Arthroplasties (with and without bone cement) for proximal femoral fractures in adults

BACKGROUND: Numerous types of arthroplasties may be used in the surgical treatment of a hip fracture (proximal femoral fracture). The main differences between the implants are in the design of the stems, whether the stem is fixed in place with or without cement, whether a second articulating joint is included within the prosthesis (bipolar prosthesis) or whether a partial (hemiarthroplasty) or total whole hip replacement is used. OBJECTIVES: To review all randomised controlled trials that have compared different arthroplasties for the treatment of hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing different arthroplasties and their insertion with or without cement, for the treatment of hip fractures. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality, by use of a ten-item checklist, and extracted data. MAIN RESULTS: Seventeen trials involving 1920 patients were included. One trial involved two comparisons. Cemented prostheses, when compared with uncemented (six trials, 549 participants) were associated with less pain at a year or later (16/52 versus 28/52; RR 0.51, 95% CI 0.31 to 0.81) and a tendency to better mobility. No significant difference in surgical complications was found. Comparison of unipolar hemiarthroplasty with bipolar hemiarthroplasty (seven trials, 857 participants, 863 fractures) showed no significant differences between the two types of implant. Two trials involving 232 patients compared uncemented hemiarthroplasty with a total hip replacement. Both studies reported increased pain for the uncemented prosthesis and one study found better mobility and a lower long-term revision rate for those treated with a THR. Two trials involving 214 participants compared cemented hemiarthroplasty versus total hip replacement. Both trials generally found little difference between prostheses. THR was associated with a slightly longer surgical time but a tendency to better functional outcome in one trial. AUTHORS' CONCLUSIONS: There is limited evidence that cementing a prosthesis in place may reduce post-operative pain and lead to better mobility. There is insufficient evidence to determine the roles of bipolar prostheses and total hip replacement. Further well-conducted randomised trials are required.