BACKGROUND

Hip fractures are a major healthcare problem, presenting a huge challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising rapidly. The majority of hip fractures are treated surgically. This review evaluates evidence for types of arthroplasty: hemiarthroplasties (HAs), which replace part of the hip joint; and total hip arthroplasties (THAs), which replace all of it.

OBJECTIVES

To determine the effects of different designs, articulations, and fixation techniques of arthroplasties for treating hip fractures in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, seven other databases and one trials register in July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different arthroplasties for treating fragility intracapsular hip fractures in older adults. We included THAs and HAs inserted with or without cement, and comparisons between different articulations, sizes, and types of prostheses. We excluded studies of people with specific pathologies other than osteoporosis and with hip fractures resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for seven outcomes: activities of daily living, functional status, health-related quality of life, mobility (all early: within four months of surgery), early mortality and at 12 months after surgery, delirium, and unplanned return to theatre at the end of follow-up.

MAIN RESULTS

We included 58 studies (50 RCTs, 8 quasi-RCTs) with 10,654 participants with 10,662 fractures. All studies reported intracapsular fractures, except one study of extracapsular fractures. The mean age of participants in the studies ranged from 63 years to 87 years, and 71% were women. We report here the findings of three comparisons that represent the most substantial body of evidence in the review. Other comparisons were also reported, but with many fewer participants. All studies had unclear risks of bias in at least one domain and were at high risk of detection bias. We downgraded the certainty of many outcomes for imprecision, and for risks of bias where sensitivity analysis indicated that bias sometimes influenced the size or direction of the effect estimate. HA: cemented versus uncemented (17 studies, 3644 participants) There was moderate-certainty evidence of a benefit with cemented HA consistent with clinically small to large differences in health-related quality of life (HRQoL) (standardised mean difference (SMD) 0.20, 95% CI 0.07 to 0.34; 3 studies, 1122 participants), and reduction in the risk of mortality at 12 months (RR 0.86, 95% CI 0.78 to 0.96; 15 studies, 3727 participants). We found moderate-certainty evidence of little or no difference in performance of activities of daily living (ADL) (SMD -0.03, 95% CI -0.21 to 0.16; 4 studies, 1275 participants), and independent mobility (RR 1.04, 95% CI 0.95 to 1.14; 3 studies, 980 participants). We found low-certainty evidence of little or no difference in delirium (RR 1.06, 95% CI 0.55 to 2.06; 2 studies, 800 participants), early mortality (RR 0.95, 95% CI 0.80 to 1.13; 12 studies, 3136 participants) or unplanned return to theatre (RR 0.70, 95% CI 0.45 to 1.10; 6 studies, 2336 participants). For functional status, there was very low-certainty evidence showing no clinically important differences. The risks of most adverse events were similar. However, cemented HAs led to less periprosthetic fractures intraoperatively (RR 0.20, 95% CI 0.08 to 0.46; 7 studies, 1669 participants) and postoperatively (RR 0.29, 95% CI 0.14 to 0.57; 6 studies, 2819 participants), but had a higher risk of pulmonary embolus (RR 3.56, 95% CI 1.26 to 10.11, 6 studies, 2499 participants). Bipolar HA versus unipolar HA (13 studies, 1499 participants) We found low-certainty evidence of little or no difference between bipolar and unipolar HAs in early mortality (RR 0.94, 95% CI 0.54 to 1.64; 4 studies, 573 participants) and 12-month mortality (RR 1.17, 95% CI 0.89 to 1.53; 8 studies, 839 participants). We are unsure of the effect for delirium, HRQoL, and unplanned return to theatre, which all indicated little or no difference between articulation, because the certainty of the evidence was very low. No studies reported on early ADL, functional status and mobility. The overall risk of adverse events was similar. The absolute risk of dislocation was low (approximately 1.6%) and there was no evidence of any difference between treatments. THA versus HA (17 studies, 3232 participants) The difference in the risk of mortality at 12 months was consistent with clinically relevant benefits and harms (RR 1.00, 95% CI 0.83 to 1.22; 11 studies, 2667 participants; moderate-certainty evidence). There was no evidence of a difference in unplanned return to theatre, but this effect estimate includes clinically relevant benefits of THA (RR 0.63, 95% CI 0.37 to 1.07, favours THA; 10 studies, 2594 participants; low-certainty evidence). We found low-certainty evidence of little or no difference between THA and HA in delirium (RR 1.41, 95% CI 0.60 to 3.33; 2 studies, 357 participants), and mobility (MD -0.40, 95% CI -0.96 to 0.16, favours THA; 1 study, 83 participants). We are unsure of the effect for early functional status, ADL, HRQoL, and mortality, which indicated little or no difference between interventions, because the certainty of the evidence was very low.  The overall risks of adverse events were similar. There was an increased risk of dislocation with THA (RR 1.96, 95% CI 1.17 to 3.27; 12 studies, 2719 participants) and no evidence of a difference in deep infection.

