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Choosing the Best Treatment after Hip Fracture: Fixation or Joint Replacement

Posted on: 11/11/2003
Hip fracture? You're not alone. Every year more than a quarter of a million people in North America have one. When this many people are affected, doctors want to know: what's the best way to treat the problem?

For most broken hips, there are two choices: fix it or replace it. Fixing the fracture with a plate and screws or just screws is called internal fixation. This is a faster and easier way to treat a hip fracture, but there's a risk that the fracture won't heal. If the fracture has displaced, it usually means that the blood supply to the top of the femur has been cut off. This can result in a condition in which the top of the femur dies. It's called avascular necrosis (AVN). When AVN happens, the patient ends up needing a joint replacement.

There are several types of hip replacements to choose from: total, partial, or a special swivel type called a bipolarimplant. The good thing about a hip replacement is that it does away with the potential for AVN due to a displaced fracture.

Doctors at McMaster University in Ontario, Canada, reviewed studies from 1969 to 2002. They found nine trials with a total of 1,162 patients to compare. All subjects either had internal fixation or joint replacement. Several measures were used to compare the two treatment methods. These included the number of deaths, pain levels, function, operating time, infection, and the need for revision.

The authors found a greater risk of death and infection with a total hip replacement in the first four months. Pain levels and function were equal between the two treatment choices. Patients who had a total hip replacement lost more blood, and the operation usually took longer than for internal fixation.

The authors of this study say that hip replacement after hip fracture means only one operation to fix the problem. The risk of complications is higher with joint replacement. On the other hand, the need for a second surgery after internal fixation can be as high as 50 percent in some patients.

Is death more likely after total hip replacement compared with internal fixation? It appears so. Researchers think a larger study with more patients will give us the final answer about the best treatment after hip fracture.

Mohit Bhandari, MD, MSc, et al. Internal Fixation Compared with Arthroplasty for Displaced Fractures of the Femoral Neck. In The Journal of Bone and Joint Surgery. September 2003. Vol. 85-A. No. 9. Pp. 1673-1681.

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