|Year : 2021 | Volume
| Issue : 3 | Page : 61-65
Functional outcome of bipolar hemiarthroplasty for fracture neck femur: A retrospective observational study
Gaurav Rai1, Tarun Naugraiya1, Arvind Karoria2
1 Department of Orthopaedics, GRMC, Gwalior, Madhya Pradesh, India
2 Department of Orthopaedics, GMC, Shivpuri, Madhya Pradesh, India
|Date of Submission||27-Aug-2021|
|Date of Decision||23-Sep-2021|
|Date of Acceptance||01-Oct-2021|
|Date of Web Publication||20-Dec-2021|
Dr. Tarun Naugraiya
House Number L-13, Site-1st, City Centre, Landmark: Infront of Hero Showroom, Gwalior - 474 011, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The femoral neck fracture continues to be unsolved fractures, and the guidelines for management are still evolving. Hip fractures are common injuries, especially seen in the elderly in the emergency setting. It is also seen in young patients who perform in athletics or high-energy trauma. Immediate diagnosis and management are required to prevent complications. Materials and Methods: The retrospective study was done who were admitted and underwent bipolar hemiarthroplasty in the past 5 years. Results: The highest mortality was when the surgery was delayed for more than 2 months after injury. A delay of few days did not lead to increased mortality compared to other series, and cemented hemiarthroplasty does not lead to significant long-term cognitive impairment, the increasing time after surgery, there was an increasing proportion of patients with painful hip, and almost 80% of patients at the end of 5 years had poor outcome. Conclusion: The majority of the cases of fracture neck of femur in elderly was due to fall on ground indicating them to be a fragility fracture. Most of the patients were not able to squat and sit cross legged which is an important social requirement in Indian subcontinent. Hemiarthroplasty was not a good surgery for patients who have a longer life expectancy.
Keywords: Bipolar hemiarthroplasty, functional outcome, Harris hip score, neck of femur fracture
|How to cite this article:|
Rai G, Naugraiya T, Karoria A. Functional outcome of bipolar hemiarthroplasty for fracture neck femur: A retrospective observational study. J Orthop Dis Traumatol 2021;4:61-5
|How to cite this URL:|
Rai G, Naugraiya T, Karoria A. Functional outcome of bipolar hemiarthroplasty for fracture neck femur: A retrospective observational study. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Jul 3];4:61-5. Available from: https://jodt.org/text.asp?2021/4/3/61/332943
| Introduction|| |
The incidence of femoral neck fractures, one of the most common traumatic injuries in the elderly increases continuously due to the aging of population on the planet and urbanization. In terms of global economic instability, increasingly more funds would have to be paid by the health systems for treatment of those fractures. Probably, it will be necessary to revise and optimize some current therapeutic standards.
The number of hip fractures worldwide is expected to increase from 1.7 million in 1990 to 6.3 million in 2050. Assuming that the age-related incidence will increase by only 1%/year, the number of hip fractures in the world will reach the figure of 8.2 million in 2050.
Compared to internal fixation, hip hemiarthroplasty is more commonly performed in elderly patients with displaced femoral neck fractures because of more significant improvements in pain and early ambulation, lower rates of re-operation, and other advantages.
Internal fixation is considered better for younger patients. However, some authors have reported a high re-operation rate in older patients with un-displaced fractures, because of fixation failure, avascular necrosis of the femoral head and others.
The advantages of bipolar hemiarthroplasty compared to total hip arthroplasty were that the surgical procedure was simple, the volume of blood was small, and the incidence of dislocation was low. Another reason is that Asian people are used to cultures that they do not require chairs. Naturally, they sit on the floor with their legs crossed, and most of the work for farmers and workers demand them to squat for most of their labor times. These habits demand larger range of motion to their hip joint, and their joint should not be dislocated. Therefore, despite many reports on long-term results that had demonstrated unacceptably high rates of pain and migration, bipolar hemiarthroplasty still has been popularized in Asia.
Hemiarthroplasty is the more often surgical option currently used for the management of displaced intracapsular femoral neck fractures in elderly patients to restore their mobility and prevent of complications related to decreased ambulation following fracture.
However, this surgical intervention is not without morbidity and mortality during perioperative period.
