess the mortality, revision, and complication rates; the Student t
test was used to assess operative time and stem subsidence; and Kendall's
Tau-b coefficient was used to assess the correlation between subsidence and
Barrack grading. The level of significance was set at p < 0.05.
There were two immediate postoperative deaths in the hemiarthroplasty
group, both as a result of pulmonary embolism. Five additional patients in the
hemiarthroplasty group died and one refused to be evaluated for a three-year
review, leaving thirty-three of the original forty-one patients available for
final follow-up at a mean of thirty-nine months (range, thirty to sixty-six
months) postoperatively. All five of the patients who died after the immediate
postoperative period but before the final follow-up died of causes unrelated
to the hemiarthroplasty. Two had remained mobile and independent. One patient
died before any formal follow-up arrangement. The other two patients had
decreased walking capability; one relied on a wheelchair, and the other used a
cane.
Three patients in the total hip arthroplasty group died of causes unrelated
to the procedure before the final follow-up and one patient refused to have a
follow-up evaluation, leaving thirty-six of the original forty patients
available for final follow-up at a mean of forty-one months (range, thirty to
sixty-eight months) postoperatively. There was no difference between the two
groups with regard to the rate of mortality (p = 0.194). The patient who
refused follow-up was confined to a wheelchair following a cerebrovascular
accident. Two patients died of cancer; of these, one was able to walk 3 mi
(4.8 km) before his terminal illness and one was confined to a wheelchair
secondary to metastatic disease. One patient died fourteen months after the
hip replacement from complications of bronchopneumonia; at the time of the
last follow-up, she was mobile with no walking aids.
Clinical Outcome
At the time of the final follow-up, the hemiarthroplasty group had
significantly greater hip disability, represented by higher Oxford hip scores
(p = 0.033) and shorter self-reported walking distances (p = 0.039), than the
total hip arthroplasty group did. The hemiarthroplasty group also had
slightly, but not significantly, lower Short Form-36 physical scores than the
total hip arthroplasty group did (p = 0.356)
(Table II).
Of interest, compared with the preoperative scores, both groups had
significantly higher (worse) Oxford hip scores (p < 0.001) and lower scores
on the Short Form-36 physical component (p = 0.021 for the hemiarthroplasty
group and p = 0.001 for the total hip arthroplasty group), indicating
decreased function. Compared with the preoperative status, patient-reported
walking distance decreased significantly after hemiarthroplasty (p < 0.001)
but increased after total hip arthroplasty (p = 0.023).
Radiographic Results
Acetabular Component
In the total hip arthroplasty group, radiographs were available for
thirty-two hips after a mean duration of follow-up of forty months (range,
twelve to sixty-six months). These radiographs demonstrated no evidence of
wear of the cemented polyethylene cup in any hip.
In the hemiarthroplasty group, radiographs were available for thirty-two
hips after a mean duration of follow-up of thirty-six months (range, thirteen
to sixty months). Acetabular erosion was seen in twenty-one (66%) of the
thirty-two hips. The prevalence and severity of acetabular erosion are shown
in Figure 1.
Femoral Component
Cementing technique, as assessed on the immediate postoperative
radiographs, was significantly superior in the total hip arthroplasty group (p
= 0.028) (see Appendix). Alignment of the stems was similar in both groups on
the anteroposterior (p = 0.066) and lateral radiographs (p = 0.084) (see
Appendix).
After three years, the mean amount of subsidence of the femoral stem at the
stem-cement interface was 1.94 mm (range, 0 to 11 mm) in the hemiarthroplasty
group and 1.74 mm (range, 0 to 18 mm) in the total hip arthroplasty group (p =
0.767). The
Barrack19 cementing
grade was not associated with stem subsidence (correlation coefficient,
0.147). Subsidence occurred only at the stem-cement interface.
Complications
Perioperative complications that occurred within thirty days after surgery
are presented in Table III.
With the numbers available, there were no significant differences between the
two groups.
No dislocations occurred in the hemiarthroplasty group, but three patients
(7.5%) in the total hip arthroplasty group had early dislocation in the
immediate postoperative period. Two of these three patients sustained a
dislocation after a fall on Days 8 and 14, and the third patient sustained a
dislocation after turning awkwardly in bed on Day 2. Two of the three patients
had no additional instability after closed reduction. The remaining patient
had development of dementia, sustained multiple dislocations that were treated
with closed reduction, and was not a candidate for revision arthroplasty.
Revisions
In the hemiarthroplasty group, two hips were revised to total hip
arthroplasty because of severe pain associated with acetabular erosion. After
the revision procedure, these two patients had improved Oxford hip scores and
markedly improved walking distances that were comparable with those in the
total hip arthroplasty group. Two additional patients had grade-2 and 3
acetabular erosion. At the time of the most recent follow-up, one was awaiting
revision to total hip arthroplasty and the other had declined additional
intervention. Another patient had severe pain in association with grade-1
acetabular erosion, was undergoing additional investigation, and was likely to
need revision. One patient in the hemiarthroplasty group required revision
surgery because of a periprosthetic fracture thirty-three months
postoperatively. In the total hip arthroplasty group, one patient required
revision because of pain secondary to massive femoral stem subsidence (18 mm).
No other patient in the total hip arthroplasty group required revision. The
overall rate of revision or planned revision was 14.6% (six of forty-one) in
the hemiarthroplasty group, compared with 2.5% (one of forty) in the total hip
arthroplasty group. This difference between the groups approached significance
(p = 0.058).
Displaced intracapsular fracture of the femoral neck can be treated with
internal fixation, unipolar or bipolar hemiarthroplasty, or total hip
replacement. In a meta-analysis, Bhandari et
al.20 concluded
that arthroplasty was associated with lower revision rates but a higher
prevalence of infection, greater blood loss, and longer operative time when
compared with internal fixation. In that report, no distinction was made
between the use of hemiarthroplasty and total hip replacement.
