Hemiarthroplasty for Displaced Femoral Neck Fractures in the Elderly Has a Low Conversion Rate

Hip Hemiarthroplasty in Patients with Multiple Myeloma: A Retrospective Case Series and Review of the Literature

Objectives  Femoral neck fractures in multiple myeloma patients are usually managed with hemiarthroplasty or total hip arthroplasty, depending on the presence of acetabular infiltration. Due to the paucity of dedicated studies, the aim of the present study is to review the clinical outcomes of hip hemiarthroplasty in patients with multiple myeloma and to review the literature regarding the outcomes and survival in these patients' subset. Methods  There were 15 patients (16 cases), with a mean age of 71.7 years, who had myeloma and received hip hemiarthroplasty for displaced femoral neck fractures had their radiographs and clinical data assessed for this study. From those, 13 cases received bipolar and 3 unipolar hemiarthroplasty. Results  After a mean follow-up of 18.2 months since the time of surgery, 3 cases suffered periprosthetic fractures (18.75%), 4 cases (25%) had heterotopic ossification, and 1 case (6.25%) had acetabular erosion. The 1- and 5-year patient mortality rates for the study cohort were 53.3 and 73.3%, respectively. Conclusion  Hip hemiarthroplasty remains a viable treatment option in myeloma patients; however, the potentially high morbidity and mortality in these patients should be sensibly understood before the surgery to achieve satisfactory expectations.

Perioperative Outcomes of Intramedullary Nail vs Hemiarthroplasty vs Total Hip Arthroplasty for Intertrochanteric Fracture: An Analysis of 31,519 Cases

Background

The purpose of this study is to compare 30-day perioperative outcomes following treatment of intertrochanteric (IT) fractures with intramedullary nail (IMN), total hip arthroplasty (THA), or hemiarthroplasty (HA).

Methods

Using the National Surgical Quality Improvement Program database, we conducted a retrospective cohort study of patients who had sustained an IT fracture treated with primary IMN, THA, or HA between 2017 and 2020. International Classification of Diseases, 10th Revision codes S72.141-S72.146, subtypes A through C, were used to identify eligible patients and were cross-referenced to primary Current Procedural Terminology codes, used to identify the following procedure types: 27245: IMN; 27130: THA; and 27236: HA. Revision cases and patients who underwent arthroplasty for osteoarthritis were excluded. Outcomes of interest included reoperation, readmission, operative time, length of stay, and major and minor complications. Multivariate regression was used to evaluate differences in postoperative outcomes between groups.

Results

There were 29,809 IT fractures treated with IMN (94.6%), 1493 treated with HA (4.7%), and 217 treated with THA (0.70%). There was a statistically significant increase in 30-day reoperation rates (adjusted odds ratio [aOR] = 1.99 [95% confidence interval = 1.51, 2.63], P < .001) when combining all arthroplasty patients compared to IMN. There was no statistically significant difference in the overall complication rate between IMN (13.58%) and HA (14.60%, aOR = 1.09, P = .315) or THA (11.98%, aOR = 1.00, P = .998). When compared to IMN (0.12%), there was a statistically significantly decreased need for transfusion in the HA group (aOR = 0.71 [95% confidence interval = 0.61, 0.80], P < .001).

Conclusions

Primary HA is associated with an increased 30-day reoperation rate and decreased need for blood transfusion, but there were no other significant differences in postoperative morbidity identified among IMN, THA, and HA in the treatment of IT fractures. Given the challenges and inferior outcomes associated with conversion arthroplasty, the lack of significant difference in morbidity between the 3 groups suggests that primary arthroplasty may be a safe and viable treatment option in selected patients with IT fractures. Comparative studies with longer clinical follow-up will be necessary to establish the appropriate indications and further evaluate the clinical outcomes of primary arthroplasty in the treatment of IT fractures.

Symptomatic Acetabular Erosion After Hip Hemiarthroplasty: Is It a Major Concern? A Retrospective Analysis of 2477 Hemiarthroplasty Cases

Background/Objectives: Acetabular erosion is a postoperative condition that can occur after hip hemiarthroplasty (HA), potentially leading to pain and requiring conversion to total hip arthroplasty (THA). Given the discrepancy in its incidence and impact in the literature, this study aims to report the incidence of symptomatic acetabular erosion and the subsequent conversion to THA in all HA cases performed in a single health system. Methods: A total of 2477 HA cases had their clinical notes and serial radiographs examined for this retrospective study. Outcome measures included any records of hip or groin pain and conversion to THA that were attributed to acetabular erosion as documented in the clinical notes. Results: Two thousand four hundred and seventy-seven HA cases were reviewed in this study. The mean age for all patients in the study was 81.5 years and the mean follow up was 3.7 years. Out of the 2477 HA cases, only 12 HA cases (0.48%) in 12 patients had data records of chronic hip pain, attributable to acetabular wear in the clinical notes, of variable severity and presentations. The mean duration until the clinical documentation of acetabular wear-induced pain was 25.6 months (range, 1.4-146.4 months), with most symptomatic hip erosion cases presented within the first year (50% presented within the first 6 months) after the index HA surgery. Despite that, only five cases underwent conversion to THA (0.2%) while seven patients received conservative management. Conclusions: In patients older than 65 years of age who are candidates for HA, the incidence of symptomatic hip erosion and the subsequent conversion to THA is low and hence HA remains a viable treatment option. Based on the duration until clinical presentation of acetabular erosion, this study suggests that the state of acetabular cartilage during surgery may influence the development of early acetabular wear in most symptomatic patients. On the other hand, hip hemiarthroplasty is a rare treatment option for displaced femoral neck fractures in patients younger than 65 years of age, and its use in this patient subset depends on conditional and patient-related factors such as the activity level, cognitive function, and medical comorbidities.

Traumaplasty: When and How to Perform Acute Arthroplasty for Fractures Around the Hip in the Elderly Patient

Acute fractures around the hip are prevalent injuries associated with potentially devastating outcomes. The growing utilization of arthroplasty for femoral neck fractures in the elderly is likely a result of improvements in reoperation rates and postoperative function. Compared to hemiarthroplasty, total hip arthroplasty is associated with a slight functional benefit that is unlikely noticeable for many patients, as well as minimal differences in complications and patient reported outcome measures. However, the evidence supporting cement use in femoral stem fixation is robust. Multiple high power randomized controlled trial-based studies indicate cement fixation brings more predictable outcomes and fewer reoperations. In the setting of acute acetabular fracture, total hip arthroplasty is a favorable approach for elderly patients and fracture patterns associated with increased risk of revision after open reduction and internal fixation. Variations in patient characteristics and fracture patterns demand careful consideration whenever selecting the optimal treatment. In fracture patient populations, comanagement is an important consideration when seeking to reduce complications and promote cost-effective quality care.

Revision Risk of Unipolar and Bipolar Hemiarthroplasties in the Dutch Arthroplasty Register

BACKGROUND

Hemiarthroplasty (HA) for hip fractures can be performed with a unipolar or bipolar head. We describe the use of unipolar and bipolar HA after a hip fracture in the Netherlands and determined revision rates and risk factors.

METHODS

All HAs for an acute hip fracture registered in the Dutch Arthroplasty Register (LROI) during 2007 to 2021 were included; 44,127(88%) unipolar and 6,013(12%) bipolar HAs. Competing risk survival analyses were performed with revision for any reason as the endpoint. Multivariable Cox regression analyses were performed adjusting for patient and surgery-related factors.

