|Year : 2022 | Volume
| Issue : 2 | Page : 78-82
Outcome of cemented hemiarthroplasty of hip in elderly patients operated for neck of femur fracture
Sudeep Kumar1, Anup Kumar1, Alapati Hari Venkata Bramesh1, KV Charan Teja1, Mohammed Roshen Abdul Razek1, Ravi Kumar2
1 Department of Orthopaedics, AIIMS, Patna, Bihar, India
2 Department of Orthopaedics, LNJP, Patna, Bihar, India
|Date of Submission||19-Jan-2022|
|Date of Decision||30-Jan-2022|
|Date of Acceptance||02-Feb-2022|
|Date of Web Publication||28-May-2022|
Room 48, OPD Orthopaedics, AIIMS, Patna - 801 507, Bihar
Source of Support: None, Conflict of Interest: None
Introduction: Femoral neck fractures are a common entity in elderly patients. This commonly occurs following trivial injury and the insult is compounded by osteoporosis in this age group. Cemented hemiarthroplasty is recommended by several studies and by several registries, due to low comorbidities compared to uncemented hemiarthroplasty. Significantly improved mobility scores, low pain scores make this a treatment of choice. Materials and Methods: This study included 108 patients who presented with fracture neck of the femur with an average age of 68.30 years and were operated with hemiarthroplasty by two consultant orthopedic surgeons in a standard operative setting over 5 years with modular bipolar prosthesis using lateral approach (Hardinge approach). Patients on follow-up were evaluated using Oxford Hip Score and Forgotten Joint Score. Results: The mean Oxford Hip Score was 39.46 suggestive of satisfactory joint function which may not require any further treatment. The mean Forgotten Joint Score was 83.46 suggestive of high degree of forgetting artificial joint. Conclusion: A very high Oxford Hip Scores and very high Forgotten Joint Scores after surgery suggests that the patients have retained or regained their independence and are doing good. This goes on to suggest that in spite of advancements in surgical techniques and implants for osteosynthesis, hemiarthroplasty done in indicated cases gives a good functional outcome and a lasting solution for these fractures.
Keywords: Forgotten Joint Score, hemiarthroplasty, neck of femur fractures, Oxford Hip score
|How to cite this article:|
Kumar S, Kumar A, Venkata Bramesh AH, Charan Teja K V, Abdul Razek MR, Kumar R. Outcome of cemented hemiarthroplasty of hip in elderly patients operated for neck of femur fracture. J Orthop Dis Traumatol 2022;5:78-82
|How to cite this URL:|
Kumar S, Kumar A, Venkata Bramesh AH, Charan Teja K V, Abdul Razek MR, Kumar R. Outcome of cemented hemiarthroplasty of hip in elderly patients operated for neck of femur fracture. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Jul 3];5:78-82. Available from: https://jodt.org/text.asp?2022/5/2/78/346220
| Introduction|| |
Femoral neck fractures in the elderly population are one of the common causes of orthopedic admission. It includes either intracapsular or extracapsular fractures, majority being intracapsular. The treatment of choice in displaced intracapsular femoral neck fractures is hip arthroplasty– total or hemi replacement. Total hip arthroplasties are frequently used in young patients requiring higher functional demands as per the NICE recommendation. Total hip arthroplasties have better functional outcome compared to hemiarthroplasty at the expense of increased intraoperative blood loss, increased cost, longer surgical duration, and higher rates of dislocation. Total hip arthroplasty is mainly recommended for younger and active individuals with fractures which are difficult to fix (Garden type 3/4)., There is no clear agreement regarding the management in young, active patients where an osteosynthesis procedure is the treatment of choice.
Majority of elderly patients (60%) have severe systemic diseases (The American Society of Anesthesiologists Grade 3) and are of an average age of over 80 years. Their associated comorbidities make them difficult candidates for optimization prior to surgery.
