Total Hip Arthroplasty versus Hemiarthroplasty for Femoral Neck Fracture: Propensity-Score Matched Cohort Study and Survey of Orthopaedic Surgeons in Ontario
Total hip arthroplasty , Hemiarthroplasty , Hip fracture , Comparative effectiveness research , Femoral neck fracture , Propensity score analysis , Population-based study , Survey , Orthopaedic Surgery , Practice variation
Background There is significant variation in treatment of displaced femoral neck fractures in older patients and ongoing controversy regarding optimal treatment. Methods This thesis examined surgical practice variation in the use of total hip arthroplasty (THA) versus hemiarthroplasty for femoral neck fracture and compared clinical outcomes across a matched group of patients who underwent either procedure. We linked healthcare databases at ICES to create a population-based cohort of 49,597 patients aged 60 years and older who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 – 2017. We used multilevel logistic regression modeling to quantify the association between patient-, surgeon-, and institution-level variables and treatment with THA. We compared clinical outcomes in a subset of propensity-score matched patients using survival analysis. We developed, tested, and administered a survey to orthopaedic surgeons in Ontario to better understand the reasons underlying this treatment variation. We used a vignette-based experimental design and multilevel and multivariable linear regression modeling to determine factors associated with treatment recommendation. Results 9.4% of cohort patients (n=4,638) were treated with THA. Treating surgeon and institution accounted for most of the treatment variation. Patient factors associated with THA included: younger age, male sex, lower comorbidity burden, and rheumatoid arthritis. Long-term care residence, use of home care services, dementia, and marginalization were negatively associated with THA. Patients treated with THA had higher risk of hip dislocation at two years post-operation. Risk of revision was similar between treatment groups at 30 days, one year, and two years post-operation. Our survey response rate was 61.1% (n=302), and 60.3% of surgeons practiced in the community. Surgeon-level predictors of treatment with THA included: higher volume of THA for fracture, elective THA practice, and increasing years in practice. Pre-existing hip arthritis increased likelihood to recommend THA, while increasing patient age and comorbidity burden decreased likelihood to recommend THA. Conclusion There is significant treatment variation at the patient-, surgeon-, and institution-levels for patients undergoing arthroplasty for femoral neck fracture in Ontario. Shared decision making should involve discussion of increased risk of short-term hip dislocation with THA.