We read this editorial and the linked systematic review with
interest, but are concerned about the inferences drawn. Hemiarthoplasty
prostheses have evolved from uncemented monoblocks, such as the Austin
Moore prosthesis, to modern cemented monoblocks and bipolar components.
The attempt to group hemiarthroplasty outcomes has given rise to
misleading conclusions.
We have reconsidered the outcomes from this review, by focusing on
the papers that specify the uncemented and cemented component fixation.
The uncemented outcomes have significantly skewed the overall results:
• Austin Moore hemiarthroplasty(1); 13% dislocations, 25% reoperation
and 3% deep infection. General complications are not recorded.
• Cemented hemiarthroplasty(2,3,4,5,6,7) : 2% dislocations, 7%
reoperation, 2% deep infection and 30% general complications.
• Total Hip replacement: 6% dislocations, 5% reoperation, 2% deep
infection and 33% general complications.
The review describes a statistically significant but clinically
unimportant difference in Harris Hip score of 5.4, which should be put in
context; the difference between an occasional ache and a mild pain not
affecting average activity alone carries a Harris score difference of 10.
Although the first author’s affiliations have been declared, it
should be borne in mind that any widespread change of practice towards the
use of more expensive total hip arthroplasties will generate significant
benefits for companies such as Depuy; indeed given our calculations they
will be the only beneficiary.
Cemented hemiarthroplasties have a similar outcome to total hip
arthroplasty for intracapsular neck of femur fractures, and offer
considerable health economic benefits.
The sub-heading of the editorial was misleading, and indeed much
stronger than Madsen’s conclusion. We would go further; total hip
arthroplasty for fractured neck of femur should be reserved for defined
indications such as co-existent rheumatoid arthritis. Hemiarthroplasty
should remain the standard procedure.
References:
1 Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus
total hip arthroplasty for displaced subcapital fractures of femur—13 year
results of a prospective randomised study. Injury 2000;31:793-7.
2 Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized
comparison of reduction and fixation, bipolar hemiarthroplasty, and total
hip arthroplasty. Treatment of displaced intracapsular hip fractures in
healthy older patients. J Bone Joint Surg Am 2006;88:249-60.
3 Baker RP, Squires B, GarganMF, Bannister GC. Total hip arthroplasty
and hemiarthroplasty in mobile, independent patients with a displaced
intracapsular fracture of the femoral neck: a randomized, controlled
trial. J Bone Joint Surg Am 2006;88:2583-9.
4 Blomfeldt R, Tornkvist H, Eriksson K, Soderqvist A, Ponzer S,
Tidermark J. A randomised controlled trial comparing bipolar
hemiarthroplasty with total hip replacement for displaced intracapsular
fractures of the femoral neck in elderly patients. J Bone Joint Surg Br
2007;89:160-5.
5 Eyssel M, Schwenk W, Badke A, Krebs S, Stock W. [Total
endoprosthesis or dual head prosthesis in endoprosthetic management of
femoral neck fractures?] Unfallchirurg 1994;97:347-52.
6 Healy WL, Iorio R. Total hip arthroplasty: optimal treatment for
displaced femoral neck fractures in elderly patients. ClinOrthop Relat Res
2004;43-8.
7 Xu X, Liu Y, Liu J, Li Y. Prosthetic replacement in treatment of
subcapital femoral neck fractures in the elderly. Chin J Traumatol
2002;5:28-31.
Rapid Response:
Misleading conclusions from systematic analysis?
We read this editorial and the linked systematic review with
interest, but are concerned about the inferences drawn. Hemiarthoplasty
prostheses have evolved from uncemented monoblocks, such as the Austin
Moore prosthesis, to modern cemented monoblocks and bipolar components.
The attempt to group hemiarthroplasty outcomes has given rise to
misleading conclusions.
We have reconsidered the outcomes from this review, by focusing on
the papers that specify the uncemented and cemented component fixation.
The uncemented outcomes have significantly skewed the overall results:
• Austin Moore hemiarthroplasty(1); 13% dislocations, 25% reoperation
and 3% deep infection. General complications are not recorded.
• Cemented hemiarthroplasty(2,3,4,5,6,7) : 2% dislocations, 7%
reoperation, 2% deep infection and 30% general complications.
• Total Hip replacement: 6% dislocations, 5% reoperation, 2% deep
infection and 33% general complications.
The review describes a statistically significant but clinically
unimportant difference in Harris Hip score of 5.4, which should be put in
context; the difference between an occasional ache and a mild pain not
affecting average activity alone carries a Harris score difference of 10.
Although the first author’s affiliations have been declared, it
should be borne in mind that any widespread change of practice towards the
use of more expensive total hip arthroplasties will generate significant
benefits for companies such as Depuy; indeed given our calculations they
will be the only beneficiary.
Cemented hemiarthroplasties have a similar outcome to total hip
arthroplasty for intracapsular neck of femur fractures, and offer
considerable health economic benefits.
The sub-heading of the editorial was misleading, and indeed much
stronger than Madsen’s conclusion. We would go further; total hip
arthroplasty for fractured neck of femur should be reserved for defined
indications such as co-existent rheumatoid arthritis. Hemiarthroplasty
should remain the standard procedure.
References:
1 Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus
total hip arthroplasty for displaced subcapital fractures of femur—13 year
results of a prospective randomised study. Injury 2000;31:793-7.
2 Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized
comparison of reduction and fixation, bipolar hemiarthroplasty, and total
hip arthroplasty. Treatment of displaced intracapsular hip fractures in
healthy older patients. J Bone Joint Surg Am 2006;88:249-60.
3 Baker RP, Squires B, GarganMF, Bannister GC. Total hip arthroplasty
and hemiarthroplasty in mobile, independent patients with a displaced
intracapsular fracture of the femoral neck: a randomized, controlled
trial. J Bone Joint Surg Am 2006;88:2583-9.
4 Blomfeldt R, Tornkvist H, Eriksson K, Soderqvist A, Ponzer S,
Tidermark J. A randomised controlled trial comparing bipolar
hemiarthroplasty with total hip replacement for displaced intracapsular
fractures of the femoral neck in elderly patients. J Bone Joint Surg Br
2007;89:160-5.
5 Eyssel M, Schwenk W, Badke A, Krebs S, Stock W. [Total
endoprosthesis or dual head prosthesis in endoprosthetic management of
femoral neck fractures?] Unfallchirurg 1994;97:347-52.
6 Healy WL, Iorio R. Total hip arthroplasty: optimal treatment for
displaced femoral neck fractures in elderly patients. ClinOrthop Relat Res
2004;43-8.
7 Xu X, Liu Y, Liu J, Li Y. Prosthetic replacement in treatment of
subcapital femoral neck fractures in the elderly. Chin J Traumatol
2002;5:28-31.
Competing interests:
None declared
Competing interests: No competing interests