Hemiarthroplasty For Hip Fracture Research Articles

Hip fracture surgery performed by cadaveric simulation-trained versus standard-trained orthopaedic trainees: a preliminary multicentre randomized controlled trial.

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required.

High-dose dual-antibiotic loaded bone cement in patients undergoing hemiarthroplasty

Hip fractures continue to be a major cause of morbidity and mortality in the older population. 1 Moran CG Wenn RT Sikand M Taylor AM Early mortality after hip fracture: is delay before surgery important?. J Bone Joint Surg Am. 2005; 87: 483-489 Crossref PubMed Scopus (546) Google Scholar Furthermore, due to substantial improvements in life expectancy worldwide, the annual number of patients with hip fracture is expected to reach an all-time high over the course of the next two decades. 2 Cooper C Campion G Melton 3rd, LJ Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992; 2: 285-289 Crossref PubMed Scopus (2406) Google Scholar Although there is currently no gold standard for the surgical management of patients with hip fractures, hemiarthroplasty continues to be one of the more popular treatment options in these patients. 3 Bhandari M Einhorn T A Guyatt G et al. Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med. 2019; 381: 2199-2208 Crossref PubMed Scopus (178) Google Scholar Concurrently, surgical site infection (SSI) is a devastating complication following hemiarthroplasty, and one of the leading causes of mortality and morbidity in these patients. 4 Gupta A Shin J Oliver D Vives M Lin S Incidence and risk factors for surgical site infection (SSI) after primary hip hemiarthroplasty: an analysis of the ACS-NSQIP hip fracture procedure targeted database. Arthroplasty. 2023; 5: 1-7 Crossref PubMed Scopus (0) Google Scholar High-dose dual-antibiotic loaded cement for hip hemiarthroplasty in the UK (WHiTE 8): a randomised controlled trialIn this trial, the use of high-dose dual-antibiotic loaded cement did not reduce the rate of deep surgical site deep infection among people aged 60 years or older receiving a hemiarthroplasty for intracapsular fracture of the hip. Full-Text PDF Open Access

HIP PRECAUTIONS ON DISCHARGE FOLLOWING HEMIARTHROPLASTY FOR NECK OF FEMUR FRACTURES: A SURVEY

Hip precautions are currently practiced in three-quarters of trauma hospitals in the UK, despite national recommendations from the ‘Blue Book’ not stating it as a requirement. Valuable therapist time is utilised alongside the need for specialised equipment, which can potentially delay discharge whilst it is being arranged. Objective of this study was to explore the current practice of the use of hip precautions on discharge following hemiarthroplasty for hip fractures. To also explore whether they are necessary and to identify areas for improvement to benefit patient care overall.Online survey distributed to various Trauma and Orthopaedic Departments across the UK. Survey was available over a 4-month period, collecting 55 responses overall.Majority of responses were from trauma and orthopaedic consultants who were aware of the ‘Blue Book’ recommendations. The majority of trusts who responded did not practice hip precautions and did not feel this increased the risk of dislocations on discharge. Recommendations included integration of hip precautions in the post-op advice in coordination with the physiotherapist and information leaflets on discharge regarding hip precautions. Hip precautions were not commonly practiced, for reasons including patient compliance and the inherently stable procedure of a hemiarthroplasty compared to a THR, reducing the need for hip precautions.Hip precautions are not widely regarded as a useful practice for post-hip hemiarthroplasty, viewed as utilising more resources and increasing costs and risk due to increased hospital stay. Thus, this potentially delays discharge overall. A consistent approach should be implemented in treating patients post-hip hemiarthroplasty.

Predicting Prolonged Wound Drainage after Hemiarthroplasty for Hip Fractures: A Stacked Machine Learning Study.

