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Abstract
Background:
Intertrochanteric femoral fractures have been
estimated to occur in more than 200,000 patients
each year in the United States, with reported
mortality rates ranging from 15% to 20%. Most
intertrochanteric femoral fractures occur in patients
over 70 years of age. Hip fractures (intertrochanteric
and femoral neck fractures) account for 30% of
all hospitalized patients in the United States,
and the estimated cost for treatment is approximately
$8 billion a year.
The
management of unstable osteoporotic intertrochanteric
fractures in the elderly is challenging because
of difficult anatomical reduction, poor bone quality,
and sometimes a need to protect the fracture from
stresses of weight bearing. Internal fixation
in these cases usually involves prolonged bed
rest or limited ambulation, to prevent implant
failure secondary to osteoporosis. This might
result in higher chances of complications like
pulmonary embolism, deep vein thrombosis, pneumonia,
and decubitus ulcer. The purpose of this study
is to analyze the role of primary cemented hemiarthroplasty
in cases of unstable osteoporotic intertrochanteric
femur fractures.
Methods: A retrospective
study conducted at Queen Alia hospital to analyze
16 cases of primary cemented hemiarthroplasty
performed for osteoporotic unstable intertrochanteric
fractures Evans type III or IV fractures). There
were 12 females and 4 males with a mean age of
80 years (range, 75-100 years).
Results: We had good results in the majority
of the patients in terms of return to pre-fracture
level of activity, independent ambulation and
satisfaction with the procedure. Patients over
the age of 80 years who underwent hemiarthroplasty
all progressed well without any complications.
One patient died due to an unrelated causes (myocardial
infarction), there was one case of deep infection,
no cases of deep vein thrombosis, one patient
had superficial skin infection and one had bed
sores with no other significant postoperative
complication.
Conclusion: Cemented hemiarthroplasty is
a successful procedure for the elderly population
over 70 years with femoral neck fractures. Return
to pre-morbid level of activity and independent
functions occur early, avoiding the hazards of
prolonged incumbency to prevent implant failure
secondary to osteoporosis. This might result in
higher chances of complications like pulmonary
embolism, deep vein thrombosis, pneumonia, and
decubitus ulcer. Good functional results were
obtained by early cemented hemiarhroplasty, although
further prospective randomized trials are required
to support our conclusion.
Keywords:
Hemiarthroplasty, osteoporotic fractures, unstable
intertrochanteric fractures
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INTRODUCTION
Fractures
of the proximal femur and hip are relatively common
injuries in adults. Several epidemiological studies
have suggested that the incidence of fractures of the
proximal femur is increasing, not unexpectedly, since
the general life expectancy of the population has increased
significantly during the past few decades. These fractures
are associated with substantial morbidity and mortality;
approximately 15% to 20% of patients die within 1 year
of fracture. After 1 year, patients appear to resume
their age-adjusted mortality rate.
Most proximal femoral fractures occur in elderly individuals
as a result of only moderate or minimal trauma. In younger
patients these fractures usually result from high-energy
trauma. Despite similar locations of the fracture, the
differences in low- and high-velocity injuries in older
versus younger patients outweigh the similarities. More
often than not, high-velocity injuries are more difficult
to treat and are associated with more complications
than low-velocity injuries.
Femoral neck fractures and intertrochanteric fractures
occur with about the same frequency.
They are both more common in women than in men by a
margin of three to one. Other risk factors include Caucasian
race, neurological impairment, malnutrition, impaired
vision, malignancy, and decreased physical activity.
Osteoporosis, although present in the population at
risk, has not been shown to be more prevalent in those
with fractures than in age-matched controls.
Subtrochanteric fractures, which account for 10% to
15% of proximal femoral fractures, have a bimodal distribution
pattern, appearing commonly in patients 20 to 40 years
of age and in those over 60 years of age. Fractures
in younger patients usually result from high-energy
trauma.
The prognosis for each of the three major categories
of hip fractures is entirely different.
