Randomized Trial of Hemiarthroplasty versus Internal Fixation for Femoral Neck Fractures: No Differences at 6 Years

Abstract

Background Hemiarthroplasty has been shown superior to internal fixation for displaced femoral neck fractures (FNF) in the first 2 years. However, there are unanswered questions about the performance of hemiarthroplasty over the longer term compared with internal fixation. Questions/purposes We sought to compare hemiarthroplasty with internal fixation in terms of (1) outcomes scores for pain, hip function, and quality of life at a minimum of 5 years after surgery in a randomized trial. A secondary purpose was to compare (2) patient survival and (3) frequency of reoperation in the two groups. Methods A total of 222 consecutive patients older than 60 years, including those cognitively impaired, with FNF were randomized to either internal fixation with two parallel screws or bipolar hemiarthroplasty. At a minimum followup of 4.9 years (mean, 5.9 years; range, 4.9-7.2 years), 68 of the 70 surviving patients were examined by a study nurse and study physiotherapist blinded to initial treatment. Questionnaires on hip function (Harris hip score), quality of life (Eq5D), and activity of daily living function (Barthel ADL) were administered. The Barthel ADL index score was split into good function (score 95 or 100) and reduced function (score below 95).

Does Arthroplasty Provide Better Outcomes Than Internal Fixation At Mid- and Long-term Followup? A Meta-analysis

“…In addition, arthroplasty often was associated with an assumed risk of long-term complications, such as periprosthetic fracture and aseptic loosening [21]. In our meta-analysis, we found that arthroplasty was associated with a greater risk of hip dislocation at long-term followup, which was consistent with results of previous studies [5,10,12,17], whereas higher risk of nonunion and avascular osteonecrosis were found in the internal fixation group at mid-and long-term followups.…”

“…There was no significant heterogeneity (p = 0.62; I 2 = 0%) between studies, so we used a fixedeffect model for the meta-analysis of mortality. Data regarding patient mortality at mid-term and long-term followups were provided in nine studies [3,5,6,12,14,[16][17][18]21] involving 1033 patients (Table 3). Subgroup analysis showed that there was no difference in comparison of either THA or hip arthroplasty with internal fixation at mid-and long-term followups ( Table 4).…”

“…Function was higher at mid-term (SMD = 0.55; 95% CI, 0.02-1.09; p = 0.04) in patients treated with arthroplasty than in those treated with internal fixation, with no differences found at long-term followup (SMD = 0.14; 95% CI, À0.35 to 0.62; p = 0.04).There was significant heterogeneity (p \ 0.01; I 2 = 77%) among studies, so we used a random-effect model for this analysis. Five studies [3,5,14,17,21], with a total of 677 patients provided patient function outcomes at mid-term and long-term postoperatively. Subgroup analysis showed that function outcome was superior in patients treated with either THA or hemiarthroplasty than for patients treated by internal fixation (Table 4).…”

“…Some studies [2,12] with short-term followup showed that a statistically significant incremental trend in risk of death occurred after arthroplasty compared with the risk during short-term followup after internal fixation. However, long-term results [5,10,21] showed no difference in mortality rates between arthroplasty and internal fixation in patients treated for displaced femoral neck fractures. In our meta-analysis, we found no difference in patient mortality between the two procedures at mid-and long-term followups.…”

“…Evidence from a meta-analysis [8] showed short-term results of arthroplasty to be superior to those of internal fixation. However, long-terms results of arthroplasty compared with results of internal fixation remain controversial [3,5,6,10,12,19,21].We therefore compared mid-and long-term results after arthroplasty or internal fixation in patients with femoral neck fractures. Eleven RCTs that reported outcomes with at least 4 years of followup were identified.…”