Hip replacement using a hemiarthroplasty (HA) is a common surgical procedure in elderly patients with fractures of the femoral neck. Data from the Swedish Hip Arthroplasty Register suggest that there is a higher risk for revision surgery with the bipolar HA compared with the unipolar HA.
In this study we analysed the reoperation and the dislocation rates for Exeter HAs in patients with a displaced femoral neck fracture, comparing the unipolar and bipolar prosthetic designs. Additionally, we compared the outcome for HAs performed as a primary intervention with those performed secondary to failed internal fixation.
We studied 830 consecutive Exeter HAs (427 unipolar and 403 bipolar) performed either as a primary operation for a displaced fracture of the femoral neck or as a secondary procedure after failed internal fixation of a fracture of the femoral neck. Cox regression analyses were performed to evaluate factors associated with reoperation and prosthetic dislocation. Age, gender, the surgeon’s experience, indication for surgery (primary or secondary) and type of HA (unipolar or bipolar) were tested as independent variables in the model.
The prosthetic design (uni- or bipolar) had no influence on the risk for reoperation or dislocation, nor had the age, gender or the surgeon’s experience. The secondary HAs were associated with a significantly increased risk for reoperation (HR 2.6, CI 1.5–4.5) or dislocation (HR 3.3, CI 1.4–7.3) compared to the primary HAs. We found no difference in the risk for reoperation or dislocation when comparing Exeter unipolar and bipolar HAs, but special attention is called for to reduce the risk of prosthesis dislocation and reoperation after a secondary HA.
Background and purpose
Treatment of displaced femoral neck fractures in Sweden has shifted towards more arthroplasties, especially hemiarthroplasties. We describe the hemiarthroplasty population in Sweden 2005 through 2009.
Since 2005, the Swedish Hip Arthroplasty Register has registered hemiarthroplasties on a national basis. We assessed hemiarthroplasty procedures in the Register 2005–2009 regarding patient details, implants, and surgical techniques. Completeness of recordings was calculated compared to the Swedish National Patient Register.
Completeness increased from 89% to 96% during the study period. 21,346 hemiarthroplasty procedures were assessed. The relative number of patients with femoral neck fracture as diagnosis increased from 91% to 94%; the proportion of men increased from 27% to 30%. The median age increased from 83 to 84 years in men and from 84 to 85 years in women. Patients classified as having evident cognitive impairment increased from 19% to 22%. More men than women were ASA 4. The proportion of monoblock-type implants (Austin-Moore and Thompson) decreased from 18% to 0.9%. Modular implants increased generally, but in 2009 bipolar implants decreased in favor of unipolar implants. Lubinus and Exeter stems, and Mega Caput and Vario Cup implant heads were most common. The use of uncemented implants decreased from 10% to 3%. Use of the anterolateral approach increased from 47% to 56%.
Important changes in surgical technique and implant choice occurred during the observation period. We interpret these changes as being reflections of the continuing effort by Swedish orthopedic surgeons to improve the quality of treatment, because the changes are consistent with recent findings in the Swedish Hip Arthroplasty Register and in other scientific studies.
Although not all elderly patients with femoral neck fractures are candidates for THA, active, mentally competent, independent patients achieve the most durable functional scores with THA compared with hemiarthroplasty. However, a relatively high frequency of early or late dislocation could reduce the potential benefits with THA.
We asked whether the incidence of first-time, recurrent dislocation, and revision differed in patients with hip fractures having THA or hemiarthroplasty.
Patients and Methods
We retrospectively reviewed 380 patients with hip fractures (380 hips) who underwent THAs between 1995 and 1999, and compared them with 412 patients with hip fractures (412 hips) who underwent hemiarthroplasties between 1990 and 1994. The mean followup was 8 years (range, 1–20 years).
THA had a higher early risk of first-time dislocation and a higher late risk: 19 (4.5%) of the 412 hips treated with hemiarthroplasty had at least one dislocation whereas 30 (8.1%) of the 380 hips treated with THA had at least one dislocation. The cumulative number of dislocations at the most recent followup (first time and recurrent dislocations) was 58 (13%) for the 380 THAs and 22 (5%) for the 412 hemiarthroplasties. At the 10-year followup, eight THAs (2%) had revision (six recurrent dislocations, two loosenings), and 42 hemiarthroplasties (10%) had revision (40 acetabular protrusions, one recurrent dislocation).
