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Hip Replacement

NIHR Signal Outcomes similar for full or partial hip replacement after hip fracture

Published on 12 February 2020

doi: 10.3310/signal-000875

For older people with hip fracture, the choice between full or partial hip replacement does not greatly influence outcomes. In this trial, approximately 8% of patients having each operation required further surgery within a 24-month period. Mortality rates were also similar at around 13%.

This multinational trial included 1,495 adults aged over 50 with a hip fracture, who were previously able to walk unassisted. It found that both hemiarthroplasty (partial replacement) and total hip replacement achieved similar results in terms of function, pain and serious adverse events.

Current NICE guidance recommends total hip replacement over hemiarthroplasty, largely based on a trial of 120 patients which found that function was better following total hip replacement. The results of this larger study suggest there is little difference, and so the decision as to which intervention to use needs to be made on a case-by-case basis.

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Why was this study needed?

In the UK, hip fractures account for over 60,000 hospital admissions a year. Hip fractures primarily affect older people, and many experience long-term effects even after rehabilitation, often leading to further illness and loss of independence.

Hip fractures are usually treated surgically, replacing damaged parts with prostheses (artificial parts). There are two main treatment options: either just the top of the thigh bone (femoral head) is replaced (hemiarthroplasty), or total hip replacement can be performed which in addition replaces the acetabulum (hip socket).  

There is some uncertainty as to the optimal procedure. Total hip replacement is often regarded as having the potential to give better hip function and quality of life; however, there are concerns that this is offset by an increased risk of dislocation and need for secondary procedures. This trial aimed to clarify the outcomes for both procedures.

What did this study do?

The HEALTH randomised controlled trial involved 1,495 people aged over 50 years with a displaced femoral neck fracture, who had been able to walk before their injury. Participants underwent either total hip replacement or hemiarthroplasty.

The trial was conducted in 80 centres in Canada, the US, Spain, the UK, the Netherlands, Norway, Finland, Australia, New Zealand, and South Africa. Patients were assessed at one week, 10 weeks, and at 6, 9, 12, 18, and 24 months after surgery, either in-person or by telephone.

A limitation of this trial is the length of follow-up; longer follow-up would be beneficial to compare outcomes over time. This is compounded by the fact that the number of patients with complete outcome data on function reduced over the 24 month period.

What did it find?

  • There was no difference between procedures in the main surgical outcome of whether a secondary hip procedure was required within 24 months. This occurred in 57 of 718 patients (7.9%) who received total hip replacement and 60 of 723 patients (8.3%) who had hemiarthroplasty (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.64 to 1.40).
  • Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip replacement and 17 patients (2.4%) assigned to hemiarthroplasty (HR 2.00, 99% CI 0.97 to 4.09).
  • Function, as measured using the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), was slightly better in those who had total hip replacement. However, the differences were not enough to be considered clinically important: WOMAC total score, range 0 to 96 (mean difference [MD] −6.37, 99% CI −9.18 to −3.56); WOMAC pain score, range 0 to 20 (MD −0.93, 99% CI −1.42 to −0.44); WOMAC stiffness score, range 0 to 8 (MD −0.44, 99% CI −0.65 to −0.23); and WOMAC function score, range 0 to 68 (MD −4.97, 99% CI −7.11 to −2.83).
  • There was no difference in quality of life according to the European Quality of Life-5 Dimensions (EQ-5D) questionnaire or the 12-Item Short Form General Health Survey (SF-12).
  • Mortality was similar for both groups: 14.3% among those assigned total hip replacement and 13.1% among those assigned to hemiarthroplasty (HR 1.10, 99% CI 0.77 to 1.58). Serious adverse events occurred in 300 patients (41.8%) given total hip replacement and 265 patients (36.7%) who had hemiarthroplasty (HR 1.16, 99% CI 0.9 to 1.51).

What does current guidance say on this issue?

NICE guidance on the management of hip fractures states that patients with a displaced intracapsular hip fracture should be offered either total hip replacement or hemiarthroplasty. The aim should be to allow patients to fully weight bear (without restriction) in the immediate postoperative period.

However, NICE recommends that total hip replacement rather than hemiarthroplasty should be offered to those who meet the following criteria: were able to walk independently out of doors with no more than the use of a stick, are not cognitively impaired, and are medically fit for anaesthesia and the procedure.

What are the implications?

This large trial challenges NICE’s advice in favour of total hip replacement, suggesting hemiarthroplasty is a reasonable alternative. There was no significant difference between procedures in terms of revision surgery, function, quality of life, serious adverse events or death within two years. Further research looking at longer-term outcomes is warranted.

