Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults

Martyn J Parker; Kurinchi Selvan Gurusamy

doi:10.1002/14651858.CD001708.pub2

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Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 1 Length of surgery ( in minutes).

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Analysis 1.2

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 2 Operative blood loss (in millilitres).

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Analysis 1.3

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 3 Number of patients transfused.

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Analysis 1.4

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 4 Mean units blood transfused.

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$Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 5 Non‐union of fracture within follow‐up period (includes early displacement).$

Analysis 1.5

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 5 Non‐union of fracture within follow‐up period (includes early displacement).

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Analysis 1.6

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 6 Avascular necrosis.

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Analysis 1.7

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 7 Dislocation of prosthesis.

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Analysis 1.8

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 8 Loosening of prosthesis.

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Analysis 1.9

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 9 Acetabular wear (as defined by each study).

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Analysis 1.10

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 10 Fracture below/around implant.

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Analysis 1.11

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 11 Re‐operations minor (e.g. removal of fixation, dislocation of arthroplasty).

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Analysis 1.12

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 12 Re‐operations moderate (e.g. fixation to arthroplasty, drainage, girdlestone).

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Analysis 1.13

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 13 Re‐operations major (e.g. revision arthroplasty, hemiarthroplasty to THR).

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Analysis 1.14

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 14 Total re‐operation rate (within follow‐up period of study).

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Analysis 1.15

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 15 Superficial wound infection.

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Analysis 1.16

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 16 Deep wound infection.

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Analysis 1.17

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 17 Pneumonia.

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Analysis 1.18

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 18 Deep vein thrombosis.

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Analysis 1.19

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 19 Pulmonary embolism.

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Analysis 1.20

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 20 Thromboembolic complications combined.

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Analysis 1.21

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 21 Congestive cardiac failure/heart failure.

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Analysis 1.22

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 22 Myocardial infarction.

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Analysis 1.23

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 23 Stroke (cerebrovascular accident).

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Analysis 1.24

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 24 Confusional state.

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Analysis 1.25

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 25 Gastrointestinal complications.

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Analysis 1.26

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 26 Pressure sores.

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Analysis 1.27

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 27 Total medical complications (as defined in each study).

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Analysis 1.28

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 28 Length of hospital stay (in days).

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Analysis 1.29

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 29 Mortality 30 days.

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Analysis 1.30

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 30 Mortality up to 3 to 6 months.

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Analysis 1.31

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 31 Mortality up to 12 months.

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Analysis 1.32

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 32 Mortality up to 24 to 48 months.

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Analysis 1.33

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 33 Mortality 10 years.

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Analysis 1.34

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 34 Residual pain at 1 year.

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Analysis 1.35

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 35 Residual pain at 1 year (subgrouped by cemented versus uncemented).

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Analysis 1.36

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 36 Mean pain score at 1 to 2 years.

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Analysis 1.37

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 37 Mean pain score at 1 to 2 years (subgrouped by cemented versus uncemented).

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Analysis 1.38

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 38 Pain at 2 to 3 years.

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Analysis 1.39

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 39 Failure to return to same residence at final follow‐up.

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Analysis 1.40

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 40 Failure to regain mobility.

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Analysis 1.41

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 41 Harris hip score (at 1 year).

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Analysis 1.42

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 42 Hip rating questionnaire at 1 year.

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Analysis 1.43

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 43 Hip scores (at 1 year).

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Analysis 1.44

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 44 Mean Eq‐5d score (at 1 year).

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Analysis 1.45

Comparison 1 Internal fixation versus arthroplasty (all types), Outcome 45 Barthel index score of below 95 at 1 year.

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Analysis 2.1

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 1 Length of surgery (in minutes).

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Analysis 2.2

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 2 Operative blood loss (in millilitres).

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Analysis 2.3

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 3 Number of patients transfused.

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Analysis 2.4

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 4 Re‐operations minor ( eg fixation‐ removal of metalwork, dislocation of hemiarthroplasty).

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Analysis 2.5

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 5 Re‐operations moderate (eg fixation to hemiarthroplasty or total hip replacement, drainage, girdlestone).

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Analysis 2.6

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 6 Re‐operations major (eg revision hemiarthroplasty or conversion to total hip replacement).

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Analysis 2.7

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 7 Total re‐operation rate (within follow‐up period of study).

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Analysis 2.8

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 8 Superficial wound infection.

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Analysis 2.9

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 9 Deep wound infection.

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Analysis 2.10

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 10 Length of hospital stay (in days).

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Analysis 2.11

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 11 Mortality at 30 days.

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Analysis 2.12

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 12 Mortality up to 3 to 6 months.

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Analysis 2.13

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 13 Mortality up to 12 months.

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Analysis 2.14

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 14 Mortality 24 to 48 months.

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Analysis 2.15

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 15 Mortality 10 years.

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Analysis 2.16

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 16 Pain at one year.

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Analysis 2.17

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 17 Failure to return to same residence at final follow‐up.

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Analysis 2.18

Comparison 2 Internal fixation versus hemiarthroplasty, Outcome 18 Failure to regain mobility.

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Analysis 3.1

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 1 Length of surgery (in minutes).

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Analysis 3.2

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 2 Operative blood loss (in millilitres).

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Analysis 3.3

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 3 Number of patients transfused.

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Analysis 3.4

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 4 Re‐operations minor (Fixation removal of metalwork, dislocation of THR).

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Analysis 3.5

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 5 Re‐operations moderate (Fixation to hemiarthroplasty or THR, drainage, girdlestone).

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Analysis 3.6

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 6 Re‐operations major (revision THR).

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Analysis 3.7

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 7 Total re‐operation rate (within follow‐up period of study).

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Analysis 3.8

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 8 Superficial wound infection.

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Analysis 3.9

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 9 Deep wound infection.

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Analysis 3.10

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 10 Hospital stay (days).

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Analysis 3.11

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 11 Mortality up to 2 to 4 months.

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Analysis 3.12

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 12 Mortality at 12 to 18 months.

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Analysis 3.13

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 13 Mortality at 24 months.

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Analysis 3.14

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 14 Mortality at 4 years.

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Analysis 3.15

Comparison 3 Internal fixation versus Total Hip Replacement, Outcome 15 Pain at 1 year.

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Table 1. Methodological quality assessment scheme

1. Was there clear concealment of allocation?	Score 3 if allocation was concealed (e.g. numbered sealed opaque envelopes drawn consecutively). Score 2 if there was a possible chance of disclosure before allocation. Score 1 if the method of allocation concealment or randomisation was not stated or was unclear. Score 0 if allocation concealment was clearly not concealed such as those trials using quasi‐randomisation (e.g. even or odd date of birth).
2. Were the inclusion and exclusion criteria clearly defined?	Score 1 if text states the type of fracture and which patients were included and/or excluded. Otherwise score 0.
3. Were the outcomes of trial participants who withdrew or excluded after allocation described and included in an intention‐to‐treat analysis?	Score 1 if yes or text states that no withdrawals occurred, or data are presented that, by clearly showing 'participant flow', allow this to be inferred. Otherwise score 0.
4. Were the treatment and control groups adequately described at entry and if so were the groups well matched or appropriate co‐variate adjustment made?	Score 1 if at least four admission details given (e.g. age, sex, mobility, function score, mental test score, fracture type) with no significant difference between groups or appropriate adjustment made. Otherwise score 0.
5. Did the surgeons have prior experience of the operations they performed in the trial, prior to its commencement?	Score 1 if text states there was an introductory period or that surgeons were experienced. Otherwise score 0.
6. Were the care programmes other than trial options identical?	Score 1 if text states they were or if this can be inferred. Otherwise score 0.
7. Were the outcome measures clearly defined in the text with a definition of any ambiguous terms encountered?	Score 1 if yes. Otherwise score 0.
8. Were the outcome assessors blind to assignment status?	Score 1 if assessors of pain and function at follow‐up were blinded to treatment outcome. Otherwise score 0.
9. Was the timing of outcome measures appropriate? A minimum of 24 months active follow‐up for all surviving trial participants.	Score 1 if yes. Otherwise score 0.
10. Was loss to follow‐up reported and if so were less than 5% of trial participants lost to follow‐up?	Score 1 if yes. Otherwise score 0.

Table 1. Methodological quality assessment scheme

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Table 2. Methodological quality assessment results (see Table 1 for criteria)

Study ID	Item 1	Item 2	Item 3	Item 4	Item 5	Item 6	Item 7	Item 8	Item 9	Item 10
Soreide 1979	0	0	0	0	0	0	1	0	0	0
Jensen 1984	2	0	0	0	0	1	1	0	1	1
Svenningsen 1985	1	0	0	0	0	0	1	0	1	1
Skinner 1989	0	1	0	0	0	0	1	0	0	0
van Vugt 1993	1	1	0	1	0	0	1	0	1	1
Jonsson 1996	2	1	0	0	0	1	1	0	1	1
Neander 1997	1	1	0	0	0	0	1	0	0	1
van Dortmont 2000	2	1	1	1	0	1	1	0	1	1
Davison 2001	2	1	0	1	0	1	0	1	1	0
Puolakka 2001	2	1	0	1	0	0	1	0	1	1
Johansson 2002	1	1	0	0	0	1	1	0	1	0
Parker 2002	2	1	1	1	1	1	0	0	1	1
Rogmark 2002	3	1	0	0	1	1	1	0	1	1
Roden 2003	2	1	0	0	0	0	0	0	1	1
Tidermark 2003	2	1	0	1	1	1	1	0	1	1
Blomfeldt 2005	2	1	1	1	1	1	1	0	1	1
STARS 2006	3	1	1	0	0	0	1	0	1	1
Frihagen 2007	3	1	1	1	0	0	1	1	1	1
Mouzopoulos 2008	0	1	0	1	0	1	1	1	1	0

Table 2. Methodological quality assessment results (see Table 1 for criteria)

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Comparison 1. Internal fixation versus arthroplasty (all types)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Length of surgery ( in minutes) Show forest plot	8		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.1 Fixation versus hemiarthroplasty	6		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Fixation versus total hip replacement	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Internal fixation versus replacement arthroplasty (various)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Operative blood loss (in millilitres) Show forest plot	7		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 Fixation versus hemiarthroplasty	6		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Fixation versus total hip replacement	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of patients transfused Show forest plot	6	1231	Risk Ratio (M‐H, Random, 95% CI)	0.24 [0.09, 0.64]

3.1 Fixation versus hemiarthroplasty	4	831	Risk Ratio (M‐H, Random, 95% CI)	0.24 [0.11, 0.53]
3.2 Fixation versus total hip replacement	1	102	Risk Ratio (M‐H, Random, 95% CI)	0.07 [0.02, 0.22]
3.3 Internal fixation versus replacement arthroplasty (various)	1	298	Risk Ratio (M‐H, Random, 95% CI)	1.08 [0.71, 1.63]
4 Mean units blood transfused Show forest plot	2	547	Mean Difference (IV, Random, 95% CI)	‐0.57 [‐1.10, ‐0.04]

