For older people with hip fracture, the choice between full or partial hip replacement does not greatly influence outcomes. In this trial, approximately 8% of patients having each operation required further surgery within a 24-month period. Mortality rates were also similar at around 13%.
This multinational trial included 1,495 adults aged over 50 with a hip fracture, who were previously able to walk unassisted. It found that both hemiarthroplasty (partial replacement) and total hip replacement achieved similar results in terms of function, pain and serious adverse events.
Current NICE guidance recommends total hip replacement over hemiarthroplasty, largely based on a trial of 120 patients which found that function was better following total hip replacement. The results of this larger study suggest there is little difference, and so the decision as to which intervention to use needs to be made on a case-by-case basis.
Why was this study needed?
In the UK, hip fractures account for over 60,000 hospital admissions a year. Hip fractures primarily affect older people, and many experience long-term effects even after rehabilitation, often leading to further illness and loss of independence.
Hip fractures are usually treated surgically, replacing damaged parts with prostheses (artificial parts). There are two main treatment options: either just the top of the thigh bone (femoral head) is replaced (hemiarthroplasty), or total hip replacement can be performed which in addition replaces the acetabulum (hip socket).
There is some uncertainty as to the optimal procedure. Total hip replacement is often regarded as having the potential to give better hip function and quality of life; however, there are concerns that this is offset by an increased risk of dislocation and need for secondary procedures. This trial aimed to clarify the outcomes for both procedures.
What did this study do?
The HEALTH randomised controlled trial involved 1,495 people aged over 50 years with a displaced femoral neck fracture, who had been able to walk before their injury. Participants underwent either total hip replacement or hemiarthroplasty.
The trial was conducted in 80 centres in Canada, the US, Spain, the UK, the Netherlands, Norway, Finland, Australia, New Zealand, and South Africa. Patients were assessed at one week, 10 weeks, and at 6, 9, 12, 18, and 24 months after surgery, either in-person or by telephone.
A limitation of this trial is the length of follow-up; longer follow-up would be beneficial to compare outcomes over time. This is compounded by the fact that the number of patients with complete outcome data on function reduced over the 24 month period.
What did it find?
- There was no difference between procedures in the main surgical outcome of whether a secondary hip procedure was required within 24 months. This occurred in 57 of 718 patients (7.9%) who received total hip replacement and 60 of 723 patients (8.3%) who had hemiarthroplasty (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.64 to 1.40).
- Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip replacement and 17 patients (2.4%) assigned to hemiarthroplasty (HR 2.00, 99% CI 0.97 to 4.09).
- Function, as measured using the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), was slightly better in those who had total hip replacement. However, the differences were not enough to be considered clinically important: WOMAC total score, range 0 to 96 (mean difference [MD] −6.37, 99% CI −9.18 to −3.56); WOMAC pain score, range 0 to 20 (MD −0.93, 99% CI −1.42 to −0.44); WOMAC stiffness score, range 0 to 8 (MD −0.44, 99% CI −0.65 to −0.23); and WOMAC function score, range 0 to 68 (MD −4.97, 99% CI −7.11 to −2.83).
- There was no difference in quality of life according to the European Quality of Life-5 Dimensions (EQ-5D) questionnaire or the 12-Item Short Form General Health Survey (SF-12).
- Mortality was similar for both groups: 14.3% among those assigned total hip replacement and 13.1% among those assigned to hemiarthroplasty (HR 1.10, 99% CI 0.77 to 1.58). Serious adverse events occurred in 300 patients (41.8%) given total hip replacement and 265 patients (36.7%) who had hemiarthroplasty (HR 1.16, 99% CI 0.9 to 1.51).
What does current guidance say on this issue?
NICE guidance on the management of hip fractures states that patients with a displaced intracapsular hip fracture should be offered either total hip replacement or hemiarthroplasty. The aim should be to allow patients to fully weight bear (without restriction) in the immediate postoperative period.
However, NICE recommends that total hip replacement rather than hemiarthroplasty should be offered to those who meet the following criteria: were able to walk independently out of doors with no more than the use of a stick, are not cognitively impaired, and are medically fit for anaesthesia and the procedure.
What are the implications?
This large trial challenges NICE’s advice in favour of total hip replacement, suggesting hemiarthroplasty is a reasonable alternative. There was no significant difference between procedures in terms of revision surgery, function, quality of life, serious adverse events or death within two years. Further research looking at longer-term outcomes is warranted.
Citation and Funding
Bhandari M, Einhorn TA, Guyatt G et al. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med. 2019;381:2199-208.
Supported by grants from the Canadian Institutes of Health Research (MCT-90168), the National Institutes of Health (1UM1AR063386-01), ZorgOnderzoek Nederland-Medische Wetenschappen (ZonMw) (17088.2503), Sophies Minde Foundation for Orthopaedic Research, McMaster Surgical Associates, and Stryker Orthopaedics. CinicalTrials.gov number, NCT00556842.
International Osteoporosis Foundation. Facts and statistics. Nyon, Switzerland: International Osteoporosis Foundation; 2017.
NHS website. Hip fracture. London: Department of Health and Social Care; updated 2019.
NICE. Hip fracture: management. CG124. London: National Institute for Health and Care Excellence; 2011, updated 2017.
RCP. National Hip Fracture Database (NHFD) annual report 2018. London: Royal College of Physicians; 2018.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre