Cecilia Rogmark

Primary arthroplasty is better than internal fixation of displaced femoral neck fractures: a meta-analysis of 14 randomized studies with 2,289 patients.

Background The treatment of displaced femoral neck fractures has long been debated. 14 randomized controlled studies (RCTs) comparing internal fixation with primary arthroplasty may give material for evidence-based decision making. Methods Computerized databases were searched for RCTs published between 1966 and 2004. 14 RCTs containing 2,289 patients were included in a metaanalysis regarding complications, reoperations and mortality. The analysis was performed with software from the Cochrane collaboration. Results Primary arthroplasty leads to significantly fewer major method-related hip complications and reoperations, compared to internal fixation. There was no significant difference in mortality between the two groups at 30 days and 1 year. Most of the studies found better function and less pain after primary arthroplasty. Interpretation Primary arthroplasty should be used in most patients with displaced femoral neck fracture. The healthy, lucid individual, 70–80 years old, should be given a total hip arthroplasty. The older, impaired or institutionalized patient would benefit from a hemiarthroplasty.

Incidence of hip fractures in Malmö, Sweden, 1992-1995. A trend-break.

The incidence of hip fractures in Malmö, Sweden, has been studied since 1924. Predictions based on material from the 1950s to the 1980s have shown an almost exponential increase in incidence. During 1992-1995, 2,268 patients aged 50 and older, with hip fractures, were admitted to Malmö University Hospital, the only hospital in the city treating hip fractures. 76% were women with a mean age of 81 (SD 8) years, and the mean age of men was 78 (SD 9) years. 47% of the fractures were cervical. The annual incidences per 10,000 inhabitants were 36 in men and 85 in women. The corresponding numbers of subjects over 80 years were 170 men and 297 women. These findings show that the incidence is no longer increasing. The causes of such a trend-break could be successful osteoporosis prevention, an increasing proportion of non-Scandinavian immigrants with a lower genetic risk of osteoporotic fractures, or a healthier elderly population. Increasing number of the population at risk already have two operated hips, due to previous fractures or arthrosis. Other causes may be fewer prescriptions of sedatives and higher winter temperatures.

Long-term follow-up of replacement compared with internal fixation for displaced femoral neck fractures: RESULTS AT TEN YEARS IN A RANDOMISED STUDY OF 450 PATIENTS

In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function. Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck.

Internal Fixation Versus Arthroplasty for Displaced Femoral Neck Fractures: What is the Evidence?

A review of the current evidence for internal fixation versus hemiarthroplasty versus primary total hip arthroplasty for displaced femoral neck fractures was undertaken. At the meta-analysis level no difference in postoperative pain, function, or quality of life can yet be demonstrated. A significant difference in mortality has also not been found, but a trend towards higher mortality after primary arthroplasty is possible. Internal fixation (IF) has less morbidity, but a higher risk of revision and less cost-effectiveness. Independent adjudication for IF technique is rare in studies and bias towards higher revision rates due to technical failure is an issue. Randomized trials comparing IF with arthroplasty remain underpowered in specific subgroups of patients, in which IF revision rates could be acceptable. In hemiarthroplasty the data suggest minimal differences in outcome between the prosthesis types. The cementless Austin-Moore prosthesis is out-dated. Currently a cemented unipolar or bipolar, depending on costs, hemi-arthroplasty is the treatment of choice for an elderly patient with functional limitations before the fracture. The role of modern, uncemented hemiarthroplasty designs are uncertain until more data are published. Total hip arthroplasty (THA) should be considered in any active older patient with a displaced femoral neck fracture. Patients with concomitant osteoarthritis, rheumatoid arthritis, or renal failure do poorly with other treatment options and should be treated with THA. Randomized trials have shown THA to be a cost-effective treatment with lower revision rates than IF. THA may also appear to be superior to hemiarthroplasty in specific subgroups, but larger trials are needed to confirm this observation.

Prevalence of osteoporosis and incidence of hip fracture in women--secular trends over 30 years.

