Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. Comparison between external fixation and sliding hip screw in the management of trochanteric fracture of the femur in Nepal. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur--13 year results of a prospective randomised study. Internal fixation versus primary prosthetic replacement in acute femoral neck fractures: a prospective, randomized clinical study. Postoperative mental impairment in hip fracture patients. A randomized study of reorientation measures in 223 patients. Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment. Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement. Dynamic hip screw compared with external fixation for treatment of osteoporotic pertrochanteric fractures. A prospective, randomized study.
A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail. Orthopaedic surgeons vary in their management of displaced intracapsular fractures of the hip in healthy older patients. The aim of this investigation was to determine the functional, clinical, and resource consequences of three different types of surgical treatment.
                The study was a multicenter randomized controlled trial. Reduction and fixation was compared with bipolar hemiarthroplasty with cement and total hip replacement with cement. Participating surgeons elected to randomize their patients to be treated with either one of the three types of procedures or with either fixation or bipolar hemiarthroplasty. Functional outcomes were measured with a hip-rating questionnaire and the EuroQol health status measure. Clinical outcomes included mortality and complications. The direct health service costs were compared. Participants were followed up for two years.
                Two hundred and seven patients were randomized to be treated with one of the three operations, and ninety-one were randomized to be treated with either fixation or bipolar hemiarthroplasty. There were no differences in the mortality rates among the treatment groups. The rate of secondary surgery was highest in the fixation group (39% compared with 5% in the group treated with bipolar hemiarthroplasty and 9% in the group treated with total hip replacement). The fixation group had the worst hip-rating-questionnaire and EuroQol scores at four and twelve months. The total hip replacement group had significantly better functional outcome scores at twenty-four months than the other two groups. Although fixation was initially the least costly procedure, this short-term advantage was eroded by significantly higher costs for subsequent hip-related hospital admissions.
                Arthroplasty is more clinically effective and cost-effective than reduction and fixation in healthy older patients with a displaced intracapsular fracture of the hip. The long-term results of total hip replacement may be better than those of bipolar hemiarthroplasty. We conducted a randomised controlled trial to compare external fixation of trochanteric fractures of the femur with the more costly option of the sliding hip screw. Patients in both groups were matched for age (mean 67 years, 50 to 100) and gender. We excluded all pathological fractures, patients presenting at more than one week, fractures with subtrochanteric extension or reverse obliquity, multiple fractures or any bone and joint disease interfering with rehabilitation. The interval between injury and operation, the duration of surgery, the amount of blood loss, the length of hospital stay and the cost of treatment were all significantly higher in the sliding hip screw group (p < 0.05). The time to union, range of movement, mean Harris hip scores and Western Ontario and McMaster University knee scores were comparable at six months. The number of patients showing shortening or malrotation was too small to show a significant difference between the groups. Pin-track infection occurred in 18 patients (60%) treated with external fixation, whereas there was a single case of wound infection (3.3%) in the sliding hip screw group. In this prospective randomised trial we compare the mortality, morbidity and functional results of patients following each of the three principal methods of treatment for displaced subcapital fractures of the femur. Two hundred and ninety patients over the age of 65 years were included and randomly allocated to undergo closed reduction and internal fixation with a sliding compression screw plate or uncemented Austin Moore hemiarthroplasty or cemented Howse II total hip arthroplasty (THA). Nineteen patients were subsequently excluded. The 13 year results show that there was no statistical difference in the mortality between the three groups (81, 85 and 91% respectively). Internal fixation and hemiarthroplasty groups fared poorly with a revision rate of 33 and 24%, respectively, compared with 6.75% in the THA group. The dislocation rate was 13% following hemiarthroplasty and 20% following THA. Average Harris hip scores were 62, 55 and 80, respectively, for the internal fixation, hemiarthroplasty and THA groups. In the long term, both internal fixation and hemiarthroplasty resulted in a poor outcome with respect to pain and mobility. Despite high early complications, THA resulted in least pain and most mobility both in the short and long-term and was encouraging with a revision rate of only 6.25%. THA should be seriously considered in physiologically active patients with a displaced subcapital fracture of the femur. A prospective, randomized clinical study has been performed on 104 patients with an acute femoral neck fracture, comparing internal fixation (von Bahr screws) with primary prosthetic replacement (Christiansen endoprosthesis). Immediate weight bearing was allowed in both groups. The postoperative mortality rate was similar in the two groups. Internal fixation proved to be a less time-consuming operation, gave a shorter hospitalization time and was associated with a significantly reduced morbidity rate compared with prosthetic replacement. No blood transfusion was needed in the internal fixation group. Primary prosthetic replacement was associated with earlier postoperative mobilization, probably gave a more definitive treatment with fewer reoperations, and showed better results at 1-year follow-up. Mental impairment is a common and serious complication in geriatric surgery. We studied 223 hip fracture patients. They were over 64 years of age (mean 81), with no history of mental deterioration