Evaluating Pain Management from Peripheral Nerve Block for Geriatric Patients following Bipolar Hemiarthroplasty for Displaced Femoral-Neck Fracture

INTRODUCTION

The purpose of this study was to evaluate peripheral nerve block (PNB) effectiveness in postoperative pain management and surgical outcomes for displaced femoral-neck fracture in geriatric patients (>70 years) who underwent bipolar hemiarthroplasty (BHA).

METHODS

From January 2017 to December 2021, 231 geriatric patients with displaced femoral-neck fracture who consecutively underwent BHA were retrospectively reviewed. Patients were divided into two groups: the patient-controlled analgesia (PCA) group (n = 132) who received only intravenous (IV) PCA for postoperative pain management, and all others who received PNB with IV PCA (PNB+PCA) such as femoral nerve block or fascia iliaca compartment block after surgery (n = 99). Primary outcomes were postoperative visual analog scale (VAS) at rest and during activity at 6, 24, and 48 h postoperatively. Secondary outcomes were postoperative complications, changes in hemoglobin, length of hospital stay, and total morphine usage after surgery.

RESULTS

Postoperative resting VAS at 6 h and 48 h was significantly lower in the PNB+PCA group compared with the PCA group (p = 0.075, p = 0.0318, respectively). However, there was no significant difference in either resting VAS at 24 h or active VAS. Complications of pneumonia and delirium until 1 month postoperative were significantly lower in the PNB + PCA group than the PCA group (p = 0.0022, p = 0.0055, respectively).

CONCLUSION

PNB with IV PCA seems to have a beneficial effect on geriatric femoral-neck patients who underwent BHA with postoperative analgesia for reducing postoperative resting pain and complications, especially pneumonia and delirium.

Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases

OBJECTIVE

Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population.

METHODS

A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves.

RESULTS

Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039).

CONCLUSION

Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Short-Term Outcomes of Uncemented Bipolar Hemiarthroplasty Using Stainless Steel Fully Hydroxyapatite-Coated Stem in Transcervical Fracture of the Femur

Background

Bipolar hemiarthroplasty is the standard of care for transcervical fracture in the elderly. Stainless steel being cheaper is preferred over titanium in developing nations for implants and prostheses. This study was conducted for assessing the short-term outcomes of uncemented bipolar hemiarthroplasty done using hydroxyapatite-coated stainless steel prosthesis.

Methods

Sixty-five patients, >60 year of age operated between 2018 and 2020 at tertiary care centre with stainless steel (316L) completely coated with hydroxyapatite bipolar hemiarthroplasty implants were retrospectively followed up. Radiological outcomes were assessed based on pedestal formation, stem position, radiological limb length discrepancy, sinkage of stem, spot welds and stress shielding. Clinical and functional outcomes were assessed based on mean Harris Hip score.

Results

Mean Harris Hip score at baseline, 3-week follow-up, 6-week follow-up, 3-month follow-up and 1-year follow-up was 45.9 (SD 2.5), 63.2 (SD 6.5), 75.1 (SD 9.9), 83.9 (SD 9.8) and 87.1 (SD 9.9), respectively. Excellent, good, fair, poor results were seen in 32.31, 40, 18.46, 9.23 of the patients, respectively. Valgus, central and varus stem position was seen in 49.23, 40, 10.77 percent of the patients, respectively. Pedestal formation, radiological limb length discrepancy, sinkage, spot welds, stress shielding was seen in 6.15, 32.31, 3.07, 53.85, 40 percent of the patients, respectively.

Conclusion

Short-term outcomes of this study provides evidence that using a more affordable fully hydroxyapatite-coated stainless steel prosthesis for uncemented bipolar hemiarthroplasty is an appropriate treatment option for the transcervical femur fracture.

Bipolar Hemiarthroplasty in Unstable Intertrochanteric Fractures with an Effective Wiring Technique

Purpose

Bipolar hemiarthroplasty has recently been acknowledged as an effective option for treatment of unstable intertrochanteric fracture. Trochanteric fragment nonunion can cause postoperative weakness of the abductor muscle and dislocation; therefore, reduction and fixation of the fragment is essential. The purpose of this study was to perform an evaluation and analysis of the outcomes of bipolar hemiarthroplasty using a useful wiring technique for management of unstable intertrochanteric fractures.

Materials and Methods

A total of 217 patients who underwent bipolar hemiarthroplasty using a cementless stem and a wiring technique for management of unstable intertrochanteric femoral fractures (AO/OTA classification 31-A2) at our hospital from January 2017 to December 2020 were included in this study. Evaluation of clinical outcomes was performed using the Harris hip score (HHS) and the ambulatory capacity reported by patients was classified according to Koval stage at six months postoperatively. Evaluation of radiologic outcomes for subsidence, breakage of wiring, and loosening was also performed using plain radiographs at six months postoperatively.

Results

Among 217 patients, five patients died during the follow-up period as a result of problems unrelated to the operation. The mean HHS was 75±12 and the mean Koval category before the injury was 2.5±1.8. A broken wire was detected around the greater trochanter and lesser trochanter in 25 patients (11.5%). The mean distance of stem subsidence was 2.2±1.7 mm.

Conclusion

Our wiring fixation technique can be regarded as an effective additional surgical option for fixation of trochanteric fracture fragments during performance of bipolar hemiarthroplasty.

The impact of increasing femoral offset and stem anteversion on postoperative dislocation in bipolar hemiarthroplasty

BACKGROUND

Femoral offset and anteversion have been reported to affect the incidence of dislocation following bipolar hemiarthroplasty, although the magnitudes of contributions of the femoral offset and stem anteversion on dislocation, both singly and in combination is not fully understood.

METHODS

Using the CT data of 61 patients (61 hips), including 30 male and 31 female who underwent bipolar hemiarthroplasty, three-dimensional dynamic motion analysis was performed using a modular implant that enabled adjustment of femoral offset and stem anteversion independently. The pattern of impingement and relationship between femoral offset/stem anteversion and range of motion were evaluated using the software.

FINDINGS

We found that a higher femoral offset and stem anteversion correlate with a greater range of motion of flexion and internal rotation. Furthermore, an increased femoral offset has a great effect on increasing range of motion of flexion than stem anteversion, and increased both femoral offset and stem anteversion have fewer effect on the flexion, whereas increasing stem anteversion has a great impact on internal rotation than offset, especially in the case with lower femoral anteversion. However, a higher stem anteversion decrease the range of motion of external rotation, whereas a higher femoral offset leads to an increased range of motion of external rotation.

INTERPRETATION

We demonstrated that both a higher femoral offset and stem anteversion substantially affected the range of motion in flexion, internal rotation and external rotation. However, these are not independent, but rather mutually confounding, the surgeons should consider retaining femoral/anterior offset in bipolar hemiarthroplasty.

Dissociation of Bipolar Hemiarthroplasty of the Hip and Review of Literature

Component dissociation after a bipolar hemiarthroplasty is an uncommon complication that usually necessitates reoperation due to difficulties in closed reduction. To our knowledge, only a few cases have been published in the recent literature. We present a case of disassembly location of in a 68-year-old woman who underwent bipolar hemiarthroplasty 10 years ago due to a left hip femoral neck fracture. She began complaining about pain and difficulty to bear weight after an unintentional internal rotation movement of her left hip. The initial radiographs showed the disassembly of the bipolar hip prosthesis, and the patient underwent conversion to total hip arthroplasty. We conducted a literature review to explain the potential causes and mechanisms.

Patients with femoral neck fractures treated by bipolar hemiarthroplasty have superior to unipolar hip function and lower erosion rates and pain: a systematic review and meta-analysis of randomized controlled studies

PURPOSE

We assessed acetabular erosion, hip function, quality of life (QoL), pain, deep infection, mortality, re-operation and dislocation rates in patients with displaced femoral neck fractures (dFNFs) treated with unipolar versus bipolar hemiarthroplasty at different postoperative time points.

METHODS

Relevant Randomized Controlled Trials (RCTs) were identified, following comprehensive literature research in Medline, Cochrane Central and Scopus databases, from conception until August 31th, 2021 and analyzed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Database research retrieved 120 studies; sixteen met eligibility criteria, providing 1813 (1814 hips) evaluable patients. Acetabular erosion was significantly higher for unipolar group at 6 and 12 months (p = 0.02 and p = 0.01 respectively). Patients in the bipolar group presented significantly better hip function at 12 and 24 months (p = 0.02 and p = 0.04 respectively). Postoperative pain was significantly less in the bipolar group at 12, 24 and 48 months (p = 0.01). No statistically significant differences were found regarding the postoperative rates of deep infection, mortality, re-operation and dislocation.

CONCLUSION

This study showed that patients with dFNFs treated with bipolar hemiarthroplasty have lower acetabular erosion rates at 6 and 12 months postoperatively, better hip function at 12 and 24 months, better QoL and less pain, when compared with unipolar. No statistically significant difference could be established regarding deep infection, mortality, re-operation and dislocation rates.

Comparison of clinical outcomes with proximal femoral nail anti-rotation versus bipolar hemiarthroplasty for the treatment of elderly unstable comminuted intertrochanteric fractures

BACKGROUND

Although proximal femoral nail anti-rotation (PFNA) and bipolar hemiarthroplasty (BHA) are selected by most of the orthopaedic surgeons for elderly intertrochanteric fractures (ITFs) patients, there is still no consensus on the superiority of PFNA and BPH for the elderly with unstable comminuted ITFs. The study aims to compare the curative effects of PFNA and cementless BHA on unstable comminuted ITFs in the elderly.

