Mid-Term Survivals After Cementless Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fractures in Elderly Patients

Background

Treatment of unstable intertrochanteric fracture in elderly patients remains challenging. The purpose of this prospective study is to determine clinical and radiological results of cementless bipolar hemiarthroplasty using a fully porous-coated stem in osteoporotic elderly patients with unstable intertrochanteric fractures with follow-up over 5 years.

Calcar Preservation Arthroplasty for Unstable Intertrochanteric Femoral Fractures in Elderly

Background

The treatment of unstable intertrochanteric fractures in elderly is still controversial. The purpose of this study is to present treatment strategies for unstable intertrochanteric fractures with hemiarthroplasty using standard uncemented collared femoral stems and at the same time preserving the fractured calcar fragment.

Methods

Fifty-four patients aged 75 years or older with unstable intertrochanteric fractures were included in this prospective cohort study. All patients were treated with calcar preserving hemiarthroplasty using cementless collored femoral stems. Fractured calcar fragment was stabilized either by compaction between the implant and femur or fixed with cable grip system. Follow-up evaluations were performed at least 24 months and later. Palmer and Parker mobility score and visual analogue scale (VAS) pain score were assessed. We also analyzed radiographs of the operated hip at each follow-up visit.

Results

The patients were 15 males and 39 females with a mean age of 81.3 years (range, 75 to 93 years). The average operative time was 86.6 minutes. The mean transfused blood units were 1.2 units. The average duration of hospital stay was 5.3 days. The preoperative mean mobility score was 6.20. This score was found to be 4.96 on postoperative third day and 5.90 at 24 months postoperatively. The results of the statistical analysis revealed significant increase in the mobility scores at each follow-up after three days. Radiological interpretation revealed no loosening in the cable-grip systems, and no significant subsidence (> 5 mm) of prosthesis was observed.

Conclusions

Calcar preservation arthroplasty is a good option for elderly patients with severe osteoporosis, frail constitution and the patients who are at higher risk for second operation due to unstable intertrochanteric fractures.     

Cemented bipolar hemiarthroplasty with a cerclage cable technique for unstable intertrochanteric hip fractures in elderly patients

Aim

The purpose of this study is to evaluate the clinical and radiological outcomes of cemented bipolar arthroplasty as a primary treatment for unstable intertrochanteric fracture in the elderly patients.

Methods

Twenty hips with unstable intertrochanteric fractures were followed for more than 2 years after cemented bipolar hemiarthroplasty. The mean age was 69 years, and the mean follow-up period was 30.5 months. We evaluated the results by Harris hip score, complications, and radiologic findings.

Results

At the last follow-up, the mean Harris hip score was 83.3 points. Radiologically, there was no case of osteolysis. All stems were stable without significant changes in alignment or progressive subsidence.

Conclusions

Bipolar hemiarthroplasty with calcar reconstruction is a good option for unstable intertrochanteric fractures in elderly patients with severe osteoporosis with strict indication selection. Longer-term studies with larger numbers of patients are required to address the issues of late complications.     

Cemented Bipolar Hemiarthroplasty Provides Definitive Treatment for Femoral Neck Fractures at 20 Years and Beyond

Background

Displaced femoral neck fractures frequently are treated with bipolar hemiarthroplasties. Despite the frequency with which bipolar hemiarthroplasty is used to treat these fractures, there are few long-term data.

Questions/purposes

We sought to evaluate (1) the cumulative incidence of revision for any reason of bipolar hemiarthroplasties at 20 years, and the proportion of patients who lived more than 20 years who still have the prosthesis in situ from the index arthroplasty, (2) the cumulative incidence of aseptic loosening at 20 years, and (3) the Harris hip score of the surviving patients at long term.

Methods

We performed 376 cemented bipolar hemiarthroplasties for displaced femoral neck fractures in 359 patients between 1976 and 1985. At a minimum of followup of 20 years (mean, 24 years; range, 20–31 years), 339 of 359 patients (94%) were deceased, leaving 20 patients in the study group. Of those, one patient was confirmed to be lost to followup and two others had radiographic followup only. Three hundred fifty-nine patients (99.2%) (376 of the original 379 hips) were followed until death, revision of the hemiarthroplasty, or for at least 20 years (of clinical followup). Bipolar hemiarthroplasty was performed for displaced femoral neck fractures. Cemented fixation was the standard of care between 1976 and 1985 at our institution. The mean age of the patients at the time of surgery was 79 years (range, 60–99 years). The cumulative incidence of revision, estimated with death as a competing risk, and radiographs were evaluated for signs of aseptic loosening by a surgeon not involved in the clinical care of the patients. Clinical function was evaluated with the Harris hip score. The mean age of the patients at the time of surgery was 79 years.

