Aims

The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons.

Aims: To find out if osteosynthesis (OS) or hemiarthroplasty (HA) is better in terms of functional outcome. Patients and methods: In 1989–1996, all displaced cervical hip fractures were prospectively, using the same forms, registered at the University Hospitals of Oulu in Finland and Lund in Sweden. Cross-matchings was performed for age, sex, preoperative residence, and ambulatory capacity. Results: The first study comprised 357 pairs (OS with two hook pins and cementless Austin-Moore HA): OS was associated with a better functional outcome and lower mortality, but a higher re-operation rate than hemiarthroplasty. The second study had 446 pairs (OS two hook pins and cemntless HA): OS was associated with better function and lower mortality than HA, especially in younger patients, and it is recommended as the primary treatment for cervical non-pathological hip fractures in patients younger than 80 years and with good ambulatory capacity, whereas the oldest patients can also be safely treated by HA. The third study comprised 82 pairs (OS with three screws and cementless HA): Functional recovery is slightly better after OS with three screws than after uncemented HA, although no significant differences were seen in a sample of this size. On the other hand, OS is associated with a higher re-operation rate. Conclusion: OS seemed somewhat better in terms of functional outcome.

Background

Systematic reviews disagree, but some recent studies have shown better function and less pain after operation with bipolar hemiarthroplasty compared to fixation by two screws in elderly patients operated for displaced femoral neck fractures. There is still uncertainty regarding the mortality associated with both procedures.

Background

A well conducted randomised study found similar functional results for patients with displaced femoral neck fracture comparing operation with a modern uncemented bipolar hemiarthroplasty with a cemented bipolar hemiarthroplasty. The mortality associated with the two procedures has not been sufficiently investigated.

Abstract

Recent NICE guidelines suggest that Total Hip Arthroplasty (THA) be offered to all patients with a displaced intracapsular neck of femur fracture who: are able to walk independently; not cognitively impaired and are medically fit for the anaesthesia and procedure. This is likely to have significant logistical implications for individual departments.

Data from the National Hip Fracture Database was analysed retrospectively between January 2009 and November 2011. The aim was to determine if patients with displaced intracapsular neck of femur fractures admitted to a single tertiary referral orthopaedic trauma unit received a THA if they met NICE criteria. Case notes were then reviewed to obtain outcome and complication rates after surgery.

Five hundred and forty-six patients were admitted with a displaced intracapsular neck of femur fracture over the described time period. Sixty-five patients met the NICE criteria to receive a THA (mean age 74 years, M:F = 16: 49); however, 21 patients had a THA. The other patients received either a cemented Thompson or bipolar hemiarthroplasty. Within the THA cohort there were no episodes of dislocation, venous thromboembolism, significant wound complications or infections that required further surgery. Within the hemiarthroplasty cohort there was 2 mortalities, 2 implant related infections, 1 dislocation and 2 required revision to a THA.

There is evidence to suggest better outcomes in this cohort of patients, in terms pain and function. There is also a forecasted cost saving for departments, largely due to the relative reduction in complications. However, there were many cases (44) in our department, which would have been eligible for a THA, according to the NICE guidelines, who received a hemiarthroplasty. This is likely a reflection of the increased technical demand, and larger logistical difficulties faced by the department. We did note more complications within the hemiarthroplasty group, however, the numbers are too small to address statistical significance, and a longer follow up would be needed to further evaluate this. There is a clear scope for optimisation and improvement of infrastructure to develop time and resources to cope with the increased demand for THA for displaced intracapsular neck of femur fractures, in order to closely adhere to the NICE guidelines.

Aims

Our aim was to prepare a systematic review and meta-analysis to compare the outcomes of cemented and cementless hemiarthroplasty of the hip, in elderly patients with a fracture of the femoral neck, to investigate the mortality, complications, length of stay in hospital, blood loss, operating time and functional results.

Introduction: Arthroplasty is the most effective management of displaced intracapsular femoral neck fracture. Hemiarthroplasty (HEMI) is associated with acetabular erosion and loosening in mobile active patients and total hip arthroplasty (THA) with instability.

We sought to establish whether HEMI or THA gave better results in independent mobile patients with displaced femoral neck fracture.

Method: Eighty-one patients were randomised into two groups. One arm received a modular HEMI, the second a THA using the same femoral stem. Patients were followed for a mean of three years after surgery.

Results: After HEMI, eight patients died, two were revised to THA and there is intention to revise three. One patient had a Peri-prosthetic fracture. Mean walking distance was 1.08 miles and Oxford Hip Score (OHS) 22.5. Twenty patients (64.5% of survivors) had radiological evidence of acetabular erosion.

After THA, three patients died, three dislocated, one required revision. Mean walking distance was 2.23 miles and OHS was 18.8. There was no radiological evidence of polyethylene wear

Patients with THAs after three years walked further (p=0.039) and had a lower OHS (p=0.033).

Discussion: HEMI is associated with a higher actual and potential revision rate than THA because of acetabular erosion, higher OHS after three years and shorter walking distances.

