Displaced intracapsular hip fractures: hemiarthroplasty or total arthroplasty?

The role of total hip arthroplasty for the treatment of displaced intracapsular fractures of the proximal femur in active patients is controversial. Some authors have shown that such patients, when treated with a bipolar or unipolar hemiarthroplasty, are at increased risk of having acetabular erosion develop that might require later revision to a total hip replacement. In fact, the results of some authors were not substantially different from those reported for elective total hip arthroplasty and were better than results reported for hemiarthroplasty. However, other authors have strongly recommended avoiding total hip replacement in active elderly patients without preexisting acetabular disease (osteoarthritis, rheumatoid arthritis, Paget's disease). Although the current belief is that there is a place for primary total hip arthroplasty after intracapsular hip fracture, and that this procedure should be reserved for patients with preexisting symptomatic acetabular disease, in a preliminary prospective comparative study of 46 active patients without preexisting acetabular disease, the current author found better results with cemented Charnley's total hip arthroplasty than with cemented Thompson's hemiarthroplasty. Long-term outcome and more detailed indications for total hip replacement as the primary treatment for intracapsular displaced fractures of the proximal femur are topics for additional study.     

Cemented hemiarthroplasty or hip replacement for intracapsular neck of femur fracture? A comparison of 7732 matched patients using national data

Background

The treatment of choice for intracapsular neck of femur (NOF) fractures in younger, more active patients remains unknown. Some surgeons advocate total hip replacement (THR).

Aim

This study aimed to compare complications following THR and hemiarthroplasty using the Hospital Episode Statistics (HES) database in England.

Method

Dislocation and revision rates were extracted for all patients with NOF fracture who underwent either cemented hemiarthroplasty or cemented THR between January 2005 and December 2008. To make a ‘like for like’ comparison all 3866 THR patients were matched to 3866 hemiarthroplasty patients (from a total of 41,343) in terms of age, sex and Charlson score.

Results and conclusion

Eighteen-month dislocation was significantly higher in the THR group (2.4% vs. 0.5%, odds ratio (OR) 3.90 (2.99–5.05), p < 0.001). This difference was sustained at the 4-year stage (2.9% vs. 0.9%, OR 3.18 (1.58–6.94), p = 0.001) in a subset of patients with longer follow-up. There was no significant difference in revision rate up to 4 years (1.8% vs. 2.1%, OR 0.85 (0.46–1.55), p = 0.666). In this national analysis of matched patients short- and medium-term dislocation rates following THR were significantly higher than following cemented hemiarthroplasty, without any difference in revision rates at 4 years. The low risk of dislocation may be acceptable in order to experience the apparent functional benefits of THR.     

The management of intracapsular hip fractures in the 'young elderly' internal fixation or total hip replacement?

There is a lack of consensus about how to treat intracapsular hip fractures in the 'young elderly' (50-75 years). Evidence for older more mobile patients seems to point towards Internal Fixation (IF) for undisplaced fractures and Total Hip Replacement (THR) for displaced fractures. Radiographs of 263 patients from the Norfolk and Norwich University Hospital, who have suffered an intracapsular hip fracture between 2000-2009 were reviewed. The complication and mortality rates were noted. A Hip function questionnaire (Oxford hip score (OHS)) and Numeric pain score (NPS) were sent out to patients, then methods of treatment (IF and THR) were compared. In displaced fractures THR compared favourably to IF, OHS (16.0 vs. 20.0 p 0.029), NPS (2.0 vs. 4.0 p 0.007), complications (Odds Ratio (OR) 2.90; p 0.006) and death rate (OR 3.61; p 0.007). Although not statistically significant when stratified for age, the youngest age group (50-60) still achieved better function with a THR (13.0 vs. 18.0 ; p 0.129). There was little difference in the results for undisplaced fractures. This retrospective cross-sectional study showed IF is associated with a much higher complication rate than THR for patients who sustained a displaced hip fracture. THR also showed a better functional outcome and reduced pain. IF should be used in undisplaced fractures as there was no difference in functional outcome or complication rate. A large randomised controlled trial is needed to confirm these results.     

Displaced femoral neck fractures: internal fixation or arthroplasty?

Femoral neck fractures are a challenge for orthopedic surgeon due to the high rate of complication for such fractures. The aim of this study was to propose a treatment algorithm based on author's current concept in management of femoral neck fractures. Fractures were classified according Garden in four types but, for practical reasons, fractures were considered undisplaced (Garden I and II) and displaced (Garden III and IV). Treatment method was chosen based on next criteria: patient's age, associated pathology, patient's mental status and expectations, quality of the bone (osteoporosis), type and age of fracture, quality of reduction. Based on this criteria, the proposal algorithm may led to close reduction and internal fixation, open reduction and internal fixation or arthroplasty.     

