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.     

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     

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.     

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.     

Does surgeon volume for total hip arthroplasty affect outcomes after hemiarthroplasty for femoral neck fracture?

We conducted a study to compare complication rates in patients treated with hemiarthroplasty for femoral neck fracture by surgeons with variable experience in primary total hip arthroplasty (THA) and revision THA. A cohort of Medicare beneficiaries (N = 115,352) was identified from Medicare part A claims from 1994 and 1995. All patients had undergone hemiarthroplasty for femoral neck fracture. Patients were grouped according to surgeon procedure volume (how many primary and revision THAs surgeon performed per year): 0 (no volume), 1-5 (low volume), 6-24 (mid volume), and 25+ (high volume). Claims were evaluated up to 5 years after surgery to identify patient encounters for complications, such as mortality, dislocation, and infection. Compared with patients treated by no-volume surgeons, patients treated by high-volume surgeons had significantly lower rates of mortality, prosthetic dislocation, and superficial infection. The difference was significant for mortality at 30 days (5.6% vs 6.5%), 90 days (10.8% vs 12.8%), and 1 year (22.3% vs 23.8%); for prosthetic dislocation at 1 year (1.2% vs 1.7%); and for superficial infection at 90 days (1.1% vs 1.6%), 1 year (1.4% vs 1.9%), and 5 years (1.5% vs 2.0%). Revision surgery rates, however, were statistically higher for the high-volume group than for the no-volume group at 90 days (0.9% vs 0.7%), 1 year (3.3% vs 2.9%), and 5 years (8.4% vs 7.7%). There were no differences in rates of venous thromboembolism or deep infection between the groups. Surgical experience in primary and revision THA has a significant effect on patient outcomes after hemiarthroplasty for femoral neck fracture.     

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.     

Is discontinuation of clopidogrel necessary for intracapsular hip fracture surgery? Analysis of 102 hemiarthroplasties

Background

An increasing number of elderly patients are managed with long-term antiplatelet therapy. Such patients often present with hip fracture requiring surgical intervention and may be at increased risk of perioperative bleeding and complications. The aim of this study was to ascertain whether it is necessary to stop clopidogrel preoperatively to avoid postoperative complications following hip hemiarthroplasty surgery in patients with intracapsular hip fracture.

Materials and methods

A retrospective review of 102 patients with intracapsular hip fracture with either perioperative clopidogrel therapy [clopidogrel group (CG)] or no previous clopidogrel exposure [no clopidogrel group (NCG)] who underwent hip hemiarthroplasty surgery was undertaken. Statistical comparison on pre- and postoperative haemoglobin, American Society of Anesthesiologists (ASA) grade, comorbidities, operative time, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rate between the two groups was undertaken. Regression analysis was undertaken to ascertain the risk ratios (RR) of complications and transfusion associated with clopidogrel.

Results

There was no difference with respect to ASA grade, comorbidities (except cardiac comorbidities), pre- and postoperative haemoglobin levels, operation time, age or gender between the two groups. Four and two patients, respectively, required transfusion postoperatively in the CG and NCG (p = 0.37). There was no difference with respect to LOS, wound infection, haematoma or reoperation rate between the two groups postoperatively. The covariate-adjusted RR for complications and transfusion while being on clopidogrel were 0.43 [95 % confidence interval (CI) 0.07–2.60] and 3.96 (95 % CI 0.40–39.68), respectively.

Conclusion

Continuing clopidogrel therapy throughout the perioperative period in patients with intracapsular hip fracture is not associated with an increased risk of complications following hip hemiarthroplasty surgery.     

Does total hip arthroplasty provide better outcomes than hemiarthroplasty for the femoral neck fracture? A systematic review and meta-analysis

Purpose: By comparing the outcomes of total hip arthroplasty with hemiarthroplasty in elderly patients with a femoral neck fracture to investigate the one-year mortality, dislocation, infection, reoperation rate, and thromboembolic event. Methods: The PubMed, EMBASE databases, and Cochrane library were systematically searched from the inception dates to April 1, 2020 for relevant randomized controlled trials in English language using the keywords: “total hip arthroplasty”, “hemiarthroplasty” and “femoral neck fracture” to identify systematic reviews and meta-analyses. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration’ stools, and discussed any disagreements. The third reviewer was consulted for any doubts or uncertainty. We derived risk ratios and 95% confidence intervals. Mortality was defined as the primary outcome. Secondary outcomes were other complications, dislocation, infection, reoperation rate, and thromboembolic event. Results: This meta-analysis included 10 studies with 1419 patients, which indicated that there were no significant differences between hemiarthroplasty and total hip arthroplasty in reoperation, infection rate, and thromboembolic event. However, there was a lower mortality and dislocation rate association with total hip arthroplasty at the one-year follow-up. Conclusion: Based on our results, we found that total hip arthroplasty was better than hemiarthroplasty for a hip fracture at one-year follow-up.     

Hip hemi-arthroplasty for neck of femur fracture: What is the current evidence?