RESULTS

The 1-year, 5-year, and 10-year revision rates were comparable for unipolar and bipolar HA. Cox regression analysis showed a hazard ratio of 1.2 (95% confidence interval (CI) 1.0 to 1.4)) after adjustment for confounders for bipolar heads. In cases of a cemented stem, the 1-year cumulative incidence of revision was lower (1.5% (CI 1.4 to 1.7%) compared to uncemented stems (2.4% (CI 2.1 to 2.7%); uncemented stems showed higher risks for revision after adjustment compared to cemented stems (hazard ratio 1.4 (CI 1.2 to 1.5)). The anterior, antero-lateral, and straight-lateral approach showed lower risk for revision compared to the postero-lateral approach.

CONCLUSION

The revision rate for bipolar HA and unipolar HA was comparable. However, after adjustment for potential confounders the risk for revision showed an estimated 20% increased revision risk for bipolar heads, although not statistically significant. For both head types, the risk for revision was significantly higher when an uncemented stem was chosen or the postero-lateral approach was used.

Outcomes of Osteosynthesis Versus Hemiarthroplasty in Elderly Patients With Arbeitsgemeinschaft Fur Osteosynthesefragen-Orthopedic Trauma Association (AO-OTA) 31A2 Hip Fractures

Background Intertrochanteric femur fractures account for more than half of the cases of hip fractures. These injuries are among the most common fractures in elderly individuals. Elderly patients suffer from other comorbidities such as diabetes mellitus or hypertension and are prone to low surgical tolerance with increased postoperative morbidity and mortality. Although the ideal choice of treatment for intertrochanteric femur fractures in the elderly remains debatable, the use of hemiarthroplasty in elderly patients provides an early mobilization and decreased postoperative morbidity. In this study, we aimed to assess the functional outcomes of bipolar hemiarthroplasty and osteosynthesis in Arbeitsgemeinschaft Fur Osteosynthesefragen-Orthopedic Trauma Association (AO-OTA) 31A2 hip fractures using the Harris Hip Score. Methodology A total of 60 elderly patients with AO/OTA 31A2 hip fractures were divided into two groups and treated with bipolar hemiarthroplasty and osteosynthesis using proximal femoral nail (PFN). Functional scores were assessed at two months, four months, and six months postoperatively using the Harris Hip Score. Results The mean age of the patients was 73.03 ± 7.57 years in the study. The majority of the patients were females, 38 (63.33%), with 18 females in the osteosynthesis group and 20 females in the hemiarthroplasty group. The average operative time was 144.93 ± 9.76 minutes in the hemiarthroplasty group and 86.07 ± 11 minutes in the osteosynthesis group. Blood loss was 263.67 ± 42.95 mL in the hemiarthroplasty group and 84.5 ± 15.05 mL in the osteosynthesis group. The average Harris Hip Score at two months, four months, and six months was 64.77 ± 4.33, 72.67 ± 3.54, and 79.72 ± 2.53, respectively, for the hemiarthroplasty group and 57.83 ± 2.83, 64.13 ± 3.89, and 72.83± 3.89, respectively, for the osteosynthesis group (p < 0.001 for all follow-up scores). One death was encountered in the hemiarthroplasty group. Other complications included superficial infection noted in two (6.67%) patients in both groups. There was one episode of hip dislocation in the hemiarthroplasty group. Conclusions The use of bipolar hemiarthroplasty in intertrochanteric femur fractures in elderly patients can prove to be better in comparison to osteosynthesis, but the use of osteosynthesis can be effective for patients who cannot tolerate major blood loss and longer surgical times.

Conversion Hip Arthroplasty Using Standard and Long Stems after Failed Internal Fixation of Intertrochanteric Fractures

OBJECTIVE

Failed internal fixation of intertrochanteric fractures (FIF-ITF) is often treated by conversion hip arthroplasty (CHA). This study aimed to evaluate the results and complications of using standard and long femoral stems in this operation.

METHODS

This retrospective, multi-center study enrolled 31 total hip arthroplasty (THA) and 23 hemiarthroplasties (HA) cases (30 women, 24 men; mean age 76 years) after FIF-ITF between 2012 and 2019, divided into two groups: standard stem group (n = 20) and long stem group (n = 34). The initial internal fixation includes 38 cases of proximal femoral nail anti-rotation (PFNA), eight cases of the dynamic hip screw (DHS), and eight cases of locking proximal femoral plate (LPFP). The indications for CHA included 38 cases of failure of fixation, seven cases of nonunion, and nine cases of avascular necrosis or posttraumatic osteoarthritis. Perioperative data and complications related to fracture and operation were collected, and preoperative and postoperative clinical and radiological data were analyzed. Clinical outcomes were assessed using Harris hip score (HHS) and 36-item Short Form survey (SF-36: including physical function (PF) score and body pain (BP) score). Statistical analyses were performed using the chi-square or Fisher's exact test, and the 2-sample t-test or Wilcoxon rank sum test.

RESULTS

At an average of 5.6 years with a minimum of 2 years follow-up. A significant overall surgeon-related complication rate was detected (27.8% [15/54]), five cases had an intraoperative femur fracture, one case had a late periprosthetic femoral fracture, two cases had a stem penetration, one case had a cement leakage, and two patients had an early postoperative dislocation, one infection and three cases of stem loosening or subsidence. Long stems had an increased risk of complication (13/34) compared to standard stems (2/20) (P = 0.031). The operation time and blood loss in the long stem group were higher than those in the standard stem group (P = 0.002; 0.017). HHS and SF-36 significantly improved in both groups from preoperative to the final follow-up and did not present significant differences at the final follow-up (P > 0.05).

CONCLUSION

CHA following FIF-ITF showed a successful mid-term clinical result, long stem arthroplasty should be approached with caution for the risks of higher complication rate, especially intraoperative femoral fractures.

Factors associated with and 1-year outcomes of fear of falling in a geriatric post-hip fracture assessment

Background

Hip fracture causes not only physical injury but also psychological trauma. Fear of falling (FoF) is related to poor recovery, loss of mobility and mortality. There is limited data on the clinical factors affecting post-hip fracture FoF and its consequences.

Objective

To investigate the factors associated with and 1-year outcomes of post-hip fracture FoF.

Methods

An observational prospective cohort study. Data were collected on hospital admission, at a geriatric outpatient assessment 4–6 months post-hip fracture and by telephone interviews 1 year after the index fracture. FoF was assessed with a dichotomous single-item question. Logistic regression analyses were conducted to examine the age, gender and multivariable-adjusted association between baseline and the geriatric assessment domains with FoF. Follow-up outcomes included changes in mobility, living arrangements and mortality.

Results

Of the 916 patients included, 425 (49%) had FoF at the time of their geriatric assessment. These patients were predominantly female and were living alone in their own homes with supportive home care. They scored lower on tests of physical performance. Less FoF was documented in patients with diagnosed cognitive disorders before the index fracture and in those with Clinical Dementia Rating ≥ 1. After adjusting for age and gender, no association was observed between FoF and any of the 1-year follow-up outcomes.

Conclusion

Post-hip fracture FoF is common and associated with female gender, polypharmacy, poor daily functioning, poor physical performance and depressive mood. Patients with cognitive disorders have less FoF than those without. FoF appears to have no impact on the follow-up outcomes.

The fate of positive intraoperative cultures following conversion total hip arthroplasty

INTRODUCTION

The objectives of this study are to report the rates of positive intraoperative cultures obtained during conversion total hip arthroplasty (THA) according to index surgery, and to describe the natural history of treatment for a consecutive series of patients with unexpected positive intraoperative cultures during conversion THA.

METHODS

We reviewed all patients at 2 institutions undergoing conversion THA from prior open reduction and internal fixation (ORIF) of acetabular and hip fractures or hemiarthroplasty for displaced femoral neck fractures from 2011 to 2018. Intraoperative cultures were taken in 105 patients. Positive intraoperative cultures during conversion were recorded and managed with an infectious diseases consult. The outcomes including PJI at 90 days and 1 year follow-up were documented.

