Femoral Neck Fractures Evidence Review Where is the Evidence Leading Us?

Burden of Hip Fractures The disability adjusted life-years lost as a result of hip fractures ranks in the top 10 of all cause disability globally Cooper et al, 2002

Current Practice? Operative management of displaced femoral neck fractures in elderly patients. An international survey Bhandari M, Devereaux PJ, Tornetta P 3rd, Swiontkowski MF, Berry DJ, Haidukewych G, Schemitsch EH, Hanson BP, Koval K, Dirschl D, Leece P, Keel M, Petrisor B, Heetveld M, Guyatt GH. J Bone Joint Surg Am. 2005;87:

Characteristics of Surgeons Age (41-50yr)45.0% Gender (male)98.2% Type of Practice (Academic)76.5% Supervise Residents84.0% Trauma fellowship73.3% Reconstructive fellowship26.0% Volume of hip #(>100)53.0%

Displaced Fractures Age<60 yrs 80% Internal Fixation 80% Multiple Screws Age:60-80 yrs 89% arthroplasty 33% unipolar Age>80 years 94% arthroplasty 60% unipolar

Cannulated Screws Surgeon Preferences: Inverted Triangle- 51% Capsulotomy- 20% Aspiration of Intracapsular Hematoma- 10% 3 Cannulated Screws- 73%

Arthroplasty Surgeon Preferences: Posterior Approach 44% Capsular Repair- 60% Cemented- 69% No drains- 66%

Hierarchy of Evidence Randomized Trials Prospective Cohort Studies Retrospective Case Series Case Control Studies Opinion Meta- analysis Level 1 Level 2 Level 3 Level 4 Level 5

Internal Fixation OR Arthroplasty?

Internal Fixation Versus Arthroplasty for Displaced Fractures of the Femoral Neck: A Meta-Analysis Mohit Bhandari MD, MSc*, Philip J Devereaux MD*, Marc F. Swiontkowski MD^, Paul Tornetta III MD#, William Obremskey MD, MPH**, Kenneth J. Koval MD^, Sean Nork MD#, Sheila Sprague, BSc*, Emil H. Schemitsch MD and Gordon H. Guyatt MD, MSc* From the *Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario and the Departments of Orthopaedics, Hospital for Joint Diseases, New York, New York, ^University of Minnesota, Minneapolis, **University of North Carolina, Raleigh, North Carolina, # Harborview Medical Centre, Seattle, Washington, #Boston Medical Centre, Boston, Massachusetts, and St. Michael’s Hospital, University of Toronto, Toronto, Ontario. Journal of Bone and Joint Surgery 2003:85A: Internal Fixation or Arthroplasty for Displaced Femoral Neck Fractures? Level I Evidence?

IF vs Arthroplasty Early decrease in Mortality risk with IF No difference in Mortality at 1 yr Reduction in Revisions with Arthroplasty Pain and Functional Outcomes Similar More Blood Loss and O.R time with Arthroplasty Increased infection risk with Arthroplasty

< 4 Month Mortality Internal Fixation may reduce risk of mortality by 22% (48% RRR, 19% RRI) Unadjusted crude rates: 9% Arthroplasty vs 6% Internal Fixation Underpowered for the comparison with 1162 patients

Revision Surgery All Arthroplasty vs IF N=1901 patients 11% rate Arthroplasty 35% rate in Internal Fixation Relative Risk: 0.23, 95%CI: P< Arthroplasty reduced risk of revision by 77% (58%-87%)

Revision Rates

Revision Surgery Revisions following internal fixation: Nonunions (weighted mean=18.5%, range 5-28%) AVN (weighted mean=9.7%, range 5-18%)

Revision Surgery Revisions following arthroplasty Dislocations Overall weighted mean=0.82%, range 0-22% THA- weighted mean=6.9%, range 0- 22%

Pain and Function Pain relief and function were similar in patients treated with arthroplasty or internal fixation, RR no/little pain 1.12, 95% CI , RR good function 0.99, 95% CI Arthroplasty significantly increased the risk of infection (12 studies, n=1822) compared to internal fixation RR: 1.81, 95% CI , p = 0.009

Argument for IF of Displaced Fractures Less Blood loss, O.R Time Significantly less infection rates No difference in Pain and Function Possible decrease in mortality risk by as much as 48% Although high revision rates  65% patients may never need a re-op!

Screws or SHS for Displaced Fractures?

Subgroup Analysis (Meta-analysis) Screw and side plate constructs performed significantly (five- fold) better than multiple screws in reducing the risk of revision surgery Level II evidence

Multiple Screws or SHS? Meta-analysis ( Parker MJ, Cochrane Review) N=27studies involving 5269 participants (5274 fractures) were included in the study “No difference among various implants” SHS versus 3 or more screws (4 trials, n=414 patients ) on fracture healing complications suggested a trend in favour of compression screw and side plate fixation 25% Reduction in Risk of Complications! Level II evidence

Total Vs Hemi-Arthroplasty?

Direct Comparisons 2 RCTs N=180 patients Keating Ravikumar Level II

Primary Outcome:Rel. Risk Reoperation 13%0.86 P=0.63 Mortality 21.8%0.71P=0.13 Dislocation7.4%1.54 P=0.17 Wound Infection5.4% 0.69 P=0.46 DVT 6%2.95 P=0.29 Pain and Function: Hip pain 42.1%0.76P=0.03 Functional Limit 53.5%0.90P=0.13

What Hemiarthroplasty? Unipolar Vs Bipolar

Cochrane Meta-analysis. Parker (2005) N=7 RCTs, 857 participants No differences in complications, mortality or function Level II

Summary Evidence suggests arthroplasty for displaced (Garden IV) femoral neck fractures is currently the best alternative The optimal arthroplasty for treated displaced femoral neck fractures remains unknown

Summary The role of internal fixation remains unclear Earlier studies may have used the wrong comparison group The optimal internal fixation device may not be the current standard “multiple screws”