Total Hip Replacement for Displaced Subcapital Hip Fractures

Richard W. McCalden, M.D., MPhil(Edin), FRCSC
Assistant Professor of Orthopaedic Surgery
University of Western Ontario
London Health Science Centre
London, ON

The treatment of displaced subcapital hip fractures is becoming increasingly common and has an enormous impact on our health care system. In North America, these fractures are treated by either some form of internal fixation (IF) or various forms of hemiarthroplasty (HA). There is considerable evidence demonstrating better functional outcome and less need for reoperation with HA compared to IF in the treatment of displaced subcapital hip fractures in the elderly1,2.

What is the role of total hip replacement (THR) in the treatment of displaced subcapital hip fractures? The potential advantage of using THR relates to its highly predictable results, with survivorship of greater than 90% at 10 years, and its unparalleled results in terms of pain relief and overall function. In addition, the use of THR avoids the potential need for revision secondary to acetabular pain from ongoing acetabular erosion. The potential disadvantages of THR include the increased cost, increased surgical time and blood loss (which may lead to increased morbidity or mortality) and the potential increased rate of dislocation compared to HA.

Several studies from Scandinavia, where THR is commonly used to treat hip fractures, have reported on a series of patients with displaced subcapital hip fractures who were randomized to receive either IF or some form of arthroplasty (HA or THR)3-6. In every series, the overall reoperation rate was significantly less and general function was considerably better in those patients receiving a THR. The rate of dislocation ranged from 2% to 22% and was linked to both the surgical approach and the mental status of the patient.

When is THR indicated rather than HA in the treatment of a displaced subcapital hip fracture? It is relatively clear that a patient with antecedent symptomatic osteoarthritis or inflammatory arthritis of their hip, who subsequently suffers a displaced subcapital hip fracture, would benefit most from a THR compared to a HA (Figures 1 & 2). In addition, a patient who suffers a pathological femoral neck fracture with concomitant acetabular pathology should have a THR performed. What remains unclear is whether certain hip fracture patients, with no pre-existing hip pathology, would benefit from THR rather than HA. Rogmark et al.4 have suggested that patients between the ages of 70 to 80, who live in their own home, who do not require any walking aids and are alert mentally represent the ideal candidates for THR. In contrast, those patients who are greater than 80 years of age, who live in a nursing home, who have required ambulatory assists and are mentally confused are best treated with HA. While this concept holds some merit, there is no truly randomized controlled trial to support this strategy.

In summary, it is clear that most elderly patients who suffer a displaced subcapital hip fracture would be best treated with some form of arthroplasty rather than IF. Currently in North America, a well cemented HA using either a unipolar or bipolar articulation represents the standard of care7. At present, it would appear that the only absolute indication for THR would be a patient with antecedent symptomatic hip arthritis or a pathological hip fracture. A randomized control trial comparing THR to HA in the high-demand elderly patient is required to further define the role and demonstrate clearly the benefits of THR.

References

  1. 1. Bhandari M., Devereaux P.J., Swiontkowski M.F., Tornetta P. 3rd, Obremskey W., Koval K.J., Nork S., Sprague S., Schemitsch E.H., Guyatt G.H. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am. 2003 Sep;85-A(9):1673-81.
  2. Roden M., Schon M., Fredin H. Treatment of displaced femoral neck fractures: a randomized minimum 5-year follow-up study of screws and bipolar hemiprostheses in 100 patients. Acta Orthop Scand. 2003 Feb;74(1):42-4.
  3. Tidermark J., Ponzer S., Svensson O., Soderqvist A., Tornkvist H. Internal fixation compared with total hip replacement for displaced femoral neck fracture in the elder: A randomised controlled trial. J Bone Joint Surg (Br) 2003; 85-B: number 3, April 2003, pg. 380-8.
  4. Rogmark C., Carlsson A., Johnell O., Sernbo I. A prospective randomised trial of internal fixation versus arthroplasty for displaced fracture of the neck of the femur: Functional outcome for 450 patients at two years. J Bone Joint Surg (Br) 2002; 84-B: 183-8.
  5. Ravikumar K.J., Marsh G. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of the femur: 13-year results of a prospective randomized study. Injury 2000; 31:793-7.
  6. Johansson T., Jacobsson S.A., Ivarsson I., Knutsson A., Wahlstrom O. Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips. Acta Orthop Scand. 2000 Dec;71(6):597-602.
  7. 7. Haidukewych G.J., Israel T.A., Berry D.J. Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop. 2002 Oct;(403):118-26.


Legend

mccalden figure 1
Figure 1: AP radiograph of 69-year-old man with antecedent OA of hip who fell and suffered displaced femoral neck fracture.
mccalden figure 2
Figure 2: Post-operative AP radiograph demonstrating reconstruction with cementless THR.

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