Displaced proximal humerus fractures in older patients: reverse total shoulder arthroplasty or nonoperative treatment?

BackgroundReverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs) in older patients has been shown to be an effective treatment modality. Recent studies have questioned the superiority of RTSA over nonoperative treatment. The purpose of this study was to compare outcomes after RTSA and nonoperative treatment of PHF.MethodsA retrospective case-matched review of 72 displaced PHFs who underwent either RTSA or nonoperative treatment between August 2016 and August 2019 was conducted. Nine RTSA and 6 nonoperative patients were excluded. Thirty-seven RTSAs in 36 patients (1 bilateral) were compared to twenty patients who met operative criteria for RTSA but did not elect to undergo surgery.ResultsMean VAS pain scores decreased significantly in both groups at the final follow-up. Although there was no statistically significant difference in VAS scores at the time of most-recent follow-up between the two cohorts (1.5 RTSA vs. 1.9 nonop, P = .49), patients who underwent RTSA had a more rapid improvement in pain than nonoperative patients. RTSA patients had significantly lower VAS scores at 2 weeks (2.7 ± 3.1 vs. 5.6 ± 3.2, P = .03), 6 weeks (1.7 ± 2.8 vs. 4.1 ± 3.4, P = .02), and 3 months (1.6 ± 2.8 vs. 3.7 ± 3.2, P = .04) postoperatively. RTSA patients also had better forward flexion (125.4 ± 26.4° vs. 92.1 ± 35.1°, P = 0.001) and abduction (87.1 ± 11.6° vs. 75 ± 13.4°, P = .002) than nonoperative patients at the final follow-up (minimum 6 months). There was a statistically significant difference in mean American Shoulder and Elbow Surgeons scores after RTSA compared with nonoperative patients at the time of final follow-up for acute RTSA and for 3- and 4-part fracture subgroups. Eight patients (21.6%) experienced a complication after RTSA, of which 3 required revision surgery.Discussion/ConclusionOlder patients with displaced PHF have significant improvement in pain and function after both RTSA and nonoperative treatment although RTSA does come with a greater risk of complications. Patients who undergo RTSA have a greater increase in overhead motion and abduction and experience a more rapid improvement in pain, with significantly lower pain scores in the early postoperative period.     

Total hip replacement for displaced intracapsular neck of femur fracture. Are current guidelines appropriate for all patients? Five-year retrospective analysis of 315 cases

BackgroundAccording to the National Hip Fracture Database (NHFD), in 2018 31.4% of patients with displaced intracapsular neck of femur (NOF) fracture who, National Institute for Health and Care Excellence (NICE) viewed eligible for total hip replacement (THR), received this operation.We aimed to identify the compliance of performing THR for those patients in our unit and identify the reasons for proceeding with the alternative type of surgery.MethodsA five-year retrospective review of eligible patients was conducted between January 2014 and Dec 2018. Statistical analysis was performed between groups who did or didn't receive THR. Reasons for not performing THR were identified from pre-operative ward rounds notes.ResultsIn 2018 our unit performed THR for 44% of eligible cases. This was the highest result over five-years and higher than the national average.Out of the 348 eligible cases, pathological or undisplaced intracapsular fractures were excluded. Reminder received THR (138), hip hemiarthroplasty (166) or internal fixation (11).The average age was 77. Younger patients were more likely to receive THR than 80 years or older (p<0.05). THR group scored 0.4 points higher on AMTS and 0.2 lower on ASA scale then non-THR group (9.8 vs. 9.4 and 2.7 vs. 2.5 respectively). Mean time to surgery was 1.24 days with no significant difference between THR and non-THR group (1.6 vs. 1.1) but a slight delay to surgery during the weekends was noted (1.3 vs 1.8 days).Reasons for not performing THR were well documented as a combination of mobility restrictions and serious medical comorbidities. Retrospectively we judged the surgical decision making to be correct in 95% of cases.ConclusionsAnnual NHFD report comments on poor national and individual hospital's compliance with NICE guidelines without allowing surgeons to justify their choice of the procedure undertaken.Surgical decisions are made in a highly specialised multi-disciplinary environment taking into consideration individual patient's frailty and potential morbidity. Details of those discussions should be collected in NHFD to allow further analysis of reasons why surgeons decide not to offer THR to a patient NHFD views as eligible for this procedure. This could help in understanding the complex factors impacting on decision making in those cases.Level of evidence:Level III     

Unipolar or bipolar hemiarthroplasty for femoral neck fractures in the elderly?