THA is a preferable option to HEMI in independent mobile elderly patients with displaced intracapsular femoral neck fracture.

Arthroplasty is the most effective management of displaced intracapsular femoral neck fracture. Hemiarthroplasty (HEMI) is associated with acetabular erosion and loosening in mobile patients and total hip arthroplasty (THA) with instability.

We sought to establish whether HEMI or THA gave better results in independent mobile patients with displaced intracapsular femoral neck fracture.

Eighty-two patients were randomised into two groups. One arm received a modular HEMI, the second a THA using the same femoral stem. Patients were followed for a mean of three years after surgery.

After HEMI, eight patients died, two were revised to THA and there is intention to revise three. One patient had a periprosthetic fracture. Mean walking distance was 1.08 miles and Oxford Hip Score (OHS) 22.5. Twenty patients (64.5% of survivors) had radiological evidence of acetabular erosion.

After THA, four patients died, three dislocated, one required revision. Mean walking distance was 2.23 miles and OHS was 18.8.

HEMI is associated with a higher rate of revision than THA and potential revision because of acetabular erosion. THA after three years displayed superior walking distances (p=0.039) and lower OHS (p=0.033).

THA is a preferable option to HEMI in independent mobile elderly patients with displaced intracapsular femoral neck fracture.

The April 2023 Trauma Roundup. 360. looks at: Displaced femoral neck fractures in patients aged 55 to 70 years: internal fixation or total hip arthroplasty?; Tibial plateau fractures: continuous passive motion approves range of motion; Lisfranc fractures: to fuse or not to fuse, that is the question; Is hardware removal after clavicle fracture plate fixation beneficial?; Fixation to coverage in Grade IIIB open fractures – what’s the time window?; Nonoperative versus locking plate fixation in the proximal humerus; Retrograde knee nailing or lateral plate for distal femur fractures?

Over the past decade there has been a shift in the approach to management of many femoral neck fractures. As noted by Miller et al. those trends are reflected in the practice patterns of surgeons applying for board certification through the American Board of Orthopaedic Surgeons. From 1999 to 2011 there was a trend toward total hip arthroplasty and corresponding small decreases in the use of hemi-arthroplasty and internal fixation for treatment of femoral neck fractures. For many years the treatment approach has been a simple diagnosis-related algorithm predicated upon classification of the fracture as displaced (historically treated with hemi-arthroplasty) or non-displaced (historically treated with internal fixation). More recently, however, the focus has shifted to a patient-centered approach. In the patient-centered approach factors such as age, functional demands, pre-existent hip disease and bone quality should all be considered. In the contemporary setting it is still important to distinguish between displaced and non-displaced fracture patterns. Non-displaced femoral neck fractures, regardless of patient age or activity, are well-suited to closed reduction and internal fixation, most commonly with three cannulated screws. The union rate is high in non-displaced fractures treated with internal fixation and the benefits of preserving the native hip joint are substantial. Displaced femoral neck fractures in younger active patients, particularly those without pre-existent hip arthritis, are best treated with early anatomic reduction and internal fixation. While a subgroup of young, active patients who undergo ORIF may fail, the benefits of native hip preservation in that group are again substantial. Displaced femoral neck fractures in older patients or those with substantial pre-existing hip arthritis are best treated with arthroplasty. The biggest practice change has been the trend to total hip arthroplasty as opposed to hemi-arthroplasty for a subgroup of patients. Total hip arthroplasty is now favored in almost all active, cognitively well-functioning patients as the degree of pain relief is better and the risk of reoperation is lower in the current era (32mm and 36mm femoral heads). Hemi-arthroplasty, either uni-polar or bi-polar, remains an appropriate treatment for cognitively impaired patients who also have limited functional demands in whom the risk of dislocation is particularly high

The December 2023 Trauma Roundup. 360. looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery

Displaced femoral neck fractures can have devastating impacts on quality of life and patient function. Evidence for optimal surgical approach is far from definitive. The Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty (HEALTH) trial aimed to evaluate unplanned secondary procedures following total hip arthroplasty (THA) versus hemi-arthroplasty (HA) within two years of initial surgery for displaced femoral neck fractures. Secondary objectives evaluated differences in patient function, health-related quality of life, mortality, and hip-related complications HEALTH is a large randomized controlled trial that included 1,495 patients across 81 centers in 10 countries. Patients aged 50 years or older with displaced femoral neck fractures received either THA or HA. Participants were followed for 24 months post-fracture and a Central Adjudication Committee adjudicated fracture eligibility, technical placement of prosthesis, additional surgical procedures, hip-related complications, and mortality. The primary analyses were a Cox proportional hazards model with time to the primary study endpoint as the outcome and THA versus HA as the independent variable. Using multi-level linear models with three levels (centre, patient, and time), with patient and centre entered as random effects, the effect of THA versus HA on quality of life (Short Form-12 (SF-12) and EQ-5D), function (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), and mobility (Timed Up and Go Test (TUG)) were estimated separately. The majority of patients were female (70.1%), 70 years of age or older (80.2%), and able to ambulate without the aid of an assistive device before their fracture (74.4%), and the injury in the majority of the patients was a subcapital femoral neck fracture (61.9%). The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to THA and 60 of 723 patients (8.3%) who were randomly assigned to HA (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 hemi- arthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total WOMAC total score, pain score, stiffness score, and function score, modestly favored THA over HA. Mortality was similar in the two treatment groups (14.3% among the patients assigned to THA and 13.1% among those assigned to HA, p=0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to THA and in 265 patients (36.7%) assigned to HA. Among 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 THA and those who were assigned to undergo HA, and THA provided a clinically unimportant improvement over HA in function and quality of life over 24 months