Prolonged wound drainage (PWD) is one of the most important reasons that increase the risk of early periprosthetic joint infection after arthroplasty. It is very important to evaluate the risk factors for PWD in the surgical field after arthroplasty surgery. This can be accomplished using machine learning or artificial intelligence methods. Our aim in this study was to compare machine learning methods in predicting possible PWD. The study was carried out on clinical, laboratory, and radiological data of 313 patients who underwent hemiarthroplasty (HA) for proximal femur fractures. We preprocessed the dataset and trained and tested machine learning methods using cross validation. We compared various machine learning algorithms (linear discriminant analysis, decision tree, k-nearest neighbors, gradient boosting machine, and logistic regression [LR]) based on performance measures. We also combined the most successful algorithms with a metaclassifier. To help understand the relationship between risk factors, we provided a risk factor severity ranking. To estimate the risk of PWD, classification was performed with first-level classifiers and then integrated as a LR-based meta-learner stacking method. More performance improvements were achieved with the stacking method. We found that the stacking method was superior to other methods in PWD classification. We determined that the volume of fluid collected from the drain, morbid obesity class, blood transfusion, and body mass index score were the four most important risk factors according to stacking.

Tönnis angle and acetabular depth ratio: predictors of dislocation following hemiarthroplasty for hip fracture.

Despite efforts to mitigate possible modifiable risk factors, dislocations following hemiarthroplasty for hip fracture still occur, with reported incidence rates ranging from 1.5 to 11%. The aim of this study was to investigate whether acetabular dysplasia is a significant contributing factor to dislocation, and since non-modifiable, whether it should affect patient selection for this treatment option. This is a multicentre nested case-control study of patients treated at 2 separate centres over a 10-year period from January 2011 to December 2020. All cases of hemiarthroplasty dislocation following hip fracture were identified from local databases, and 4 random controls were selected for every case. Tönnis angle (TA) and Acetabular-depth-ratio (ADR) was measured on the injured side using AP pelvis radiographs. Patients with TA > 10° and/or ADR < 250 were considered to have abnormal acetabular morphology. 35 cases of dislocation were identified and 140 random controls were selected. Cases of dislocation had a larger mean TA (8.8° vs. 5.5°, p < 0.001) and lower mean ADR (254 vs. 289, p < 0.001) than controls. 20 out of 35 (57%) cases were considered to have abnormal acetabular morphology, compared to 19 out of 140 (14%) controls. The odds of dislocation is 8.5 times greater (odds ratio = 8.49, 95%CI = 3.73, 19.39) in patients with abnormal TA and/or ADR. This study demonstrates that TA > 10° and ADR < 250 are useful criteria to identify patients at greater risk of hip hemiarthroplasty dislocation due to acetabular dysplasia. Special consideration to preoperative planning should be taken in these patients. Future research should focus on methods to minimise risk in this subset of patients, including evaluating total hip arthroplasty with dual mobility component vs hemiarthroplasty.

Increased postoperative glycemic variability is associated with increased mortality in diabetic patients undergoing hip arthroplasty for hip fracture.

Increased glycemic variability (GV) during hospitalization has been associated with increased rates of surgical site and periprosthetic joint infections (PJI) following elective total joint arthroplasty. Uncertainty exists surrounding GV as a predictor for complications in urgent arthroplasty cases following hip fractures. In this study, we evaluated the association between GV and postoperative complications in diabetic patients undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fractures. We analyzed data on 2421 consecutive patients who underwent THA or HA at our institution from 2011 to 2020. Patients with a known diagnosis of diabetes mellitus who had a minimum of three postoperative glucose values taken within the first week after surgery were included. GV was assessed using a coefficient of variation. Outcomes included short- and long-term mortality, reoperations, prosthetic joint infection (PJI) requiring revision and readmissions for any cause. The final cohort consisted of 482 patients (294 females, 188 males). Higher GV was associated with an increased 90-day mortality (p = 0.017). GV was not associated with 30-day mortality (p = 0.45), readmissions of any cause at 30 or 90days (p = 0.99, p = 0.91, respectively), reoperation of any cause (p = 0.91) or PJI requiring revision surgery (p = 0.42). Higher GV in the postoperative period is associated with increased rates of mortality in diabetic patients following THA and HA for hip fractures. Efforts should be made to monitor and control glucose variability in the postoperative period.

Outcomes of Hemiarthroplasty via lateral approach in elderly patients

Background: Hip fractures are common and comprise 20% of operative workload of an orthopaedic trauma unit [1]. Hemiarthroplasty for hip fracture is one of the commonest procedures undertaken in Orthopaedics. A number of different surgical approaches may be used for the operation including the anterior, antero-lateral, lateral and posterior approach. Currently the two most commonly used approaches for hemiarthroplasty of the hip are the lateral [7] and the posterior approach [8]. Methods: Patients >60years with displaced neck of femur facture without distal neurovascular deficit presenting and giving written and informed consent were evaluated clinically and radiologically. Total 42 patients underwent surgery with lateral approach. No mortality was observed among the cases. Modified Harris Hip Score (mHHS) was used to compare outcomes. Data was collected in the standard pro forma and patients were followed up at 2, 6 and 12 weeks.Results: Modified Harris Hip Score at 12 weeks was 66.90±9.41 in Lateral approach. The mHHS has increased with successive follow up which was statistically significant. At 12 weeks according mHHS, 4.8% has excellent result, 7.1% had good result, 21.4% had fair result and 66.7% had relatively poor result. The quality of life of the patient has been improving in subsequent follow up and it was statistically significant.Conclusion: Hemiarthroplasty via Lateral approach in elderly patients is safe and effective as operative outcome of the patient significantly increases with time. Post-operative pain, blood loss, prosthesis dislocation and other surgery related complications were minimum and the approach was more suitable for the patient.

FUNCTIONAL OUTCOME OF PIRIFORMIS MUSCLE SPARING POSTEROLATERAL APPROACH IN BIPOLAR HEMIARTHROPLASTY: A RETROSPECTIVE STUDY.

INTRODUCTION: Hemiarthroplasty for hip fracture is a common surgical procedure and is the treatment of choice for displaced intracapsular neck of femur fracture. Numerous approaches are used to access the hip joint. The standard posterior approach is used by many surgeons to preserve the abductor complex but is associated with higher dislocation rate. In this study we assess functional outcomes of piriformis sparing posterolateral approach for hemiarthroplasty of hip. MATERIAL AND METHODOLOGY: We retrospectively reviewed 96 patients who underwent bipolar hemiarthroplasty of hip performed by chief surgeon between May 2018 to September 2020. All the database was retrieved from institutional database of tertiary care hospital. Functional outcome was measured by modied HARRIS HIP SCORE. RESULTS: Till minimum 1 year follow up we noticed that there was no single case of hip dislocation. Joint proprioception was preserved. In the nal follow up average Harris hip score was 92.2. No infection, nerve injury, implant migration occurred in our study. DISCUSSION: The main aim of the arthroplasty procedure is to decrease pain, to achieve mobility and restore anatomy. The piriformis sparing approach not only preserves abductor complex but also piriformis muscle. The muscle works like cradle, at the posterosuperior part of the joint, an area with a high risk of dislocation. The only disadvantage was noted in this approach was increased exposure difculty in obese patients CONCLUSION: From this study we conclude that Piriformis sparing posterolateral approach is safe, demands some technical aspects and should be used by surgeons using posterolateral approach.

60 The Effect of the 2020 COVID-19 Pandemic on Periprosthetic Joint Infection in Hip Fracture Surgery

Abstract Aim To assess whether this change of practice had an effect on the infection rate in hip fracture surgery. Method An audit was conducted to assess the re-operation rate on hip fracture patients over the three months of the initial “lockdown” (23rd March to 23rd May 2020) and compared to the 2 months immediately before and the same period in 2019. Cases were identified from the Theatre ORACLE system (GE Healthcare). Anonymised patient data was collected from the Electronic Patient Record (EPR) and paper case notes. Results During the pandemic period, a total of 45 patients underwent surgery for hip fractures with a median age 84 years (range 28-95 years). These represent similar cohorts to the periods immediately before lockdown and the previous year. The infection rate increased from 0% in the 2019 period to 2.5% prior to lockdown and 11.1% after the lockdown measures were implemented. All infections were in patients who received hemiarthroplasty. The rate of total hip replacement went down from 19.1% in 2019 to 10.0% just before the pandemic and just 4.4% during the pandemic Conclusions There was a marked increase in the number of re-operations for infection in patients who received hemiarthroplasty for hip fractures during the lockdown period.