We tried to look into our Indian perspective and Indian data as per the hemiarthroplasty of elderly following neck of femur fractures. We could not find a large database or longer follow-up studies, especially with Indian make implants. Our study aims to see the follow-up of elderly neck of femur fractures operated with cemented hemiarthroplasty with Indian make implants. In this study, we assume that the outcome of cemented hemiarthroplasty of the hip for femoral neck fractures was satisfactory with Indian make implants.
| Materials and Methods|| |
The study was observational type. Ethical clearance was obtained for the study. Consent was taken from the patients for involvement in the study. The patients were evaluated clinically and radiologically regarding the joint function, signs of infection, aseptic loosening, and other complications during follow-up. They were evaluated using Oxford Hip Score [Figure 1] to assess the satisfactory level of the joint. Forgotten Joint Score [Figure 2] was also assessed to find out the awareness of artificial joint.
We reviewed the patients who presented to the emergency and outpatient care of our hospital with the neck of femur fracture following trivial injury or after getting primary care in other health-care centers. Over 120 elderly patients (mean age of 68.30 years ranging from 56 to 95) [Table 1] were presented during the span of 6 years from June 2014 to July 2020. One hundred and eight patients were operated for hemireplacement of hip joint using lateral Hardinge approach in lateral position. All these surgeries were done in regional anesthesia (spinal or epidural or combined block). These patients were offered Indian make INOR company implant (manufactured in Maharashtra) and the USA Food and Drug Administration (FDA) approved Exeter bipolar stem. Majority of patients opted for INOR due to monetary issues.
INOR provides bipolar head from size 33 mm to 59 mm, three different stem sizes (small, medium, and large) and three different neck sizes (short, extended, and long). The implant used for all the cases in this present study was of implant company INOR. 40 g of DePuy CMW3 Gentamicin Bone Cement was used along with canal blocking with Exeter plug. We did canal packing with ribbon gauze and cementing with cement gun and proximal seal was used for pressurization [Figure 3].
|Figure 3: Intraoperative images showing technique of cementing and implantation|
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These patients were given one shot of preoperative intravenous cefazolin 1.5 g and then twice daily for the next 2 days in the postoperative period. Patients were mobilized in and out of the bed and were made to walk with support under the supervision of a physiotherapist [Figure 4] and [Figure 5]. Patients were regularly followed up for a minimum period of 6 months and then on yearly basis.
|Figure 4: Pre- and post-operative X-rays showing cemented hemiarthroplasty of the right hip|
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We excluded 3three patients from the study who opted for Stryker or DePuy implants. Nine patients died during this period due to natural causes and 18 patients did not turn up for follow-up. Seventy-eight patients were evaluated clinically and Oxford Hip Scoring and Forgotten Joint Scoring were done in them [Figure 6]. Among the operated 78 patients, 35.89% were males and 58.97% were operated on the right side [Figure 7].
- Patients treated with cemented hemiarthroplasty
- Patients treated with Indian make INOR.
- Patients managed conservatively
- Patients treated with uncemented hemiarthroplasty
- Patients with psychiatric illness
- Patients lost to follow-up
- Patients had any other orthopedic procedure performed in the same or opposite limb.
| Results|| |
Patients were evaluated for the severity of pain and associated permitted level of activity. The Oxford Hip Score was ranging from 12 to 59 with a mean of 39.46, majority over a score of 40. The Forgotten Joint Score was ranging from 47.91 to 100 with a mean score of 85.68 [Table 2] and [Figure 8]. One patient had <four responses in Forgotten Joint Score and was not included in the mean score calculation. The average surgical duration was 1 h. There was no incidence of intraoperative femur fracture and average blood loss was amounting to 150 ml. There was no incidence of revision arthroplasty or periprosthetic fracture. There was no incidence of prosthesis-related infection.
