Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults

BACKGROUND: Displaced intracapsular fractures may be treated by either reduction and internal fixation which preserves the femoral head, or by replacement of the femoral head with an arthroplasty. OBJECTIVES: To review all randomised trials that have compared internal fixation and arthroplasty. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), MEDLINE (1966 to January 2002), EMBASE (1988 to 2002, Week 2), Current Contents (1993 to 2002, Week 4), PREMEDLINE (January 2002) and selected orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists where possible. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults. DATA COLLECTION AND ANALYSIS: Trial quality was assessed by use of a 10 item scale. Data from the majority of trials were independently extracted by three reviewers with the remaining extracted by two. Additional information was sought from trialists. After grouping into three broad categories, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed effects model. MAIN RESULTS: Thirteen trials involving 2091 patients were included. Internal fixation had a reduced length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection. Arthroplasty had a lower re-operation rate in comparison with fixation. No definite differences for hospital stay, mortality, degree of residual pain, regain of mobility or regain of same residential state were found. REVIEWER'S CONCLUSIONS: Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip. Definite conclusions cannot be made for differences in pain and residual disability between the two groups. Future studies should concentrate on better reporting of final outcome measures and there is still a need for studies to define which patient groups are better served by the different treatment methods.