Changes in blood pressure during cemented hemiarthroplasty for hip fracture in elderly patients under spinal anaesthesia.

ABSTRACTBlood pressure changes around cement insertion during total hip arthroplasty have been investigated; however, there is little agreement regarding whether a similar phenomenon occurs during hemiarthroplasty in the elderly under spinal anaesthesia. Therefore, our objective was to examine blood pressure around cement insertion during hemiarthroplasty in the elderly. For this retrospective, single-centre, case series study, we identified 430 hips of patients aged >65 years who underwent cemented hemiarthroplasty under spinal anaesthesia from January 2010 to August 2018. The maximum regulation ratio (MRR) was used to express changes in blood pressure immediately after cement insertion and was calculated as follows: the greatest difference (positive or negative) during 5 min after cement insertion into the bone canal divided by systolic blood pressure just before cement insertion. The timings of vasopressor administration and blood transfusion were recorded. The median MRR was compared for each American Society of Anesthesiologists (ASA) classification. The mean MRR was 4.0% (SD:10.4; range −26 to 83). MRR of patients with a >10% increase in blood pressure was significantly less than that of patients with a <10% change in blood pressure. Vasopressor was used in three patients 10 min after cement insertion into the bone canal. There was no significant difference between MRR groups and ASA classification (p = 0.182, respectively). MRR was not significantly different for each ASA classification. However, few cases showed a reduction in blood pressure immediately after cement insertion, regardless of ASA classification.

Factors associated with prolonged wound drainage after hemiarthroplasty for hip fractures in elderly.

The aim of this study was to determine the incidence of prolonged wound drainage (PWD) and the amount of drainage fluid after hip hemiarthroplasty (HA) and to investigate the risk factors for the development of PWD associated with the patient, fracture and surgical treatment. Data from 313 patients who underwent HA were prospectively analysed. The mean drainage time and drainage amount of patients with PWD were calculated. Patient demographic data, pre-operative ASA scores and anticoagulation status, presence of diabetes, fracture type, surgical approach, femoral stem type, cable usage, amount of drain output, blood transfusion quantity, time from injury to surgery, time from surgery to discharge and patient blood tests were investigated. The incidence of PWD after HA was 8.9% (28 patients). The mean drainage time in patients with PWD was 4.9 ± 1.85 (3-9) days, and the mean collected total fluid volume was 51.1 ± 26.9 (21-132) mL. PWD was more commonly observed in the lateral approach group (p < 0.001) and morbidly obese patients (p < 0.001). In the PWD group, the mean post-operative first-day haemoglobin value was lower (p < 0.001), more blood transfusions were required (p < 0.001) and the amount of drainage output from the closed suction drain (CSD) was higher (p < 0.001). The duration of hospitalization was longer in patients with PWD (p < 0.001). Lateral approach, morbid obesity and increased drainage output were found to be associated with PWD in logistic regression analysis. Lateral approach, morbid obesity and increased drainage output were found to be risk factors for the occurrence of PWD.

Early Peri-Prosthetic Joint Infection after Hemiarthroplasty for Hip Fracture: Outcomes of Debridement, Antibiotics, and Implant Retention.