AUTHORS' CONCLUSIONS

For people undergoing HA for intracapsular hip fracture, it is likely that a cemented prosthesis will yield an improved global outcome, particularly in terms of HRQoL and mortality. There is no evidence to suggest a bipolar HA is superior to a unipolar prosthesis. Any benefit of THA compared with hemiarthroplasty is likely to be small and not clinically appreciable. We encourage researchers to focus on alternative implants in current clinical practice, such as dual-mobility bearings, for which there is limited available evidence.

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

AIMS

Conventional patient-reported surveys, used for patients undergoing total hip arthroplasty (THA), are limited by subjectivity and recall bias. Objective functional evaluation, such as gait analysis, to delineate a patient's functional capacity and customize surgical interventions, may address these shortcomings. This systematic review endeavours to investigate the application of objective functional assessments in appraising individuals undergoing THA.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied. Eligible studies of THA patients that conducted at least one type of objective functional assessment both pre- and postoperatively were identified through Embase, Medline/PubMed, and Cochrane Central database-searching from inception to 15 September 2023. The assessments included were subgrouped for analysis: gait analysis, motion analysis, wearables, and strength tests.

RESULTS

A total of 130 studies using 15 distinct objective functional assessment methods (FAMs) were identified. The most frequently used method was instrumented gait/motion analysis, followed by the Timed-Up-and-Go test (TUG), 6 minute walk test, timed stair climbing test, and various strength tests. These assessments were characterized by their diagnostic precision and applicability to daily activities. Wearables were frequently used, offering cost-effectiveness and remote monitoring benefits. However, their accuracy and potential discomfort for patients must be considered.

CONCLUSION

The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes. Gait analysis and the TUG, along with advancing wearable sensor technology, have the potential to enhance patient care, surgical planning, and rehabilitation.

© 2024 The British Editorial Society of Bone & Joint Surgery.

Background. The role of positive psychological factors in acute rehabilitation after total hip replacement (THR) is unclear. Purpose. (a) Examine the trajectory of functional ability among older adults after THR from presurgery to discharge from acute rehabilitation and (b) determine which physical and psychological factors at admission would predict functional ability at discharge and length of stay in rehabilitation. Methods. This prospective cohort study included 30 participants (age M = 76.20 years) from an inpatient geriatric rehabilitation center. They completed the Geriatric Depression Scale and Positive Affect questionnaire. The FIM® Motor domain of Functional Independent Measure (mFIM) was recorded presurgery, at admission, and upon discharge. Findings. Functional ability improved at discharge; however, the presurgery functional ability was not regained. Positive affect explained the length of stay in rehabilitation above and beyond the presurgery mFIM. Implications. Occupational therapists should improve ways to enhance self-care and positive affect in acute rehabilitation.

BACKGROUND

Total hip arthroplasty (THA) significantly improves pain and function in patients who have end-stage hip osteoarthritis. However, patient expectations regarding recovery and functional outcomes are often unclear. This study aimed to describe the trajectory of daily physical activity in the first year following primary THA, using wearable technology to collect objective data on gait speed, step count, standing duration, and estimated performance on the 6-minute walk test. Understanding postoperative recovery patterns can help manage patient expectations and improve counseling effectiveness.

METHODS

A prospective cohort study was conducted on 57 patients undergoing THA. Patients were provided with a device to track daily physical activity. Daily metrics, including gait speed, step count, standing duration, steadiness, and estimated 6-minute walk test performance, were collected and averaged weekly for analysis. Device adherence was monitored by tracking days without data output. Days without recorded data were excluded from analysis to account for nonwear time and ensure accuracy of the activity metrics.

RESULTS

Postoperatively, there was a significant increase in average daily step count compared to preoperative levels at 6 weeks (P < 0.001), 6 months (P < 0.001), and 12 months (P < 0.001) after surgery. Steadiness showed improvement at 12 months postoperative (P < 0.001). Standing duration increased significantly at 6 weeks postoperative (P = 0.002), but decreased at 6 and 12 months postoperative. Gait speed decreased at 6 weeks (P = 0.003), but increased at 6 and 12 months postoperative (P = 0.032, P = 0.021). The estimated 6-minute walk test distance improved significantly at 6 and 12 months postoperative (P = 0.038, P = 0.039).

CONCLUSIONS

The study offers valuable insights into the trajectory of daily physical activity following THA. There were significant improvements in various objective measures of physical activity postoperatively, which highlights the effectiveness of THA in enhancing functional outcomes and quality of life for patients who have end-stage hip osteoarthritis. Effective counseling regarding expected recovery and rehabilitation strategies is crucial to optimize postoperative outcomes and improve patient satisfaction, particularly as these improvements do not occur immediately following surgery. These findings can help guide clinical decision-making and patient counseling.

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