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Randomized Comparison of Reduction and Fixation, Bipolar Hemiarthroplasty, and Total Hip Arthroplasty: Treatment of Displaced Intracapsular Hip Fractures in Healthy Older Patients

on behalf of the Scottish Orthopaedic Trials Network; Keating, J.F. FRCSEd(Orth); Grant, A. DM; Masson, M. MSc; Scott, N.W. MSc; Forbes, J.F. PhD

Journal of Bone & Joint Surgery - American Volume: February 2006 - Volume 88 - Issue 2 - p 249–260
doi: 10.2106/JBJS.E.00215
Scientific Articles

Background: Orthopaedic surgeons vary in their management of displaced intracapsular fractures of the hip in healthy older patients. The aim of this investigation was to determine the functional, clinical, and resource consequences of three different types of surgical treatment.

Methods: The study was a multicenter randomized controlled trial. Reduction and fixation was compared with bipolar hemiarthroplasty with cement and total hip replacement with cement. Participating surgeons elected to randomize their patients to be treated with either one of the three types of procedures or with either fixation or bipolar hemiarthroplasty. Functional outcomes were measured with a hip-rating questionnaire and the EuroQol health status measure. Clinical outcomes included mortality and complications. The direct health service costs were compared. Participants were followed up for two years.

Results: Two hundred and seven patients were randomized to be treated with one of the three operations, and ninety-one were randomized to be treated with either fixation or bipolar hemiarthroplasty. There were no differences in the mortality rates among the treatment groups. The rate of secondary surgery was highest in the fixation group (39% compared with 5% in the group treated with bipolar hemiarthroplasty and 9% in the group treated with total hip replacement). The fixation group had the worst hip-rating-questionnaire and EuroQol scores at four and twelve months. The total hip replacement group had significantly better functional outcome scores at twenty-four months than the other two groups. Although fixation was initially the least costly procedure, this short-term advantage was eroded by significantly higher costs for subsequent hip-related hospital admissions.

Conclusions: Arthroplasty is more clinically effective and cost-effective than reduction and fixation in healthy older patients with a displaced intracapsular fracture of the hip. The long-term results of total hip replacement may be better than those of bipolar hemiarthroplasty.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

1 Department of Orthopaedic Trauma, Royal Infirmary, Little France, Old Dalkeith Road, Edinburgh EH16 4SU, Scotland. E-mail address:

2 Health Services Research Unit, University of Aberdeen, Aberdeen AB25 2ZD, Scotland

3 Royal Infirmary of Edinburgh, Edinburgh EH16 4SU, Scotland

4 Department of Public Health, University of Aberdeen, Aberdeen AB25 2ZD, Scotland

5 School of Clinical Sciences and Community Health, University of Edinburgh, Teviot Place, Edinburgh EH9 9AG, Scotland

Hip fractures are very common injuries, and 50% of them are displaced intracapsular fractures1. Randomized trials of patients with limited mobility or impaired cognitive function have suggested that a unipolar cementless hemiarthroplasty is the treatment of choice2-6. The best choice for orthopaedic management of patients who are sixty years of age or older and are otherwise healthy remains controversial7. Reduction and fixation, bipolar hemiarthroplasty with cement, and total hip replacement with cement are the usual alternatives that are considered. The use of these options varies considerably among different surgeons and centers. Each has advantages and drawbacks, and to our knowledge there has been no formal randomized comparison of these procedures.

We performed a multicenter randomized trial to compare reduction and fixation with bipolar and total arthroplasty for the treatment of displaced intracapsular hip fractures in previously healthy, mobile patients. The aim was to determine the impact of these particular choices on functional outcome, clinical parameters, and resource utilization more than two years after the surgery.

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Materials and Methods

Settings and Locations Where the Data Were Collected

The trial was approved by the Scottish Multicentre Research Ethics Committee and subsequently by the appropriate local research ethics committee for each center. Forty-six surgeons in eleven Scottish orthopaedic units participated; five of the units were in university-affiliated teaching hospitals, and six were in district general hospitals. Recruitment began in the first center in June 1996 and began at the other centers in 1997, 1998, or 1999. The last participant was recruited in May 2000. An independent data-monitoring committee, which included an orthopaedic surgeon, a geriatrician, and a statistician, met in November 1998 and August 2000 to review interim analyses. On the first occasion, they recommended continued recruitment as planned, and on the second occasion, they recommended full follow-up for two years before the results were reported.

