The Journal of Bone and Joint Surgery (American). 2006;88:249-260.
doi:10.2106/JBJS.E.00215
© 2006 The Journal of Bone and Joint Surgery, Inc.
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Randomized Comparison of Reduction and Fixation, Bipolar Hemiarthroplasty, and Total Hip Arthroplasty

Treatment of Displaced Intracapsular Hip Fractures in Healthy Older Patients

J.F. Keating, FRCSEd(Orth)1, A. Grant, DM2, M. Masson, MSc3, N.W. Scott, MSc4, J.F. Forbes, PhD5 on behalf of the Scottish Orthopaedic Trials Network

1 Department of Orthopaedic Trauma, Royal Infirmary, Little France, Old Dalkeith Road, Edinburgh EH16 4SU, Scotland. E-mail address: john.keating{at}ed.ac.uk
2 Health Services Research Unit, University of Aberdeen, Aberdeen AB25 2ZD, Scotland
3 Royal Infirmary of Edinburgh, Edinburgh EH16 4SU, Scotland
4 Department of Public Health, University of Aberdeen, Aberdeen AB25 2ZD, Scotland
5 School of Clinical Sciences and Community Health, University of Edinburgh, Teviot Place, Edinburgh EH9 9AG, Scotland

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

In support of their research for or preparation of this manuscript, the authors received a grant from the National Health Service R&D Health Technology Assessment Programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Executive Health Department. None of the authors received 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 authors are affiliated or associated.

NOTE: The authors acknowledge the participation of surgeons in the following orthopaedic units: Aberdeen Royal Infirmary, Dumfries and Galloway Royal Infirmary, Edinburgh Royal Infirmary, Falkirk Royal Infirmary, Glasgow Royal Infirmary, Western Infirmary Glasgow, Law Hospital Lanarkshire, Ninewells Hospital Dundee, Perth Royal Infirmary, Queen Margaret Hospital Dunfermline, and Royal Alexandra Hospital Paisley.

Background: Orthopaedic surgeons vary in their management of displaced intracapsular fractures of the hip in healthy older patients. The aim of this investigation was to determine the functional, clinical, and resource consequences of three different types of surgical treatment.

Methods: The study was a multicenter randomized controlled trial. Reduction and fixation was compared with bipolar hemiarthroplasty with cement and total hip replacement with cement. Participating surgeons elected to randomize their patients to be treated with either one of the three types of procedures or with either fixation or bipolar hemiarthroplasty. Functional outcomes were measured with a hip-rating questionnaire and the EuroQol health status measure. Clinical outcomes included mortality and complications. The direct health service costs were compared. Participants were followed up for two years.

Results: Two hundred and seven patients were randomized to be treated with one of the three operations, and ninety-one were randomized to be treated with either fixation or bipolar hemiarthroplasty. There were no differences in the mortality rates among the treatment groups. The rate of secondary surgery was highest in the fixation group (39% compared with 5% in the group treated with bipolar hemiarthroplasty and 9% in the group treated with total hip replacement). The fixation group had the worst hip-rating-questionnaire and EuroQol scores at four and twelve months. The total hip replacement group had significantly better functional outcome scores at twenty-four months than the other two groups. Although fixation was initially the least costly procedure, this short-term advantage was eroded by significantly higher costs for subsequent hip-related hospital admissions.

Conclusions: Arthroplasty is more clinically effective and cost-effective than reduction and fixation in healthy older patients with a displaced intracapsular fracture of the hip. The long-term results of total hip replacement may be better than those of bipolar hemiarthroplasty.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.


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