4.1 Fixation versus hemiarthroplasty	2	547	Mean Difference (IV, Random, 95% CI)	‐0.57 [‐1.10, ‐0.04]
5 Non‐union of fracture within follow‐up period (includes early displacement) Show forest plot	15	2178	Risk Ratio (M‐H, Fixed, 95% CI)	27.94 [15.65, 49.86]

5.1 Fixation versus hemiarthroplasty	10	1454	Risk Ratio (M‐H, Fixed, 95% CI)	24.24 [12.68, 46.36]
5.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Fixed, 95% CI)	22.59 [5.52, 92.50]
5.3 Internal fixation versus replacement arthroplasty (various)	1	409	Risk Ratio (M‐H, Fixed, 95% CI)	110.67 [6.89, 1776.91]
6 Avascular necrosis Show forest plot	12	2051	Risk Ratio (M‐H, Fixed, 95% CI)	19.22 [8.16, 45.27]

6.1 Fixation versus hemiarthroplasty	9	1394	Risk Ratio (M‐H, Fixed, 95% CI)	13.06 [4.82, 35.42]
6.2 Fixation versus total hip replacement	2	248	Risk Ratio (M‐H, Fixed, 95% CI)	20.66 [2.83, 150.74]
6.3 Internal fixation versus replacement arthroplasty (various)	1	409	Risk Ratio (M‐H, Fixed, 95% CI)	61.09 [3.77, 989.69]
7 Dislocation of prosthesis Show forest plot	15		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

7.1 Fixation versus hemiarthroplasty	10	1806	Risk Ratio (M‐H, Random, 95% CI)	0.27 [0.06, 1.16]
7.2 Fixation versus total hip replacement	6	806	Risk Ratio (M‐H, Random, 95% CI)	0.08 [0.02, 0.25]
7.3 Internal fixation versus replacement arthroplasty (various)	1	298	Risk Ratio (M‐H, Random, 95% CI)	1.27 [0.40, 4.07]
8 Loosening of prosthesis Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Fixation versus hemiarthroplasty	6	1185	Risk Ratio (M‐H, Fixed, 95% CI)	0.22 [0.08, 0.61]
8.2 Internal fixation versus total hip replacement	1	320	Risk Ratio (M‐H, Fixed, 95% CI)	0.10 [0.00, 1.97]
9 Acetabular wear (as defined by each study) Show forest plot	5	940	Risk Ratio (M‐H, Fixed, 95% CI)	0.21 [0.05, 0.90]

9.1 Fixation versus hemiarthroplasty	5	940	Risk Ratio (M‐H, Fixed, 95% CI)	0.21 [0.05, 0.90]
10 Fracture below/around implant Show forest plot	5	1128	Risk Ratio (M‐H, Random, 95% CI)	0.40 [0.09, 1.67]

10.1 Fixation versus hemiarthroplasty	3	617	Risk Ratio (M‐H, Random, 95% CI)	0.49 [0.05, 4.56]
10.2 Fixation versus total hip replacement	1	102	Risk Ratio (M‐H, Random, 95% CI)	0.31 [0.01, 7.40]
10.3 Internal fixation versus replacement arthroplasty (various)	1	409	Risk Ratio (M‐H, Random, 95% CI)	0.18 [0.02, 1.50]
11 Re‐operations minor (e.g. removal of fixation, dislocation of arthroplasty) Show forest plot	17	2618	Risk Ratio (M‐H, Random, 95% CI)	1.36 [0.69, 2.68]

11.1 Fixation versus hemiarthroplasty	11	1623	Risk Ratio (M‐H, Random, 95% CI)	2.36 [1.05, 5.30]
11.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Random, 95% CI)	0.86 [0.16, 4.70]
11.3 Internal fixation versus replacement arthroplasty (various)	2	680	Risk Ratio (M‐H, Random, 95% CI)	0.24 [0.00, 22.30]
12 Re‐operations moderate (e.g. fixation to arthroplasty, drainage, girdlestone) Show forest plot	17	2618	Risk Ratio (M‐H, Random, 95% CI)	9.35 [5.79, 15.07]

12.1 Fixation versus hemiarthroplasty	11	1623	Risk Ratio (M‐H, Random, 95% CI)	7.56 [4.88, 11.72]
12.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Random, 95% CI)	17.96 [4.31, 74.91]
12.3 Internal fixation versus replacement arthroplasty (various)	2	680	Risk Ratio (M‐H, Random, 95% CI)	45.28 [3.31, 619.46]
13 Re‐operations major (e.g. revision arthroplasty, hemiarthroplasty to THR) Show forest plot	17	2618	Risk Ratio (M‐H, Random, 95% CI)	0.41 [0.19, 0.87]

13.1 Fixation versus hemiarthroplasty	11	1623	Risk Ratio (M‐H, Random, 95% CI)	0.47 [0.16, 1.41]
13.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Random, 95% CI)	0.24 [0.03, 2.12]
13.3 Internal fixation versus replacement arthroplasty (various)	2	680	Risk Ratio (M‐H, Random, 95% CI)	0.19 [0.01, 4.21]
14 Total re‐operation rate (within follow‐up period of study) Show forest plot	19	3045	Risk Ratio (M‐H, Random, 95% CI)	3.22 [2.31, 4.47]

14.1 Fixation versus hemiarthroplasty	11	1623	Risk Ratio (M‐H, Random, 95% CI)	3.13 [1.95, 5.03]
14.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Random, 95% CI)	3.43 [1.45, 8.10]
14.3 Internal fixation versus replacement arthroplasty (various)	4	1107	Risk Ratio (M‐H, Random, 95% CI)	3.26 [1.65, 6.43]
15 Superficial wound infection Show forest plot	14	1986	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.53, 1.38]

15.1 Fixation versus hemiarthroplasty	9	1373	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.46, 1.58]
15.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Fixed, 95% CI)	0.43 [0.13, 1.50]
15.3 Internal fixation versus replacement arthroplasty (various)	1	298	Risk Ratio (M‐H, Fixed, 95% CI)	1.53 [0.50, 4.62]
16 Deep wound infection Show forest plot	15	2825	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.30, 0.93]

16.1 Fixation versus hemiarthroplasty	10	1592	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.24, 0.91]
16.2 Fixation versus total hip replacement	2	248	Risk Ratio (M‐H, Fixed, 95% CI)	2.62 [0.11, 63.28]
16.3 Internal fixation versus replacement arthroplasty (various)	3	985	Risk Ratio (M‐H, Fixed, 95% CI)	0.59 [0.17, 2.07]
17 Pneumonia Show forest plot	5	1003	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.51, 1.40]

17.1 Fixation versus hemiarthroplasty	4	857	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.56, 1.61]
17.2 Fixation versus total hip replacement	1	146	Risk Ratio (M‐H, Fixed, 95% CI)	0.12 [0.01, 2.37]
18 Deep vein thrombosis Show forest plot	9	1558	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.50, 1.96]

18.1 Fixation versus hemiarthroplasty	4	945	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [0.50, 3.96]
18.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.08, 1.52]
18.3 Internal fixation versus replacement arthroplasty (various)	1	298	Risk Ratio (M‐H, Fixed, 95% CI)	1.53 [0.39, 5.98]
19 Pulmonary embolism Show forest plot	9	1558	Risk Ratio (M‐H, Fixed, 95% CI)	1.30 [0.59, 2.86]

19.1 Fixation versus hemiarthroplasty	4	945	Risk Ratio (M‐H, Fixed, 95% CI)	1.89 [0.58, 6.15]
19.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Fixed, 95% CI)	1.92 [0.37, 10.12]
19.3 Internal fixation versus replacement arthroplasty (various)	1	298	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.10, 2.48]
20 Thromboembolic complications combined Show forest plot	13	2174	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.70, 1.83]

20.1 Fixation versus hemiarthroplasty	7	1152	Risk Ratio (M‐H, Fixed, 95% CI)	1.34 [0.67, 2.68]
20.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.22, 2.06]
20.3 Internal fixation versus replacement arthroplasty (various)	2	707	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.52, 2.72]
21 Congestive cardiac failure/heart failure Show forest plot	4	1057	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.45, 1.70]

21.1 Fixation versus hemiarthroplasty	1	455	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.33, 3.09]
21.2 Fixation versus total hip replacement	2	193	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.16, 5.04]
21.3 Internal fixation versus replacement arthroplasty (various)	1	409	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.31, 2.00]
22 Myocardial infarction Show forest plot	6	1068	Risk Ratio (M‐H, Fixed, 95% CI)	0.58 [0.22, 1.51]

22.1 Fixation versus hemiarthroplasty	1	455	Risk Ratio (M‐H, Fixed, 95% CI)	5.07 [0.24, 104.94]
22.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.12, 1.82]
22.3 Internal fixation versus replacement arthroplasty (various)	1	298	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.03, 2.08]
23 Stroke (cerebrovascular accident) Show forest plot	9	1645	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.43, 1.69]

23.1 Fixation versus hemiarthroplasty	4	725	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.23, 3.09]
23.2 Fixation versus total hip replacement	3	213	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.20, 4.50]
23.3 Internal fixation versus replacement arthroplasty (various)	2	707	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.32, 2.11]
24 Confusional state Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

24.1 Fixation versus hemiarthroplasty	2	675	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.55, 1.39]
25 Gastrointestinal complications Show forest plot	3	703	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.23, 1.30]

25.1 Hemiarthroplasty	2	557	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.28, 2.13]
25.2 Total hip replacement	1	146	Risk Ratio (M‐H, Fixed, 95% CI)	0.17 [0.02, 1.46]
26 Pressure sores Show forest plot	7	1380	Risk Ratio (M‐H, Fixed, 95% CI)	1.11 [0.55, 2.23]

26.1 Fixation versus hemiarthroplasty	4	819	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.47, 2.66]
26.2 Fixation versus total hip replacement	2	152	Risk Ratio (M‐H, Fixed, 95% CI)	1.45 [0.25, 8.31]
26.3 Internal fixation versus replacement arthroplasty (various)	1	409	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.18, 4.33]
27 Total medical complications (as defined in each study) Show forest plot	13	2173	Risk Ratio (M‐H, Random, 95% CI)	0.73 [0.58, 0.92]

27.1 Fixation versus hemiarthroplasty	7	1151	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.51, 1.02]
27.2 Fixation versus total hip replacement	4	315	Risk Ratio (M‐H, Random, 95% CI)	0.62 [0.36, 1.06]
27.3 Internal fixation versus replacement arthroplasty (various)	2	707	Risk Ratio (M‐H, Random, 95% CI)	0.79 [0.51, 1.22]
28 Length of hospital stay (in days) Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

