Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults

Peterborough and Stamford Hospitals NHS Foundation Trust, Orthopaedic Department, Peterborough District Hospital, Thorpe Road, Peterborough, Cambridgeshire, UK, PE3 6DA.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 02/2006; DOI: 10.1002/14651858.CD000086.pub2
Source: PubMed


Internal fixation, commonly used for extracapsular hip fractures, may fail particularly in unstable fractures. Replacement of the hip using arthroplasty, often used for intracapsular fractures, has been used as an alternative.
To compare replacement arthroplasty with internal fixation for the treatment of extracapsular hip fractures in adults.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles.
Randomised and quasi-randomised trials comparing replacement arthroplasty with an internal fixation implant for adults with an extracapsular hip fracture.
Both review authors independently assessed 10 aspects of trial quality and extracted data. We requested additional information from trial investigators. Where appropriate, limited pooling of data was performed.
Two randomised controlled trials including a total of 148 people aged 70 years or over with unstable extracapsular hip fractures in the trochanteric region were identified and included in this review. Both had methodological limitations, including inadequate assessment of longer-term outcome. One trial compared a cemented arthroplasty with a sliding hip screw. This found no significant differences between the two methods of treatment for operating time, local wound complications, mechanical complications, reoperation, mortality or loss of independence of previously independent patients at one year. There was, however, a higher blood transfusion need in the arthroplasty group. The other trial compared a cementless arthroplasty versus a proximal femoral nail. It also found a higher blood transfusion need in the arthroplasty group, together with a greater operative blood loss, and a longer length of surgery. There were no significant differences between the two interventions for mechanical complications, local wound complications, reoperation, general complications, mortality at one year or long-term function. None of the pooled outcome data yielded statistically significant differences between the arthroplasty and internal fixation, with the exception of the significantly higher numbers of participants in the arthroplasty group requiring blood transfusion (relative risk 1.71, 95% confidence interval 1.05 to 2.77).
There is insufficient evidence from randomised trials to determine whether replacement arthroplasty has any advantage over internal fixation for extracapsular hip fractures. Further larger well-designed randomised trials comparing arthroplasty versus internal fixation for the treatment of unstable fractures are required.

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    • "Given, however, the rate of early mechanical failure and the necessary caution in resuming weight-bearing, several authors both in France 5—8 and elsewhere 9—15 in the 1980s and 1990s recommended hip arthroplasty as in cervical fracture. The few comparative studies of the two techniques fail to come down definitively in favour of any one method [16]. "
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    ABSTRACT: In trochanteric fracture, whatever its anatomic type, internal fixation is currently the standard attitude, with arthroplasty as a relatively unusual option. Hip implants are an excellent alternative to osteosynthesis in unstable trochanteric fracture in patients aged over 75 years. A non-randomised prospective multicenter study compared osteosynthesis by trochanteric nailing (n=113) to hip arthroplasty (n=134) in unstable trochanteric fracture (AO types 31 A2.2 and 3 and A3.3) in 247 patients over the age of 75 years. The series was recruited during 2007 in seven centres, four of which included only arthroplasties, two only osteosyntheses and one both. The two groups were comparable in age, sex, preoperative Parker score, pre-fracture place of residence, fracture type, time to surgery and preoperative comorbidity. The sole difference was in operators, with more senior surgeons in arthroplasty (62% versus 27%). Three-month mortality was identical in the two groups (21.2% versus 21%). General complications did not differ, although mechanical complications were more frequent in the nailing group (12.5% versus 2.8%). Functional results (Parker and PMA scores) were better in the implant than in the nail group. The present study validated hip arthroplasty in these indications. Cemented stems associated to a dual-mobility acetabular component gave the best results. Prospective, level of evidence III.
    Orthopaedics & Traumatology Surgery & Research 09/2011; 97(6 Suppl):S95-100. DOI:10.1016/j.otsr.2011.06.009 · 1.26 Impact Factor
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    • "Hemiarthroplasty has been used for unstable intertrochanteric fractures since 1971,25 however less frequently as compared to femoral neck fractures.47 Its initial use was as a salvage procedure for failed pinning or other complications.48 "
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    ABSTRACT: The management of unstable osteoporotic intertrochantric fractures in elderly is challenging because of difficult anatomical reduction, poor bone quality, and sometimes a need to protect the fracture from stresses of weight bearing. Internal fixation in these cases usually involves prolonged bed rest or limited ambulation, to prevent implant failure secondary to osteoporosis. This might result in higher chances of complications like pulmonary embolism, deep vein thrombosis, pneumonia, and decubitus ulcer. The purpose of this study is to analyze the role of primary hemiarthroplasty in cases of unstable osteoporotic intertrochanteric femur fractures. We retrospectively analyzed 37 cases of primary hemiarthroplasty performed for osteoporotic unstable intertrochanteric fractures (AO/OTA type 31-A2.2 and 31-A2.3 and Evans type III or IV fractures). There were 27 females and 10 males with a mean age of 77.1 years (range, 62-89 years). Two patients died due to unrelated cause (myocardial infarction) within 6 months of surgery and remaining 35 patients were followed up to an average of 24.5 months (range,18-39 months). The average surgery time was 71 min (range, 55-88 min) with an average intraoperative blood loss of 350 ml (range, 175-500 ml). Six patients needed blood transfusion postoperatively. The patients walked on an average 3.2 days after surgery (range, 2-8 days). One patient had superficial skin infection and one had bed sore with no other significant postoperative complications. One patient of Alzheimer's disease refused to walk and had a poor result. A total of 32 out of 35 patients (91%) had excellent to fair functional results and 2 had poor result with respect to the Harris hip score (mean 84.8±9.72, range 58-97). One patient who had neurological comorbidity refused to walk post operatively and was labeled as failed result. Hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in elderly results in early ambulation and good functional results although further prospective randomized trials are required before reaching to conclusion.
    Indian Journal of Orthopaedics 10/2010; 44(4):428-34. DOI:10.4103/0019-5413.67122 · 0.64 Impact Factor
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    ABSTRACT: To determine evidence-based best practices for elderly hip fracture patients from the time of hospital admission to 6 months postfracture. MEDLINE, Cochrane Library, CINAHL, Embase, PEDro, Ageline, NARIC, and CIRRIE databases were searched for potentially eligible articles published between 1985 and 2004. Two independent reviewers determined studies appropriate for inclusion using standardized selection criteria, extracted data, evaluated internal validity, and then rated studies according to levels of evidence. Only Level 1 or 2 evidence was included in our summary of clinical recommendations. Spinal anesthesia, pressure-relieving mattresses, perioperative antibiotics, and deep vein thromboses prophylaxes had consistent evidence of benefit. Routine preoperative traction was not associated with any benefits and should be abandoned. Types of surgical management, postoperative wound drainage, and even "multidisciplinary" care, lacked sufficient evidence to determine either benefit or harm. There was little evidence to either determine best subacute rehabilitation practices or to direct ongoing medical issues (e.g., nutrition). Studies conducted during the subacute recovery period were heterogeneous in terms of treatment settings, interventions, and outcomes studied and had no clear evidence for best treatment practices. The evidence for perioperative practices is relatively robust and evidence-based perioperative treatment guidelines can be easily established. Conversely, more evidence is required to better guide the care of elderly patients with hip fracture during the subacute recovery period and convalescence.
    Journal of General Internal Medicine 12/2005; 20(11):1019-25. DOI:10.1111/j.1525-1497.2005.00219.x · 3.42 Impact Factor
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