Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Joseph D. Zuckerman, MD*,
New York University-Hospital for Joint Diseases, New York, NY
Among the recurring discussions that take place in case conferences that most of us attend (e.g., whether to use a posterior stabilized or cruciate-retaining knee replacement; bone-patella-bone or hamstring for reconstruction of the anterior cruciate ligament; or lumbar laminectomy versus laminectomy and fusion for stenosis) perhaps the most common topic is the treatment of displaced femoral neck fractures—to fix or replace, and if to replace, whether to use hemiarthroplasty or total hip replacement. And while each one of us may strongly favor one approach over another, there is a relative paucity of quality data available to support one position over another. The article by Keating et al. provides important information that may serve to shorten some of these conference discussions. Their results indicate that in a relatively healthy group of patients who were sixty years of age or older, the outcome of total hip replacement was significantly better than either reduction and fixation or hemiarthroplasty.
The authors are to be congratulated on their efforts. They utilized a multicenter, randomized comparison of reduction and fixation, bipolar and hemiarthroplasty, and total hip arthroplasty and used outcome criteria that included reoperations, hip scores, quality-of-life measures, and total costs. Although this was not a true randomized control trial (Level-1 evidence) the randomization protocol was a realistic one in that it provided surgeons with the option to include their patients if they believed that a specific treatment option was either indicated or contraindicated for the specific patient involved. As a result, the study provides us with Level-2 evidence but the conclusions remain strong nonetheless.
The strengths of this study are in its randomized design, completeness of the data collection, inclusion of clinical and functional outcomes, and the longitudinal economic analysis to reflect total costs. The patients were generally healthy, cognitively intact, and mobile prior to fracture. Although no age criteria were utilized, all patients were at least sixty years of age, with an average age of seventy-five years. This study treated healthy older patients, and, as such, the conclusions apply primarily to this group. The implications for other types of patients who sustain displaced femoral neck fractures are not completely known. However, the focus on this healthy older group of patients is appropriate based on life expectancy and anticipated functional needs.
Weaknesses of the study also include the study design. The treating surgeons were provided with substantial latitude with respect to determining eligibility. If the trial treatment options were judged unsuitable by the recruiting surgeon, the patient was not eligible for the trial. As a result, only 13% of patients with displaced femoral neck fractures were determined to be eligible for the study. Although 58% of those deemed ineligible were ineligible on the basis of poor cognitive function or poor mobility, 29% were deemed ineligible by the orthopaedic surgeon on the basis of assessment of clinical factors. Another 13% were deemed ineligible because of age (either too old or too young) which also, in part, reflects the view of the treating orthopaedist. Although the latitude provided to the treating clinicians did negatively impact the study design, I do not believe it adversely influenced the findings and conclusions of the authors. Another area of concern includes the potential impact of total hip arthroplasty being performed by more "senior surgeons" while other procedures were less likely to have a senior surgeon involved. The impact on the prevalence of complications is difficult to assess but should be considered.
In conferences, when I am asked about my approach to displaced femoral neck fractures, my response has generally been to proceed with reduction and fixation in "younger, more active" elderly patients and to make use of unipolar hemiarthroplasty for the "older," lower-demand patients. This study as well as others1,2 that have been reported have definitely caused me to reconsider my approach. I find myself much more comfortable with the use of primary total hip arthroplasty for the management of older patients with displaced femoral neck fractures. Although we do not have the definitive answers as yet, the study by Keating et al. will certainly provide us with a more evidence-driven discussion.
*The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
References
1. Roden M, Schon M, Fredin H. Treatment of displaced femoral neck fractures: a randomized minimum 5-year follow-up study of screws and bipolar hemiprotheses in 100 patients. Acta Orthop Scand. 2003;74:42-4.
2. Parker MJ, Khan RJ, Crawford J, Pryor GA. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. J Bone Joint Surg Br. 2002; 84:1150-5.
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