Background: Orthopaedic surgeons vary in their management of
displaced intracapsular fractures of the hip in healthy older patients. The
aim of this investigation was to determine the functional, clinical, and
resource consequences of three different types of surgical treatment.
Methods: The study was a multicenter randomized controlled trial.
Reduction and fixation was compared with bipolar hemiarthroplasty with cement
and total hip replacement with cement. Participating surgeons elected to
randomize their patients to be treated with either one of the three types of
procedures or with either fixation or bipolar hemiarthroplasty. Functional
outcomes were measured with a hip-rating questionnaire and the EuroQol health
status measure. Clinical outcomes included mortality and complications. The
direct health service costs were compared. Participants were followed up for
Results: Two hundred and seven patients were randomized to be
treated with one of the three operations, and ninety-one were randomized to be
treated with either fixation or bipolar hemiarthroplasty. There were no
differences in the mortality rates among the treatment groups. The rate of
secondary surgery was highest in the fixation group (39% compared with 5% in
the group treated with bipolar hemiarthroplasty and 9% in the group treated
with total hip replacement). The fixation group had the worst
hip-rating-questionnaire and EuroQol scores at four and twelve months. The
total hip replacement group had significantly better functional outcome scores
at twenty-four months than the other two groups. Although fixation was
initially the least costly procedure, this short-term advantage was eroded by
significantly higher costs for subsequent hip-related hospital admissions.
Conclusions: Arthroplasty is more clinically effective and
cost-effective than reduction and fixation in healthy older patients with a
displaced intracapsular fracture of the hip. The long-term results of total
hip replacement may be better than those of bipolar hemiarthroplasty.
Level of Evidence: Therapeutic Level II. See Instructions
to Authors for a complete description of levels of evidence.