The risk of revision for recurrent dislocation increases with THA, but it remains lower than the risk of revision for wear of cartilage and acetabular protrusion in hemiarthroplasty.
Level of Evidence
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Background and purpose
Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age.
Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up.
The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7–2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27–0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life.
Interpretation The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.
Femoral-neck fracture in the elderly population is a problem that demands the attention of the orthopaedic community as life expectancy continues to increase. There are several different treatment options in use, and this variety in and of itself indicates the absence of an ideal single treatment option. Recent debate has focussed on the probable superiority of total hip arthroplasty (THA) over hemiarthroplasty for femoral-neck fracture. Clinical trials and systematic reviews of such trials have not provided a convincing answer to this question.
We analysed data from national registries evaluating prosthetic replacements for femoral-neck fracture in the elderly. We compared revision and reoperation rates of hemiarthroplasty and THA, analysed the prognostic variables that influenced implant survival and the major causes of failure.
Data from the Australian and Italian registries indicate that THA has an increased revision rate compared with bipolar hemiarthroplasty in femoral-neck fracture in the elderly. The registries identify that age over 75 years and the use of the anterior surgical approach are associated with better survivorship in patients who have a hemiarthroplasty. Cemented fixation of the femoral stem in hemiarthroplasty and THA is supported by registry data. Acetabular erosion accounted for a very low percentage of hemiarthroplasty revisions and reoperations.
Our review of data from national registries supports the continued use of bipolar hemiarthroplasty in femoral-neck fracture in the elderly and identifies age, method of fixation and surgical approach as important prognostic variables in determining implant survival.
Patients with neuromuscular disease reportedly have a higher incidence of postoperative dislocation after bipolar hemiarthroplasty. Although the literature has focused on a high prevalence of preoperative neurologic conditions in patients who had dislocations after bipolar hemiarthroplasties, the relative incidence of dislocation in patients with neuromuscular disease and without is unclear.
We therefore (1) asked whether the incidence of postoperative dislocation after bipolar hemiarthroplasty was greater in patients with neuromuscular disease than for those without, and (2) whether function differed between the two groups, and (3) explored potential risk factors for dislocation in two groups.
We retrospectively reviewed 190 patients who underwent bipolar hemiarthroplasties for fracture of the femoral neck between 1996 and 2008. Of the 190 patients, 42 had various neuromuscular diseases and 148 had no history of neuromuscular disease. Intraoperative stability was tested and posterior soft tissue repair was performed in all patients. We determined the incidence of dislocation, postoperative leg length discrepancy, and femoral offset in patients with or without neuromuscular disease.
The incidence of dislocation was 2.6% in all patients. We observed similar rates of dislocation in the two groups: 4.8% (two of 42 hips) in patients with neuromuscular disease and 2.0% (three of 148 hips) in patients without neuromuscular disease.
In femoral neck fractures in patients with neuromuscular disease, careful preoperative management and operative technique such as a posterior soft tissue repair might decrease the risk of postoperative dislocation; therefore, we consider the bipolar hemiarthroplasty a reasonable treatment option.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Background and purpose
Hip arthroplasty is an option for elderly patients with osteoporosis for the treatment of failure after fixation of trochanteric and subtrochanteric fractures, either as a total hip arthroplasty (THA) or as a hemiarthroplasty (HA). We analyzed the reoperation rate and risk factors for reoperation in a consecutive series of patients.
All patients (n = 88) operated from 1999 to 2006 with a THA (n = 63) or an HA (n = 25) due to failure of fixation of a trochanteric fracture (n = 63) or subtrochanteric fracture (n = 25) were included. Background data were collected from the patient records. A search was performed in the national registry of the Swedish National Board of Health and Welfare in order to find information on all reoperations. The follow-up time was 5–11 years.
