Cementless bipolar hemiarthroplasty in femoral neck fractures in elderly

Short-Term Outcomes of Uncemented Bipolar Hemiarthroplasty Using Stainless Steel Fully Hydroxyapatite-Coated Stem in Transcervical Fracture of the Femur

Background

Bipolar hemiarthroplasty is the standard of care for transcervical fracture in the elderly. Stainless steel being cheaper is preferred over titanium in developing nations for implants and prostheses. This study was conducted for assessing the short-term outcomes of uncemented bipolar hemiarthroplasty done using hydroxyapatite-coated stainless steel prosthesis.

Methods

Sixty-five patients, >60 year of age operated between 2018 and 2020 at tertiary care centre with stainless steel (316L) completely coated with hydroxyapatite bipolar hemiarthroplasty implants were retrospectively followed up. Radiological outcomes were assessed based on pedestal formation, stem position, radiological limb length discrepancy, sinkage of stem, spot welds and stress shielding. Clinical and functional outcomes were assessed based on mean Harris Hip score.

Results

Mean Harris Hip score at baseline, 3-week follow-up, 6-week follow-up, 3-month follow-up and 1-year follow-up was 45.9 (SD 2.5), 63.2 (SD 6.5), 75.1 (SD 9.9), 83.9 (SD 9.8) and 87.1 (SD 9.9), respectively. Excellent, good, fair, poor results were seen in 32.31, 40, 18.46, 9.23 of the patients, respectively. Valgus, central and varus stem position was seen in 49.23, 40, 10.77 percent of the patients, respectively. Pedestal formation, radiological limb length discrepancy, sinkage, spot welds, stress shielding was seen in 6.15, 32.31, 3.07, 53.85, 40 percent of the patients, respectively.

Conclusion

Short-term outcomes of this study provides evidence that using a more affordable fully hydroxyapatite-coated stainless steel prosthesis for uncemented bipolar hemiarthroplasty is an appropriate treatment option for the transcervical femur fracture.

A systematic review and meta-analysis of cemented and uncemented bipolar hemiarthroplasty for the treatment of femoral neck fractures in elderly patients over 60 years old

Background

Currently, whether bone cement can be applied in bipolar hemiarthroplasty to treat femoral neck fractures (FNFs) in elderly patients is controversial. The aim of this systematic review and meta-analysis was to compare the effectiveness and safety of cemented bipolar hemiarthroplasty (CBH) versus uncemented bipolar hemiarthroplasty (UCBH) in the treatment of FNFs among elderly patients over 60 years old.

Materials and methods

The Pubmed, Web of science, Cochrane Library and EMBASE databases were searched comprehensively for relevant articles from their inception to May 2022. Studies about comparing outcomes between CBH and UCBH for FNFs in elderly patients aged more than 60 years were included. Outcomes including operation time, intra-operative blood loss, length of hospital stay, wound infections, residual pain, revisions, re-operations, complications related to prosthesis, general complications, and mortality. The Review Manager 5.3 software provided by the Cochrane Collaboration Network was used to perform the meta-analysis of comparable data.

Results

A total of 6 randomized controlled trials (RCTs) and 9 observational studies were included in this analysis, with 33,118 patients (33,127 hips). Results of the meta-analysis indicated that the operation time [WMD = 13.01 min, 95% CI (10.79, 15.23)], intra-operative blood loss [WMD = 80.57 ml, 95% CI (61.14, 99.99)], incidence of heterotrophic ossification [OR = 2.07, 95% CI (1,14, 3.78)], were increased in the CBH group but the incidence of intra-operative fractures [OR = 0.24, 95% CI (0.07, 0.86)], periprosthetic fractures [OR = 0.24, 95% CI (0.18, 0.31)], aseptic loosening of prosthesis [OR = 0.20, 95% CI (0.09, 0.44)], wound infections [OR = 0.80, 95% CI (0.68, 0.95)] and re-operation rates [OR = 0.61, 95% CI (0.54, 0.68)] were lower in the CBH group by comparison with the UCHB group. However, there were no significant differences in residual pain, length of hospital stay, prosthetic dislocation, prosthetic subsidence (> 5 mm), acetabulum erosion, revisions, pulmonary infections, pulmonary embolisms, urinary tract infections, deep venous thromboses, decubitus, cardiovascular accidents (arrhythmia/myocardial infarction), and respiratory failure between the two groups. In terms of mortality, perioperative mortality (within 72 h) [OR = 2.39, 95% CI (1.71, 3.32)] and 1-week mortality postoperatively [OR = 1.22, 95% CI (1.05, 1.41)] in CBH group were higher than those in UCBH group, but there were no significant differences in mortality at 1 month, 3 months, 1 year, and 2 years postoperatively between CBH group and UCBH group.

Conclusion

This meta-analysis found that elderly patients over 60 years old with FNFs who underwent CBH had longer operation time, higher incidence of heterotrophic ossification, intra-operative blood loss, and mortality within 72 h of operation and at 1-week postoperatively, but lower incidence of periprosthetic fractures, aseptic loosening of prosthesis, intra-operative fractures, wound infections and re-operations. Other outcomes were not significantly different between the two groups.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021274253.

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.

Comparative Study of Surgical Management of Fracture Neck of Femur with Cemented Versus Uncemented Bipolar Hemiarthroplasty

INTRODUCTION

There is evidence for use of cemented hemiarthroplasty resulting in greater anchoring and lesser peri prosthetic fracture. However, this procedure results in more haemodynamic instability and cardiopulmonary complications termed as 'cement reaction' or bone cement implantation syndrome. There has been a heightened interest among surgeons to compare cemented and uncemented hemiarthroplasty for fracture neck of femur.