Background: There are currently no treatment algorithms specifically for early peri-prosthetic joint infection (PJI) after hemiarthroplasty for hip fracture. Commonly, debridement, antibiotics, and implant retention (DAIR) is attempted as first-line management, despite lack of evidence supporting this strategy in this patient group. The purpose of this study was to evaluate outcomes of DAIR for early PJI after hemiarthroplasty for hip fracture in our unit. Methods: The departmental database from December 2008 to January 2019 was searched to identify all patients in our unit who were treated for early PJI after hemiarthroplasty for hip fracture. Data for included patients were collected from electronic healthcare records and analyzed. Primary outcome measure was treatment success, defined as patient survival to discharge, with eradication of infection and implant retention. Results: Twenty-six patients were identified and included in the study. Mean age was 84.7 years. All except one patient were American Society of Anesthesiologists (ASA) class 3 or 4. All patients were McPherson host grade B or C. Twenty-three of 26 patients underwent DAIR and three of 26 proceeded directly to excision arthroplasty. Debridement, antibiotics, and implant retention was successful in three of 23 patients (13%) after a single procedure, with success in two additional patients after a second procedure, giving overall success rate of five of 23 patients (22%). Conclusions: Debridement, antibiotics, and implant retention has a high failure rate in treating early PJI after hemiarthroplasty for hip fracture. These patients are generally elderly and frail with multiple host and wound compromising factors. Debridement, antibiotics, and implant retention should not be recommended as first-line management for the majority of these patients, for whom getting it right the first time is of vital importance to avoid consequences associated with failed surgical procedures. Further multicenter studies that also explore alternate treatment strategies are required to devise an algorithm specifically for hip fracture patients, to aid decisions on treatment and improve outcomes.

Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture

BackgroundGlobally, hip fractures are among the top 10 causes of disability in adults. For displaced femoral neck fractures, there remains uncertainty regarding the effect of a total hip arthroplasty as compared with hemiarthroplasty.MethodsWe randomly assigned 1495 patients who were 50 years of age or older and had a displaced femoral neck fracture to undergo either total hip arthroplasty or hemiarthroplasty. All enrolled patients had been able to ambulate without the assistance of another person before the fracture occurred. The trial was conducted in 80 centers in 10 countries. The primary end point was a secondary hip procedure within 24 months of follow-up. Secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points.ResultsThe primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to total hip arthroplasty and 60 of 723 patients (8.3%) who were randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P=0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored total hip arthroplasty over hemiarthroplasty. Mortality was similar in the two treatment groups (14.3% among the patients assigned to total hip arthroplasty and 13.1% among those assigned to hemiarthroplasty, P=0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to total hip arthroplasty and in 265 patients (36.7%) assigned to hemiarthroplasty.ConclusionsAmong independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00556842.)

Effects of postoperative osteoporosis treatment on subsequent fracture and the 5-year survival rates after hemiarthroplasty for hip fracture.

This study aims to investigate the status of osteoporosis treatment in patients who underwent hemiarthroplasty for an osteoporotic hip fracture and to compare subsequent fractures and the 5-year survival rates of these patients with those who did not receive the osteoporosis treatment. Patients > 65 years of age who underwent hemiarthroplasty for an osteoporotic hip fracture were included in this retrospective multicenter study. Patients who died within 12 months postoperative, who were lost to follow-up, and those with malignancy and secondary osteoporosis were excluded. Group I comprised patients who had no postoperative osteoporosis screening and treatment, and Group II comprised those who received the screening and treatment. A total of 460 of 562 patients (82%) did not receive osteoporosis treatment after hip fracture. No significant difference was observed between the groups in terms of subsequent fracture numbers and fracture sites (p = 0.296 and 0.240, respectively). Mean 5-year survival rate was significantly higher in Group II (p = 0.002). According to our results, elderly patients who underwent hemiarthroplasty for an osteoporotic hip fracture were not commonly screened or treated for osteoporosis. Our results demonstrated no significant difference between the groups in terms of subsequent fracture. However, we observed a significant high 5-year survival rate among patients who received the osteoporosis treatment.