METHODS

From January 2012 to December 2016, we retrospectively reviewed 62 ITFs patients up to the inclusion and exclusion criteria in the study. Depending on the type of surgery, the patients were divided into two groups: Group BHA (n= 30) and Group PFNA (n = 32). The ITFs were classified according to Evans-Jensen. Hospitalization time, operation time, bleeding loss, weight bearing duration, Harris hip scores, 10-m walking speed, gait and postoperative complications were compared between the two groups.

RESULTS

There was no significant difference between the groups in hospital stay (P > 0.05). The BHA group trended to have a shorter operation time and a larger volume of blood loss (P < 0.01).The weight bearing duration was shorter in the BHA group than the PFNA group (P < 0.05).The Harris hip score was higher, the 10-m walking speed was faster and the gait was better in group BHA than group PFNA at three months postoperatively (P < 0.05), but there was no significant difference between the two groups at 6 and 12 months postoperatively (P > 0.05). There was no significant difference in postoperative complications between the two groups (P > 0.05).

CONCLUSION

The BHA allows an earlier return to weight-bearing activity, but ultimately has the same effective treatments as the PFNA for the elderly with unstable comminuted ITFs.

Prophylactic placement of external iliac artery balloon catheter in a patient with intrapelvic prosthesis migration after hemiarthroplasty: A case report

Intrapelvic prosthesis migration is a rare but serious complication of bipolar hemiarthroplasty in femoral neck fractures. The external iliac artery is one of the most frequently damaged arteries during the removal of a migrated implant from the pelvic region. This report describes a case in which prophylactic placement of an external iliac artery balloon catheter was performed to reduce blood loss in the event of vascular injury during implant removal surgery in the pelvic region.

Clinical results of short external rotators preserving posterolateral approach for hemiarthroplasty after femoral neck fractures in elderly patients

INTRODUCTION

Even though the dislocation rate is lower in the hemiarthroplasty (HA) than total hip arthroplasty, it has still developed as one of serious complications in elderly patients. We have used short external rotators (SER) preserving posterolateral approach to reduce dislocation after hip arthroplasty, especially in elderly patients. The present study was conducted to introduce SER preserving posterolateral approach and report the dislocation rate after HA via this approach in elderly patients with femoral neck fractures.

METHODS

Between January 2015 and July 2019, 307 consecutive elderly patients aged over 70 years who underwent cementless bipolar HA for femoral neck fractures and were followed up for at least one year, were enrolled in this study. All surgeries were performed using the SER preserving posterolateral approach. The demographic and perioperative data were examined and the complications including dislocation were investigated.

RESULTS

Mean operation time was 54.3 min, and mean estimated blood loss was 252.4 cc. The mean follow-up time was 22.1 months, HHS was 67.5 points at the final examination Dislocation following HA developed in only one patient (0.3%) with dementia during hospital stay, which was reduced closely with no subsequent recurrence. Periprosthetic femoral fracture occurred in two patients, which was treated with internal fixation in one patient and with stem revision in the other patient. There was no surgical site infection or periprosthetic infection as complications.

CONCLUSION

The SER preserving technique in posterolateral approach effectively can be effective for reducing the dislocation after HA in elderly patients with femoral neck fracture. It can be encouraged in posterolateral approach for HA, especially in elderly patients under the risk of dislocation.

Fracture fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: A systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION

There are three common types of operative options for unstable intertrochanteric fracture (ITF), i.e. dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA). Results of these operations are still inconclusive. This systematic review and network meta-analysis was therefore conducted to compare the efficacy among those operative strategies.

HYPOTHESIS

These three operative techniques (i.e., DHS, PFN, and BHA) were not different in operative failure, reoperation, and Harris Hip Score (HHS) for unstable ITF.

MATERIAL AND METHODS

Randomized controlled trials (RCTs) comparing outcomes among DHS, PFN, and BHA in patients with unstable ITFs were searched from Medline and Scopus databases. Primary outcomes included operative failure, reoperation, and HHS. Direct meta-analysis (DMA) and network meta-analysis (NMA) were performed to compare among three operative techniques. Qualitative and quantitative evidences of all included studies were tested for heterogeneity, transitivity, and consistency in NMA. The surface under the cumulative ranking curve (SUCRA) was used to estimate the probability of being the best in lowering poor clinical outcomes, but high HHS.

RESULTS

Seven RCTs (n=528) were eligible. DMA showed that DHS and PFN were significantly higher risk of operative failure compared with BHA with risk ratio (RR) and 95% confidence interval of 7.98 (1.35, 47.06) and 3.08 (1.00, 9.51), respectively. Compared with BHA, PFN was 4.47 (1.04, 21.60) times significantly higher risk of reoperation, and lower HHS at 3-6months [mean difference (MD)=-5.41 (-15.91, 5.10)], but higher HHS at>6-12months [MD 11.67 (2.98, 20.36)], although these HHSs were not significant. NMA and SUCRA demonstrated the highest ranks for operative failure and reoperation were DHS and PFN, whereas the highest HHS was BHA.

DISCUSSION

In specific group of unstable ITF, BHA might be the best operative technique in term of lower operative failure and reoperation, and highest HHS during short to intermediate period comparing with PFN and DHS. However, PFN had higher long-term HHS than BHA.

LEVEL OF EVIDENCE

I, meta-analysis of RCTs.

Is bipolar hemiarthroplasty an appropriate type of hip articulation following proximal femoral or total femoral resections for musculoskeletal malignancies?

BACKGROUND

Different approaches are applied for reconstruction in patients with a musculoskeletal malignancy which require a proximal femoral or total femoral resection. We aimed to evaluate the treatment outcomes of patients who underwent a proximal femoral or total femoral resection due to bone and soft tissue tumors and had an endoprosthetic reconstruction by a bipolar hemiarthroplasty type of hip articulation.

METHODS

We retrospectively identified 133 patients who underwent a proximal femoral or total femoral endoprosthetic replacement after resection of a bone or soft tissue malignancy. There were 74 male and 59 female patients, with a mean age of 55.02 ± 16.92 years (range 11-84 years) and a median follow-up of 24.47 ± 24.45 months (range 6-164 months). Patient demographics, surgical, and oncological data were recorded. Acetabular wear was measured using the classification proposed by Baker. Functional assessment was performed using the Musculoskeletal Tumor Society (MSTS) functional score.

RESULTS

There was no statistically significant difference among primary diagnostic groups in terms of gender, prosthesis type, trochanter major resection, local recurrence, complication/revision rate, and MSTS Score (p > 0.05, for each parameter). On the other hand, a statistically significant difference was detected in terms of degree of acetabular erosion among diagnostic groups (p < 0.001); the acetabular erosion rate (AER) was found to be lower in patients with metastatic carcinoma than in patients with a diagnosis of primary bone or soft tissue sarcoma. The univariable analysis revealed that the effect of age, primary diagnosis, localization, follow-up time, and presence and number of distant organ metastasis variables on AER were found to be statistically significant (p = 0.018, p = 0.035, p = 0.002, p = 0.007, p = 0.031, p = 0.040, respectively).

CONCLUSION

In patients who undergo a proximal femoral or a total femoral resection due to a musculoskeletal tumor, bipolar hemiarthroplasty is an adequate type of hip articulation method, since it does not affect the revision requirements and functional outcomes of patients with acetabular erosion.

Fatigue Failure of Outer Metal Dome of Bipolar Monoblock Shell in Hemiarthroplasty Hip: Case Report and Review of Literature

Introduction

We report a rare case of transmural wear-through of the polyethylene inner liner leading to fatigue failure of polished outer metallic dome of bipolar monoblock shell in cemented hemiarthroplasty 5-years after the index surgery.

Case Presentation

A 62-year-old active man reported with 6 months of worsening right hip pain. He had undergone cemented bipolar hemiarthroplasty for sub-capital fracture of the right femur 5 years back. Radiographs demonstrate significant full-thickness wear-through of the Cobalt-Chromium head through the polyethylene inner liner and outer metal dome into the acetabulum. Biomechanics study revealed inadequate thickness of outer metallic dome of monoblock shell. Revision Total hip arthroplasty was performed. At the 5-year follow-up, radiographs show stable components and no clinical abnormality.

Conclusion

Albeit rare, this failure mode aimed to raised awareness, routine follow-up, and quality assurance.

The predictive value of the Charlson Comorbidity Index in 1-year mortality

BACKGROUND

Hip fractures have a significant impact on morbidity and mortality in the elderly. Aims: We retrospectively evaluated the predictive role of the Charlson Comorbidity Index (CCI) for 1-year mortality in elderly patients with unstable intertrochanteric hip fractures (ITHF) treated with bipolar hemiarthroplasty. The secondary objective was to identify other relationships, if any, between the variables recorded and mortality.

METHODS

We included ≥75-year-old patients with unstable ITHF treated with bipolar hemiarthroplasty. We recorded patient gender, age, Body Mass Index, pre-fracture walking ability (Parker Mobility score, modified Harris Hip Score), America Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), time to surgery, time to mobilization, hospital stay, and postoperative complications. Uni- and multivariate logistic regression analysis were performed. Sensitivity and specificity were calculated using a ROC curve.

RESULTS

A total of 135 patients with a mean age of 87.34 ± 5.5 years were included. The overall 1-year mortality rate was 18.5%. The CCI (OR 1.64 CI 95% 1.21-2.23; p 0.00821) and postoperative complications (OR 3.5 CI 95% 1.19-10.23 p 0.0202) were identified as independent predictors of 1-year mortality in the univariate regression and confirmed in the multivariate regression. CCI sensitivity to predict 1-year mortality was 80%.

