Introduction

Doctors have not agreed on the best treatment for displaced fractures (those where the fractured parts of the bone move relative to each other) involving the hip - fractures of the femoral neck of the femur.¹

Each year more than 125,000 people break their hip in this way. It is predicted that by the year 2050 more than 250,000 people will have femoral neck fractures. For older people such fractures can be very debilitating, particularly for those with other medical problems. Roughly one person in three over 80 will suffer a femoral neck fracture. The inability to move around easily and without pain can obviously affect the morale and the health of older people.

Surgical options

There is some controversy among orthopedic surgeons about the best way to treat such fractures. Generally, connecting the parts of the fractured bone with special surgical screws, called internal fixation, was considered to be the best treatment for older people with such displaced femoral neck fractures. However, no scientific study had been done to verify that this was indeed the best and most cost-effective treatment. Cost-effectiveness is becoming increasingly important to patients and the general public today. A new study has analyzed the relative cost-effectiveness and benefits of four different ways to treat this kind of fracture, which is not only common in older people, but can be extremely debilitating.

This study was designed to determine the best and most cost effective treatment for displaced femoral neck fractures in people 65 years and older. Four different kinds of treatment were analyzed:

• internal fixation or reattaching the bones with special surgical screws
• unipolar hemiarthroplasty: In this treatment, the ball (head) of the fractured upper end of the femur is removed and replaced with an artificial metal ball-and-stem, which is inserted into the shaft of the femur; the metal prosthetic head is placed in the bony hip socket.
• bipolar hemiarthroplasty: The head of the fractured upper end of the femur is removed and replaced with a metal head-and-stem (as above), together with a plastic socket which fits in the person's bony hip socket.
• total hip arthroplasty: Here, both the bony head and the bony socket are removed, and replaced by a metal prosthetic head-and-stem AND a plastic socket.

Results of different approaches

The physicians doing the analysis examined data from a large number of research studies. They evaluated the following medical factors:

• Mobility and ability to walk without pain after the operation
• The speed of recovery and rehabilitation therapy
• The risk of having to have additional corrective surgery
• Survival rates
• Other problems caused by the injury such as inability to sleep well, bone degeneration and psychological well being.

They found that internal fixation, traditionally regarded as the "gold standard", was used most often, particularly for the more healthy patients. Elderly patients, however, often had other medical problems that needed correcting before it was safe to proceed with hip surgery, and such delays frequently caused inadequate bony healing at the fracture site. Internal fixation is difficult to perform and should be done immediately, or very soon, after the fracture to avoid bone degeneration.

Unipolar hemiarthroplasty caused rehabilitation problems in the more active patients. Bipolar hemiarthroplasty was beneficial for certain patients who had other medical problems.

Compared with these methods, total hip arthroplasty generally gave a much better outcome, with greater mobility and with less pain; 90% of the patients who underwent total hip arthroplasty experienced no or very little pain two years after the operation and seemed to be functional sooner.

Their analyses disclosed that it was very important to prepare the patient properly for the operation and to use preventive antibiotics and a very sterile operating room. The physical and mental condition of the patient prior to the fracture was also important. The scientists found that for total hip arthroplasty it was crucial that the patient be very careful not to stress the joint immediately after the operation to avoid a hip joint dislocation.

Which type of surgery is best?

To determine which treatment was most cost-effective, the scientists analyzed the operation costs, the costs of hospital stays, the cost of rehabilitation and therapy, the cost of re-operations and complications. They studied the records of 185 older patients having differing kinds of treatment. Total hip arthroplasty was not significantly more expensive than the other three treatments, and, taken together, was the most cost-effective procedure.

The medical scientists stressed that further study should be undertaken with a larger, more randomized sampling. However, they came to the conclusion that total hip arthroplasty, usually used for cases of severe arthritis, was the most successful and cost effective treatment for most older patients. It was consistently less painful and provided greater mobility, functionality and durability. However, hemiarthroplasty should be considered for those patients who have other serious medical problems, and bipolar hemiarthroplasty should be used in those patients who have difficulty in balancing.