Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: an updated meta-analysis

Objectives

To compare the outcomes of cemented and uncemented hemiarthroplasty for treating displaced femoral neck fractures.

Method

We searched the PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases from 1966 to Mar 2012. No language restriction was applied. Reference lists of all the selected articles were hand-searched for any additional trials. Trial quality was assessed using the modified Jadad Scale. Two authors independently extracted data from all eligible studies, including study design, participants, interventions, and outcomes (mortality, hospital stay, blood loss, operation time, residual pain, and complications). The data were using fixed-effects and random-effects models with mean differences and risk ratios for continuous and dichotomous variables, respectively.

Results

A total of 12 studies involving 1805 patients were identified in this analysis. Meta-analysis showed longer operation time (SMD, ?0.43, 95 % CI ?0.56, ?0.30) in cemented versus uncemented hemiarthroplasty. There was no significant difference between the two treatment groups regarding mortality (OR, 1.08, 95 % CI 0.88, 1.34), hospital stay (SMD, ?1.21, 95 % CI ?2.24, ?0.18), blood loss (SMD, ?0.12, 95 % CI ?0.33, 0.10), operation time (SMD, ?0.43, 95 % CI ?0.56, ?0.30), residual pain (OR, 1.42, 95 % CI 0.99, 2.03), and complications (OR, 0.82, 95 % CI 0.63, 1.08).

Conclusions

The available evidence suggested there was no significant difference between uncemented and cemented hemiarthroplasty in treating displaced femoral neck fractures.     

Cemented or uncemented hemiarthroplasty for displaced intracapsular femoral neck fractures

The aim of this study was to establish whether or not to cement the hemiarthroplasty for displaced intracapsular femoral neck fractures in the elderly. Consecutive patients treated by hemiarthroplasty in adjacent hospitals were reviewed. The same monoblock prosthesis was used; in hospital A they were uncemented (121 patients), and in hospital B they were cemented (123 patients). Notes were reviewed retrospectively. Surviving patients (50 and 56 respectively) were assessed prospectively for pain and functional ability using validated scoring systems. Follow-up was 32-36 months. Patient demographics were similar. Fewer of the cemented group had been revised or were awaiting revision ( P=0.036). There was no difference in general complication or mortality rates. There was a highly statistically significant greater deterioration in pain ( P=0.003), walking ability ( P=0.002), use of walking aids ( P=0.003) and activities of daily living ( P=0.009) in the uncemented group. Our findings support the use of cemented hemiarthroplasty in the elderly.     

Cannulated screws versus hemiarthroplasty for displaced intracapsular femoral neck fractures in demented patients

BACKGROUNDS AND AIMS: There are no randomised trials comparing internal fixation and hemiarthroplasty for a displaced intracapsular femoral neck fracture in relation to mental state. MATERIAL AND METHODS: To establish what should be the treatment of first choice, a prospective randomised clinical study was performed on 60 demented patients with displaced intracapsular femoral neck fractures, comparing internal fixation (n = 31) with hemiarthroplasty (n = 29). RESULTS: There was no significant difference in the mortality rate of both groups. Hemiarthroplasty was associated with significantly more loss of blood and more wound complications. Reoperation for secondary displacement of the fracture after internal fixation occurred in four patients. Although not-statistically significant, failure of internal fixation seemed to be higher after an inadequate osteosynthesis. CONCLUSION: Postoperative mortality is high and the chance of successful rehabilitation very small for both types of treatment in this group of patients. In our opinion, demented patients should not be treated with a major surgical procedure like hemiarthroplasty. Internal fixation should be considered the treatment of choice, because it is a smaller operation than prosthetic replacement, with less morbidity. If adequate reduction can not be achieved, a primary hemiarthroplasty should be performed.     

