Cementless hemiarthroplasty in femoral neck fractures: evaluation of clinical results and measurement of migration by EBRA-FCA

Radiological subsidence and acetabular erosion after tapered uncemented hemiarthroplasty in femoral neck fractures a 10- to 13- year follow-up study

BACKGROUND

Contemporary uncemented hemiarthroplasties are being used after displaced femoral neck fractures, however, their functional and radiological results remain controversial. The aim of this study was to evaluate the clinical and radiological results of a tapered uncemented stem combined with a uni- or bipolar hemiarthroplasty after a minimum follow-up of ten years.

PATIENTS AND METHODS

135 patients underwent uncemented hip hemiarthroplasty after a displaced femoral neck fracture between 2004 and 2007. Their mean age was 81.5 years old (range, 70 to 90). 38 patients were evaluated with a minimum follow-up of ten years. We analysed the complications and the postoperative clinical result according to the Merle D´Aubigné and Postel scale. Radiological femoral type according to Dorr et al., femoral canal filling and the appearance of stem loosening, subsidence and acetabular erosion according to Baker et al., were also assessed.

RESULTS

There were two early periprosthetic femoral fractures. The mean clinical score was 15.8 (range, 9 to 17). Six hips were converted to a total hip arthroplasty due to acetabular erosion, and three stems were revised due to an infection, a late periprosthetic fracture and one aseptic loosening. The survival rate for any cause was 85.4% (Confidence interval (CI) 76 - 92.4%). The survival rate for revision surgery on the acetabular side at 10 years was 92.6% (CI 85 - 100%) and on the femoral side was 97.6% (CI 94.4 - 100%). 14 hips showed non-progressive radiological subsidence and 9 acetabular erosion. Stem subsidence was related to a femoral canal filling < 80% (p = 0.035) and acetabular erosion to a cylindrical femur (p = 0.024).

CONCLUSION

Bone fixation can be obtained with a contemporary uncemented stem in hemiarthroplasty for patients over 70 years old with a femoral neck fracture. Acetabular erosion was frequent after ten years, however, the rate of revision surgery was low.

Bone Loss Following Cementless Hemiarthroplasty for the Treatment of Femoral Neck Fracture

BACKGROUND

With the advances in medicine, an increasing number of the ageing population are a public health concern in terms of age-related complications. Among them, displaced neck fractures often require surgical intervention or arthroplasty to achieve the mobilization of the elderly and good life quality. The aim of the study is to monitor the changes in bone mineral density (BMD) around the femoral stem and the effects on functional outcomes in patients treated with cementless hemiarthroplasty following femoral neck fracture.

MATERIALS AND METHODS

Seventy-one patients aged 70 years or older who were treated with cementless hemiarthroplasty for a displaced femoral neck fracture were prospectively followed for 2 years. The percent change in the periprosthetic BMD in each Gruen zone was compared to the baseline using dual-energy X-ray absorptiometry (DEXA). Demographic factors [age, body mass index (BMI), and sex] that could possibly influence BMD and the clinical outcome were evaluated.

RESULTS

Fifty-one patients were available for the final follow-up. The mean age was 76.5 (range 70-89) years. The mean BMI was 28.9 (range 22.7-37.2). The mean Harris hip score at the final follow-up was 84.3 (range 72-93). There was a significant decrease in BMD in all Gruen zones (p < 0.001), except in zone 3 (R3, p = 0.547). The reduction in BMD was highest in the calcar and the greater trochanter region. The femur diaphysis was relatively spared, with zone 3 showing no significant bone mineral loss. The age and BMI of the patients were not correlated with the postoperative change in BMD in any of the Gruen zones. The degree of reduction in bone density was not correlated with the clinical outcome.

CONCLUSIONS

Cementless hemiarthroplasty for the treatment of femoral neck fracture in elderly patients achieves a good clinical outcome despite significant bone loss around the femoral stem. The reduction in BMD is more pronounced in the metaphyseal region.

High incidence of migration with poor initial fixation of the Accolade stem

BACKGROUND

Numerous cementless femoral stem design variations are in clinical use. Because initial implant instability and micromotion are associated with aseptic loosening of the femoral component, migration analysis provides an early assessment of implant survivorship.

QUESTIONS/PURPOSES

We determined the (1) migration pattern of the Accolade cementless femoral stem; (2) clinical factors predisposing to stem migration; (3) self-reported patient outcomes; and (4) our current rate of aseptic stem loosening.

METHODS

We retrospectively analyzed 81 femoral stems for aseptic migration using Ein-Bild-Roentgen-Analyse-femoral component analysis. Postoperatively, patients completed the WOMAC and SF-12 questionnaires. We assessed radiographic factors potentially associated with subsidence: indices of bone shape and quality, canal fill of the implant, and radiographic signs of loosening. Minimum followup was 24 months (mean, 29 months; range, 24-48 months).

RESULTS

The average subsidence at 24 months was 1.3 mm (range, 0-1.5 mm). In the first 2 years, 36% of stems subsided more than 1.5 mm. Large stem size was associated with subsidence. Radiolucent lines (> 1.5 mm in three zones) were present in 10% of stems and associated with lower questionnaire scores. The 5-year survivorship for aseptic loosening of the 367 stems was 97% with revision as end point and 95% for radiographic failure.