and acutely admitted to hospital from independent living conditions. They were randomized into two groups. One of these was subjected to reorientation measures during the perioperative phase, i.e., presurgery admission to the orthopedic ward, accompanied home visits during the hospital stay and access to reorientation devices--they received a large clock, calendar, radio, TV-set, telephone and were encouraged to wear their own clothing. Otherwise, there were no differences in the treatment given to the two groups. We used monitoring of cognitive function with the Short Portable Mental Status Questionnaire (SPMSQ) and a feedback program for evaluation of the treatment results. There was a low incidence of postoperative cognitive deterioration in both groups, compared with historical controls. However, no difference in mental status was noted when we compared the two groups. The conclusion is that attributes were less important than the psychological environment for postoperative mental deterioration. The mean total continuous hospitalization (transfers between departments and hospitals included) in the reorientation group was 22 (95% CI: 17-43) days, the corresponding figures for the controls were 30 (14-29) days. We studied 60 patients with an acute displaced fracture of the femoral neck and with a mean age of 84 years. They were randomly allocated to treatment by either internal fixation with cannulated screws or hemiarthroplasty using an uncemented Austin Moore prosthesis. All patients had severe cognitive impairment, but all were able to walk independently before the fracture. They were reviewed at four, 12 and 24 months after surgery. Outcome assessments included complications, revision surgery, the status of activities of daily living (ADL), hip function according to the Charnley score and the health-related quality of life (HRQOL) according to the Euroqol (EQ-5D) (proxy report). General complications and the rate of mortality at two years (42%) did not differ between the groups. The rate of hip complications was 30% in the internal fixation group and 23% in the hemiarthroplasty group; this was not significant. There was a trend towards an increased number of re-operated patients in the internal fixation group compared with the hemiarthroplasty group, 33% and 13%, respectively (p = 0.067), but the total number of surgical procedures which were required did not differ between the groups. Of the survivors at two years, 54% were totally dependent in ADL functions and 60% were bedridden or wheelchair-bound regardless of the surgical procedure. There was a trend towards decreased mobility in the hemiarthroplasty group (p = 0.066). All patients had a very low HRQOL even before the fracture. The EQ-5D(index) score was significantly worse in the hemiarthroplasty group compared with the internal fixation group at the final follow-up (p < 0.001). In our opinion, there is little to recommend hemiarthroplasty with an uncemented Austin Moore prosthesis compared with internal fixation, in patients with severe cognitive dysfunction. In a prospective trial of 278 patients aged over 65 years, treatment of displaced subcapital fractures was randomly allocated to closed reduction and internal fixation with a sliding compression screwplate, Moore hemiarthroplasty, or total hip treatment with a Howse semicaptive prosthesis. One year after operation there was little difference between the three groups in mortality (25 per cent) or general complications. The revision rate within the first year was highest for internal fixation (25 per cent), but many of the replacements also required a further anaesthetic for reduction of a dislocation (Moore, 11 per cent; Howse 12.5 per cent). Total hip replacement resulted in the least pain and most mobility at 1 year, while hemiarthroplasty was worst in these respects. We conclude that internal fixation and particularly primary total hip replacement should be given serious consideration in the management of the elderly patient with a displaced subcapital fracture. Although the use of a sliding hip screw is considered to be the preferred treatment for pertrochanteric femoral fractures, we theorized that external fixation could produce clinical outcomes equal to, if not better than, the outcomes obtained with conventional treatment. Furthermore, because external fixation is minimally invasive, we expected a lower rate of morbidity and a reduced need for blood transfusions. Therefore, we compared the two treatments in a clinical trial of elderly patients with pertrochanteric fracture.
                Forty consecutive elderly female patients who had a pertrochanteric fracture were randomized to be treated with either fixation with a 135 degrees four-hole sliding hip screw (Group A) or an external fixation device with hydroxyapatite-coated pins (Group B). The inclusion criteria were female gender, an age of at least sixty-five years, an AO/OTA type-A1 or A2 fracture, and a bone mineral density T-score of less than -2.5. There were no differences in patient age, fracture type, bone mineral density, comorbidities, length of hospital stay, or quality of reduction between the two groups.
                The average intraoperative time (and standard deviation) was 64 +/- 6 minutes in Group A and 34 +/- 5 minutes in Group B (p < 0.005). The average number of units of blood transfused postoperatively was 2.0 +/- 0.1 in Group A and none in Group B (p < 0.0001). Group B had less pain five days postoperatively (p < 0.05). Varus collapse of the fracture at six months averaged 6 degrees +/- 8 degrees in Group A and 2 degrees 1 degrees in Group B (p < 0.002). No pin-track infections occurred in Group B. The average Harris hip score at six months was 62 +/- 19 points in Group A and 63 +/- 17 points in Group B.
                This study showed that external fixation with hydroxyapatite-coated pins is an effective treatment for this fracture in this patient population. The operative time is brief, the blood loss is minimal, the fixation is adequate, and the reduction is maintained over time.
Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip. Definite conclusions cannot be made for differences in pain and residual disability between the two groups. Future studies should concentrate on better reporting of final outcome measures and function. There is still a need for studies to define which patient groups are better served by the different treatment methods.