CONCLUSION

CCI has shown acceptable sensitivity in the prediction of 1-year mortality in elderly patients with unstable ITHF treated with bipolar hemiarthroplasty. It is of utmost importance to prevent postoperative complications due to their significant impact on 1-year mortality.

Unipolar versus bipolar hemiarthroplasty for hip fractures in patients aged 90 years or older: A bi-centre study comparing 209 patients

BACKGROUND

This study aimed to evaluate the outcome of unipolar and bipolar hemiarthroplasty to treat hip fractures in patients aged ≥ 90 years.

METHODS

We conducted this study from 2007 to 2018 based on the electronic databases of two hospitals. Patients aged ≥ 90 years, treated for Arbeitsgemeinschaft Osteosynthese 31-B3 type fractures, were included. One hospital conducted the treatment only with unipolar prostheses; the other hospital used only bipolar prostheses. We assessed 23 peri‑ and postoperative variables including any revision, dislocation, and survival. The follow-up was completed after a minimum of 2 years postoperatively. At follow-up, the functional status was evaluated via telephone using the Parker score for every living patient.

RESULTS

One-hundred unipolar prostheses, and 109 bipolar prostheses were examined. The patients' mean age was 92.9 years (range 90-102). Dementia was differently distributed between the groups (p < 0.001), with a lower survival risk (Odds Ratio 1.908; Confidence Interval 1.392 - 2.615; log rank <0.001). Based on this result, unipolar demonstrated significantly higher mortality rates compared with bipolar prostheses (log rank < 0.001). No effects were found for dislocation, revision and overall complication rate. At follow-up, 37 patients were available for functional status. The mean Parker score was 3.7 (range 0-9), with no effect.

CONCLUSIONS

Intracapsular hip fractures in patients aged ≥ 90 years can be treated with unipolar or bipolar hemiarthroplasty. The type of prostheses did not influence dislocation, revision, general complication, or functional status. The groups were significantly affected by dementia, a risk factor for shorter survival.

Cutibacterium acnes Infection of Hip Bipolar Hemiarthroplasty Resulting in Protrusio Acetabuli: A Case Report and Review of Literature

INTRODUCTION

Hip bipolar hemiarthroplasty is commonly done for elderly patients who suffer from femoral neck fractures, with good functional outcomes. Prosthetic acetabular protrusio is a rare complication following bipolar hemiarthroplasty and can occur in prosthetic joint infections (PJIs) due to destructive osteolysis and resorption of surrounding bone. Among PJI pathogens, Cutibacterium acnes is increasingly being implicated. In our paper, we review the current literature of C. acnes PJIs and report a unique case of C. acnes infection of hip bipolar hemiarthroplasty complicated by protrusio acetabuli.

CASE REPORT

The patient is a 77-year-old Asian-Chinese man who suffered from left hip pain 10 years after bipolar hemiarthroplasty surgery. Radiographic evaluation showed acetabular protrusio with extensive femoral osteolysis. Subsequent intraoperative cultures revealed C. acnes infection. The patient successfully underwent antibiotic treatment and a two-staged revision total hip arthroplasty.

CONCLUSION

C. acnes is an increasingly recognized cause of PJIs and can cause significant morbidity. It should not be simply regarded as a contaminant of tissue or cultures. C. acnes PJIs require antibiotic treatment and early surgery with debridement and revision. This reported case presented technical challenges due to the infection resulting in prosthetic acetabular protrusio.

Cementing a collarless polished tapered femoral stem through the anterior approach : evaluation of cement mantle quality and component alignment

AIMS

The aim of this study was to radiologically evaluate the quality of cement mantle and alignment achieved with a polished tapered cemented femoral stem inserted through the anterior approach and compared with the posterior approach.

METHODS

A comparative retrospective study of 115 consecutive hybrid total hip arthroplasties or cemented hemiarthroplasties in 110 patients, performed through anterior (n = 58) or posterior approach (n = 57) using a collarless polished taper-slip femoral stem, was conducted. Cement mantle quality and thickness were assessed in both planes. Radiological outcomes were compared between groups.

RESULTS

No significant differences were identified between groups in Barrack grade on the anteroposterior (AP) (p = 0.640) or lateral views (p = 0.306), or for alignment on the AP (p = 0.603) or lateral views (p = 0.254). An adequate cement mantle (Barrack A or B) was achieved in 77.6% (anterior group, n = 45) and in 86% (posterior group, n = 49), respectively. Multivariate analysis revealed factors associated with unsatisfactory cement mantle (Barrack C or D) included higher BMI, left side, and Dorr Type C morphology. A mean cement mantle thickness of ≥ 2 mm was achieved in all Gruen zones for both approaches. The mean cement mantle was thicker in zone 7 (p < 0.001) and thinner in zone 9 for the anterior approach (p = 0.032). Incidence of cement mantle defects between groups was similar (6.9% (n = 4) vs 8.8% (n = 5), respectively; p = 0.489).

CONCLUSION

An adequate cement mantle and good alignment can be achieved using a collarless polished tapered femoral component inserted through the anterior approach. Cite this article: Bone Joint J 2021;103-B(7 Supple B):46-52.

Direct anterior approach versus direct lateral approach in total hip arthroplasty and bipolar hemiarthroplasty for femoral neck fractures: a retrospective comparative study

BACKGROUND

In the current literature, there is no consensus on the best surgical approach in hip replacement for femoral neck fractures (FNFs).

AIM

The aim of this study is to compare the direct anterior approach (DAA) and the direct lateral approach (DLA) in patients treated with bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) for FNFs.

MATERIALS AND METHODS

Patients with displaced FNFs (Garden type III and IV) treated operatively using BHA and THA were enrolled. The surgical approach techniques DAA and DLA are compared. The analysed variables are: mean surgery time, number of blood units transfused perioperatively, percentage of patients transfused, perioperative complications, pain and functional outcomes at 1 and 6 months and mortality at 1, 3 and 12 months.

RESULTS

Between 2015 and 2017, 37 patients underwent BHA by the DAA and 38 patients underwent BHA by the DLA, 69 patients underwent THA by the DAA and 60 patients underwent THA by the DLA. For THA, the DAA compared to the DLA had a higher mean surgery time (100.8 min vs. 97.7 min), a lower mean number of blood units transfused perioperatively (1.4 U vs. 1.9 U), a significantly lower percentage of patients transfused (53.6% vs. 71.7%), a higher rate of perioperative complications (10.1% vs. 1.6%), a lower pain referred and better functional outcomes in the first 6 postoperative months and a significantly lower mortality rate at 12 months (2.9% vs. 16.7%). For BHA, the advantages of the DAA over DLA are not as significant.

CONCLUSIONS

The direct anterior approach in THA for FNFs provides significant benefits in the early post-operative period compared to the direct lateral approach in terms of functional recovery, residual pain, blood loss and mortality rate in the elderly active population.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

[Hemiarthroplasty for geriatric femoral neck fractures]

OBJECTIVE

Restoration of pain-free joint function by implantation of a bipolar hemiarthroplasty via anterolateral approach.

INDICATIONS

Elderly multimorbid patients >70 years, age >80 years, low functional demand.

CONTRAINDICATIONS

Infection. Relative contraindications: dysplastic hip joint.

SURGICAL TECHNIQUE

Supine position. Anterolateral approach. Incision of the iliotibial tract and entering the interval between tensor fasciae latae muscle/gluteus medius muscle. Capsulotomy. Femoral neck osteotomy. Removal of the femoral head and determination of the size of the bipolar prosthetic head. Inspection of the acetabulum. Adduction, external rotation ("figure 4" position) of the leg. Medullary preparation of the femur with rasps up to the correct level and size of the planed stem. Ensure the correct rotation of anteversion (10-15°). Trial reduction and examination of hip stability. Verification with image intensifier. Cement restrictor, jet lavage, drying the medullary canal, injection of bone cement and insertion of the prosthetic stem. Assembly/attachment of the definitive bipolar head to the stem. Reduction of the joint. Wound closure.

POSTOPERATIVE MANAGEMENT

Early mobilization and full weight bearing. Limitation of hip flexion >90°, rotation and adduction for 6 weeks. Venous thromboembolism prophylaxis. Osteoporosis evaluation and management. Clinical-radiological control (after 6 weeks, 1/3/5 years).

RESULTS

The implantation of a cemented hemiarthroplasty using the anterolateral approach is a muscle-sparing and dislocation-safe surgical procedure with a low risk of revision, which enables early patient mobilization and a good hip joint function.

Influence of the knot position on the union of the greater trochanter after bipolar hip arthroplasty via the modified Dall approach: a prospective non-randomized study

Background

In our institute, all elderly patients with displaced femoral neck fracture were treated with cemented bipolar hemiarthroplasty (BHA) using the modified Dall approach. To our knowledge, there are no reports on the knot position of the greater trochanter reattachment. The aim of this study was to determine influence of two knot positions (anterior or posterior) on the complications of the greater trochanter.

Methods

This is a prospective non-randomized study conducted on 95 elderly patients (95 hips) from September 2013 to December 2017. The knot position was changed from anterior to posterior alternately. The X-ray images obtained immediately after the operation were compared with those obtained at 3 months postoperatively; thereafter, the status of the greater trochanter was classified into three types: type A, no apparent shifting and fracture; type C, over 1-mm shifting of the fragment; and type F, fracture of the greater trochanter.