人工股骨头置换治疗老年股骨颈骨折—骨水泥与非骨水泥型假体的比较

目的对比骨水泥型和非骨水泥型两种假体在治疗股骨颈骨折中的应用差别。方法回顾了本机构近3年65岁以上股骨颈骨折实施人工股骨头置换的病例共221例,按应用骨水泥型和非骨水泥型假体进行分组。随访时间为1、3、6、12个月。比较两组间的手术时间、出血量、并发症发生率、术后下地时间、髋关节Harris评分等。结果两组在手术时间、术中并发症及下地时间存在差异,出血量、输血量、术后并发症及功能评分无差异。结论两种假体都能很好的应用于股骨颈骨折的治疗,需注意围手术期并发症的发生。     

半髋关节置换与全髋关节置换治疗股骨颈骨折的系统评价

目的 应用Cochrane系统评价的方法,评价半髋关节置换与全髋关节置换治疗股骨颈骨折的效果差异,以期为临床选择髋关节置换的方式提供依据. 方法 计算机检索MEDLINE(1975年至2007年5月)、Cochrane图书馆(2007年第2期)、EMBASE(1980至2007年)、ScienceDirect数据库(1975年至2007年5月)、LWW全文数据库(1975年至2007年5月)和中国生物医学文献数据库(CBM,1978至2007年)、中文生物医学期刊目次数据库(CMCC,1994至2007年)、中国医学学术会议论文数据库(CMAC,1994至2007年)、中国期刊全文数据库(CJFD,1994至2007年)、中文科技期刊数据库(1989至2007年).手工检索<中华创伤杂志>、<中华骨科杂志>、<中华创伤骨科杂志>、<中国矫形外科杂志>、<创伤外科杂志>和<实用骨科杂志>,均从创刊检索至2007年1月,收集半髋关节置换与全髋关节置换治疗股骨颈骨折的随机对照实验.纳入研究的方法学质量按Cohrane Reviewer's Handbook4.2.6随机对照试验的质量标准进行评价.采用Cochrane协作网提供的Review Manager 5软件进行Meta分析. 结果 纳入随机对照实验6篇,共788例患者.Meta分析显示,半髋关节置换与全髋关节置换相比,后者治疗后翻修率低(RR合并=2.27,95%CI=1.36～3.81,P=0.002),术后疼痛发生率低(RR合并=11.83,95%CI=5.11～27.39,P<0.01),但术后假体脱位发生率高(RR合并=0.59,95%CI=0.38～0.94,P=0.020).同时在不同的评分标准下,全髋置换术后髋关节功能都优于半髋置换.在术后死亡率、切口感染率方面,两者差异无统计学意义(P<0.05). 结论 半髋关节置换与全髋关节置相比,全髋置换能降低翻修率、减轻术后疼痛、提高术后髋关节功能,半髋置换能够减少假体脱位、手术时间、术中出血.但是在术后死亡率、切口感染率方面,两者差异无统计学意义(P>0.05).     

The uncemented bipolar hemiarthroplasty for displaced femoral neck fractures: 6-year follow-up of 171 cases

We report a study of 168 consecutive patients (171 prostheses) with a displaced femoral neck fracture and a physiologic age older than 75 years who were treated with an uncemented bipolar Monk hard-top hemiarthroplasty. Four prostheses dislocated postoperatively, but none after discharge. Two prostheses were later extracted. Five patients sustained an ipsilateral femoral fracture. Totally, 7 patients (4 percent) were reoperated on.

One year after the operation, 22 percent of the patients were dead. An increased mortality rate was recorded during the first 6 months after surgery. At follow-up 6 (3-9) years after the operation, 4 of the 62 patients alive had weight-bearing pain. Three had subsidence of the prosthesis, but none had protrusion of the acetabulum. Ninety-five percent of the patients were free from complications requiring a reoperation or outpatient evaluation.     