Results

The 20-year cumulative incidence of revision for any reason was 3.5% (95% CI, 1.6%–5.3%). Of the 20 patients who survived more than 20 years, seven had the implant intact. The 20-year cumulative incidence of revision for aseptic loosening was 1.4% (95% CI, 0.2%–2.6%). The mean Harris hip score in patients who were still living and patient who did not have revision surgery was 63 ± 22, however 13 of the 20 patients had undergone revision surgery.

Conclusions

The long-term survivorship of bipolar hemiarthroplasty prostheses used to treat displaced femoral neck fractures in the elderly was high, and the procedure can be considered definitive for the majority of elderly patients with a femoral neck fracture. In this series, 6% (20 patients, 339 of 359) of the patients survived more than 20 years after treatment of a femoral neck fracture with a bipolar hemiarthroplasty. Of those, 35% (seven of 20) survived with their index prosthesis in situ.

Level of Evidence

Level IV, therapeutic study.     

Cementless bipolar hemiarthroplasty in femoral neck fractures in elderly

Background:

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.

Results:

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).

Conclusion:

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.     

Current Trends of Stem Use in Hemiarthroplasty for Femoral Neck Fracture in South Korea

Background

Hemiarthroplasty is a common operation to treat femoral neck fracture in elderly patients. The choice of whether to use cemented stem or cementless stem in hemiarthroplasty has been controversial in clinical practice. However, recent trends regarding stem choice in South Korea are not known or documented. In this study, we assessed the trends of stem fixation in hemiarthroplasty for femoral neck fractures in South Korea.

Methods

Data of patients with femoral neck fractures, who were operated on between the years of 2007 and 2011 and were ≥ 50 years old at the time of operation, were obtained from the Health Insurance Review and Assessment Service. All new visits or admissions to clinics or hospitals for femoral neck fractures were identified using the International Classification of Disease Tenth Revision diagnostic code (S720). The trends in the utilization of cemented and cementless hemiarthroplasty were then analyzed.

Results

The proportion of cementless hemiarthroplasty increased from 42.7% of all surgical procedures in 2007 to 61.4% of all surgical procedures in 2011 (p < 0.001), while the use of cemented hemiarthroplasty demonstrated a corresponding decrease.

Conclusions

There was a current trends towards using cementless stems in hemiarthroplasty for femoral neck fractures in South Korea.     

Behaviour of the ultra-short anatomic cementless femoral stem in young and elderly patients

Purpose

The question arises as to whether it is possible to obtain rigid fixation of the ultra-short metaphyseal-fitting anatomic cementless stem without diaphyseal fixation in the elderly as well as younger patients. We investigated whether ultra-short, metaphyseal-fitting anatomic cementless femoral stem would provide similar functional improvements in the younger and elderly patients, radiographically secure implant fixation would be achieved in both groups, the bone content would be preserved in both groups, and complication rates would be similar in both groups.

Methods

A total of 100 patients (114 hips) in the younger patient group and 100 patients (112 hips) in the elderly patient group were included in the study. Their mean age was 43.9 ± 6.11 years (range, 31–65 years) in the younger patient group and 78.9 ± 12.1 years (range, 66–91 years) in the elderly patient group. The mean duration of follow-up was 7.5 years (range, six to nine years) in the younger patient group and 7.6 years (range, six to nine years) in the elderly patient group.

Results

The mean postoperative Harris hip scores (95 points versus 91 points), WOMAC scores (11 points versus 15 points), thigh pain (none in either group), UCLA activity scores (6.5 points versus 4.5 points), and radiographic results were not significantly different between the two groups. No hip in either group had an aseptic loosening. No hip in either group had clicking or squeaking sounds or ceramic fractures.

Conclusion

The cementless ultra-short, metaphyseal-fitting anatomic cementless femoral component provides stable fixation without any need of diaphyseal fixation in both younger and elderly patients. Despite the concern, the poor bone quality in elderly patients did not compromise the stability, and osseointegration of this ultra-short, anatomic cementless femoral stem was achieved in all elderly patients.     

The cementless anatomic medullary locking femoral component: an independent clinical and radiographic assessment

Objective

To review the clinical performance of the anatomic medullary locking (AML) femoral stem in total hip arthroplasty.

