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Adjudication committee
- First opponent: Professor John Keating, The University of Edinburgh, UK
- Second opponent: Senior Consultant Mona Badawy, Haukeland University Hospital, Norway
- Third member and chair of the evaluation committee: Professor Magne Røkkum, University of Oslo
Chair of the Defence
Professor Knut Stavem, University of Oslo
Principal Supervisor
Professor emeritus Stein-Erik Utvåg, University of Oslo
Summary
A displaced femoral neck fracture (FNF) is a severe injury and will require hospitalization and surgery. The most common treatment options in Norway for FNFs are closed reduction and internal fixation (IF), hemiarthroplasty (HA) or total hip arthroplasty (THA). Patients with these fractures have a high risk of subsequent surgical complications, reduced function, hip pain, and reduced health-related quality of life. The literature on patients older than 70 years with displaced FNFs is extensive, and most studies have advocated arthroplasty as the treatment of choice. The middle-aged patient group aged 55-70 years is less well described and the treatment for displaced FNFs in this age group is still controversial. These patients are probably still working and demand a high level of activity and quality of life. The risk of persisting and serious problems after treatment and the health economic aspect are therefore a great challenge, even though the overall incidence of hip fractures has decreased in recent decades. A Norwegian study reported the overall annually hip fracture incidence in the particular age group 55-70 years to be 92 per 10.000 (53/10.000 women and 39/10.000 men) in the period 2009-2013. The average age for low-energy hip fractures is about 80 years, almost 70% are women. About 40% of all hip fractures are displaced FNFs. Most of these displaced FNFs are caused by a low-energy trauma, and the patients often have comorbidities, including osteoporosis, which may increase the risk of complications and the need for additional surgery.
Studies reporting bone mineral density at the time of fracture are rare and often describe a more geriatric population. For patients under 60 years of age, IF is usually recommended, as many surgeons endeavor to prevent replacement of the hip joint. Studies investigating outcomes after FNF in patients younger than 70 years have found a high risk of reoperation after IF due to mechanical failure, non-union or avascular necrosis. This may indicate that many hip fracture patients under 70 years of age are more osteoporotic and frailer than individuals of the same age in the general population. Thus, it might be preferable to treat FNFs in this intermediate age group with an arthroplasty, as in patients older than 70 years.
In paper I we presented data on 2.713 patients reported to the national Norwegian Hip Fracture Register (NHFR) aged 55-70 years with displaced intracapsular femoral neck fractures in the period January 2005-December 2012. We found a high rate of reoperation for patients treated with IF (33%). Patients treated with HA or THA were significantly more satisfied and reported less pain. Although patients treated with HA were the frailest patient group with a crude one-year mortality of 15%, results were better for arthroplasty than in the IF group.
In paper II, we aimed to assess patient-related risk factors for low-energy displaced FNFs compared with sex- and age-matched controls. In this single center matched case-control study, we included 50 patients between 50-70 years of age with a low-energy displaced FNF and 150 participants randomly selected and matched by age and gender without a fracture from a normal population. We recorded patient baseline data, patient-reported outcome measurements (PROM), specific functional hip scores and performed Dual-energy X-ray Absorptiometry (DXA). We found more comorbidities assessed by Charlson Comorbidity Score (CCI) and there were more patients with ASA class 2-3 in the fracture group. Patients in the fracture group had lower body mass index (BMI) and there were more smokers in this group.
In paper III we aimed to assess the effect of closed reduction and IF with cannulated screws versus THA for low-energy displaced FNFs in patients between 55 and 70 years according to PROMs, complications, and reoperations. In this multicenter randomized controlled trial, 102 patients were randomly allocated to either IF (51 pas.) or THA (51 pas.). The follow-up period was 24 months. ASA classification, CCI Score, NYHA, and mMRC Dyspnea scale were recorded to report comorbidity. The EQ-5D-3L index score, EQ-VAS, VAS pain, and VAS satisfaction were accessed at each follow-up. Reoperations and complications were registered continuously. The primary outcome was the Harris Hip Score (HHS) at 12 months. Secondary outcomes were HHS at 4 and 24 months, Oxford Hip Score (OHS), and Hip Disability and Osteoarthritis Score (HOOS) at 4, 12, and 24 months after index surgery. We used the minimal clinically important differences (MCID) to determine clinical relevance.
Nine patients (18%) allocated to IF were converted to arthroplasty during index surgery because of unacceptable fracture reduction. Twenty-six patients (51%) in the IF group and two patients (3.9%) in the THA group had at least one major reoperation during the follow-up period. The primary outcome, HHS at 12 months follow-up, was superior in the THA group (89.8 points) compared to IF (84.5). Although statistically significant, the mean difference of 5.3 points (95% CI 0.8 - 9.8, p=0.021) was smaller than the predefined MCID of 10 points. We found better results for the THA groups for all secondary outcomes.
In conclusion, patients with a low-energy displaced FNF between 55-70 years were more osteoporotic and frailer than their peers of a general population. Patients treated with IF had a high risk for reoperation. Compared to IF, treatment with THA leads to superior patient-reported functional outcome, more satisfaction, better quality of life, and less pain. We suggest that low-energy displaced femoral neck fractures in patients between 55-70 years of age should preferably be treated with arthroplasty.
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