RESULTS

Overall, 19 of 105 patients (18%) undergoing conversion THA had positive intraoperative cultures, with the highest rates in the hemiarthroplasty 7/16 (44%) and acetabular ORIF 9/48 (19%) groups. All 19 patients were initially treated conservatively: 8 received IV antibiotics, 10 received no additional therapy, and 1 received oral antibiotics. 4/9 acetabular fracture conversions developed PJI at 1 year, with 3 requiring multiple irrigation and debridement/polyethylene exchanges to control the infection while the 4th patient required 2-stage exchange. There were no 1-year PJI from any of the other index procedures after conversion. All 7 hemiarthroplasty patients with positive cultures were treated to resolution with 4-8 weeks IV antibiotics alone.

CONCLUSIONS

Patients undergoing conversion THA from prior hip or acetabular fracture have a high rate of positive intraoperative cultures. As such, all patients undergoing conversion THA from prior hip or acetabular fracture fixation should undergo thorough diagnostic workup prior to surgery, and have intraoperative cultures obtained during surgery if infection remains suspicious. Further work should be performed to develop MSIS criteria for preoperative management of patients undergoing conversion THA.

SuperPath approach is a recommendable option in frail patients with femoral neck fractures: a case-control study

INTRODUCTION

The treatment of intracapsular femoral neck fractures (FNFs) in the elderly is usually based on hip replacement, both total hip arthroplasty (THA) and hemiarthroplasty (HA). Recently, several tissue-sparing approaches for hip arthroplasty had been described with promising results in terms of hospitalization length, blood loss and dislocation rate. The aim of the present study was to compare the blood loss and the transfusion rate in a cohort of patients with FNF treated using an HA through both the SuperPath (SP) and the traditional posterolateral (PL) approaches.

MATERIALS AND METHODS

We retrospectively collected data from patients affected by FNFs between January 2018 and February 2020. All patients with intracapsular FNF treated with a single HA implant (Profemur L, MicroPort Orthopedics Inc., USA) via PL or SP approaches were included. Exclusion criteria were pathological fractures, polytrauma and preoperatively transfused patients.

RESULTS

Thirty-five patients were included and analysed in the present study. 17 patients were classified in the SP group, and 18 in the PL one. The rate of antithrombotic therapy was higher in the SP group compared with the PL group [10 (58, 82%) vs 4 (22, 2%)]. While the two groups did not differ in terms of preoperative haemoglobin (Hb), 48 h postoperative Hb and Hb reduction, a significative difference was observed in terms of blood transfusion rate (1 SP vs 9 PL, p = 0.0072).

CONCLUSIONS

The SuperPath approach in patients with FNF under antithrombotic therapy assures lower transfusion rate, potentially reducing complication rates and improving patients' outcomes.

Acetabular complications are the most common cause for revision surgery following proximal femoral endoprosthetic replacement : what is the best bearing option in the primary and revision setting?

AIMS

Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs.

METHODS

This is a retrospective review of 233 patients who underwent PFEPR. The mean age was 54.7 years (SD 18.2), and 99 (42.5%) were male. There were 90 patients with primary bone tumours (38.6%), 122 with metastatic bone disease (52.4%), and 21 with haematological malignancy (9.0%). A total of 128 patients had monopolar (54.9%), 74 had bipolar hemiarthroplasty heads (31.8%), and 31 underwent acetabular arthroplasty (13.3%).

RESULTS

At a mean 74.4 months follow-up, the overall revision rate was 15.0%. Primary malignancy (p < 0.001) and age < 50 years (p < 0.001) were risk factors for revision. The risks of death and implant failure were similar in patients with primary disease (p = 0.872), but the risk of death was significantly greater for patients who had metastatic bone disease (p < 0.001). Acetabular-related implant failures comprised 74.3% of revisions; however, no difference between hemiarthroplasty or arthroplasty groups (p = 0.209), or between monopolar or bipolar hemiarthroplasties (p = 0.307), was observed. There was greater radiological wear in patients with longer follow-up and primary bone malignancy. Re-revision rates following a revision PFEPR was 34.3%, with dual-mobility bearings having the lowest rate of instability and re-revision (15.4%).

CONCLUSION

Hemiarthroplasty and arthroplasty PFEPRs carry the same risk of revision in the medium term, and is primarily due to acetabular complications. There is no difference in revision rates or erosion between monopolar and bipolar hemiarthroplasties. The main causes of failure were acetabular wear in the hemiarthroplasty group and instability in the arthroplasty group. These risks should be balanced and patient prognosis considered when contemplating the bearing choice. Dual-mobility, constrained bearings, or large diameter heads (> 32 mm) are recommended in all revision PFEPRs. Cite this article: Bone Joint J 2021;103-B(10):1633-1640.

Comparing Postoperative Leg Length Discrepancy and Femoral Offset Using Two Different Surgical Approaches for Hemiarthroplasty of the Hip

INTRODUCTION

The direct anterior approach (DAA) and anterolateral approach (ALA) may be used for hip hemiarthroplasty (HHA) as a treatment for femoral neck fractures. The DAA often utilizes intraoperative fluoroscopy to determine leg length and offset, while the ALA traditionally utilizes an intraoperative clinical exam to determine offset and leg length. This study will evaluate two techniques: the "grid fluoroscopy [GF] technique" and the "intraoperative exam [IE] technique," each performed by one of two separate surgeons, and compare each technique's accuracy to restore leg length and femoral offset in a patient population that underwent HHA.

METHODS

Two investigators retrospectively reviewed charts of 208 randomly selected patients who had an HHA from either a DAA or ALA performed by two different surgeons for the treatment of femoral neck fractures. Postoperative AP pelvis radiographs were measured to determine offset and leg length compared with the non-operative extremity. Non-normal continuous variables were provided by median and interquartile range. Data were analyzed with the Mann-Whitney U test and Student's t-test.

RESULTS

After inclusion and exclusion criteria, data were reviewed on 173 hemiarthroplasties. The mean age was 80.3 years (± 11.2 years). Of the surgical patients, 65.9% were female, and 70.9% identified their ethnicity as white. The DAA was used in 93 patients and ALA in 80 patients. Analysis comparing the two techniques demonstrated no statistically significant differences in median leg length between GF technique (1.02 IQR -0.1, 2.0 mm) and IE technique (1.25 IQR -2.4, 1.3 mm,) (p=0.67). There was also no statistically significant difference in offset between GF technique (1.3 IQR 0.2, 2.1 mm) and IE technique (0.6 IQR -2.7 mm, 3.2 mm) (p=0.13). However, a difference was found in mean length of surgery that was statistically significant. We found that the mean length of surgery for the IE technique was 74.8 ± 24.7 minutes versus the GF technique, which was 95.1 ± 23.0 minutes, (p<0.0001).

DISCUSSION

There was no significant difference between leg length and offset with the use of intraoperative fluoroscopy with DAA compared to no intraoperative imaging with ALA. Our study suggests that DAA and ALA are equally effective approaches for re-establishing symmetric leg length and offset in HHA for femoral neck fractures. In this study, the ALA had a shorter surgical time compared to DAA, potentially due to the utilization of intraoperative fluoroscopy for this particular technique during the DAA.

Cemented and uncemented hemiarthroplasty for femoral neck fracture in elderly patients: a systematic review and meta-analysis

BACKGROUND

Cemented hemiarthroplasty to treat femoral neck fractures (FNFs) in elderly patients is controversial. Therefore, this study aimed to compare cemented vs uncemented outcomes.