28.1 Fixation versus hemiarthroplasty	4	821	Mean Difference (IV, Random, 95% CI)	1.12 [‐3.07, 5.31]
28.2 Fixation versus total hip replacement	1	75	Mean Difference (IV, Random, 95% CI)	4.70 [2.51, 6.89]
28.3 Internal fixation versus replacement arthroplasty (various)	1	298	Mean Difference (IV, Random, 95% CI)	‐0.68 [‐2.43, 1.07]
29 Mortality 30 days Show forest plot	4	780	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.46, 1.24]

29.1 Fixation versus hemiarthroplasty	4	780	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.46, 1.24]
30 Mortality up to 3 to 6 months Show forest plot	15	2320	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.70, 1.08]

30.1 Fixation versus hemiarthroplasty	10	1345	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.66, 1.07]
30.2 Fixation versus total hip replacement	3	268	Risk Ratio (M‐H, Fixed, 95% CI)	2.52 [0.89, 7.14]
30.3 Internal fixation versus replacement arthroplasty (various)	2	707	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.34, 1.27]
31 Mortality up to 12 months Show forest plot	14	2317	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.81, 1.11]

31.1 Fixation versus hemiarthroplasty	8	1213	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.78, 1.13]
31.2 Fixation versus total hip replacement	3	268	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.68, 2.05]
31.3 Internal fixation versus replacement arthroplasty (various)	3	836	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.61, 1.30]
32 Mortality up to 24 to 48 months Show forest plot	15	2335	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.87, 1.09]

32.1 Fixation versus hemiarthroplasty	9	1204	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.84, 1.10]
32.2 Fixation versus total hip replacement	3	295	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.71, 1.53]
32.3 Internal fixation versus replacement arthroplasty (various)	3	836	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.74, 1.29]
33 Mortality 10 years Show forest plot	2	864	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.92, 1.05]

33.1 Fixation versus hemiarthroplasty	1	455	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.90, 1.03]
33.2 Internal fixation versus replacement arthroplasty (various)	1	409	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.90, 1.13]
34 Residual pain at 1 year Show forest plot	5	750	Risk Ratio (M‐H, Random, 95% CI)	1.24 [0.79, 1.94]

34.1 Fixation versus hemiarthroplasty	2	366	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.62, 1.05]
34.2 Fixation versus total hip replacement	2	128	Risk Ratio (M‐H, Random, 95% CI)	3.08 [0.90, 10.56]
34.3 Internal fixation versus replacement arthroplasty (various)	1	256	Risk Ratio (M‐H, Random, 95% CI)	1.3 [1.05, 1.61]
35 Residual pain at 1 year (subgrouped by cemented versus uncemented) Show forest plot	5	750	Risk Ratio (M‐H, Random, 95% CI)	1.24 [0.79, 1.94]

35.1 Fixation versus cemented (hemi)arthroplasty	3	384	Risk Ratio (M‐H, Random, 95% CI)	1.96 [0.91, 4.23]
35.2 Fixation versus uncemented (hemi)arthroplasty	2	366	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.62, 1.05]
36 Mean pain score at 1 to 2 years Show forest plot	3	521	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.68, 0.26]

36.1 Internal fixation versus hemiarthroplasty	2	437	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.43, 0.39]
36.2 Internal fixation versus replacement arthroplasty (various types)	1	84	Std. Mean Difference (IV, Random, 95% CI)	‐0.62 [‐1.06, ‐0.19]
37 Mean pain score at 1 to 2 years (subgrouped by cemented versus uncemented) Show forest plot	3	521	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.68, 0.26]

37.1 Internal fixation versus cemented (hemi)arthroplasty	2	197	Std. Mean Difference (IV, Random, 95% CI)	‐0.42 [‐0.78, ‐0.07]
37.2 Internal fixation versus uncemented (hemi)arthroplasty	1	324	Std. Mean Difference (IV, Random, 95% CI)	0.17 [‐0.05, 0.38]
38 Pain at 2 to 3 years Show forest plot	2	322	Risk Ratio (M‐H, Random, 95% CI)	3.49 [0.11, 115.59]

38.1 Fixation versus total hip replacement	2	322	Risk Ratio (M‐H, Random, 95% CI)	3.49 [0.11, 115.59]
39 Failure to return to same residence at final follow‐up Show forest plot	2	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.54, 1.33]

39.1 Fixation versus hemiarthroplasty	2	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.54, 1.33]
40 Failure to regain mobility Show forest plot	6	593	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.74, 1.39]

40.1 Fixation versus hemiarthroplasty	6	593	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.74, 1.39]
41 Harris hip score (at 1 year) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

41.1 Fixation versus hemiarthroplasty	2	223	Mean Difference (IV, Fixed, 95% CI)	‐6.61 [‐9.73, ‐3.49]
41.2 Fixation versus total hip replacement	1	65	Mean Difference (IV, Fixed, 95% CI)	‐10.30 [‐12.78, ‐7.82]
42 Hip rating questionnaire at 1 year Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

42.1 Fixation versus hemiarthroplasty	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
42.2 Fixation versus total hip replacement	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
43 Hip scores (at 1 year) Show forest plot	3		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

43.1 Fixation versus hemiarthroplasty	3	374	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.38 [‐0.58, ‐0.17]
43.2 Fixation versus total hip replacement	2	168	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.77 [‐1.10, ‐0.45]
44 Mean Eq‐5d score (at 1 year) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

44.1 Fixation versus hemiarthroplasty	2	341	Mean Difference (IV, Fixed, 95% CI)	‐0.07 [‐0.14, ‐0.00]
44.2 Fixation versus total hip replacement	1	130	Mean Difference (IV, Fixed, 95% CI)	‐0.12 [‐0.33, 0.09]
45 Barthel index score of below 95 at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