The reoperation rate was 16% (14/88 hips). A periprosthetic fracture occurred in 6 patients, a deep prosthetic infection in 5 patients, and a dislocation of the prosthesis in 3 patients. Standard-length femoral stems had an increased risk of reoperation (11/47) compared to long stems (3/41) (HR = 4, 95% CI: 1.0–13; p = 0.06).
The high reoperation rate reflects the complexity of the surgery. Using long femoral stems that bridge previous holes and defects may be one way to reduce the risk for reoperation.
Most patients with displaced femoral neck fractures are treated by THA and hemiarthroplasty, but it remains uncertain which if either is associated with better function and lower risks of complications.
We performed a meta-analysis of randomized controlled trials (RCTs) to determine whether THA was associated with lower rates of reoperations, mortality, complications, and better function compared with hemiarthroplasty.
We searched the PubMed, Embase, Chinese Biomedicine Literature, and Cochrane Register of Controlled Trials databases and identified 12 RCTs (including a total of 1320 patients) for meta-analysis. Risk ratios (RRs) and weighted mean differences (WMDs) from each trial were pooled using random-effects or fixed-effects models depending on the heterogeneity of the included studies.
THA was associated with a lower risk of subsequent reoperations compared with hemiarthroplasty (RR = 0.53; 95% CI, 0.34–0.84). There was no difference in mortality between patients undergoing THA and hemiarthroplasty (RR = 0.81; 95% CI, 0.60–1.09). For complications, there was a higher risk of dislocation in patients undergoing THA (RR = 1.99; 95% CI, 1.26–3.15), but there were no differences in local infections (RR = 1.60; 95% CI, 0.74–3.46) and general complications (RR = 1.15; 95% CI, 0.91–1.45). Patients with THA had higher Harris hip scores at 1 year (WMD = 3.81; 95% CI, 0.87–6.74) and at 3 or 4 years (WMD = 10.07; 95% CI, 6.92–13.21).
Despite more dislocations, THA can benefit patients with displaced femoral neck fractures with a lower reoperation rate and higher functional scores.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-012-2293-8) contains supplementary material, which is available to authorized users.
Hip hemiarthroplasty dislocation is a serious complication in treatment of displaced intracapsular hip fractures. We investigated factors associated with an increased risk of dislocation after cemented hip hemiarthroplasty following the posterolateral approach.
Between January 2002 and December 2008, 602 hip fractures were treated with cemented unipolar hip hemiarthroplasty. A registry-based analysis was carried out to determine the total number of hemiarthroplasty dislocations in these patients. A control group of 96 patients without dislocation was randomly selected. Logistic regression analysis was performed to evaluate clinical and operative factors associated with dislocation.
Thirty-four patients (5.6%) experienced at least one dislocation. Most were the result of a fall and occurred within two months after surgery. There was a trend for increased dislocation in patients who had been operated on more than 48 hours after admission and in patients who had a longer operative time. Smaller centre-edge angle and hip offset were observed in patients with dislocation. Recurrent dislocation was a significant problem, as 18 patients (62%) experienced multiple dislocations.
The risk of hemiarthroplasty dislocation following the posterolateral surgical approach may be reduced by prompt surgical treatment and fall prevention in the early postoperative period. Patients with smaller acetabular coverage seem more predisposed to dislocation after the posterolateral approach and may be more suitable for other surgical approaches.
Medicine & Public Health; Orthopedics
This study was performed to explore the cost-effectiveness of total hip replacement compared with hemiarthroplasty in the treatment of displaced femoral neck fractures in active otherwise healthy older patients in whom the optimum treatment is believed to be an arthroplasty procedure.
A Markov decision model was used to determine whether total hip arthroplasty or hemiarthroplasty was most cost-effective for the management of a displaced femoral neck fracture in this patient population.
Total hip arthroplasty was associated with an average cost $3,000 more than hemiarthroplasty, and the average quality-adjusted life year gain was 1.53. The incremental cost-effectiveness ratio associated with the total hip replacement treatment strategy is $1960 per quality-adjusted life-year.