Results

Regarding age at operation, sex, BMI, size of the greater trochanteric fragment, stem type, and surgeon, there was no significant difference between two groups. In the anterior group, 34 hips (72.3%), 5 hips (10.6%), and 8 hips (17.0%) were classified under type A, C, and F, respectively. In the posterior group, 44 hips (91.7%), 1 hip (2.1%), and 3 hips (6.3%) were classified under type A, C, and F, respectively. There were significantly fewer greater trochanteric complications in the posterior group.

Conclusions

The posterior knot position improved the union of the greater trochanter after BHA compared with the anterior knot position.

Trial registration

We had approved IRB at our hospital clinical research review committee. Retrospectively registered.

Joint motion of bipolar hemiarthroplasty in routine hip functional movements: a dynamic motion study

Background

Many motion studies have shown that the inner bearing of bipolar prostheses moves less than expected under non-weight-bearing and static weight-bearing positions, which are not routine functional movements performed postoperatively. The aim of this study was to investigate the behaviours of bipolar prostheses during normal gait and simulative squatting.

Methods

Thirty-one femoral neck fracture patients were enrolled, and fluoroscopy examinations of walking on a treadmill, simulative squatting, and non-weight-bearing abduction-adduction and flexion-extension motions were performed at an average of 40 months postoperatively. The rate of acetabular cartilage degeneration was calculated. The ranges of motion of the outer bearing and inner bearing were determined, and the O/I ratios were calculated. Clinical efficacy was assessed by HHS and EQ-5D score.

Results

The inner bearing moved more than the outer bearing did, with an O/I ratio of 0.81, during the normal gait examination, while the motion of the outer bearing was obviously dominant during the simulative squatting and non-weight-bearing abduction-adduction and flexion-extension examinations. The mean acetabular cartilage degeneration rate was 0.82 ± 0.54 mm/year at the follow-up. In subgroup analyses, the motion of the outer bearing decreased to some extent with the increase in acetabular wear, and the corresponding O/I ratios among the groups showed a trend of decreasing first and then increasing. The HHS and EQ-5D scores of the patients with osteolysis and femoral stem loosening were much worse than those with fixed implants.

Conclusion

Bipolar prostheses do function as originally intended during gait, but movement primarily occurs at the outer bearing during other examinations. The motion patterns of bipolar prostheses change with the increase in acetabular wear.

Reoperation rate, mortality and ambulatory ability after internal fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: a study on Korean Hip Fracture Registry

INTRODUCTION

The treatment of unstable intertrochanteric fracture in elderly patients is challenging and how to treat these patients remains controversial. The purposes of this study were to compare (1) reoperation rate, (2) mortality and (3) the postoperative change of walking ability between patients undergoing internal fixation (IF) and those undergoing bipolar hemiarthroplasty (HA) due to this type of fracture based on the data from the Korean Hip Fracture Registry.

MATERIALS AND METHODS

Between July 2014 and June 2016, we extracted 623 unstable intertrochanteric fractures (616 patients aged ≥ 65 years) according to the classification of the Association for the Study of Internal Fixation-American Orthopaedic Trauma Association. Among the 564 patients, 396 were treated with IF (IF group) and 168 with bipolar HA (HA group). We compared the reoperation rate and mortality between IF group and HA group. In patients, who were followed up more than 2 years after the surgery, we compared the postoperative change of walking activity from ambulatory outdoors (Koval's grade 1, 2, 3) to housebound (Koval's grade 4, 5, 6).

RESULTS

The rate of reoperation was higher in the IF group (24/396, 6.1%) than in the HA (4/168, 2.4%) (p = 0.046). At the final follow-up, 79 (35.7%) of the 221 IF patients became housebound, whereas 21 (23.3%) of the 90 HA patients became housebound (p = 0.022).

CONCLUSION

This study showed HA was associated with lower rate of reoperation and lower decrement rate of walking ability compared to IF in elderly patients with unstable intertrochanteric fractures.

Low rates of all-cause revision in displaced subcapital femoral neck fractures treated with hip hemiarthroplasty - a retrospective review of 4516 patients from a single institute

Background

Femoral neck fracture (FNF) is among the commonest fractures affecting the geriatric population. Hemiarthroplasty (HA) is a standard treatment procedure and has been performed by hip surgeons for decades. Recently, primary total hip replacement has proved advantageous for the treatment of such fractures.

The aim of this study is to retrospectively review all causes of failure of all patients who underwent HA in our institute and reevaluated whether HA remains a favourable choice of treatment for patients with displaced FNFs.

Methods

A total of 4516 patients underwent HA at our centre from 1998 to 2017. The HA implants included unipolar and bipolar prostheses. Patients diagnosed with displaced FNF, underwent primary HA initially, required second revision procedures, and followed up for a minimum of 36 months were included in this study. Data were collected and comprehensively analysed.

Results

In 4516 cases, 99 patients underwent second surgeries. The revision rate was 2.19%. Reasons for failure were acetabular wear (n = 30, 30.3%), femoral stem subsidence (n = 24, 24.2%), periprosthetic fracture (n = 22, 22.2%), infection (n = 16, 16.2%), and recurrent dislocation (n = 7, 7.1%). The mean follow-up period was 78.1 months. The interval between failed HA and revision surgery was 22.8 months.

Conclusion

HA has a low revision rate and remains a favourable choice of treatment for patients with displaced FNFs.

Levels of evidence

Level III, Retrospective Cohort Study, Therapeutic Study.

Preprosthesis fracture of femoral and loosening of the femoral prosthesis during closed reduction of hip dislocation: A case report

INTRODUCTION

Dislocation after bipolar hip hemiarthroplasty is an uncommon complication. Although closed manoeuvre reduction under general anaesthesia is a common and effective method for dislocation of the hemiarthroplasty. However, closed reduction leads to preprosthesis fracture of femoral and loosening of femoral prosthesis is a rare situation, which requires incision reduction and a revision hemiarthroplasty.

PRESENTATION OF CASE

A 80-year-old female had cementless bipolar hip hemiarthroplasty due to a right femoral neck fracture. At the 11 days of postoperation, the patient had a dislocation of the hemiarthroplasty when squatting. The patient had preprosthesis fracture and loosening of the prosthesis during closed reduction. Eventually, the patient had an open reduction and femoral stem revision. There was no re-dislocation and no re-fracture at one-year follow-up.

DISCUSSION

Closed manoeuvre reduction is a common and effective method for dislocation of the hemiarthroplasty. But if not done properly, it may lead to preprosthesis fracture of femoral and loosening of the femoral prosthesis. Preprosthesis fracture of femoral and loosening of femoral prosthesis is a complex complication. This condition requires operative treatment. A personalized surgical plan and proper techniques should be done before the operation.

CONCLUSION

Closed reduction should be performed gently to avoid preprosthesis fracture and loosening of the prosthesis. If this happens, a high-resolution CT examination should be performed immediately to evaluate the fracture and the rotation of the prosthesis. In the case of dislocation after bipolar hip hemiarthroplasty in patients with Alzheimer's disease, we hypothesize that early wearing braces to limit squat might help prevent this condition.

Risk factors for radiological changes after bipolar hemiarthroplasty for osteonecrosis of the femoral head

OBJECTIVES

This study aimed to report the mid-term radiological outcomes of patients with bipolar hemiarthroplasty (BHA) for stage 3 osteonecrosis of the femoral head (ONFH), and to identify the risk factors for postoperative radiological changes.

METHODS

We retrospectively investigated 62 patients (38 men and 24 women; mean age, 50.1 years) aged <70 years who underwent primary BHA for Association Research Circulation Osseous stage 3 ONFH between 1998 and 2010. The mean follow-up period after BHA was 12.8 years. The following changes were assessed on follow-up radiographs: outer head migration, polyethylene wear, and femoral osteolysis. The association between demographic data and the development of postoperative radiological changes was evaluated.

RESULTS

Radiological changes were found in 20 hips (32.3%) at a mean of 8.1 years after BHA; of these, three hips (4.8%) underwent total hip arthroplasty conversion at a mean of 10.9 years after BHA. Both univariate and multivariate analysis revealed that younger age and female sex were independent risk factors for the development of postoperative radiological changes.

CONCLUSION

The current results suggest that the indication of BHA should be carefully determined in young or female patients with ONFH, even when the disease is in the early stage.

Bipolar hemiarthroplasty versus total hip arthroplasty in allograft-prosthesis composite reconstruction of the proximal femur following primary bone tumour resection

AIMS

The consensus is that bipolar hemiarthroplasty (BHA) in allograft-prosthesis composite (APC) reconstruction of the proximal femur following primary tumour resection provides more stability than total hip arthroplasty (THA). However, no comparative study has been performed. In this study, we have compared the outcome and complication rates of these two methods.

METHODS

In a retrospective study, 57 patients who underwent APC reconstruction of proximal femur following the primary tumour resection, either using BHA (29) or THA (28), were included. Functional outcome was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and Harris Hip Score (HHS). Postoperative complications of the two techniques were also compared.

RESULTS

The mean follow-up of the patients was 8.3 years (standard deviation (SD) 5.5) in the BHA and 6.9 years (SD 4.7) in the THA group. The mean HHS was 65 (SD 16.6) in the BHA group and 88 (SD 11.9) in the THA group (p = 0.036). The mean MSTS score of the patients was 73.3% (SD 16.1%) in the BHA and 86.7% (SD 12.2%) in the THA group (p = 0.041). Limping was recorded in 19 patients (65.5%) of the BHA group and five patients (17.8%) of the THA group (p < 0.001). Dislocation occurred in three patients (10.3%) of the BHA group and two patients (7.1%) of the THA group.

