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10.37547/tajmspr/Volume07Issue03-02
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SUBMITED
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ACCEPTED
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PUBLISHED
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Vol.07 Issue03 2025
CITATION
Bianca Gabriella de Oliveira, Rennan Martins da Cruz, Jorge Rangel Zilli,
Pedro Henrique Ribeiro de Oliveira, Igor Santana Franco Amaral, &
Marcella Rodrigues Costa Simões. (2025). Total arthroplasty and
hemiarthroplasty in the treatment of hip fractures: a systematic review
with meta-analysis. The American Journal of Medical Sciences and
Pharmaceutical Research, 7(03), 6
–
12.
https://doi.org/10.37547/tajmspr/Volume07Issue03-02
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Total arthroplasty and
hemiarthroplasty in the
treatment of hip fractures:
a systematic review with
meta-analysis
Bianca Gabriella de Oliveira
Médica pela Universidade Salvador-UNIFACS, Salvador, BA, Brasil
Rennan Martins da Cruz
Médico residente em Ortopedia e Traumatologia do Centro Médico de
Campinas, Campinas, SP
Jorge Rangel Zilli
Médico residente em Ortopedia e Traumatologia do Hospital Regional da
Ceilândia, Brasília, DF
Pedro Henrique Ribeiro de Oliveira
Médico residente em Ortopedia e Traumatologia do Hospital Regional da
Ceilândia, Brasília, DF
Igor Santana Franco Amaral
Médico residente em Ortopedia e Traumatologia do Centro Médico de
Campinas, Campinas, SP
Marcella Rodrigues Costa Simões
Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
Corresponding author
: Bianca Gabriella de Oliveira. Rua araçari,
número 18, bairro muchila 2 (dois), Feira de Santana - Bahia, CEP
44005756
Abstract:
Objective: To analyze the effectiveness of
hemiarthroplasty compared to total arthroplasty in the
treatment of hip fractures. Methodology: Systematic
literature review, with a quantitative and qualitative
approach to the data collected, which was structured
according to the guidelines of the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
(PRISMA):
“total
hip
arthroplasty”
and
‘hemiarthroplasty’ with ‘AND’ and ‘OR’ combinations.
Results: The five articles selected evaluated the
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effectiveness of hemiarthroplasty and total hip
arthroplasty techniques using the WOMAC score,
Harris Hip Score (HHS), SF-36 (Short Form Health
Survey 36) and/or Visual analogue scale (VAS). Total
arthroplasty showed better results in most studies
(p<0.01). Conclusion: Total
arthroplasty was considered the procedure of choice,
especially for active elderly patients.
Keywords:
Arthroplasty
Replacement
Hip;
Hemiarthroplasty; Hip Fractures.
Introduction:
The impact of a hip fracture is life-
threatening, with extensive health complications due
to reduced quality of life as a result of potential
thrombotic events and loss of function. Fractures of
the proximal femur, which are more prevalent in the
elderly,
include the therapeutic
options
of
hemiarthroplasty or total hip arthroplasty. Both
involve the replacement of the femoral head with a
prosthesis or the combined replacement of the
femoral head and acetabulum with prostheses1.
The literature shows the benefits of total implantation
in terms of patient function and quality of life
compared to hemiarthroplasty. However, it is known
that there is an increased risk of dislocation, greater
caution immediately post-surgery, leading to the
possibility of re-approach to reduce or revise the
prosthesis. However, meta-analyses of recent studies
involving patients with deviated hip fractures suggest
that total hip arthroplasty results in fewer reoperations
and
substantially
better
function
than
hemiarthroplasty,
taking
into
account
physiotherapeutic
management
and
mobility
appropriate to the procedure performed2,3.
Previous studies have shown that in general there
were fewer complications with total hip arthropathy
than with hemiarthroplasty. Because of this, some
health guidelines recommend this surgery for patients
with displaced femoral neck fractures, which is
associated with significantly better function over 24
months4.