Currently available data support the use of total hip arthroplasty as the more cost-effective treatment strategy in this specific population. The increased upfront cost appears to be offset by the improved functional results when compared with hemiarthroplasty in this select patient group.
Background and purpose
Elderly patients with displaced femoral neck fractures are commonly treated with a hemiarthroplasty (HA), but little is known about the long-term failure of this treatment. We compared reoperation rates for patients aged at least 75 years with displaced femoral neck fractures treated with either internal fixation (IF), cemented HA, or uncemented HA (with or without hydroxyapatite coating), after 12–19 years of follow-up.
4 hospitals with clearly defined guidelines for the treatment of 75+ year-old patients with a displaced femoral neck fracture were included. Cohort 1 (1991–1993) with 180 patients had undergone IF; cohort 2 (1991–1995) with 203 patients had received an uncemented bipolar Ultima HA stem (Austin-Moore); cohort 3 (1991–1995) with 209 patients had received a cemented Charnley-Hastings HA; and cohort 4 (1991–1998) with 158 patients had received an uncemented hydroxyapatite-coated Furlong HA. Data were retrieved from patient files, from the region-based patient administrative system, and from the National Registry of Patients at the end of 2010. We performed survival analysis with adjustment for comorbidity, age, and sex.
Cemented HA had a reoperation rate (RR) of 5% and was used as reference in the Cox regression analysis, which showed significantly higher hazard ratios (HRs) for IF (HR = 3.8, 95% CI: 1.9–7.5; RR = 18%), uncemented HA (HR = 2.2, CI: 1.1–4.5; RR = 11%) and uncemented hydroxyapatite-coated HA (HR = 3.6, CI: 1.8–7.4; RR = 16%).
Cemented HA has a superior long-term hip survival rate compared to IF and uncemented HA (with and without hydroxyapatite coating) in patients aged 75 years or more with displaced femoral neck fractures.
Hemiarthroplasty is the most commonly used treatment for displaced femoral neck fractures in the elderly. There is limited evidence in the literature of improved functional outcome with cemented implants, although serious cement-related complications have been reported. We performed a randomized, controlled trial in patients 70 years and older comparing a cemented implant (112 hips) with an uncemented, hydroxyapatite-coated implant (108 hips), both with a bipolar head. The mean Harris hip score showed equivalence between the groups, with 70.9 in the cemented group and 72.1 in the uncemented group after 3 months (mean difference, 1.2) and 78.9 and 79.8 after 12 months (mean difference, 0.9). In the uncemented group, the mean duration of surgery was 12.4 minutes shorter and the mean intraoperative blood loss was 89 mL less. The Barthel Index and EQ-5D scores did not show any differences between the groups. The rates of complications and mortality were similar between groups. Both arthroplasties may be used with good results after displaced femoral neck fractures.
Level of Evidence: Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Femoral neck fractures in the elderly are frequent, represent a great health care problem, and have a significant impact on health insurance costs. Reconstruction options using hip arthroplasty include unipolar or bipolar hemiarthroplasty (HA), and total hip arthroplasty (THA). The purpose of this review is to discuss the indications, limitations, and pitfalls of each of these techniques.
The Pubmed database was searched for all articles on femoral neck fracture and for the reconstruction options presented in this review using the search terms "femoral neck fracture", "unipolar hemiarthroplasty", "bipolar hemiarthroplasty", and "total hip arthroplasty". In addition, cross-referencing was used to cover articles eventually undetected by the respective search strategies. The resulting articles were then reviewed with regard to the different techniques, outcome and complications of the distinct reconstruction options.
THA yields the best functional results in patients with displaced femoral neck fractures with complication rates comparable to HA. THA is beneficially implanted using an anterior approach exploiting the internervous plane between the tensor fasciae latae and the sartorius muscles allowing for immediate full weight-bearing. Based on our findings, bipolar hemiarthroplasty, similar to unipolar hemiarthroplasty, cannot restorate neither anatomical nor biomechanical features of the hip joint. Therefore, it can only be recommended as a second line of defense-procedure for patients with low functional demands and limited live expectancy.
THA is the treatment of choice for femoral neck fractures in patients older than 60 years. HA should only be implanted in patients with limited life expectancy.