Other comparative studies have demonstrated that total hip arthroplasty and
hemiarthroplasty are superior to internal fixation for achieving pain relief
and restoring
function9,11,21,22.
A number of studies have compared total hip arthroplasty with
hemiarthroplasty for the treatment of this problem.
In the study by Dorr et
al.13, eighty-nine
patients with a displaced femoral neck fracture were prospectively randomized
to receive total hip arthroplasty with cement, hemiarthroplasty with cement,
or hemiarthroplasty without cement. After a minimum duration of follow-up of
two years, there was no difference between the results associated with total
hip arthroplasty with cement and hemiarthroplasty with cement but the results
associated with hemiarthroplasty without cement were poor. Function improved
with time after total hip replacement but not after hemiarthroplasty.
In a retrospective study of 166 displaced femoral neck fractures, Gebhard
et al.23 found that
total hip arthroplasty demonstrated superior longevity when compared with
hemiarthroplasty with and without cement. After a mean duration of follow-up
of fifty-six months, the revision rate was 2.2% after total hip replacement,
7.9% after hemiarthroplasty with cement, and 13% after hemiarthroplasty
without cement. Pain was the main reason for revision in two-thirds of the
patients managed with hemiarthroplasty.
In the study by Lee et
al.24, 126
consecutive patients with a displaced intracapsular fracture of the femoral
neck were managed with total hip arthroplasty. With revision as the end point,
the survival rate was 95% after five years, 94% after ten years, and 84% after
twenty years. Six patients required revision because of aseptic loosening.
Increased rates of femoral stem loosening have been reported after total
hip arthroplasty for the treatment of intracapsular femoral neck fractures in
active patients with no preexisting hip
pathology25. In the
present series, in which a cemented collarless polished tapered stem was used,
there was only one revision because of massive subsidence (18 mm) at the
stem-cement interface, albeit after a mean duration of follow-up of only three
years.
In a randomized, prospective study of octogenarians who had sustained a
displaced fracture of the femoral neck, Calder et
al.5 reported that
the rate of acetabular erosion at two years postoperatively was 2.2% for hips
that had been treated with a unipolar prosthesis and 0% for hips that had been
treated with a bipolar prosthesis. However, Soreide et
al.6 reported an
acetabular protrusion rate of 26% for patients older than seventy-five years
of age who had been managed with a bipolar Christiansen prosthesis.
In the study by D'Arcy and
Devas26, 361
femoral neck fractures were treated with a Thompson hemiarthroplasty with
cement. Acetabular erosion developed after 11% of the procedures. Importantly,
acetabular erosion occurred more frequently in younger patients. In addition,
the surgeons used a hemiarthroplasty head design that allowed sizing
increments of only 3.2 mm. In our previous
study7, we used
acetabular components with head sizes that were available in 2-mm increments
and reported a 36% rate of revision because of acetabular erosion. In the
present study, we again used hemiarthroplasty head sizes that were available
in 2-mm increments and found that 66% of the patients had acetabular erosion.
We suggest that the ability to precisely fit an acetabular component, while
desirable, is less important than the activity level of the patient. We
believe that our relatively younger and more active patients had a higher rate
of acetabular erosion because of increased physical demands. This observation
has been commented on by other
authors23,26.
Dislocation is the major concern after primary total hip arthroplasty for
the treatment of intracapsular femoral neck fractures. Berry et
al.8 demonstrated a
1.8-fold increased hazard estimate of dislocation risk when the preoperative
diagnosis of hip fracture was compared with osteoarthritis.
Tidermark et al.9
reported the lowest dislocation rates (2%) for total hip arthroplasty, using
the transgluteal approach in patients who had sustained a displaced
intracapsular fracture of the femoral neck. Our standard postoperative
protocol for the prevention of dislocation includes the use of an abduction
wedge, patient education, and physiotherapy supervision in activities of daily
living.
The strengths of the present study are that it was a prospectively
randomized, controlled trial that eliminated treatment variables such as the
type of femoral component, the method of implantation, and the surgical
approach. In addition, the populations were comparable, allowing for a
meaningful analysis of the two types of arthroplasty.
Our findings suggest that total hip arthroplasty is superior to
hemiarthroplasty for the treatment of mentally competent, independent, and
active patients. In the present study, total hip arthroplasty was associated
with better functional outcomes, fewer complications, and fewer revisions
after a mean duration of follow-up of three years. Both groups experienced
functional deterioration postoperatively as compared with the preoperative
levels; however, patients in the total hip arthroplasty group had less
deterioration and maintained their walking distances.
The present study did not address the role of total hip arthroplasty in
older, less active, and less mentally competent patients. The critical issue
in that group is whether hemiarthroplasty would be a sufficient procedure
because of their reduced activity and life expectancy. Painful acetabular
erosion was the principal cause of revision in our active patients. It may be
that in less active, older patients, bipolar hemiarthroplasty confers the
stability needed to reduce the risk of dislocation yet avoids acetabular
erosion. Additional studies should be considered in that group of
patients.
The Oxford hip score questionnaire and tables showing postoperative Barrack
cementing grade and femoral stem positions are available with the electronic
versions of this article, on our web site at
(go to
the article citation and click on Supplementary Material) and on our quarterly
CD-ROM (call our subscription department, at 781-449-9780, to order the
CD-ROM). ?
Note: The authors thank Sister Sandy Shaw for her invaluable
help in ensuring that the prostheses were available to all hospitals involved
in the study. They also thank Michael Spratt and Elise Whitely, medical
statisticians, North Bristol NHS Trust, for their help with the statistical
analysis.
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