Comparing Total Hip Arthroplasty and Hemi-Arthroplasty on Secondary Procedures and Quality of Life in Adults With Displaced Hip Fractures

Hip Fracture Evaluation With Alternatives of Total Hip Arthroplasty Versus Hemi-Arthroplasty: A Multi-Centre Randomized Trial Comparing Total Hip Arthroplasty and Hemi-Arthroplasty on Secondary Procedures and Quality of Life in Patients With Displaced Femoral Neck Fractures

Status

Completed

Phases

Study type

Interventional

Source

ClinicalTrials.gov

Registry ID

NCT00556842

Acronym

HEALTH

Enrollment

1495

Registered

2007-11-12

Start date

2009-03-31

Completion date

2019-05-30

Last updated

2020-07-07

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

Femoral Neck Fractures, Hip Fractures

Keywords

Hemi-Arthroplasty, Total Hip Arthroplasty

Brief summary

Each year, hip fracture, an injury that can impair independence and quality of life, occurs in about 280,000 Americans and 36,000 Canadians. By the year 2040, the annual healthcare costs associated with hip fractures are expected to reach $9.8 billion in the United States and $650 million in Canada. It is important to have in place optimal practice guidelines for the surgical handling of this injury. One type of hip fracture, called a displaced femoral neck fracture, is often treated with a hip replacement surgery. Patients undergoing a hip replacement may receive either a total hip replacement, in which the head of the femur and the hip joint socket are replaced, or a partial hip replacement, in which only the head of the femur is replaced. This study will compare the two different hip replacement procedures to determine which one results in better outcomes after surgery in adults aged 50 and older.

Detailed description

One type of hip fracture, called a femoral neck fracture, involves a break in the narrow part of the femur bone where the head of the femur is joined to the main shaft. The break can be either undisplaced, which involves very little separation at the fracture site, or displaced, in which there is substantial separation. For displaced fractures, surgeons usually choose between internal fixation and hip arthroplasty, which is also known as hip replacement. Patients receiving hip arthroplasty may undergo either a total hip arthroplasty or a hemi-arthroplasty. Which surgical method is best for the patient is unknown. Advocates of total hip replacement claim better improvements in patient function and quality of life. On the other hand, advocates of hemi-arthroplasty, which include most orthopaedic surgeons, claim reduced rates of dislocation and deep vein thrombosis, shorter operating times, less blood loss, and a technically less demanding surgical procedure. This study will compare total hip arthroplasty and hemi-arthroplasty on rates of revision surgery 2 years after patients aged 50 and older sustain femoral neck fractures and undergo surgery. The study will also compare the impact of the two different surgical procedures on function, quality of life, and post-surgical complications. Results from this study may impact current orthopaedic practice. Participation in this study will last 2 years. Before surgery, participants will complete a baseline assessment that will include x-rays, a medical history review, and a physical examination. Participants will then be randomly assigned to undergo either total hip arthroplasty or hemi-arthroplasty to repair their hip fractures. All surgeons will need to meet certain criteria to partake in the study and will have expertise in whichever surgical procedure they are performing. Surgeons will also follow the manufacturers' implant guidelines during surgery. Specific aspects of both the preoperative and post-operative care, such as weight bearing status, the prevention of thromboembolic disease, and the use of antibiotics and calcium supplementation, will be standardized for all participants. Within 2 days of under going surgery, x-rays will be performed again. Follow-up assessments will be completed either by phone or in-person at the hospital or clinic. They will occur 1 and 10 weeks after surgery and 6, 9, 12, 18, and 24 months after surgery. All assessments will include questionnaires and interviews on health status, hip function, pain, functional mobility, and revision surgery. Some of the in-person assessments will also include x-rays.

Interventions

DEVICETotal hip arthroplasty

Proscribed approaches will include minimally invasive total hip arthroplasty (i.e., two incision approaches) and hinged prostheses or capture cups. Other surgical approach aspects, the use of cemented components, the implant manufacturer, and femoral head size will not be standardized. Surgeons will use the manufacturers' specific implant guidelines for insertion.

DEVICEHemi-arthroplasty

Surgeons will use modern implants for hemi-arthroplasty, excluding non-modular, non-canal filling unipolar implants such as Moore's and Thompson's prostheses. The choice of modular unipolar versus bipolar hemi-arthroplasty will not be standardized. Whether implants are inserted with cement or a press-fit design will also not be standardized. Surgeons will use the manufacturers' specific implant guidelines for insertion.

