Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur--13 year results of a prospective randomised study

In this prospective randomised trial we compare the mortality, morbidity and functional results of patients following each of the three principal methods of treatment for displaced subcapital fractures of the femur. Two hundred and ninety patients over the age of 65 years were included and randomly allocated to undergo closed reduction and internal fixation with a sliding compression screw plate or uncemented Austin Moore hemiarthroplasty or cemented Howse II total hip arthroplasty (THA). Nineteen patients were subsequently excluded. The 13 year results show that there was no statistical difference in the mortality between the three groups (81, 85 and 91% respectively). Internal fixation and hemiarthroplasty groups fared poorly with a revision rate of 33 and 24%, respectively, compared with 6.75% in the THA group. The dislocation rate was 13% following hemiarthroplasty and 20% following THA. Average Harris hip scores were 62, 55 and 80, respectively, for the internal fixation, hemiarthroplasty and THA groups. In the long term, both internal fixation and hemiarthroplasty resulted in a poor outcome with respect to pain and mobility. Despite high early complications, THA resulted in least pain and most mobility both in the short and long-term and was encouraging with a revision rate of only 6.25%. THA should be seriously considered in physiologically active patients with a displaced subcapital fracture of the femur.     

Internal fixation or arthroplasty for displaced subcapital fractures in the elderly?

A series of 200 patients aged over 69 years admitted to this hospital with a non-pathological displaced subcapital fracture of the femur, haue been studied prospectively. Approximately one-half were treated by internal fixation and the remainder by a hemiarthroplasty, the method of treatment being dictated by the preference of the on-call consultant. This has enabled a comparison between the two groups.

At 1 year from injury there was no significant difference in the mortality or function of the survivors. Internal fixation resulted in fewer postoperative complications, a shorter hospital stay and a reduced cost of treatment. The reoperation rate for internal fixation was three times that after hemiarthroplasty.

Despite the problem of non-union, this study suggests that internal fixation is the treatment of choice for displaced subcapital fractures in the elderly.     

Pugh nail system as a form of treatment for fractures of the proximal femur

A retrospective study of the results of treatment of 177 patients who had sustained a fracture of the proximal femur was undertaken. The social background, type of injury, operation performed, duration of stay after operation, mortality and morbidity were recorded and compared with the results published by other workers. It is concluded that the Pugh sliding nail system adequately fixes most fractures of the proximal femur. It allows early postoperative mobilization and discharge to the home environment for most patients. The overall mortality and morbidity compares favourably with results published for the dynamic compression screw. Treatment of the elderly patient with a displaced subcapital fracture of the femoral neck remains a problem, due to the high incidence of failure of fixation. It may be that for this group of patients a primary hemiarthroplasty is the treatment of choice. A prospective study to resolve this issue is required. The cost of a Pugh nail is considerably less than that of a dynamic compression screw.     

Subcapital femoral neck fracture after closed reduction and internal fixation of an intertrochanteric hip fracture: a case report and review of the literature.

A subcapital femoral neck fracture in a healed intertrochanteric fracture treated by an open reduction and internal fixation is a rare, but catastrophic, event. We present the case of an 86-year-old woman, a community ambulator, who sustained a displaced right intertrochanteric hip fracture during a fall. She was treated with closed reduction and internal fixation with a dynamic compression hip screw and side plate. Four months later, she was noted to have a displaced subcapital femoral neck fracture and underwent hip screw and side plate hardware removal and cemented bipolar hemiarthroplasty. Both postoperative recoveries were uncomplicated, and she was discharged to a rehabilitation facility able to ambulate with minimal assistance. This devastating complication in patients with osteoporosis may be prevented by deeper placement of the dynamic hip compression lag screw to within 5 mm to 8 mm of the subchondral bone, which may decrease the stress forces in the subcapital femoral neck.     

人工股骨头置换与全髋关节置换术治疗股骨颈骨折

目的了解、评价人工股骨头置换与全髋关节置换术治疗股骨颈骨折的价值和选择。方法从１９９０年１月～１９９６年１２月住院治疗的股骨颈骨折病例中,选择年龄、性别、随访时间均相仿的人工股骨头置换术患者５４例,全髋置换术患者６０例,进行回顾性分析。结果发现两种术式的住院时间相仿,早期并发症均较低;人工股骨头置换组的中、远期并发症、再手术率较高,全髋置换组手术创伤。假体费用较大,随访功能优良率较高。结论全髋置换术适合于５５岁以上、有移位的头下型患者,人工股骨头置换术适合高龄或全身情况较差者。     

Lateral Radiograph of the Hip in Fracture Neck of Femur: Is it a Ritual?

