Session X - Geriatrics
Sun., 10/10/04 Geriatrics, Paper #56, 8:00 am
·Internal Fixation versus Hemiarthroplasty for Displaced Femoral Neck Fractures in Elderly Patients with Severe Cognitive Impairment: A Randomized Controlled Trial
Purpose: There is a growing opinion that patients with displaced femoral neck fractures would benefit from a more patient-related, rather than a strictly diagnosis-related, approach. Consequently, the treatment should be based on the patient's age, functional demands, and individual risk profile. For the relatively healthy, active, and lucid elderly patient, a number of recent randomized controlled trials have shown that a primary total hip replacement (THR) is superior to internal fixation (IF). However, for the cognitively impaired patients, the dislocation rate is unacceptably high after THR. In addition to the increased risk for prosthetic dislocations, patients with severe cognitive dysfunction bring significant challenges to the treating surgeon because of lack of compliance, inability to assimilate rehabilitation, and frequent co-morbidities. The primary aim of this study was to compare the outcome in patients with displaced femoral neck fractures randomly allocated to either IF or hemiarthroplasty (HA). The secondary aim was to describe the health-related quality of life (HRQoL) within this defined group of patients with severe cognitive impairment.
Methods: Sixty patients (54 women, 90%) with a mean age of 84 years (range, 70 to 96) with an acute displaced femoral neck fracture (Garden III and IV) after a fall were entered in the study. The inclusion criteria were age 70, diagnosed dementia or severe cognitive dysfunction or both, <3 correct answers on a 10-item mental test (Short Portable Mental Status Questionnaire, SPMSQ), and independent walking capability with or without walking aids. They were randomly allocated to treatment by either IF with cannulated screws or HA with an uncemented Austin Moore arthroplasty. Their status was reviewed at 4, 12, and 24 months after surgery. Outcome measurements included general complications, hip complications, revision surgery, activities of daily living (ADL) status, hip function according to Charnley, and health-related quality of life (HRQoL) according to EuroQol (EQ-5D) (proxy report).
Results: No patients were lost to follow-up. General complications and mortality rate did not differ between groups. The two-year mortality rate was 42%. The hip complications rate was 30% in the IF group compared with 23% in the HA group (NS). There was a trend toward an increased number of re-operated patients in the IF group compared with the HA group, 33% and 13%, respectively (P = 0.067), but the total number of surgical procedures necessary did not differ. The deterioration in ADL function between pre-fracture and final follow-up was highly significant in both groups (P <0.005) but there was no difference between groups. There was a trend toward worse walking capability in the HA group at the final follow-up (P = 0.066) with 72% bedridden or bound to a wheel chair, compared with 47% in the IF group. All patients had an extremely low HRQoL even before fracture, EQ-5D index score, 0.26. The decline in the mean EQ-5D index score comparing pre-fracture to the 24-month follow-up was 0.07 (NS) in the IF group compared with 0.20 (P <0.001) in the HA group. The EQ-5D index score was significantly better in the IF group at the final follow-up (P <0.01).
Conclusion/Significance: The mortality rate was very high and the deterioration in ADL function, walking ability, and HRQoL was pronounced in both randomization groups, reflecting the major impact of the severe cognitive dysfunction. The results imply that IF provides a better outcome than an uncemented Austin Moore HA in walking ability and HRQoL and comparable results regarding general complications and hip complications but a trend towards an increased need for revision surgery. The surprisingly high hip-complication and re-operation rate and the inferior outcome regarding walking ability and HRQoL in the HA group may partly be explained by the design and uncemented fixation of the Austin Moore HA. In our opinion, there does not seem to be any obvious advantage to perform an uncemented Austin Moore HA compared with IF in patients with severe cognitive dysfunction.