METHODS

A literature review using Pubmed, EMBASE, Cochrane Library, and Science Citation Index databases was conducted. Studies comparing outcomes of cemented with uncemented hemiarthroplasty for FNFs in elderly patients up to March 2020 were included. Dichotomous outcomes were pooled and reported as relative risk (RR) or odds ratio (ORs), while continuous outcomes were pooled and reported as the mean difference (MD) or standardized mean difference (SMD).

RESULTS

The analysis included 39 studies with a total of 112 576 patients. Pooled analysis revealed that compared with cemented, patients with uncemented intervention had better outcomes for intraoperative blood loss (OR 0.19; 95% CI 0.01-0.37), systolic blood pressure (OR 2.83; 95% CI 1.51-5.28), surgery duration (SMD, 0.51; 95% CI 0.2-0.81), length of anesthesia (OR 0.28; 95% CI 0.11-0.45), 6-month mortality (OR 1.11; 95% CI 1.03-1.2), cardiovascular accidents (OR 2.14; 95% CI 1.07-4.28), respiratory failure (OR 8.26; 95% CI 1.38-49.4), fat embolisms (OR 1.58; 95% CI 1.29-1.93), and heterotrophic ossification (OR 2.3; 95% CI 1.3-4.06), but more intraoperative accidents (OR 0.34; 95% CI 0.26-0.45), postoperative fractures (OR 0.27; 95% CI 0.21-0.34), reoperations (OR 0.59; 95% CI 0.53-0.65), and revisions (OR 0.62; 95% CI 0.44-0.88).

CONCLUSIONS

Meta-analysis of hemiarthroplasty outcomes shows that elderly patients who underwent uncemented vs cemented procedures had better results for several factors that are important for not only improved recovery in elderly populations, but also more intraoperative and postoperative risks.

Hemiarthroplasty versus total arthroplasty for displaced femoral neck fractures in the elderly: meta-analysis of randomized clinical trials

INTRODUCTION

Displaced femoral neck fractures (FNF) are complicated by high mortality rates and continue to represent an important cause of disability, having a negative impact on patient mobility and physical independence. The purpose of this study was to update and analyse current outcomes and evidence concerning hip hemiarthroplasty (HHA) versus total hip arthroplasty (THA) for displaced femoral neck fractures in the elderly. Thus, a meta-analysis of randomized clinical trials was conducted.

MATERIALS AND METHODS

This meta-analysis was conducted according to the PRISMA guidelines. In October 2019, the following databases were accessed: Embase, Google Scholar, Pubmed, Scopus. All randomized clinical trials (RCTs) comparing total hip arthroplasty versus hip hemiarthroplasty for displaced femoral neck fractures were included in the present study. For the statistical analysis and the methodological quality assessment, the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen) and STATA/MP Software 14.1 (StataCorp, College Station, TX) were used.

RESULTS

Data from 2325 (1171 HHA vs 1154 THA) patients were collected. The mean follow-up was 58.12 months. The HHA group reported lower values of the mean Harris hip score (EE 3.22; p = 0.2), surgical duration (EE 21.75; p < 0.0001), length of the hospitalization stay (EE 0.8; p = 0.4). The HHA group evidenced lower dislocations rate (OR 1.78; p = 0.01, Fig. 4), but higher rate of acetabular erosion (OR 0.08; p = 0.0006). At a mean of 58.12 ± 52.8 months follow-up, revisions rate scored reduced in the THA group (OR 0.76; p = 0.2). Subgroup analysis of RCTs < 5 years follow-up revealed reduced revision in favour of the HHA group (OR 2.19; p = 0.03), while subgroup analysis of RCTs > 5 years follow-up revealed reduced revision in favour of the THA group (OR 0.25; p = 0.0003). The Kaplan-Meier curve detected similarity of patients survivorship between the two groups (HR 1.06; p = 0.3).

CONCLUSION

For the elderly population, both HHA and THA are valid solutions to treat displaced femoral neck fractures, with comparable survivorship. HHA detected reduced dislocations, while for THA a lower risk of acetabular erosion and further revision surgeries were reported.

LEVEL OF EVIDENCE

Level I, meta-analysis of randomized clinical trials.

What Factors Increase Revision Surgery Risk When Treating Displaced Femoral Neck Fractures With Arthroplasty: A Secondary Analysis of the HEALTH Trial

OBJECTIVES

HEALTH was a randomized controlled trial comparing total hip arthroplasty with hemiarthroplasty in low-energy displaced femoral neck fracture patients aged ≥50 years with unplanned revision surgery within 24 months of the initial procedure being the primary outcome. No significant short-term differences between treatment arms were observed. The primary objective of this secondary HEALTH trial analysis was to determine if any patient and surgical factors were associated with increased risk of revision surgery within 24 months after hip fracture.

METHODS

We analyzed 9 potential factors chosen a priori that could be associated with revision surgery. The factors included age, body mass index, major comorbidities, independent ambulation, type of surgical approach, length of operation, use of femoral cement, femoral head size, and degree of femoral stem offset. Our statistical analysis was a multivariable Cox regression using reoperation within 24 months of index surgery as the dependent variable.

RESULTS

Of the 1441 patients included in this analysis, 8.1% (117/1441) experienced reoperation within 24 months. None of the studied factors were found to be predictors of revision surgery (P > 0.05).

CONCLUSION

Both total and partial hip replacements are successful procedures in low-energy displaced femoral neck fracture patients. We were unable to identify any patient or surgeon-controlled factors that significantly increased the need for revision surgery in our elderly and predominately female patient population. One should not generalize our findings to an active physiologically younger femoral neck fracture population.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Retrospective cohort trial protocol of screw fixation compared with hemiarthroplasty for displaced femoral neck fractures in elderly patients

BACKGROUND

There is limited evidence for the evaluation of the efficacy and safety of the hemiarthroplasty versus screw fixation in elderly patients with the displaced femoral neck fractures. Our current investigation aimed at assessing the complications, functional outcome, and revision rate of the patients (over 65 years old) who received internal fixation or hemiarthroplasty via a same senior surgeon.

METHODS

A retrospective study was conducted on elderly patients with displaced femoral neck fractures from May 2014 to February 2018. The current study was carried out at our hospital and it was approved through our institutional review committee of West China Hospital. Inclusion criteria were as follows: the patients were 65 years or older, this is the anesthesia grade. The higher grade of the patients,the greater risk of surgery. level I-III, and the patients with displaced intracapsular fractures of the femoral neck, with the radiographic and clinical follow-up of 12 months or more. The major outcome was the revision rate between the 2 groups. And the secondary outcomes contained the life quality and functional outcome detected via utilizing the interview-administered and self-administered questionnaires, length of hospital stay, surgery time, and hip-related complications (such as hip dislocation, loosening or breakage of implant, wound problems, infection, osteolysis, neurovascular injury, and bone nonunion).

RESULTS

It was assumed that hemiarthroplasty would result in fewer revisions or complications and better functional scores in comparison with internal fixation technique.

Hemiarthroplasty for Femoral Neck Fractures in the Elderly: A Comparison of Cemented and Uncemented Femoral Stems

The incidence of displaced femoral neck fractures among elderly patients is increasing as the population ages.Historically, the preferred treatment for displaced femoral neck fractures in elderly patients has been hemiarthroplasty with use of cemented fixation of the implant. However, there is evidence that this technique may be associated with fat embolization and subsequent cardiopulmonary arrest in the early postoperative period. Cementing techniques are also associated with increased operative time when compared with cementless techniques.There is increasing evidence that, among elderly patients, the use of uncemented hemiarthroplasty has equivalent functional outcomes and overall mortality rates when compared with the use of hemiarthroplasty with cemented fixation. The main complication associated with uncemented hemiarthroplasty is intraoperative periprosthetic fracture.

