Arthroplasty Versus Internal Fixation For Displaced Femoral Neck Fracture In The Elderly: A Systematic Review

BackgroundHip fracture is a very common orthopedic injury and the incidence is steadily increasing. An estimated 1.6 million people sustain a hip fracture every year. Each year more than 5 million people in the world experience disability from a hip fracture. A hip fracture is a life changing event for any patient, and the risk of disability, increased dependence, and death is substantial.About half of the hip fractures are intracapsular femoral neck fractures, and epidemiological studies predict that the incidence of these fractures will continue to increase. Femoral neck fractures in the young, healthy, and active patients with good bone quality are almost always treated using reduction with internal fixation. Operative alternatives for displaced femoral neck fractures differ greatly throughout the world, but mainly include prosthetic replacement (arthroplasty) and internal fixation (IF). Options for arthroplasty include unipolar hemiarthroplasty, bipolar hemiarthroplasty and total hip arthroplasty. Options for internal fixation include multiple screws, a compression screw and side plate or an intramedullary hip screw device. However, whether arthroplasty or IF is more appropriate for displaced femoral neck fractures in elderly patients is still being debated. IF preserves the femoral head; in addition, it has shorter operative time, less blood loss and operative trauma, while arthroplasty might increase operative mortality. However, some authors favour arthroplasty because the replacement of the femoral neck can decrease the rate of revision surgery and the complications related to healing of the fracture.A number of clinical studies comparing arthroplasty with IF have been undertaken. They include observational studies, randomised controlled trials (RCTs) and systematic reviews. The first RCT was performed by Soreide et al. in 1979, followed by the studies of Sikorski et al. and Skinner et al.. Most of these RCTs are relatively small. A meta-analysis by Lu-Yao et al. is mainly based on observational studies. There are a few RCTs collected in two other systematic reviews conducted by Bhandari et al. and Rogmark et al..These studies have mainly focused on the short-term mortality, rates of reoperation and surgical complications and did not refer to the general medical complications, such as thromboembolic complications, pressure sores and cerebrovascular accidents, although these are equally important. In this paper we address these issues by conducting an up-to-date meta-analysis of RCTs published up to May 2008. The purpose is to evaluate the clinical outcomes comparing arthroplasty with IF, including the long-term mortality, revision surgery rates and surgical complications, as well as general medical complications. It is hoped that the findings will improve our understanding of the treatment for displaced femoral neck fracture in elderly patients.ObjectiveTo compare the therapeutic effects of arthroplasty with that of intenal fixation for displaced femoral neck fractures in elder patients,providing the best evidence for the clinical decision. Methods1.After put forward a question,an detailed inclusion and exclusion criteria were established according to PICO steps,and then comprehensive search strategy of literature were made to search the relevantRandomized Controlled Trials(RCTs).2.According to Cochrane systematic review, Cochrane library,Medline, Embase, CNKI,VIP,and Chinese Biomedical Database were retrieved for randomized controlled trials(RCTs) comparing relevant interventions for the treatment of displaced femoral neck fractures in elder patients before the end of September 2009.Furthermore,we also handsearched relevant reference and some Chinese orthopedic journals.Finally,RCTs which met the specific inclusion and exclusion criteria were included.These RCTs were associated with arthroplasty with the therapeutic effects of arthroplasty with that of intenal fixation for displaced femoral neck fractures in elder patients3.The methodology quality of each inclusion study was critically assessed according to the quality criteria of RCT which include four items:randomization, allocation concealment, blindness and follow-up.The validity of each trail was referred to as A, B or C scale according to Cochrane handbook for systematic reviews.4. After critical appraisal, data of each RCT on relevant outcome parameter were extracted. Software Revman 4.2.8 the Cochrane Collaboration provided were used for meta-analysis. For each study,relative risk(RR) and 95% confidence intervals(95% CI)were calculated for dichotomous outcomes and weighted mean differences(WMD) and 95% confidence intervals(95%CI) were