45.1 Fixation versus hemiarthroplasty	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Internal fixation versus arthroplasty (all types)

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Comparison 2. Internal fixation versus hemiarthroplasty

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Length of surgery (in minutes) Show forest plot	6		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Screws versus Thompson	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Screws versus Moore	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.3 Screws or SHS versus bipolar hemiarthroplasty	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Operative blood loss (in millilitres) Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 Screws versus Thompson	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Screws versus Moore	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.3 Screws or SHS versus bipolar hemiarthroplasty	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Number of patients transfused Show forest plot	5	1060	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.29, 0.53]

3.1 Screws versus Moore	2	507	Risk Ratio (M‐H, Fixed, 95% CI)	0.12 [0.06, 0.26]
3.2 Screws v Christiansen bipolar	1	104	Risk Ratio (M‐H, Fixed, 95% CI)	0.03 [0.00, 0.45]
3.3 Screws or SHS versus bipolar hemiarthroplasty	2	449	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.56, 1.14]
4 Re‐operations minor ( eg fixation‐ removal of metalwork, dislocation of hemiarthroplasty) Show forest plot	12		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

4.1 Screws versus Thompson	2	91	Risk Ratio (M‐H, Random, 95% CI)	0.31 [0.01, 7.15]
4.2 Screws versus Moore	3	617	Risk Ratio (M‐H, Random, 95% CI)	5.39 [0.23, 126.75]
4.3 SHS versus Moore	1	182	Risk Ratio (M‐H, Random, 95% CI)	0.04 [0.00, 0.67]
4.4 SHS versus Stanmore bipolar	1	43	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
4.5 Screws, SHS or nail & plate versus Christiansen bipolar	2	273	Risk Ratio (M‐H, Random, 95% CI)	1.15 [0.04, 31.12]
4.6 SHS versus Thompson or Monk bipolar	1	280	Risk Ratio (M‐H, Random, 95% CI)	4.02 [0.75, 21.56]
4.7 2 von Bahr screws versus Variokopf bipolar hemiarthroplasty	1	100	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.35, 3.26]
4.8 2 Olmed screws versus bipolar hemiarthroplasty	1	219	Risk Ratio (M‐H, Random, 95% CI)	2.80 [1.31, 5.98]
5 Re‐operations moderate (eg fixation to hemiarthroplasty or total hip replacement, drainage, girdlestone) Show forest plot	12		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1 Screws versus Thompson	2	91	Risk Ratio (M‐H, Random, 95% CI)	6.12 [1.13, 33.22]
5.2 Screws versus Moore	3	617	Risk Ratio (M‐H, Random, 95% CI)	8.15 [2.46, 26.98]
5.3 SHS versus Moore	1	182	Risk Ratio (M‐H, Random, 95% CI)	10.00 [3.16, 31.60]
5.4 SHS versus Stanmore bipolar	1	43	Risk Ratio (M‐H, Random, 95% CI)	3.14 [0.71, 13.87]
5.5 Screws, SHS or nail & plate versus Christiansen bipolar	2	273	Risk Ratio (M‐H, Random, 95% CI)	3.72 [1.28, 10.76]
5.6 SHS versus Thompson or Monk bipolar	1	280	Risk Ratio (M‐H, Random, 95% CI)	17.43 [5.41, 56.09]
5.7 2 von Bahr screws versus Variokopf bipolar hemiarthroplasty	1	100	Risk Ratio (M‐H, Random, 95% CI)	7.39 [2.38, 22.91]
5.8 2 Olmed screws versus bipolar hemiarthroplasty	1	219	Risk Ratio (M‐H, Random, 95% CI)	8.37 [3.45, 20.32]
6 Re‐operations major (eg revision hemiarthroplasty or conversion to total hip replacement) Show forest plot	12		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 Screws versus Thompson	2	91	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 Screws versus Moore	3	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.32, 1.60]
6.3 SHS versus Moore	1	182	Risk Ratio (M‐H, Fixed, 95% CI)	0.03 [0.00, 0.42]
6.4 SHS versus Stanmore bipolar	1	43	Risk Ratio (M‐H, Fixed, 95% CI)	0.10 [0.01, 1.62]
6.5 Screws, SHS or nail & plate versus Christiansen bipolar	2	273	Risk Ratio (M‐H, Fixed, 95% CI)	0.08 [0.01, 0.52]
6.6 SHS versus Thompson or Monk bipolar	1	280	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.07, 6.36]
6.7 2 von Bahr screws versus Variokopf bipolar hemiarthroplasty	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.30 [0.01, 7.10]
6.8 2 Olmed screws versus bipolar hemiarthroplasty	1	219	Risk Ratio (M‐H, Fixed, 95% CI)	8.76 [0.48, 160.76]
7 Total re‐operation rate (within follow‐up period of study) Show forest plot	14		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 Screws versus Thompson	2	91	Risk Ratio (M‐H, Fixed, 95% CI)	5.15 [1.22, 21.68]
7.2 Screws versus Moore	3	617	Risk Ratio (M‐H, Fixed, 95% CI)	5.82 [3.85, 8.79]
7.3 SHS versus Moore	1	182	Risk Ratio (M‐H, Fixed, 95% CI)	1.36 [0.85, 2.18]
7.4 SHS versus Stanmore bipolar	1	43	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.36, 2.23]
7.5 Screws, SHS or nail & plate versus Christiansen bipolar	2	273	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [0.72, 2.47]
7.6 SHS versus Thompson or Monk bipolar	1	280	Risk Ratio (M‐H, Fixed, 95% CI)	7.04 [3.34, 14.83]
7.7 SHS versus hemiarthroplasty (unknown type)	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	2.4 [0.92, 6.23]
7.8 Screws or SHS versus bipolar hemiarthroplasty	1	229	Risk Ratio (M‐H, Fixed, 95% CI)	7.21 [3.21, 16.22]
7.9 2 von Bahr screws versus Variokopf bipolar hemiarthroplasty	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	3.93 [1.91, 8.07]
7.10 2 Olmed screws versus bipolar hemiarthroplasty	1	219	Risk Ratio (M‐H, Fixed, 95% CI)	4.16 [2.28, 7.58]
8 Superficial wound infection Show forest plot	9	1502	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.50, 1.53]