The Value of Serological Screening Prior to Conversion Total Hip Arthroplasty

BACKGROUND

This study sought (1) to assess the value of serological testing prior to conversion total hip arthroplasty (THA) in predicting infection and (2) to identify optimal serological values for routine diagnostic workup prior to conversion THA.

METHODS

All patients at our tertiary referral center undergoing conversion THA after hip/acetabular fracture procedure from 2013 to 2018 were retrospectively reviewed. Inclusion criteria were patients previously undergoing hemiarthroplasty or open reduction and internal fixation of acetabular, intertrochanteric, and subtrochanteric fractures that progressed to conversion THA due to post-traumatic arthritis having erythrocyte sedimentation rate/C-reactive protein (CRP) prior to conversion. Infection was defined as positive intraoperative cultures not deemed contaminant in collaboration with infectious disease consult and/or development of PJI within 1 year postoperatively.

RESULTS

Twelve of 87 (14%) patients undergoing conversion THA developed infection. The mean erythrocyte sedimentation rate (37.2 vs 24.4 mm/h, P = .2062) and CRP (22.4 vs 9.0 mg/L, P = .0026) in the infected cohort were elevated compared to the noninfected group. An optimal cutoff value for CRP of 12 mg/L (area under the curve = 0.77, 95% confidence interval 0.58-0.97) revealed 75% sensitivity, 84% specificity, 43% positive predictive value, and 95% negative predictive value (P < .0001) in the entire cohort.

CONCLUSIONS

Even without clinical signs and symptoms, patients undergoing conversion THA from internal fixation of hip/acetabular fractures are still at high risk for developing periprosthetic joint infection. All patients undergoing conversion THA should have CRP measured preoperatively as a part of the diagnostic workup for underlying infection. Further research should be devoted to creating a preoperative diagnostic algorithm incorporating CRP, similar to Musculoskeletal Infection Society criteria, dedicated to patients undergoing conversion THA.

LEVEL OF EVIDENCE

Level III, Diagnostic retrospective cohort study.

Effects of Chronic Kidney Disease on Hemiarthroplasty Outcomes for Fragility Hip Fracture in Diabetic Patients: A Nationwide Population-Based Observational Study

BACKGROUND

The aim of this study is to compare perioperative outcomes, readmission, and mortality after hemiarthroplasty for hip fractures in diabetic patients with different renal function statuses.

METHODS

In this retrospective population-based cohort study, diabetic patients who received primary hemiarthroplasty for hip fracture between January 1997 and December 2013 were identified from the Taiwan National Health Insurance Research Database. Primary outcomes were perioperative outcomes including infection and revision. Secondary outcomes were all-cause readmission and mortality.

RESULTS

A total of 29,535 diabetic patients were included: 8270 patients had chronic kidney disease (CKD group), 1311 patients underwent permanent dialysis (dialysis group), and 19,954 patients did not have CKD (non-CKD group). During a mean follow-up of 4.5 years, these 3 groups had comparable risks of any infection, including superficial and deep infection. Dialysis patients had a significantly higher risk of revision than did CKD and non-CKD patients (subdistribution hazard ratio 1.65, 95% confidence interval 1.16-2.36; subdistribution hazard ratio 1.57, 95% confidence interval 1.10-2.24, respectively). Compared with the non-CKD group, the dialysis group had significantly higher risks of readmission and mortality at all time points, namely 3 months after surgery, 1 year after surgery, and the final follow-up. The CKD group also had higher risks of readmission and mortality than did the non-CKD group at all time points.

CONCLUSION

CKD is associated with poor outcomes following hemiarthroplasty for fragility hip fracture. CKD patients may have higher risks of surgical complications including revision than non-CKD patients, and they have significantly elevated risks of readmission and mortality.

Direct Anterior Approach Versus Posterolateral Approach for Hemiarthroplasty in the Treatment of Displaced Femoral Neck Fractures in Geriatric Patients

Background

In the present study, we aimed to evaluate early clinical and biochemical outcomes of direct anterior approach (DAA) versus posterolateral approach (PLA) for hemiarthroplasty in the treatment of displaced femoral neck fractures in geriatric patients.

Material/Methods

Between September 2012 and September 2017, a total of 110 patients who underwent hemiarthroplasty for displaced femoral neck fractures were retrospectively analyzed. The patients were divided into 2 groups according to the surgical technique PLA (Group 1, n=54) and DAA (Group 2, n=56). Clinical and biochemical results were compared.

Results

There was no significant difference in the demographic characteristics of the patients, fixation type, and follow-up (P>0.05). However, there was a significant difference in the duration of surgery, amount of blood transfusion, change from baseline in postoperative hemoglobin levels, amount of intraoperative gauze dressing, amount of drainage fluid from the surgical wound, postoperative VAS scores, incision length, length of hospital stay, and Barthel Index scores in favor of DAA group (P<0.05). There was no significant difference in the degree of mobilization (P>0.05). None of the patients had postoperative complications in Group 1, while 3 patients in Group 2 developed a lateral femoral cutaneous nerve lesion and one patient had a missed iatrogenic fracture of the greater trochanter.

Conclusions

Our study results suggest that early clinical and biochemical outcomes are better in DAA than PLA with early return to daily living activities in patients undergoing hemiarthroplasty for displaced femoral neck fractures.

Age matters when comparing hemiarthroplasty and total hip arthroplasty for femoral neck fractures in Medicare patients

INTRODUCTION

The optimal treatment of patients with a displaced intracapsular femoral neck fracture remains controversial. We utilised a national database of Medicare patients to determine if there was any difference in complications and reoperation rate of patients undergoing total hip arthroplasty (THA) or hemiarthroplasty (HA) for femoral neck fractures.

METHODS

This study utilised the PearlDiver Patient Records Database, a national for-fee database of Medicare patient procedure and diagnosis records from 2005 to 2012. Outcome procedures and diagnoses including revision, dislocation, infection, and cardiovascular events that occurred during the study time period were also identified over the entire study period as well as 90 days and 2 years.

RESULTS

We identified 275,439 patients with femoral neck fractures who underwent HA and 26,017 patients who underwent THA, respectively. Patients undergoing HA had significantly lower rates (p < 0.0001) of revision 2.48% versus 3.85% (OR = 0.633; 95% CI, 0.592-0.678), dislocation 1.76% versus 3.39% (0.512; 0.476-0.551), infection 3.44% versus 4.87% (0.694; 0.657-0.737). There was no statistical significant difference in 2-year cardiac morbidity (p = 0.252). However, when controlling for age, patients 65-69 years showed no significant difference in infection or revision over the study period or at 2 years.

CONCLUSIONS

In this study, patients who underwent THA for femoral neck fractures had a higher rate of dislocations, infections and increased rates of repeat surgery than those who underwent HA but this difference was not significant in patients 65-69 years. Hemiarthroplasty may result in fewer complications in older Medicare patients although this difference may not be present in younger Medicare patients.

Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: A pooled analysis of 30,250 participants data

PURPOSE

To assess the clinical outcomes of unipolar versus bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures in older patients and to report whether bipolar implants yield better long-term functional results.

METHODS

We searched PubMed, Scopus, EBSCO, and Cochrane Library for relevant randomized clinical trials (RCTs) and observational studies, comparing unipolar and bipolar hemiarthroplasty. Data were extracted from eligible studies and pooled as relative risk (RR) or mean difference (MD) with corresponding 95% confidence intervals (CI) using RevMan software for Windows.