Background and purpose
Monoblock acetabular cups represent a subtype of uncemented cups with the polyethylene liner molded into a metal shell, thus eliminating—or at least minimizing—potential backside wear. We hypothesized that the use of monoâ€‹block cups could reduce the incidence of osteolysis and aseptic loosening, and thus improve survival compared to modular designs.
Patients and methods
We identified all 210 primary total hip arthroplasty (THA) procedures in the Swedish Hip Arthroplasty Register that used uncemented monoblock cups during the period 1999–2010. Kaplan-Meier and Cox regression analyses with adjustment for age, sex, and other variables were used to calculate survival rates and adjusted hazard ratios (HRs) of the revision risk for any reason. 1,130 modular cups, inserted during the same time period, were used as a control group.
There was a nearly equal sex distribution in both groups. Median age at the index operation was 47 years in the monoblock group and 56 years in the control group (p < 0.001). The cumulative 5-year survival with any revision as the endpoint was 95% (95% CI: 91–98) for monoblock cups and 97% (CI: 96–98) for modular cups (p = 0.6). The adjusted HR for revision of monoblock cups compared to modular cups was 2 (CI: 0.8–6; p = 0.1). The use of 28-mm prosthesis heads rather than 22-mm heads reduced the risk of cup revision (HR = 0.2, CI: 0.1–0.5; p = 0.001).
Both cups showed good medium-term survival rates. There was no statistically significant difference in revision risk between the cup designs. Further review of the current patient population is warranted to determine the long-term durability and risk of revision of monoblock cup designs.
The conversion of hemiarthroplasty (unipolar or bipolar) of the hip to total hip replacement has been reported to be associated with very high rates of intra- and postoperative complications. We present a prospective analysis of the outcome of conversion surgery in patients with failed hemiarthroplasty.
Materials and Methods:
Forty-four cases, 30 women and 14 men, average age 62 years (range 42-75 years) of failed hemiarthroplasty were converted to total hip replacement between January 1998 and December 2004. Groin pain was the main presenting complaint in the majority of the patients (24 out of 44). Six patients had infection and were operated with staged procedure. All acetabular and the majority (86.5%) of femoral components used in our series were uncemented.
After an average follow-up of 6.4 years (range, two to nine years) Harris hip scores improved from 38 (range 15-62) preoperatively to 86 (range 38 to 100) and 22 (50%) patients were community ambulators without support while 17 (38%) needed minimal support of cane. Fifteen out of 18 (83%) patients who had isolated groin pain preoperatively experienced no pain postoperatively while three patients (17%) reported only partial improvement. Intraoperative and postoperative complications included iatrogenic fracture of the femur in two, femoral perforation in two, partial trochanteric avulsion in two, fracture of the acetabular floor in three hips, and postoperative dislocation in one. None of these complications resulted in a poor long-term outcome. The rate of loosening in our series was 2.3% (one out of 44) after a mean follow-up of 6.4 years with a mean survival of 97.4% at 72 months.
Conversion of symptomatic hemiarthroplasty to total hip arthroplasty is a safe option that gives good functional results, with marginally higher rates of intra-operative complications. The patients should be warned of the possibility of incomplete relief of groin pain postoperatively.
Conversion; hemiarthroplasty; total hip arthroplasty
Cemented hip arthroplasty is an established treatment for femoral neck fracture in the mobile elderly. Cement pressurization raises intramedullary pressure and may lead to fat embolization, resulting in fatal bone cement implantation syndrome, particularly in patients with multiple comorbidities. The cementless stem technique may reduce this mortality risk but it is technically demanding and needs precise planning and execution. We report the perioperative mortality and morbidity of cementless bipolar hemiarthroplasty in a series of mobile elderly patients (age >70 years) with femoral neck fractures.
Materials and Methods:
Twenty-nine elderly patients with mean age of 83 years (range:71-102 years) with femoral neck fractures (23 neck of femur and 6 intertrochanteric) were operated over a 2-year period (Nov 2005–Oct 2007). All were treated with cementless bipolar hemiarthroplasty. Clinical and radiological follow-up was done at 3 months, 6 months, 12 months, and then yearly.