The uncemented bipolar hemiarthroplasty for displaced femoral neck fractures. 6-year follow-up of 171 cases

We report a study of 168 consecutive patients (171 prostheses) with a displaced femoral neck fracture and a physiologic age older than 75 years who were treated with an uncemented bipolar Monk hard-top hemiarthroplasty. Four prostheses dislocated postoperatively, but none after discharge. Two prostheses were later extracted. Five patients sustained an ipsilateral femoral fracture. Totally, 7 patients (4 percent) were reoperated on. One year after the operation, 22 percent of the patients were dead. An increased mortality rate was recorded during the first 6 months after surgery. At follow-up 6 (3-9) years after the operation, 4 of the 62 patients alive had weight-bearing pain. Three had subsidence of the prosthesis, but none had protrusion of the acetabulum. Ninety-five percent of the patients were free from complications requiring a reoperation or outpatient evaluation.     

骨水泥与非骨水泥微创半髋关节置换术治疗老年股骨颈骨折的疗效分析

目的回顾性比较骨水泥和非骨水泥微创半髋关节置换术(MIS-HA)治疗老年股骨颈骨折的短期临床疗效。方法自2012-01—2013-04采用前外侧入路分别行骨水泥(70例70髋,骨水泥组)和非骨水泥(70例70髋,非骨水泥组)MIS-HA治疗140例老年移位股骨颈骨折,比较2组手术时间、术中出血量、术后引流量、总失血量、输血率、并发症、髋关节功能Harris评分。结果非骨水泥组70例获得随访,平均随访23(14~28)个月;骨水泥组术中因肺栓塞死亡1例,69例获得随访,平均随访20(14~28)个月。2组术中Sp O295%者、舒张压下降≥20 mm Hg者、术后引流量、输血率比较,差异无统计学意义(P0.05);与骨水泥组相比,非骨水泥组手术时间较短、术中出血量较少、总失血量较少,差异有统计学意义(P0.05);2组在术后3、6、12个月比较髋关节功能Harris评分,差异无统计学意义(P0.05)。2组均无血管神经损伤,并发症比较差异无统计学意义(P0.05)。结论前外侧入路MIS-HA治疗老年股骨颈骨折具有创伤小、并发症少、恢复快等优点,骨水泥和非骨水泥型MIS-HA均可获得良好的临床结果。     

骨水泥型半髋置换治疗高龄股骨颈骨折的疗效分析

目的探讨骨水泥型半髋置换治疗高龄股骨颈骨折患者的临床疗效。方法回顾性分析在我院骨科接受手术治疗的21例高龄股骨颈骨折患者,平均年龄84岁。术前按Garden分型,Ⅲ型14例;Ⅳ型7例。所有患者均采用骨水泥型半髋置换治疗。结果患者手术时间平均为60 min,术后均无神经、血管损伤和假体周围骨折等并发症发生。术后随访6～24个月,平均14个月,按Harris评分标准进行功能评定:优16例,良3例,可2例,优良率90.5%。结论骨水泥型人工半髋置换手术治疗高龄股骨颈骨折创伤小;术后髋关节功能恢复良好;可早期下床活动;明显提高患者术后生活质量;临床效果满意。     

The direct anterior approach in hemiarthroplasty for displaced femoral neck fractures

Purpose

Hip replacement is the most common treatment for displaced femoral neck fractures in the elderly, and minimally invasive surgery is popular in the field of orthopaedic surgery. This study evaluated the outcome of monopolar hemiarthroplasty by the direct anterior approach over a postoperative period up to 2.5 years.

Methods

A total of 86 patients with displaced femoral neck fractures were included (mean age of 86.5 years). Surviving patients were reviewed three months (retrospectively) and one to 2.5 years (prospectively) after surgery. One-year mortality was 36 %.