BackgroundThe number of hip fractures during recent decades has been reported to be increasing, partly because of an increasing proportion of elderly women in the society. However, whether changes in hip fracture annual incidence in women are attributable to secular changes in the prevalence of osteoporosis is unclear.MethodsBone mineral density was evaluated by single-photon absorptiometry at the distal radius in 456 women aged 50 years or above and living in the same city. The measurements were obtained by the same densitometer during three separate time periods: 1970-74 (n = 106), 1987-93 (n = 175) and 1998-1999 (n = 178), and the age-adjusted prevalence of osteoporosis in these three cohorts was calculated. Additionally, all hip fractures sustained in the target population of women aged 50 years or above between 1967 and 2001 were registered, whereupon the crude and the age-adjusted annual incidence of hip fractures were calculated.ResultsThere was no significant difference in the age-adjusted prevalence of osteoporosis when the three cohorts were compared (P = 1.00). The crude annual incidence (per 10,000 women) of hip fracture in the target population increased by 110% from 40 in 1967 to 84 in 2001. The overall trend in the crude incidence between 1967 and 2001 was increasing (1.58 per 10,000 women per year; 95 percent confidence interval, 1.17 to 1.99), whereas the age-adjusted incidence was stable over the same period (0.22 per 10,000 women per year; 95 percent confidence interval, -0.16 to 0.60).ConclusionsThe increased number of hip fracture in elderly women is more likely to be attributable to demographic changes in the population than to secular increase in the prevalence of osteoporosis.

Higher risk of reoperation for bipolar and uncemented hemiarthroplasty: 23,509 procedures after femoral neck fractures from the Swedish Hip Arthroplasty Register, 2005–2010

Background and purpose Hemiarthroplasty as treatment for femoral neck fractures has increased markedly in Sweden during the last decade. In this prospective observational study, we wanted to identify risk factors for reoperation in modular hemiarthroplasties and to evaluate mortality in this patient group. Patients and methods We assessed 23,509 procedures from the Swedish Hip Arthroplasty Register using the most common surgical approaches with modular uni- or bipolar hemiarthroplasties related to fractures in the period 2005–2010. Completeness of registration (individual procedures) was 89–96%. The median age was 85 years and the median follow-up time was 18 months. Results 3.8% underwent reoperation (any further hip surgery), most often because of implant dislocation or infection. The risk of reoperation (Cox regression) was higher for uncemented stems (hazard ratio (HR) = 1.5), mainly because of periprosthetic femoral fractures. Bipolar implants had a higher risk of reoperation irrespective of cause (HR = 1.3), because of dislocation (1.4), because of infection (1.3), and because of periprosthetic fracture (1.7). The risk of reoperation due to acetabular erosion was lower (0.30) than for unipolar implants, but reoperation for this complication was rare (1.7 per thousand). Procedures resulting from failed internal fixation had a more than doubled risk; the risk was also higher for males and for younger patients. The surgical approach had no influence on the risk of reoperation generally, but the anterolateral transgluteal approach was associated with a lower risk of reoperation due to dislocation (HR = 0.7). At 1 year, the mortality was 24%. Men had a higher risk of death than women (1.8). Interpretation We recommend cemented hemiarthroplasties and the anterolateral transgluteal approach. We also suggest that unipolar implants should be used, at least for the oldest and frailest patients.

Projections of total hip replacement in Sweden from 2013 to 2030

Background and purpose — The continuously increasing demand for joint replacement surgery in the past decades imposes higher constraints on the budgets of hospitals and healthcare providers. We undertook an analysis of historical trends in total hip replacement performed in Sweden between 1968 and 2012 in order to provide projections of future demand. Data and methods — We obtained data on total hip replacements registered every year and on the evolution of the Swedish population between 1968 and 2012. We assumed the existence of a maximum incidence. So we adopted a regression framework that assumes the existence of an upper limit of total hip replacement incidence. Results — We found that the incidence of total hip replacement will continue to increase until a projected upper incidence level of about 400 total hip replacements per 105 Swedish residents aged 40 years and older will be reached around the year 2107. In 2020, the estimated incidence of total hip replacement will be 341 (95% prediction interval (PI): 302–375) and in 2030 it will be 358 (PI: 317–396). Using official forecasted population growth data, about 18,000 operations would be expected to be performed in 2020 and 20,000 would be expected to be performed in 2030. Interpretation — Growing incidence, population growth, and increasing life expectancy will probably result in increased demand for hip replacement surgery. Our findings could serve as a basis for decision making.