Study design

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

TREATMENT

Masking

NONE

Eligibility

Sex/Gender

ALL

Age

50 Years to No maximum

Healthy volunteers

Inclusion criteria

* Adult men or women aged 50 years and old (with no upper age limit) * Fracture of the femoral neck, as confirmed with either anteroposterior or lateral hip radiographs, computed tomography, or magnetic resonance imaging (MRI) * Displaced fracture that is not, in the judgment of the attending surgeon, optimally managed by reduction and internal fixation * Operative treatment is planned within 72 hours of the patient being medically cleared for surgery * Patient was ambulatory prior to the fracture, though they may have used an aid such as a cane or a walker * Anticipated medical optimization for arthroplasty of the hip * Provision of informed consent by patient or proxy * Low energy fracture (defined as a fall from standing height), with no other trauma * Assurance from site that surgeons with expertise in both total hip arthroplasty and hemi-arthroplasty are available to perform surgery (Note: Surgeons do not need to be experts in both techniques)

Exclusion criteria

* Not suitable for hemi-arthroplasty (i.e., inflammatory arthritis, rheumatoid arthritis, pathologic fractures (secondary to cancer), or severe osteoarthritis of the hip) * Associated major injuries of the lower extremity (e.g., ipsilateral or contralateral fractures of the foot, ankle, tibia, fibula, knee, or femur; dislocations of the ankle, knee, or hip; or femoral head defects or fracture) * Retained hardware around the affected hip that will interfere with arthroplasty * Infection around the hip (soft tissue or bone) * Bone metabolism disorder except osteoporosis (e.g., Paget's disease, renal osteodystrophy, osteomalacia) * Patients with a previous history of frank dementia that would interfere with the assessment of primary outcome (e.g., secondary procedures at 2 years). * Likely problems, in the judgment of the investigators, with maintaining follow-up (e.g., no fixed address, plans to move out of town in the next year, or intellectually challenged and without adequate family support) * Enrolled in another ongoing drug or surgical intervention trial * Patients whose fracture occurred as a result of violence.

Design outcomes

Primary

Measure	Time frame	Description
Number of Participants With Revision Surgery	Measured 2 years after original surgery	The primary outcome is any unplanned secondary procedure within 2 years of the initial joint replacement surgery.

Secondary

Measure	Time frame	Description
Hip Function and Pain	Measured 2 years after original surgery	Hip function and pain were measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), which is a self-administered questionnaire that assesses 3 dimensions of pain, disability, joint stiffness in knee and hip osteoarthritis. This questionnaire uses a Likert scale, with the responses: none, mild, moderate, severe, and extreme. A higher score indicates worse pain, stiffness, and functional limitations. The ranges are: 0-20 for pain, 0-8 for stiffness, 0-68 for physical function. The sum of the pain, stiffness, and physical function subscales provides the WOMAC total score, which ranges from 0-96.
Number of Participants With Functional Mobility Problems	Measured 2 years after original surgery	Functional outcome measured using the Timed Up and Go (TUG) test. The TUG test is a standardized, physical test to assess balance and mobility in the participants. The participant is timed while they perform simple physical movements, such as rising from an arm chair, walking 10 feet, walking back to the chair, and sitting down. A faster time indicates that the participant has greater functional performance, while a lower score may identify participants who are at risk for increased falls in the community. We analyzed the TUG as a dichotomous outcome with the following categories: a) patients who complete the test in ≤12 seconds, and b) those who require \>12 seconds to complete the test or were unable to complete the test. We selected 12 seconds as the cut-off because this was the threshold used by the Centers for Disease Control and Prevention. We report the number of participants in each group who required \>12 seconds to complete the test or were unable to complete the test
Health-Related Quality of Life (SF-12)	Measured 2 years after original surgery	Health-related quality of life measured using the SF-12 Health Survey, which is a standardized instrument to measure health- related quality of life. This self-administered, 12-item questionnaire covers eight main health domains that make up the Physical and Mental Health Composite Scores (PCS & MCS). Each domain consists of one or two questions and is scored separately from 0 (lowest level) to 100 (highest level). Higher scores represent better health-related quality of life.
Health-Related Quality of Life (EQ-5D)	Measured 2 years after original surgery	Health-related quality of life was measured using the EQ-5D, which is a standardized instrument that comprises of a short descriptive system questionnaire and a visual analogue scale (EQ-5D VAS). The questionnaire provides a simple descriptive profile of a respondent's health state. When the descriptive system profile is linked to a 'value set', a single summary index value for health status on a 0 to 1 scale is derived that can be used in economic evaluations of healthcare interventions. A health utility value of 1 indicates perfect health while a score of 0 indicates death. The EQ-5D VAS assesses the individual's health today on a scale from 0-100, with the 0 being 'worst imaginable state of health' and 100 being 'best imaginable state of health'.
Complications, Including Mortality, Dislocation, Infection, Femoral Fracture, Deep Venous Thrombosis, and Prosthesis Loosening	Measured 2 years after original surgery	Hip-related complications including peri-prosthetic fracture, hip instability or dislocation, implant failure (loosening/subsidence and breakage), would healing problems (including superficial/deep infection, wound necrosis), soft tissue problems (e.g. pseudotumor), heterotopic ossification, abductor failure, implant wear and corrosion, osteolysis, neurovascular injury, decreased function, or pain. Measured at 1 and 10 weeks, 6, 9,12, 18, 24 months.