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Eligibility Criteria

All patients with a displaced intracapsular hip fracture who presented to a participating unit were considered for inclusion in the study. Patients with an undisplaced or valgus impacted intracapsular fracture were not included. The inclusion criteria were normal cognitive function (a mini-mental test score8 of >6), an ability to be mobile independent of another person prior to the fracture, and no serious concomitant disease (or other clinical reason for exclusion). The trial treatment options had to be judged suitable by the recruiting surgeon; if a surgeon believed that a particular procedure was clearly indicated or clearly contraindicated, then that patient was not eligible for the trial. There were no formal age criteria for eligibility. However, the protocol indicated that it was expected that those recruited would be sixty years of age or older.

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At the start of the trial, participating surgeons elected to randomize patients to be treated with either one of the three surgical procedures (three-way randomization) or with either fixation or bipolar hemiarthroplasty (two-way randomization). Entry of a patient into the trial and treatment allocation were accomplished through a centralized fully automated computer-based telephone service. Assignment was stratified by the consultant surgeon with minimization on gender and age category9.

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Details of the Interventions

The three randomly allocated treatments were reduction and fixation, bipolar hemiarthroplasty with cement, and total hip replacement with cement. All operations were performed within forty-eight hours after trial entry. The senior surgeon responsible for the care of each patient ensured that all procedures were performed by surgeons who were competent to undertake the allocated procedure. This allowed the option for a more senior surgeon to undertake a more technically difficult procedure. Other choices regarding the operation, such as the use of cannulated hip screws or a sliding hip screw for the reduction and fixation, the surgical approach (lateral or posterior) for the arthroplasty, the type of cemented implant, and the use of antibiotics or thromboprophylaxis, were made by the treating surgeon. Details of the procedure were recorded for each patient. Subsequent management, including the choice of the procedure if more surgery was judged to be necessary, was also at the discretion of the responsible surgeon. When the allocated procedure was not performed, the participant remained in the trial and was considered to be in the allocated group for the purpose of the analysis (intention-to-treat principle). The reasons why a surgeon might judge that an alternative procedure would be more appropriate could be clinical (e.g., an inability to reduce a fracture) or organizational (e.g., the institution is not equipped to perform the allocated procedure or equipment fails).

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Data Collection

Data were collected at four time-points: during the acute admission and, with the use of questionnaires mailed to the patients, at four, twelve, and twenty-four months following the surgery. All data collection was coordinated by four geographically based research nurses who had not participated in patient recruitment or randomization. The surgical details were recorded by the operating surgeon, who otherwise had no role in collecting or analyzing data. The nurses collected other clinical data from case notes, and they contacted participants when the mailed questionnaires were not returned. One research nurse (M.M.) coordinated data collection and ensured consistency and completeness across the study centers.

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The trial was designed to evaluate functional, clinical, and economic outcomes. The primary outcome was hip function at two years after trial entry.

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Functional Outcomes

Functional outcomes were assessed with use of a modification of the hip-rating questionnaire, a hip-specific questionnaire10 developed for the assessment of the functional outcome of total hip replacement. A 100-point scale gives equal weight to four domains (global [the overall impact of the hip problem], pain, walking, and function). The questionnaire was modified by replacing the word “arthritis” with “hip problem” to make it appropriate for patients with hip fractures. The EuroQol (EQ-5D) questionnaire11,12 was used as a general health outcome measure.

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Clinical Outcomes

The main clinical measures were mortality, readmission to the hospital, and a reoperation. The date and cause of deaths were verified from death certificates. Secondary clinical measures included fixation failure, nonunion, osteonecrosis, prosthetic dislocation, and postoperative complications, including proven wound infection, septicemia, deep venous thrombosis, pulmonary embolism, stroke, and myocardial infarction.

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Economic Outcome Measures

Direct health-service costs were estimated by prospectively measuring patient-specific health-service utilization documented for all trial participants from the date of trial entry up to two years. Data regarding health-service utilization included all hospitalization episodes (inpatient and day cases), the duration of the inpatient stay, and all visits to outpatient clinics. These were valued on a center and specialty-specific basis with use of average costs per day or visit calculated from the Scottish system of hospital cost statistics. Inpatient stays after the initial stay were classified as hip-related or non-hip-related on the basis of information abstracted from the individual hospital patient records. Operating theater costs were based on an analysis of the time in the theater, the composition of a typical trauma team (number and grades of the members of the team), and the equipment and consumables used. The cost of the prosthesis and the hardware used for each patient was estimated on the basis of unit costs derived from the four Scottish university orthopaedic centers. All costs are reported according to the Scottish price base of financial year 2000-2001.

