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Meta-Analysis
. 2010 Jun 16;2010(6):CD001706.
doi: 10.1002/14651858.CD001706.pub4.

Arthroplasties (with and without bone cement) for proximal femoral fractures in adults

Martyn J Parker  1 , Kurinchi Selvan Gurusamy, Shin Azegami
Affiliations
Meta-Analysis

Arthroplasties (with and without bone cement) for proximal femoral fractures in adults

Martyn J Parker et al. Cochrane Database Syst Rev. .

Abstract

Background: Numerous types of arthroplasties may be used in the surgical treatment of a hip fracture (proximal femoral fracture). The main differences between the implants are in the design of the stems, whether the stem is cemented or uncemented, whether a second articulating joint is included within the prosthesis (bipolar prosthesis), or whether a partial (hemiarthroplasty) or total whole hip replacement is used.

Objectives: To review all randomised controlled trials comparing different arthroplasties for the treatment of hip fractures in adults.

Search strategy: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2009), CENTRAL (The Cochrane Library 2009, Issue 3), MEDLINE, EMBASE and trial registers (all to September 2009), and reference lists of articles.

Selection criteria: All randomised and quasi-randomised controlled trials comparing different arthroplasties and their insertion with or without cement, for the treatment of hip fractures.

Data collection and analysis: Two review authors independently assessed trial quality, by use of a 10-item checklist, and extracted data.

Main results: Twenty-three trials involving 2861 older and mainly female patients with proximal femoral fractures are included. Cemented prostheses, when compared with uncemented prostheses (6 trials, 899 participants) were associated with a less pain at a year or later and improved mobility. No significant difference in surgical complications was found. One trial of 220 participants compared a hydroxyapatite coated hemiarthroplasty with a cemented prosthesis and reported no notable differences between the two prosthesis. Comparison of unipolar hemiarthroplasty with bipolar hemiarthroplasty (7 trials, 857 participants, 863 fractures) showed no significant differences between the two types of implant. Seven trials involving 734 participants compared hemiarthroplasty with a total hip replacement (THR). Most studies involved cemented implants. Dislocation of the prosthesis was more common with the THR but there was a general trend within these studies to better functional outcome scores for those treated with the THR.

Authors' conclusions: There is good evidence that cementing the prostheses in place will reduce post-operative pain and lead to better mobility. From the trials to date there is no evidence of any difference in outcome between bipolar and unipolar prosthesis. There is some evidence that a total hip replacement leads to better functional outcome than a hemiarthroplasty. Further well-conducted randomised trials are required.

PubMed Disclaimer

Conflict of interest statement

The lead review author, Dr Martyn Parker, is the principal investigator of one of the trials included in this review (Parker 2009). Data for this review and its assessment was undertaken by the other two authors for this review. In addition Martyn Parker has received payment and reimbursement from a number of commercial companies for attending meetings to give lectures or advising on different aspects of hip fracture treatment. Martyn Parker has also received royalties for the design and development of an implant for the internal fixation of intracapsular hip fractures from the company BBraun.