Design

A clinical and radiographic review.

Setting

A tertiary lower limb joint replacement centre.

Patients

Two hundred and twenty-one patients with noninflammatory gonarthrosis.

Interventions

Two hundred and twenty-seven primary total hip arthroplasties with the noncemented AML component completed by two surgeons.

Main Outcome Measures

Independent review by two experienced reviewers of the postoperative Harris hip score, radiographs of component fixation, size and degree of diaphyseal fill.

Results

Harris hip score was 84 (range from 43 to 98); component fixation showed bone ingrowth in 41%, stable fixation with fibrous ingrowth in 56% and unstable fixation in 3%; severe thigh pain in 4% of cases correlated with unstable fixation, and there was mild thigh pain in 20% of cases.

Conclusion

The AML femoral stem performs well in replacement arthroplasty compared with other noncemented stems.     

Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly: A retrospective case series

Background:

The management of unstable osteoporotic intertrochantric fractures in elderly is challenging because of difficult anatomical reduction, poor bone quality, and sometimes a need to protect the fracture from stresses of weight bearing. Internal fixation in these cases usually involves prolonged bed rest or limited ambulation, to prevent implant failure secondary to osteoporosis. This might result in higher chances of complications like pulmonary embolism, deep vein thrombosis, pneumonia, and decubitus ulcer. The purpose of this study is to analyze the role of primary hemiarthroplasty in cases of unstable osteoporotic intertrochanteric femur fractures.

Materials and Methods:

We retrospectively analyzed 37 cases of primary hemiarthroplasty performed for osteoporotic unstable intertrochanteric fractures (AO/OTA type 31-A2.2 and 31-A2.3 and Evans type III or IV fractures). There were 27 females and 10 males with a mean age of 77.1 years (range, 62–89 years).

Results:

Two patients died due to unrelated cause (myocardial infarction) within 6 months of surgery and remaining 35 patients were followed up to an average of 24.5 months (range,18–39 months). The average surgery time was 71 min (range, 55–88 min) with an average intraoperative blood loss of 350 ml (range, 175–500 ml). Six patients needed blood transfusion postoperatively. The patients walked on an average 3.2 days after surgery (range, 2–8 days). One patient had superficial skin infection and one had bed sore with no other significant postoperative complications. One patient of Alzheimer’s disease refused to walk and had a poor result. A total of 32 out of 35 patients (91%) had excellent to fair functional results and 2 had poor result with respect to the Harris hip score (mean 84.8±9.72, range 58-97). One patient who had neurological comorbidity refused to walk post operatively and was labeled as failed result.

Conclusion:

Hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in elderly results in early ambulation and good functional results although further prospective randomized trials are required before reaching to conclusion.     

Cemented hip hemiarthroplasty clinical observations on unstable intertrochanteric fracture in elderlies

Objective

To observe the clinical effect of steel cable or greater trochanter reattachment (GTR) device combined with cemented hip hemiarthroplasty for unstable intertrochanteric fracture in elderlies.

Materials and methods

From July 2002 to June 2014, a total of 57 elderly patients with unstable intertrochanteric fracture, including 23 males and 34 females, were treated. Their ages ranged from 80 to 95 years, with the average of 83 years. According to Evans-Jensen classification, there were 18 type IIa cases, 13 type IIb cases and 26 type III cases. All patients received cemented bipolar femoral head replacement, using steel cable or GTR device to stabilize the unstable intertrochanteric fracture.

Results

All patients had successful operation procedure and were followed up for 36 months. Postoperative X-ray revealed satisfying postoperative position of artificial hip joint, without subsidence or loosening. Three cases with the use of steel cable alone to treat greater trochanter fracture suffered from rupture of steel cable. The patients using GTR device showed good reduction at the site of displaced greater trochanter fracture and a firm fixation. The clinical outcome measured with Harris hip score and Barthel Index at the time of final follow-up was significantly different between the groups.

Conclusion

Hip hemiarthroplasty for elderly patients with unstable intertrochanteric fracture can meet the load bearing requirement at early stage and reduce postoperative complications prominently. Moreover, GTR devices can effectively solve the instability problem of posterior-lateral side of hip caused by displacement of greater trochanter in unstable intertrochanteric fracture.

