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

 

Abstract

Background

Numerous types of arthroplasties may be used in the surgical treatment of a hip fracture (proximal femoral fracture). The main differences between the implants are in the design of the stems, whether the stem is cemented or uncemented, whether a second articulating joint is included within the prosthesis (bipolar prosthesis), or whether a partial (hemiarthroplasty) or total whole hip replacement is used.

Objectives

To review all randomised controlled trials comparing different arthroplasties for the treatment of hip fractures in adults.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2009), CENTRAL (The Cochrane Library 2009, Issue 3), MEDLINE, EMBASE and trial registers (all to September 2009), and reference lists of articles.

Selection criteria

All randomised and quasi-randomised controlled trials comparing different arthroplasties and their insertion with or without cement, for the treatment of hip fractures.

Data collection and analysis

Two review authors independently assessed trial quality, by use of a 10-item checklist, and extracted data.

Main results

Twenty-three trials involving 2861 older and mainly female patients with proximal femoral fractures are included. Cemented prostheses, when compared with uncemented prostheses (6 trials, 899 participants) were associated with a less pain at a year or later and improved mobility. No significant difference in surgical complications was found. One trial of 220 participants compared a hydroxyapatite coated hemiarthroplasty with a cemented prosthesis and reported no notable differences between the two prosthesis. Comparison of unipolar hemiarthroplasty with bipolar hemiarthroplasty (7 trials, 857 participants, 863 fractures) showed no significant differences between the two types of implant. Seven trials involving 734 participants compared hemiarthroplasty with a total hip replacement (THR). Most studies involved cemented implants. Dislocation of the prosthesis was more common with the THR but there was a general trend within these studies to better functional outcome scores for those treated with the THR.

Authors' conclusions

There is good evidence that cementing the prostheses in place will reduce post-operative pain and lead to better mobility. From the trials to date there is no evidence of any difference in outcome between bipolar and unipolar prosthesis. There is some evidence that a total hip replacement leads to better functional outcome than a hemiarthroplasty. Further well-conducted randomised trials are required.

 

Plain language summary

Comparison of different types of artificial hip joints that may be used for treating fractures of the hip

Many different types of artificial hip joints (arthroplasties) may be used to treat hip fractures, which are breaks (fractures) in the thigh bone (femur) near the hip joint. Differences in these artificial joints include different shapes of the stem set into the bone; the incorporation of a secondary joint (bipolar joint); joints that replace only the ball part of the ball and socket hip joint (hemiarthroplasty) and those that also involve replacing the socket part of the hip joint (total hip replacement). In addition an arthroplasty may be of the press fit type or secured in place within the bone using a filler (bone cement).

Twenty-three trials involving 2861 older and mainly female patients with hip fractures are included in this review. The findings from the three main comparisons are summarised here. Six studies involving 899 participants compared a press fit arthroplasty with one that was secured in place with bone cement. Those joints that were cemented in place resulted in less pain and better mobility than those that were of the press fit type. Seven trials involving 857 participants compared those implants which have a second joint built into them (bipolar hemiarthroplasties) with those without this additional joint (unipolar hemiarthroplasties). No notable differences between these two types of implant were demonstrated. Seven studies of 734 participants compared different types of hemiarthroplasty with a total hip replacement. Most implants had been cemented in place. There was a trend to better functional outcomes after total hip replacement, but firm conclusions could not be made because of the lack of patient numbers.

There is good evidence that people with arthroplasties that are cemented in place have less pain and better mobility after the operation than those, which are inserted as a press fit. There is limited evidence that a total hip replacement leads to better functional outcome than a hemiarthroplasty.

 

Resumen

Antecedentes

Artroplastias (con y sin cemento óseo) para la fractura proximal de fémur en adultos

Se pueden utilizar numerosos tipos de artroplastias en el tratamiento quirúrgico de la fractura de cadera (fractura proximal de fémur). Las diferencias principales entre los implantes están relacionadas con el diseño de los vástagos, si el vástago es cementado o no, si se incluye una segunda articulación en la prótesis (prótesis bipolar), o si se realiza reemplazo parcial (hemiartroplastia) o total de cadera.

Objetivos

Analizar todos los ensayos controlados aleatorios que compararon las diferentes artroplastias para el tratamiento de la fractura de cadera en adultos.

Estrategia de búsqueda

Se hicieron búsquedas en el Registro Especializado del Grupo Cochrane de Lesiones Óseas, Articulares y Musculares (Cochrane Bone, Joint and Muscle Trauma Group) (septiembre 2009), CENTRAL (The Cochrane Library 2009, número 3), MEDLINE, EMBASE, en registros de ensayos (todos hasta septiembre 2009), y en listas de referencias de artículos.

Criterios de selección

Ensayos controlados aleatorios y cuasialeatorios que comparan las diferentes artroplastias y su inserción, con o sin cemento para el tratamiento de las fracturas de caderas.

Obtención y análisis de los datos

Dos revisores evaluaron de forma independiente la calidad de los ensayos con una lista de control de diez ítems, y extrajeron los datos.

