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In this multicenter, randomized trial comparing cemented with modern uncemented hemiarthroplasty in persons 60 years of age or older with an intracapsular hip fracture, cemented hemiarthroplasty resulted in a modestly but significantly better quality of life and a lower risk of periprosthetic fracture than uncemented hemiarthroplasty.

Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (−1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (−2 to 4; p=0·71). Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. Canadian Institutes of Health Research.

BackgroundFemoral neck fractures are common injuries in the elderly and represent a major source of morbidity and mortality. Due to the benefits, bipolar hip hemiarthroplasty (BHH) is a popular method to treat. The purpose of this study is to evaluate the functional and radiographic outcomes for BHH comparing the direct anterior approach (DAA) to the anterolateral approach (ALA) to the hip joint.MethodsWe used a prospective, randomized observational study design, where we enrolled 83 patients at a level-I-trauma center presenting with indication for BHH. We followed up the participants at defined intervals over a period of 1 year. The follow-up examinations were carried out at defined time intervals for a period of 1 year. Calculations were performed with Statistical Package for Social Sciences (SPSS) 21.0.ResultsConcerning postoperative pain sensation, the anterior group had statistically significantly decreased pain levels at one (p = 0.02), seven (p = 0.04) and 14 days (p = 0.02) following the intervention when compared to the ALA sample. The postoperative modified Barthel-Index showed a statistically significant difference on the first postoperative day at the anterior group.ConclusionAlthough we compared two minimally invasive approaches, our results shows a statistically significant difference in pain intensity and mobility for the early postoperative period using the direct anterior approach.

Background Intravenous tranexamic acid (TA) has proven efficacy in reducing blood loss and incidence of transfusion of blood products in elective total joint arthroplasty. However, evidence of efficacy in the setting of intracapsular hip fractures needing hip hemiarthroplasty (HA) or total hip arthroplasty (THA) are scarce. This study aimed to assess post-operative transfusion incidence in this clinical setting. Methods Over a five-year period 250 patients with intracapsular neck of femur fractures requiring arthroplasty were randomised to two groups. The treatment group received three-dose intravenous TA protocol and the control group received usual treatment without administration of TA. Blood loss was estimated from the change in Hb levels on day 1, 3 and 5 after surgery compared to preoperative levels. Transfusions of blood products were recorded when they were triggered by an a priori protocol. Post-operative complications were recorded during patient hospital admission. Results The intervention group showed significantly lower transfusion incidence of packed red blood cells (PRBC) (6 vs. 15, p  = 0.04, OR = 0.37, 95%CI OR = 0.14 to 0.99) and in the group of patients who received a blood transfusion, a trend was observed for patients who received TA to have lesser number of units of PRBC (mean = 1.3 vs. 1.6, p  = 0.51). A significant difference was noted in post-operative Hb levels of day 1,3 and 5. Backward stepwise multivariable regression analysis showed the use of TA was the most significant factor for reduction in postoperative blood transfusion ( p  = 0.047, OR = 0.37, 95% CI OR = 0.14 to 0.99). Assessment of the strength of the correlation showed modest correlation (Pearson correlation − 0.13 p  = 0.04, 95% CI correlation= -0.25 to -0.01). There was no increase in adverse events in patients who received TA. Conclusion The use of TA in setting of intracapsular hip fractures requiring arthroplasty reduces blood loss, the need for transfusion of blood products and may reduce surgical site complications without increasing the risk of VTE.

