Introduction and Aims: To aid the comparison of results of different techniques of femoral revision at total hip replacement and in choosing types of revision, a number of radiographic classifications have been proposed. We aimed to determine the reliability of five popular radiographic classification systems for grading the extent of femoral bone deficiency.

Method: Twenty pre-revision total hip replacement femoral radiographs were assessed by a senior consultant specialist in revision surgery, a junior consultant, a fellow and a trainee registrar. The femoral bone deficiency was classified using the systems of the American Academy of Orthopaedic Surgeons (AAOS) and EndoKlinik, and those described by Paprosky, Gross and Gustillo. Intra-observer agreement and inter-observer agreement between assessors were determined using the kappa coefficient. Radiographs were reassessed after a minimum of two weeks. Kappa coefficients of 0.6–0.8 (substantial) or > 0.8 (almost perfect) were considered to indicate acceptable agreement. Intra-operative measurement of deficiency was also undertaken.

Results: Intra-oberser agreement was rated as acceptable for the Paprosky, Gross and Gustillo systems, each giving substantial agreement, but was unacceptable for the AAOS and EndoKlinik systems. Inter-observer agreement was unacceptable for all systems except the Gross classification system, which was rated as having substantial agreement.

Conclusion: Comparing results of femoral revision between different surgeons based on bone deficiency according to the most popular radiographic classification systems is doubtful because of poor reliability. These classifications can be used by an individual surgeon as a guide to management, but most classifications should not be used to recommend the type of femoral revision to other surgeons.

Aim: To clarify the issue of whether or not to cement the hemiarthroplasty in the treatment of displaced intra-capsular femoral neck fractures in the elderly. Method: All patients with displaced intracapsular femoral neck fractures treated with hemiarthroplasty between January 1997 and May 1998, in 2 hospitals within the same Deanery, were reviewed. The same prosthesis was used; in hospital A they were uncemented, and in B cemented. There were 121 patients in hospital A and 123 in hospital B; all patients alive at follow-up (50 and 56 respectively) were interviewed for pre-fracture and current assessments of pain and functional ability using validated scoring systems. Follow-up was 32–36 months. Results: Patient demographics were similar. Cemented procedures took 15 minutes longer. In-patient stay was the same. Signiþcantly fewer of the cemented group had been revised or were awaiting revision (p=0.036). There was no difference in mortality rates at any point. Prospective assessment of surviving patients revealed highly statistically signiþcant greater deterioration in pain (p=0.003), walking ability (p=0.002), use of walking aids (p=0.003) and activities of daily living (p=0.009) in the uncemented group. The trend for more dependent accommodation in the uncemented group failed to reach statistical signiþcance (p=0.14). Conclusions: Our þndings support the use of cemented hemiarthroplasty for displaced intracapsular femoral neck fractures in the elderly.

The best management of displaced intracapsular femoral neck fractures in the elderly remains undecided. Most are treated by hemiarthroplasty. The aim of this study was to establish whether the advantages of cement outweigh the disadvantages.

All patients with displaced intracapsular femoral neck fractures treated with herniarthroplasty between January 1997 and May 1998, in 2 hospitals within the same Deanery, were reviewed. The same prosthesis was used, but in hospital A they were uncemented, and in B cemented. There were 122 patients in hospital A and 123 in B. We conducted a detailed retrospective analysis of hospital notes. All surviving patients (50 and 56 respectively) were interviewed to obtain pre-fracture and current scores of pain, walking ability, use of walking aids, activities of daily living (ADL) and accommodation status, using validated scoring systems. The relative deterioration over the follow-up period (32–36 months) was determined and the groups compared.

Patient demographics confirmed comparability of groups. There was no greater incidence of intra-operative fall in diastolic blood pressure, or oxygen saturation in the cemented group. Cemented procedures were on average 15 minutes longer. Median in-patient stay was the same. Significantly fewer of the cemented group had been revised or were awaiting revision (p=0. 036). There was no difference in mortality rates at any point between surgery and follow-up. Prospective assessment of surviving patients revealed highly statistically significant greater deterioration in pain (p=0. 003), walking ability (p=0. 002), use of walking aids (p=0. 003) and ADL (p=0. 009) in the uncemented group. The trend for more dependent accommodation in the uncemented group failed to reach statistical significance (p=0. 14).

In conclusion, the cemented group faired significantly better than the uncemented group. Our findings suggest the advantages of cement outweigh the disadvantages, and we support the use of cemented hemiarthroplasty for the displaced intracapsular femoral neck fracture in the elderly patient.

Introduction: The best method of management of displaced intracapsular femoral neck fractures in elderly patients remains undecided. Most are treated by hemiarthroplasty.

Aim: To clarify the issue of whether or not to use cement in hemiarthroplasty for displaced, intracapsular, femoral neck fractures in the elderly.

Methods: Consecutive patients with displaced, intracapsular, femoral neck fractures treated by hemiarthroplasty between January 1997 and May 1998, in two hospitals within one region were reviewed. The same monoblock prosthesis was used; in Hospital A they were uncemented (121 patients), and in Hospital B they were cemented (123 patients). All surviving patients (50 and 56 respectively) were interviewed for assessments of pre-fracture and current pain, walking ability, use of walking aids and activities of daily living (ADL), using validated scoring systems. The average follow-up was 36 months.

Results: The patients’ demographical data were similar (the mean age was 82 and 84 years respectively). There was no greater incidence of intra-operative fall in diastolic blood pressure or oxygen saturation in the cemented group. Cemented procedures took, on average, 15 minutes longer. Fewer of the cemented group had been revised or were awaiting revision (p=0.036). There was no difference in complication or mortality rates at any time between surgery and follow-up (p=0.86). Prospective assessment revealed highly significant differences in favour of cement, in terms of pain (p=0.003), walking ability (p=0.002), use of walking aids (p=0.004) and ADL (p=0.009).

Conclusion: Our findings support the use of cemented hemiarthroplasty for the displaced intracapsular femoral neck fracture in the elderly patient.

Aim: To establish the surgical treatment of displaced intracapsular femoral neck fractures in hospitals across the United Kingdom.

Methods: The on-call registrars in all 223 hospitals receiving acute orthopaedic admissions in the UK, were interviewed by telephone. Their usual practices were recorded for two groups of patients, active and frail. The proportions of hospitals using the different surgical options were determined.

Results: Despite stereotyped clinical features, management varied between specialists within some hospitals: two or more different methods of treatment were in routine use for active patients in 22% of hospitals, and for frail patients in 27%. The management also varied between hospitals. Overall, for active patients, bipolar hemiarthroplasty was in use in 41%, internal fixation in 37%, unipolar hemiarthroplasty in 32% and total hip replacement in 16% of hospitals. For frail patients either Austin-Moore or Thompson prostheses or both were in use in 94% of hospitals. Where used, Austin-Moore prostheses were uncemented in 93% of hospitals, and Thompson prostheses cemented in 79%. Bipolar prostheses were in use in 8%, and the alternative of internal fixation undertaken for frail patients in 1% of hospitals.

Conclusions: The findings demonstrated a lack of consensus in several aspects of the treatment of displaced intracapsular fractures of the femoral neck, with implications for consideration of best practice, in the UK, and worldwide.