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Sample Size

The original aim was to recruit 150 participants into each group to achieve a 90% power to identify a 7-point difference in the hip-rating score (with the assumption of a standard deviation of 13.5). However, recruitment was slower than expected, and some surgeons recruited patients only into the fixation and bipolar hemiarthroplasty groups. Revised power calculations on the basis of a projected total recruitment of 272 patients were presented to, and accepted as reasonable by, the data-monitoring committee at their first meeting in 1998. Calculations indicated that this sample size would provide 80% power to identify a difference of 7 points in the hip-rating score between the fixation and bipolar hemiarthroplasty groups and to identify a difference of 9 points in the other two comparisons.

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Statistical Methods

Comparisons between groups were made on a pairwise basis. For the comparison between fixation and bipolar hemiarthroplasty, data from both the two-way and the three-way randomization were used. For the other two comparisons, only data from the three-arm randomization were used. Analysis was performed on an “intention-to-treat” basis; that is, participants were analyzed according to the allocated procedure, not the operation that was actually performed. No adjustment was made for multiple significance testing.

Two separate analyses were undertaken: an unadjusted analysis and an analysis that took into account the minimization variables and, for the comparison of fixation with bipolar hemiarthroplasty, whether the randomization had been two-way or three-way. For the unadjusted analysis, the independent-samples t test was used to compare continuous outcomes, the chi-square test was used to compare dichotomous outcomes, and the log-rank test was used to compare time-to-event outcomes. Kaplan-Meier survival curves were also produced. For the adjusted analysis, adjustment was made for covariates with use of multiple regression, logistic regression, and Cox regression, respectively. When the adjusted and unadjusted analyses produced similar results, only the results of the adjusted analyses are reported. Depending on the type of data, differences between the groups are expressed as a difference in means, an odds ratio, or a hazard ratio with 95% confidence intervals.

Prespecified stratified analyses were conducted to compare the patients who were sixty to seventy-four years of age at the time of randomization with those who were seventy-five years of age or older. In addition, the rates of fixation failure and dislocation were examined according to the type of surgical approach.

The full-sample method was employed to summarize the cumulative distribution of health-service costs across care settings, for up to two years, with use of arithmetic mean costs observed for all patients. Confidence intervals for estimated untransformed arithmetic mean costs were estimated analytically and empirically with use of bootstrapping techniques to check for the adequacy of the assumptions made regarding the normality of the cost distributions. We found that standard t tests and t-test-based confidence intervals were very similar to those based on the bootstrap.

Undiscounted mean incremental costs are presented. Although costs were recorded for up to two years following the injury, the discounting of costs incurred in the second year at conventional rates of 3% to 6% would have had very little effect on the magnitude of the cost estimates, as most of the costs were incurred within one year after the injury. We also considered how sensitive our findings were to the cost of key resource categories by allowing for different values of the total cost of hip-related admissions (following the index episode) and the cost of prostheses (and hardware). Both of these parameters were varied over a range from –50% to +100% around the baseline values recorded for the trial participants.

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Two hundred and ninety-nine patients were enrolled in the study; one withdrew on the way to surgery, 207 were randomized to be treated with one of the three trial operations, and ninety-one were randomized to be treated with either fixation or bipolar hemiarthroplasty. In total, 118 were allocated to the fixation group; 111, to the bipolar hemiarthroplasty group; and sixty-nine, to the total hip replacement group. An audit of the recruitment in the main centers showed that 13% of patients with a displaced intracapsular hip fracture were judged to be eligible for the study, and 69% of them consented to randomization. Common reasons for ineligibility were failure of the mental test (30%), poor prefracture mobility (28%), a judgment that the patient was too elderly (9%), and a judgment that the patient was too young (4%). Other patients (29%) were deemed ineligible for a range of clinical reasons that, in the view of the clinician responsible for the care of the patient, indicated that a particular treatment option was appropriate.