CONCLUSION

While the dislocation rate was not higher in THA than with BHA, the functional outcome was significantly superior. Based on our results, we recommend THA in APC reconstruction of the proximal femur. Cite this article: Bone Joint J 2020;102-B(4):524-529.

Histological evaluation of the acetabular labrum after bipolar hip hemiarthroplasty: a case report

We report herein the microstructure of the acetabular labrum obtained from a patient with stem loosening but without bipolar cup migration who had undergone hemiarthroplasty for femoral neck fracture 18 years ago. We used light and scanning electron microscopy to investigate the influence of bipolar cup on acetabular labrum in vivo. Deparaffinized blocks were treated with 2 N NaOH to digest the cell matrix, allowing the collagen fibers, constituting the acetabular labrum, to be observed under scanning electron microscopy. Although chondrocyte atrophy was seen, the basic structure was not different from the normal tissue images of the elderly. However, in the deep part of the acetabular labrum, there was an area that was not stained with Alcian blue observed with light microscopy, and there was an amorphous tissue without type II collagen fibrils observed with scanning electron microscopy. These findings proved that the acetabular labrum has partially degenerated over the long term after bipolar hemiarthroplasty, and that the acetabular labrum can survive in vivo in such a condition. Given that hemiarthroplasty has a possibility to preserve the face-to-face tissue in the long term in vivo, it may be one of the valuable options for modern or future joint reconstruction surgery.

Mid-term survivals of cemented calcar-replacement bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients

BACKGROUND

The literature has limited evidence regarding the mid-term survivals of cemented calcar-replacement bipolar hemiarthroplasty (HA) in elderly patients with unstable intertrochanteric (IT) fracture. The purpose of the present study was to evaluate clinical and radiological outcomes of cemented calcar-replacement bipolar HA for unstable IT fractures in elderly patients.

METHODS

One hundred and twenty-two patients with the mean age of 80.6 years were enrolled in this retrospective study after they met the selection criteria. Demographics, main clinical characteristics, and operative data were recorded for all patients. Functional outcomes were assessed according to Koval's categories. Clinical and radiological evaluations were performed. Kaplan-Meier survival analysis was used to construct the cumulative survival rate. The mean follow-up time was 25.7 ± 2.9 months (ranges 0-72 months).

RESULTS

Based on Koval's categories, 3 or 4-level decrease was detected in 21 patients (17%). Three patients (2 periprosthetic infections, 1 periprosthetic fracture) underwent reoperation during follow-up. No patient underwent revision of bipolar HA prosthesis. Femoral stem loosening and stem subsidence was the most common complication, observed in 22 patients (18%), followed by acetabular erosion that was seen in 12 patients (9.8%). The mean cumulative survival rate of prosthesis was 56.5% (95% confidence interval: 51.3-61.6).

CONCLUSION

Based on the results of our study, cemented calcar-replacement HA is an appropriate treatment option in elderly patients with unstable IT fractures owing to the advantages of satisfactory functional outcomes and lower reoperation rates. However, orthopedic surgeons should consider the low survival rates of cemented calcar-replacement HA prosthesis because of the increased femoral loosening in osteoporotic elderly patients.

Comparison of bipolar hemiarthroplasty and total hip arthroplasty with dual mobility cup in the treatment of old active patients with displaced neck of femur fracture: A retrospective cohort study

Background

The standard treatment of displaced femoral neck fracture is arthroplasty. THA is reportedly superior to BHA in terms of hip pain, function and reoperation rate. On the other hand THA has a higher rate of dislocation. Total hip replacement with dual mobility cup increases the range of motion and reduces the chances of dislocation. The aim of this study is to compare the functional outcome, rate of dislocation, complications and mortality between BHA and THA with dual mobility cuff for the treatment of displaced neck of femur fracture.

Patients and method

This is a non-commercialized retrospective cohort study conducted at our tertiary care level 1 trauma centre. Patients of age group 60 years and above who underwent hip arthroplasty (BHA or THA with dual mobility implant) between 2015 and 2017 for displaced neck of femur fracture with a complete follow up for one year were included. Both groups were assessed for postoperative surgical complications including dislocation, fracture, surgical site infection, and medical complications, one-year mortality and functional outcome were analysed via Harris Hip Score (HHS) at the latest follow up.

Results

Overall 104 patients were included in the study out of which 77 patients underwent BHA while 27 underwent THA with dual mobility cup. Baseline characteristics were found to be similar in both groups. Mean pre-op HHS for bipolar group was found to be 71.01 while for THA with dual mobility cup group it was 73.52 with the difference being statistically insignificant (P = 0.12). Mean post-op HHS for bipolar group was noted to be 68.82 whereas for THA with dual mobility cup group it was 76.81. The difference was found to be statistically significant with a P-value of <0.01. With regards to post-operative complications and one-year post-operative mortality, no significant difference was noted between both groups.

Conclusion

In relatively young and active elderly patients with displaced neck of femur fracture, a THA with dual mobility cuff provides better hip functional outcome, does not increase mortality or morbidity as compared to BHA and can be considered as primary treatment modality.

•

The standard treatment of displaced femoral neck fracture is arthroplasty.

•

Total Hip Arthroplasty is reportedly superior to Bipolar Hemiarthroplasty in terms of hip pain, function and reoperation rate.

•

Total Hip Arthroplasty has a higher rate of dislocation rate than Bipolar Hemiarthroplasty.

•

Total Hip Arthroplasty with Dual mobility cup increases the functional outcome and reduces the chances of dislocation.

Autograft-prosthesis composite use for a Vancouver type B1 periprosthetic femur fracture with pelvic acetabular component migration after bipolar hemiarthroplasty: A case report

Introduction

Bipolar hemiarthroplasty (BHA) is a commonly performed procedure for elderly patients with an intra-capsular fracture of the femoral neck. However, surgeons performing BHA worry about the rate of acetabular wear, and acetabular prosthesis protrusion can pose a challenging surgical problem. The number of periprosthetic femur fractures is expected to increase. Generally, well-fixed stems require open reduction and internal fixation (ORIF), whereas loose stems require revision arthroplasty.

Case report

A 68-year-old Asian woman was admitted to our hospital. She had sustained a left displaced femoral neck fracture at the age of 58 years. BHA was performed via a posterior approach in another hospital. Ten years later, she presented with severe left hip pain following a low-energy fall. A radiograph of the hip joint demonstrated a Vancouver type B1 periprosthetic femur fracture with severe acetabular prosthetic protrusion. Single-stage reconstructive surgery was performed. A transgluteal approach was used, with distal extension to the fracture site of the femur. Acetabular reconstruction was performed using a Kerboull-type plate in combination with massive allografts for the large bone defects of the acetabulum. Regarding the femoral side, the proximal bone fragment and cementless stem that had been fixed were longitudinally opened with an osteotomy and separated. After that, the stem was changed to a cemented long stem and combined with the prior proximal bone fragments using cement and wires in an allograft-prosthesis composite technique (autograft-prosthesis composite).

Conclusion

Although the standard treatment for Vancouver type B1 periprosthetic femur fractures is ORIF, it would have been difficult to reconstruct the hip joint solely with osteosynthesis because the femur was severely shortened by marked migration of the BHA. Single-stage reconstructive surgery using an autograft-prosthesis composite was effective treatment for a Vancouver type B1 periprosthetic femur fracture with concomitant severe acetabular prosthetic protrusion after BHA.

Proximal femoral nailing is superior to hemiarthroplasty in AO/OTA A2 and A3 intertrochanteric femur fractures in the elderly: a systematic literature review and meta-analysis

INTRODUCTION

Unstable intertrochanteric femoral fractures in the elderly require either fixation or joint sacrificing surgery; proximal femoral nail (PFN) and bipolar hemiarthroplasties (BPH) are the most common interventions. PFN is considered to be the ideal construct for these fractures; however, the usage of hemiarthroplasties to facilitate earlier mobilization has been on a rise. Currently there is no consensus on the superiority of one of these two techniques over the other and the present review was done to determine this.

RESEARCH QUESTION

Is PFN a better alternative to BPH for unstable intertrochanteric femur fractures in the elderly?

OBJECTIVE

The present systematic review and meta-analysis was conducted to determine the superiority of PFN over BPH by comparing the primary outcomes like mortality, Harris Hip scores (HHS), complications, and re-operations. Additionally, secondary outcomes like blood loss, duration of surgery, and period of hospital stays were also compared.

METHODOLOGY

Three databases of PubMed, EMBASE, and SCOPUS were searched for relevant articles that directly compared PFN and BPH in unstable intertrochanteric femur fractures in the elderly.

RESULTS

We analyzed a total of seven studies published between the years 2005 to 2017. There were four retrospective and three prospective randomized controlled studies. The number of patients in these studies ranged from 53 to 303.

PRIMARY OUTCOMES

There was a significant difference in HHS between two groups with standard mean difference of - 0.51 (range - 0.67 to -0.36), favouring the PFN group. The rate of mortality was higher in the BPH group with odds ratio of 2.07 (range 1.40-3.08). Implant-related complications like fractures and subsidence were more in BPH group but this was not significant.

SECONDARY OUTCOMES

Mean surgical time (standard mean difference 2.19) and blood loss (3.75) were significantly less in the PFN group. The duration of hospital stay was also found to be significantly less in the PFN group (2.66).

CONCLUSION

Proximal femoral nails are superior to bipolar hemiarthroplasties for unstable intertrochanteric femoral fractures in the elderly. PFN imparts better functional outcomes and has lower rates of overall mortality. Additionally it is faster surgery, with lesser blood loss contributing to better results.