Intertrochanteric fractures usually unite if reduction
and fixation are properly done, and, although malunions
may be a problem, late complications are rare. A wide
area of bone is involved, most of which is cancellous,
and both fragments are well supplied with blood. Fractures
of the neck of the femur are intracapsular and involve
a constricted area with comparatively little cancellous
bone and a periosteum that is thin or absent. Although
the blood supply to the distal fragment is sufficient,
the blood supply to the femoral head may be impaired
or entirely lacking; for this reason, avascular necrosis
and later degenerative changes of the femoral head often
follow femoral neck fractures. Subtrochanteric fractures
are associated with high rates of nonunion and implant
fatigue failure because of the high stresses in this
region.
If the diagnosis of a hip fracture is questionable in
an acutely painful hip, bone scanning and MRI have demonstrated
excellent sensitivity in identifying these injuries.
In a study by Quinn and McCarthy, T1-weighted MR images
were found to be 100% sensitive in patients with equivocal
roentgenographic findings. Traditionally, bone scan
has been thought to be unreliable before 48 to 72 hours
after fracture, but a study by Holder et al. found a
sensitivity of 93% regardless of time from injury, including
fractures less than 24 hours old. Osteoporosis and instability
are one of the most important factors leading to unsatisfactory
results. Also in these elderly patients with unstable
osteoporotic fractures, a period of restricted mobilisation
is suggested, which may cause complications like atelectasis,
bed sores, pneumonia, and deep vein thrombosis. Thus
fracture stability, bone strength, and early rehabilitation
determined the final results in cases of intertrochantric
fractures.
MATERIALS AND METHODS
A
retrospective study conducted at Queen Alia Hospital
to analyze 16 cases of primary cemented hemiarthroplasty
performed for osteoporotic unstable intertrochanteric
fractures Evans type III or IV fractures). There were
12 females and 4 males with a mean age of 80 years (range,
75-100 years).
Associated co-morbidities included
combinations of diabetes mellitus, hypertension, chest
disorders, cardiac disorders, renal diseases, hepatic
diseases, neurological and psychiatric illness. Most
of the patients had more than 3 coexisting morbidities.
The fractures were classified according to AO/OTA and
Evans classification. Only AO/OTA type 31-A2.2 and 31-A2.3
and Evans type III or IV fractures were included in
this study. Although the AO/OTA classification classifies
these fractures as pertrochanteric, however since we
also used the Evans classification we retained the terminology
of the intertrochanteric fracture to avoid confusion,
as there were patients with associated fractures that
might significantly affect the final functional outcome.
All patients were community ambulators prior to trauma.
Most required an aid like a cane or a walking stick.
None of our patients had any significant preexisting
hip pathology.
Prosthetic replacement for intertrochanteric fractures
has been advocated but has not gained widespread support.
Pinder, Durnin, and Cook; Heiman; and Stern and Angerman
all reported the use of Leinbach prostheses in selected
patients, with good results in 86% to 94%. Green, Moore,
and Proano, and Haentjens et al. reported primary bipolar
arthroplasty for unstable intertrochanteric fractures
in elderly patients. In patients with severe osteoporosis
with significant comminution, prosthetic replacement
may be considered; however, the extensive surgery necessary
may be unjustified in elderly patients with low activity
demands and limited life expectancies. Prosthetic replacement
is a useful technique for an occasional patient with
an intertrochanteric nonunion and failure of fixation.
All cases were operated
on using a standard anterolateral approach in lateral
position. The fracture anatomy was assessed and a cut
was taken high up in the neck (almost subcapital level)
to facilitate removal of the femoral head. With the
removal of the head, the fracture now had three main
fragments namely the greater trochanter, the lesser
trochanter, and the shaft.
Postoperative protocol
for patients with cemented implants (bipolar or total
hips) involved full weight-bearing as soon as possible
(as per patient ability to stand supported) and active
hip and knee exercises. Patients with hybrid hip replacements
were initially mobilized to partial weight-bearing for
three weeks and then graduated to full weight-bearing
over the next three weeks.
Patients were reviewed
at two weeks (for staple removal), six weeks, three
months, six months, and 12 months and assessed using
clinical and radiological criteria. Clinical criteria
used were absence of pain and limp, as well as the ability
to perform activities of daily living independently
and the Harris Hip scores (performed to quantify results
only). All patients were studied radiologically for
signs of loosening, or subsidence.