The average follow-up was 36 months (range 26-49 months). The average duration of surgery and blood loss was 28 min from skin to skin (range, 20–50 min) and 260 ml (range, 95–535 ml), respectively. Average blood transfusion was 1.4 units (range, 0 to 4 units) Mean duration of hospital stay was 11.9 days (7–26 days). We had no perioperative mortality or serious morbidity.
We lost two patients to follow-up after 12 months, while three others died due to medical conditions (10–16 months post surgery). Twenty-four patients were followed to final follow-up (average 36 months; range: 26–49 months). All were ambulatory and had painless hips; the mean Harris hip score was 85 (range: 69–96).
Cementless bipolar hemiarthroplasty for femoral neck fractures in the very elderly permits early return to premorbid life and is not associated with any untoward cardiac event in the perioperative period. It can be considered a treatment option in this select group.
Cementless bipolar; femoral neck fractures; comorbidities; elderly
Numerous papers have been published on the medium- and long-term results of hemiarthroplasties (HAs) after femoral neck fracture in the elderly. We were not aware of any articles that describe the outcome of HA until the patient dies.
Between 1975 and 1989, 307 bipolar hemiarthroplasties were performed in 302 consecutive patients with a displaced femoral neck facture. Patients with osteoarthritis of the hip, rheumatoid arthritis (RA), or senile dementia were not included in the study. All patients were followed annually until they died or until they needed a revision operation.
The mortality rate was 28% after 1 year, and 63% after 5 years. The last patient who did not need a revision operation died in October 2010. Revision operations for aseptic loosening, protrusion, or both had to be performed in 34 patients (16%). A difference in reoperation rate was observed between patients less than 75 years of age (38%) and those who were older (6%).
Apart from age below 75 years, male sex appeared to be predictive of a revision operation. HA is a safe and relatively inexpensive treatment for patients over 75 years of age with a displaced femoral neck fracture.
Controversy still exists regarding using cemented or uncemented hemiarthroplasty for femoral neck fractures in elderly patients. The aim of this study is to compare the effectiveness and safety of the two surgical techniques in femoral neck fracture patients over 70 years old.
We searched PUBMED, EMBASE, Cochrane Library, CNKI and VIP Database from inception to December 2012 for relevant randomized controlled trials (RCTs). Outcomes of interest include postoperative hip function, residue pain, complication rates, mortality, reoperation rate, operation time and intraoperative blood loss. Odds ratios (OR) and weighted mean differences (WMD) from each trial were pooled using random-effects model or fixed-effects model given on the heterogeneity of the included studies.
7 RCTs involving 1,125 patients (1,125 hips) were eligible for meta-analysis. Our results demonstrate that cemented hemiarthroplasty is associated with better postoperative hip function (OR = 0.48, 95% CI, 0.31–0.76; P = 0.002), lower residual pain (OR = 0.43, 95%CI, 0.29–0.64; P<0.0001), less implant-related complications (OR = 0.15, 95%CI, 0.09–0.26; P<0.00001) and longer operation time (WMD = 7.43 min, 95% CI, 5.37–9.49 min; P<0.00001). No significant difference was observed between the two groups in mortality, cardiovascular and cerebrovascular complications, local complications, general complications, reoperation rate and intraoperative blood loss.
Compared with uncemented hemiarthroplasty, the existing evidence indicates that cemented hemiarthroplasty can achieve better hip function, lower residual pain and less implant-related complications with no increased risk of mortality, cardiovascular and cerebrovascular complications, general complications, local complications and reoperation rate in treating elderly patients with femoral neck fractures.