Clinical Outcomes of Bipolar Hemiarthroplasty versus Total Hip Arthroplasty: Assessing the Potential Impact of Cement Use and Pre-Injury Activity Levels in Elderly Patients with Femoral Neck Fractures

Purpose

This study was performed to analyze the potential impact of cement use and favorable pre-injury activity on clinical outcomes of bipolar hemiarthroplasty (BHA) compared with total hip arthroplasty (THA) in elderly patients with femoral neck fractures.

Materials and Methods

Systematic review and meta-analysis of 12 clinical studies (5 randomized controlled trials and 7 comparative studies). Subgroup analysis was performed based on type of fixation method (cemented vs. cementless) and in the patient with independent ambulation, respectively.

Results

A significantly higher dislocation rate was observed in patients treated with THA compared with those treated with BHA in individuals capable of independent ambulation before injury (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.05-0.62; P=0.05, Z=1.98). Also, the dislocation rate was significantly higher in patients treated with cemented THA compared with those treated with cemented BHA (OR, 0.18; 95% CI, 0.05-0.62; P=0.006, Z=2.73). EQ-5D was significantly higher in those treated with cemented THA compared with patients treated with cemented BHA. Lastly, HHS was significantly higher in patients treated with cementless THA compared with those treated with cementless BHA.

Conclusion

An increase in the dislocation rate was observed when THA was performed in elderly patients with femoral neck fracture and who were pre-injury independent walkers. In addition, cemented THA was associated with a higher dislocation rate compared with cemented BHA. However, the dislocation rate in those treated with cementless THA were similar to patients treated with cementless BHA. With regards to functional score, THA was superior to BHA in both cementless and cemented fixation.

Topical tranexamic acid in elderly patients with femoral neck fractures treated with hemiarthroplasty: efficacy and safety? - a case-control study

Background

Perioperative blood management is an important issue in the treatment of elderly patients at an increased risk of postoperative complications. Accordingly, tranexamic acid (TXA) is widely administered to reduce blood loss and transfusion requirements. In this case-control study, the effect of topical TXA on the outcomes of elderly patients with femoral neck fractures after hemiarthroplasty was evaluated.

Methods

This study enrolled elderly patients (age ≥ 70 years) who underwent cementless bipolar hemiarthroplasty for femoral neck fractures between January 2015 and January 2017. The study group comprised 72 patients who received TXA via topical administration during surgery. After propensity matching, the control group comprised 72 patients who did not receive topical TXA. The perioperative and postoperative parameters of the two groups were compared.

Results

The estimated blood loss, vacuum tube drainage, and total transfusion volume were significantly lower in the study group than the control (p = 0.024, 0.003, and 0.019, respectively). Despite a lack of significant intergroup differences in the lengths of ICU and hospital stays; rates of ICU admission, venous thromboembolism, delirium, and readmission; and rates of in-hospital and 1-year mortality, the incidence of postoperative medical complications was significantly lower in the study group (p = 0.003).

Conclusion

Topical TXA administration appears to be a simple and effective option for reducing blood loss, transfusion requirements, and medical complications after hemiarthroplasty in elderly patients with femoral neck fractures.

Comparison of Mid-term Survivorship and Clinical Outcomes between Bipolar Hemiarthroplasty and Total Hip Arthroplasty with Cementless Stem: A Multicenter Retrospective Study

Objectives

To compare the clinical outcome between bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) using a U2 HA cementless hip stem, and the results of elderly femoral neck fracture patients who underwent BHA with a cementless hip stem.

Methods

A multicenter retrospective study enrolled 96 BHA and 115 THA cases using U2 HA cementless hip stems with mean age (BHA: 67.9 years; THA: 64.1 years), body height (BHA: 160.4 cm; THA: 160.7 cm) and weight (BHA: 62.7 kg; THA: 64.5 kg) recorded. Mean follow‐up durations were, respectively, 7.1 (BHA) and 7.8 (THA) years. Survivorship analyses and Oxford hip scores were compared.

Results

Both the BHA and the THA groups revealed high survival rates at 5‐year (100%) and 10‐year (100.0% and 90.1%) follow‐up. The THA group achieved better joint performance and pain relief. The cementless HA stems had survived perfectly for 10 years for elderly femoral neck fracture patients following BHA.

Conclusions

The U2 HA cementless hip stem provides an effective solution for both BHA and THA surgeries, and for elderly femoral neck fracture patients undergoing BHA. According to the findings of the current study, THA may be inadequate for addressing avascular necrosis, and pain control is a considerable concern for patients who have undergone BHA.

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.

The influence of bone cement and American Society of Anesthesiologists (ASA) class on cardiovascular status during bipolar hemiarthroplasty for displaced femoral-neck fracture: A multicenter, prospective, case-control study

BACKGROUND

Little is known about how bone cement and American Society of Anesthesiologists (ASA) classification influence the cardiovascular system in elderly patients with femoral-neck fractures treated with cemented hemiarthroplasty. Therefore, we performed a case-control study to investigate these questions and compared the following:≥ASA III with≤ASA II patients who underwent cemented hemiarthroplasty; and cemented with cementless hemiarthroplasty in≥ASA III patients.

HYPOTHESIS

ASA classification influences the cardiovascular system during cemented hemiarthroplasty and bone cement influences intraoperative blood pressure [IBP] in patients rated≥ASA III.

MATERIALS AND METHODS

This multicenter, prospective study included patients with acute displaced femoral-neck fractures. Baseline data, medical history, anesthesia, FiO₂, vasopressor use, femoral component, IBP, SpO₂, and complications were evaluated. Of 200 patients, 100 were cemented (mean age, 77±10 years), and 100 were cementless (mean age, 78±9 years). Cemented hemiarthroplasty employed a third-generation technique (plugging, irrigating, drying and filling the canal with cement under pressurization).

RESULTS

Systolic blood pressure (SBP) decreased significantly during cementing, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 106.9±20.3 [range, 59-172]; p=0.007), in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), and post-stem-insertion, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 103.9±20.7 [range, 53-178]; p=0.0004), and in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 111.2±24.6 [range, 70-156]; p=0.009). In≥ASA III patients, SBP decreased significantly during cementing or rasping, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), in cementless patients (from 115.0±17.7 [range, 85-150] to 100.7±15.7 [range, 75-142]; p=0.004), and post-stem-insertion, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 111.2±SD [range]; p=0.009), and in cementless patients (from 115.0±17.7 [range, 85-150] to 89.4±17.5 [range, 58-140]; p<0.0001). There were no lethal complications.

CONCLUSIONS

This study indicate a similar hemodynamic change intraoperatively between≤ASA II patients and≥ASA III patients in the cemented group, and between patients with cemented and cementless hemiarthroplasty in the≥ASA III patients. With modern hemiarthroplasty techniques, bone cement might be as safe as cementless techniques in elderly,≥ASA III patients.

LEVEL OF EVIDENCE

III, multicenter case-control cohort study.

Nationwide multicenter follow-up cohort study of hip arthroplasties performed for osteonecrosis of the femoral head

PURPOSE

To identify modifiable factors related to post-operative dislocation and reoperation in patients with osteonecrosis of the femoral head (ONFH) in a large cohort.

METHODS

We studied 4995 hip arthroplasties: total hip arthroplasty (THA) was performed in 79% of patients; bipolar hemiarthroplasty (BP), 17%; total resurfacing arthroplasty (tRS), 3%; and hemi-resurfacing arthroplasty (hRS), 1%. A new type of BP (accounting for 49% of BPs) comprised a femoral component with a polished or smooth, small-diameter (approximately 10 mm) neck with a round or oval axial cut surface and no sharp corners.

RESULTS

The infection rate was relatively low (0.56%) even though 58% of cases of ONFH were associated with systemic steroid use, a known risk factor for infection. Post-operative dislocation occurred in 4.3% of cases, with re-operation needed in 3.9%. The dislocation rate was related to surgery type: 5.2% in THA, 0.9% in BP, and 0% in tRS and hRS. Among total arthroplasties with six month or longer follow-up (3670 THAs and 159 tRSs), the risk factors for post-operative dislocation were younger (≤ 40 years) or older (≥ 62 years) age, higher body weight, posterolateral approach, and smaller prosthetic head diameter. Regarding the need for re-operation, higher body weight and surgery type were identified as risk factors.

CONCLUSIONS

The relatively high dislocation rate of 5.2% in THA is a cause for concern. The identified risk factors for dislocation should be considered when selecting THA for treatment. Prosthesis survivorship in hRSs was inferior to that in BPs or THAs. Body weight also affected the survivorship of hip arthroplasties.

Midterm Results of Conversion from Failed Bipolar Hemiarthroplasty to Total Hip Arthroplasty

BACKGROUND

Conversion from failed bipolar hemiarthroplasty (HA) to total hip arthroplasty (THA) presents a great challenge to orthopedic surgeons for bipolar head removal and cup placement with or without change of femoral stem. Conversion THA after failed bipolar arthroplasty is known to offer both symptomatic and functional improvement. This study evaluates the midterm functional outcome and complications, especially dislocation associated with femoral head diameter, after conversion THA.

MATERIALS AND METHODS

Forty eight hips with the conversion of bipolar HA to THA were followed up for an average 6.2 years (range 2.0-11.5 years). Twenty one hips had conversion surgery to THA using metal-on-metal articulation (28 or 32 mm head). Nine hips used ceramic-on-ceramic (28-40 mm) and eighteen hips used large head metal-on-metal bearing (>40 mm). Outcome was evaluated using Harris Hip Score (HHS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) score. The radiographs were analyzed for evidence of osteolysis and/or loosening. The complications were evaluated, especially dislocation with different femoral head diameter.