CONCLUSIONS

The high incidence of migration and stems with radiographic failure raises concerns about patient clinical function and long-term survivorship of this stem design. This migration pattern may be due to poor initial stability with a subsequent lack of osseointegration. Our results differ from radiographic findings and clinical durability of other similar cementless stem designs.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Migration pattern of cementless press fit cups in the presence of stabilizing screws in total hip arthroplasty

The aim of this study was to evaluate the initial acetabular implant stability and late acetabular implant migration in press fit cups combined with screw fixation of the acetabular component in order to answer the question whether screws are necessary for the fixation of the acetabular component in cementless primary total hip arthroplasty. One hundred and seven hips were available for follow-up after primary THA using a cementless, porous-coated acetabular component. A total of 631 standardized radiographs were analyzed digitally by the "single-film-x-ray-analysis" method (EBRA). One hundred and one (94.4 %) acetabular components did not show significant migration of more than 1 mm. Six (5.6%) implants showed migration of more than 1 mm. Statistical analysis did not reveal preoperative patterns that would identify predictors for future migration. Our findings suggest that the use of screw fixation for cementless porous-coated acetabular components for primary THA does not prevent cup migration.

A new uncemented hydroxyapatite-coated femoral component for the treatment of femoral neck fractures

Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck.

We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years.

Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D.

Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years.

The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck.

Cementless bipolar hemiarthroplasty in femoral neck fractures in elderly

BACKGROUND

Cemented hip arthroplasty is an established treatment for femoral neck fracture in the mobile elderly. Cement pressurization raises intramedullary pressure and may lead to fat embolization, resulting in fatal bone cement implantation syndrome, particularly in patients with multiple comorbidities. The cementless stem technique may reduce this mortality risk but it is technically demanding and needs precise planning and execution. We report the perioperative mortality and morbidity of cementless bipolar hemiarthroplasty in a series of mobile elderly patients (age >70 years) with femoral neck fractures.

MATERIALS AND METHODS

Twenty-nine elderly patients with mean age of 83 years (range:71-102 years) with femoral neck fractures (23 neck of femur and 6 intertrochanteric) were operated over a 2-year period (Nov 2005-Oct 2007). All were treated with cementless bipolar hemiarthroplasty. Clinical and radiological follow-up was done at 3 months, 6 months, 12 months, and then yearly.

RESULTS

The average follow-up was 36 months (range 26-49 months). The average duration of surgery and blood loss was 28 min from skin to skin (range, 20-50 min) and 260 ml (range, 95-535 ml), respectively. Average blood transfusion was 1.4 units (range, 0 to 4 units) Mean duration of hospital stay was 11.9 days (7-26 days). We had no perioperative mortality or serious morbidity. We lost two patients to follow-up after 12 months, while three others died due to medical conditions (10-16 months post surgery). Twenty-four patients were followed to final follow-up (average 36 months; range: 26-49 months). All were ambulatory and had painless hips; the mean Harris hip score was 85 (range: 69-96).

CONCLUSION

Cementless bipolar hemiarthroplasty for femoral neck fractures in the very elderly permits early return to premorbid life and is not associated with any untoward cardiac event in the perioperative period. It can be considered a treatment option in this select group.

Assessment of the initial stability of the Symax femoral stem with EBRA-FCA: a multicentric study of 85 cases

We report a study of 85 Symax femoral stems that were followed at regular intervals with radiographs at 6, 12, 24 and 36 months. The radiological migration of each stem was measured using the computer-assisted EBRA -FCA method. In 30 cases in which the EBRA method did not provide a complete measurement another computer-assisted method (Roman version 1.7) was employed. In all cases the distal migration of the stems was minimal, The threshold migration value used to define the stability of a stem was 1.5 mm at 24 months. The mean migration within the first two years was -0.17 mm (+/- 0.3) at 6 months, -0.31 mm (+/- 0.4) at 12 months and -0.45 mm (+/- 0.5) at 24 months. Only two cases exceeded the threshold limit of 1.5 mm at the two-year follow-up, but both values were lower than 2 mm. In the 25 cases which reached three-year follow-up the mean distal migration was -0.84 (+/-0.7). In four of them the subsidence exceeded 1.5 mm, but only one exceeded 2 mm. These data represent a positive predictive factor for the minimal risk of future aseptic loosening.

Cementless hemiarthroplasty for femoral neck fractures in elderly patients

OBJECTIVES

The use of cement is associated with increased morbidity and mortality rate in elderly patients, hence cementless hemiarthroplasty is suggested. We evaluated the results of cementless hemiarthroplasty for femoral neck fractures in elderly patients with high-risk clinical problems.

MATERIALS AND METHODS

Forty-eight patients (29 females, 19 males) with a mean age of 88 years (range: 78 to 102 years). having femoral neck fractures were treated with the use of cementless hemiarthroplasty. Porous-coated femoral stems were used in 30 patients (62%) and modular type femoral revision stems in 18 patients (38%). Bipolar femoral heads were used in all patients. Radiological follow-up after operation was done at the one, three, six months and annually.

RESULTS

The mean follow-up period was 4.2 years (range: 18 months to eight years). None of the patients died during hospitalization. Medical complications occurred in six patients (12%) within the follow-up period and four patients (8%) died within this period. Only two hips were converted to total hip arthroplasty due to acetabular erosion. Femoral revision was planned for one patient with a subsidence of > 3 mm. None of the patients had acetabular protrusion or heterotopic ossification. The mean Harris-hip score was 84 (range: 52 to 92). Dislocation occurred in one patient (2%).

CONCLUSION

Cementless hemiarthroplasty is a suitable method of treatment for femoral neck fractures in elderly patients with high-risk clinical problems especially of a cardiopulmonary nature. This method decreases the risk of hypotension and fat embolism associated with cemented hemiarthroplasty.