8.1 Screws versus Thompson	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.00, 1.48]
8.2 Screws versus Moore	3	617	Risk Ratio (M‐H, Fixed, 95% CI)	1.45 [0.56, 3.77]
8.3 SHS versus Stanmore bipolar	1	43	Risk Ratio (M‐H, Fixed, 95% CI)	0.21 [0.01, 4.11]
8.4 Screws, SHS or nail & plate versus Christiansen bipolar	2	273	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.11, 2.13]
8.5 SHS versus Thompson or Monk bipolar	1	280	Risk Ratio (M‐H, Fixed, 95% CI)	6.0 [0.25, 145.88]
8.6 Screws or SHS versus bipolar hemiarthroplasty	1	229	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [0.41, 4.87]
9 Deep wound infection Show forest plot	11		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 Screws versus Thompson	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 Screws versus Moore	3	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.17 [0.04, 0.75]
9.3 SHS versus Moore	1	198	Risk Ratio (M‐H, Fixed, 95% CI)	0.15 [0.01, 2.79]
9.4 SHS versus Stanmore bipolar	1	43	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.5 Screws, SHS or nail & plate versus Christiansen bipolar	2	273	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.08, 1.66]
9.6 SHS versus Thompson or Monk bipolar	1	280	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.03, 16.21]
9.7 Screws or SHS versus bipolar hemiarthroplasty	2	448	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.48, 3.11]
10 Length of hospital stay (in days) Show forest plot	5	1036	Mean Difference (IV, Random, 95% CI)	0.79 [‐2.13, 3.72]

10.1 Screws versus Thompson	1	60	Mean Difference (IV, Random, 95% CI)	4.5 [‐11.20, 20.20]
10.2 Screws versus Moore	1	455	Mean Difference (IV, Random, 95% CI)	0.30 [‐5.20, 5.80]
10.3 Screws or SHS versus bipolar hemiarthroplasty	2	449	Mean Difference (IV, Random, 95% CI)	‐0.80 [‐2.60, 1.00]
10.4 SHS versus hemiarthroplasty (unknown type)	1	72	Mean Difference (IV, Random, 95% CI)	3.90 [2.45, 5.35]
11 Mortality at 30 days Show forest plot	4	780	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.46, 1.24]

11.1 SHS or screws versus bipolar hemiarthroplasty	4	780	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.46, 1.24]
12 Mortality up to 3 to 6 months Show forest plot	10	1474	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.64, 1.03]

12.1 Screws versus Thompson	2	91	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.52, 2.00]
12.2 Screws versus Moore	3	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.56, 1.08]
12.3 SHS versus Stanmore bipolar	1	42	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.03, 2.05]
12.4 Screws, SHS or nail & plate versus Christiansen bipolar	2	273	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.61, 2.08]
12.5 Screws or SHS versus bipolar hemiarthroplasty	2	451	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.41, 1.23]
13 Mortality up to 12 months Show forest plot	10	1528	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.78, 1.11]

13.1 Screws versus Thompson	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.34 [0.85, 2.11]
13.2 Screws versus Moore	3	617	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.73, 1.21]
13.3 SHS versus Stanmore bipolar	1	41	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.09, 1.92]
13.4 Screws, SHS or nail & plate versus Christiansen bipolar	2	273	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.60, 1.54]
13.5 Screws or SHS versus bipolar hemiarthroplasty	2	451	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.55, 1.24]
13.6 SHS versus hemiarthroplasty (unknown type)	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.27, 2.53]
14 Mortality 24 to 48 months Show forest plot	11	1519	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.84, 1.08]

14.1 Screws versus Thompson	2	91	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.91, 1.49]
14.2 Screws versus Moore	3	580	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.73, 1.06]
14.3 2 von Bahr screws versus Variokopf bipolar hemiarthroplasty	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.55 [0.48, 4.97]
14.4 SHS versus Stanmore bipolar	1	42	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.30, 2.31]
14.5 SHS or nail & plate versus Christiansen bipolar	1	169	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.67, 1.56]
14.6 Screws or SHS versus bipolar hemiarthroplasty	2	451	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.71, 1.32]
14.7 SHS versus hemiarthroplasty (unknown type)	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.43, 1.67]
15 Mortality 10 years Show forest plot	1	455	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.90, 1.03]

15.1 Screws versus Moore	1	455	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.90, 1.03]
16 Pain at one year Show forest plot	3	561	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.82, 1.18]

16.1 Screws versus Thompson	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16.2 Screws versus Moore	2	366	Risk Ratio (M‐H, Fixed, 95% CI)	0.80 [0.62, 1.04]
16.3 Screws or SHS versus bipolar hemiarthroplasty	1	195	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.99, 1.61]
17 Failure to return to same residence at final follow‐up Show forest plot	2	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.54, 1.33]