Reducing Implant Infection in Orthopaedics (RIIiO): a pilot study for a randomised controlled trial comparing the influence of forced air versus resistive fabric warming technologies on postoperative infection rates following orthopaedic implant surgery in adults

BackgroundApproximately 70,000 to 75,000 proximal femoral fracture repairs take place in the UK each year. Hemiarthroplasty is the preferred treatment for adults aged over 60 years. Postoperative infection affects up to 3% of patients and is the single most common reason for early return to theatre. Ultraclean ventilation was introduced to help mitigate the risk of infection, but it may also contribute to inadvertent perioperative hypothermia, which itself is a risk for postoperative infection. To counter this, active intraoperative warming is used for all procedures that take 30 min or more. Forced air warming (FAW) and resistive fabric warming (RFW) are the two principal techniques used for this purpose; they are equally effective in prevention of inadvertent perioperative hypothermia, but it is not known which is associated with the lowest infection rates. Deep surgical site infection doubles operative costs, triples investigation costs and quadruples ward costs. The Reducing Implant Infection in Orthopaedics (RIIiO) study seeks to compare infection rates with FAW versus RFW after hemiarthroplasty for hip fracture. A cost-neutral intervention capable of reducing postoperative infection rates would likely lead to a change in practice, yield significant savings for the health economy, reduce overall exposure to antibiotics and improve outcomes following hip fracture in the elderly. The findings may be transferable to other orthopaedic implant procedures and to non-orthopaedic surgical specialties.MethodsRIIiO is a parallel group, open label study randomising hip fracture patients over 60 years of age who are undergoing hemiarthroplasty to RFW or FAW. Participants are followed up for 3 months. Definitive deep surgical site infection within 90 days of surgery, the primary endpoint, is determined by a blinded endpoint committee.DiscussionHemiarthroplasty carries a risk of deep surgical site infection of approximately 3%. In order to provide 90% power to demonstrate an absolute risk reduction of 1%, using a 5% significance level, a full trial would need to recruit approximately 8630 participants. A pilot study is being conducted in the first instance to demonstrate that recruitment and data management strategies are appropriate and robust before embarking on a large multi-centre trial.Trial registrationISRCTN, ISRCTN74612906. Registered on 27 February 2017.

Yasli Kalca Cevresi Kiriklarda Femur Basi Kemik Mineral Yogunlugunun Degerlendirilmesi

Objective: It is usually challenging to decide which hip fractures should be fixed and which should be replaced to avoid fixation failure and revision. Therefore, it may be of benefit to evaluate the bone mineral density of the fixation point of the femoral head preoperatively. In this study we tried to investigate the relationship between the bone mineral density (BMD) of the fixation point of femoral head, which is the primary compressive trabeculation area, and other parts of the proximal femur evaluated routinely during Dual-Energy X-ray absorptiometry (DXA) measurements. Methods: Retrieved femoral heads of 29 patients during hemiarthroplasty for hip fracture were evaluated using DXA. These results were correlated with the DXA measurements of proximal femora of uninvolved hips of patients. Results: Mean BMD values of retrieved femoral head primary compressive trabecular region (PC-BMD) values were 0.610 ± 11 (g/cm²). Although there were significant positive correlation of PC-BMD with neck, Ward's and total proximal femoral region as expected, highest correlation coefficient was calculated at femoral neck region. These results did not differ when patients were regrouped according to uninvolved side BMD values as osteoporotic and osteopenic. There were no difference in both sexes in this relationship between values of PC-BMD, neck BMD, Ward’s BMD and total BMD. Conclusion: As expected, a positive relationship was found between PC-BMD values and neck BMD, ward’s BMD and total BMD values with neck BMD revealing the highest correlation. Preoperative bone mineral densitometric evaluation of the uninvolved hip, especially the neck region seems to be helpful to evaluate the densitometric status of femoral head to predict early failure when fixation was attempted.