RESULTS

Average HHS significantly improved from 42 preoperatively to 86 postoperatively and the average WOMAC score also significantly improved from 47 to 22 postoperatively. Radiological evaluation showed all the femoral components were stable. There was one acetabular component loosening, which required revision 9 years after conversion to THA. One dislocation and one recurrent dislocation were recorded in isolated acetabular revision hip; whereas one dislocation, one recurrent dislocation, and one trochanteric nonunion occurred in the hips with revision of both components. All dislocations occurred in hips with a femoral head size of 28 mm (P = 0.052). The cup and femoral head interval length was the most significant factor contributing to dislocation (P = 0.013).

CONCLUSIONS

Conversion THA after failed bipolar HA offers a reliable pain relief and functional improvement. To prevent dislocation, it is highly recommended to use a larger diameter femoral head, especially where the cup size is big.

Lower preoperative Hounsfield unit values are associated with intra-operative fractures in cementless bipolar hemiarthroplasty

The use of Hounsfield units (HU) from CT scanning to assess regional BMD has been described. Therefore, we evaluated whether HU could be used to identify osteoporosis of the proximal part of the femur. The results showed that HU assessment is associated with the presence of intra-operative fracture during arthroplasty.

INTRODUCTION

The aim with this study was to determine the association of preoperative Hounsfield unit (HU) in hip computed tomography (CT) with intra-operative osteoporotic fracture during cementless hemiarthroplasty.

METHODS

In this retrospective study, we reviewed all patients who underwent cementless bipolar hemiarthroplasty for femoral neck fractures between 2014 and 2016. Patients with intra-operative metaphyseal fractures (n = 25) during surgery were identified from a retrospectively collected patient database and matched with nonfracture controls (n = 75) on the basis of age and sex. The differences between patients with intra-operative fractures and without intra-operative fractures were compared regarding preoperative HU. Correlations of HU value of femur neck with BMD and T scores were determined.

RESULTS

Analysis of HU values at the fracture level showed a significantly lower value in the fracture group than in the controls (1186 vs 1340, p = 0.005). The correlation between HU and BMD of femur neck was significant (r ² = 0.347; p < 0.001). The correlation between HU of femur neck and BMD of spine was also significant (r ² = 0.133; p < 0.001).

CONCLUSIONS

HU assessment using preoperative CT scan is associated with the presence of intra-operative fracture during bipolar hemiarthroplasty. We believe that HU values of the proximal femur could be used to assess local bone quality.

Intraoperative blood pressure changes during cemented versus uncemented bipolar hemiarthroplasty for displaced femoral neck fracture: a multi-center cohort study : The effect of bone cement for bipolar hemiarthroplasty in elderly patients

INTRODUCTION

The purpose of this study was to compare the cemented bipolar hemiarthroplasty with uncemented about the change of intraoperative blood pressure and the incidence of major complications in elderly patients with femoral neck fracture.

MATERIALS AND METHODS

This multiple center prospective cohort study included only patients with acute displaced femoral neck fracture (Garden stage III or IV). All patients were treated with cemented or uncemented bipolar hemiarthroplasty using modified Hardinge or Watson-Jones approach in the lateral decubitus position. Baseline data, medical history, type of anesthesia, FiO₂ value, the number of vasopressor using during operation, femoral component, intraoperative blood pressure, SaO₂, and major complications were evaluated.

RESULTS

Of 164 patients (45 males and 119 females), 86 underwent cemented and 78 underwent uncemented bipolar hemiarthroplasty. Baseline medical histories were similar in both groups. In both the cemented and uncemented groups, intraoperative systolic blood pressure significantly decreased during cementing or rasping (106.3 and 103.6 mmHg) and after femoral component insertion (103.3 and 99.1 mmHg) compared to before rasping (120.7 and 116.4 mmHg) (p < 0.0001, respectively). Donaldson's grade seemed more favorable in uncemented group than in cemented group during cementing or rasping, during stem insertion; however, no patients experienced the lethal complication in both groups.

CONCLUSIONS

Intraoperative blood pressure did not change during cemented and uncemented bipolar hemiarthrplasty for displaced femoral neck fracture. If the standard modern cement technique was performed during operation, bone cement is a safe and acceptable for elderly patients who have a lot of medical histories.

Isolated acetabular revision with femoral stem retention after bipolar hip arthroplasty

INTRODUCTION

In bipolar hemiarthroplasty, migration of the outer cup component into the acetabular cup, with evidence of severe osteolysis in the acetabulum, commonly occurs without loosening of the femoral component. The merits of retaining the stable femoral component in these cases have been debated. Our study aimed to determine whether revision of the acetabular component in isolation could be successfully performed.

MATERIALS AND METHODS

The data of 54 patients (61 hips), 44 women, and 10 men, aged 67.7 (range 47-86) years at the time of the index revision, were analyzed. The average time from primary operation to revision surgery was 14.9 (range 1.0-27.0) years, with an average follow-up time after revision of 5.2 (range, 1.0-18.7) years. Indications for acetabular revision included migration of the outer cup component (N = 55), disassembly of the bipolar cup (N = 4), and recurrent dislocation (N = 2). Fixation of the femoral stem was cementless in 49 hips and cemented in 12. Bone grafting for osteolysis of the proximal femur around the stem was performed in six hips. An acetabular reinforcement ring with a cemented cup was used in 31 hips, with cementless cup fixation in 29 hips, and cemented cup in one case.

RESULTS

On average, the Harris hip score improved from 57.0 ± 21.6 to 87.4 ± 6.40 points after revision. Two cases of femoral periprosthetic fracture were treated with osteosynthesis 3 year post-revision. There was no evidence of loosening of the femoral stem or subsidence, with a non-progressive radiolucent line <2 mm identified in one case. There was no incidence of dislocation or deep infection, and all components were judged to be stable at the final follow-up.

CONCLUSION

Isolated acetabular revision can be reliably performed in cases of failed bipolar hemiarthroplasty with a well-fixed femoral component.

Comparative Study of Bipolar Hemiarthroplasty for Femur Neck Fractures Treated with Cemented versus Cementless Stem

PURPOSE

To compare and analyze clinical and radiologic outcomes of cemented versus cementless bipolar hemiarthroplasty for treatment of femur neck fractures.

MATERIALS AND METHODS

A total of 180 patients aged 65 years and over older who underwent bipolar hemiarthroplasty for treatment of displaced femur neck fractures (Garden stage III, IV) from March 2009 to February 2014 were included in this study. Among the 180 patients, 115 were treated with cemented stems and 65 patients with cementless stems. Clinical outcomes assessed were: i) postoperative ambulatory status, ii) inguinal and thigh pain, and iii) complications. The radiologic outcome was femoral stem subsidence measured using postoperative simple X-ray.

RESULTS

The cemented group had significantly lower occurrence of complications (postoperative infection, P=0.04) compared to the cementless group. There was no significant difference in postoperative ambulatory status, inguinal and thigh pain, and femoral stem subsidence.

CONCLUSION

For patients undergoing bipolar hemiarthroplasty, other than complications, there was no statistically significant difference in clinical or radiologic outcomes in our study. Selective use of cemented stem in bipolar hemiarthroplasty may be a desirable treatment method for patients with poor bone quality and higher risk of infections.

Osteosynthesis versus endoprosthesis for the treatment of femoral neck fracture in Asian elderly patients

BACKGROUND

The purpose of this study was to compare the clinical results between osteosynthesis and endoprosthesis for femoral neck fractures in asian elderly patients, and to analysis the factors that may affect the failure of osteosynthesis.

METHODS

A retrospective review of 382 hips over 65-year old with femoral neck fracture was done. Within non-displaced fracture group, 81 cases (56.6 %) underwent internal fixation (IF) and with 62 cases (43.3 %) having bipolar hemiarthroplasty (BPHA). As for displaced fracture group, 60 cases (25.1 %) underwent internal fixation (IF) with 179 cases (74.8 %) having BPHA. Average follow-up period for the patients was 36.8 months. Analysis was conducted on complications depending on fracture types and osteoporosis, and clinical evaluation was done on gait capability by using Koval walking ability.

RESULTS

In non-displaced group, BPHA group showed statistically significant lower percentage of complications compared to IF group, but re-operation rate and the degradations of Koval score were no significant differences. In displaced group, complication, re-operation rate and the degradations of Koval score of BPHA group were statistically better than those of IF group. Association between osteoporosis and non-union is no statistically significant.

CONCLUSIONS

Endoprosthetic replacement could be a primary option for displaced femoral neck fracture in elderly asian patients. The choice of surgical treatment methods of non-displaced fracture in elderly asian patients should be determined carefully considering the age and the presence of osteoporosis.

The value of modular hemiarthroplasty for unstable femoral neck fractures in elderly patients with coxarthrosis

Background

Displaced femoral neck fractures are common in the elderly patient. The surgical treatment options consist of a hemiarthroplasty (HA) or total hip arthroplasty (THA). However, the best surgical choice is still under debate. Bipolar HAs do not address preexisting arthritic changes of the acetabulum, which may lead to an unfavorable clinical outcome. The purpose of the present study was to conduct a long term follow-up analysis of the bipolar hemiarthroplasty with particular focus on the influence of preoperative acetabular osteoarthritis on the functional outcome.