Fractures of the femoral neck in elderly patients can be treated by internal fixation, hemiarthroplasty, or total hip arthroplasty (THA), and the treatment modality used should be determined on the basis of considerations of the degree of fracture displacement, age, functional demands, and the risk factors for surgery and anesthesia. We studied 85 active elderly patients who underwent minimally invasive two-incision THA or conventional bipolar hemiarthroplasty (BHA) within 2 weeks of injury for the treatment of acute displaced femoral neck fractures. Patients were followed up for a minimum of 24 months. The average operation times were 70 minutes in the THA group and 46 minutes in the BHA group (p=0.002), and average blood losses during the perioperative period were 921 cc and 892 cc, respectively (p=0.562). In the THA group, the average postoperative Harris hip score was 88.3 and the average Western Ontario and McMaster University score was 28.8, whereas in the BHA group the corresponding scores were 80.4 (p=0.006) and 32.5 (p=0.012), respectively. There were 2 cases of hip dislocation in the THA group, and 2 cases in the BHA group underwent conversion to THA. Our short-term follow-up results were better for minimally invasive two-incision THA than for conventional BHA for the treatment of acute displaced femoral neck fractures in active elderly patients.
Femoral neck fractures; Arthroplasty; Hemiarthroplasty
Background and purpose
Treatment options for failed internal fixation of hip fractures include prosthetic replacement. We evaluated survival, complications, and radiographic outcome in 30 patients who were operated with a specific modular, uncemented hip reconstruction prosthesis as a salvage procedure after failed treatment of trochanteric and subtrochanteric fractures.
Patients and methods
We used data from the Swedish Hip Arthroplasty Register and journal files to analyze complications and survival. Initially, a high proportion of trochanteric fractures (7/10) were classified as unstable and 12 of 20 subtrochanteric fractures had an extension through the greater trochanter. Modes of failure after primary internal fixation were cutout (n = 12), migration of the femoral neck screw (n = 9), and other (n = 9).
Mean age at the index operation with the modular prosthesis was 77 (52–93) years and the mean follow-up was 4 (1–9) years. Union of the remaining fracture fragments was observed in 26 hips, restoration of proximal bone defects in 16 hips, and bone ingrowth of the stem in 25 hips. Subsidence was evident in 4 cases. 1 patient was revised by component exchange because of recurrent dislocation, and another 6 patients were reoperated: 5 because of deep infections and 1 because of periprosthetic fracture. The cumulative 3-year survival for revision was 96% (95% CI: 89–100) and for any reoperation it was 83% (68–93).
The modular stem allowed fixation distal to the fracture system. Radiographic outcome was good. The rate of complications, however—especially infections—was high. We believe that preoperative laboratory screening for low-grade infection and synovial cultures could contribute to better treatment in some of these patients.
In order to prevent hip arthroplasty dislocations, information regarding the direction of the dislocation is important for accurate implant positioning and for optimising the postoperative regimens in relation to the surgical approach used. The aim of this study was to analyse the influence of the surgical approach on the direction of the dislocation in patients treated by a hemiarthroplasty (HA) or total hip arthroplasty (THA) after a femoral neck fracture. Fracture patients have a high risk for dislocations, and this issue has not been previously studied in a selected group of patients with a femoral neck fracture. We analysed the radiographs of the primary dislocation in 74 patients who had sustained a dislocation of their HA (n = 42) or THA (n = 32). In 42 patients an anterolateral (AL) surgical approach was used and in 32 a posterolateral (PL). The surgical approach significantly influenced the direction of dislocation in patients treated with HA (p < 0.001), while no such correlation was found after THA (p = 0.388). For THA patients there was a correlation between the mean angle of anteversion of the acetabular component and the direction of dislocation when comparing patients with anterior and posterior dislocations (p = 0.027). These results suggest that the surgical approach of a HA has an influence on the direction of dislocation, in contrast to THA where the position of the acetabular component seems to be of importance for the direction of dislocation in patients with femoral neck fractures.
The use of cement is associated with increased morbidity and mortality rate in elderly patients, hence cementless hemiarthroplasty is suggested. We evaluated the results of cementless hemiarthroplasty for femoral neck fractures in elderly patients with high-risk clinical problems.
Materials and Methods:
Forty-eight patients (29 females, 19 males) with a mean age of 88 years (range: 78 to 102 years). having femoral neck fractures were treated with the use of cementless hemiarthroplasty. Porous-coated femoral stems were used in 30 patients (62%) and modular type femoral revision stems in 18 patients (38%). Bipolar femoral heads were used in all patients. Radiological follow-up after operation was done at the one, three, six months and annually.
