Institute for Musculoskeletal Health, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia.
Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.
J Bone Joint Surg Am. 2022 May 18;104(10):919-927. doi: 10.2106/JBJS.21.00972. Epub 2022 Feb 17.
Previous randomized studies have suggested that there is no short-term difference between the risk of revision following total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fracture in elderly patients. The aim of the present study was to compare the long-term revision rates of primary THA and HA for femoral neck fracture in order to determine whether unipolar or bipolar HA increases the all-cause risk of revision in patients 50 to 79 years old.
Data for 36,188 patients who underwent primary arthroplasty, including 13,035 unipolar and 8,220 bipolar HAs and 14,863 THAs, from September 1, 1999, to December 31, 2019, were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Unadjusted analyses were performed, as well as analyses adjusted for age, sex, femoral cement, and procedure year. The primary outcome was time to first revision for any cause. Secondary analyses were performed for the reason for revision (i.e., infection, dislocation, and periprosthetic fracture). Instrumental variable analysis of hospital preference (for either HA or THA) was performed in order to mitigate the effect of any unmeasured confounding. All analyses were restricted to hospitals performing at least 10 procedures in the prior year.
A total of 18,955 procedures were available for the comparison of modular unipolar HA to THA. Both the adjusted analysis performed with use of Cox proportional hazards (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.64 to 2.31; p < 0.001) and the instrumental variable analysis (HR, 2.82; 95% CI, 1.89 to 4.22; p < 0.001) demonstrated a higher risk of revision following modular unipolar HA compared with THA from 3 months postoperatively. A total of 13,168 procedures were available for the comparison of bipolar HA to THA. The adjusted analysis performed with use of Cox proportional hazards showed a significantly higher risk of revision for bipolar HA (HR, 1.29; 95% CI, 1.08 to 1.54; p = 0.01). The instrumental variable analysis showed a similar effect size that was not significant (HR, 1.27; 95% CI, 0.91 to 1.78; p = 0.16).
Bipolar HA and THA demonstrated no significant difference in revision risk at long-term follow-up. Unipolar HA demonstrated higher risk of revision from 3 months postoperatively compared to THA. The higher risk of revision for dislocation observed following THA may be offset by the higher risk of revision for acetabular erosion or pain following bipolar HA, resulting in more equivalent revision risk.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
先前的随机研究表明，在老年髋部骨折患者中，全髋关节置换术（THA）和半髋关节置换术（HA）的翻修风险在短期并无差异。本研究旨在比较初次股骨颈骨折行 THA 和 HA 的长期翻修率，以确定在 50-79 岁患者中，单极还是双极 HA 会增加全因翻修风险。
从 1999 年 9 月 1 日至 2019 年 12 月 31 日，从澳大利亚矫形协会国家关节置换登记处获取了 36188 例初次关节置换患者的数据，包括 13035 例单极和 8220 例双极 HA 以及 14863 例 THA。进行了未调整分析以及调整了年龄、性别、股骨水泥和手术年份的分析。主要结局是任何原因的首次翻修时间。对翻修原因（即感染、脱位和假体周围骨折）进行了二次分析。为了减轻任何未测量的混杂因素的影响，进行了医院偏好的工具变量分析（即 HA 或 THA）。所有分析均限于前一年至少进行 10 例手术的医院。
共有 18955 例手术可用于比较模块化单极 HA 与 THA。使用 Cox 比例风险（风险比[HR]，1.94；95%置信区间[CI]，1.64 至 2.31；p<0.001）进行的调整分析和工具变量分析（HR，2.82；95%CI，1.89 至 4.22；p<0.001）均表明，模块化单极 HA 在术后 3 个月后翻修风险更高。共有 13168 例手术可用于比较双极 HA 与 THA。使用 Cox 比例风险的调整分析显示，双极 HA 的翻修风险显著更高（HR，1.29；95%CI，1.08 至 1.54；p=0.01）。工具变量分析显示出相似但不显著的效应大小（HR，1.27；95%CI，0.91 至 1.78；p=0.16）。
在长期随访中，双极 HA 和 THA 的翻修风险无显著差异。与 THA 相比，单极 HA 在术后 3 个月时翻修风险更高。THA 后脱位的翻修风险较高，可能会被双极 HA 后髋臼侵蚀或疼痛导致的翻修风险较高所抵消，从而导致翻修风险更接近。
治疗性 III 级。有关证据水平的完整描述，请参阅作者说明。
