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Carroll C, Stevenson M, Scope A, et al. Hemiarthroplasty and Total Hip Arthroplasty for Treating Primary Intracapsular Fracture of the Hip: A Systematic Review and Cost-Effectiveness Analysis. Southampton (UK): NIHR Journals Library; 2011 Oct. (Health Technology Assessment, No. 15.36.)

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Hemiarthroplasty and Total Hip Arthroplasty for Treating Primary Intracapsular Fracture of the Hip: A Systematic Review and Cost-Effectiveness Analysis.

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1Background

Description of health problem

Hip fracture is a common problem in the population aged ≥ 60 years. The annual rate of hip fracture in women in the UK has been reported to be exponentially distributed and to be 20 per 10,000, 38 per 10,000 and 73 per 10,000 at 65, 70 and 75 years of age, respectively.1 Only 5% of fractures occur in men and women under the age of 60 years.2 Owing to increasingly ageing populations, the absolute number of hip fractures is expected to rise.35 Half of all hip fractures are displaced intracapsular fractures, i.e. unstable fractures in which the blood supply to the femoral head may be impaired, affecting the rate of fracture healing.2,6,7

The treatment for displaced intracapsular fractures is currently determined by the mobility and functional demands of the patient. Individuals with a displaced intracapsular fracture and low pre-fracture mobility, cognitive impairment or low functional demands are generally treated with hemiarthroplasty (HA);2,8,9 as many as 37% of individuals with hip fractures may be cognitively impaired.10 Other patients with displaced intracapsular fractures, i.e. young patients and very frail elderly patients with limited mobility or cognitive impairment, tend to be treated with internal fixation.8 However, there is no consensus regarding the optimal treatment for older individuals who are cognitively intact and have high pre-fracture mobility or function: the options are HA or total hip arthroplasty (THA).8,9,11 The reported rate of THA in the Trent region of the UK for 1991–2004 was 2.3 per 100,000 diagnosed hip fractures.12 The vast majority of mobile patients with a displaced intracapsular hip fracture are treated by HA rather than by THA.13

The principal outcomes associated with hip arthroplasty are dislocation, revision rates and resultant quality of life. THA has been associated with higher rates of dislocation, which may be due to the greater degree of mobility permitted.4,14 It has also been reported that higher rates of dislocation are more likely if the surgical approach is posterolateral rather than anterolateral and if a smaller femoral head is used.1517 The incidence or recurrence of dislocation has been found to be significantly related to a reduction in an individual's quality of life.18 HA is particularly associated with pain, infection, loosening of the joint and acetabular erosion.6,19 Postoperative complications such as loosening and acetabular erosion, in particular, can necessitate revision surgery. Revision rates may therefore be higher for HA than for THA.

Current service provision

In the UK, the vast majority of mobile patients with a displaced intracapsular hip fracture are treated by HA rather than by THA.13 A survey of 223 UK hospitals in 2000 reported that, for active patients, HA was undertaken at 73% of hospitals, THA at 16% and internal fixation at 37% (the proportions exceed 100% as some hospitals reported using more than one method of treatment). Cemented prostheses were used in 74% of arthroplasties for active patients.11 The actual number of patients receiving only the two interventions for intracapsular hip fracture, and who were without cognitive impairment and were also independently mobile prior to the fracture, is not known. The National Joint Registry does not report these discrete data.

Description of technology under assessment

The technologies under assessment are HA and THA. HA involves replacing the femoral head, whereas THA replaces both the femoral head and the acetabular articular surface. HA may be unipolar (generally used for patients with lower functional demands2) or, more recently, the more mobile bipolar, which aims to reduce acetabular erosion.6 These prostheses may or may not be cemented into place.2

© 2011, Crown Copyright.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK98307

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