Among the options for correcting deviated femoral
neck fractures, articles have shown that hip
arthroplasty has better benefits and quality of life for
patients compared to hemiarthroplasty4,5. The aim of
this study was therefore to analyze the efficacy of
hemiarthroplasty (HA) compared to total arthroplasty
(TA) in the treatment of hip fractures.
METHODOLOGY
Systematic literature review, with a quantitative and
qualitative approach to the data collected, which was
structured according to the guidelines of the Preferred
Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA), and a checklist was then structured
to analyze the results. We considered: 1) framing the
questions for a literature review; 2) identifying relevant
research; 3) assessing the quality of the studies; 4)
summarizing the evidence; 5) interpreting the results.
The search for studies that met the established criteria
took place in June 2024 in databases linked to the
Medical Literature Analysis and Retrieval System Online
(MEDLINE), using the SPICE strategy to identify the
relevant studies:
- Scenario: patients with hip fracture.
- Perspective: individuals with proximal femur fracture.
- Intervention: Surgical correction.
- Comparison: Ability to walk, improvement in quality of
life and biomechanical function.
- Result: Total hip arthroplasty was more effective than
hemiarthroplasty.
- Study design: Randomized controlled trials,
counterbalanced crossovers.
Database search method From April to June 2024,
records were analyzed from 3 electronic databases
(Pubmed, Biblioteca Virtual da Saúde BVS, Ebsco
Sportdiscus). The keywords were obtained using the
PubMed "mesh terms" query. The search was
conducted with the English terms for: TOTAL
ARTROPLASTY
OR
HEMIARTROPLASTY
with
a
combination of "AND" and "OR".
The studies were then screened according to their
subject matter, restricting them to studies that dealt
with the surgical correction of proximal femoral
fractures.
The inclusion criteria were: studies comparing the
techniques
of
total
hip
arthroplasty
and
hemiarthroplasty in the treatment of femoral neck
fractures; studies published up to 15 years ago; studies
with a population over 50 years old. We excluded animal
studies; non-original studies; studies reporting
treatments for fractures of other segments of the
femur; studies published more than 15 years ago;
studies with young patients.
This systematic review was registered in PRÓSPERO
under ID
CRD42024572129.
RESULTS
A total of 123 articles were selected. 81 studies were
eliminated due to their publication time of more than 15
years. An analysis of the title led to the exclusion of 11
articles and of a further 16 after reading the abstract,
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which did not correspond to the objectives of the
study. This left 15 articles for full reading, and only five
studies
were
selected
which
compared
hemiarthroplasty and total hip arthroplasty in patients
with femoral neck fractures (Figure 1).
Figure 1- PRISMA protocol and selection of studies.
The five articles selected evaluated the effectiveness of
hemiarthroplasty
and
total
hip
arthroplasty
techniques. The primary results of some of the studies
took into account the WOMAC (Western Ontario and
McMaster Universities Osteoarthritis Index) a quality
of life questionnaire (pain, joint stiffness and physical
activity) in patients with osteoarthritis, the Harris Hip
Score (HHS) a specific assessment tool for evaluating
the results of total hip arthroplasty. The SF-36 (Short
Form Health Survey 36) is a generic evaluation
questionnaire with eight components: functional
capacity, physical aspects, pain, general health, vitality,
social aspects, emotional aspects and mental health.
The main complications associated with the procedures
were also analyzed. A total of 1988 participants were
included, with an average age of 50 and 80 years.
Table 1 shows the studies chosen and their outcomes
6,7,8,9,10.
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Table 1- Outcome of the selected studies.
Table 2 contains the Harris Hip Score of surgical
intervention by total hip arthroplasty or hip
hemiarthroplasty during the final period of each study
6,7,8,9,10.
Table 2- Harris Hip Score of surgical intervention by total hip arthroplasty or hip hemiarthroplasty during
the final period of each study.
Figure 2 shows the forest graph of the Harris Hip Score analysis of the patients analyzed in the study 6,7,8,9,10.
Figure 2- Forest graph of the Harris Hip Score analysis of the patients analyzed in the study.
