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Better long-term results with THR than internal fixation in elderly patients
Researchers find significantly lower complication and reoperation rates in their THR patients.
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A new study confirms that at four-year follow-up, primary total hip replacement yields better outcomes than internal fixation for elderly patients with displaced femoral neck fractures.
Previous studies have shown total hip replacement (THR) to be superior to internal fixation in relatively healthy, elderly, lucid patients with such fractures during the first two years. However, Swedish researchers set out to determine whether patients maintain the superior outcomes over four years follow-up.
Internal fixation vs. THR group
Richard Blomfeldt, MD, and colleagues at the Stockholm Soder Hospital in Stockholm randomized 102 elderly patients (mean age, 80 years) with displaced femoral neck fractures to treatment with either internal fixation or THR. The researchers compared differences in outcomes, hip complications, reoperation rates and hip function using Charnley’s classification system. They also evaluated health-related quality of life using the EuroQual-5D.
Surgeons performed internal fixation with cannulated screws on 53 patients, and performed THR for another 49 patients. All patients lived independently, could walk independently and none had severe cognitive dysfunction.
“The complication and reoperation results were significantly lower in the total hip replacement group,” said Blomfeldt, who presented the results at the Orthopaedic Trauma Association 21st Annual Meeting. “The outcomes regarding hip function and health-related quality of life were at least as good,” he noted.
Significant differences
Researchers found significant differences between groups at 48 months follow-up. “Hip complications were significantly more frequent in the internal fixation group — 42% compared to 4% in the THR group. Reoperations were also significantly more frequent in the internal fixation group — 47% compared to 4% in the THR group,” Blomfeldt said.
Between 24 and 48 months follow-up, hip complications increased from 36% to 42% in the internal fixation group, but the THR group experienced no further hip complications.
Researchers found similar reoperation rates, which increased from 42% to 47% in the internal fixation group. The THR group experienced no additional reoperations between 24 and 48 months follow-up, however.
Decrease in differences
In analyzing the three dimensions of the Charnley classification system — pain, mobility and walking ability — the researchers found significantly lower pain in the THR group at four, 12 and 24 months.
Although a trend toward less pain remained in the THR group, the difference decreased by 48 months follow-up. “The main reason for this finding was that most of the patients with a fracture healing complication after internal fixation were reoperated with a hip arthroplasty. Some patients with problems related to the fracture fixation implant also had had their screws removed,” Blomfeldt told Orthopedics Today.
Findings were similar with walking abilities, which were significantly better in the THR group at four, 12 and 24 months. This difference also decreased by 48 months follow-up, however.
As for quality of life, THR patients experienced a minor decrease, while internal fixation patients had a significant deterioration during the first year. But, the difference between groups had decreased at 12, 24 and 48 months follow-up because of many reoperations in the internal fixation group.
“We noticed a deterioration regarding walking ability and quality of life in both groups between the 24- and 48-month follow-up, probably reflecting the natural course of aging, the increased frequency of comorbidities and new fractures of the lower extremity,” Blomfeldt said.
For more information:
- Blomfeldt R, Ponzer S, Törnkvist H, Tidermark J. A four-year follow-up of a randomized controlled trial comparing internal fixation with total hip replacement in elderly patients with displaced femoral neck fractures. #2. Presented at the Orthopaedic Trauma Association 21st Annual Meeting. Oct. 19-22, 2005. Ottawa.
- Blomfeldt R, Törnkvist H, Ponzer S, et al. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surgery Am. 2005 87(8):1680-8.