R. BARRINGTON. From the Bristol. Royal. Infirmary,. Bristol. A prospective randomised trial of surgical treatment for the displaced subcapital femoral fracture in.
INTERNAL FIXATION VERSUS DISPLACED SUBCAPITAL
HEMIARTHROPLASTY FRACTURE OF THE
A PROSPECTIVE J.
From
RANDOMISED
M.
SIKORSKI,
the
Bristol
R.
Royal
FOR FEMUR
THE
STUDY
BARRINGTON
Infirmary,
Bristol
A prospective randomised trial of surgical treatment for the displaced subcapital femoral fracture in patients of7O years or more is presented. Two hundred and eighteen patients were randomly allocated into one of three treatment groups: manipulative reduction and internal fixation using Garden screws; Thompson hemiarthroplasty through a posterior (Moore) approach; and Thompson hemiarthroplasty through an anterolateral (McKee) approach. There is no significant difference in the mortality of the internal fixation and posterior arthroplasty groups. Both groups showed a significantly higher mortality than patients operated on through the anterior approach. The technical results of operation were worse in the internally fixed group, with only 40 per cent being satisfactory. Mobilisation was best achieved after the posterior approach. It is concluded that Thompson hemiarthroplasty, using an anterolateral approach, is the safest operation in this group of patients. Patients
sustaining
a
subcapital
femoral neck are currently ment hemiarthroplasty or
fracture
treated either by manipulative
of
goal
can
reduction
is
be
of the
reduced,
a
fracture
then
achieved.
Even
satisfactory,
formidable may
when
both
necrosis
(Barnes
et al.
attempt
at obtaining
reduction
of
the
I 976).
is and
of fixation,
failure
femoral
head
Thus
many
union
is made
empirical section of achieving
If the
fixation
always
fixation
seem
of union may
patients
and
all
occur
in whom
ultimately
with and
opposed inherently considered
fractures of the femoral neck 1976). However, this solution
on the basis that replacement more hazardous and unreasonable to expose
increased
risk
for the
revision operations. Comparisons plasty have been
sake
©
1981
VOL.
for
reprints
British
63-B,
No.
should
Editorial
3.
1981
of the
of internal reported.
J. M. Sikorski, FRCS, Senior Nedlands, Western Australia R. Barrington, FRCS, Senior Requests
an
require the run and
Society
who
fixation Initial
Lecturer 6009. Orthopaedic be
few
sent
to
of Bone
would
Registrar, Mr
J. M. and
Joint
The
General
based
trials
alternative
(Hunter
retrospective
studies
However, 1 975) Thus,
there
1 978;
did
anterior
not
approach
to the
between by the fact (Chan
other carry
the that
like and
important the same
hip seems
M#{246}lster
different results. the mortality of when done as a
compare
is a suggestion be
analyses.
Soreide,
discrepancy explained
that there may not all arthroplasties
I 969,
on retrospective
(Riley
and Raugstad 1979) have shown quite They found no difference between internal fixation and hemiarthroplasty
two the
groups.
Hoskinson risks,
variables. and the
to be associated
with
problems than the posterior. The present, prospective, study seeks to answer the following questions. Is internal fixation inherently less hazardous than hemiarthroplasty, and does it lead to
proceeding approach
to affect
the the
admitted
1 977
and
were
included
was patient The
arthroplasty? outcome?
PATIENTS Patients
require
Surgery,
were
prospective
was was to
and hemiarthroreports favoured
in Orthopaedic
these
safer
equally good rehabilitation? Is there a price attempting to reduce a fracture, failing, and
(D’Arcy has been
arthroplasty therefore it all patients
but
as the
fewer
operations. For this reason, primary prosthetic has been advocated for all elderly patients
displaced Devas
fixation
primary procedure. The types of study is probably
fracture
not
prosthetic replacement. In this group of patients primary failure gives prolonged disability, and they the risks of long periods of pain, immobility repeated replacement
Two
Manipulative
be difficult.
adequate
late failure
avascular
task.
internal
1974),
by a replacereduction
and internal fixation of the fracture. On grounds, a well-aligned and united proximal femur is preferable to an implant. However, this
the
University Infirmary,
to
January
displaced was
Bristol with
in a randomised (conforming aged
Australia,
George
Royal
to Stage
Street,
in the
Infirmary
surgical
between
fractures
ofsurgical
of the
ifthe
III or IV of Garden
1964),
year
of presentation. Elizabeth
LSI
3EX,
January
femoral
treatment
Queen Leeds
the
METHODS
subcapital trial
70 or more
of Western Great
the
I 980
AND
Does
to pay for only then
Patients II Medical
neck fracture and
the were
Centre,
England.