RESULTS
We had good results
in the majority of the patients in terms of return to
pre-fracture level of activity, independent ambulation
and satisfaction with the procedure. Patients over the
age of 80 years who underwent hemiarthroplasty all progressed
well without any complication. One patient died due
to an unrelated cause (myocardial infarction), there
was one case of deep infection, no cases of deep vein
thrombosis, one patient had superficial skin infection
and one had bed sores with no other significant postoperative
complication.
We had good results in the patients that we treated,
in terms of return to pre-fracture level of activity,
independent ambulation and satisfaction with the procedure.
We used the anterolateral approach in all patients and
the blood loss averaged 300 ml.
Hemiarthroplasty was reserved
for patients of age more than 80 who were independently
mobile, had severe co-morbidities and needed excessive
movement. We performed cemented bipolar hemi-arthroplasties
in 16 patients.
| Complication |
Number
of patients
|
| Deep
infection |
1
|
| Superficial
infection |
1
|
| Deep
venous thrombosis |
0
|
| Dislocation
|
1
|
| Death |
1
|
| Bed
sore |
1
|
DISCUSSION
For displaced
fractures of the femoral neck, reduction, compression,
and rigid internal fixation are required if union is
to be predictable. Because nonunion and avascular necrosis
develop frequently after internal fixation of displaced
femoral neck fractures, many surgeons recommend primary
prosthetic replacement as an alternative in elderly
but ambulatory patients. It must be remembered, however,
that although the use of a prosthesis avoids nonunion
and avascular necrosis, it may also be followed by complications.
Hudson et al. reported an 8-year outcome study of 367
femoral neck fractures treated surgically. Their study
showed a higher rate of revision in patients over 80
years of age treated with internal fixation of a displaced
intertrochanter fracture compared with those who were
treated with hemiarthroplasty. However, there was no
difference in the revision rates of non-displaced fractures
treated by either internal fixation or hemiarthroplasty
in this age group. In patients between the ages of 65
and 80 years, regardless of the amount of displacement,
no difference was noted in revision rates after hemiarthroplasty
or internal fixation. However, these authors noted a
significantly higher mortality rate associated with
internal fixation than with hemiarthroplasty for patients
in this age group. Complications, revision rates, and
other outcomes were the same regardless of whether unipolar
or bipolar prosthesis was used and whether an anterior
or posterior approach for hemiarthroplasty was used
in patients between 65 and 80 years.
Several authors have listed the advantages and disadvantages
of, as well as the indications for, prosthetic replacement
for recent displaced fractures of the femoral neck,
and no two totally agree. The advantages can be summarized
as follows:
1. Prosthetic replacement allows immediate weight-bearing
to return elderly patients to activity and help avoid
complications of recumbency and inactivity. When the
concept of prosthetic replacement was first introduced,
this perhaps was the most important advantage. As patients
with internal fixation devices are more aggressively
mobilized than in the past and the majority are allowed
at least partial immediate weight-bearing. This advantage
is less distinct than previously thought.
2. As a primary procedure, prosthetic replacement
eliminates avascular necrosis and nonunion as complications
of femoral neck fractures. There still is no completely
reliable way of identifying femoral heads with a significantly
damaged blood supply before definitive surgery. Developing
MRI technology may allow definitive preoperative identification
of these avascular femoral heads and thus provide useful
information in making the decision between prosthetic
replacement and internal fixation.
3. Prosthetic replacement of displaced femoral
neck fractures reduces the incidence of reoperation
compared to internal fixation. In a meta-analysis of
106 reports on displaced femoral neck fractures, Lu-Yao
et al. found the incidence of reoperation within 2 years
to range from 20% to 36% after internal fixation. The
reoperation rate after hemiarthroplasty within the same
time interval was 6% to 18%. This argument applied only
to elderly individuals with a limited life expectancy
because the cumulative rate of reoperation for prosthetic
replacement certainly increases with time.
The recognized disadvantages
of using a prosthesis in a fresh intertrochanter femoral
neck fracture are as follows:
1. After the femoral head and neck have been
discarded in favor of a metal implant, salvage procedures
become complicated if there is mechanical failure or
infection. The use of a prosthesis for most fractures
of the femoral neck ignores the fact that at least two
thirds of patients treated by internal fixation have
functional hips that last the remainder of their lifetimes.