Countries

Canada, United States

Participant flow

Participants by arm

Arm	Count
Total Hip Arthroplasty Participants will undergo total hip arthroplasty. Total hip arthroplasty: Proscribed approaches will include minimally invasive total hip arthroplasty (i.e., two incision approaches) and hinged prostheses or capture cups. Other surgical approach aspects, the use of cemented components, the implant manufacturer, and femoral head size will not be standardized. Surgeons will use the manufacturers' specific implant guidelines for insertion.	718
Hemi-Arthroplasty Participants will undergo hemi-arthroplasty. Hemi-arthroplasty: Surgeons will use modern implants for hemi-arthroplasty, excluding non-modular, non-canal filling unipolar implants such as Moore's and Thompson's prostheses. The choice of modular unipolar versus bipolar hemi-arthroplasty will not be standardized. Whether implants are inserted with cement or a press-fit design will also not be standardized. Surgeons will use the manufacturers' specific implant guidelines for insertion.	723
Total	1,441

Baseline characteristics

Characteristic	Total	Hemi-Arthroplasty	Total Hip Arthroplasty
Age, Continuous	78.8 years STANDARD_DEVIATION 8.4	78.6 years STANDARD_DEVIATION 8.6	79.1 years STANDARD_DEVIATION 8.3
Major Coexisting Conditions Anemia or other blood disease	103 participants	55 participants	48 participants
Major Coexisting Conditions Back pain	135 participants	71 participants	64 participants
Major Coexisting Conditions Cancer	145 participants	80 participants	65 participants
Major Coexisting Conditions Depression	154 participants	84 participants	70 participants
Major Coexisting Conditions Diabetes	280 participants	145 participants	135 participants
Major Coexisting Conditions Heart disease	496 participants	249 participants	247 participants
Major Coexisting Conditions High blood pressure	877 participants	443 participants	434 participants
Major Coexisting Conditions Kidney disease	138 participants	67 participants	71 participants
Major Coexisting Conditions Lung disease	249 participants	122 participants	127 participants
Major Coexisting Conditions Osteoarthritis, degenerative arthritis	202 participants	91 participants	111 participants
Major Coexisting Conditions Osteopenia	58 participants	30 participants	28 participants
Major Coexisting Conditions Osteoporosis	224 participants	110 participants	114 participants
Major Coexisting Conditions Rheumatoid arthritis	34 participants	21 participants	13 participants
Major Coexisting Conditions Ulcers or stomach disease	116 participants	67 participants	49 participants
Prefracture Functional Status Able to ambulate without assistive device	1072 Participants	541 Participants	531 Participants
Prefracture Functional Status Uses assistive device for ambulation	369 Participants	182 Participants	187 Participants
Prefracture Living Status Institutionalized	57 Participants	27 Participants	30 Participants
Prefracture Living Status Not institutionalized	1384 Participants	696 Participants	688 Participants
Previous Surgery to Affected Hip	3 Participants	1 Participants	2 Participants
Race/Ethnicity, Customized Black	27 Participants	15 Participants	12 Participants
Race/Ethnicity, Customized East Asian	14 Participants	7 Participants	7 Participants
Race/Ethnicity, Customized Hispanic or Latino	13 Participants	6 Participants	7 Participants
Race/Ethnicity, Customized Middle Eastern	2 Participants	1 Participants	1 Participants
Race/Ethnicity, Customized Native or Aboriginal	3 Participants	1 Participants	2 Participants
Race/Ethnicity, Customized South Asian	9 Participants	6 Participants	3 Participants
Race/Ethnicity, Customized White	1367 Participants	684 Participants	683 Participants
Sex: Female, Male Female	1009 Participants	499 Participants	510 Participants
Sex: Female, Male Male	432 Participants	224 Participants	208 Participants

Adverse events

Event type	EG000 affected / at risk	EG001 affected / at risk
deaths Total, all-cause mortality	103 / 718	95 / 723
other Total, other adverse events	132 / 718	118 / 723
serious Total, serious adverse events	300 / 718	265 / 723

Outcome results

Primary

Number of Participants With Revision Surgery

The primary outcome is any unplanned secondary procedure within 2 years of the initial joint replacement surgery.