Citation and Funding

Bhandari M, Einhorn TA, Guyatt G et al. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med. 2019;381:2199-208.

Supported by grants from the Canadian Institutes of Health Research (MCT-90168), the National Institutes of Health (1UM1AR063386-01), ZorgOnderzoek Nederland-Medische Wetenschappen (ZonMw) (17088.2503), Sophies Minde Foundation for Orthopaedic Research, McMaster Surgical Associates, and Stryker Orthopaedics. CinicalTrials.gov number, NCT00556842.

Bibliography

International Osteoporosis Foundation. Facts and statistics. Nyon, Switzerland: International Osteoporosis Foundation; 2017.

NHS website. Hip fracture. London: Department of Health and Social Care; updated 2019.

NICE. Hip fracture: management. CG124. London: National Institute for Health and Care Excellence; 2011, updated 2017.

RCP. National Hip Fracture Database (NHFD) annual report 2018. London: Royal College of Physicians; 2018.

Why was this study needed?

In the UK, hip fractures account for over 60,000 hospital admissions a year. Hip fractures primarily affect older people, and many experience long-term effects even after rehabilitation, often leading to further illness and loss of independence.

Hip fractures are usually treated surgically, replacing damaged parts with prostheses (artificial parts). There are two main treatment options: either just the top of the thigh bone (femoral head) is replaced (hemiarthroplasty), or total hip replacement can be performed which in addition replaces the acetabulum (hip socket).  

There is some uncertainty as to the optimal procedure. Total hip replacement is often regarded as having the potential to give better hip function and quality of life; however, there are concerns that this is offset by an increased risk of dislocation and need for secondary procedures. This trial aimed to clarify the outcomes for both procedures.

What did this study do?

The HEALTH randomised controlled trial involved 1,495 people aged over 50 years with a displaced femoral neck fracture, who had been able to walk before their injury. Participants underwent either total hip replacement or hemiarthroplasty.

The trial was conducted in 80 centres in Canada, the US, Spain, the UK, the Netherlands, Norway, Finland, Australia, New Zealand, and South Africa. Patients were assessed at one week, 10 weeks, and at 6, 9, 12, 18, and 24 months after surgery, either in-person or by telephone.

A limitation of this trial is the length of follow-up; longer follow-up would be beneficial to compare outcomes over time. This is compounded by the fact that the number of patients with complete outcome data on function reduced over the 24 month period.

What did it find?

  • There was no difference between procedures in the main surgical outcome of whether a secondary hip procedure was required within 24 months. This occurred in 57 of 718 patients (7.9%) who received total hip replacement and 60 of 723 patients (8.3%) who had hemiarthroplasty (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.64 to 1.40).
  • Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip replacement and 17 patients (2.4%) assigned to hemiarthroplasty (HR 2.00, 99% CI 0.97 to 4.09).
  • Function, as measured using the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), was slightly better in those who had total hip replacement. However, the differences were not enough to be considered clinically important: WOMAC total score, range 0 to 96 (mean difference [MD] −6.37, 99% CI −9.18 to −3.56); WOMAC pain score, range 0 to 20 (MD −0.93, 99% CI −1.42 to −0.44); WOMAC stiffness score, range 0 to 8 (MD −0.44, 99% CI −0.65 to −0.23); and WOMAC function score, range 0 to 68 (MD −4.97, 99% CI −7.11 to −2.83).
  • There was no difference in quality of life according to the European Quality of Life-5 Dimensions (EQ-5D) questionnaire or the 12-Item Short Form General Health Survey (SF-12).
  • Mortality was similar for both groups: 14.3% among those assigned total hip replacement and 13.1% among those assigned to hemiarthroplasty (HR 1.10, 99% CI 0.77 to 1.58). Serious adverse events occurred in 300 patients (41.8%) given total hip replacement and 265 patients (36.7%) who had hemiarthroplasty (HR 1.16, 99% CI 0.9 to 1.51).

What does current guidance say on this issue?

NICE guidance on the management of hip fractures states that patients with a displaced intracapsular hip fracture should be offered either total hip replacement or hemiarthroplasty. The aim should be to allow patients to fully weight bear (without restriction) in the immediate postoperative period.

However, NICE recommends that total hip replacement rather than hemiarthroplasty should be offered to those who meet the following criteria: were able to walk independently out of doors with no more than the use of a stick, are not cognitively impaired, and are medically fit for anaesthesia and the procedure.

What are the implications?

This large trial challenges NICE’s advice in favour of total hip replacement, suggesting hemiarthroplasty is a reasonable alternative. There was no significant difference between procedures in terms of revision surgery, function, quality of life, serious adverse events or death within two years. Further research looking at longer-term outcomes is warranted.