calculated for dichotomous outcomes. Before outcome measures of each trial were pooled, clinical heterogeneity should be considered. If interventions of each trial were different,subgroup analysis should be applied. The results of individually randomized trials were pooled whenever possible,with use of the fixed effects model of Mantel-Haenszel. Heterogeneity between comparable studies was tested, with the use of a standard chi-square test. The random—effects model of DerSimonian and Laird was used when there was statistical evidence of heterogeneity(P<0.1). However,if the results of certain outcome measures were not pooled or if the outcome events rarely happened, evaluation should rely on detailed description.Results1. Search resultsA total of 328 papers were retrieved, but only 20 published randomized controlled trials including 3287 patients were suitable for the review.2.Meta-analysis results2.1 Postoperative Mortality2.1.1 Mortality at 1 m postoperativelyNine reports, on a total of 1375 patients, provided mortality at lm postoperatively. There was no significant heterogeneity (P=1.130>0.05) between studies, so it was used as a fixed effect model. A meta-analysis showed the single study did not significantly change the overall pooled effect of internal fixation compared with arthroplasty in mortality [RR=1.42,95%CI(0.89,2.24)].2.1.2Mortality at 4-6m postoperativelyForteen reports, on a total of 2313 patients, provided mortality at 4-6m postoperatively. There was no significant heterogeneity (P=0.610>0.05) between studies, so it was used as a fixed effect model. A meta-analysis showed the single study did not significantly change the overall pooled effect of internal fixation compared with arthroplasty in mortality [RR=1.17,95%CI(0.93,1.46)].2.1.3Mortality at 1y postoperativelySeventeen reports, on a total of 3109 patients, provided mortality at 1y postoperatively. There was no significant heterogeneity (P=0.070>0.05) between studies, so it was used as a fixed effect model. A meta-analysis showed the single study did not significantly change the overall pooled effect of internal fixation compared with arthroplasty in mortality [RR=1.12,95%CI(0.98,1.29)].2.1.4Mortality at 2y postoperativelyEleven reports, on a total of 1707 patients, provided mortality at 1y postoperatively. There was no significant heterogeneity (P=0.070>0.05) between studies, so it was used as a fixed effect model. A meta-analysis showed the single study did not significantly change the overall pooled effect of internal fixation compared with arthroplasty in mortality [RR=1.01,95%CI(0.86,1.18)].2.2.1 Re-operation at 2y postoperativelyNine reports, on a total of 1557 patients,provided re-operation at 2y postoperatively.There was no significant heterogeneity (P=0.3>0.05) between studies, so it was still used as a fixed effect model.We found that it had significant difference between various studies on re-operation of arthroplasty versus internal fixation [RR=0.13,95%CI(0.09,0.17)].2.2.2Re-operation at 5y postoperativelyTwo reports, on a total of 380 patients,provided re-operation at 5y postoperatively.There was no significant heterogeneity (P=0.770>0.05) between studies, so it was still used as a fixed effect model.We found that it had significant difference between various studies on re-operation of arthroplasty versus internal fixation [RR=0.11,95%CI(0.06,0.22)].2.3.1 Major complications at 2y postoperativelyTen reports, on a total of 1431 patients,provided major complications at 2y postoperatively.There was no significant heterogeneity (P=0.110>0.05) between studies, so it was still used as a fixed effect model.We found that it had significant difference between various studies on re-operation of arthroplasty versus internal fixation [RR=0.20,95%CI(0.15,0.27)].2.3.2Major complications at 5y postoperativelyTen reports, on a total of 1431 patients,provided major complications at 5y postoperatively.There was no significant heterogeneity (P=0.110>0.05) between studies, so it was still used as a fixed effect model.We found that it had significant difference between various studies on re-operation of arthroplasty versus internal fixation [RR=0.18,95%CI(0.11,0.30)].Conclusion1.For elder patients with displaced femoral neck fractures, arthroplasty is surpass internal fixation with lower rate of re-operation and lower incidence of complications.2.Although there was no significant difference in comparison of arthroplasty with either intenal fixation on the mortality at different time points,arthroplasty can significantly improve the quality of the life of the patients. For better health, we need to more carefully consider issues of long-term outcomes and intraoperative and preoperative factors and report them in a liable, consistent and standardised manner.