Functional outcome of hemiarthroplasty vs internal fixation for femoral neck fracture in elderly population: A comparative prospective study

RK S. Dhakad; Abhilekh Mishra; Tarun Naugraiya; Vivek Singh Dhakad

doi:10.4103/jodp.jodp_20_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 5 | Issue : 1 | Page : 3-7

Functional outcome of hemiarthroplasty vs internal fixation for femoral neck fracture in elderly population: A comparative prospective study

RK S. Dhakad, Abhilekh Mishra, Tarun Naugraiya, Vivek Singh Dhakad
Department of Orthopaedics, GRMC, Gwalior, Madhya Pradesh, India

Date of Submission	31-Aug-2021
Date of Decision	02-Nov-2021
Date of Acceptance	10-Dec-2021
Date of Web Publication	15-Mar-2022

Correspondence Address:
Vivek Singh Dhakad
C-870 Anand Nagar, C-Block Sagar Tal Road, Gwalior - 474 012, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_20_21

Abstract

Introduction: Femoral neck fractures are one among the leading causes of death in elderly patients. Magnitude of fracture displacement, patient's age, comorbid disorders, and prefracture activity level are some of the critical factors in determining the clinical practice for treating femoral neck fracture. In this study, we have studied the functional outcome and survivorship in fracture neck of femur in the elderly population operated with both internal fixation (IF) and cemented hemiarthroplasty (HA). Material and Method: All 100 patients were reviewed clinically and radiologically at 15 days, 1 month, and then subsequent 1 year. Out of 100 patients, 54 have been operated with HA and 46 have been operated with screw fixation. Results: Overall reoperation rate in HA group was 5.05%, with total mortality rate being 7.4% compared to 6.5% of IF group. Out of 46 patients of screw fixation, the overall reoperation rate was 20% with 4 patients being developed avascular necrosis and 13 being developed nonunion, and rest of the patients have average Harris hip score of 60–65 with 34%, while patients having poor Harris hip score compared to those of HA with Harris hip score of 80–90 with 88.2% having excellent to fair. Conclusion: Hip arthroplasty as compared to Internal fixation for the treatment of femoral neck fractures significantly reduces the risk of reoperation at the cost of higher superficial infection and blood loss. Furthermore, postoperative function as evaluated by the Harris hip score was significantly higher in the arthroplasty compared to the IF group up to the 6-month evaluation.

Keywords: Avascular necrosis, Harris hip score, hemiarthroplasty, internal fixation, reoperation

How to cite this article:
S. Dhakad R K, Mishra A, Naugraiya T, Dhakad VS. Functional outcome of hemiarthroplasty vs internal fixation for femoral neck fracture in elderly population: A comparative prospective study. J Orthop Dis Traumatol 2022;5:3-7

How to cite this URL:
S. Dhakad R K, Mishra A, Naugraiya T, Dhakad VS. Functional outcome of hemiarthroplasty vs internal fixation for femoral neck fracture in elderly population: A comparative prospective study. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Mar 30];5:3-7. Available from: https://jodt.org/text.asp?2022/5/1/3/339674

Introduction

Fracture neck of the femur has posed a great challenge to the orthopedic surgeons since a long time.^[1] In spite of so many methods and procedures that have been tried to overcome this mishap, it still lives up to its disrepute of being the “unsolved fracture” as far as treatment and results are concerned.^[2]

These fractures are usually sustained by the elderly people by trivial injury, but no age is immune or exempted in either of the sex and it is more common in the elderly. Economically, the fracture neck femur leads to enormous financial burden to the individual, family, and society and ultimately to the nation as a whole.^[3] The interruption to the peculiar vascular supply pattern of the neck of femur, the continuous lysis of the fracture hematoma by synovial fluid, and the lack of periosteum over the neck render and make the definite treatment of this entity difficult.^[4],[5]

The prolonged immobilization which is required after osteosynthesis, and that too with the uncertainty of having a patent vascular supply left to the head, and the vast incidence of nonunion and avascular necrosis, especially in the elderly population, paved the way to the thought of primary head excision and prosthetic replacement in the elderly patient, and thus, the concept of arthroplasty came in vogue. However, whether arthroplasty or internal fixation (IF) is more appropriate for femoral neck fractures in the elderly patients is still being debated.^[6] Proponents of prosthetic replacement argue that replacement of the femoral head eliminates the necessity for revision surgery due to avascular necrosis and nonunion, both of which are difficult situations to manage following osteosynthesis.^[7]

The aim of this study was to evaluate clinical and radiographic results and quality of life and functional outcome at long-term follow-up in a population of patients treated age more than 50 years with bipolar hemiarthroplasty (HA) and IF for an intracapsular fracture of the proximal femur.