Citation and Funding

Bhandari M, Einhorn TA, Guyatt G et al. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med. 2019;381:2199-208.

Supported by grants from the Canadian Institutes of Health Research (MCT-90168), the National Institutes of Health (1UM1AR063386-01), ZorgOnderzoek Nederland-Medische Wetenschappen (ZonMw) (17088.2503), Sophies Minde Foundation for Orthopaedic Research, McMaster Surgical Associates, and Stryker Orthopaedics. CinicalTrials.gov number, NCT00556842.

Bibliography

International Osteoporosis Foundation. Facts and statistics. Nyon, Switzerland: International Osteoporosis Foundation; 2017.

NHS website. Hip fracture. London: Department of Health and Social Care; updated 2019.

NICE. Hip fracture: management. CG124. London: National Institute for Health and Care Excellence; 2011, updated 2017.

RCP. National Hip Fracture Database (NHFD) annual report 2018. London: Royal College of Physicians; 2018.

Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture

Published on 27 September 2019

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.

N Engl J Med , 2019

BACKGROUND: Globally, hip fractures are among the top 10 causes of disability in adults. For displaced femoral neck fractures, there remains uncertainty regarding the effect of a total hip arthroplasty as compared with hemiarthroplasty. METHODS: We randomly assigned 1495 patients who were 50 years of age or older and had a displaced femoral neck fracture to undergo either total hip arthroplasty or hemiarthroplasty. All enrolled patients had been able to ambulate without the assistance of another person before the fracture occurred. The trial was conducted in 80 centers in 10 countries. The primary end point was a secondary hip procedure within 24 months of follow-up. Secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points. RESULTS: The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to total hip arthroplasty and 60 of 723 patients (8.3%) who were randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P = 0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored total hip arthroplasty over hemiarthroplasty. Mortality was similar in the two treatment groups (14.3% among the patients assigned to total hip arthroplasty and 13.1% among those assigned to hemiarthroplasty, P = 0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to total hip arthroplasty and in 265 patients (36.7%) assigned to hemiarthroplasty. CONCLUSIONS: Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00556842.).

Expert commentary

Prior randomised studies have shown clear advantages of replacement arthroplasty over fixation. What has remained controversial was whether to replace only the head or the whole joint. This study challenges previous evidence and questions whether the current practice and guidelines recommending total hip replacement need reviewing.

The strengths of the study were the size and two-year follow up. Weaknesses include the primary outcome was revision surgery, which is subjective, and the lack of health economic analysis. What was interesting, and different from the previous literature, was the secondary outcomes, which included a specific hip score (WOMAC) and a generic quality of life score (EQ5D); both of these showed no difference in function. Reassuring was the low rate of hip revision for instability.

It certainly opens up the question to future researchers, perhaps utilising the National Hip Fracture Database, to help give more definitive answers to the optimal treatment for this patient population.

Tim Chesser, Consultant Trauma and Orthopaedic Surgeon, North Bristol NHS Trust; Board Member Falls and Fragility Fracture Audit Programme

The commentator declares no conflicting interests

Expert commentary

Previous studies indicated that total hip replacement provides better outcomes than ‘hemiarthroplasty’ (where just the broken ball is replaced). However, total hip replacement is a bigger, more expensive operation. Surgeons have struggled to identify which patients would have the most benefit from total hip replacement, and hospitals have struggled to provide enough suitably-trained surgeons to do the surgery in a timely manner.

The HEALTH trial provides the best evidence yet to help address these issues. Surgeons and patients can now be reassured that the risk of failure of the surgery is no greater following the quicker, easier hemiarthroplasty operation. However, total hip replacement may still benefit some patients who had high demands upon their hip before their injury. These potential functional benefits need to be offset against the slightly higher risk of hip instability and of course the greater cost of total hip replacement.

Matt Costa, Professor of Orthopaedic Trauma Surgery, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford; Honorary Consultant Trauma Surgeon, John Radcliffe Hospital, Oxford

The commentator declares no conflicting interests

Expert commentary

This study highlights the uncertainty as to whether patients sustaining a displaced intracapsular neck of femur fracture benefit most from hemiarthroplasty or total hip replacement.

Current NICE guidance states that patients who walk independently outdoors with no more than the aid of a stick prior to their injury should receive a total hip replacement.

Future work may refine the patient subgroups that are thought more likely to benefit from either procedure, but outcomes at two years appear comparable for those who independently ambulate.

Collecting long-term outcome data with health economic analysis is crucial to provide guidance for clinical practice.

Antony Palmer, NIHR Academic Clinical Lecturer in Trauma and Orthopaedics, University of Oxford

The commentator declares no conflicting interests