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Best displaced femoral neck fracture treatment influenced by surgeon, patient factors
Some surgeons prefer total hip arthroplasty over hemiarthroplasty or internal fixation for displaced femoral neck fractures, despite its higher cost and mortality.
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Whether hemiarthroplasty is an outdated way of treating displaced femoral neck fractures or if it still has its place when used in certain patients depends on which orthopedist you talk to.
In a debate on the topic at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting, Javad Parvizi, MD, FRCS, and Carlos J. Lavernia, MD, concluded total hip arthroplasty (THA) produces generally superior function and clinical scores, but they noted fracture fixation and possibly hemiarthroplasty may be preferable for surgeons with less THA experience.
“If you look at the evidence-based issues regarding the basic science and the clinical issues that make you decide one way or another, you also have to think what kind of surgeon you are,” Lavernia said. “If you are doing two total hips a year, you may be better off just fixing that fracture.”
Meta-analysis favors total hip
To make his case in favor of THA for this indication, Lavernia cited a meta-analysis that reviewed 3,800 clinical trials, 15 of which were randomized, and he said they arrived at similar conclusions: Total hips do better functionally and they hurt a lot less. However, THA traditionally has more complications and is approach-dependent, Lavernia said.
This image shows a cemented hemiarthroplasty with a bipolar head.
Images: Parvizi J
“If you go anterolateral, you get a less dislocations [than] if you go posteriorly. There is no question about it, [patients] have a lot more pain if you do a hemi than if you do a total.”
In a 450-patient study of these fractures conducted over 10 years that Lavernia discussed, 45% of patients with internal fixation had failures, mostly due to avascular necrosis and nonunions, compared to a 7% failure rate in patients with THA. Also, a level 1 randomized, prospective trial that included 102 patients demonstrated complication rates of 40% for internal fixation and 4% for THA, he said. These studies were done at experienced hip centers.
However, THA success also depends on implant design, according to Lavernia. Cartilage and metal combinations, especially with cobalt-chrome heads are not a good combination and will remain an issue with the aging population.
Underpowered THA studies
“A very optimal approach for treatment of hip fracture still remains inconclusive,” Parvizi, an Orthopedics Today Editorial Board member, said in his presentation.
He noted THA has low revision rates when used to treat femoral neck fractures and produces reliable results in active elderly patients. But, Parvizi criticized the studies Lavernia chose to highlight for their small sample size and methodological limitations. For example, he said in a study focusing on WOMAC scores for patients with THA or hemiarthroplasty, there were no significant differences in Harris Hip Scores or the time it took patients in either group to “get up and go.”
According to Parvizi, Lavernia also did not mention a meta-analysis of three randomized controlled trials that examined long-term outcomes in THA and hemiarthroplasty among with 278 patients. It showed a greater tendency toward dislocation in THA over hemiarthroplasty patients.
Increased mortality rates
Furthermore, Parvizi said many studies of THA for this indication do not include procedural costs, mortality rates or the patients’ preoperative status.
“Most of these patients are independent: 6 months after surgery, only 15% of these patients are able to walk unaided. That is a very dismal outcome,” he said of the THA results. There is a 6.9% THA dislocation rate in this analysis — almost eight times higher than that for hemiarthroplasty — and 25% of patients are dead within 1 year of surgery, Parvizi added.
In addition, THA is more complicated than bipolar procedures and therefore has a higher cost of surgery of about $150 per minute in most hospitals, Parvizi said. For trauma surgeons who do not normally perform THA, the cost would increase. Implant type also can affect cost, as component prices range from $150 to $1,200 depending on the material used, he said.
“Hip arthroplasty is not for everyone. It is for very active patients who are elderly; it is not for the very young patients who we should still attempt to fix,” and hemiarthroplasty remains an option for elderly patients with comorbidities in an attempt to reduce operative time and decrease complications, Parvizi said. – by Jeff Craven
Reference:
- Lavernia CJ, Parvizi J. Displaced femoral neck fractures: The hemi is dead; long live the THA – Affirmative/Negative. Symposium H: Hot topics in joint preservation and joint arthroplasty. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb 7-11. San Francisco.
For more information:
- Carlos J. Lavernia, MD, can be reached at Orthopaedic Institute at Mercy Hospital, Mercy Hospital Outpatient Center, 3659 South Miami Ave., Suite 4008, Miami, FL 33133; 888-544-2148; email: carlos@orthomercy.com.
- Javad Parvizi, MD, FRCS, can be reached at Rothman Institute, 925 Chestnut St., 5th Floor., Philadelphia, PA 19107; 267-339-3617; email: parvj@aol.com.
- Disclosure: Lavernia is a paid consultant for MAKO Surgical Corp. Parvizi is a consultant for Biomet, Covidien, Smith & Nephew Orthopaedics, Stryker Orthopaedics and Zimmer.