Session VI - Geriatrics

Randomized Trial of Reduction and Fixation versus Bipolar Hemiarthroplasty versus Total Hip Arthroplasty for Displaced Subcapital Fractures in the Fit Older Patient

John F. Keating, FRCSEd (Orth); Moyra A. Masson, RGN; John F. Forbes, PhD; Neil W. Scott, PhD; Adrian Grant, PhD; Multicentre trial coordinated by Edinburgh Royal Infirmary, Edinburgh, United Kingdom

Purpose: We hoped to determine the optimum surgical treatment for displaced subcapital fractures in fit patients over 60 years of age.

Methods: A prospective randomized multicenter trial was carried out to compare reduction and fixation with cemented bipolar hemiarthroplasty and total hip replacement (THR) for displaced subcapital fractures in fit patients over 60 years of age. Forty-six surgeons in 11 centers participated. Thirty-two surgeons were randomized to all three groups. Fourteen surgeons were randomized to fixation or bipolar hemiarthroplasty only, for reasons of preference. A total of 298 patients were randomized, 64 men (22%) and 234 women (78%) with a mean age of 75 years (range, 60 to 93). There were 118 patients randomized to internal fixation, 111 patients to bipolar arthroplasty, and 69 patients to the THR group.

Outcome measures included clinical complications, a hip rating questionnaire (HRQ, Johansson et al), and a validated general disability questionnaire (EQ-5D). Follow-up data were collected at 4, 12, and 24 months. Excluding deaths and withdrawals, complete outcome data were available for 96.5% patients at 4 months, 94.5% at 12 months, and 92% at the 24-month follow-up points.

Results: After two years, there were 18 (15%) deaths among the reduction and fixation group, 18 (16%) among the hemiarthroplasty group, and 6 (8%) among the THR group. These differences were not significant. Fixation failure due to nonunion or avascular necrosis occurred in 44 patients (37%). One of these patients died before planned surgery, and 43 had further surgery. Forty-one were revised to an arthroplasty (13 THR, 23 bipolar, 5 unipolar). Of eight patients with wound infections, four had deep infections, and one ultimately had an excision arthroplasty. Two patients had metalwork removal. In the bipolar arthroplasty group there were four (3.6%) wound infections and three (2.7%) dislocations. Six patients (5%) underwent further surgery (three for dislocation, one excision arthroplasty for infection, one for a periprosthetic fracture, and one for drainage of a wound hematoma). Of the 69 patients in the THR group, 3 (4%) had infection, and 2 (3%) had at least one dislocation. Five (7.2%) patients had further surgery, (two for dislocation, two for infection, and one for wound dehiscence). Analysis of data by logistic regression demonstrated that patients with fixation were eight times more likely to require revision surgery than were those that had bipolar hemiarthroplasty and five times more likely than those that had THR. Functional outcome measured by HRQ and EQ-5D was best for the THR group (see Table 1). In terms of bed days occupied, reduction and fixation was the most expensive treatment due to the high requirement for revision surgery.

Discussion: The optimal management of displaced subcapital fractures in fit older patients continues to be a matter of debate among orthopaedic surgeons. Reduction and fixation, hemiarthroplasty, or total hip arthroplasty are all used with considerable variation between different orthopaedic surgeons and centers. No treatment is without drawbacks, and this is the first randomized trial to specifically evaluate these treatments in this group of patients. Arthroplasty (either bipolar or total) had a much lower requirement for revision surgery in this study with a superior functional outcome being noted in the THR group.

Conclusion: Arthroplasty (bipolar or total) is associated with a much lower surgical complication rate than reduction and fixation for displaced subcapital fractures in fit patients. Total hip replacement is associated with the best functional outcome.

Table. Mean score results of hip rating questionnaire and disability questionnaire at 24 months. The highest hip rating score is 100 and the highest EQ-5D score is 1. Functional outcome was significantly better with THR.

	Fixation	Hemiarthroplasty	Total hip arthroplasty
Hip rating scale	73	76	80
EQ-5D utility score	0.53	0.53	0.69