17.1 Screws versus Moore	2	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.54, 1.33]
18 Failure to regain mobility Show forest plot	6	593	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.86, 1.15]

18.1 Screws versus Thompson	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	1.87 [0.53, 6.57]
18.2 Screws versus Moore	3	419	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.75, 1.04]
18.3 2 von Bahr screws versus Variokopf bipolar hemiarthroplasty	1	84	Risk Ratio (M‐H, Fixed, 95% CI)	1.95 [1.15, 3.30]
18.4 Screws v Christiansen bipolar	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.69, 1.43]

Comparison 2. Internal fixation versus hemiarthroplasty

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Comparison 3. Internal fixation versus Total Hip Replacement

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Length of surgery (in minutes) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.1 2 Olmed screws verus Exeter THR	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Screws or SHS versus THR (various)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Operative blood loss (in millilitres) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 2 Olmed screws verus Exeter THR	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of patients transfused Show forest plot	2	240	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.20, 0.50]

3.1 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.07 [0.02, 0.22]
3.2 Screws or SHS versus THR (various)	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.43, 1.26]
4 Re‐operations minor (Fixation removal of metalwork, dislocation of THR) Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 Hansson pin versus Charnley	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.01, 3.80]
4.2 2 Olmed screws versus Lubinus or BiMetric	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.23, 1.14]
4.3 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	9.25 [1.23, 69.60]
4.4 SHS versus Howse II	1	180	Risk Ratio (M‐H, Fixed, 95% CI)	0.03 [0.00, 0.43]
5 Re‐operations moderate (Fixation to hemiarthroplasty or THR, drainage, girdlestone) Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 Hansson pin versus Charnley	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	14.4 [0.87, 238.56]
5.2 2 Olmed screws versus Lubinus or BiMetric	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	27.16 [3.66, 201.50]
5.3 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	34.26 [2.12, 553.64]
5.4 SHS versus Howse II	1	180	Risk Ratio (M‐H, Fixed, 95% CI)	59.67 [3.70, 961.20]
6 Re‐operations major (revision THR) Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 Hannson pin versus Charnley	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.01, 7.48]
6.2 2 Olmed screws versus Lubinus or BiMetric	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.01, 3.76]
6.4 SHS versus Howse II	1	180	Risk Ratio (M‐H, Fixed, 95% CI)	0.08 [0.00, 1.32]
7 Total re‐operation rate (within follow‐up period of study) Show forest plot	7		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 Hansson pin versus Charnley	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	3.35 [0.78, 14.50]
7.2 2 Olmed screws versus Lubinus or Bimetric	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	2.32 [1.36, 3.94]
7.3 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	11.56 [2.89, 46.25]
7.4 SHS versus Howse II	1	180	Risk Ratio (M‐H, Fixed, 95% CI)	1.47 [0.90, 2.38]
7.5 Screws or SHS versus THR (various)	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	4.5 [1.98, 10.21]
7.6 SHS versus THR (unknown type)	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	12.0 [1.63, 88.29]
8 Superficial wound infection Show forest plot	4	315	Risk Ratio (M‐H, Fixed, 95% CI)	0.43 [0.13, 1.50]

8.1 Hansson pin versus Charnley	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.01, 7.48]
8.2 2 Olmed screws versus Lubinus or BiMetric	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.14, 3.15]
8.3 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.01, 3.76]
9 Deep wound infection Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 SHS versus Howse II	1	178	Risk Ratio (M‐H, Fixed, 95% CI)	0.16 [0.01, 3.36]
9.2 2 Olmed screws versus Lubinus or BiMetric	1	146	Risk Ratio (M‐H, Fixed, 95% CI)	2.62 [0.11, 63.28]
9.3 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Hospital stay (days) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10.1 Screws or SHS versus THR (various)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 SHS versus THR (unknown type)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Mortality up to 2 to 4 months Show forest plot	4	406	Risk Ratio (M‐H, Fixed, 95% CI)	2.21 [0.91, 5.40]

11.1 2 Olmed screws versus Lubinus or BiMetric	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	2.03 [0.65, 6.29]
11.2 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	6.48 [0.34, 122.37]
11.3 Screws or SHS versus THR (various)	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.26, 8.70]
12 Mortality at 12 to 18 months Show forest plot	4	390	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.64, 1.64]

12.1 2 Olmed screws versus Lubinus or BiMetric	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.55, 1.76]
12.2 Screws or SHS versus THR (various)	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.44, 5.08]
12.3 SHS versus THR (unknown type)	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.27, 2.53]
13 Mortality at 24 months Show forest plot	4	433	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.79, 1.75]

13.1 Hansson pin versus Charnley	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.12, 3.48]
13.2 2 Olmed screws versus Lubinus or BiMetric	1	146	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.61, 1.66]
13.3 2 Olmed screws verus Exeter THR	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	1.85 [0.68, 5.03]
13.4 Screws or SHS versus THR (various)	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.56, 3.99]
14 Mortality at 4 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

14.1 SHS versus THR (unknown type)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Pain at 1 year Show forest plot	2	157	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [1.02, 1.90]

15.1 Hansson pin versus Charnley	1	35	Risk Ratio (M‐H, Fixed, 95% CI)	1.91 [0.80, 4.55]
15.2 Screws or SHS versus THR (various)	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.94, 1.82]

Comparison 3. Internal fixation versus Total Hip Replacement

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