The Health Investigators randomized clinical trial
included 1495 patients over the age of 50 with femoral
neck fractures. The patients were randomly divided
into 718 who underwent total arthroplasty and 723
who underwent hemiarthroplasty. The primary
outcomes were the number of patients undergoing a
new procedure within 24 months, this figure was, as a
percentage, 7.9% of patients assigned to total hip
arthroplasty and 8.3% undergoing hemiarthroplasty
(risk ratio, 0.95; 95% confidence interval [CI], 0.64 to
1.40; P=0.79). The main complications attributed to the
groups were hip instability or dislocation in 4.7% of total
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hip arthroplasty cases and 2.4% of hemiarthroplasty
cases (CI 99%). The WOMAC score (Western Ontario
and McMaster Universities
Osteoarthritis Index), which assesses pain, stiffness
and function, showed a mean difference between the
total arthroplasty and hemiarthroplasty groups, total
WOMAC score (-6.37; -9.18 to -3.56), WOMAC function
score (-4.97; -7.11 to -2.83), WOMAC pain score (-0.93;
-1.42 to -0.44), WOMAC stiffness score (-0.44; -0.65 to
-0.23). The EQ-5D visual analog scale (VAS) showed
little significant difference between the groups (0.72; -
2.02 to 3.46). The 12-item short form general health
survey (SF-12) showed a difference between the
groups in the mental component of 1.34 (-0.38 to 3.05)
and the physical component of 1.41 (-0.33 to 3.14). 6
The randomized clinical trial by Tol et al included 252
patients over the age of 70 diagnosed with a femoral
neck
fracture,
in
which
137
underwent
hemiarthroplasty and 115 total hip arthroplasty. After
12 years of study, only 20% of the patients were alive,
with no significant difference between the groups. The
modified Harris Hip Score (HHS), which does not assess
physical findings, was recorded as the primary
outcome. Patients undergoing hemiarthroplasty and
those undergoing total arthroplasty had an HHS score
of 70.3+-16.3 versus 69.3+-20 (p=0.85); HHS pain scale
39.8+-9.1 versus 37.2+-10 (p=0.44); HHS functional
scale 16.4+-8.8 versus 18.3+- 7.4 (p=0.34); satisfaction
was reached by 84% in the first group and 61% in the
second (p=0.47); displacement of the prosthesis was
not reported in either group. 97% of hemiarthroplasty
procedures were associated with a blood loss of less
than 500 ml, while this figure was 57% in total
arthroplasty; surgical time was also longer in total hip
arthroplasty (p<0.01). 7
Macaulay et al's randomized clinical trial evaluated the
clinical results of patients with femoral neck fractures,
17 of whom underwent total hip arthroplasty and 23
of
whom
underwent
hemiarthroplasty.
The
parameters between the two groups did not change at
baseline, so the SF-16 scale showed at the end of the
24-month study physical function for total hip
arthroplasty 38.6+-8.9 and hemiarthroplasty 35.1+-
12.9; bodily pain 53.2+-10.2 versus 42.4+-11.5; mental
health 54.9+-9.4 versus 40.9+-10.3. The WOMAC
(Western Ontario McMaster Universities) index after
the study period for the total arthroplasty and
hemiarthroplasty groups for pain 94.4+-6.8 versus
77.8+-20.9, limb function 81.8+-10.2 versus 65.1+-18.1
and joint stiffness 79.7+-17.6 versus 77.8+-28.5. The
average operative time for total arthroplasty was 89+-
36 and for hemiarthroplasty 82+-35 (p=0.66), the
average number of days spent in hospital for patients
undergoing the first intervention was 7.7+-5.5 and
5.4+- 2.8 for the second group. The Harris Hip Score of
patients undergoing total hip arthroplasty was 84+-12.2
and hemiarthroplasty 81.1+-11.7. Prosthesis dislocation
occurred in one patient undergoing hemiarthroplasty. 8
Baker et al's randomized clinical trial analyzed 40
patients diagnosed with a femoral neck fracture who
underwent total hip arthroplasty and 41 who
underwent hemiarthroplasty. The primary results were
based on the Harris Hip Score, the value reported for the
total hip arthroplasty group was 18.8+-12.0 and for
hemiarthroplasty 22.3+-12.0. The final physical
component of the SF-36 for total arthroplasty was
40.5+-16 and for hemiarthroplasty 38.1+-10, while the
mental component values were 52.0+-24.4 for total
arthroplasty and 55.3+-39.0 for hemiarthroplasty.