This editorial reviews and summarises the current evidence(meta-analyses and Cochrane reviews) relating to the use of hip hemi-arthroplasty for neck of femur fractures. Regarding the optimal surgical approach,two recent meta-analyses have found that posterior approaches are associated with: higher rates of dislocation compared to lateral and anterior approaches; and higher rates of re-operation compared to lateral approaches. Posterior approaches should therefore be avoided when performing hip hemi-arthroplasty procedures. Assessing the optimal prosthesis head component,three recent meta-analyses and one Cochrane review have found that while unipolar hemiarthroplasty can be associated with increased rates of acetabular erosion at short-term follow-up(up to 1 year),there is no significant difference between the unipolar hemi-arthroplasty and bipolar hemi-arthroplasty for surgical outcome,complication profile,functional outcome and acetabular erosion rates at longer-term follow-up(2 to 4 years). With bipolar hemi-arthroplasty being the more expensive prosthesis,unipolar hemi-arthroplasty is the recommended option. With regards to the optimal femoral stem insertion technique,three recent metaanalyses and one Cochrane Review have found that,while cemented hip hemi-arthroplasties are associated with a longer operative time compared to uncemented Hip Hemi-arthroplasties,cemented prostheses have lower rates of implant-related complications(particularly peri-prosthetic femoral fracture) and improved postoperative outcome regarding residual thigh pain and mobility. With no significant difference found between the two techniques for medical complications and mortality,cemented hip hemi-arthroplasty would appear to be the superior technique. On the topic of wound closure,one recent meta-analysis has found that,while staples can result in a quicker closure time,there is no significant difference in post-operative infections rates or wound healing outcomes when comparing staples to sutures. Therefore,either suture or staple wound closure techniques appear equally appropriate for hip hemiarthroplasty procedures.     

Femoral neck collapse after internal fixation of an intracapsular hip fracture: Does it indicate a poor outcome?

The degree of femoral neck collapse that occurred after 519 patients with an intracapsular hip fracture treated by internal fixation with a Targon FN implant was measured. Mean femoral neck collapse was 8.0 mm and this was increased for displaced fractures in comparison to undisplaced fractures (9.5 mm versus 5.9 mm, p < 0.0001) and for those patients that subsequently developed fracture healing complications (11.6 mm versus 7.1 mm, p < 0.0001). At one year from injury femoral neck collapse in excess of 15 mm was associated with an increase in the degree of residual pain (p = 0.01). A clear relationship between increased collapse and increased loss of mobility was demonstrated (P < 0.0001). This study confirms previous smaller studies that excessive femoral neck collapse (of more than 15 mm) is more common for displaced fractures and presents new data to demonstrate that excessive femoral neck collapse is associated with an increased risk of fracture healing complications and increased loss of function. Future studies are now justified that consider methods to reduce fracture collapse.     

Does using a modular variable offset hemiarthroplasty reduce length of stay after hip fracture? Early experience with the Exeter Unipolar hemiarthroplasty

Purpose

The Exeter Unipolar hemiarthroplasty is a variable offset modular device. We compared the early results of the Exeter Unipolar (Exeter) with the Cemented Thompson (Thompson) hemiarthroplasty in a retrospective cohort study.

Methods

One hundred and twenty-three patients underwent Thompson (n?=?68) or Exeter (n?=?55) hemiarthroplasty by 24 different primary surgeons.

Results

Median follow-up was 9 months (interquartile range (IQR) 6–11, Range 3–13). Median length of stay was lower in the Exeter group 5.72 days (IQR 4.01–7.95, Range 2.7–33.7) vs 6.99 days (IQR 4.58–9.24, Range 1.2–59), p?=?0.048. Median time to discharge from rehabilitation was also lower in the Exeter group (13.6 days (IQR 11.0–23.8, Range 5.8–59) vs 21.7 days (IQR 16.0–31.2, Range 1.2–86.3), p?=?0.0003). Three Thompson prostheses dislocated, there was one deep infection and one superficial wound infection. One Exeter prosthesis became infected requiring revision; there were no dislocations. There were no statistically significant differences between groups in other factors studied. Power analysis suggested these differences should have been observed if present. Rehabilitation was faster in the Exeter group. This might result from more accurate restoration of femoral neck offset during surgery. The higher cost of the Exeter prosthesis is likely to be offset by the reduction in length of hospital stay.

Conclusions

The Exeter Unipolar hemiarthroplasty reduces length of stay and hastens rehabilitation after hip fracture.     

Is revision as good as primary hip replacement? A comparison of quality of life

Primary total hip arthroplasty (THA) is one of the most effective ways of improving quality of life (QoL). We have compared the improvement in QoL in 62 patients who had a cemented revision of a THA with that of 62 primary replacements. One year after operation the median QoL score had been significantly improved in both groups; from 0.870 to 0.990 in the primary group (p < 0.0001) and from 0.870 to 0.980 in the revised group (p < 0.0001). There was no significant difference in the improvement in scores between the groups (p = 0.29). When reviewed after four years there was no difference in the pain score for either group (p = 0.89), but that for function had deteriorated significantly. This was associated with revision surgery (p = 0.018) and a low preoperative QoL score (p = 0.004). We conclude that both primary and revision operations give a significant improvement in the QoL but function after revision may be less durable than after a primary arthroplasty.