Results

For all stems, implant positioning with respect to stem alignment, restoration of leg length and femoral offset was correct. Acetabular protrusion was observed in 55 % of the patients one to 2.5 years postoperatively. Subsidence and intraoperative periprosthetic fractures occurred in three patients (3 %) each. All revision stems for postoperative periprosthetic fractures could be implanted using the initial surgical technique without extension of the previous approach. The mean Harris hip score was 85 points at the one to 2.5-year follow-up; 85 % of the patients were satisfied with their hip and 57 % returned to their preoperative level of mobility.

Conclusion

Based on these findings, hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional outcome and high patient satisfaction.     

More complications with uncemented than cemented femoral stems in total hip replacement for displaced femoral neck fractures in the elderly

Background and purpose — Total hip replacement (THR) is the preferred method for the active and lucid elderly patient with a displaced femoral neck fracture (FNF). Controversy still exists regarding the use of cemented or uncemented stems in these patients. We compared the effectiveness and safety between a modern cemented, and a modern uncemented hydroxyapatite-coated femoral stem in patients 65–79 years of age who were treated with THR for displaced FNF.

Patients and methods — In a single-center, single-blinded randomized controlled trial, we included 69 patients, mean age 75 (65–79) and with a displaced FNF (Garden III–IV). 35 patients were randomized to a cemented THR and 34 to a reverse-hybrid THR with an uncemented stem. Primary endpoints were: prevalence of all hip-related complications and health-related quality of life, evaluated with EuroQol-5D (EQ-5D) index up to 2 years after surgery. Secondary outcomes included: overall mortality, general medical complications, and hip function. The patients were followed up at 3, 12, and 24 months.

Results — According to the calculation of sample size, 140 patients would be required for the primary endpoints, but the study was stopped when only half of the sample size was included (n = 69). An interim analysis at that time showed that the total number of early hip-related complications was substantially higher in the uncemented group, 9 (among them, 3 dislocations and 4 periprosthetic fractures) as compared to 1 in the cemented group. The mortality and functional outcome scores were similar in the 2 groups.

Interpretation — We do not recommend uncemented femoral stems for the treatment of elderly patients with displaced FNFs.     

Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment

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.     

Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture

Background and purpose Elderly patients with displaced femoral neck fractures are commonly treated with a hemiarthroplasty (HA), but little is known about the long-term failure of this treatment. We compared reoperation rates for patients aged at least 75 years with displaced femoral neck fractures treated with either internal fixation (IF), cemented HA, or uncemented HA (with or without hydroxyapatite coating), after 12–19 years of follow-up.

Methods 4 hospitals with clearly defined guidelines for the treatment of 75+ year-old patients with a displaced femoral neck fracture were included. Cohort 1 (1991–1993) with 180 patients had undergone IF; cohort 2 (1991–1995) with 203 patients had received an uncemented bipolar Ultima HA stem (Austin-Moore); cohort 3 (1991–1995) with 209 patients had received a cemented Charnley-Hastings HA; and cohort 4 (1991–1998) with 158 patients had received an uncemented hydroxyapatite-coated Furlong HA. Data were retrieved from patient files, from the region-based patient administrative system, and from the National Registry of Patients at the end of 2010. We performed survival analysis with adjustment for comorbidity, age, and sex.

Results Cemented HA had a reoperation rate (RR) of 5% and was used as reference in the Cox regression analysis, which showed significantly higher hazard ratios (HRs) for IF (HR = 3.8, 95% CI: 1.9–7.5; RR = 18%), uncemented HA (HR = 2.2, CI: 1.1–4.5; RR = 11%) and uncemented hydroxyapatite-coated HA (HR = 3.6, CI: 1.8–7.4; RR = 16%).

Interpretation Cemented HA has a superior long-term hip survival rate compared to IF and uncemented HA (with and without hydroxyapatite coating) in patients aged 75 years or more with displaced femoral neck fractures.     

Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures: meta-analysis of randomized trials

Background  

Most patients with displaced femoral neck fractures are treated by THA and hemiarthroplasty, but it remains uncertain which if either is associated with better function and lower risks of complications.