Resultados principales

Se incluyeron 23 ensayos que incorporaron a 2861 pacientes de edad avanzada, principalmente mujeres, con fractura proximal de fémur. Las prótesis cementadas, en comparación con las prótesis no cementadas (6 ensayos, 899 participantes), se asociaron con menor dolor al año o más, y con mejor movilidad. No se encontraron diferencias significativas en las complicaciones quirúrgicas. Un ensayo con 220 participantes comparó la hemiartroplastia revestida con hidroxiapatita con una prótesis cementada y no informó ninguna diferencia significativa entre las dos prótesis. La comparación de hemiartroplastia unipolar con hemiartroplastia bipolar (7 ensayos, 857 participantes, 863 fracturas) no mostró diferencias significativas entre los dos tipos de implantes. Siete ensayos que incluyeron a 734 pacientes compararon la hemiartroplastia con el reemplazo total de cadera (RTC). La mayoría de los estudios incluyeron los implantes cementados. La luxación de la prótesis fue más común con el RTC, pero hubo una tendencia general dentro de estos estudios a mejorar las puntuaciones de resultado funcional para los pacientes con RTC.

Conclusiones de los autores

Existen pruebas convincentes de que la prótesis cementada puede reducir el dolor posoperatorio y resultar en una mejor movilidad. De los ensayos hasta la fecha, no existen pruebas de alguna diferencia en el resultado entre la prótesis bipolar y unipolar. Existen algunas pruebas de que el reemplazo total de cadera produce un resultado funcional mejor que la hemiartroplastia. Se requieren ensayos aleatorios bien realizados.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano

 

摘要

背景

成年人的近側股骨骨折的髖關節成形術(使用及未使用骨水泥)

許多種類的關節成形術可能會被用在治療髖骨骨折(近側股骨骨折)的手術病患身上。各種植入物之間最主要的不同就是骨柄的設計，有的骨柄會用骨水泥固定，有的則不會；有的在人工關節中會加入第二相連接的關節(雙極式人工關節)，而有的會使用部分(半關節成形術)或全髖關節置換術。

目標

檢視所有比較成年人中使用不同種類的關節成形術來治療髖關節骨折的隨機對照試驗。

搜尋策略

我們搜尋了 the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (2005年12月)、the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005年) 、MEDLINE、EMBASE、the UK National Research Register、 一些骨科期刊、研討會手冊以及文章的參考文獻清單。

選擇標準

納入關於治療髖骨骨折所使用的不同種類的關節成形術及其置入或未置入骨水泥的所有隨機及半隨機對照試驗。

資料收集與分析

兩位文獻回顧作者獨立地使用十個項目量表審查試驗品質，並擷取數據。

主要結論

我們納入囊括1920位參與者的十七項試驗。一項試驗包括了兩組對照。使用加入水泥的人工關節與無水泥使用的人工關節(六項試驗共549位參與者)相比，與一年或一年後降低疼痛有相關性(16/52 versus 28/52; RR 0.51, 95% CI 0.31 to 0.81)，且移動能力有改善的傾向。同時並沒有發現在手術併發症方面有任何顯著的改變。將單極的半關節成形術及雙極的半關節成形術(七項試驗共包括857位參與者及863位骨折病患)比較對照後顯示此兩種植入物之間並沒有顯著的不同。兩個包括共232位的病患的試驗將未加入骨水泥的半關節成形術和全髖關節置換術做比較。兩個研究皆指出沒有加入骨水泥的人工關節會增加疼痛感，而一個研究認為在使用全髖關節置換術後能有較佳的移動能力並且長期來說有較低的再置換率。兩個包括214位參與者的試驗比較了加入骨水泥後的髖關節成形術與全髖關節置換術的不同。兩個試驗皆發現在各種人工關節之間幾乎沒有不同。在其中一個試驗發現全髖關節置換術的手術時間雖然較長一點但是會有較佳的功能改善

作者結論

有限的證據中指出在人工關節中使用骨水泥也許能夠降低術後疼痛並且移動能力恢復較佳。但是卻沒有足夠的證據來判定雙極式人工關節與全髖關節置換術所扮演的角色。我們需要更進一步改良的隨機試驗。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

我們比較了可能會被用來治療髖關節骨折當中不同種類的人工髖關節。許多不同種類的人工髖關節(關節成形術)也許會被用做治療靠近髖關節(髖骨骨折)的大腿骨(股骨)骨折。這些不同的人工關節之間的異同處包括了用來連接骨頭的不同形狀的骨柄；次要關節(兩極式關節)的組合；只更換杵臼關節中的股骨頭部份(半關節成形術)以及包括更換髖關節的髖臼部分(全髖關節置換術)。另外，關節成形術可能會使用加壓或使用膠水(骨水泥)來使關節之間固定在其位置上。納入了549位參與者的六個研究中，比較了使用加壓方式來執行關節成形術者及使用骨水泥來將關節固定者。比起使用加壓的方式，那些使用骨水泥來固定的患者似乎引起較少的疼痛且有可能移動性也較佳。包括了857位參與者的七個試驗比較了有次要關節的人工關節組(雙極半關節成形術)及那些沒有額外關節的人工關節組(單極半關節成形術)。在這兩種植入物型是中並未發現任何顯著的差異。共有407位參與者的三個試驗中，比較了使用在全髖關節置換術上不同種類的半關節成形術。但並沒有足夠的患者數足以比較出兩種半關節成形術的不同。總結來說，從隨機試驗中並沒有足夠的證據顯示半關節成形術是最好的治療方式。但仍有些證據證明，比起僅以加壓方式處理，使用骨水泥固定的半關節成形術患者有較少的疼痛感，且在術後移動能力較佳。