RESULTS

A total of 30 studies were included (13 RCTs and 17 observational studies). Analyses included 30,250 patients with a mean age of 79 years and mean follow-up time of 24.6 months. The overall pooled estimates showed that bipolar was superior to unipolar hemiarthroplasty in terms of hip function, range of motion and reoperation rate, but at the expense of longer operative time. In the longer term the unipolar group had higher rates of acetabular erosion compared to the bipolar group. There was no significant difference in terms of hip pain, implant related complications, intraoperative blood loss, mortality, six-minute walk times, medical outcomes, and hospital stay and subsequently cost.

CONCLUSIONS

Bipolar hemiarthroplasty is associated with better range of motion, lower rates of acetabular erosion and lower reoperation rates compared to the unipolar hemiarthroplasty but at the expense of longer operative time. Both were similar in terms of mortality, and surgical or medical outcomes. Future large studies are recommended to compare both methods regarding the quality of life.

Low conversion rates toward total hip arthroplasty after hemiarthroplasty in patients under 75 years of age

INTRODUCTION

An intracapsular fracture of the femoral neck is frequent in the elderly. Patients can be treated with either total hip arthroplasty or hemiarthroplasty. There is a continuous discussion about the treatment in elderly patients who are still healthy, active and mentally untroubled. A potential consequence of hemiarthroplasty, especially in the relatively young elderly, could be conversion to total hip arthroplasty. The conversion rate must be acceptable, and clinical outcome must be sufficient to justify the treatment with hemiarthroplasty in this group of patients. This study evaluates the conversion rate of hemiarthroplasty to total hip arthroplasty and clinical outcome in patients under 75 years of age.

METHODS

This study identified 248 patients, younger than 75 years at time of operation, with a fracture of the femoral neck treated with hemiarthroplasty. Patient-reported outcome measurements (VAS pain during rest and activity and WOMAC) were assessed by telephone interviews. Furthermore, radiographic evaluation for the presence of acetabular wear was performed.

RESULTS

At a follow-up of 5.1 (0.9-9.6) years, the conversion rate was 7.3%. Mean VAS pain in rest was 0.89 (0-10), the mean VAS pain during activity was 2.2 (0-10), and the WOMAC showed a mean of 16.51 (0-64). At time of follow-up, 38.7% of patients had died. Radiographic evaluation of the unrevised group showed in one patient signs of acetabulum wear.

CONCLUSION

Hemiarthroplasty in the relatively young elderly after a fracture of the femoral neck demonstrates an acceptable conversion rate. Furthermore, unrevised patients show low complaints of pain. To prevent one conversion to total hip arthroplasty, 13.7 patients should be treated with total hip arthroplasty that will not undergo a conversion at a later stage. Therefore, hemiarthroplasty remains a viable treatment of femoral neck fractures in relatively young patients. There seems to be no space for standardized decision making concerning the choice of treatment. An individual approach is required.

Hemiarthroplasty Conversion: A Comparison to Primary and Revision Total Hip Arthroplasty

BACKGROUND

Arthroplasty is the standard of care for elderly patients with displaced femoral neck fractures, with viable options including hemiarthroplasty (HA) and total hip arthroplasty (THA). With time, HA may need to be converted to THA, but it is unclear whether this is more similar to primary or revision THA. We compare complication and revision rates between these groups within 90 days and 2 years postoperatively.

METHODS

We retrospectively reviewed 3 cohorts of patients treated at our institution: primary, conversion, and revision THA. Outcomes studied included intraoperative data, postoperative complications, and revision rates. We analyzed the groups using both parametric (analysis of variance test) and nonparametric (chi-squared test) statistics.

RESULTS

Operative time between primary THA (108.0 minutes), conversion HA (147.9 minutes), and revision THA (160.1 minutes) cohorts differed significantly (P = .011). Estimated blood loss was also different between primary THA (386 mL), conversion HA (587 mL), and revision THA cohorts (529 mL) (P = .011). At 2 years, major complication rates between primary THA (6.2%), conversion HA (11.7%), and revision THA (26.7%) cohorts also differed significantly (P = .003), as was the revision rate in the primary THA (4.6%), conversion HA (10.0%), and revision THA (18.3%) cohorts (P = .043).

CONCLUSION

This is the first study to compare short-term and midterm complications between primary, conversion, and revision THA. We observed conversion HA had similar operative time and estimated blood loss to revision THA, which was significantly higher than primary THA. However, we found that conversion HA more closely resembled primary THA with respect to perioperative complications rates.

Results of Conversion from Failed Austin-Moore Hemiarthroplasty to Cementless Total Hip Arthroplasty in Octogenarian Patients with Advanced Acetabular Erosion: A Minimum of 5 Years of Follow-Up

Austin-Moore hemiarthroplasty (HA) had been selectively used for elderly patients with femoral neck fractures. With increasing life span and activity, the sequela of Austin-Moore HA make the implant no longer favorable. The treatment of failed Austin-Moore HA with advanced acetabular erosion is challenging; however, little has been published regarding this topic. The aim of this study was to evaluate the mid-term results of using cementless total hip arthroplasty (THA) in octogenarians. Between 2008 and 2011, 47 patients (32 women and 15 men) with an average age of 86 years (range 83-89 years) were enrolled in this retrospective study. After an average follow-up period of 6.2 years (range 5.0-7.8 years), no migration or loosening of the cup or femoral stem was found. Harris hip scores improved from 36 (range 15-42) preoperatively to 87 (range 80-90). There were no complications directly associated with the procedure except for superficial infections in two patients. Our results suggest that using cementless THA can result in favorable radiographic and clinical outcomes in octogenarian patients.

Clinical Practice Guidelines in Action: Differences in Femoral Neck Fracture Management by Trauma and Arthroplasty Training

INTRODUCTION

The purpose of this study was to survey trauma and arthroplasty surgeons to investigate associations between subspecialty training and management of geriatric femoral neck fractures and to compare treatments with the American Academy of Orthopaedic Surgeons clinical practice guidelines.

METHODS

Five hundred fifty-six surgeons completed the online survey consisting of two sections: (1) surgeon demographics and (2) two geriatric hip fracture cases with questions regarding treatment decisions.

RESULTS

In both clinical scenarios, arthroplasty surgeons were more likely than trauma surgeons to recommend total hip arthroplasty (THA) (case 1: 96% versus 84%; case 2: 29% versus 10%; P ≤ 0.02) and spinal anesthesia (case 1: 70% versus 40%; case 2: 62% versus 38%; P < 0.01). Surgeons who have made changes based on clinical practice guidelines (n = 96; 21% of surveyed) cited more use of THA (n = 56; 58% of respondents) and cemented stems (n = 28; 29% of respondents).

CONCLUSION

Arthroplasty surgeons are more likely to recommend THA over hemiarthroplasty and have a higher expectation for spinal anesthesia for the management of geriatric femoral neck fractures.

Hemiarthroplasty or total hip arthroplasty in recent femoral neck fractures?

The optimal treatment of recent femoral neck fractures remains debated. The available options are internal fixation, hemiarthroplasty (HA) and total hip arthroplasty (THA). There is a consensus in favour of internal fixation in younger patients. In elderly individuals who are institutionalised and have limited physical activity, HA is usually performed when the joint line is intact. Whether HA or THA deserves preference in patients aged 60 years or over is unclear. In addition, there are two types of HA, unipolar and bipolar, and two types of THA, conventional and dual-mobility. Both HA types provide similar outcomes with satisfactory stability but a risk of acetabular wear that may eventually require conversion to THA. THA is associated with better functional outcomes and a lower risk of revision surgery in self-sufficient, physically active patients. Instability is the leading complication of conventional THA and occurs with a higher incidence compared to HA. With all implant types, preoperative factors associated with mortality and complications include walking ability and level of self-sufficiency, nutritional status, and haematocrit. An evaluation of these factors before surgery is of paramount importance. Factors amenable to treatment should be corrected by working jointly with geriatricians to develop a preoperative management strategy. In patients who are self-sufficient, physically active, and free of risk factors, THA remains the option of choice, as it provides better functional outcomes. A dual-mobility implant deserves preference to prevent instability. HA is indicated in patients whose self-sufficiency and physical activity are limited. A unipolar implant should be used, as no evidence exists that bipolar implants provide additional benefits. When performing HA, the posterior approach should be avoided given the risk of instability. For THA, in contrast, the posterior approach is a reliable option in the hands of an experienced surgeon using a dual-mobility cup. Cement fixation of the stem is recommended to minimise the risk of peri-prosthetic fracture.

