The treatment algorithms for femoral neck fractures in elderly keep changing constantly and are still controversial because of increasing stress on improving the quality of life in elderly population and associated osteoporosis. Orthopedic surgeons have almost agreed to the advantages of arthroplasty over fixation in improving the outcome in elderly population, but differences still persist as to type of arthroplasty. Options include unipolar, bipolar or total hip arthroplasty. The objective of present study is to compare the outcome of bipolar and total hip arthroplasty in fracture neck femur in Indian elderly population.

A retrospective analysis was performed for comparing the quality of life index in 60 patients over the age of 55 years who underwent bipolar hemiarthroplasty (30 patients) or total hip arthroplasty (30 patients). The follow up period ranged from 3 months to 3 years. Patients were interviewed by an independent observer by questionnaires based on Harris Hip score and Hospital for special surgery score and were examined clinically. The results were analyzed using unpaired t-test.

Though the average period of stay for total hip arthroplasty group was significantly longer but it did not affect the quality of life after 3 months. Patients undergoing total hip replacement were found to be doing significantly better with regards to muscle power, range of motion and function as assessed by unpaired t-test (p < 0.05), but no statistical significant differences were found as far as pain and walking scores were concerned.

Total hip replacement provides a better quality of life to elderly patient with femoral neck fractures compared with bipolar hemiarthroplasty in Indian population.

There is no data concerning morphological dimensions of distal femur, proximal tibia and patella in Indian population. The objective was to analyse the anthropometric data in Indian knees and to co-relate them with existing knee arthroplasty systems.

MRI scans of 25 patients (15 males & 10 females) who underwent bilateral knee scans for ligamental injuries were collected. Patients with arthritis, bone loss, varus/valgus deformity of > 15 degrees and those with immature skeleton were excluded.

The mean age was 32 yrs (18–53 yrs). Three surgeons independently measured medio-lateral (ML), antero-posterior(AP) dimensions & aspect ratio(AR) of distal femur, proximal tibia and unresected patellar thickness(PT) on three occasions one week apart to account for intra & inter-observer variability. The resultant data of 50 knees was analysed using SPSS v14.0 and compared with five prosthesis knee systems (PFC sigma, NexGen, Scorpio, IB-II & Gender specific knee). The mean ML & AP for proximal tibia was 73.3±5.3 & 47.8±4.3 mm. The mean ML & AP (lateral condyle) for distal femur was 74.3±5.9 & 65.4±5.0 mm. The mean PT was 24.7 & 21.8 mm in males & females respectively. The ML & AP showed a statistically significant positive correlation with the height of the person (ML r=0.55; AP r=0.50 & p=0.01). The tibial and femoral AR showed higher ratio for smaller knees & smaller ratio for larger knees i.e. decline in AR for increasing AP dimension. None of the prosthesis designs mimicked this decrease in AR and NexGen prosthesis infact showed an increase in AR. Gender differences in the morphological data were shown by variable tibial AR.

Most of the available TKR prosthesis designs differ from actual knee morphometry of Indian population. These data provides the basis for designing optimal prosthesis for people of Indian/Asian origin in UK and overseas.

Bipolar hip arthroplasty was introduced to alleviate the problems of hip pain, acetabular protrusion and femoral stem loosening associated with unipolar prosthesis. Earlier generation bipolar endoprosthesis used to cause varus fixation of outer head which led to the unacceptably high incidence of dislocation, component disassembly and fractures of the polyethylene bearing insert. Second generation endoprosthesis with a self centering mechanism were introduced to overcome these problems. This new design incorporates a polar offset by setting the center of rotation of the inner head proximal to the center of rotation of the outer head, which generates a valgus producing moment at the outer cup. There is a controversy whether this mechanism works in vivo, more so in indigenous prosthesis.

A retrospective observational study was done on 37 subjects, which included 21 males and 16 females. The first radiograph was taken with the patient standing and bearing full weight over the endoprosthetic leg and abducting the contra lateral limb as much as possible. The second radiograph was taken with the patient standing neutral and bearing weight on both the legs. Abduction and adduction views were then taken in supine position. The radiographs were analyzed using the method similar to that of Drinker and Murray. The adductive motion from abduction to neutral position is within the range of inner bearing oscillation. Modified Harris Hip Score was used to evaluate the patients clinically. Results were analyzed using Wilcoxon Matched-Pairs Signed-Ranks Test, Students t-test and Karl Pearson correlation statistics.

The mean outer head alignment changed from 42.46 degrees ±13.62 (range 10 to 72 degrees) to 31.93 degrees ± 10.59 (range 8 to 50 degrees) in moving from abduction to neutral position in weight bearing position. The analysis showed that 68.66% of the total motion occurred at the outer bearing in weight bearing position whereas 73.86% of the total motion occurred at the outer bearing in supine position. The difference between distribution of motion between supine and weight bearing position was not found to be statistically different using Wilcoxon Matched-Pairs Signed-Ranks Test (p = 0.3164) and unpaired students t test (p = 0.35). No correlation was found between weight of the patient and time of follow up with outer head alignment and differential distribution of motion.

Self centering mechanism of bipolar endoprosthesis works in vivo under physiological loads and aligns the cup in neutral or valgus position till an average follow up of 10 months. Though the motion occurs at both the bearing surfaces outer bearing motion clearly predominated in both weight bearing as well as supine position.

Failed internal fixation of hip fracture is a problem with varied aetiology. This becomes more complex when associated with infection. Total hip arthroplasty (THA) remains the only option to restore hip biomechanics when there is partial/complete head destruction associated with it.

A retrospective review was performed for 22 consecutive patients of THA following failed infected internal fixation between Sept. 2001 and Nov. 2007. There were 11 dynamic hip screw failures for intertrochanteric fractures, 6 failed osteotomies following proximal femoral fractures, and 5 failed screw fixations for transcervical fractures. The average age of the patients were 48.5years and average follow up period was 3.5 years (5months – 7.5years). All the patients have undergone two stage revision surgeries. The average Harris Hip Score improved from 35.5 to 82.8 at the latest follow up. None of the patients had recurrence of infection. One patient developed sciatic nerve palsy, recovered partially at 1 year following surgery. The results were comparable to primary arthroplasty in femoral neck fractures.

THA is a useful salvage procedure for failed infected internal fixation of hip fractures. Extreme care must be taken to avoid fracture and penetration of femoral shaft in such cases. Auto graft, allograft and special components like multihole cup, narrow stem should be available for reconstruction in difficult cases.

A retrospective review of MRSA screening showed that of a total of 8911 patients screened pre-operatively between May 1996 and February 2001, 83 (0.9%) had MRSA isolated from one source or another. During the same period, 115 (13.6%) of 844 positive tissue samples taken during surgery grew Staphylococcus aureus. Of these only 1 (0.01%) was reported to be methicillin-resistant (MRSA). However, a total of 366 (43.4%) isolates from tissue samples were reported as coagulase-negative staphylococci (C-NS). Of these, 312 samples were tested for methicillin sensitivity, of which 172 (55.1%) were found to be resistant.

Staphylococcus epidermidis is the most prevalent and persistent species found on most skin and mucous membranes, constituting 65% to 90% of all staphylococci. Most isolates in tissue samples were found to be methicillin-resistant coagulase-negative staphylococcus (55.1%). Hence, it may be appropriate to undertake screening for methicillin-resistant Staphylococcus epidermidis in addition to that for MRSA.