By Elizabeth Hofheinz, M.P.H., M.Ed.
Is the rate of reoperation after screw fixation for nondisplaced femoral neck fractures higher than many think? That question and more were tackled in new research from Dartmouth-Hitchcock Medical Center and the Geisel School of Medicine, Dartmouth College.
The study, “Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in the Elderly: A Cost-Effectiveness Analysis,” appears in the July 2020 edition of the Journal of Orthopaedic Trauma.
Co-author Taylor Yong, M.D., M.S. is a fifth-year orthopedic resident at the Dartmouth-Hitchcock Medical Center. Dr. Yong commented to OSN,“The stimulus for this work was more academic than clinical. That isn’t to say we aren’t familiar with failures of screw fixation. However, we had recently reviewed the multicenter randomized controlled trial on screw fixation versus hemiarthroplasty by Dolatowski et al. during one of our monthly journal clubs.1 Their work generated a lot of interesting discussion within our department, and this was what generated our desire to expand our understanding of this clinical problem.”
The authors wrote, “We constructed a Markov decision model using a low-demand, 80-year-old patient as the base case. Costs, health-state utilities, mortality rates, and transition probabilities were obtained from published literature. The simulation model was cycled until all patients were deceased to estimate lifetime costs and quality-adjusted life years (QALYs). The primary outcome was the incremental cost-effectiveness ratio with a willingness-to-pay threshold set at $100,000 per QALY. We performed sensitivity analyses to assess our parameter assumptions.”
Dr. Yong commented to OSN, “The rate of reoperation after screw fixation may be higher than we, as a community, have generally considered. Our study identified a reoperation rate of 14.6% which is only slightly higher than the pooled risk of reoperation of 14.1% identified by Overmann et al. in their systematic review and meta-analysis on the same topic.2”
“Ultimately, our model suggests hemiarthroplasty may offer greater overall quality of life (in quality-adjusted life years) at lower total cost compared to screw fixation in low-demand elderly patients. Yet, we must consider the complete profile of the patient, including medical comorbidities, and not only chronologic age, but physiologic age, since perioperative mortality can greatly impact the outcomes considered in our model.”
“Hemiarthroplasty may represent a viable option in the treatment of non-displaced and valgus impacted femoral neck fractures in the low-demand elderly patient population. Our findings are not a surrogate for shared decision-making. A well-informed discussion between the patient, their family and/or their caregivers, the surgeon, and a multi-disciplinary care team remains critical to the appropriate treatment of these patients.”
“Outside the scope of this work, but relevant nonetheless, it is important that surgeons carefully analyze the appropriate imaging to be sure that they are appropriately classifying these injuries and not under-appreciating increased posterior slope or more subtle displacement. These factors may contribute to increased rates of failure.”
“There are significant limitations inherent to the methodology of our study that really cannot be ignored. Modeling strategies generally seek to simplify a complex clinical scenario and cannot fully account for all of the nuances that comprise an actual clinical decision. The model does not account for all the variables that make each patient unique. Individual patients should remain the foundation of management decisions. Despite this and many other shortcomings, we hope our work builds on our understanding of this clinical problem.”
1. Dolatowski FC, Frihagen F, Bartels S, et al. Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in Elderly Patients: A Multicenter Randomized Controlled Trial. J Bone Joint Surg Am. 2019;101(2):136-144. doi:10.2106/JBJS.18.00316
2. Overmann AL, Richards JT, O’Hara NN, D’Alleyrand JC, Slobogean GP. Outcomes of elderly patients with nondisplaced or minimally displaced femoral neck fractures treated with internal fixation: A systematic review and meta-analysis. Injury. 2019;50(12):2158-2166. doi:10.1016/j.injury.2019.09.039