Efficacy of Different Posterior Capsulotomies on Dislocations in Hip Hemiarthroplasty: T-Shaped Capsulotomy versus Longitudinal Capsulotomy

BACKGROUND

Dislocation following hip hemiarthroplasty is one of the leading reasons necessitating a resurgery. Many studies suggested that the type of the surgical approach is the main cause for dislocation. However, no consensus has been reached yet regarding the type of the surgical approach. In this prospective clinical study, we aimed to compare the efficacy of two different capsulotomy techniques on dislocations, applied during hip hemiarthroplasties performed through the posterior approach.

MATERIALS AND METHODS

We investigated the dislocation rates in 287 patients (aged 65 and above) who underwent cemented bipolar hemiarthroplasty for displaced femoral neck fractures through the posterior capsular approach using two different capsulotomy techniques between 2009 and 2016. Patients were followed up for 12 months after hemiarthroplasty. Patients were evaluated in two groups; on whom hemiarthroplasty was performed as longitudinal (146 patients) and as T-shaped capsulotomy (141 patients).

RESULTS

Posterior dislocations occurred in seven (5%) patients who underwent hemiarthroplasty with T-shaped capsulotomy. No dislocation was observed in 146 patients who underwent hip hemiarthroplasty through posterior longitudinal capsulotomy. The difference between the two study groups was statistically significant (P < 0.007).

CONCLUSION

Capsule integrity can be achieved through a strong capsule repair which is possible through hemiarthroplasty with longitudinal capsulotomy. Longitudinal capsulotomy is an effective technique in preventing dislocations following hip hemiarthroplasty.

Inability of Older Adult Patients with Hip Fracture to Maintain Postoperative Weight-Bearing Restrictions

BACKGROUND

For elderly trauma patients, a basic goal is early mobilization, as immobilization can trigger various complications, such as venous thromboembolism, pneumonia, urinary tract infections, and pressure ulcers. Although partial weight-bearing has been shown to significantly increase mortality compared with unrestricted weight-bearing, it remains a frequent recommendation of aftercare following lower-extremity fracture fixation.

METHODS

An insole force sensor was used to measure true postoperative weight-bearing by patients ≥75 years of age treated for hip fracture compared with patients 18 to 40 years of age treated for ankle fracture. Both groups were instructed to maintain partial weight-bearing on the affected limb (≤20 kg) postoperatively. Following standardized physiotherapy training, gait analysis was performed.

RESULTS

None of the patients in the elderly test group were able to comply with the weight-bearing restriction as recommended. We found that 69% (11 of 16) of the patients exceeded the specified load by more than twofold, whereas significantly more patients in the younger control group (>75% [14 of 18]) achieved almost the entire weight-bearing restriction (p < 0.001). Only 1 of the elderly patients was able to comply with the predetermined weight-bearing restriction, and only for a short period of time. In comparison, significantly more patients in the control group (89% [16 of 18]; p < 0.001) maintained the partial load for nearly the entire time during gait analysis.

CONCLUSIONS

Elderly patients seem to be unable to maintain weight-bearing restrictions. As early mobilization of geriatric trauma patients is an important element for a successful rehabilitation, the directive of postoperative partial weight-bearing for these patients should be abandoned.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for conversion surgery to total hip arthroplasty of a hemiarthroplasty performed for a femoral neck fracture

INTRODUCTION

The purpose of this study was to determine risk factors for conversion to total hip arthroplasty (THA) in patients originally treated with hemiarthroplasty (HA) for displaced femoral neck fractures.

METHODS

In this case-controlled study, we identified 54 patients who were treated with HA for femoral neck fracture (FNF) who subsequently underwent conversion to THA at our institution between 2003 and 2013. We randomly selected 142 control patients who underwent HA for a displaced FNF without conversion surgery during the same time period. We compared demographic data, implant parameters, and radiographic data between the groups to identify risk factors for conversion surgery.

RESULTS

In the univariate analysis, younger age at index surgery (mean 75 vs. 80 years, p = 0.006), higher body mass index (26.1 vs. 23.7, p = 0.031), bipolar prosthesis (20% vs. 36%, p = 0.024), absence of dementia (6% vs. 23%, p = 0.01), increased leg length compared to contralateral limb (6.5 mm vs. 0.2 mm, p<0.001), and increased HA femoral head size compared to the contralateral femoral head (2.7 mm vs. 1.5 mm, p = 0.02) were associated with a significantly increased risk of conversion surgery. In the multivariate logistic regression, decreased age at index surgery, no dementia, use of a bipolar head, and increased leg length discrepancy (LLD) were associated with risk of conversion.

CONCLUSIONS

Patient characteristics, including younger age, increased BMI, and absence of dementia can lead to increased risk for conversion of HA to THA. Intraoperative considerations of head size and increase in ipsilateral LLD may increase the risk of conversion surgery. These factors should be considered by surgeons who employ HA for displaced FNFs.

Fixation of Trochanteric Fragments in Cementless Bipolar Hemiarthroplasty of Unstable Intertrochanteric Fracture: Cerclage Wiring

Purpose

Bipolar hemiarthroplasty (HA) is an option for the treatment of unstable intertrochanteric fracture in elderly patients. There is a raising concern regarding cable-grip related complications for the fixation of trochanteric fragments. Therefore, the aim of this study was to evaluate outcome of cementless HA with fixation for the trochanteric fragments using monofilament wires in unstable intertrochanteric fracture.

Materials and Methods

We reviewed 92 cementless bipolar HAs using a grit-blasted long stem design for unstable intertrochanteric fractures in 91 elderly patients with a mean age of 81.7 years. During the arthroplasty, trochanteric fracture fragments were fixed using 1 or 2 vertical wires and transverse wires. We evaluated the clinical outcomes such as abductor power, ambulatory ability and wire-related complications, and radiologic outcomes including the union of the trochanteric fragment and subsidence of stem.

Results

Sixty-two patients were followed for a minimum of 2 years (mean, 59 months) postoperatively. The mean abductor power and Koval category was 4.1 (range, 3 to 5) and 4.6 (range, 1 to 6). The wire was broken in 3 hips (4.8%) and the nonunion of the greater trochanter occurred in 1 hips (1.6%). Two stems subsided by 3 mm and 8 mm, respectively, during postoperative 6 weeks, after which the subsidence was not progressive.

Conclusion

Cerclage wiring of the trochanter using monofilament wire leads to acceptable outcome in cementless HA for senile patients with unstable intertrochanteric fracture. Cerclage wiring using a monofilament wire is recommended for the fixation of trochanteric fragments.

Risk factors for conversion surgery to total hip arthroplasty of a hemiarthroplasty performed for a femoral neck fracture

INTRODUCTION

The purpose of this study was to determine risk factors for conversion to total hip arthroplasty (THA) in patients originally treated with hemiarthroplasty (HA) for displaced femoral neck fractures.

METHODS

In this case-controlled study, we identified 54 patients who were treated with HA for femoral neck fracture (FNF) who subsequently underwent conversion to THA at our institution between 2003 and 2013. We randomly selected 142 control patients who underwent HA for a displaced FNF without conversion surgery during the same time period. We compared demographic data, implant parameters, and radiographic data between the groups to identify risk factors for conversion surgery.