The purpose of this retrospective study was to report on the mortality rate and functional outcome of cemented bipolar hemiarthroplasty in femoral neck fractures in elderly.
| Materials and Methods|| |
This retrospective study was done in the our institute after clearance from Ethical Committee. The cases being those who have been treated by cemented bipolar hemiarthroplasty for fracture neck femur.
Selection based on some inclusion and exclusion criteria.
- Patients with the age group of 60 years or above of either sexes
- Patients with intracapsular femur neck fracture
- Patients who were walking independently before suffering from fracture neck femur
- Patients who did not have significant neurological deficit.
- Patients <60 years of age
- Patients with associated injuries of lower limb which may interfere with their function
- Patients who were not walking independently (to rule out pathological disease) before they sustained fracture neck femur.
Records of our institute were collected, and all patients who had undergone bipolar hemiarthroplasty for fracture neck of femur from January 2013 with sample size of 107 patients were taken up for the study.
They were contacted through telephone, mail, or by visiting their residence.
The functional outcomes and clinical results of the patients were evaluated and graded using Harris hip score (HHS, squatting and crossed legged test, mini mental state examination, and timed up and go test.
Analyses methods used
- Squatting and crossed-legged sitting test
- Mini-mental state examination
- Timed up and go test.
Following observations are based on the retrospective study, and follow-up of 107 patients of displaced femoral neck fractures in geriatric population that were operated with cemented bipolar hemiarthroplasty.
The age of the patients ranged from 60 to 85 years (mean age 68.8 years) [Table 1].
Out of 107 patients, 54 patients (50.4%) were female and 53 patients (49.6%) were male [Table 2].
Out of 107 patients, 38 patients (36%) had fracture on left side and 69 patients (64%) had fracture on the right side [Table 3].
In our study, 80 patients (75%) sustained injury due to fall on ground, and 20 patients (19%) sustained injury due to road traffic accident, whereas 7 patients (6%) sustained injury due to assault [Table 4].
Out of 107 patients, 47 patients (43.9%) were operated in <10 days since injury, 24 patients (22.4%) were operated within 10–30 days since injury, 7 patients (6.54%) were operated within 30-50 days since injury, 13 patients (15.8%) were operated within 50–70 days since injury, and 12 patients (11.2%) were operated in >70 days since injury [Table 5].
Out of 107 patients, 4 patients (3.7%) were operated using a prosthesis with 39 mm head size, 13 patients (12.1%) were operated using a prosthesis with 41 mm head size, 19 patients (17.7%) were operated using a prosthesis with 43 mm head size, 30 patients (28%) were operated using a prosthesis with 45 mm head size, 18 patients (16.8%) were operated using a prosthesis with 47 mm head size, 19 patients (17.7%) were operated using a prosthesis with 49 mm head size, 4 patients (3.7%) were operated using a prosthesis with 51 mm head size [Graph 1] and [Table 6].
Out of 107 patients, 26 patients died during follow-up and two patients revised to total hip replacement; 79 patients were evaluated for functional outcome.
Out of 79 patients, 3 (4%) had excellent results, 8 (10%) had good results, 27 (34%) had fair results, and 41 (52%) had poor results. Average HHS was 67.16 [Graph 2] and [Table 7].
The average HHS s at the end of 1 year was 70.2, at the end of 2 years was 66.8, at the end of 3 years was 66.9, at the end of 4 years was 66.9, and at the end of 5 years was 65.9 [Table 8].
| Discussion|| |
In this study, 107 elderly patients of fracture neck femur treated with cemented bipolar hemiarthroplasty.
All the patients considered in our study were above 60 years of age, with most of the patients between 61 and 70 years of age.
Out of all patients, 3 (4%) had excellent results, 8 (10%) had good results, 27 (34%) had fair results, and 41 (52%) had poor results. Average HHS was 67.16.
The average HHSs at the end of 1 year were 70.2, at the end of 2 years was 66.8, at the end of 3 years was 66.9, at the end of 4 years was 66.9, and at the end of 5 years was 65.9. Benjamin Buecking et al. (2016) analyzed 126 elderly patients for 1 year of displaced femoral neck fracture by bipolar hemiarthroplasty in a study and concluded a mean HHS of 73. Rajak et al. analyzed thirty patients for 6 months who underwent bipolar hemiarthroplasty for intracapsular femoral neck fractures and found mean HHS of 83.1. von Roth et al. did a prospective study of cemented bipolar hemiarthroplasty for 20 years and found the mean HHS of 339 patients who were living and those without revision surgery was 63 ± 22.