Methods

In a retrospective observational study, the medical charts of consecutive patients treated with a bipolar hemiarthroplasty at a level one trauma center between 2004 and 2008 were reviewed before a final radiographic and clinical follow-up was performed. The outcome variables consisted of arthritic findings on the pre- and postoperative x-rays with particular focus on double fond osteophyte (DFO) and posterior wall sign (PWS) as well as the revision rate and functional scores.

Results

This study included 102 patients with a mean age of 77.2 years. Most patients (75 %) had a Kellgren-Lawrence grading scale (KLGS) of 2 or 3. While only 30 % of patients had a DFO, most patients (73 %) had a PWS. The DFO correlated significantly with the KLGS, but no correlation was seen with the clinical outcome. Most patients showed a decreased offset by a mean of −7.8 mm. The mean modified Harris Hip Score (HHS) of 90.3 and the mean Merle d'Aubigné score of 10.8 correlated significantly. Despite a significant correlation of the HSS subcategory of pain and the preoperative KLGS, there was no statistical relationship between the arthritic x-ray measurements and the clinical outcome.

Conclusions

In the presented study population, the presence of radiographic acetabular osteoarthritis did not influence the clinical outcome after bipolar hemiarthroplasty for displaced femoral neck fractures.

Bipolar Hemarthroplasty Using Cementless Conical Stem for Treatment of Dorr Type B and C Femoral Neck Fracture

PURPOSE

The current study aims to evaluate the clinical and the radiological outcome of bipolar hemiarthroplasty using cementless cone stem to treat osteoporotic femoral neck fracture and compare the results according to the proximal femur geometry.

MATERIALS AND METHODS

Seventy-five hips (75 patients) that underwent bipolar hemiarthroplasty with cementless cone stem between September 2006 and December 2011 were analyzed. The minimum follow-up period was 3 years. Thirty-three hips were classified as type B and 41 as type C. The clinical outcome was assessed using Harris hip score and the walking ability score. Radiographic evaluation was performed to evaluate the stability of the prosthesis.

RESULTS

At the most recent follow up, the mean Harris hip score was 86 (range, 70-92) and 65% recovered to preoperative ambulatory status. In the radiographic exam, stable stem fixation was achieved in all cases. For the complications, eight hips developed deep vein thrombosis while three hips showed heterotopic ossification. Dislocation and delayed deep infection occurred in one hip resepectively. There were no significance differences in Harris hip score and walking ability score when the type B group was compare with the type C.

CONCLUSION

Bipolar hemiarthroplasty with cementless cone stem showed an excellent early outcome both clinically and radiographically regardless of the shape of the proximal femur. We believe this prosthesis can provide early stability to the Dorr type B and C femur and is an effective treatment for treating osteoporotic femoral neck fracture.

Calcar femorale grafting in the hemiarthroplasty of the hip for unstable inter trochanteric fractures

BACKGROUND

The sliding screw-plate devices and cephalo-medullary nail devices have performed well in stable inter-trochanteric fractures in patients with reasonably good quality of bone. However, their suboptimal performance in comminuted fractures in the presence of osteoporotic bone has prompted many surgeons to consider bipolar hemiarthroplasty as the primary modality of management of comminuted inter-trochanteric fractures in elderly patients. However, long term stability of the hemiarthroplasty implant also may be compromised due to the presence of postero-medial bone loss at the area of the calcar.

MATERIALS AND METHODS

We have presented a simple and effective technique of calcar grafting by harvesting cortical bone strut from the neck of the fractured femur. A total of 34 patients with inter-trochanteric fractures of the femur were treated with calcar grafting. The mean age was 79.2 years. The graft was harvested from the calcar region of the head and neck fragment of the femur and wedged between the medial femoral cortex and medial edge of the prosthesis. The mean followup period was 54.5 months.

RESULTS

In 32 of 34 (94%) patients in our series, the calcar graft healed well without dislodgement. There was graft resorption in two patients associated with subsidence of the implant and loosening.

CONCLUSION

Calcar grafting using this technique provides stability to the implant in the presence of comminution and incorporates well in the majority of patients. Donor site morbidity of graft harvesting is also avoided.

Clinical and Radiologic Outcomes among Bipolar Hemiarthroplasty, Compression Hip Screw and Proximal Femur Nail Antirotation in Treating Comminuted Intertrochanteric Fractures

Purpose

In comminuted intertrochanteric fractures, various operative options have been introduced. The purpose of this study was to determine whether there were differences in clinical and radiologic outcomes among bipolar hemiarthroplasty (BH), compression hip screw (CHS) and proximal femur nail antirotation (PFNA) in treating comminuted intertrochanteric fractures (AO/OTA classification, A2 [22, 23])

Materials and Methods

We retrospectively evaluated total 150 patients (BH, 50; CHS, 50; PFNA, 50) who were operated due to intertrochanteric fractures from March 2010 to December 2012 and were older than 65 years at the time of surgery. We compared these three groups for radiologic and clinical outcomes at 12 months postoperatively, including Harris Hip Score, mobility (Koval stage), visual analogue scale and radiologic limb length discrepancy (shortening).

Results

There was no statistical significance among three groups in clinical outcomes including Harris Hip Score, mobility (Koval stage), visual analogue scale. However, there was significant differences in radiologic limb discrepancy in plain radiographs at 12 months postoperatively (radiologic shortening: BH, 2.3 mm; CHS, 5.1 mm; PFNA, 3.0 mm; P=0.000).

Conclusion

There were no clinical differences among BH, PFNA, and CHS in this study. However, notable limb length shortening could be originated during fracture healing in osteosynthesis, compared to arthroplasty (BH<PFNA<CHS).

The Comparison of Compression Hip Screw and Bipolar Hemiarthroplasty for the Treatment of AO Type A2 Intertrochanteric Fractures

Purpose

The purpose of this study was to compare the outcomes of osteosynthesis using compression hip screw fixation versus bipolar hemiarthroplasty in AO type A2 intertrochanteric fractures.

Materials and Methods

From March 2003 to December 2009, 89 patients were included in this study. They were treated using compression hip screws (43 cases) or bipolar hemiarthroplasty (46 cases). The mean age of patients was 77.7 years (65-94 years) and the mean follow-up period was 5.9 years (1-8.3 years). For comparison of the outcomes in the two groups, statistical analyses were performed with parameters including anesthesia time, operation time, amount of transfusion, hospital stay, general complications, clinical outcome, time of partial weight-bearing using a walker, and radiological failure rate.

Results

Differences in the amount of transfusion, general complications, and clinical outcome (Merle d'Aubigné and Postel score) were not statistically significant between the two groups. The bipolar hemiarthroplasty group showed better results than the compression hip screw group for anesthesia time and the time of partial weight-bearing using a walker. Radiological failures were observed in hips in one case (2.2%) of bipolar hemiarthroplasty, and in four cases (9.3%) of compression hip screw fixation.

Conclusion

Among elderly individuals with AO type A2 intertrochanteric fractures, patients treated with bipolar hemiarthroplasty were able to perform early ambulation. However, no significant difference in operation time, amount of postoperative transfusion, clinical results, hospital stay, and radiological failure rate was observed between the bipolar hemiarthroplasty and compression hip screw fixation groups.

Comparison of intertrochanteric fracture fixation with dynamic hip screw and bipolar hemiarthroplasty techniques

BACKGROUND

At present, there is no consensus on an appropriate treatment modality for intertrochanteric fractures in the elderly with background diseases. The aim of the present study was to compare treatment outcomes of intertrochanteric fractures reduced with dynamic hip screws (DHS) and bipolar hemiarthroplasty in elderly patients with background medical conditions.

METHODS

In this randomized clinical trial, 60 patients with intertrochanteric fractures, who were 45-60 years old, were randomly divided into DHS and bipolar groups. After treatment, the two groups were compared in relation to complications and mortality rates, functional status using the Harris Hip Score (HHS), range of movement and severity of pain using the visual analogue score (VAS).

RESULTS

HHS (86±9 vs. 75±7.6), range of flexion (105±11 degrees vs. 90±17 degrees) and external rotation (35±7 degrees vs. 20±7 degrees) were significantly higher in the bipolar group compared to the DHS group (P<0.05). However, there were no significant differences in pain severity between the two groups.

CONCLUSION

Reduction of intertrochanteric fractures in elderly patients with background medical conditions is more effective and less problematic with the bipolar technique compared to DHS and is better tolerated by patients, because this technique is associated with improvements in functional status and hip joint movement range.

Bipolar hemiarthroplasty for femoral neck fracture using the direct anterior approach

AIM: To evaluate whether walking ability recovers early after bipolar hemiarthroplasty (BHA) using a direct anterior approach.

METHODS: Between 2008 and 2010, 81 patients with femoral neck fracture underwent BHA using the direct anterior approach (DAA) or the posterior approach (PA). The mean observation period was 36 mo. The age, sex, body mass index (BMI), time from admission to surgery, length of hospitalization, outcome after discharge, walking ability, duration of surgery, blood loss and complications were compared.

RESULTS: There was no significant difference in the age, sex, BMI, time from admission to surgery, length of hospitalization, outcome after discharge, duration of surgery and blood loss between the two groups. Two weeks after the operation, assistance was not necessary for walking in the hospital in 65.0% of the patients in the DAA group and in 33.3% in the PA group (P < 0.05). As for complications, fracture of the femoral greater trochanter developed in 1 patient in the DAA group and calcar crack and dislocation in 1 patient each in the PA group.

CONCLUSION: DAA is an approach more useful for BHA for femoral neck fracture in elderly patients than total hip arthroplasty in terms of the early acquisition of walking ability.