Hip Fracture Surgery vs Elective Total Hip Replacement.

Hip Fracture Surgery vs Elective Total Hip Replacement To the EditorThe study byDr LeManach and colleagues1 compared differences in hospital mortality between patients undergoing hip fracture surgery and elective total hip replacement. A population matched for age, sex, and preoperative comorbidities topatientswhounderwent the2operationswas created using a multivariable logistic model and a greedy matchingalgorithmwitha1:1 ratio.Thismatchingmodel isuseful for adjusting thepatients’ baseline characteristics andcontrolling selection biases in a retrospective study, but it carries the significant assumption of no unmeasured confounders. That is, all important known factors that can affectmeasured outcomes must be measured and taken into account in the matching model. This assumption is unrealistic in this study because many preoperative and intraoperative risk factors that have been independently associated with postoperative shortterm mortality of patients undergoing the 2 operations were not included in the matching model, such as American Society of Anesthesiologists physical status classification, preoperative anemia, hypoproteinemia, cardiac medications, functional status, surgical risk score, intraoperative blood loss, hemodynamic instability and transfusion, and duration of operation.2-5 Thus, the work of Le Manach and colleagues cannot provide robust evidence for the increased hospital mortality with hip fracture surgery relative to elective total hip replacement. Researchersneedtoperformalarge-scale,multicenter, randomizedclinical trial inwhich the innumerable sourcesofbias that may contaminate the study end points areminimized. If suchstudies showaconsistentbeneficial effectofelective total hip replacement relative tohip fracture surgery onpostoperative mortality of geriatric patients, the implications for practice are immense.