Bezwada et al. did a study of 246 cementless bipolar hemiarthroplasty and found that after 2 years of follow-up the HHSs averaged 82 points (range, 54–92). Seventeen patients (10%) scored 90–100, 93 patients (55%) scored 80–89, 50 patients (30%) scored 70–79, and 8 patients (5%) scored <70.
Out of all patients, 4 patients (4%) had deep infection, 7 patients (6%) had prosthesis dislocation after surgery, 1 patient (1%) had periprosthetic fracture, 2 patients (2%) had contralateral fracture, 1 patients (1%) had cognitive dysfunction, and 2 patients (2%) had revision operation, 52 patients (48%) complained of painful gait but walking independently and 35 patients (32%) had the inability to walk without support. Chaplin et al. in their study on “Complications following hemiarthroplasty for displaced intracapsular femoral neck fractures in the absence of routine follow-up” in 40 patients found 11 patients with periprosthetic fracture, 10 patients with aseptic loosening, 10 patients with unexplained pain, 8 patients with deep infection, and 1 patient with dislocation. Saberi et al. in their study on early complications following bipolar hemiarthroplasty for femoral neck fracture in elderly patients on 150 patients found 34 complications which comprised 11 patient mortalities, 10 patients with prosthesis dislocation, 6 patients with infections, 4 patients with wound infections, 2 patients with systemic infection, 4 patients with pulmonary embolism, 2 patients with bed sores, and 1 patient with heterotropic ossification. Buecking et al. (2015) analyzed 126 elderly patients for displaced femoral neck fracture by bipolar hemiarthroplasty in a study and reported surgical complications in 16 patients and comprised 5 hematomas, 4 seromas, 2 deep infections, 3 dislocations, 1 periprosthetic fracture, and 1 wound dehiscence.
Out of 107 patients, mortality at one month was 9 patients (8.4%), mortality between 2 and 6 months was 12 patients (11.21%), andmortality between 7 months and 1 year was 14 (13.08%). In 1993, Lennox and McLauchlan did a study to determine perioperative mortality in cemented hemiarthroplasty and found 6 deaths out of 150 patients (4%) in <48 h. In 2001, Hannan et al. did a study to identify and compare the importance of significant prefracture predictors of functional status and mortality at 6 months for patients hospitalized with hip fracture and to compare risk-adjusted outcomes for hospitals providing initial care. The in-hospital mortality rate was 1.6%. At 6 months, the mortality rate was 13.5%, and another 12.8% needed total assistance to ambulate. In 2009, Lim et al. did a study to determine the mortality rate and factors related to mortality in elderly patients with acute and monotraumatic femoral neck fractures. This study included 241 patients with femoral neck fractures after bipolar hemiarthroplasty. The postoperative mortality rate 1 and 3 years after surgery was 11.2% and 19.5%, respectively. There proved to be a relationship between postoperative mortality and age, the time to surgery, and the society of anesthesiologists score. They recommended that surgery should not be delayed, and caution should be exercised for the high-risk group patients.
Out of all patients, only 13 patients (14.6%) were able to squat and sit cross legged.
Out of all patients, mini-mental status examination showed that 54 patients had no cognitive impairment, 24 patients had mild cognitive impairment, 1 patient had severe cognitive impairment [Table 9] and [Graph 3].
| Conclusion|| |
The incidence of fracture neck femur was found almost equal in both females as well as males after the age of 60 years.
The highest mortality was when the surgery was delayed for more than 2 months after injury. A delay of few days did not lead to increased mortality compared to other series.
Only one patient showing severe cognitive impairment. This shows that cemented hemiarthroplasty does not lead to significant long-term cognitive impairment. Only 14.6% patients were able to squat and sit cross-legged which is an important social requirement in the Indian subcontinent.