     

The Conversion Rate of Bipolar Hemiarthroplasty after a Hip Fracture to a Total Hip Arthroplasty

Background

Bipolar hip hemiarthroplasty is used in the management of fractures of the proximal femur. The dual articulation is cited as advantageous in comparison to unipolar prostheses as it decreases acetabular erosion, has a lower dislocation rates and is easier to convert to a total hip arthroplasty (THA) should the need arise. However, these claims are debatable. Our study examines the rate of conversion of the bipolar hemiarthroplasty to THA and the justification for using it on the basis of future conversion to THA.

Methods

All cases of bipolar hemiarthroplasty performed in our unit for hip fractures over a 9-year period (1999-2007) were reviewed. Medical notes and radiographs of all patients were reviewed, and all surviving patients that were contactable received a telephone follow-up.

Results

Of all 164 patients reviewed with a minimum of 1 year from date of surgery, 4 patients had undergone a conversion of their bipolar prosthesis to THA. Three conversions were performed for infection, dislocation, and fracture. Only one (0.6%) conversion was performed for groin pain.

Conclusions

Our study show that bipolar hemiarthroplasties for hip fractures have a low conversion rate to THAs and this is comparable to the published conversion rate of unipolar hemiarthroplasties.     

双极人工股骨头与PFNA在不稳定型股骨粗隆间骨折的疗效评析

目的评价双极人工股骨头置换与股骨近端防旋髓内针（PFNA）内固定治疗高龄骨质疏松性股骨粗隆间骨折的临床疗效,探讨其合理的治疗方法。方法回顾性分析2009年1月~2013年9月期间,在农垦三亚医院采用双极人工股骨头置换（32例）与PFNA内固定治疗（43例）共75例70岁以上的股骨粗隆间骨折患者。骨折根据AO/OTA系统分型：转子间二部分骨折分为A1型（稳定骨折）,多部分骨折为A2型（不稳定骨折）,反斜形转子间骨折为A3型（不稳定骨折）。比较2组在手术时间、出血量、术后卧床时间、并发症发生率及术后1年病死率、Harris功能评分、人工关节松动率、住院时间等方面的指标。结果 75例均获得16~24个月随访,43例PFNA组骨折均顺利愈合;32例半髋关节置换假体无脱位、假体柄无明显下沉。两组术后髋关节功能优良率、内置物并发症差异不明显（P〉0.05）,但半髋关节置换组内科并发症更少（P〈0.05）、切口长度较大（P〈0.05）、手术时间较长（P〈0.05）、术中出血量较多（P〈0.05）、术后卧床时间及下地时间较短（P〈0.05）。结论双极人工股骨头置换术和PFNA内固定术均是治疗高龄患者粗隆间不稳定骨折的有效方法。双极人工股骨头治疗高龄伴严重骨质疏松的不稳定型股骨粗隆间骨折,下床活动早、早期并发症发生率低、功能恢复满意,可明显提高患者的生活质量。     

加长柄人工股骨头置换术与PFNA内固定治疗高龄不稳定股骨粗隆间骨折的比较研究

目的比较加长柄人工股骨头置换术与股骨近端防旋髓内钉(PFNA)治疗高龄不稳定股骨粗隆间骨折的临床效果。方法回顾性比较分析自2013-06—2014-09诊治的65例高龄不稳定股骨粗隆间骨折,采用PFNA内固定治疗20例(PFNA组),采用加长柄人工股骨头置换术治疗45例(其中骨水泥组22例,生物型组23例)。比较3组手术时间、术中出血量、术后下地时间、并发症发生率,以及术后1、3、6、12个月髋关节功能Harris评分。结果 65例均获得随访9~18个月,平均12个月。3组手术时间差异有统计学意义(P0.05),PFNA组少于生物型组和骨水泥组,而生物型组少于骨水泥组。3组术中出血量差异有统计学意义(P0.05),PFNA组少于生物型组和骨水泥组,而骨水泥组少于生物型组。3组术后下地时间差异有统计学意义(P0.05),生物型组和骨水泥组明显早于PFNA组,而骨水泥组早于生物型组。生物型组和骨水泥组术后1、3、6个月髋关节功能Harris评分均优于PFNA组,但生物型组与骨水泥组比较差异无统计学意义(P0.05);术后12个月时3组髋关节功能Harris评分差异无统计学意义(P0.05)。结论对于身体状况较好、骨质稳定的高龄股骨粗隆间骨折,可首选PFNA髓内固定;对于伴有严重骨质疏松,不适合内固定治疗以及内固定失败,或预期置换后关节使用年限不长患者,加长柄人工股骨头置换术是安全、有效的手术方式。     

The direct anterior approach in hemiarthroplasty for displaced femoral neck fractures

Purpose

Hip replacement is the most common treatment for displaced femoral neck fractures in the elderly, and minimally invasive surgery is popular in the field of orthopaedic surgery. This study evaluated the outcome of monopolar hemiarthroplasty by the direct anterior approach over a postoperative period up to 2.5 years.