Figures

1.1
1.1. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 1 Length of surgery (minutes).
1.2
1.2. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 2 Operative fracture of the femur.
1.3
1.3. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 3 Operative blood loss (ml).
1.4
1.4. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 4 Mean units blood transfused.
1.5
1.5. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 5 Number of patients transfused.
1.6
1.6. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 6 Peri‐operative death.
1.7
1.7. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 7 Later fracture of the femur.
1.8
1.8. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 8 Dislocation.
1.9
1.9. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 9 Superficial wound infection.
1.10
1.10. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 10 Deep sepsis.
1.11
1.11. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 11 Wound haematoma.
1.12
1.12. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 12 Reoperations: minor.
1.13
1.13. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 13 Reoperations: major.
1.14
1.14. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 14 Reoperations: any.
1.15
1.15. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 15 Medical complications.
1.16
1.16. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 16 All reported medical complications.
1.17
1.17. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 17 Length of hospital stay (days).
1.18
1.18. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 18 Mortality before 1 month.
1.19
1.19. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 19 Mortality at 1 to 3 months.
1.20
1.20. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 20 Mortality at 1 year.
1.21
1.21. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 21 Mortality at 3 years.
1.22
1.22. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 22 Failure to regain mobility.
1.23
1.23. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 23 Change in mobility score at 6 months (from pre‐injury).
1.24
1.24. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 24 Pain at early follow up (3 months).
1.25
1.25. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 25 Pain at 1 to 2 years.
1.26
1.26. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 26 Pain score at 6 months (0 to 10: worst).
1.27
1.27. Analysis
Comparison 1 Cemented hemiarthroplasty versus uncemented hemiarthroplasty, Outcome 27 Failure to return home.
2.1
2.1. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 1 Length of surgery (minutes).
2.2
2.2. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 2 Operative blood loss (ml).
2.3
2.3. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 3 Total blood loss (ml).
2.4
2.4. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 4 Number of patients transfused.
2.5
2.5. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 5 Operative fracture of femur.
2.6
2.6. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 6 Later fracture of the femur.
2.7
2.7. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 7 Dislocation.
2.8
2.8. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 8 Superficial wound sepsis.
2.9
2.9. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 9 Deep wound sepsis.
2.10
2.10. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 10 Any wound infection.
2.11
2.11. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 11 Reoperations: minor.
2.12
2.12. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 12 Reoperations: major.
2.13
2.13. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 13 Reoperations: any.
2.14
2.14. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 14 Medical complications.
2.15
2.15. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 15 Length of hospital stay (days).
2.16
2.16. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 16 Mortality.
2.17
2.17. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 17 Residual pain.
2.18
2.18. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 18 Need to use walking aids.
2.19
2.19. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 19 Failure to return back home at 1 year.
2.20
2.20. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 20 Failure to be able to shop at 1 year.
2.21
2.21. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 21 Barthel index.
2.22
2.22. Analysis
Comparison 2 Hemiarthroplasty versus hydroxyapatite coated hemiarthroplasty, Outcome 22 Harris and ED‐5D outcome scores.
3.1
3.1. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 1 Dislocation.
3.2
3.2. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 2 Dislocation requiring open reduction.
3.3
3.3. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 3 Acetabular erosion on X‐rays.
3.4
3.4. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 4 Acetabular erosion requiring revision arthroplasty.
3.5
3.5. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 5 Deep sepsis.
3.6
3.6. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 6 Reoperations: minor.
3.7
3.7. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 7 Reoperations: major.
3.8
3.8. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 8 Reoperations: any.
3.9
3.9. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 9 Deep vein thrombosis.
3.10
3.10. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 10 Mortality at 6 months.
3.11
3.11. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 11 Mortality at 1 to 2 years.
3.12
3.12. Analysis
Comparison 3 Unipolar hemiarthroplasty versus bipolar hemiarthroplasty, Outcome 12 Failure to regain mobility.
4.1
4.1. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 1 Length of surgery (minutes).
4.2
4.2. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 2 Total blood loss (ml).
4.3
4.3. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 3 Mean volume blood transfused (ml).
4.4
4.4. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 4 Dislocation.
4.5
4.5. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 5 Fracture around implant at surgery.
4.6
4.6. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 6 Later fracture around implant.
4.7
4.7. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 7 Superficial wound infection.
4.8
4.8. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 8 Deep wound infection.
4.9
4.9. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 9 Any wound infection.
4.10
4.10. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 10 Reoperations: minor.
4.11
4.11. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 11 Reoperations: major.
4.12
4.12. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 12 Reoperations: any.
4.13
4.13. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 13 Medical complications.
4.14
4.14. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 14 Hospital stay (days).
4.15
4.15. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 15 Mortality.
4.16
4.16. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 16 Residual pain at 1 year.
4.17
4.17. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 17 Failure to regain mobility.
4.18
4.18. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 18 Poor comorbidity index.
4.19
4.19. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 19 Final outcomes for survivors (continuous outcomes for which a lower score is advantageous).
4.20
4.20. Analysis
Comparison 4 Hemiarthroplasty versus total hip replacement (THR), Outcome 20 Final outcomes for survivors (continuous outcomes for which a higher score is advantageous).
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

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Calder 1996 {published data only}
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Davison 2001 {published data only}
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    1. Calder SJ, Anderson GH, Harper WM, Gregg PJ. The place of bipolar hemiarthroplasty in displaced intracapsular hip fracture [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1995;77(Suppl I):6.
    1. Calder SJ, Anderson GH, Harper WM, Gregg PJ. The use of bipolar hemi‐arthroplasty in intracapsular hip fracture ‐ a prospective randomised trial [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1995;77‐B(Suppl I):103.
    1. Calder SJ, Anderson GH, Harper WM, Gregg PJ. The use of the Nottingham Health Profile in a randomised trial of treatment of displaced intracapsular hip fractures [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1994;76(Suppl II & III):150.
    1. Calder SJ, Anderson GH, Harper WM, Jagger C, Gregg PJ. A subjective health indicator for follow‐up: A randomised trial after treatment of displaced intracapsular hip fractures. Journal of Bone and Joint Surgery ‐ British Volume 1995;77(3):494‐6. - PubMed
Dorr 1986 {published data only}
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Emery 1991 {published data only}
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Figved 2009 {published data only}
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Harper 1994 {published data only}
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Livesley 1993 {published data only}
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Macaulay 2008 {published data only}
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Malhotra 1995 {published data only}
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Mouzopoulos 2008 {published data only}
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Parker 2009 {published and unpublished data}
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Raia 2003 {published data only}
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Rosen 1992 {published data only}
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Santini 2005 {published data only}
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Skinner 1989 {published data only}
    1. Ravikumar KJ, Marsh G, Jairaj P. Internal fixation vs hemiarthroplasty vs total hip replacement for displaced subcapital fractures of the femur ‐ 13 year results of a prospective randomised study [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1998;80(Suppl 1):50‐1.
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Sonne‐Holm 1982 {published data only}
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    1. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Displaced intracapsular hip fractures in fit, older people: a randomised comparison of reduction and fixation, bipolar hemiarthroplasty and total hip arthroplasty. Health Technology Assessment 2005; Vol. 9, issue 41:iii‐iv, ix‐x, 1‐65. Available from http://www.ncchta.org/execsumm/summ941.htm. [MEDLINE: ] - PubMed
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References to studies excluded from this review