Table I shows the characteristics of the participants and details of the procedures performed. The age of the participants averaged seventy-five years, and all were at least sixty years old. Seventy-eight percent of the patients were women. Most patients were taking some form of regular medication prior to the fracture. Eighty-six percent of the patients in the fixation group, and 84% of those in the total hip replacement group, received the allocated operation. All of those randomized to the bipolar hemiarthroplasty group received a hemiarthroplasty, except for four patients who received a unipolar prosthesis. Patients allocated to be treated with total hip replacement were more likely to have the operation performed by a senior surgeon. The operative time was shortest in the fixation group and longest for those allocated to be treated with total hip replacement.

Table II shows the results of the three pairwise comparisons of morbidity and mortality rates. The first of these comparisons provided the combined results for the two-way and three-way randomizations, and the other two comparisons used data from the three-way randomization only. Forty-four (37%) of those allocated to the fixation group had failure of the fixation within two years after the index operation. A total of eleven patients in the series had a hip dislocation, but only six of them had been originally allocated to be treated with an arthroplasty. Of the five dislocations in the fixation group, four followed revision surgery (arthroplasty) after fixation failure. Rates of other serious morbidity did not differ significantly between the groups. A higher frequency of hospital readmissions reflected the higher rates of additional surgery in the fixation group (39% compared with 5% in the bipolar hemiarthroplasty group and 9% in the total hip replacement group; Fig. 1). Of the six reoperations performed in the patients who had been allocated to the total hip replacement group, three were due to dislocation, one of which occurred after a hemiarthroplasty; two were due to infection; and one was due to wound dehiscence. Patients allocated to the total hip replacement group were most likely to receive blood transfusions. Mortality rates were similar across the groups.

The results of the patient questionnaires completed at four, twelve, and twenty-four months are summarized in Table III (fixation compared with hemiarthroplasty), Table IV (fixation compared with total hip replacement), and Table V (hemiarthroplasty compared with total hip replacement). The fixation group had a significantly worse mean score on the hip-rating questionnaire than both arthroplasty groups at four and twelve months, and this worse overall score reflected poorer scores for all of the subscales. The observed differences in the overall scores were close to the 7 points that had been judged to be clinically important when the sample size was decided on, although it should be noted that the 95% confidence intervals indicated that the true difference could be larger or smaller. The patients allocated to be treated with total hip replacement had, on the average, a better overall score than those allocated to be treated with hemiarthroplasty, and this difference was significant at twenty-four months (adjusted difference in overall score, –6.45; 95% confidence interval, –12.53 to –0.37). The largest contributions to this difference came from the walking and function subscores. The results of the prespecified subgroup analyses suggested that all of these differences between the groups were more pronounced in patients who were between sixty and seventy-four years of age than they were in those who were seventy-five years of age or older.

The results obtained with the EuroQol general health measure followed a broadly similar pattern. At four and twelve months, those allocated to be treated with total hip replacement had the best scores, and those allocated to be treated with fixation had the worst scores. At twenty-four months, however, the bipolar hemiarthroplasty group had the lowest score, which was significantly worse than the score in the total hip replacement group.

Table VI presents unadjusted mean costs and cost differences by resource category over two years. Although fixation was initially less costly than bipolar hemiarthroplasty, this short-term cost advantage was eroded by the significantly increased costs of subsequent hip-related admissions. The cumulative additional costs over two years for all hip-related episodes following fixation was £3504 higher (95% confidence interval, £1159 to £5851) than the cumulative costs for bipolar hemiarthroplasty. No significant difference was found in either the costs of the initial inpatient episode or the costs of the non-hip-related admissions following the initial episode. There was a similar pattern of cost differences between the fixation and total hip replacement groups, although only the difference in hip-related-admission costs was significant. In the comparison between bipolar hemiarthroplasty and total hip replacement, the confidence intervals around the hip-related admission costs were wide, reflecting the small numbers of patients who were readmitted to the hospital (seven and eight, respectively), and we found no significant difference between these two groups. Additional analyses were performed that (1) adjusted for age, sex, and whether the randomization had been two or three-way and (2) varied the cost of hip-related admissions and prostheses. These adjustments had little impact on the findings.

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The most striking finding of this study was the poor outcome in patients treated with reduction and fixation. This procedure was associated with a high rate of revision surgery and an inferior functional outcome compared with that of arthroplasty. This trend was particularly evident for younger patients (sixty to seventy-four years old). Although reduction and fixation had the lowest acute-admission costs (with less expensive implants, shorter operative time, and shorter initial hospital stays), the greatly increased need for readmissions and reoperations resulted in this management option having the highest costs overall. Differences between the two types of arthroplasty were less marked; however, the functional outcome at two years was significantly better following total hip replacement. Although other randomized studies of the management of displaced intracapsular hip fractures have been reported2-6,13-23, we believe that ours is the first to focus on healthy patients who were previously capable of independent mobility. We believe that we are also the first to incorporate validated functional outcome measures and an economic evaluation.

