BACKGROUND AND PURPOSE:

• American Academy of Orthopaedic Surgeons recommend total hip arthroplasty for displaced femoral neck fractures in patients who were capable of independent ambulation prior to the fracture
• The investigators of the HEALTH trial (N Engl J Med., 2019) examined the effect of total hip arthroplasty vs hemiarthroplasty and the risk for a secondary hip procedure

METHODS:

• Randomized controlled trial (RCT)
  • Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty (HEALTH) trial
• Setting
  • 80 centers in 10 countries
• Participants
  • ≥50 years of age
  • Displaced femoral neck fracture
  • History of ambulation without the assistance of another person prior to current fracture
• Exposures
  • Total hip arthroplasty procedure (replacement of only the femoral head with a prosthesis)
  • Hemiarthroplasty procedure (replacement of both the femoral head and the acetabulum with prostheses)
• Primary outcome
  • A secondary hip procedure within 24 months of follow-up
• Secondary outcome
  • Death
  • Serious adverse events
  • Hip-related complications
  • Health-related quality of life, function, and overall health

RESULTS:

• 749 patients randomized to total hip arthroplasty | 746 patients randomized to hemiarthroplasty
  • 85.1% of patients were alive at 24 months required for primary end point analysis
  • 70.1% were female | 80.2% were ≥70 years of age | 74.4% could ambulate without an assistive device before their fracture
• There was no difference in incidence of a secondary hip procedure between the groups
  • Total hip: 7.9%
  • Hemiarthroplasty: 8.3% 
  • Hazard ratio (HR) 0.95 (95% CI, 0.64 to 1.40; P=0.79)
• Hip instability or dislocation
  • Total hip: 4.7%
  • Hemiarthroplasty: 2.4%
  • HR 2.00 (99% CI, 0.97 to 4.09)
• Total hip arthroplasty was ‘modestly’ beneficial compared to hemiarthroplasty for the following
  • Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score (while statistically significant, considered clinically unimportant)
  • Pain score
  • Stiffness score
• Mortality was similar in the two treatment groups (P=0.48)
  • Total hip: 14.3%
  • Hemiarthroplasty: 13.1%
• Serious adverse events
  • Total hip: 41.8%
  • Hemiarthroplasty: 36.7%

CONCLUSION:

• This RCT did not find a significant difference in incidence of secondary hip procedures between total hip replacement and hemiarthroplasty
• Nor did total hip arthroplasty result in clinically important improvement in function and quality of life over 2 years
• The authors note that the current guidelines recommend total hip replacement but that results from this RCT

…suggest that the advantages of total hip arthroplasty may not be compelling

limited advantages of total hip arthroplasty, as well as the possible higher risk of complications, may be particularly important in regions of the world where total hip arthroplasty is not easily accessible or is cost-prohibitive

Learn More – Primary Sources:

Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture

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