Indications
Patient > 50
Displaced fractures
Issues
Fixation versus arthroplasty
Hemiarthroplasty versus THA
Hemiarthroplasty (HA)
- bipolar versus monopolar
- cemented versus uncemented
- surgical approach
Fixation versus arthroplasty of displaced fractures
Ramadanov et al J Orthop Surg Res 2023
- systematic review and meta-analysis
- both displaced and non displaced fractures
- 33 RCTs with 5700 patients
- THA and HA had the best functional outcome
- cannulated screws and DHS had highest reoperation rates
- Norwegian Hip Fracture registry
- 4335 patients > 70 with displaced subcapital fractures
- screw fixation versus bipolar HA
- 1 year mortality same in each group (25%)
- reoperation rate: 23% screw fixation v 3% in hemiarthroplasty
- more pain / higher dissatisfaction / lower quality life in screw fixation group
Hemiarthroplasty versus THA
HEALTH investigators NEJM 2019
- RCT of 1495 patients > 50 with displaced femoral neck fracture
- HA versus THA
- reoperation rate same in both groups (8%)
- dislocation: 2% HA versus 5% THA
- serious adverse events: 37% HA verus 42% THA
- modest improvement in function for THA over HA, clinically unimportant
Australian Joint Registry 2023
- 15 year revision rate THA for OA 6%
- 15 year revision rate THA for fracture 9%
Hemiarthroplasty
Hemiarthroplasty Design Options
Unipolar
- single articulation between prosthesis and acetabulum
Unipolar monoblock
- Austin Moore press fit
- Thompson cemented
- no offset options
Austin Moore Thompson
Modular unipolar
Based on standard THR concepts
- alternative offset options
- neck length options
- cemented or uncemented
Bipolar modular
Concept
- second articulation between inner smaller head and polyethylene liner
- reduce wears on acetabulum
- improved function and less pain
- may reduce dislocation
- may have better ROM
Issues
- higher cost
- may need open reduction in dislocation if femoral head disassociates from socket
- loss of motion interface / becomes unipolar
Unipolar HA verus Bipolar HA
Papavasiliou et al Eur J Orthop Surg Traumatol 2023
- systematic review of 16 RCTs and 1800 patients
- unipolar versus bipolar
- reduced acetabular erosion with bipolar
- improved function and reduced pain with bipolar
- no difference in reoperation or dislocation
Australian Joint Registry 2023
- 45,000 unipolar modular
- 28,000 bipolar modular
- 10 year revision rate unipolar 7%
- 10 year revision rate bipolar 5%
Australian Joint Registry 2023
- patients < 75
- 10 year revision rate unipolar 14%
- 10 year revision rate bipolar 8%
Revision rate AJRR all ages Revision rate AJRR < 75 years
Cemented versus uncemented HA
Cemented unipolar hemiathroplasty Uncemented bipolar hemiarthroplasty
Cement
- minimizes fracture risk in osteoporotic patients
- reduced risk thigh pain
- slightly increased cardiac risk with cement
- RCT of 400 patients
- cemented vs uncemented
- cemented HA had better early mobility
- cemented HA had significantly lower mortality
- no difference in complication or revision rate
- systematic review of 24 RCTs and 3500 patients
- cemented versus uncemented HA
- cemented had less pain and better function
- cemented had fewer fracture / loosening / revision
Technique
Vumedi lateral approach hemiarthroplasty
Vumedi posterior approach hemiarthroplasty
Approach
Posterior approach
- increased short-term morbidity
- may increase dislocation risk
Hardinge
- take off anterior 1/3 abductor tendons
Complications
Infection
Dislocation
Fracture
Leg length discrepancy
Groin pain from acetabular cartilage erosion
Severe acetabular wear
Loosening
Cement implantation syndrome
Hypoxia, hypotension and loss of consciousness concurrent with cementing
Olsen et al, Br J Anaesth 2014
- 1016 cemented hemiarthroplasties
- 28% incidence in neck fracture
- higher early mortality
Total hip arthroplasty
Indications
Young, active, mobile patient with neck of femur fracture
Issues
THA
- better functional outcome in young mobile patient
- higher cost
- higher dislocation rates
Results
HEALTH investigators NEJM 2019
- RCT of 1495 patients > 50 with displaced femoral neck fracture
- HA versus THA
- reoperation rate same in both groups (8%)
- dislocation: 2% HA versus 5% THA
- serious adverse events: 37% HA verus 42% THA
- modest improvement in function for THA over HA, clinically unimportant
Tang et al J Orthop Surg Res 2020
- systematic review of 25 RCTs and 3200 patients
- THA better functional outcomes in mid term
- higher dislocation with THA
Australian Joint Registry 2023
- 27,500 primary THA for fracture hip
- revision rate 9% at 15 years
- revision for dislocation 1.5%
- revision for fracture 2%
- revision for infection 1%
- revision for loosening 1.5%