Multicenter Scottish RCT comparing three surgeries for displaced intracapsular hip fractures in healthy, independently mobile older patients. The three arms were reduction and internal fixation, cemented bipolar hemiarthroplasty, and cemented total hip replacement. Primary outcome was hip function at two years; secondary outcomes included mortality, complications, and direct healthcare costs.
A 39% reoperation rate is the number that changed practice. Before this trial, many surgeons offered fixation to healthy older patients on the assumption that preserving the native femoral head was worth the attempt. This RCT showed that assumption is wrong: fixation fails in roughly 4 of 10 healthy patients, costs more over two years, and leaves patients with worse function even when hardware does not fail.
When a cognitively intact, independently mobile patient presents with a displaced intracapsular hip fracture, this trial is the reason we default to cemented arthroplasty. If that patient is under 75, the evidence favors THR over bipolar hemiarthroplasty — the 24-month functional advantage is statistically significant, driven by walking and daily function.
For patients 75 and older, the functional gap between arthroplasty types narrows. The THR comparison was also underpowered, so clinical judgment on dislocation risk, surgeon volume, and patient demand still applies.
One non-negotiable takeaway on technique: if you do the arthroplasty through a posterior approach, dislocation risk in this series was dramatically higher (29% vs. Under 1% lateral). That finding reinforces why posterior approach requires strict soft-tissue repair or large-head implants.
Multicenter Scottish RCT comparing three surgeries for displaced intracapsular hip fractures in healthy, independently mobile older patients. The three arms were reduction and internal fixation, cemented bipolar hemiarthroplasty, and cemented total hip replacement. Primary outcome was hip function at two years; secondary outcomes included mortality, complications, and direct healthcare costs.
A 39% reoperation rate is the number that changed practice. Before this trial, many surgeons offered fixation to healthy older patients on the assumption that preserving the native femoral head was worth the attempt. This RCT showed that assumption is wrong: fixation fails in roughly 4 of 10 healthy patients, costs more over two years, and leaves patients with worse function even when hardware does not fail.
When a cognitively intact, independently mobile patient presents with a displaced intracapsular hip fracture, this trial is the reason we default to cemented arthroplasty. If that patient is under 75, the evidence favors THR over bipolar hemiarthroplasty — the 24-month functional advantage is statistically significant, driven by walking and daily function.
For patients 75 and older, the functional gap between arthroplasty types narrows. The THR comparison was also underpowered, so clinical judgment on dislocation risk, surgeon volume, and patient demand still applies.
One non-negotiable takeaway on technique: if you do the arthroplasty through a posterior approach, dislocation risk in this series was dramatically higher (29% vs. Under 1% lateral). That finding reinforces why posterior approach requires strict soft-tissue repair or large-head implants.