This recommendation was downgraded from Strong to Moderate strength due to effect size.
Four high strength (Chammout 2019, Hedbeck 2011, Keating 2005, van den Bekerom 2010) and ten moderate strength studies (Blomfeldt 2005, Cadossi 2013, Health Investigators 2019, Iorio 2019, Li 2017, Parker 2019, Ren 2017, Sharma 2016, Ukaj 2019, Xu 2017) examined this question. The evidence demonstrates a small functional outcome benefit to patients who received total hip arthroplasty. Hemi arthroplasty was associated with a small decrease in dislocation and instability. Mortality rates were largely unaffected within the first 4 years after treatment.
The strength of the evidence is strong. However, the effect size is small, which led the expert panel to unanimously downgrade this recommendation to moderate. Patient exclusion criteria in some of these studies reflect the general bias amongst surgeons towards performing total hip arthroplasty in patients who are higher functioning and more likely to be independent community ambulators. Cautious decision making for lower functioning patients may be justified considering the bias and risk for complications.
Benefits/Harms of Implementation
Implementing this recommendation does not result in additional harm to the patient beyond that conferred by usual surgical risk. The choice of appropriate treatment requires discussion of risk and benefit with patients and families (shared decision making). This may help determine which patients might benefit more from functional improvement or avoiding complications including those patients whose preoperative function does not justify a surgical procedure involving greater risks.
Implementing this recommendation is likely to lead to greater expenditure. Total hip arthroplasty implants are priced higher than implants for hemi arthroplasty. Procedural and professional fees are higher for total hip arthroplasty than for hemi arthroplasty. The slight increase in complications with total hip arthroplasty may also generate additional charges.
Future Research
Further areas of investigation include whether potential delays in surgery occur when total hip arthroplasty is the chosen treatment, and whether this influences postoperative morbidity. Another important but unanswered question is whether the demand for total hip arthroplasty following fracture can be met by surgeons who currently employ hemi arthroplasty, or if the increasing use of total hip arthroplasty by less experienced surgeons will offset potential benefits seen in previous studies.
- Blomfeldt, R., Törnkvist, H., Ponzer, S., Söderqvist, A., Tidermark, J. Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment. Journal of Bone & Joint Surgery - British Volume 2005; 4: 523-9
- Cadossi, M., Chiarello, E., Savarino, L., Tedesco, G., Baldini, N., Faldini, C., Giannini, S. Erratum: A comparison of hemiarthroplasty with a novel polycarbonate- urethane acetabular component for displaced intracapsular fractures of the femoral neck: A randomised controlled trial in elderly patients (Bone and Joint Journal (2013) 95-B (609-615)). Bone and joint journal 2013; 11: 1582
- Chammout, G., Kelly-Pettersson, P., Hedbeck, C. J., Stark, A., Mukka, S., Skoldenberg, O. HOPE-Trial: Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians: A Randomized Controlled Trial. JB & JS Open Access 2019; 2: e0059
- Health Investigators, Bhandari, M., Einhorn, T. A., Guyatt, G., Schemitsch, E. H., Zura, R. D., Sprague, S., Frihagen, F., Guerra-Farfan, E., Kleinlugtenbelt, Y. V., Poolman, R. W., Rangan, A., Bzovsky, S., Heels-Ansdell, D., Thabane, L., Walter, S. D., Devereaux, P. J. Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture. New England Journal of Medicine 2019; 23: 2199-2208
- Hedbeck, C. J., Blomfeldt, R., Lapidus, G., Törnkvist, H., Ponzer, S., Tidermark, J. Unipolar hemiarthroplasty versus bipolar hemiarthroplasty in the most elderly patients with displaced femoral neck fractures: a randomised, controlled trial. International Orthopaedics 2011; 11: 1703-11
- Iorio, R., Iannotti, F., Mazza, D., Speranza, A., Massafra, C., Guzzini, M., D'Arrigo, C., Ferretti, A. Is dual cup mobility better than hemiarthroplasty in patients with dementia and femoral neck fracture? A randomized controlled trial. Sicotj 2019; 0: 38
- Keating, J. F., Grant, A., Masson, M., Scott, N. W., Forbes, J. F. Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty. Health Technology Assessment (Winchester, England) 2005; 41: iii-iv, ix-x, 1-65
- Li, J., Xiao, J., Zhang, Z., Jia, F., Wu, Z. A Novel Fast Mobile-Window Small Incision Technique for Hip Arthroplasty in the Elderly and Comparison with Conventional Incision. Medical Science Monitor 2017; 0: 3303-3310
- Parker, M. J., Cawley, S. Treatment of the displaced intracapsular fracture for the 'fitter' elderly patients: A randomised trial of total hip arthroplasty versus hemiarthroplasty for 105 patients. Injury 2019; 11: 2009-2013
- Ren, C., Guo, J., Gao, Y. Comparison of total hip arthroplasty and hemiarthroplasty in elderly patients with femoral neck fracture. Biomedical research (india) 2017; 16: 7127-7130
- Sharma, V., Awasthi, B., Kumar, K., Kohli, N., Katoch, P. Outcome Analysis of Hemiarthroplasty vs. Total Hip Replacement in Displaced Femoral Neck Fractures in the Elderly. Journal of Clinical and Diagnostic Research JCDR 2016; 5: RC11-3
- Ukaj, S., Zhuri, O., Ukaj, F., Podvorica, V., Grezda, K., Caton, J., Prudhon, J. L., Krasniqi, S. Dual Mobility Acetabular Cup Versus Hemiarthroplasty in Treatment of Displaced Femoral Neck Fractures in Elderly Patients: Comparative Study and Results at Minimum 3-Year Follow-up. Geriatric Orthopaedic Surgery & Rehabilitation 2019; 0: 2151459319848610
- van den Bekerom, M. P., Hilverdink, E. F., Sierevelt, I. N., Reuling, E. M., Schnater, J. M., Bonke, H., Goslings, J. C., van Dijk, C. N., Raaymakers, E. L. A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: a randomised controlled multicentre trial in patients aged 70 years and over. Journal of Bone & Joint Surgery - British Volume 2010; 10: 1422-8
- Xu, F., Ke, R., Gu, Y., Qi, W. Bipolar hemiarthroplasty vs. total hip replacement in elderly. International journal of clinical and experimental medicine 2017; 5: 7911-7920