Arthroplasties (with and without bone cement) for proximal femoral fractures in adults
Abstract
Background
Numerous types of arthroplasties may be used in the surgical treatment of a hip fracture (proximal femoral fracture). The main differences between the implants are in the design of the stems, whether the stem is fixed in place with or without cement, whether a second articulating joint is included within the prosthesis (bipolar prosthesis) or whether a partial (hemiarthroplasty) or total whole hip replacement is used.
Objectives
To review all randomised controlled trials that have compared different arthroplasties for the treatment of hip fractures in adults.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register (February 2007), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles.
Selection criteria
All randomised and quasi‐randomised controlled trials comparing different arthroplasties and their insertion with or without cement, for the treatment of hip fractures.
Data collection and analysis
Two review authors independently assessed trial quality, by use of a 10‐item checklist, and extracted data.
Main results
Nineteen trials involving 2115 patients were included. One trial involved three comparisons. Cemented prostheses, when compared with uncemented (six trials, 549 participants) were associated with a less pain at a year or later (16/52 versus 28/52; RR 0.51, 95% CI 0.31 to 0.81) and a tendency to better mobility. No significant difference in surgical complications was found. Comparison of unipolar hemiarthroplasty with bipolar hemiarthroplasty (seven trials, 857 participants) showed no significant differences between the two types of implant. Two trials involving 232 patients compared uncemented hemiarthroplasty with a total hip replacement. Both studies reported increased pain for the uncemented prosthesis and one study found better mobility and a lower long‐term revision rate for those treated with a THR. Four trials involving 415 participants compared cemented hemiarthroplasty versus total hip replacement. All trials found little difference between the prostheses, aside from significantly longer surgical times but better functional outcome scores for the THR in three studies.
Authors' conclusions
There is limited evidence that cementing a prostheses in place may reduce post‐operative pain and lead to better mobility. There is insufficient evidence to determine the roles of bipolar prostheses and total hip replacement. Further well‐conducted randomised trials are required.
Plain language summary
Comparison of different types of artificial hip joints that may be used for treating fractures of the hip
Many different types of artificial hip joints (arthroplasties) may be used to treat a break in the thigh bone (femur) near the hip joint (hip fracture). Differences in these artificial joints include different shapes of the stem set into the bone; the incorporation of a secondary joint (bipolar joint); joints that replace only the ball part of the ball and socket hip joint (hemiarthroplasty) and those that also involve replacing the socket part of the hip joint (total hip replacement). In addition an arthroplasty may be of the press fit type or secured in place within the bone using a glue (bone cement).
Six studies involving 549 participants compared a press fit arthroplasty with one that was secured in place with bone cement. Those joints that were cemented in place seemed to result in less pain and gave possibly better mobility than those that were of the press fit type. Seven trials involving 857 participants compared those prosthesis which have a second joint built into them (bipolar hemiarthroplasties) with those without this additional joint (unipolar hemiarthroplasties). No notable differences between these two types of implant were demonstrated. Five studies of 608 participants compared different types of hemiarthroplasty with a total hip replacement. There was a trend to better functional outcomes after total hip replacement, but firm conclusions could not be made because of the lack of patient numbers.
In summary there is not enough evidence from randomised trials to show which arthroplasty is best. There is some evidence that people with arthroplasties that are cemented in place may have less pain and better mobility after the operation than those, which are inserted as a press fit.