Sikorski. Surgery
030I-620X181/3082-0357
$2.00
357
358
J.
excluded
if the
treatment
was
excluded
consultant
were
grounds
for
arthritis,
the
distinction
in
strongly
charge
felt
indicated
a relatively exclusion
proportion
a
long-standing
of a malignant
between
a Stage
II and
patient
was
that
that
small were
suspicion
in
SIKORSKI,
a particular patient. the
most
fracture, in the
of
could
Thompson
a box
patients
as the in the
to
operating of
OflC
hemiarthroplasty or
to the
theatre.
three
These
groups:
through
Thompson).
admitted
trial,
cards
internal
a McKee
the
randomly
anterolateral
allocated
approach a
posterior
approach
Moore
using
posterior be obtained. patients
four
The
a satisfactory
separate
internal
1. Grades
Thompson).
should
Thus, had
with Garden offemoral neck
as 2 : I : 1 . Cards carried an alternative
arthroplasty
groups
fixation;
of pain
28
and
an
ratio
screws. indicating
of
the
three
manipulative of patients
were
were
initially
patients
A
and
technical both
the
generated:
76
femorale;
to
femoral
by occasional
and
3.
Pain either constant occasional analgesics.
4.
Pain
mild,
not
requiring
analgesics.
were
reduction
the
had
constant
and
severe.
occasional
requiring
but
regular
had
severe,
requiring
were
operation. were not
analgesics.
Capable
of using
2.
As
above,
but
3.
Limited to used indoors.
public uses
and
does
own
shopping.
two
transport.
walking
4. 5. 6.
Requires Chair-bound. Bed-bound.
walking
house
unless
indoors.
of
controlled
by
two
Garden
not
or an
in
with
in the
no step
the
the
had
to engage
and
unfractured
of
of the
irrespective
screws cortex;
Thompson
shaft, and
on technical
basis
with
with
adequacy
the
calcar
quadrants
inferior)
radiograph,
decision
on
of
of four
not;
both
1 5 degrees
the
in
for
to be within
and
penetrate
used
criteria
out
superior
contained
Walking
aids
not
were
years,
or
first
no
no
varus
was
made
radiograph
after
recorded,
each
attendance.
hospital,
patients
of three
months
or less.
death,
or
relatives mobility
examined and
analysis.
standard
deviations.
until
was the sooner. possible, or their and
Statistical
on
trauma
the
unit
second
day
and after
Thompson arthroplasty for two weeks. Otherwise
imposed.
institutions, were
orthopaedic
from
until
of pain
hips
x2
in a general
weight-bearing,
who had had a posterior to sit and were nursed flat
at intervals
estimates
nursed
fully
discharge
I. Patients aids
three
anteroposterior
were
operation, whichever were recalled when
aids. accompanied.
be
authors
Patients allowed
practitioners, the
was
was
had
crossed
and
1 to 3). The
the
restrictions
clinic aids
were
to
mobilised,
Mobility without
was
by trainees was
radiological
planes,
posterior,
in the
(Figs of
After walks
of
age
operation.
no
1 . Independent,
fixation
following
lateral
to involve
screws
All patients or
and
bone
neck
one
used:
(anterior,
subchondral
angulation
Pain
was
A total
mean
reduction
prosthesis in. The
fixation head
residual
2.
not
patient
recorded.
performed
internal
Thompson
anteroposterior
of whether
at all.
was
were
each
Their
invariably
was cemented
adequacy
prostheses
pain
was
card
men.
and
standard
approaches
not
mobility
the
Fig. 3
reduction allocated
progress
Manipulative
intensifier,
Thompson if a card
made.
a
anterior
fixation with Garden screws. Figure result ofThompson hemiarthroplasty.
screws.
allocating patients to the of either anterior or
Pain No
were
on
criteria.
almost
of experience.
image
Figure 2-Poor an undesirable
the
1.
35
posterior
was
selection
and
had
excluded
instructions
on which
and
had
allocation
the were
degrees
patients
if the
proforma
operations
varying
57
treatment
years.
The
or
fulfilled
by manipulation 57 patients
retrospectively
Fig. 2
fixation resection
(posterior
was predetermined fixation group
the
80.37±6.21
(anterior
through
When
irreducible
performed:
and
sequence
a printed
was
were
of
patients
Thompson
Fig. 1 Figure 1 -Good 3-Incomplete
Table
out
218
fracture therefore
Patients
followed.
drawn
the
was arthroplasty;
drawn
be made
was
fixation,
hemiarthroplasty
Thompson
a card
but
arthroplasty.
allotted
As soon
groups internal
fixation
common
confidently. from
internal
hemiarthroplasty
where
not
BARRINGTON
numbers rheumatoid
hip and
III fracture
R.
form
The
and
deposit Stage
M.
were clinically,
anteroposterior Results
are
Statistical
two
were weeks
Patients fate was or made
reviewed
They
were after
the
failing ascertained
friends.
At
on the
at a special
followed-up first
to attend from each
scale
range
of movements
and
lateral
radiographs
presented significance
as percentages, has been
clinics general
attendance,
shown
the
for revision
in Table of their taken or means±
assessed
using
JOINT
SURGERY
test.
THE
JOURNAL
OF BONE
AND
at
the
INTERNAL
The
mean
FIXATION
ages
Thompson
(16
Thompson
(nine
plus true the
of
those
based
per
groups
simple was of
comparable.
than expressed
men
known to of patients
have known
as the
mortality).
(Fig. women.
The
fact
for were
between ratio
of
a very
high
the
latter
per
cent
for
significantly
internal
fixation
the
higher
(P
