More than 300,000 hip fractures occur in the United States each year.
Courtesy of OREF

AAOS Now

Published 1/1/2009
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Amy Kile

When a hemi is only semi-right

OREF-funded study explores total vs. hemiarthroplasty

More than 300,000 hip fractures occur in the United States each year—a figure expected to double by 2023. To ensure that patients receive optimal treatment, William B. Macaulay, MD, is studying displaced femoral neck fracture treatments, supported by funding from the Orthopaedic Research and Education Foundation (OREF) and the American Association of Hip and Knee Surgeons (AAHKS).

“Historically, displaced femoral neck fractures have been treated with hemiarthroplasty, without a lot of thought being given to patients’ clinical and social situations and life expectancy. If you look at the literature over the past 10 years, however, total hip arthroplasty (THA) might be better,” said Dr. Macaulay.

Different patients, different treatments
“The big metal balls used in hemiarthroplasty create a stable hip, but can also lead to ‘prosthetic arthritis’ in young, active patients, who might require conversion surgery later,” he explains.

While focusing on the clinical aspects of THA versus hemiarthroplasty, Dr. Macaulay received some funding from the AAHKS Research Committee, which partnered with OREF to distribute seed money for hip- and knee-related research. Later, he successfully applied for an OREF Prospective Clinical Research Grant so that he could begin recruiting patients to participate in a randomized study.

“Patients had to trust in the flip of a coin. We had to convince them that we really weren’t sure which was the best treatment in terms of getting better, of the need for further surgery, and the potential risks. This was an honest representation of the co-investigators’ feelings about the choice of treatment,” he says.

Enlisting other institutions
Five hospitals, known as the Displaced Femoral neck fracture Arthroplasty Consortium for Treatment and Outcomes (DFACTO), enrolled enough pa­tients to evaluate and compare the outcomes of the two procedures.

To participate, patients with displaced femoral neck fractures had to be able to live independently, take care of themselves, and perform everyday tasks such as grocery shopping. They were also required to pass a short mental health exam to be sure they could complete follow-up questionnaires.

Get up and go
Patients were asked to complete a set of questionnaires both before and after surgery. All forms were returned to Columbia for analysis. Questionnaires included the Harris Hip Score and the Western Ontario and McMaster Universities Osteo­arthri­tis Index (WOMAC), a validated pain and functioning questionnaire.

“The presurgical WOMAC scores were absolutely abysmal because patients couldn’t even walk. WOMAC scores went from really bad numbers to very good numbers, regardless of the treatment the patient received,” Dr. Macaulay says.

The quantitative analysis relied on WOMAC subscores that measure stiffness and range of motion, and a Canadian-based validated functional outcome tool, the “Timed Up-and-Go Test.”

“Patients start in seated position in an armed chair and are timed as they stand up, walk 10 feet, turn around, walk back to the chair, and sit down,” Dr. Macaulay explains.

Will it be a total or a hemi?
For relatively younger, more active patients, average WOMAC scores showed less stiffness and better range of motion with the THA compared to hemiarthroplasty. But, according to Dr. Macaulay, age should not be the deciding factor. Instead, he said, the procedure should be determined on a patient-by-patient basis.

If a patient resides and expects to remain in a nursing home, the hemiarthroplasty might be better because it stabilizes the joint more quickly. Less active patients are unlikely to wear out the joint.

“Patients who live in an assisted living community with very little help fall into a gray area that needs more study. Patients who live alone, do their own shopping, and take public transportation typically do better with a THA,” Dr. Macaulay says.

Dr. Macaulay’s research won the Lawrence Dorr Award for the most outstanding paper in surgical techniques and technologies at the 2007 AAHKS Annual Meeting, and will be published in the Journal of Arthroplasty.

Clinical decision making
Dr. Macaulay believes research is important to all orthopaedic surgeons.

“Orthopaedic clinicians need research to help make difficult clinical decisions. We never thought twice about whether a better way of treating displaced femoral neck fractures existed. Everyone got a hemi,” he explains. “But this is a multibillion-dollar problem heading Medicare’s way. If we don’t treat these fractures effectively, Medicare will go bankrupt on just this one public health problem.

“That’s when you realize how important research is. OREF needs a pat on the back for encouraging guys like myself to do this research.”

Amy Kile, OREF publications manager, can be reached at kile@oref.org