Background The relevance of femoral neck fractures (FNFs) increases with the ageing of numerous societies, injury-related decline is observed in many patients. Treatment strategies have evolved towards primary joint replacement, but the impact of different approaches remains a matter of debate. The aim of this trial was to evaluate the benefit of an anterior minimally-invasive (AMIS) compared to a lateral Hardinge (LAT) approach for hemiarthroplasty in these oftentimes frail patients. Methods Four hundred thirty-nine patients were screened during the 44-months trial, aiming at the evaluation of 150 patients > 60 yrs. of age. Eligible patients were randomised using an online-tool with completely random assignment. As primary endpoint, early mobility, a predictor for long-term outcomes, was evaluated at 3 weeks via the “Timed up and go” test (TUG). Secondary endpoints included the Functional Independence Measure (FIM), pain, complications, one-year mobility and mortality. Results A total of 190 patients were randomised; both groups were comparable at baseline, with a predominance for frailty-associated factors in the AMIS-group. At 3 weeks, 146 patients were assessed for the primary outcome. There was a reduction in the median duration of TUG performance of 21.5% (CI [− 41.2,4.7], p  = 0.104) in the AMIS-arm (i.e., improved mobility). This reduction was more pronounced in patients with signs of frailty or cognitive impairment. FIM scores increased on average by 6.7 points (CI [0.5–12.8], p  = 0.037), pain measured on a 10-point visual analogue scale decreased on average by 0.7 points (CI: [− 1.4,0.0], p  = 0.064). The requirement for blood transfusion was lower in the AMIS- group, the rate of complications comparable, with a higher rate of soft tissue complications in the LAT-group. The mortality was higher in the AMIS-group. Conclusion These results, similar to previous reports, support the concept that in elderly patients at risk of frailty, the AMIS approach for hemiarthroplasty can be beneficial, since early mobilisation and pain reduction potentially reduce deconditioning, morbidity and loss of independence. The results are, however, influenced by a plethora of factors. Only improvements in every aspect of the therapeutic chain can lead to optimisation of treatment and improve outcomes in this growing patient population. Trial registration www.clinicaltrials.gov : NCT01408693 (registered August 3rd 2011).

Background The HemiSPAIRE trial is being conducted to determine whether a modified muscle sparing technique (SPAIRE-“Save Piriformis and Internus, Repairing Externus”) in hip hemiarthroplasty brings clinical benefits compared to the standard lateral technique in adults aged 60 years or older, with a displaced intracapsular hip fracture. This article describes the detailed statistical analysis plan for the trial.  Methods and design HemiSPAIRE is a definitive, pragmatic, superiority, multicentre, randomised controlled trial (with internal pilot) with two parallel groups. Participants, ward staff and all research staff involved in post-operative assessments are blinded to allocation. This article describes in detail (1) the primary and secondary outcomes; (2) the statistical analysis principles, including a survivor average causal effect (SACE) method chosen specifically to address the issue of potential bias from differential survival between trial arms, which was seen from data review by the Trial Steering Committee, the participants that will be included in each analysis, the covariates that will be included in each analysis, and how the results will be presented; (3) planned main analysis of the primary outcome; (4) planned analyses of the secondary outcomes; and (5) planned additional analyses of the primary and secondary outcomes. Trial registration ClinicalTrials.gov NCT04095611. Registered on 19 September 2019.

As the age profile of our population expands, we can expect subsequent increase in patients presenting with intracapsular fracture. The onus remains on the surgeon to make all reasonable efforts to find new and innovative means of reducing associated morbidity and mortality of the treatment of these injuries. This challenge is particularly relevant in the elderly and in patients with multiple co-morbidities. In this study, 100 patients were randomly allocated into two groups. One group had dissection to the level of the hip joint under direct diathermy control; the other group had dissection using a scalpel with supplementary electrocautery. Intraoperative total blood loss prior to dissection of the abductors was measured by collecting blood using wound swabs using a local protocol and results were statistically analysed using PROC GLM SAS. We demonstrate a clear advantage in the use of diathermy to create a hip incision showing a significant reduction in wound-related blood loss and a reduction, whilst not statistically significant, in total operative blood loss using diathermy incision. Larger randomised prospective trials are necessary to study the effects of this intervention in a larger patient population so that these end-points can be adequately assessed.

Background Suprainguinal Fascia Iliaca Compartment Block (SFICB) is a widely utilized technique for managing postoperative pain in hip surgery. The timing of its administration, either preoperative or postoperative, plays a crucial role in influencing patient outcomes. This study aims to compare the effects of preoperative versus postoperative SFICB on postoperative recovery in patients undergoing hip hemiarthroplasty (HHA). Methods In this prospective randomized trial, 60 patients scheduled for HHA were randomly assigned to two groups: Group PreS (preoperative SFICB) and Group PostS (postoperative SFICB). SFICB was performed under ultrasound guidance using 0.20% bupivacaine. The primary outcome was assessed using the Quality of Recovery-15 (QoR-15) score at 24 h postoperatively. Secondary outcomes included the Nursing Delirium Screening Scale (N-DSS), postoperative nausea/vomiting (PONV), and opioid consumption. Results Demographic variables were comparable between groups ( p  > 0.05). Spinal anesthesia duration was shorter in Group PreS ( p  = 0.005), while surgery and total procedure times were similar ( p  > 0.05). QoR-15 scores improved in both groups, with significant increases in moderate ( p  = 0.004, p  = 0.047) and severe pain ( p  < 0.001, p  = 0.028). At T1, total QoR-15 ( p  = 0.034) and severe pain score ( p  < 0.001) were significantly better in Group PreS. Preoperative fentanyl need was lower in Group PreS ( p  < 0.001). Although first rescue analgesia time was longer in Group PostS ( p  = 0.026) morphine equivalent consumption ( p  = 0.564) was similar. N-DSS, delirium incidence, and PONV showed no differences ( p  > 0.05). No complications were observed. Conclusions Preoperative SFICB improved postoperative QoR-15 scores compared to postoperative SFICB in elderly HHA patients, but optimal timing and perioperative settings require further research. Trial registration ClinicalTrials.gov (ID NCT05965544). The clinical trial was prospectively registered on July 20, 2023.

