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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