The Analysis of Postoperative Mortality after Bipolar Hemiarthroplasty for Hip Fractures in the Elderly

목적: 고령의 고관절부 골절환자에서 인공 고관절 반치환술 시행 후 발생한 사망률과 관련된 인자를 분석하여 보고하고자 한다. 대상 및 방법: 1994년 3월부터 2010년 3월까지 고관절부 골절로 인공 고관절 반치환술을 시행한 75세 이상의 환자 246명 278예를 대상으로 하였으며 평균 연령은 83.7세(75-103세)였다. 연령, 성별, 골절 형태, 동반 질환, ASA 등급, 골밀도, 수술 시기, 보행능력, 거주형태를 조사하여 수술 후 1년 내사망과 관련이 있는 인자들을 사망군과 비사망군으로 나누어 분석하였다. 결과: 수술 후 1년 사망률은 17.2%(48예)였고, 술 후 3개월까지 9.7%(27예), 4개월에서 6개월까지 5.4%(15예), 7개월에서 1년까지 2.1%(6예)였다. 수술 후 1년 사망률은 지연된 수술, 높은 ASA 등급, 보행능력, 거주 형태 등의 영향을 받았으나 연령, 성별, 골밀도, 골절 형태 등과의 유의한 관계는 없었다. 결론: 고령의 고관절부 골절 환자에서 양극성 반치환술 후 사망률 연구에서 ASA 등급, 수술 시기, 보행 능력, 거주형태가 중요한 인자로 나타났다.

Hemiarthroplasty for Hip Fractures in Elderly Patients over 80 Years Old - Comparative Analysis between Femoral Neck Fracture and Intertrochanteric Fracture -

목적: 80세 이상 노인의 불안정 대퇴골 전자간 골절에서 시행한 인공 고관절 반치환술의 상대적 수술적 위험도와 문제점들을 알아보고자 하였다. 대상 및 방법: 2005년 4월부터 2010년 5월까지 80세 이상의 고관절 골절 환자 58명을 대상으로 하였다. 1군은 경부 골절 환자 30명, 2군은 전자간 골절 환자 28명이었다. 두 군에서 나이, 내과적 질환, 골절 전 보행 상태에는 차이가 없었다. 각 군의 외상에서 수술까지 기간, 수술 시간, 출혈량, 보행 시작 시기, 입원 기간, 합병증, 재수술율, 보행 상태를 조사하여 비교하였다. 결과: 평균 수술 시간은 1군이 85.2분, 2군이 97.5분이었으며(P=0.03), 평균 출혈량은 1군이 483 cc, 2군이 695 cc이었다(P=0.006). 수술 후 보행 시작과 초기 보행 능력의 회복은 양군에 차이가 없었으며, 입원기간, 합병증, 재수술률에도 차이가 없었다. 그러나 추시에서 수상 전 보행 회복은 1군이 30예 중 25예(83.3%)이었으며, 2군은 28예 중 19예(67.8%)이었다. 결론: 2군에서 1군보다 수술시간이 길고 출혈량은 많았지만 수술적 위험도나 합병증의 발생률은 두 군에서 비슷하였다. 따라서 고령의 환자에서 발생한 전자간 골절의 일차적 치료로 인공 고관절 반치환술은 하나의 좋은 방법이 될 수 있을 것으로 생각된다.

The direct anterior approach in hemiarthroplasty for displaced femoral neck fractures

Hip replacement is the most common treatment for displaced femoral neck fractures in the elderly, and minimally invasive surgery is popular in the field of orthopaedic surgery. This study evaluated the outcome of monopolar hemiarthroplasty by the direct anterior approach over a postoperative period up to 2.5 years. A total of 86 patients with displaced femoral neck fractures were included (mean age of 86.5 years). Surviving patients were reviewed three months (retrospectively) and one to 2.5 years (prospectively) after surgery. One-year mortality was 36 %. For all stems, implant positioning with respect to stem alignment, restoration of leg length and femoral offset was correct. Acetabular protrusion was observed in 55 % of the patients one to 2.5 years postoperatively. Subsidence and intraoperative periprosthetic fractures occurred in three patients (3 %) each. All revision stems for postoperative periprosthetic fractures could be implanted using the initial surgical technique without extension of the previous approach. The mean Harris hip score was 85 points at the one to 2.5-year follow-up; 85 % of the patients were satisfied with their hip and 57 % returned to their preoperative level of mobility. Based on these findings, hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional outcome and high patient satisfaction.