Methods

This study has been done randomized prospectively after approval of institutional ethical committee. In the study duration, out of all patients presented with fracture neck of femur, 100 patients have been selected for the study randomly (the randomization method used is simple coin–currency method) and included in the study after having fulfilled the inclusion criteria such as age >50 years and medically and surgically fit for surgery and having capability to give informed consent.

Patients who gave refusal to consent, age <50 years, had suspected pathological fracture or had any preexisting hip pathology, and are bedridden or barely mobile or had significant cognitive impairment were excluded from the study.

Cases have been operated in routine hours as per admission and availability of operation theater. Most of the cases can be operated between 2^nd and 20^th day of admission.

All the patients were counseled regarding the modes of treatment. Informed and valid written consent was taken. The patients were taken for surgery after routine blood investigations, serology, chest X-ray, electrocardiography, echocardiography (if required), and X-ray of pelvis with both hips (in 15° internal rotation) anteroposterior view and lateral view of involved hip. Medical and anesthesia fitness were taken.

After preoperative assessment, cases were prepared for surgery. Under aseptic precaution and prophylactic antibiotic coverage, a dose preferably of ceftriaxone 1 g was given 30 min before the skin incision. Preparation of part was done half an hour before the surgery. Instruments were checked and sterilized beforehand, and then, patients were shifted to operation theater; then, on the basis of fracture pattern in preoperative X-ray, patients were operated [Figure 1] and [Figure 2] with appropriate and best suitable method for the fracture pattern according to Garden's type.^[8]

Figure 1: Bipolar prosthesis insertion

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Figure 2: Intraoperative fluoroscopic image of screw fixation by BDSF technique

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Out of 100 patients of intracapsular fracture neck of femur, displaced fractures (Garden's III and Garden's IV) are operated with cemented bipolar HA while undisplaced fractures (Garden's I and II) are operated with CC screw/DHS depending which is more suitable for fracture.

Follow-up

Patients discharged on 3^rd–7^th day of postoperative period depending on suture line condition. Regular follow-up at every fortnight up to 2 months, after 2 months, monthly follow-up up to 18 months. Follow-up was done using serial X-rays and Harris hip score.

Observation and Results

The fracture was most common in the age group of 51–70 years of age with female preponderance. There were 56% of patients with right-sided fractures and 44% of patients with left-sided fractures showing right-sided preponderance. In our study, most of the injuries were caused by fall on ground/trivial trauma (91%), and remaining injuries were due to rood traffic accident. 50% of patients were having Garden's Type IV fractures, 40% were having Garden's Type III, and 10% were having Gardens type II fractures in HA group patients.

The average surgical time was 71.94 min in HA group patients and 65.18 min in IF group patients (weighted mean difference, 5.76 min; 95% confidence interval 4.2–8.5, P > 0.05) [Figure 3].

Figure 3: Graph correlating duration of surgery

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Patients who underwent arthroplasty had greater blood loss than those who were treated with IF. The intraoperative average blood loss was 320 ml in HA and 140 ml in IF with weighted mean difference of 80 ml (weighted mean difference, 80 mL; 95% confidence interval, 128–210, P > 0.05) [Figure 4].

Figure 4: Graph comparing intraoperative blood loss

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In HA group, 88.2% of patients had fair-to-excellent Harris hip score, while only 7% of patients had poor at last follow-up and three patients did not survive [Table 1]. In IF group, 34% of patients had poor Harris hip score at last follow-up and only one patient certified. The results of this study show the advantage of HA in the recovery of hip function early and 1 year after surgery, the Harris score of HA group was higher than that of IF group, and the excellent and good score in HA group was also significantly higher than that in IF group (P < 0.05).

Table 1: Table comparing Harris hip score

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In IF group, 2.2% of patients developed superficial infection, 4.4% of patients developed deep infection, 2.2% of patients had dislocation after surgery, and 8.8% of patients developed avascular necrosis at around 9^th postoperative month [Figure 5] and [Figure 6]. 33.3% of patients went into nonunion, 8.8% of patients developed implant failure, and 4.4% of patients had intra-articular migration of screw. In total, nine had to go for 7 revision surgery. Three patients were reoperated with bipolar HA, five patients were reoperated with total hip arthroplasty, and one patient reoperated with implant removal f/b valgus osteotomy and DHS.