Introduction  Historically routine work up of a patient with a fracture neck of femur has always included an antero-posterior (AP) and a lateral view of the hip. The aim of the study was to know whether a lateral view of hip influenced the decision of an Orthopedic Surgeon regarding management at a District General Hospital. Methods  A prospective study was conducted from February 2005 to September 2005 at Tameside General Hospital. X-rays of patients admitted with fracture neck of femur were shown to two independent observers in the daily trauma meeting. AP view of the hip was shown initially to observers and their classification and intended treatment was recorded. They were asked if they needed a lateral view to decide on management option and answers were recorded. The observers were then showed a lateral view of same hip and asked to comment on quality of film and also whether it would change their classification or intended management. Results  There were 100 patients over six months. On AP view 56 were classified to have extra-capsular fracture, 37 were classified as displaced subcapital fracture and seven were classified undisplaced subcapital fracture. There was an interobserver variation in one patient between undisplaced or displaced subcapital fracture. The observers felt they would need a lateral X-ray on three occasions and there was a change in classification from undisplaced subcapital to displaced subcapital fracture on first occasion. There was no change in management plan in all the 100 patients after looking at a lateral X-ray. Conclusion  We can conclude that unless required for management a lateral X-ray of hip should be avoided routinely in all patients with fracture neck of femur as it would not only be cost effective but will also reduce radiation exposure to patient and relieve work pressure on radiographers, nursing and portering staff.     

A study of the influence of technical adequacy on the clinical result of moore hemiarthroplasty

The Moore and Thompson hemiarthroplasties are still commonly used for the displaced subcapital fracture in the elderly. The cemented Thompson has been claimed to be superior to the uncemented Moore prosthesis. However, the use of cement is associated with greater risks and the uncemented Moore appears to give good results in approximately two-thirds of patients.

The technical adequacy of uncemented hemiarthroplasty has rarely been considered in assessing the outcome. This study indicates that, on the basis of four radiological criteria, incorrect insertion of the prosthesis leads to a high chance of a poor clinical result at 6 months. Good results are more likely when the postoperative radiograph shows the prosthesis to have been inserted accurately. This is possible in most cases, except where the femur is grossly osteoporotic with a wide intramedullary canal. Uncemented hemiarthroplasty can produce satisfactory results but, like uncemented total joint replacement, is a more demanding procedure.     

A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years

It remains a matter of debate whether displaced fractures of the neck of the femur should be treated by internal fixation or arthroplasty. We have compared the two methods with regard to complications, mortality and functional outcome. We studied 409 patients, aged 70 years and over, with subcapital fractures graded as Garden 3 or 4, in a two-year prospective multicentre study from 12 Swedish hospitals. They were randomised to internal fixation or arthroplasty. Patients who were mentally confused, bedridden or in a nursing-home were excluded from the survey. After two years the rate of failure was 43% in the internal fixation (IF) and 6% in the arthroplasty group (p < 0.001). In the IF group 36% had impaired walking and 6% had severe pain compared with 25% and 1.5%, respectively, in the arthroplasty group (both p < 0.05). There was no difference in mortality. With a high rate of failure and poor functional outcome after IF, we recommend primary arthroplasty for displaced fractures of the neck of the femur in patients over 70 years of age.     

Failure of hemiarthroplasty for fractures of the neck of the femur

Hemiarthroplasty is commonly used in the treatment of displaced subcapital fractures of the femur. Review of 92 patients at least 4 years after this operation showed that 19 per cent had required further operations. Review of a separate series of 70 patients each of whom had undergone a revision operation after a hemiarthroplasty showed that over half needed operation within 3 years of the original treatment. The average age at revision was 70 years and some patients required operation at up to 79 years of age. The results from both series indicate that the medical condition of the patient at the time of fracture provided a better prognosis for survival than age alone. They also suggest that hemiarthroplasty should be reserved for patients over 79 and for medically unfit patients over 65.     