This prospective randomized trial compared the efficacy of unipolar versus bipolar hemiarthroplasty in elderly patients (> or = 65 years) with displaced femoral neck fractures in terms of quality of life and functional outcomes. One hundred fifteen patients with a mean age of 82.1 years were enrolled in this study and randomized to either unipolar or bipolar hemiarthroplasty. Quality of life and functional outcomes were assessed using the Musculoskeletal Functional Assessment instrument and Short Form-36 health survey. Seventy-eight patients completed 1 year of followup. There were no differences between the groups in estimated blood loss, length of hospital stay, mortality rate, number of dislocations, postoperative complications, or ambulatory status at 1 year. There also were no significant differences between the two groups at either point in postoperative Short Form-36 or Musculoskeletal Functional Assessment instrument scores. Results of this prospective randomized study suggest that the bipolar endoprosthesis provides no advantage in the treatment of displaced femoral neck fractures in elderly patients regarding quality of life and functional outcomes.     

Posterior multifragmentation of the femoral neck: Does it portend a poor outcome in internally fixed intracapsular hip fractures?

Aim

To establish whether posterior multifragmentation of intracapsular proximal femoral fractures leads to an increased incidence of non-union and avascular necrosis following internal fixation by contemporary methods.

Methods

After preoperative radiography which was evaluated for posterior fragmentation, 1042 intracapsular hip fractures (471 undisplaced and 571 displaced) were treated with reduction and internal fixation. The rates of non-union and avascular necrosis in the presence or absence of fragmentation were compared in both undisplaced and displaced groups.

Results

The undisplaced cases comprised 460 non-fragmented and 11 fragmented fractures. The complication rates were 14% and 18%, respectively. Displaced fractures consisted of 489 non-fragmented and 82 fragmented cases. In this group, complication rates were 43% and 40%, respectively. No difference was statistically significant.

Conclusions

Using current methods of internal fixation of intracapsular hip fractures, there is no significant association between the posterior multifragmentation of the femoral neck observed on preoperative radiography and the later development of fracture healing complications.     

Cemented or uncemented hemiarthroplasty for the treatment of femoral neck fractures?: A Finnish database study of 25,174 patients

Background and purpose

Cemented hemiarthroplasty is preferred in treating displaced fractures of the femoral neck in the elderly. The cementing process may cause a fat embolism, leading to serious complications or death. In this study, we wanted to determine whether use of uncemented hemiarthroplasty (HA) would lead to reduced mortality and whether there are differences in the complications associated with these different types of arthroplasty.

Patients and methods

From the PERFECT database, which combines information from various treatment registries, we identified 25,174 patients who were treated with hemiarthroplasty for a femoral neck fracture in the years 1999–2009. The primary outcome was mortality. Secondary outcomes were reoperations, complications, re-admissions, and treatment times.

Results

Mortality was lower in the first postoperative days when uncemented HA was used. At 1 week, there was no significant difference in mortality (3.9% for cemented HA and 3.4% for uncemented HA; p = 0.09). This was also true after one year (26% for cemented HA and 27% for uncemented HA; p = 0.1). In patients treated with uncemented HA, there were significantly more mechanical complications (3.7% vs. 2.8%; p < 0.001), hip re-arthroplasties (1.7% vs. 0.95; p < 0.001), and femoral fracture operations (1.2% vs. 0.52%; p < 0.001) during the first 90 days after hip fracture surgery.

Interpretation

From registry data, mortality appears to be similar for cemented and uncemented HA. However, uncemented HA is associated with more frequent mechanical complications and reoperations.Displaced fractures of the femoral neck are being increasingly treated with arthroplasty instead of osteosynthesis (Rogmark et al. 2010). Hemiarthroplasty (HA) is used in most patients (Bhandari et al. 2005). The operation can be performed using either cemented or uncemented femoral components. Cemented components have been preferred, since they have been associated in meta-analyses with less postoperative pain and better mobility after surgery (Parker et al. 2010). However, these studies have mostly compared relatively outdated non-modular types of hemiarthroplasty.After the introduction of modular hemiarthroplasty to hip fracture surgery in recent years, a number of prospective trials comparing cemented and uncemented hemiarthroplasty have been published, with very similar results for both (Figved et al. 2009, DeAngelis et al. 2012, Taylor et al. 2012). However, in a recent registry study comparing (mostly modular) cemented and uncemented hemiarthroplasty, more reoperations were detected in patients treated with uncemented hemiarthroplasty (Leonardsson et al. 2012). One explanation for this discrepancy may be the relatively small sample size and incomplete follow-up associated with prospective studies (Talsnes et al. 2013).We studied mortality and results after hemiarthroplasty using Finnish registry-based data.     

Displaced femoral neck fractures: is there a standard of care?

Many factors must be considered in treating displaced femoral neck fractures. For younger patients, ORIF is preferred, whereas arthroplasty is the better option for elderly patients. For institutionalized elderly patients with a low activity level or impaired mental status, the choice should be hemiarthroplasty (either unipolar or bipolar). For high-demand, active patients, evidence continues to mount toward THA as the favored treatment option. However, there is a need for larger clinical trials to demonstrate the most cost-effective way to treat sub-populations of an ever-growing number of patients with displaced femoral neck fractures.     