Aims. Displaced femoral neck fractures (FNF) may be treated with partial (hemiarthroplasty, HA) or total hip arthroplasty (THA), with recent recommendations advising that THA be used in community-ambulant patients. This study aims to determine the association between the proportion of FNF treated with THA and year of surgery, day of the week, surgeon practice, and private versus public hospitals, adjusting for known confounders. Patients and Methods. Data from 67 620 patients in the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 1999 to 2016 inclusive were used to generate unadjusted and adjusted analyses of the associations between patient, time, surgeon and institution factors, and the proportion of FNF treated with THA. Results. Overall, THA was used in 23.7% of patients. THA was more frequently used over time, in younger patients, in healthier patients, in cases performed on weekdays (adjusted odds ratio (OR) 1.27; 95% confidence interval (CI) 1.14 to 1.41), in private hospitals (adjusted OR 4.34; 95% CI 3.94 to 4.79) and by surgeons whose hip arthroplasty practice has a relatively higher proportion of elective patients (adjusted OR 1.65; 95% CI 1.49 to 1.83). Conclusion. Practice variation exists in the proportion of FNF patients treated with THA due to variables other than patient factors. This may reflect variation in resources available and surgeon preference, and uncertainty regarding the relative indication

Introduction. Displaced femoral neck fractures in elderly are normally treated with 2 screws/pins (IF) or bipolar hemiarthroplasty (HA). The aim of this study was to compare IF and HA as treatment for displaced femoral neck fractures using reoperations and functional result (patient satisfaction, pain, and quality of life) as outcome. Material and Methods. From January 2005 all hip fractures in Norway are reported to the Norwegian Hip Fracture Register. At 4, 12, and 36 months postoperatively a questionnaire assessing satisfaction (VAS 0-100), pain (VAS 0-100), and quality of life (EQ-5D) is sent to the patients. To ensure more than 3 years follow-up, only patients operated in 2005 were included in the present study. Consequently 1,968 patients over 70 years of age operated with IF (n = 958) or HA (n = 1,010) due to displaced femoral neck fractures were included in the analyses on reoperations. Of these, 280 patients responded to all questionnaires and were included in the analyses on functional results (IF: n = 135, HA: n = 145). The patients remained in the same treatment group according to the intention-to-treat principle. Results. Through December 2008 496 (51.8%) patients had died in the IF group and 519 patients (51.4%) in the HA group. There were 238 (24.8%) reoperations performed in the IF group and 26 (2.6%) in the HA group. For the 280 patients included in the analyses on functional results, no preoperative differences were found between the two treatment groups concerning sex, comorbidity (ASA-class), cognitive dysfunction, and EQ-5Dindexscore. However, the patients in the HA group were older than the patients in the IF group (79.7 vs 77.7 years, p = 0.002). At all follow-ups, the HA-group were significant more satisfied with the result of the operation compared to the IF-group. The HA group reported less pain compared to the IF group after four months (18 vs 35, p<0.001) and after twelve months (16 vs 29, p<0.001). After 3 years no difference in pain between the two groups could be found. After four months the EQ 5Dindexscore was 0.69 in the HA-group and 0.58 in the IF-group (p<0.001), after twelve months 0.75 in the HA-group and 0.67 in the IF-group (p = 0.001), and after 3 years follow-up 0.74 in the HA-group and 0.71 in the IF-group (p<0.089). Discussion and Conclusion. There were more reoperations in the IF group than in the HA group. The superior functional results found in the HA group after 4 and 12 months were less evident after 3 years. For this frail patient group, a short rehabilitation period with minimized need for reoperations is important, and consequently, a hemiarthroplasty should be recommended as treatment for displaced femoral neck fractures

Aims

This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time.

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

Aims

The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients.

The June 2014 Hip & Pelvis Roundup³⁶⁰ looks at: Modular femoral necks: early signs are not good; is corrosion to blame for modular neck failures; metal-on-metal is not quite a closed book; no excess failures in fixation of displaced femoral neck fractures; noise no problem in hip replacement; heterotopic ossification after hip arthroscopy: are NSAIDs the answer?; thrombotic and bleeding events surprisingly low in total joint replacement; and the elephant in the room: complications and surgical volume.