RESULTS

In the univariate analysis, younger age at index surgery (mean 75 vs. 80 years, p = 0.006), higher body mass index (26.1 vs. 23.7, p = 0.031), bipolar prosthesis (20% vs. 36%, p = 0.024), absence of dementia (6% vs. 23%, p = 0.01), increased leg length compared to contralateral limb (6.5 mm vs. 0.2 mm, p<0.001), and increased HA femoral head size compared to the contralateral femoral head (2.7 mm vs. 1.5 mm, p = 0.02) were associated with a significantly increased risk of conversion surgery. In the multivariate logistic regression, decreased age at index surgery, no dementia, use of a bipolar head, and increased leg length discrepancy (LLD) were associated with risk of conversion.

CONCLUSIONS

Patient characteristics, including younger age, increased BMI, and absence of dementia can lead to increased risk for conversion of HA to THA. Intraoperative considerations of head size and increase in ipsilateral LLD may increase the risk of conversion surgery. These factors should be considered by surgeons who employ HA for displaced FNFs.

Comparison of functional outcome of bipolar hip arthroplasty and total hip replacement in displaced femoral neck fractures in elderly in a developing country: a 2-year prospective study

PURPOSE

To compare the short-term functional outcome between bipolar hip arthroplasty (BHA) and total hip replacement (THR) in displaced femoral neck fractures in elderly patients in a developing country.

MATERIALS AND METHODS

A prospective study was conducted which included a total of 42 patients of age more than 60 years with closed displaced femoral neck fractures, and the patients were randomized into two groups of 21 patients each and their outcomes were compared.

RESULTS

At 24-month follow-up, patients in BHA group had a mean modified Harris hip score of 83.85 ± 6.62 and patients in THR group had a mean modified Harris hip score of 88.00 ± 5.76 (p value = 0.067). Seven (35%) patients in BHA group and 11 (55%) patients in THR group had hip scores from 91 to 100 (excellent), 9 (45%) patients in BHA and seven patients (35%) in THR had hip scores 81-90 (fair) and 4 (20%) patients in BHA group and 2 (10%) patients in THR group were rated 71-80 (good) and none was found in poor category. Total amount of blood  loss while performing BHA was 238.15 ± 20.43 ml compared to 336.85 ± 23.56 ml in THR (p < 0.0001). Mean of total duration of surgery was found to be 51.80 ± 8.70 min in BHA group which was significantly lesser than 119.10 ± 16.75 min of THR group (p < 0.0001).

CONCLUSION

BHA being comparable to THR in terms of functional outcome by modified Harris hip scoring with significantly less blood loss during surgery, less duration of surgery, more cost-effective can be recommended as first line of surgical management in elderly patients with displaced femur neck fractures in developing countries.

LEVEL OF EVIDENCE

Level II, lesser-quality randomized controlled trial.

Conversion of Hip Hemiarthroplasty to Total Hip Arthroplasty Utilizing a Dual-Mobility Construct Compared With Large Femoral Heads

BACKGROUND

Conversion of hemiarthroplasty to total hip arthroplasty (THA) has a historically high, up to 20%, postoperative dislocation rate. As such, dual-mobility (DM) constructs are an attractive option to mitigate this complication. We analyzed survivorship free of revision, complications, and clinical outcomes of hemiarthroplasties conversion to THAs utilizing DM constructs compared with large femoral heads (≥36 mm).

METHODS

Conversion of 16 hemiarthroplasties to THAs with a specific DM construct compared with 13 conversions utilizing large femoral heads (≥36 mm) from 2011 to 2014 were reviewed. Mean age at conversion in the DM group was 75 years (range, 57-93 years); 75% were female. Significantly more patients with a dislocated hemiarthroplasty were converted to DM constructs compared to large femoral heads (44% vs 0%; P = .01). Mean follow-up was 3 years.

RESULTS

Survivorship free of revision was 100% in the DM group compared with 92% in the large femoral head cohort at 2 years (P = .7). One (8%) patient converted to a large femoral head underwent revision to a constrained liner for recurrent dislocations while no patients experienced a postoperative dislocation in the DM group (P = .4). Harris Hip Scores improved from 54 to 82 (P < .01) in the DM group, and from 52 to 86 in the large femoral head group (P < .01).

CONCLUSION

Larger effective femoral heads used during conversion of hemiarthroplasties to THAs resulted in high survivorship free of revision, minimal complications, and excellent clinical outcomes at short-term follow-up. In patients at highest risk for postoperative dislocation, including those with dislocating hemiarthroplasties, DM constructs resulted in no postoperative dislocations.

The Outcomes of Total Hip Replacement in Patients with Parkinson's Disease: Comparison of the Elective and Hip Fracture Groups

INTRODUCTION

The aim of the study was to compare the clinical outcomes following elective and traumatic total hip arthroplasty in Parkinson's disease patients.

MATERIALS AND METHODS

Ten patients with osteoarthritis comprise the elective group (mean age at operation 74 years; mean follow-up 82 months). Thirteen patients with femoral fracture comprise the hip fracture group (mean age 76 years; mean follow-up 54 months). All patients were followed up at 6 and 36 months postoperatively and at the time of the latest follow-up.

RESULTS

Despite the significant improvement in Merle d'Aubigné-Postel and pain scores, disability related to Parkinson's disease increased during the follow-up. Whereas more than 1/3 of hip fracture patients and all elective patients walked independently at 36 months after total hip arthroplasty, 43% of living patients from both groups were able to walk independently at the time of the latest follow-up. The medical complications were seen mainly in patients with hip fracture.

CONCLUSIONS

Excellent pain relief with preserved walking ability without support of another person and acceptable complication profile was observed in Parkinson's disease patients at 36 months after elective total hip arthroplasty. This procedure may be indicated in Parkinson's disease patients after careful and individualized planning.

Short-Term Outcomes Following Hip Fractures in Patients at Least 100 Years Old

BACKGROUND

The number of hip fractures is rising as life expectancy increases. As such, the number of centenarians sustaining these fractures is also increasing. The purpose of this study was to determine whether patients who are ≥100 years old and sustain a hip fracture fare worse in the hospital than those who are younger.

METHODS

Using a large database, the New York Statewide Planning and Research Cooperative System (SPARCS), we identified patients who were ≥65 years old and had been treated for a hip fracture over a 12-year period. Data on demographics, comorbidities, and treatment were collected. Three cohorts were established: patients who were 65 to 80 years old, 81 to 99 years old, and ≥100 years old (centenarians). Outcome measures included hospital length of stay, estimated total costs, and in-hospital mortality rates.

RESULTS

A total of 168,087 patients with a hip fracture were identified, and 1,150 (0.7%) of them had sustained the fracture when they were ≥100 years old. Centenarians incurred costs and had lengths of stay that were similar to those of younger patients. Despite the similarities, centenarians were found to have a significantly higher in-hospital mortality rate than the younger populations (7.4% compared with 4.4% for those 81 to 99 years old and 2.6% for those 65 to 80 years old; p < 0.01). Male sex and an increasing number of medical comorbidities were found to predict in-hospital mortality for centenarians sustaining extracapsular hip fractures. No significant predictors of in-hospital mortality were identified for centenarians who sustained femoral neck fractures. An increased time to surgery did not influence the odds of in-hospital mortality.

CONCLUSIONS

Centenarians had increased in-hospital mortality, but the remaining short-term outcomes were comparable with those for the younger cohorts with similar fracture patterns. For this extremely elderly population, time to surgery does not appear to affect short-term mortality rates, suggesting a potential benefit to preoperative optimization.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.