Methods

A total of 86 patients with displaced femoral neck fractures were included (mean age of 86.5 years). Surviving patients were reviewed three months (retrospectively) and one to 2.5 years (prospectively) after surgery. One-year mortality was 36 %.

Results

For all stems, implant positioning with respect to stem alignment, restoration of leg length and femoral offset was correct. Acetabular protrusion was observed in 55 % of the patients one to 2.5 years postoperatively. Subsidence and intraoperative periprosthetic fractures occurred in three patients (3 %) each. All revision stems for postoperative periprosthetic fractures could be implanted using the initial surgical technique without extension of the previous approach. The mean Harris hip score was 85 points at the one to 2.5-year follow-up; 85 % of the patients were satisfied with their hip and 57 % returned to their preoperative level of mobility.

Conclusion

Based on these findings, hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional outcome and high patient satisfaction.     

Long-term results of cementless femoral reconstruction following intertrochanteric osteotomy

Purpose

The objective of this retrospective cohort study was to assess the long-term outcome of cementless femoral reconstruction in patients with previous intertrochanteric osteotomy (ITO).

Methods

We evaluated the clinical and radiographic results of a consecutive series of 45 patients (48 hips, mean age 50 years) who had undergone conversion hip replacement following ITO with a cementless, grit-blasted, double-tapered femoral component. Clinical outcome was determined using the Harris hip score. Stem survival for different end points was assessed using Kaplan-Meier survivorship analysis.

Results

At a mean follow-up of 20 (range, 16–24) years, 11 patients (12 hips) had died, and no patient was lost to follow-up. Six patients (six hips) underwent femoral revision, two for infection, three for aseptic loosening and one for periprosthetic fracture. Mean Harris hip score at final follow-up was 78 points (range, 23–100 points). Stem survival for all revisions was 89% (95%CI, 75–95) at 20 years, and survival for aseptic loosening was 93% (95%CI, 80–98).

Conclusions

The long-term results with this type of cementless femoral component in patients with previous intertrochanteric osteotomy are encouraging and compare well to those achieved in patients with normal femoral anatomy.     

An orthopedic surgeon survey on the treatment of displaced femoral neck fracture: opposing views

Objective

To examine the reasons for practice variation in the treatment of displaced femoral neck fractures.

Design

A survey, asking surgeons to choose either hemiarthroplasty or internal fixation for 2 different female patients with a displaced femoral neck fracture.

Setting

The Canadian Orthopaedic Association Meeting, Halifax, May 1995.

Patients

The scenario in the first patient was of an independent 70-year-old woman with no pre-existing medical conditions. The scenario in the second patient was of a housebound 84-year-old woman with co-morbidity.

Main outcome measures

Proportion of surgeons choosing either hemiarthroplasty or internal fixation for each case scenario. Distribution of reasons to explain the treatment decision.

Results

Ninety-nine surgeons responded. For the case of the 70-year-old woman, 47% chose hemiarthroplasty and 53% chose internal fixation (p = 0.60), and for the 84-year-old woman, 96% chose hemiarthroplasty. These findings were consistent within the subgroups of teaching surgeons and community practice surgeons. Surgeons with 10 years or less of practice tended to favour hemiarthroplasty whereas those with more than 15 years’ practice favoured internal fixation. Important reasons for treatment choice were avoidance of reoperation in the hemiarthroplasty group (85%) and better hip function in the fixation group (83%), durability (83%) and ease of revision (77%).

Conclusion

The surgeon’s interpretation of the importance of reoperation and function underlies the differences in treatment decision regarding the management of femoral neck fractures in elderly patients.     

Cementless hemiarthroplasty for femoral neck fractures in elderly patients

Objectives:

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.

Results:

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%).

Conclusion:

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.     

Intertrochanteric fractures in elderly high risk patients treated with Ender nails and compression screw

Background:

Ender and Simon Weidner popularized the concept of closed condylocephlic nailing for intertrochanteric fractures in 1970. The clinical experience of authors revealed that Ender nailing alone cannot provide secure fixation in elderly patients with osteoporosis. Hence we conducted a study to evaluate the efficacy of a combined fixation procedure using Ender nails and a cannulated compression screw for intertrochanteric fractures.