Objective The relationship between the surgical approach used for hemiarthroplasty and periprosthetic bone mineral density (BMD) is not well understood. We have previously described a decrease in BMD 1 year postoperatively. Here, we assessed the medium-term changes in periprosthetic BMD. Methods We performed a follow-up study of patients with femoral neck fracture (FNF) who underwent uncemented hemiarthoplasty using a direct lateral or anterolateral approach. Dual-energy X-ray absorptiometry (DXA) was used to evaluate the changes in BMD in 23 patients over 5 years. Results A mean 6% loss of total BMD occurred over 1 year, but between 1 and 5 years, BMD was restored to the baseline value. The mean total BMD in the anterolateral group had decreased by 2% after 3 months and 3% after 12 months, and increased by 2% after 5 years, vs. decreases of 7%, 8%, and 3% for the direct lateral group. Between 1 and 5 years, BMD increased in Gruen zones 2, 3, 4, 5, and 6 in both groups. There was a significantly larger increase in zone 4 in the lateral group (4%) than the anterolateral group. Conclusion The surgical approach affects periprosthetic BMD in patients with FNF. Furthermore, BMD is restored to the baseline value 5 years postoperatively. ClinicalTrials.gov registration number: NCT03753100.

Background Hemiarthroplasty has been shown superior to internal fixation for displaced femoral neck fractures (FNF) in the first 2 years. However, there are unanswered questions about the performance of hemiarthroplasty over the longer term compared with internal fixation. Questions/purposes We sought to compare hemiarthroplasty with internal fixation in terms of (1) outcomes scores for pain, hip function, and quality of life at a minimum of 5 years after surgery in a randomized trial. A secondary purpose was to compare (2) patient survival and (3) frequency of reoperation in the two groups. Methods A total of 222 consecutive patients older than 60 years, including those cognitively impaired, with FNF were randomized to either internal fixation with two parallel screws or bipolar hemiarthroplasty. At a minimum followup of 4.9 years (mean, 5.9 years; range, 4.9–7.2 years), 68 of the 70 surviving patients were examined by a study nurse and study physiotherapist blinded to initial treatment. Questionnaires on hip function (Harris hip score), quality of life (Eq5D), and activity of daily living function (Barthel ADL) were administered. The Barthel ADL index score was split into good function (score 95 or 100) and reduced function (score below 95). Results The mean survival of the groups was similar with 66.4% (73 of 110) of the patients undergoing hemiarthroplasty and 70.5% (79 of 112) of the patients undergoing internal fixation having died since surgery (p = 0.51). Only 12 of 31 living patients in the internal fixation group had retained their native hips at a mean of 6 years. Between 2 and 6 years, there were two new major reoperations (both in the internal fixation group, for avascular necrosis and deep wound infection). The mean Harris hip score was 66 (SD 19) and 67 (SD 20) in the internal fixation and hemiarthroplasty groups, respectively (p = 0.96). The mean Eq5D index was 0.50 (SD 0.40) in the internal fixation group and 0.34 (SD 0.36) in the hemiarthroplasty group (p = 0.10). Function in terms of ADLs was comparable between the groups; of the patients in the internal fixation group, 42% reported good function on the Barthel ADL index, and the corresponding number in the hemiarthroplasty group was 51% (p = 0.44). Conclusions Hemiarthroplasty has predictable and good long-term results after FNF and is the treatment of choice compared with internal fixation. Further studies will evaluate if total hip arthroplasty has advantages over hemiarthroplasty in patients with fracture with long life expectancy. Level of Evidence Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.