The internal validity of the study was high. Care was taken to minimize bias by using a centralized method of randomization and by excluding participating surgeons from data collection and analysis. The groups that we compared were similar at baseline, follow-up was unusually complete, the analysis was based on intention to treat, and the participants themselves assessed their outcome with use of standardized questionnaire-based instruments at up to two years postoperatively.

Although this trial was large for an orthopaedic study, the estimated differences are statistically imprecise, and this is an important limitation. It applies in particular to the comparisons involving total hip replacement because some surgeons were not willing to randomize their patients to be treated with what they believed was an inappropriately complex procedure. The sample size was based on the judgment that it was clinically important to identify differences in the hip-rating-questionnaire score of approximately 7 points. The observed differences between fixation and arthroplasty at four and twelve months, and between total hip replacement and hemiarthroplasty at twenty-four months, were close to this value, but there were wide confidence intervals, indicating that the true differences could have been larger or smaller. Imprecision was a particular problem for statistically rare clinical events, such as death.

The main issue in the interpretation of the findings in this trial is their generalizability. To an extent, this is an issue in all randomized controlled trials; patients who are eventually recruited have gone through a selection process, and they differ from those who are not recruited. It is then a matter of judgment whether those recruited are sufficiently similar to patients who are cared for by another surgeon for the results to be generalized to that practice. The three procedures compared in our trial were markedly different, and, because of these differences, surgeons often had strong views about which patients should or should not be treated with each of the three operations. This was particularly true for total hip replacement. Some surgeons indicated that they would not be willing to randomize any patient to be treated with this procedure. (They were, however, usually sufficiently uncertain regarding the comparative benefits of fixation and hemiarthroplasty to randomize patients to receive either of those procedures.) Other surgeons, while agreeing to recruit patients into the trial, sometimes had strong views on the management of individual patients so some potentially eligible patients were deemed ineligible. There are other reasons why recruitment into a trial like ours will always be difficult. These patients are often frail and in pain, and they are admitted to the hospital on an emergency basis at all times of the day. Securing informed consent for entry into a trial is therefore unusually difficult and time-consuming. This can lead to eligible patients being missed. About one in eight patients who were seen for a displaced intracapsular hip fracture at the trial centers were considered eligible for entry into the trial. All patients had to have been previously healthy and mobile, and alternative procedures had to be considered clinically appropriate for them. Recruitment was therefore slow, and the results can be generalized only to these types of patients.

Not all participants received the operation to which they had been randomly allocated. The reasons were clinical (e.g., an inability to reduce a fracture) or organizational (e.g., the institution was not equipped to perform the allocated procedure or the equipment failed). However, all analyses were based on the allocation groups (the intention-to-treat principle) to avoid biased selection of groups for comparison. Secondary observational analyses based on the actual operation performed showed a slight widening of the differences observed in the intention-to-treat analyses.

There was some variation in surgical practice due to the multicenter design of the study. However, all patients in the reduction-and-fixation group were treated with either cannulated screws or a sliding hip screw, and there was no evidence that the type of implant had a bearing on the results. Similarly, all of the arthroplasties were performed with cemented components, and the total hip implants were either Exeter or Charnley designs, both of which have been documented as having satisfactory long-term results. Analysis revealed no relationship between the result and the specific implant used, although patients who had the arthroplasty performed through a posterior exposure had a higher rate of dislocation (four of fourteen compared with one of 112).

Other recent randomized studies have also demonstrated high reoperation rates (34% to 43%) following reduction and fixation of displaced intracapsular hip fractures5,6,22,23. The most common reasons for the reoperations were fixation failure and nonunion. Although osteonecrosis is a well-recognized complication of this fracture, it is not the most common cause of reoperations. The other randomized studies included patients with limited mobility or cognitive function, and it is often assumed that healthy older patients have a lower complication rate following reduction and fixation. However, in our study of a healthy group of patients, reduction and fixation had a failure rate similar to those reported in the other studies. The poorer functional outcome was particularly marked in the younger patients. However, the timing of the follow-up could have influenced the findings with regard to the reoperations. Whereas fixation failures commonly occurred soon after the surgery, there might be disproportionately larger numbers of failures of the arthroplasties beyond the current follow-up period of two years. An additional potential confounding variable is the experience of the surgeons who performed the internal fixation procedures compared with that of the surgeons who did the arthroplasties.