With the increasing time after surgery, there was an increasing proportion of patients with painful hip, and almost 80% of patients at the end of 5 years had poor outcome. This indicates that, though the incidence of other complication was at par what was given in literature, hemiarthroplasty was not a good surgery for patients who have a longer life expectancy.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Filipov O. Epidemiology and social burden of the femoral neck fractures. J IMAB 2014;20:516-8.
Johnell O, Kanis J. Epidemiology of osteoporotic fractures. Osteoporos Int 2005;16 Suppl 2:S3-7.
Waaler Bjørnelv GM, Frihagen F, Madsen JE, Nordsletten L, Aas E. Hemiarthroplasty compared to internal fixation with percutaneous cannulated screws as treatment of displaced femoral neck fractures in the elderly: Cost-utility analysis performed alongside a randomized, controlled trial. Osteoporos Int 2012;23:1711-9.
Bhandari M, Devereaux PJ, Tornetta P
, Swiontkowski MF, Berry DJ, Haidukewych G, et al.
Operative management of displaced femoral neck fractures in elderly patients. An international survey. J Bone Joint Surg Am 2005;87:2122-30.
Kain MS, Marcantonio AJ, Iorio R. Revision surgery occurs frequently after percutaneous fixation of stable femoral neck fractures in elderly patients. Clin Orthop Relat Res 2014;472:4010-4.
Lee SB, Sugano N, Nakata K, Matsui M, Ohzono K. Comparison between bipolar hemiarthroplasty and THA for osteonecrosis of the femoral head. Clin Orthop Relat Res 2004;424:161-5.
Muraki M, Sudo A, Hasegawa M, Fukuda A, Uchida A. Long-term results of bipolar hemiarthroplasty for osteoarthritis of the hip and idiopathic osteonecrosis of the femoral head. J Orthop Sci 2008;13:313-7.
D'Angelo F, Giudici M, Molina M, Margaria G. Mortality rate after hip hemiarthroplasty: Analysis of risk factors in 299 consecutives cases. J Orthop Traumatol 2005;6:111-6.
Shah SN, Wainess RM, Karunakar MA. Hemiarthroplasty for femoral neck fracture in the elderly surgeon and hospital volume-related outcomes. J Arthroplasty 2005;20:503-8.
Buecking B, Boese CK, Bergmeister VA, Frink M, Ruchholtz S, Lechler P. Functional implications of femoral offset following hemiarthroplasty for displaced femoral neck fracture. Int Orthop 2016;40:1515-21.
Rajak MK, Jha R, Kumar P, Thakur R. Bipolar hemiarthroplasty for intracapsular femoral neck fractures in elderly patients. J Orthop Surg (Hong Kong) 2013;21:313-6.
von Roth P, Abdel MP, Harmsen WS, Berry DJ. Cemented bipolar hemiarthroplasty provides definitive treatment for femoral neck fractures at 20 years and beyond. Clin Orthop Relat Res 2015;473:3595-9.
Bezwada HP, Shah AR, Harding SH, Baker J, Johanson NA, Mont MA. Cementless bipolar hemiarthroplasty for displaced femoral neck fractures in the elderly. J Arthroplasty 2004;19:73-7.
Chaplin VK, Matharu GS, Knebel RW. Complications following hemiarthroplasty for displaced intracapsular femoral neck fractures in the absence of routine follow-up. Ann R Coll Surg Engl 2013;95:271-4.
Saberi S, Arabzadeh A, Khomeisi B, Berehnegard E, Mortazavi SM. Early complications following bipolar hemiarthroplasty for femoral neck fracture in elderly patients. Acad J Surg 2014;1:45-8.
Lennox IA, McLauchlan J. Comparing the mortality and morbidity of cemented and uncemented hemiarthroplasties. Injury 1993;24:185-6.
Hannan EL, Magaziner J, Wang JJ, Eastwood EA, Silberzweig SB, Gilbert M, et al.
Mortality and locomotion 6 months after hospitalization for hip fracture: Risk factors and risk-adjusted hospital outcomes. JAMA 2001;285:2736-42.
Lim YW, Kwon SY, Han SK, Sun DH, Choi SP, Kim YS. Postoperative mortality and factors related to mortality after bipolar hemiarthroplasty in patients with femoral neck fractures. J Arthroplasty 2009;24:1277-80.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]