Hemiarthroplasty Comparable to Total Hip Surgery for Femoral Neck Fracture - Study

By Gene Emery

September 27, 2019

(Reuters Health) - Hemiarthroplasty (HA) improves function and quality of life just as effectively as total hip arthroplasty (THA) in patients with displaced femoral neck fractures who were independently ambulatory before the fracture, the largest study ever done on hip fracture surgery has concluded.

"Our findings are pretty compelling," chief author Dr. Mohit Bhandari of McMaster University in Ontario, Canada, told Reuters Health in an email. He said the surprising results show that for patients, "a full hip replacement may not be your best bet."

He predicted that "the enthusiasm for THA for elderly hip fracture patients will be dampened (by the new findings), and guidelines, we hope, will reflect the evidence."

The results of the HEALTH study were released Thursday at the Orthopedic Trauma Association annual meeting in Denver and online by the New England Journal of Medicine.

The findings come in the wake of meta-analyses that have concluded that total hip replacement provides better function than hemiarthroplasty with fewer reoperations. However, supporters of just replacing the femoral head say total hip surgery carries a higher risk of surgical morbidity and carries a higher risk of dislocation.

"The American Academy of Orthopaedic Surgeons and National Institute of Health and Care Excellence guidelines recommend total hip arthroplasty in all patients with displaced femoral neck fractures who are able to ambulate independently. Our findings suggest that the advantages of total hip arthroplasty may not be compelling," the team said.

Dr. Bhandari, professor and head of the division of orthopaedic surgery at McMaster, said "HEALTH is easily 5- to 6-fold (and in many cases 10-fold) larger than prior smaller trials." It involved 1,495 patients and was conducted at 80 sites in 10 countries. All of the volunteers were age 50 or older and all had been able to get around by themselves before sustaining a low-energy displaced fracture of the femoral neck. The study was not blinded.

After 24 months of follow-up, 7.9% of the patients randomly assigned to total hip arthroplasty required a second hip procedure versus 8.3% of those in the hemiarthroplasty group (P=0.79).

The risk was higher during the first year with total hip arthroplasty and higher during the second year for hemiarthroplasty recipients, although only the second-year difference was statistically significant (P=0.01).

Mortality was also comparable in the two groups, with rates of 14.3% with total hip replacement and 13.1% with hemiarthroplasty (P=0.48).

Hip instability or dislocation was twice as likely with total hip surgery, with a rate of 4.7% versus 2.4% for hemiarthroplasty (but the 99% confidence interval was 0.97 to 4.09).

Similarly, serious adverse events were more common with total hip replacement, but not significantly so. The rates were 41.8% with total hip and 36.7% with replacing just the ball.

But the Bhandari team said functional assessments measuring things such as pain and stiffness "modestly favored total hip arthroplasty over hemiarthroplasty."

"Total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months," they concluded.

Dr. Bhandari said the less-complicated operation should save money.

"THA is more expensive with no evidence of benefit over HA - no improvement in function, no difference in secondary revisions, and possibly more serious adverse events," he said.

SOURCE: https://bit.ly/2lc0R5h

N Engl J Med 2019.