Costs of internal fixation and arthroplasty for displaced femoral neck fractures

We included in a prospective, randomized study 68 patients aged 70 years or older, with displaced cervical hip fractures. The patients were randomized to internal fixation with hook-pins (36) or primary arthroplasty (32) (total or hemiarthroplasty due to their prefracture status) and followed for 2 years. Patients with rheumatoid arthritis, mental confusion and/or residence in an institution were excluded. The postoperative stay in hospital, rehabilitation wards or nursing homes were recorded as well as complications and the costs of surgery. The aim of this study was to compare the accumulated costs of each method, during the first 2 years after the fracture. In the internal fixation group, 15/36 were considered failures, as compared to 1/32 in the arthroplasty group. As regards primary treatment of the fracture, the durations of surgery and hospital stay were shorter after internal fixation, but the total need for hospitalization/ institutionalizaion was somewhat longer in these patients. The mean 2-year cost for a patient with internal fixation was USD 21,000 and of one with primary arthroplasty USD 15,000. We conclude that primary arthroplasty is a cost-efficient treatment. Considering the very much higher failure rate after internal fixation—leading to increased suffering for these patients—primary arthroplasty stands out as the best method for displaced fractures of the femoral neck.

Primary hemiarthroplasty in old patients with displaced femoral neck fracture: a 1-year follow-up of 103 patients aged 80 years or more

103 patients with displaced femoral neck fractures (Garden 3-4) treated with primary hemiarthroplasty in the Department of Orthopedics, Malmo University Hospital, Sweden 1998-1999 were followed in a prospective, consecutive study for 1 year. Inclusion criteria were age of at least 80 years, signs of mental changes and/or residence in an institution. The control group consisted of 69 patients with internal fixation (Hansson hook pins). The arthroplasty group required more blood transfusions, a longer operation and had more superficial infections. No differences were detected as regards other complications, length of hospital stay, in-hospital mortality or ability to return home. The 1-year mortality rates were similar in the arthroplasty (29/103) and control groups (28/69). Within 1 year, we found a lower failure rate in the arthroplasty group (6/103) than in the control group (18/69). In the arthroplasty group, 2/103 had dislocations. Of the surviving arthroplasty patients at 12 months, 31/74 could walk as well as before the fracture and 55/74 had no pain. We recommend primary hemiarthroplasty for demented and/or institutionalized patients over 80 years with displaced femoral neck fractures.

Posterior approach and uncemented stems increases the risk of reoperation after hemiarthroplasties in elderly hip fracture patients

Background Hemiarthroplasties are performed in great numbers worldwide but are seldom registered on a national basis. Our aim was to identify risk factors for reoperation after fracture-related hemiarthroplasty in Norway and Sweden. Material and methods A common dataset was created based on the Norwegian Hip Fracture Register and the Swedish Hip Arthroplasty Register. 33,205 hip fractures in individuals > 60 years of age treated with modular hemiarthroplasties were reported for the period 2005–2010. Cox regression analyses based on reoperations were performed (covariates: age group, sex, type of stem and implant head, surgical approach, and hospital volume). Results 1,164 patients (3.5%) were reoperated during a mean follow-up of 2.7 (SD 1.7) years. In patients over 85 years, an increased risk of reoperation was found for uncemented stems (HR = 2.2, 95% CI: 1.7–2.8), bipolar heads (HR = 1.4, CI: 1.2–1.8), posterior approach (HR = 1.4, CI: 1.2–1.8) and male sex (HR = 1.3, CI: 1.0–1.6). For patients aged 75–85 years, uncemented stems (HR = 1.6, 95% CI: 1.2–2.0) and men (HR = 1.3, CI: 1.1–1.6) carried an increased risk. Increased risk of reoperation due to infection was found for patients aged < 75 years (HR = 1.5, CI: 1.1–2.0) and for uncemented stems. For open surgery due to dislocation, the strongest risk factor was a posterior approach (HR = 2.2, CI: 1.8–2.6). Uncemented stems in particular (HR = 3.6, CI: 2.4–5.3) and male sex increased the risk of periprosthetic fracture surgery. Interpretation Cemented stems and a direct lateral transgluteal approach reduced the risk of reoperation after hip fractures treated with hemiarthroplasty in patients over 75 years. Men and younger patients had a higher risk of reoperation. For the age group 60–74 years, there were no such differences in risk in this material.