Figure 5: 9-month follow-up X-rays showing avascular necrosis in patients operated with BDSF

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Figure 6: 8-month follow-up X-ray of patient showing nonunion

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In HA group, 1.8% of patients developed superficial infection, 3.7% of patients developed deep infection, 3.7% of patients had prosthetic hip dislocation after surgery, and one patient had cognitive dysfunction, for which the exact cause was not known. Out of total three reoperation, one patient who had dislocation, open reduction was performed and two patients with deep infection were operated with antibiotic impregnated cement spacer. Overall reoperation rate was 5.5% in HA and 20% in IF (RRR - 3.8 with P = 0.002); thus, screw fixation was a risk factor for a major reoperation.

Discussion

Surgical treatment of femoral neck fracture is one of the most common procedures performed by orthopedic surgeons. However, the optimal treatment option of displaced femoral neck fractures remains a matter of debate.^{[9],[10],[11],[12],[13],[14]} Current treatment options include reduction and IF, HA, or total hip arthroplasty.^[13]

Numerous studies have provided evidence for better outcomes after arthroplasty when compared with IF in terms of overall functional scores, abductor muscles function, independent ambulation without walking aids, and quality of life.^{[14],[15],[16],[17],[18]}

In the present study, we classified the fractures according to Garden's classification in two groups, displaced and undisplaced,^[8] and intervened them with appropriate and best suitable method for the fracture pattern and evaluated the functional outcome for the treatment of femoral neck fractures in elderly patients using closed reduction and IF with cannulated hip screws and hip HA. The results of this study show the advantage of HA in the recovery of hip function early. In 1 year after surgery, the Harris score of HA group was significantly higher than that of IF group, and the excellent and good score in the HA group was also significantly higher than that in the IF group (P < 0.05). The reason was probably that HA could not only allow early ambulation but also avoid IF-related complications, both of which were beneficial for the recovery of hip joint function.

IF preserves the femoral head; in addition, it has shorter operative time, less blood loss, and operative trauma, while arthroplasty might increase operative mortality,^[19] but high proportion of IF-related complications occurred after surgery. On the one hand, due to the blood supply of femoral neck and head had been damaged at the moment of injury. On the other hand, the osteoporotic bone of elderly patients could also have an impact on the treatment of IF. The holding force of the screws on fracture broken end might be weak for osteoporotic bone, while the relative extension of fracture healing time caused by destruction of femoral neck blood supply required IF more firmly. The contradiction between the two could result in IF loosening, displacement, or even failure.

In this study, 9% of patients had the loosening and displacement of IF implants, in IF group. Nonunion rate in the study was 29.5%.

Arthroplasty as a mode of treatment of displaced femoral neck fractures in comparison with IF is associated with a significantly lower risk of revision surgery, at the cost of higher infection, blood loss, and surgical time rates.^{[15],[17],[20]}

Unlike IF group, HA group had very few complications related to operation. However, the associated complications can occur after artificial joint replacement operation, including joint dislocation and prosthesis loosening. However, the artificial joint was more stable for using bipolar HA, and two prosthetic dislocations occurred in HA group. Meanwhile, there was no case of femoral prosthesis loosening. After complications occurred after surgery, the subsequent question was how to deal with these complications, which was bound to involve reoperation. Hence, the high incidence of IF-related complications would lead to a higher incidence of reoperation. 20.5% [Table 2] and [Table 3].

Table 2: Table showing complications of internal fixation group

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Table 3: The results of mortality and survival time comparison

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Keating et al.^[15] recently compared reduction and IF to HA and total hip arthroplasty in patients older than 60 years of age with displaced femoral neck fractures. In their study, at the 2-year follow-up, the rate of reoperation in the IF group was 39% compared to 5% and 9% in the HA and total hip arthroplasty groups, respectively. In addition, the IF group had worse functional and quality of life outcome scores compared with the arthroplasty groups.^[15]

The results of mortality and survival time analysis were not significantly different between the two groups and the patients who died had high risk for operation.

Conclusion

IF with cannulated screws and DHS for femoral neck fractures in the elderly has substantial complications and reoperation (20%) rates.

In line with the literature, the present study showed that hip HA compared to IF for the treatment of femoral neck fractures significantly reduces the risk of reoperation at the cost of higher superficial infection, blood loss.^{[21],[22],[23]} Furthermore, postoperative function as evaluated by the Harris hip score was significantly higher in the HA compared to the IF group, up to 2-year evaluation. The findings suggest that HA might be a better choice than IF in treating elderly patients with a femoral neck fracture.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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