Displacement of the prosthesis occurred in three
patients in the total arthroplasty group. 9
Hedbeck et al presented a randomized clinical trial in
which 60 hemiarthroplasties and 60 total hip
arthroplasties were performed to repair femoral neck
fractures. The primary results of the article were that
according to the Harris Hip Score, patients who
underwent hemiarthroplasty of the hip had a score of
75.2+-15.4 at the end of the 48-month study, and those
who underwent total hip arthroplasty had a score of
89.0+-8.1 (p<0.001). The pain subscale for the groups
was 35.1+-7.0 versus 43.0+-1.8; the functional subscale
was 31.4+-10.6 versus 37.2+-7.8; deformity and the
degree of range of movement did not differ between
the groups (p<0.001).10
DISCUSSION
Comparing total hip arthroplasty and hemiarthroplasty
through the HEALTH study, it is possible to analyze that
there is no identifiable difference in relation to
reintervention procedures between the groups. 6 In
addition, other studies state that patients with total hip
arthroplasty have a reduced risk of mortality when
compared to patients with hemiarthroplasty. On the
other hand, some recent studies claim that
hemiarthroplasty compared to THA has lower
dislocation rates, less surgical complexity, shorter
operating times and lower blood loss. 7,8
Hip fractures are responsible for more days of
hospitalization than any other musculoskeletal injury
and account for more than two thirds of patients
hospitalized for fractures. Currently, surgical treatment
is indicated for this type of pathology, which can be total
hip arthroplasty (THA) or hemiarthroplasty (HA). Both
procedures involve risks for patients, although they are
widely accepted methods of hip replacement after
fracture.14,15,16
There are several surgical approaches to total hip
arthroplasty, including the posterior approach (PA), the
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lateral approach (LA) and the direct anterior approach
(DAA), all of which have their advantages and
disadvantages. The PA involves splitting the gluteus
maximus to access the hip joint posteriorly, and also
allows excellent exposure of the acetabulum and
femur and avoids disruption of the hip abductors.
However, the PA has been linked to an increased risk
of dislocation compared to the other types of
approach. The AL involves splitting the gluteus medius
to access the hip joint anterolaterally. It has a lower
risk of dislocation, but is associated with injury to the
superior gluteal nerve and impaired abductor function.
Finally, the AAD has its internervous and intermuscular
plane between the sartorius and tensor fascia lata. This
last approach has some advantages, such as shorter
hospital stays, earlier functional recovery and lower
risk of dislocation, leading to its growing popularity as
an approach to total hip arthroplasty. 12
The other surgical option for addressing hip injuries is
hemiarthroplasty, which consists of partial hip
replacement. In this surgical procedure, a quick but
effective operation is required with minimal trauma or
physiological disruption, so the approach can be
carried out in three different ways, laterally with
displacement of the greater trochanter, anteriorly
through the anterior capsule of the hip joint and
posteriorly through the posterior capsule of the hip
joint. However, the lateral approach is considered
inadequate because it causes excessive surgical
trauma. Because of this, the main techniques for
inserting a hemiarthroplasty are the anterior and
posterior approaches. Because of this, the main
techniques for inserting a hemiarthroplasty are the
anterior and posterior approaches.11,13,16
CONCLUSION
Most studies have shown evidence of functional
improvement, better quality of life and greater patient
satisfaction when treated with total hip arthroplasty.
Therefore, total arthroplasty was considered the
procedure of choice, especially for active elderly
patients.
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