Investigators Compare Total Hip Arthroplasty with Hemiarthroplasty for Fractures

Mohit Bhandari, MD, PhD

While hip fracture rates remain high for geriatric adults, the best course of action to treat these injuries remains debatable.

A team of investigators, led by Mohit Bhandari, MD, PhD, McMaster University, randomly assigned 1495 patients at least 50-years old with a displaced femoral neck fracture to undergo either a total hip arthroplasty or a hemiarthroplasty at 80 centers in 10 countries.

For geriatric adults, hip fractures represent a top 10 cause of disability globally. However, for displaced femoral neck fractures, it is unknown what the effect of a total hip arthroplasty is compared with hemiarthroplasty.

The patients enrolled in the study were able to ambulate without the assistance of another person prior to the fracture occurring.

The primary end point of the study was a secondary hip procedure within 2 years of follow-up and the secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points.

The primary end point occurred in 57 of the 718 patients who were randomly assigned to undergo the total hip arthroplasty and in 60 of the 723 patients assigned to undergo the hemiarthroplasty (HR, 2.00; 99% CI, .97-4.09).

Function, which was measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored the total hip arthroplasty group over the hemiarthroplasty group.

The team also found that mortality was similar in the 2 treatment groups—14.3% for patients who underwent a total hip arthroplasty and 13.1% for those assigned to undergo a hemiarthroplasty (P =.48).

A total of 300 patients assigned to the total hip arthroplasty and 265 patients assigned to hemiarthroplasty experienced a serious adverse event.

“Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty,” the authors wrote. “Total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months.”

According to an analysis for the Study of Osteoporotic Fractures (SOF) Research Group, when diagnosed with osteoporosis, women aged 80 years or older face a three-fold probability of a hip fracture within 5 years, with the severity increasing even further for women diagnosed with comorbidities or poor prognosis.

The investigators, led by Lisa Langsetmo, PhD, of the University of Minnesota Twin Cities, conducted a prospective cohort study across 4 US sites, including 1528 women (mean age 84.1 years) identified as potentially able to benefit from osteoporosis treatment.

The use of drug treatment to prevent fractures decreases as age increases, while concerns about comorbidities and prognosis increase with age.

During the 5-year study duration, 125 (8%) of the women experienced a hip fracture and 287 (18.8%) died without ever experiencing a hip fracture.

The 5-year mortality probability was 24.9% (95% CI, 21.8-28.1) among women with osteoporosis as compared to 19.4% (95% CI, 16.6-22.3) among women who were only at high fracture risk. Both groups saw an increase in mortality alongside comorbidities and poorer prognosis.

Fracture probability across 5 years was 13% (95% CI, 10.7-15.5) among women with osteoporosis and 4% (95% CI, 2.8-5.6) among the other group.

Among women with 3 or more comorbid conditions, hip fracture probability was 18.1% (95% CI, 12.3-24.9) among women with osteoporosis, while it was 2.5% (95% CI, 1.3-4.2) among the other group.

The study, “Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture,” was published online in The New England Journal of Medicine.