The mean follow-up period was 4.2 years (range: 18 months to eight years). None of the patients died during hospitalization. Medical complications occurred in six patients (12%) within the follow-up period and four patients (8%) died within this period. Only two hips were converted to total hip arthroplasty due to acetabular erosion. Femoral revision was planned for one patient with a subsidence of > 3 mm. None of the patients had acetabular protrusion or heterotopic ossification. The mean Harris-hip score was 84 (range: 52 to 92). Dislocation occured in one patient (2%).
Cementless hemiarthroplasty is a suitable method of treatment for femoral neck fractures in elderly patients with high-risk clinical problems especially of a cardiopulmonary nature. This method decreases the risk of hypotension and fat embolism associated with cemented hemiarthroplasty.
Cementless femoral prosthesis; cementless hemiarthroplasty; femoral neck fracture; hemiarthroplasty in elderly
Femoral neck fractures with a vertical orientation have been associated with an increased risk for failure as they are both axial and rotational unstable and experience increased shear forces compared to the conventional and more horizontally oriented femoral neck fractures. The purpose of this study was to analyse outcome and risk factors for reoperation of these uncommon fractures.
A cohort study with a consecutive series of 137 hips suffering from a vertical hip fracture, treated with one method: a sliding hips screw with plate and an antirotation screw. Median follow-up time was 4.8 years. Reoperation data was validated against the National Board of Health and Welfare’s national registry using the unique Swedish personal identification number.
The total reoperation rate was 18%. After multivariable Logistic regression analysis adjusting for possible confounding factors there was an increased risk for reoperation for displaced fractures (22%) compared to undisplaced fractures (3%), and for fractures with poor implant position (38%) compared to fractures with adequate implant position (15%).
The reoperation rate was high, and special attention should be given to achieve an appropriate position of the implant.
Hip fracture; Osteosynthesis; Basicervical fracture; Vertical hip fracture
Today, dislocated femoral neck fractures are commonly treated with a cemented hip arthroplasty. However, cementing of the femoral component may lead to adverse effects and even death. Uncemented stems may lower these risks and hydroxyapatite (HA) coating may enhance integration, but prosthetic stability and clinical outcome in patients with osteoporotic bone have not been fully explored. We therefore studied fixation and clinical outcome in patients who had had a femoral neck fracture and who had received a fully HA-coated stem prosthesis.
Patients and methods
50 patients with a dislocated femoral neck fracture were operated with the fully HA-coated Corail total or hemiarthroplasty. 38 patients, mean age 81 (70–96) years, were followed for 24 months with conventional radiographs, RSA, DEXA, and for clinical outcome.
31 of the 38 implants moved statistically significantly up to 3 months, mainly distally, mean 2.7 mm (max. 20 mm (SD 4.3)), and rotated into retroversion mean 3.3º (–1.8 to 17) (SD 4.3) and then appeared to stabilize. Distal stem migration was more pronounced if the stem was deemed to be too small. There was no correlation between BMD and stem migration. The migration did not result in any clinically adverse effects.
The fully hydroxyapatite-coated Corail stem migrates during the first 3 months, but clinical outcome appears to be good, without any adverse events.
Background and purpose
The appropriate fixation method for hemiarthroplasty of the hip as it relates to implant survivorship and patient mortality is a matter of ongoing debate. We examined the influence of fixation method on revision rate and mortality.
We analyzed approximately 25,000 hemiarthroplasty cases from the AOA National Joint Replacement Registry. Deaths at 1 day, 1 week, 1 month, and 1 year were compared for all patients and among subgroups based on implant type.
Patients treated with cemented monoblock hemiarthroplasty had a 1.7-times higher day-1 mortality compared to uncemented monoblock components (p < 0.001). This finding was reversed by 1 week, 1 month, and 1 year after surgery (p < 0.001). Modular hemiarthroplasties did not reveal a difference in mortality between fixation methods at any time point.
This study shows lower (or similar) overall mortality with cemented hemiarthroplasty of the hip.