|Figure 8: Graphical distribution of Oxford Hip Score and Forgotten Joint Score of study population|
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| Discussion|| |
Different treatment modalities are available for the neck of femur fractures such as screw fixation, sliding hip screw fixation, and arthroplasty. Among them, arthroplasty is preferred among elderly population owing to its functional benefits (early mobilization) to the patients. Arthroplasty can be done using cemented or uncemented stems. Physical fitness, functional demand, cognitive function, and affordability of the patient have influence on the decision to use a particular type of prosthesis. The early prosthetic designs such as Moore and Thompson were designed to be used without cement. The potential advantages of cemented stem include reduced postoperative pain and reduced revision rate. The major side effects of cement include very rare cementing-related immediate complications, for example, cardiac arrhythmias and cardiorespiratory collapse due to embolization. Uncemented stem requires relatively less operative time, fewer blood transfusions but require good bone stock, whereas cemented stems are used with poor bone stock. A study by Fenelon et al. showed no difference in mortality rates at 1 week, 1 month, and 1 year with uncemented stems. Uncemented hemiarthroplasty has a complication of perioperative fracture. This happens mostly in an attempt to give a good canal fitting stem and with Indian companies, the stem options are very limited. In case, one tries to go for maximum size, more broaching is required and thus increases the chance of intraoperative femur fractures.
The cemented stem if done properly gives a stem on which the patient can immediately weight bear. This is in contrast to uncemented stem whereas if a thin stem or not very tight-fitting stem has been put then some time to integrate the stem has to be given. If the patient is not mobilizing full weight, then it defeats the whole purpose of doing a hemiarthroplasty in these high-risk elderly populations.
A meta-analysis done by Li et al. on the outcome of cemented versus uncemented hemiarthroplasty included 782 uncemented and 795 cemented hips and showed that uncemented prosthesis shortens the operation time, but does not reduce mortality, blood loss, and hospital stay. The incidence of prosthetic-related complications was higher in uncemented patients.
In a study by Yurdakul et al., 133 patients over the age of 65 years were divided into two groups requiring treatment with cemented and uncemented stems. This study concluded that walking scores and pain scores were better in the early follow-up period whereas the duration of surgery and perioperative mortality rates were lower in uncemented groups. There was no significant difference in terms of the length of hospital stay, Harris Hip Score, or follow-up mortality rates.
Yoon et al. in their study concluded that no significant difference exists regarding the incidence of deep infection, superficial infection, pneumonia, and urinary tract infection. In the analysis of the Dutch Arthroplasty Register consisting of 22,356 hemiarthroplasties, long-term mortality rates did not differ between patients with cemented or uncemented femoral stem after an acute femoral neck fracture and revision rates were lower in the cemented group compared with uncemented hemiarthroplasty.
Another meta-analysis in the UK involving 1169 patients randomized into cemented and uncemented groups showed that there was a significantly increased operative time of 8 min for cemented prosthesis and increased intraoperative blood loss and incidence of intraoperative femur fracture in the cemented group was 0.2% and in the uncemented group was 4.6%. There was lower reduction in mobility scores and lower pain scores signifying less pain in the cemented group.
In a retrospective study on a population of 655 (393 cemented, 262 uncemented) conducted by Frenken et al. found that significantly higher incidence of periprosthetic fractures and postoperative infections were in the uncemented group compared to the cemented group. This study recommended cemented hemiarthroplasty in patients with femoral neck fracture. Based on the analysis of different literature, many studies suggested cemented hemiarthroplasties for displaced femoral neck fracture owing to its low prosthetic-related complications and improved outcome scores. In this study, we used Oxford Hip Score to assess function and pain associated with hip replacement and Forgotten Joint Score was used to assess the patient-related outcome of the replaced joint.
| Conclusion|| |
In our study, we highlighted the use of Indian makes prosthesis in a large series of patients. We did feel that the choices of stem sizes, head sizes, and offset are some of the limiting factors in these implants and there is a definite chance of design improvement. The cost of these implants is however very low (one-third to half) when compared to the USA FDA-approved company's implant. The very fact that in most of our country the implant cost is worn by the patients, it is a tough choice between selecting a costlier implant by the family members for the patients. For an elderly patient who is mainly dependent upon his family for treatment and they are also hand to mouth for their daily living it poses a tough choice for the treating doctor and his patient. Our study shows that these implants although have their inherent issues but the outcome of the patients have been very good all things considered.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]