Materials and Methods:

76 patients with intertrochanteric fractures were treated using intramedullary Ender nails and cannulated compression screw from January 2004 to December 2007. The mean age of the patients was 80 years (range 70-105 years).Using the Evan’s system of classification 49 were stable and 27 unstable fractures. Inclusion criteria was high risk elderly patients (age > 70 years) with intertrochanteric fracture. The exclusion criteria included patients with pressure sores over the trochanteric region. Many patients had pre-existing co-morbidities like diabetes mellitus, hypertension, COPD, ischemic heart disease, CVA and coronary artery bypass surgery. The two Ender nails of 4.5mm each were passed across the fracture site into the proximal neck. This was reinforced with a 6.5 mm cannulated compression screw passed from the sub trochanteric region, across the fracture into the head.

Results:

The mean follow-up was 14 months (range 9-19 months) Average time to fracture union was 10 weeks (range 6-16 weeks). The mean knee ROM was 130° (± 5°). There was no case of nail penetration into hip joint. In five cases with advanced osteoporosis there was minimal migration of Ender nails distally.

Conclusions:

The Ender nailing combined with compression screw fixation in cases of intertrochanteric fractures in high risk elderly patients could achieve reliable fracture stability with minimal complications.     

Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials

Purpose

Displaced femoral neck fractures in healthy elderly patients have traditionally been managed with hemiarthroplasty (HA). Recent data suggest that total hip arthroplasty (THA) may be a better alternative.

Methods

A systematic review of the English literature was conducted. Randomized controlled trials comparing all forms of THA with HA were included. Three authors independently extracted articles and predefined data. Results were pooled using a random effects model.

Results

Eight trials totalling 986 patients were retrieved. After THA 4 % underwent revision surgery versus 7 % after HA. The one-year mortality was equal in both groups: 13 % (THA) versus 15 % (HA). Dislocation rates were 9 % after THA versus 3 % after HA. Equal rates were found for major (25 % in THA versus 24 % in HA) and minor complications (13 % THA versus 14 % HA). The weighted mean of the Harris hip score was 81 points after THA versus 77 after HA. The subdomain pain of the HHS (weighted mean score after THA was 42 versus 39 points for HA), the rate of patients reporting mild to no pain (75 % after THA versus 56 % after HA) and the score of WOMAC (94 points for THA versus 78 for HA) all favored THA. Quality of life measured with the EQ-5D favored THA (0.69 versus 0.57).

Conclusions

Total hip arthroplasty for displaced femoral neck fractures in the fit elderly may lead to higher patient-based outcomes but has higher dislocation rates compared with hemiarthroplasty. Further high-quality randomized clinical trails are needed to provide robust evidence and to definitively answer this clinical question.     

Factors affecting transfusion requirement after hip fracture: Can we reduce the need for blood?

Background

Hip fractures are common injuries that result in blood loss and frequently require the transfusion of blood products. We sought to identify risk factors leading to increased blood transfusion in patients presenting with hip fractures, especially those factors that are modifiable.

Methods

We retrospectively reviewed the cases of all patients who had fixation of their hip fractures between October 2005 and February 2010. The need for transfusion was correlated with potential risk factors, including age, sex, preoperative hemoglobin, fracture type, fixation method and more.

Results

A total of 835 patients had fixation of their hip fractures during the study period; 631 met the inclusion criteria and 249 of them (39.5%) were transfused. We found an association between need for blood transfusion and female sex (p = 0.018), lower preoperative hemoglobin (p < 0.001), fracture type (p < 0.001) and fixation method (p < 0.001). Compared with femoral neck fractures, there was a 2.37 times greater risk of blood transfusion in patients with intertrochanteric fractures (p < 0.001) and a 4.03 times greater risk in those with subtrochanteric fractures (p < 0.001). Dynamic hip screw (DHS) fixation decreased the risk of transfusion by about half compared with intramedullary nail or hemiarthroplasty. We found no association with age, delay to operation (p = 0.17) or duration of surgery (p = 0.30).

Conclusion

The only modifiable risk factor identified was fixation method. When considering blood transfusion requirements in isolation, we suggest a potential benefit in using a DHS for intertrochanteric and femoral neck fractures amenable to DHS fixation.