Functional outcome of modified Pauwels�� intertrochanteric osteotomy and total hip arthroplasty in femoral neck fractures in elderly patients

Background:

A high union rate (75%-100%) with a lower incidence of avascular necrosis (8%-9.3%) has been reported with intertrochanteric osteotomy in femoral neck fractures in elderly whereas arthroplasty eliminates the incidence of nonunion and avascular necrosis We present a series of femoral neck fracture in elderly treated with modified Pauwels’ intertrochanteric osteotomy and total hip arthroplasty for their functional outcome.

Materials and Methods:

29 elderly patients of 60 years and above sustaining fresh subcapital femoral neck fracture underwent total hip arthroplasty (group I, n=14) and modified Pauwels’ intertrochanteric osteotomy (group II, n=15). Functions were evaluated using modified Harris hip score, d''Aubigne and postel criteria and SF-36 score at 6, 12, 52 and 100 weeks.

Results:

The fracture union in group II was achieved in 14 (93.3%) patients at the fracture site at an average of 15 weeks and osteotomy united in all patients. Avascular necrosis of the femoral head was observed in one patient (6.7%). Average operative time was 88.9 and 65.6 minutes in group I and II, respectively (P value = 0.00001). An average of 0.8 and 0.2 unit blood was transfused in patients in group I and II, respectively (P value = 0.001). Average time of full weight bearing was 6.1 weeks and 11.6 weeks in group I and group II, respectively. At 100 weeks 71.4% (n = 10) patients in group I and 80% (n = 12) patients in group II showed good to excellent results on the basis of modified Harris hip score. 71.4% (n = 10) patients in group I and 66.6% (n = 10) patients in group II showed good to excellent results on the basis of d''Aubigne criteria. Average SF-36 score was 17.2% in group I and 17.6% in group II. Revision osteotomy was performed in one patient in group II because of implant cut through. Another patient in group II underwent THR because of painful hip. One patient in group I presented with dislocation after 3 weeks of surgery.

Conclusion:

Functional results of total hip arthroplasty and intertrochanteric osteotomy are comparable and the valgus intertrochanteric osteotomy with osteosynthesis in subcapital femoral neck fractures in elderly patients of sixty years and above may be considered as an option.     

Müller straight stem total hip arthroplasty for fractured neck of femur

We present the results of a retrospective review of 50 Müller straight stem total hip replacements performed for femoral neck fracture over a 10-year period. PATIENTS AND METHODS: Between 1992 and 2002, 50 Müller straight stem total hip replacements were performed for femoral neck fracture in 42 female and 8 male patients with a mean age of 74 years. RESULTS: No hips have required revision surgery. Two patients have suffered early dislocations and there have been three major medical complications. The mean Merle D'Aubigne-Postel score was 15.1. Of the 25 radiographs available for review there were no cases of radiological loosening. DISCUSSION: This is further evidence that total hip replacement in the right hands provides good results for the treatment of displaced intracapsular femoral neck fractures. The Müller straight stem gives acceptable results in a select group of patients.     

Treatment of the displaced intracapsular fracture for the ‘fitter’ elderly patients: A randomised trial of total hip arthroplasty versus hemiarthroplasty for 105 patients

Controversy exists for the optimum method of surgical treatment for the ‘fitter’ elderly patient with a displaced intracapsular fracture. 105 patients were randomised to treatment with either a cemented polished tapered stem hemiarthroplasty or a cemented total hip arthroplasty (THR) with a cemented acetabular cup. All patients were followed up for a minimum of one year using a blinded assessment of functional outcome.Those patients treated with a THR had a tendency to a longer hospital stay and increased medical (12 versus 62) and surgical complications (4 versus 2) in comparison to those treated by hemiarthroplasty. Mean operative times (842 versus 52 min) and operative blood loss (335mls versus 244mls) were increased for THR. Final outcome measures of residual pain and regain of function were similar for both methods of treatment.We recommend that caution should be exercised regarding the increased promotion of THR for intracapsular hip fractures until further studies are completed.     

Incidence of periprosthetic fractures after hip hemiarthroplasty: Are uncemented prostheses unsafe?

Displaced intracapsular fractures of the neck of femur are routinely treated in the elderly with either cemented or uncemented hemiarthroplasty. Recent evidence suggests a superior outcome with the use of cement, but uncemented prostheses are still employed for those with multiple co-morbidities or particular frailty. In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) recommendations are used to identify which patients should receive a cemented prosthesis. These are simply based upon the presence of cardiorespiratory disease, particularly in the frail elderly patient.