AIM

To compare cemented and uncemented hemiarthroplasty in terms of blood loss during the procedure, post-operative complications, mortality, functional recovery and long term clinical outcome.

MATERIALS AND METHODS

In a prospective study spanning 8 years from January 2006 to January 2014 in a tertiary care hospital, 52 cases of fracture of neck were selected. Twenty four patients underwent cemented and 28 patients underwent uncemented hemiarthroplasty. Mean follow up duration was 59.3 months. Harris Hip Score evaluation was done at each follow up. Radiological evaluation was done at each follow up for calcar length and periprosthetic fractures.

RESULTS

Mean age of patients was 70 years. Harris Hip scores at 3, 6 and 12 months did not show statistically significant differences. Periprosthetic osteolysis or loosening was not seen in the present study. No complications noted in uncemented hemiarthroplasty. Four patients who had cemented hemiarthroplasty had infections. No mortality occurred during admission and within 12 months after surgery.

CONCLUSION

No significant difference was noted between the cemented and uncemented hemiarthroplasty procedures on long term follow up in terms of functionality. No re-operations and no mortality reported. Cemented hemiarthroplasty had more blood loss and minimal post-operative complications.

Early Results of a Geriatric Hip Fracture Program in India for Femoral Neck Fracture

Geriatric hip fractures are a challenging clinical problem throughout the world. Hip fracture services have been shown to shorten time to surgery, decrease the cost of admissions, and improve the outcomes. We instituted a geriatric hip fracture program for comanagement of these injuries by orthopedic and internal medicine teams at our hospital in India. From January 2010 till December 2011, 119 patients with a femoral neck fracture were treated with cemented modular hemiarthroplasty under this program using a cost-effective Indian implant. The cohort included 63 males and 56 females with a mean age of 70.7 years (range 55-98 years). Hypertension (n = 42) and diabetes mellitus (n = 29) were the most common comorbidities. The follow-up period ranged from 12 to 37 months with an average of 24 months. The surgery was performed within 24 hours of admission in 60.5% (n = 72) patients. The use of antiplatelet drugs was the most common reason for delay of surgery. The mean length of hospital stay was 10.4 days (range 3-24 days) with 77% (n = 92) of patients discharged within 1 week of admission. On follow-up, good to excellent Harris hip scores were seen in 88% of patients with 76% of patients returning to the preinjury ambulatory status. The mortality rate was 6% at 6 months follow-up and 10.9% at 2 years. Our study shows that a hip fracture program can be instituted in India. The program helped us in achieving the goal of early surgery, mobilization, and discharge from hospital with decreased mortality.

Intra-operative fractures in cementless bipolar hemiarthroplasty

PURPOSE

To compare patients with or without intra-operative fracture during cementless bipolar hemiarthroplasty.

METHODS

Records of 76 men and 202 women who underwent cementless bipolar hemiarthroplasty for femoral neck fractures were reviewed. Patients with and without intra-operative fractures and patients with different types of intra-operative fractures were compared.

RESULTS

Two men and 22 women aged 62 to 93 (mean, 80) years sustained intra-operative fractures at the lesser trochanter (n=18), the greater trochanter (n=5), and the subtrochanter (n=1). All 18 lesser trochanteric fractures and 4 of the greater trochanteric fractures were recognised intra-operatively and managed with cerclage wiring (n=21) or conversion to cemented hemiarthroplasty with cerclage wiring (n=1). The remaining 2 fractures were recognised postoperatively on radiographs and managed conservatively or with revision surgery and cerclage wiring and plating on day 4. Intra-operative fractures correlated with female gender (p=0.03) and operative delay to optimise patients (p=0.02), whereas the fracture site correlated with the time of fracture recognition (p=0.01). Postoperatively, 5 patients were allowed partial weight bearing and 18 were instructed to mobilise with a wheelchair for at least 6 weeks. One patient died from an unrelated cause. At one year, 21 patients reported no hip pain and 2 reported minimal pain. 17 could walk with or without aids and 6 were wheelchair-bound.

CONCLUSION

Surgeons should be familiar with the size difference in trial and actual implants used in bipolar hemiarthroplasty in order to better estimate the extent of broaching required. In most patients with an intra-operative fracture, the one-year outcome was not compromised, despite the poorer short-term outcome.

Bipolar hemiarthroplasty for intracapsular femoral neck fractures in elderly patients

PURPOSE

To report outcome of 30 patients who underwent bipolar hemiarthroplasty for intracapsular femoral neck fractures.

METHODS

18 women and 12 men aged 56 to 86 (mean, 70) years with Garden type III (n=7) or IV (n=23) intracapsular femoral neck fractures underwent cemented (n=5) or uncemented (n=25) bipolar hemiarthroplasty. Pain was evaluated using the visual analogue score. Mobility status was classified as ambulation with or without aid (a cane or walker). Stability of the prosthesis was classified as stable or unstable. Functional outcome was evaluated using the Harris Hip Score.

RESULTS

The mean length of hospital stay was 15.3 (range, 4-29) days. At the 6-month follow-up, 21 patients had no pain, 6 had mild pain, and 3 had moderate pain. The mean Harris Hip Score was 83.1; functional outcome was excellent in 10 patients, good in 13, fair in 5, and poor in 2. The latter 2 were non-ambulatory; one of whom had sustained a periprosthetic fracture intra-operatively, which was managed by encerclage wiring, and the other had a neglected prosthetic dislocation at 3 months, which was converted to an excision arthroplasty.

CONCLUSION

Bipolar hemiarthroplasty conferred good short-term outcome.