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

backgroundNumerous types of arthroplasties may be used in the surgical treatment of a hip fracture (proximal femoral fracture). The main differences between the implants are 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 the whole hip joint is replaced.

objectivesTo review all randomised trials that have compared different arthroplasties for the treatment of hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register which is compiled by regular searches of the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE and CINAHL. Additional trials were identified by searching reference lists of relevant articles, conference proceedings, and contact with trialists. Date of most recent search: October 2003. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing different arthroplasties (and/or cement), for the treatment of hip fractures. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a ten-item checklist and extracted data. MAIN

resultsFifteen trials involving 1670 patients were included. One trial involved two comparisons. Cemented prostheses, when compared with uncemented (five trials, 482 participants) were associated with a lower risk of failure to regain mobility (relative risk (RR) 0.60; 95% confidence interval (CI) 0.44 to 0.82) and of post-operation pain at a year or later (RR 0.51, 95% CI 0.31 to 0.81). For this comparison, there were no significant differences in any other outcome. Comparison of unipolar hemiarthroplasty with bipolar hemiarthroplasty (seven trials, 857 participants) showed no significant differences between the two types of implant. Two trials of 269 patients compared different types of hemiarthroplasty with a total hip replacement and two trials of 151 patients compared either different types of prosthesis head or different bipolar prostheses. Because of the limited number of cases and the use of different prostheses, no definite conclusions could be made from these four studies. REVIEWERS'

conclusionsCementing prostheses in place seems to reduce pain post-operatively and results in better mobility, but because of the under-reporting of outcomes and the small number of patients involved, no definite conclusions can be made. The role of bipolar prostheses and total hip replacement is uncertain. Further well-conducted randomised trials are required.