Cement Emerges As the Most Predictable Option for Hip Hemiarthroplasty

Commentary It happens every day in our hospitals. A frail eighty-five-year-old woman with various medical problems is admitted with a displaced femoral neck fracture. After the workup, she is deemed fit for surgery with recommendations to “minimize hypotension and keep the hematocrit above 30.” She is brought to the operating room late in the afternoon and the attending surgeon is asked, “Is this a cemented or press-fit hemiarthroplasty?” The surgeon is fond of the shorter procedure time and the supposedly reduced cardiovascular effects associated with cementless arthroplasty, which would be valuable for this frail patient. However, on reviewing the radiographs, the surgeon notes osteopenia and a wide, patulous femoral canal. The surgeon is worried about failing to obtain a good press-fit, causing an intraoperative fracture, or seeing subsidence on the follow-up postoperative radiographs. Up until now, he or she has had to base the decision on limited literature that primarily employed old Austin Moore implants. Taylor et al. have released the results of a randomized controlled trial comparing hemiarthroplasty with modern cemented and uncemented implants to treat a femoral neck fracture. One hundred and sixty patients were randomized, and outcomes were measured with use of validated functional outcome scores, visual analog pain scores, and complication rates. The results are quite compelling. The functional outcome scores were essentially the same in the two groups at six months and at one year postoperatively. The operating room time and intraoperative blood loss were virtually identical. The rate of cardiovascular and respiratory complications was identical. However, the uncemented group had significantly more orthopaedic technical problems than the cemented group. The uncemented group had a 7.5% rate of intraoperative fractures and a 15% rate of postoperative fractures within two years. No intraoperative fractures and one postoperative fracture were observed in the cemented group. These differences were both significant at the key p < 0.05 level. Subsidence occurred in 22.5% of the uncemented prostheses and 1.3% of the cemented prostheses (p < 0.001). The reoperation rate was similar in the two groups. The study had two significant limitations. First, forty-six patients were excluded from randomization because they were believed to be too frail for arthroplasty with cemented implants. Thus, the sickest population, which would in theory be most susceptible to cardiovascular collapse during placement of bone cement, was excluded. Unfortunately, this cohort represents the group in which surgeons are the most concerned about introducing bone cement, and the exclusion of these patients limits the generalizability of the study by biasing the study toward arthroplasty with cement. Second, the procedures were performed primarily by registrars. The technical complexity of press-fitting a femoral stem implant into osteopenic bone requires a degree of surgical experience before it can be properly employed. Therefore, studying inexperienced surgeons also biases the study toward arthroplasty with cement. That said, I submit that in the United States the majority of hip fracture care is undertaken by surgeons in the early stage of their practice, and it is rarely undertaken by surgeons who are dedicated to total joint replacement. What, then, should the surgeon in our example do? The reality is that there is support for use of both press-fit and cemented hemiarthroplasty components for the treatment of femoral neck fractures. Given the multiple frailties and comorbidities of the population with such fractures, their true independence and functional status after the surgery probably has little to do with whether the prosthesis is fixed with cement or a press-fit interface, as long as a stable construct is obtained. Knowing that the functional results of the two procedures were very similar, and that we are unlikely to have larger studies to identify a clinically meaningful difference, the decision-making perspective shifts toward choosing a procedure that causes the least complications. The results of the study by Taylor et al. demonstrate that obtaining a good press-fit in patients treated with hemiarthroplasty for hip fracture is challenging (as demonstrated by the higher intraoperative fracture rate and higher rate of postoperative subsidence) and that the purported benefits of shorter operating room time and lower blood loss are nonexistent. Hemiarthroplasty with cement remains the gold standard against which all other procedures must be measured.