Okike Kanu, Prentice Heather A, Chan Priscilla H, Fasig Brian H, Paxton Elizabeth W, Bernstein Joseph, Ahn Jaimo, Chen Foster
Department of Orthopaedic Surgery, Hawaii Permanente Medical Group, Honolulu, Hawaii.
Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California.
J Bone Joint Surg Am. 2024 Jan 17;106(2):120-128. doi: 10.2106/JBJS.23.00486. Epub 2023 Nov 16.
Practice patterns regarding the use of unipolar hemiarthroplasty, bipolar hemiarthroplasty, and total hip arthroplasty (THA) for femoral neck fractures in older patients vary widely. This is due in part to limited data stipulating the specific circumstances under which each form of arthroplasty provides the most predictable outcome. The purpose of this study was to investigate the patient characteristics for which unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA might be preferable due to a lower risk of all-cause revision.
A U.S. health-care system's hip fracture registry was used to identify patients ≥60 years old who underwent unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA for hip fracture from 2009 through 2021. Unipolar and bipolar hemiarthroplasty were compared with THA within patient subgroups defined by age (60 to 79 versus ≥80 years) and American Society of Anesthesiologists (ASA) classification (I or II versus III); patients with an ASA classification of IV or higher were excluded. Multivariable Cox proportional hazard regression analysis was used to evaluate all-cause revision risk while adjusting for confounders, with mortality considered as a competing risk.
There were 14,277 patients in the final sample (median age, 82 years; 70% female; 80% White; 69% with an ASA classification of III; median follow-up, 2.7 years), and the procedures included 7,587 unipolar hemiarthroplasties, 5,479 bipolar hemiarthroplasties, and 1,211 THAs. In the multivariable analysis of all patients, both unipolar (hazard ratio [HR] = 2.15, 95% confidence interval [CI] = 1.48 to 3.12; p < 0.001) and bipolar (HR = 1.92, 95% CI = 1.31 to 2.80; p < 0.001) hemiarthroplasty had higher revision risks than THA. In the age-stratified multivariable analysis of patients aged 60 to 79 years, both unipolar (HR = 2.17, 95% CI = 1.42 to 3.34; p = 0.004) and bipolar (HR = 1.69, 95% CI = 1.08 to 2.65; p = 0.022) hemiarthroplasty also had higher revision risks than THA. In the ASA-stratified multivariable analysis, patients with an ASA classification of I or II had a higher revision risk after either unipolar (HR = 3.52, 95% CI = 1.87 to 6.64; p < 0.001) or bipolar (HR = 2.31, 95% CI = 1.19 to 4.49; p = 0.013) hemiarthroplasty than after THA. No difference in revision risk between either of the hemiarthroplasties and THA was observed among patients with an age of ≥80 years or those with an ASA classification of III.
In this study of hip fractures in older patients, THA was associated with a lower risk of all-cause revision compared with unipolar and bipolar hemiarthroplasty among patients who were 60 to 79 years old and those who had an ASA classification of I or II.
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
老年患者股骨颈骨折采用单极半髋关节置换术、双极半髋关节置换术和全髋关节置换术（THA）的治疗模式差异很大。部分原因是规定每种关节置换术能提供最可预测结果的具体情况的数据有限。本研究的目的是调查因全因翻修风险较低而可能更适合采用单极半髋关节置换术、双极半髋关节置换术或THA的患者特征。
利用美国一个医疗保健系统的髋部骨折登记处，确定2009年至2021年期间因髋部骨折接受单极半髋关节置换术、双极半髋关节置换术或THA的60岁及以上患者。在按年龄（60至79岁与≥80岁）和美国麻醉医师协会（ASA）分级（I或II级与III级）定义的患者亚组中，将单极和双极半髋关节置换术与THA进行比较；排除ASA分级为IV级或更高的患者。使用多变量Cox比例风险回归分析评估全因翻修风险，同时调整混杂因素，并将死亡率视为竞争风险。
最终样本中有14277例患者（中位年龄82岁；70%为女性；80%为白人；69%的ASA分级为III级；中位随访时间2.7年），手术包括7587例单极半髋关节置换术、5479例双极半髋关节置换术和1211例THA。在对所有患者的多变量分析中，单极（风险比[HR]=2.15，95%置信区间[CI]=1.48至3.12；p<0.001）和双极（HR=1.92，95%CI=1.31至2.80；p<0.001）半髋关节置换术的翻修风险均高于THA。在对60至79岁患者的年龄分层多变量分析中，单极（HR=2.17，95%CI=1.42至3.34；p=0.004）和双极（HR=1.69，95%CI=1.08至2.65；p=0.022）半髋关节置换术的翻修风险也高于THA。在ASA分层多变量分析中，ASA分级为I或II级的患者在接受单极（HR=3.52，95%CI=1.87至6.64；p<0.001）或双极（HR=2.31，95%CI=1.19至4.49；p=0.013）半髋关节置换术后的翻修风险高于接受THA后的风险。在≥80岁的患者或ASA分级为III级的患者中，未观察到半髋关节置换术和THA之间的翻修风险有差异。
在这项针对老年患者髋部骨折的研究中，对于60至79岁以及ASA分级为I或II级的患者，与单极和双极半髋关节置换术相比，THA与全因翻修风险较低相关。
治疗性III级。有关证据水平的完整描述，请参阅作者须知。