Roentgen stereophotogrammetric analysis and clinical assessment of unipolar versus bipolar hemiarthroplasty for subcapital femur fracture: a randomized prospective study

Background: Hemiarthroplasty is a well‐established treatment for displaced subcapital fracture, but controversy exists about the optimal implant type. Bipolar hemiarthroplasty has proposed advantages over unipolar hemiarthroplasty in terms of better clinical results and decreased wear of acetabular cartilage. Methods: This study is a randomized prospective study of 51 patients (52 hips) receiving either bipolar or unipolar hemiarthroplasty for displaced subcapital fractures. The outcome measurements were clinical scores and Roentgen stereophotogrammetric analysis (RSA) analysis to determine the rate of acetabular wear. Results: Twenty‐three patients completed 2‐year follow‐up. The RSA data demonstrated that there was slightly less acetabular wear by bipolar prostheses than by unipolar. The combined mean three‐dimensional wear of the bipolar prostheses was 0.6 mm compared with 1.5 mm for the unipolar prostheses (P= 0.04). The bipolar group generally achieved higher scores in terms of the Harris Hip Score, Western Ontario and McMaster University Index of Osteoarthritis (WOMAC) questionnaire and 6‐min walk test. These results were statistically significant at 3 months but not at 12 and 24 months. Conclusion: This study suggests that while the bipolar prosthesis performs slightly better than the unipolar in terms of acetabular cartilage wear and clinical outcomes, it remains debatable whether the benefits are worth the increased cost of the prosthesis.     

Systematic review of cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures in older patients

The purpose of this review was to assess the effectiveness and safety of cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures in older patients. We searched the Cochrane Library, MEDLINE and EMBASE for published randomized clinical trials comparing cemented with uncemented hemiarthroplasty for femoral neck fractures. Eight trials assessing 1,175 hips were eligible for meta-analysis. The pooled results showed that there was no significant difference between cemented and uncemented group with regard to the mortality, reoperation rates and postoperational complications. The overall incidence of residual pain at 1 year after operation was 23.6% in the cemented prosthesis and 34.4% in the uncemented, with significant difference (relative risk 0.69, 95% CI 0.53-0.90; P = 0.007; fixed-effect models).The available evidence suggested that compared with uncemented hemiarthroplasty, cemented hemiarthroplasty in treating the elderly with displaced femoral neck fractures was not associated with a higher risk of mortality, reoperation and complications but can reduce the risk of residual pain and provide better functional results.     

Intraoperative fractures during uncemented Furlong bipolar hemiarthroplasty

Uncemented bipolar hemi-arthroplasty is one of the methods used to treat elderly patients with displaced intracapsular fractures of the femoral neck. In an effort to achieve a tight fit during uncemented hip hemiarthroplasty there are instances where intraoperative fractures have occurred. We retrospectively reviewed 165 consecutive uncemented Furlong Hydroxyapatite ceramic coated bipolar hemiarthroplasty performed for displaced intracapsular fracture neck of femur, and found 7.4% (12) intraoperative fractures of the proximal femur. Nine fractures involved the calcar, one each occurred in the anterior wall, posterior wall and greater trochanter. All fractures were linear and minimally displaced. Of the five fractures that occurred during reaming two were fixed with circlage wires. The remaining seven fractures occurred during prosthesis implantation of which three were fixed with circlage wires or cables. All patients had standard postoperative management and were allowed full weight bearing except in two patients (both fixed fractures) who were kept partial weight bearing for 6 weeks post operation. At 1 year follow up, all patients were mobilising full weight bearing and were pain free. We conclude, fractures of the proximal femur that occur while performing uncemented (Furlong) hemi-arthroplasty for the fractures of the femoral neck may not require any further intervention if the fracture involves the medial column, and is minimally displaced with a stable implant, regardless of whether they occur during reaming or implantation.     

Degenerative changes in normal femoral heads in the elderly

Unipolar hemiarthroplasty and bipolar hemiarthroplasty are frequently chosen for treating subcapital hip fracture; however, clinical outcome varies substantially. Although total hip arthroplasty is indicated for subcapital hip fracture in patients with degenerative hip disease, there is a lack of data on the incidence and extent of degenerative change in patients with subcapital hip fracture without obvious degenerative hip disease. This investigation evaluated articular cartilage in 25 consecutive femoral heads removed from elderly patients who sustained acute femoral neck fracture. All patients' femoral heads demonstrated grade 2 or 3 chondromalacia with an average involvement of 54% of the whole femoral head surface area. Review of the literature describes the cost-to-benefit ratio associated with painful hip arthroplasty. This study demonstrated a high incidence of femoral head degenerative change, which may account for the variable clinical results and proliferation of the term unsolved fracture. In the patient with a subcapital hip fracture, total hip arthroplasty may prove to be a better alternative.     