The rates of mortality and general complications did not differ significantly across the study groups. Other randomized trials have revealed similar findings24. Although reduction and fixation is a shorter, less invasive surgical procedure, many patients with displaced intracapsular hip fracture have medical co-morbidities that contribute to the risk of general complications. In addition, the need for revision surgery in the fixation group may have contributed to the similarity of the mortality rates among the three groups at the two-year follow-up point. This would be consistent with the finding of a recent meta-analysis that one-year mortality rates were similar following different types of treatment of these fractures (despite a suggestion of lower rates after fixation at four months)24.

One question raised by our findings is whether the poorer functional outcome after reduction and fixation just reflects the failures that required additional surgery. At twenty-four months, the functional outcome for the patients who were managed with fixation and did not have subsequent surgery was clearly better than the outcome for those managed with fixation who did have subsequent surgery. However, even those who did not have additional surgery had a mean score that was lower than that for the total hip replacement group.

The best clinical and functional outcomes in this study were observed after total hip replacement. This has not been a popular method of treating these fractures in the past, at least in part because of a perception that it is associated with an unacceptably high rate of prosthetic dislocation. We did not find this to be the case, and the recent meta-analysis showed a mean rate of dislocation of 6.9%24. This is certainly higher than what is expected after arthroplasty for primary osteoarthritis, but we believe that it is still acceptably low.

The reason for the apparent functional deterioration in the bipolar hemiarthroplasty group in our trial is not clear. Chance cannot be ruled out without further follow-up. Alternatively, it may be explained by early acetabular erosion associated with the bipolar head. As the study design did not include long-term radiographic follow-up, any further comment on this possibility would be speculative.

In our cost estimates, we accounted for the resource consequences of the initial procedure following the injury, subsequent hip-related and non-hip-related episodes, and the use of other health services. The costs reflected contemporary techniques employed by orthopaedic surgeons and utilization of health services by patients allocated to one of three treatment groups. Although we believe that our methods for estimating the differences in health service costs are robust, the absolute and relative differences primarily reflect the numbers of hip-related readmissions. While there were marked differences between the number of readmissions following fixation and those following both types of arthroplasty, which were reflected in the significant differences in costs, there were relatively few readmissions after either bipolar or total hip arthroplasty (seven compared with eight). The observed difference in cost between the two arthroplasty groups, which was not significant, reflected the high costs of the readmissions following bipolar hemiarthroplasty. The differences also reflect observed practice in Scottish centers between 1996 and 2002 and the specific resource unit costs recorded in our study. Both resource use and cost will vary across different health-care systems and may change over time as novel techniques are adopted and new patterns of service use become established.

The poorer outcomes and higher costs following fixation indicate that it is not cost-effective compared with either bipolar hemiarthroplasty or total hip replacement; this conclusion should remain true unless there is a dramatic convergence in revision rates across the procedures.

On the basis of our findings, we no longer recommend reduction and fixation for the treatment of previously healthy older patients with a displaced intracapsular hip fracture. Arthroplasty with cement is our treatment of choice. In this study, the two-year results of total hip replacement appeared to be better than those of bipolar hemiarthroplasty, but this finding was based on relatively small numbers of patients; hence, other important differences between the treatment groups could not be ruled out. Ideally, this comparison should be replicated in other trials. Longer-term follow-up of the patients treated with arthroplasty in this study might allow identification of the reasons for the deterioration in function observed at two years following the bipolar hemiarthroplasties. It would also determine whether the satisfactory outcomes of total hip replacement are maintained.▪

A commentary is available with the electronic versions of this article, on our web site () and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

In support of their research for or preparation of this manuscript, the authors received a grant from the National Health Service R&D Health Technology Assessment Programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Executive Health Department. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

NOTE: The authors acknowledge the participation of surgeons in the following orthopaedic units: Aberdeen Royal Infirmary, Dumfries and Galloway Royal Infirmary, Edinburgh Royal Infirmary, Falkirk Royal Infirmary, Glasgow Royal Infirmary, Western Infirmary Glasgow, Law Hospital Lanarkshire, Ninewells Hospital Dundee, Perth Royal Infirmary, Queen Margaret Hospital Dunfermline, and Royal Alexandra Hospital Paisley.

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