Christie 1994 {published data only}
    1. Christie J, Burnett R, Potts HR, Pell AC. Echocardiography of transatrial embolism during cemented and uncemented hemiarthroplasty of the hip. Journal of Bone and Joint Surgery ‐ British Volume 1994;76(3):409‐12. [MEDLINE: ] - PubMed
Clark 2001 {published data only}
    1. Clark DI, Ahmed AB, Baxendale BR, Moran CG. Cardiac output during hemiarthroplasty of the hip. A prospective, controlled trial of cemented and uncemented prostheses. Journal of Bone and Joint Surgery ‐ British Volume 2001;83(3):414‐8. [MEDLINE: ] - PubMed
Faraj 1999 {published data only}
    1. Faraj AA, Branfoot T. Cemented versus uncemented Thompson's prostheses: a functional outcome study. Injury 1999;30(10):671‐5. [EMBASE: 1999401247] - PubMed
Field 2005 {published data only}
    1. Field RE, Rushton N. Five‐year clinical, radiological and post‐mortem results of the Cambridge Cup in patients with displaced fractures of the neck of the femur. Journal of Bone and Joint Surgery ‐ British Volume 2005;87‐B(10):1344‐51. [EMBASE: 2005481155] - PubMed
Georgescu 2004 {published data only}
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Gierer 2002 {published data only}
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Graf 2000 {published data only}
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Johnson 2001 {published data only}
    1. Johnson MM, Thompson B, Hartford JM. Complications of cemented versus noncemented hemiarthroplasty for femoral neck fractures [abstract]. Mid‐America Orthopaedic Association 19th annual meeting; 2001 April 18‐22; Amelia Island (FL). http://www.jbjs.org/abstracts/maoa01/abs_001.htm (accessed 24/11/03).
Karpman 1992 {published data only}
    1. Karpman RR, Lee TJ, Moore BM. Austin‐Moore versus bipolar hemiarthroplasty for displaced femoral neck fractures: a randomized prospective study [abstract]. Annual Meeting of the American Academy of Orthopaedic Surgeons; 1992 Feb 20‐25; Orlando (FL). http://www.aaos.org/wordhtml/anmeet92/scipro/ppr418.htm (accessed 23 February 2001).
    1. Karpman RR, Lee TK, Moore BM. Austin‐Moore versus bipolar hemi‐arthroplasty for displaced femoral neck fractures: a randomized prospective study [abstract]. Orthopaedic Transactions 1992;16:749‐50.
Leidinger 2002 {published data only}
    1. Leidinger W, Hoffmann G, Meierhofer JN, Wolfel R. Reduction of severe cardiac complications during implantation of cemented total hip endoprostheses in femoral neck fractures [Verminderung von schweren kardialen Komplikationen wahrend der Implantation von zementierten Hufttotalendoprothesen bei Oberschenkelhalsfrakturen]. Unfallchirurg 2002;105(8):675‐9. - PubMed
Pitto 2000 {published data only}
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Sadr 1977 {published data only}
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References to ongoing studies

Bonke 1999 {published data only}
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Kavcic 2006 {published data only}
    1. Kavcic G, Hudoklin P, Mikek M, Hussein M. Hemiarthroplasty versus total arthroplasty for treatment of femoral neck fractures. European Journal of Trauma 2006;32(Supplement I):24.
Moroni 2002 {published data only}
    1. Moroni A, Pegreffi F, Romagnoli M, Giannini S. Cemented vs uncemented fixation of femoral neck fractures in osteoporotic patients. A prospective randomized study [abstract]. Hip International 2002;12(2):245‐6.
    1. Moroni A, Pegreffi F, Romagnoli M, Hoang‐Kim A, Tesei F, Giannini S. Results in osteoporotic femoral neck fractures treated with cemented vs uncemented hip arthroplasty. Journal of Bone and Joint Surgery. British Volume 2009;91‐B(Suppl I):167.
Patel 2008 {published data only}
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Taylor {published data only}
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Additional references

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Moore 1952
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Ravikumar 1998
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Thompson 1954
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References to other published versions of this review

Parker 2001
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Parker 2004
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Parker 2006
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