The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison

The displaced femoral neck fracture poses difficult decision-making issues for the orthopedic surgeon. Young patients frequently require a rapid open reduction and rigid internal fixation in the face of multiple associated injuries. Elderly patients present the typical decision dilemma of internal fixation versus arthroplasty. Consecutive, randomized, prospective series of cases for evaluation of alternatives in the treatment of this difficult fracture are lacking. Between 1982 and 1984, 34 elderly patients with displaced femoral neck fractures were randomized to open reduction or hemiarthroplasty study groups. Although the surgical risks are relatively high, two-year observations showed better functional results in the cemented hemiarthroplasty group.     

The Hastings bipolar hemiarthroplasty for subcapital fractures of the femoral neck. A 10-year prospective study

In a 10-year prospective study, 561 displaced subcapital fractures of the femoral neck in 546 patients were treated with the Hastings bipolar hemiarthroplasty. Within six months of their operations, 148 patients had died. In 322 hips followed up, 243 with adequate serial radiographs separated by more than one year, only 14 (5.6%) showed acetabular erosion. A group of 91 had been reviewed for between three and nine years (mean, 4 years 10 months) and of these, 95% had no pain or slight pain only. Comparison with an earlier series of conventional hemiarthroplasties reported from this institution showed that the clinical results were similar, but that the erosion rate had been halved.     

Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement

In a prospective trial of 278 patients aged over 65 years, treatment of displaced subcapital fractures was randomly allocated to closed reduction and internal fixation with a sliding compression screwplate, Moore hemiarthroplasty, or total hip treatment with a Howse semicaptive prosthesis. One year after operation there was little difference between the three groups in mortality (25 per cent) or general complications. The revision rate within the first year was highest for internal fixation (25 per cent), but many of the replacements also required a further anaesthetic for reduction of a dislocation (Moore, 11 per cent; Howse 12.5 per cent). Total hip replacement resulted in the least pain and most mobility at 1 year, while hemiarthroplasty was worst in these respects. We conclude that internal fixation and particularly primary total hip replacement should be given serious consideration in the management of the elderly patient with a displaced subcapital fracture.     

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.     

Displaced intracapsular neck of femur fractures in mobile independent patients: total hip replacement or hemiarthroplasty?

The aim of this study was to compare the outcome of total hip replacement (THR) with hemiarthroplasty in mobile and socially independent patients with displaced intracapsular fractured neck of femur. Thirty-two patients who had been treated by THR were reviewed after a mean of 3.7 years and compared with 42 patients who had been treated by hemiarthroplasty who were reviewed at 3.9 years. At follow-up none of the THRs had required revision whereas 38% of the hemiarthroplasties had required conversion to THR. Six percent of THRs had dislocated. The modified Harris Hip score rated 86% of THRs as 'good' or 'excellent,' whereas only 12% of the remaining hemiarthroplasties achieved a similar rating. Seventy-seven percent of the patients who had received a THR estimated that they could walk more than a mile compared to 27% of the remaining hemiarthroplasties. THR gave a vastly superior functional outcome compared to hemiarthroplasty in this group of patients.     

Cemented bipolar hemiarthroplasty for displaced intracapsular fracture in the mobile active elderly patient

Fifty-three patients who were independently mobile outside their home at the time of a displaced intracapsular fractured neck of femur were reviewed at a mean follow-up of 32 months after treatment with a cemented bipolar hemiarthroplasty. Forty-four had no or mild pain. Eleven of the sixteen able to walk 1 mile before fracture were able to do so at review, once significant co-morbidity was excluded. There were no dislocations. Two had been revised, one for technical failure. These results are significantly better than would be expected with conventional hemiarthroplasty in this group of patients. They are comparable with results of total hip replacement (THR) but without the risk of dislocation. Patients able to walk 1 mile before fracture regained their pre-fracture mobility significantly better than those able to walk 500 yards. We suggest that ability to walk 1 mile should define the mobile active elderly for future studies and in guiding treatment.     

Treatment of displaced subcapital fractures with the Charnley-Hastings hemiarthroplasty

Between December 1982 and June 1986, 98 displaced subcapital femoral neck fractures were treated using the Charnley-Hastings bipolar hemiarthroplasty. Although the patients were elderly, often with associated medical problems, the operation was well tolerated and the mortality at one and six months was 14.4% and 24.5% respectively. Fifty-four hips were reviewed after an average follow-up of 33 months; 64.8% of patients had a good or excellent result. The fair or poor results were seen mainly in patients with poor pre-operative mobility and multiple medical problems. A significant cause of morbidity was dislocation (two interprosthetic) which occurred in six hips. There were two cases of deep sepsis but neither patient was fit for further surgery. There were no cases of acetabular erosion requiring revision surgery.