Bhandari’s Paradox : Patient’s expectation vs Surgeon’s choice (THR vs HRA)

In displaced femoral neck fractures in elderly, the two main treatment options are – Hemiarthroplasty (HRA) which is quicker, with a lower risk of dislocation and Total hip arthroplasty (THA) which provides superior long-term function and durability. Despite evidence favoring THA in many cases, actual surgical practices often lean heavily toward hemiarthroplasty. This discrepancy, highlighted by research from Mohit Bhandari and colleagues, has been termed “Bhandari’s Paradox” by Joseph Bernstein, MD.

Defining Bhandari’s paradox

It is a huge contrast observed between patient’s expectation and treatment option used by surgeons in displaced neck of femur fractures in elderly.

• 2011 study by Bhandari and team: 93% of respondents (functionally independent individuals at high risk for hip fractures) preferred THA over HRA, valuing its potential for better mobility and longevity despite the higher risk of complications like dislocation.
• Hochfelder et al. (analyzing 33,226 elderly patients with femoral neck fractures): 93% received HRA
• Perry et al. (analyzing 114,119 cases): Only 10.2% underwent THA.

Reasons behind the paradox

1. Cognitive Challenges in Decision-Making: Choosing between THA and HRA requires a complex decision analysis keeping in mind the various patient and outcome-based factors which can overwhelm the “unaided human mind,” resulting in choice of the historical default “HRA” even when THA might be more appropriate.
2. Financial Incentives: Surgeons proficient only in HRA may hesitate to refer patients to THA specialists due to economic considerations, further tilting the balance toward the simpler procedure.
3. Behavioral Biases and “Thinking Fast”: Drawing from Daniel Kahneman’s dual-process theory, Bernstein notes that surgeons often rely on fast, intuitive decision-making rather than deliberate analysis. Elderly patients presenting with hip fractures may appear frail, delirious, or low-functioning due to acute issues like pain or dehydration prompting a quick assumption of short life expectancy and favoring HRA. The need for expeditious surgery (to minimize mortality risk) exacerbates this bias.

Joseph M. Lane, MD, emphasizes that RCTs comparing THA and HRA often exclude cognitively impaired patients, who comprise 40-65% of hip fracture cases based on formal testing. When accounting for cognitive and functional impairments, only about 20% of patients may truly benefit from THA’s enhanced function, reducing the paradox’s apparent scale.

Resolving the paradox

In a subsequent abstract by Bernstein and Jaimo Ahn, the authors propose 4 resolutions to Bhandari’s Paradox:

1. Anticipated Short Life Expectancy: Patients may prioritize HRA’s lower dislocation risk over THA’s longevity if they expect a shorter lifespan.
2. High Discount Rates for Future Benefits: Individuals might undervalue long-term gains (e.g., better function years later) compared to immediate risks.
3. External Costs of THA: These include higher morbidity/mortality, surgeon discomfort with THA, delays in transferring care, or financial burdens.
4. Misapplication of Preferences: Patient desires may not be accurately incorporated into decisions.

To address the cognitive overload, Bernstein and Ahn developed a decision aid using a modified Markov process. This tool calculates expected utility based on inputs like life expectancy, functional values, dislocation/prosthetic failure risks, and discounting for deferred benefits.

References:

1. Bernstein J. Not the Last Word: Bhandari’s Paradox. Clin Orthop Relat Res. 2018;476(4):674-677. Available at: https://notthelastword.com/wp-content/uploads/2018/07/2018-NTLW-Bhandari-Paradox.pdf
2. Bernstein J, Ahn J. Resolving the Bhandari Paradox. Abstract presented at [event details]. Available at: https://program.eventact.com/Lecture/156926/3097424
3. Bhandari M, et al. Surgical preferences of patients at risk of hip fractures: Hemiarthroplasty versus total hip arthroplasty. BMC Musculoskelet Disord. 2011;12:289.