|Treatment of common hip fractures
|Butler M, Forte M, Kane RL, Joglekar S, Duval SJ, Swiontkowski M, Wilt T
This review assessed the effect of surgical treatments for subcapital and intertrochanteric or subtrochanteric hip fractures in elderly patients. The authors suggested that, due to methodological limitations, the evidence base was inconclusive. This conclusion reflected the evidence presented and is likely to be reliable.
To assess the effect of surgical treatments for subcapital and intertrochanteric or subtrochanteric hip fractures in elderly patients.
MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched from 1985 to April 2008 for articles in English. Search terms were reported and a filter was used to identify methodologically high-quality randomised controlled trials (RCTs). The reference lists of systematic reviews were scanned for additional trials.
RCTs of surgical treatments in patients, aged 50 years or older, with non-pathologic hip fractures (subcapital and intertrochanteric or subtrochanteric) from low energy trauma, were eligible for inclusion. The outcomes of interest were pain, mobility, and mortality. Trials used surgical implants that were available for use in the USA, or were similar to those already in use; trials of external fixators were excluded.
Data were generally inconsistently reported. Patient data were either derived from trials examining the general elderly population, or from those that identified healthy, mobile, and independent individuals. Most of the included trials were of people living in the community, and patients were generally aged over 70 years. The included interventions were extramedullary, intramedullary, or femoral-neck multiple implants; hemi-arthroplasty; or total hip replacement. The included outcomes (in addition to mortality) were functioning, quality of life, residence, and pain.
Two independent reviewers selected the papers for inclusion in the review and disagreements were resolved by consensus.
Assessment of study quality
Trial quality was assessed using a modified version of an established checklist. Trials were rated good, fair, or poor on aspects of allocation concealment, randomisation process, description of patient sample, and attrition; heavier weighting was assigned to the last three criteria.
Two reviewers assessed the quality of included trials and disagreements were resolved by the consensus of at least three reviewers.
At least two reviewers independently extracted data to enable the calculation of relative risks and 95% confidence intervals. Differences were resolved by consensus.
Methods of synthesis
Heterogeneity precluded a meta-analysis. The method of assessing heterogeneity was not reported. Relative risks and 95% confidence intervals for mortality were presented in forest plots, and a narrative synthesis was presented for the remaining outcomes. A summary rating of the evidence was provided, using methods developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group.
Results of the review
Seventy-six RCTs were included in the review. There were 35 RCTs of femoral-neck fractures, 40 RCTs of intertrochanteric fractures, and one RCT of subtrochanteric fractures. The overall strength of evidence was reported to be low.
Mortality: There were no statistically significant differences in mortality arising from hemi-arthroplasty versus total hip replacement, internal fixation versus hemi-arthroplasty, and internal fixation versus total hip replacement. Likewise, there were no statistically significant differences in the comparisons of plate or screw devices and intramedullary nails, in trials of patients with intertrochanteric and subtrochanteric fractures.
Pain and functional outcomes: For femoral-neck fractures, total hip replacement resulted in less pain and better functioning than hemi-arthroplasty (two RCTs). Comparisons of internal fixation and hemi-arthroplasty (eight RCTs) reported mixed results in terms of functioning, pain levels, and quality of life; any differences were only sustained in the short term. Comparisons of internal fixation and total hip replacement (four RCTs) resulted in improved mobility, less pain, and better functioning and quality of life in those receiving total hip replacement, but the differences were not sustained in the long term. Trials comparing all implants (three RCTs) found that total hip replacement was associated with improved mobility and pain levels compared with internal fixation. Overall, total hip replacement was reported to improve patient-focused outcomes over internal fixation. For intertrochanteric fractures, most trials comparing plate or screw devices and intramedullary nails had short-term follow-up (less than one year) and there was no evidence to suggest the superiority of one device over another.
Due to methodological limitations, the evidence base was inconclusive for surgical treatments for subcapital and intertrochanteric or subtrochanteric hip fractures in elderly patients.
The review question was clear and the inclusion criteria appeared to be sufficiently detailed to allow replication. The search strategy included some relevant sources, but the restriction to English-language trials means that relevant trials could have been missed and language bias introduced. There was no apparent search for unpublished material, and no evaluation of potential publication bias. The review process was conducted with adequate attempts to minimise errors and bias throughout. The validity assessment criteria appeared to be appropriate, but there were no individually reported results to enable verification of this. The method of synthesis seemed appropriate, given the observed heterogeneity.
The authors' conclusion reflected the evidence presented and is likely to be reliable.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that future high quality trials should focus on surgical treatment choices for nursing home residents. Consideration should also be given to establishing the value of a shorter recovery time relative to the cost of a new device.
Agency for Healthcare Research and Quality. Contract Number: HHSA 290 2007 10064 1.
Butler M, Forte M, Kane RL, Joglekar S, Duval SJ, Swiontkowski M, Wilt T. Treatment of common hip fractures. Rockville, MD, USA: Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment; 184. 2009
Subject indexing assigned by CRD
Hip Fractures; Humans; Technology Assessment, Biomedical
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.