Hip Replacement Patient c/o Pain in Left Hip

Pelvic X-ray showing the hip replacement. Patient complaining of pain while walking and climbing stairs. Hip replacement was done 10 years ago.

Key Messages

• There is no 'best treatment' for this type of broken hip.
• More people needed additional surgery on their broken hip after treatment with condylocephalic nails or static fixed angle plates.
• There may be no difference between a short cephalomedullary nail and a dynamic fixed angle plate.
• We found too few studies to know whether any of these treatments were better at improving quality of life.

We searched for studies that compared one or more of these treatments:

• Using metal implants to fix the broken parts of the bone. These long or short nails may be inserted downwards from the hip joint towards the knee (cephalomedullary nails). Some nails may be inserted upwards from the knee towards the hip joint (condylocephalic nail). Alternatively, the surgeon may use a 'fixed angle plate' which sits on the outer edge of the broken bone and is attached to the bone with screws or pins. Often the screws for these plates slide in a sleeve and the plate is called a dynamic fixed angle plate. Without this, it is a static fixed angle plate.
• Replacing the broken hip with an artificial one. This can be done using a hemiarthroplasty (HA), which replaces only the ball part of the joint, or with a total hip arthroplasty (THA) which replaces all of the hip joint including the socket.
• Using external fixation. Pins or screws are placed into the bones around the fracture and a metal frame holds these nails in place. The frame sits outside the body, around the broken hip.
• Treatment without an operation, usually requiring a period of rest in bed whilst the leg is held in position using traction with weights.

We found 184 studies with 26,073 people with this type of hip fracture. We included 73 of these studies in a network meta-analysis. We found little or no difference in how many people died with each treatment. We were unsure whether any of the treatments were better than another at reducing deaths within 12 months of surgery.

For most treatments, we also found little or no difference in whether people needed to have additional surgery on their broken hip. However, for the condylocephalic nail and the static fixed angle plate, more people needed additional surgery compared to people treated with a dynamic fixed angle plate. These treatments may increase the chance of needing additional surgery. We are not very confident in these findings due to various issues with the studies.

Summary of Findings on Hip Replacement Procedures

A hip replacement can be done using a hemiarthroplasty (HA), which replaces part of the hip joint. The replacements can be unipolar (a single artificial joint), or bipolar (with an additional joint within the HA). Alternatively, surgery may replace the whole hip joint ‐ a total hip arthroplasty (THA). Both of these artificial joints can be fixed in place with or without bone cement.

We included 58 studies, with 10,654 adults with 10,662 hip fractures.

Key Results

• Cemented HAs vs. uncemented HAs: Cemented HAs improve health-related quality of life (HRQoL) and reduce the risk of death at 12 months after surgery. The sizes of these benefits ranged from a small to a large effect. There may be little or no difference between treatments in the ability to use the hip, but the evidence was very uncertain.
• Bipolar HAs vs. unipolar HAs: The type of HA probably makes little or no difference to how many people die within 4 months or up to 12 months after surgery and may make little or no difference to the need for additional surgery. No studies reported functional status.
• THAs vs. HAs: For most outcomes, it is uncertain whether there are differences between these treatments. There may not be a difference in the risk of additional surgery but the possibility of an important benefit of THA cannot be ruled out. Risk of most complications was similar, but hip dislocation is increased with THA.

Conclusions

For people having a HA, a cemented replacement probably produces a better outcome overall than an uncemented replacement. There is no evidence that a bipolar HA leads to different outcomes from a unipolar HA. Differences between a total hip replacement and partial hip replacement are small and may not be clinically important.