Uncemented Thompson's hemiarthroplasty: safe, palliative and cost-effective surgery in the infirm patient-a consecutive series of 1445 cases

Reoperation and revision rates at ten years after 1,312 cemented Thompson’s hemiarthroplasties

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

Methods

Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries.

Results

In total, 1,312 Thompson’s hemiarthroplasties were analyzed (mean age at surgery 82.8 years); 125 complications were recorded, necessitating 82 returns to theatre. These included 14 patients undergoing aspiration or manipulation under anaesthesia, 68 reoperations (5.2%) for debridement and implant retention (n = 12), haematoma evacuation (n = 2), open reduction for dislocation (n = 1), fixation of periprosthetic fracture (n = 5), and 48 revised stems (3.7%), for infection (n = 13), dislocation (n = 12), aseptic loosening (n = 9), persistent pain (n = 6), periprosthetic fracture (n = 4), acetabular erosion (n = 3), and metastatic bone disease (n = 1). Their status at ten years is summarized as follows: 1,180 (89.9%) dead without revision, 34 (2.6%) dead having had revision, 84 (6.6%) alive with the stem unrevised, and 14 (1.1%) alive having had revision. Cumulative implant survivorship was 90.3% at ten years; patient survivorship was 7.4%.

Conclusion

The Thompson’s stem demonstrates very low rates of complications requiring reoperation and revision, up to ten years after the index procedure. Fewer than one in ten patients live for ten years after fracture. This study supports the use of a cemented Thompson’s implant as a cost-effective option for frail hip fracture patients.

Cite this article: Bone Jt Open 2022;3(9):710–715.

Geriatric Femoral Neck Fractures: Hemiarthroplasty Implant Trends Across a Health System From 2006 to 2018

Introduction:

Hemiarthroplasty is increasingly used for the treatment of geriatric femoral neck fractures in an effort to optimize value-based care. The current American Association of Orthopaedic Surgeons (AAOS) guidelines released in 2014 for the treatment of geriatric hip fractures recommend the utilization of monopolar cemented constructs. The purpose of this study was to evaluate hip hemiarthroplasty implant cost variability and implant selection trends from 2006 to 2018.

Materials and Methods:

A retrospective review of 940 geriatric hip fractures treated with hemiarthroplasty was conducted across 3 institutions from 2006 to 2018. Variables examined were construct type, surgeon, operative time, patient mortality, and implant cost. Statistical analysis consisted of multigroup comparative tests and multiple linear regression analyses to evaluate correlative measures.

Results:

The study population was 85.0 ± 7.9 years of age with a body mass index of 24.0 ± 5.5. A total of 33 (3.5%) patients were deceased at the 90-day postoperative mark and 45 (4.8%) patients at the 1-year mark. There was no statistical difference in terms of mortality between the 4 implant cohorts at the 90-day mark (P = .56) and 1-year mark (P = .24). The bipolar press-fit construct was the most expensive, US$3900.61 ± US$2607.54, and the monopolar cemented construct was the least expensive, US$2618.68 ± US$1834.16. The mean operative time was 6 minutes greater for press-fit implants, 93.6 ± 32.0, than cemented implants, 87.1 ± 33.6 (P = .02). The use of monopolar cemented implants increased from 12.1% to 83.3%, while bipolar press-fit decreased from 57.6% to 4.6% from 2013 to 2018.

Discussion:

The use of a bipolar and/or press-fit implant significantly increases construct cost despite little evidence in the literature of improved outcomes. Contrary to previous research, cemented implants do not increase the operative time.

Conclusions:

Encouragingly, selection of the most cost-conscience implant, monopolar cemented, has been increasing since 2014, which may reflect the influence of current AAOS guidelines.

Level of Evidence:

Diagnostic Level III.

Cementless Bipolar Hemiarthroplasty for Low-energy Intracapsular Proximal Femoral Fracture in Elderly East-Asian Patients: A Longitudinal 10-year Follow-up Study

Purpose

Short-term outcomes following cemented and cementless hemiarthroplasties (HAs) are reported to be comparable, however, long-term outcomes of cementless HA—especially among Asian patients—is limited. We aimed to assess long-term outcomes in elderly East-Asian patients with intracapsular proximal femoral fractures treated with cementless HA.

Materials and Methods

We enrolled 135 patients treated with cementless HA who met our inclusion criteria. We documented bone/implant-related complications (e.g., incidences of revision hip surgery, femoral stem subsidence, dislocation, intraoperative and postoperative periprosthetic fractures, contralateral hip fractures). We included those patients who are still alive 10 years after the index surgery in the final functional analysis of the existence of pain, ambulatory status, and residential status.

Results

The mean age at injury was 78.3 years (range: 60–85 years). At the 10-year follow-up, 26 of the original patients (19.3%) had survived. During follow-up, revision hip surgery was conducted in two patients (1.5%). We recorded the incidence of intraoperative fractures, postoperative periprosthetic fractures, and contralateral fractures in two (1.5%), eight (5.9%), and six patients (4.4%), respectively. Among the 10-year survivors, six patients (23.1% of the survivors) complained of groin pain, but generally reported the pain to be tolerable.

Conclusion

Among elderly East-Asian patients, the incidence of revision surgery after cementless HA may be lower than that in their European counterparts, whereas the incidence of periprosthetic fractures can still be considerably higher. For patients undergoing cementless HA, prevention of such secondary fractures is of critical importance.