Hemiarthroplasty for unstable intertrochanteric hip fractures: A systematic review and meta-analysis

Unstable intertrochanteric hip fractures remain prevalent in the elderly with impacts on function and quality of life. Both hemiarthroplasty and internal fixation methods have been surgical options, with consensus yet to be reached on the optimal approach. This review compares intraoperative and postoperative clinical outcomes between the two techniques.

Systematic review and meta-analysis was conducted, searching four databases for studies on patients who received either internal fixation (IF) or hemiarthroplasty (HA) for unstable intertrochanteric hip fractures. The primary outcome was Harris Hip Score (HHS), with secondary outcomes of intraoperative and postoperative clinical findings. Intra-study risk of bias was graded using ROBINS-I and Cochrane Risk-of-Bias tool, with assessment of evidence certainty using the GRADE approach.

HHS for HA was significantly greater at 3 and 6-month post-operation compared to IF, with a weighted mean difference of 12.5 (95% CI: 8.6-16.4) and 5.3 (95% CI: 2.9-7.7) respectively. Furthermore, HA's relative risk (RR) of reoperations was lower at 0.6 (95% CI: 0.3-1.0), RR of nonunion of fractures was lower at 0.5 (95% CI: 0.3 - 0.9) and RR of prosthesis failure lower at 0.4 (95% CI: 0.2-1.0). Intraoperatively, HA had a longer operation time by 12.2 min (95% CI: 6.6-17.9) and greater blood loss of 152.8 mL (95% CI: 108.1-197.6). Post-operatively, HA had a higher RR of 1-year mortality rate at 1.6 (95% CI: 1.2 - 2.1) and higher RR of SSI at 1.4 (95% CI: 1.0-2.1). Otherwise, there is no difference in post-operative complications of deep vein thrombosis, limb length deformity and periprosthetic fractures.

HA provided superior early functional outcome and a reduced relative risk of mechanical complications at the cost of increased intraoperative burden, higher early post-operative mortality and SSI risk. IF hence offers lowered intraoperative stress and reduced post-operative morbidity. Surgical choice should ultimately be individualised based on patient priorities and risk profile.