It is appropriate to remember Boyd and Salvatore's comment:
"The sacrifice of the head and neck and replacement
by a metallic foreign substance is not the answer for
the majority of patients; in over half, the best available
material is in the acetabulum, and its indiscriminate
removal should be avoided."
2. The operation for inserting a prosthesis generally
is considered to be more extensive than that required
for an uncomplicated internal fixation procedure. Larger
exposure is required, and blood loss is greater. Many
authors have reported slightly higher perioperative
mortality rates for patients treated with prosthetic
replacement than for those treated with internal fixation.
However, this finding has a definite selection bias
because patients undergoing hemiarthroplasty tend to
be more elderly and have more medical comorbidities.
In the meta-analysis by Lu-Yao et al., there was a trend
for higher mortality rates with hemiarthroplasty within
the first month after the operation, but this trend
was not statistically significant (p = 0.22). After
the first month, there were no differences in the cumulative
mortality rates between the two groups.
Relative Indications for
Hemiarthroplasty
1. Advanced physiological
age. This alone is not a true indication for a prosthesis,
although some local and systemic diseases that occur
in older patients, especially if they occur in combination,
might be. Prosthetic replacement probably should be
reserved for patients 70 years of age or older with
a life expectancy of no more than 10 to 15 years. Some
definite exceptions to this statement are mentioned
later.
2. Fracture-dislocation of the hip in an older
individual. If the fracture involves the superior weight-bearing
surface of the head (Pipkin type II; the Pipkin classification
system is discussed under Dislocation and Fracture-Dislocation
of the Hip), the insertion of a prosthesis is preferable
to closed treatment or open reduction of the fragment.
If a substantial fragment of the inferior part of the
head is fractured (Pipkin type I), the dislocation should
be reduced promptly and, if the head fragment is not
caught in the joint, treated closed; if necessary, open
reduction of the hip can be performed and the fragment
can be removed. Such treatment results in a good hip
if the superior weight-bearing surface of the head is
intact.
Stronger Indications
1. A fracture
that cannot be satisfactorily reduced or fixed with
stability, especially with posterior comminution.
2. Femoral neck fractures that lose fixation
several weeks after operation.
3. Some preexisting lesions of the hip.
In these patients, an arthroplasty already may have
been indicated and the fracture merely makes the decision
immediate; for example, patients with avascular necrosis
of the head of the femur from unknown causes, from irradiation,
or from a previous dislocation, as well as patients
with severe rheumatoid or degenerative arthritis of
the hip, probably will have a better hip after insertion
of a prosthesis than before the fracture.
Furthermore, in one study of rheumatoid patients, Strömqvist,
Kelly, and Lidgren reported a 95% rate of loss of reduction
or superior segmental collapse compared with 50% in
a matched non-rheumatoid group. Most of these patients
are candidates for total hip arthroplasty rather than
femoral head replacement.
4. Malignancy. A malignancy may be an
indication for the insertion of a prosthesis. A patient
with a short life expectancy, whether the fracture is
pathological or primarily the result of trauma, is best
treated with a prosthesis. If the fracture is pathological,
the insertion of a prosthesis offers not only a good
solution, but also an opportunity to obtain an open
biopsy and to establish a definite diagnosis. In pathological
fractures, supplementing the fixation with methylmethacrylate
usually provides sufficient stability.
5. Neurologic disorders. Patients subject
to uncontrolled epileptic seizures and patients with
severe uncontrolled Parkinsonism are better treated
with a primary prosthesis. Many of these disorders are
controllable, however, and thus the indication may not
always be absolute.
6. Old, undiagnosed fractures of the intertrochanter
femoral neck. Occasionally a fracture of the femoral
neck goes undiscovered for several weeks. Sometimes
multiple injuries may delay treatment of a fracture
even after its diagnosis. An untreated, unreduced, and
unimpacted fracture of the femoral neck that is more
than 3 weeks old should have a primary prosthesis.
7. Fracture of the neck of the femur with
complete dislocation of the femoral head. This lesion
is rare and is best treated by primary prosthetic replacement
because avascular necrosis of the head is certain under
these circumstances.
8. A patient who probably cannot withstand
two operations. If a patient's general condition
prohibits a second operation, a primary prosthesis is
justified. In patients who have multiple medical problems,
we occasionally perform a closed reduction with percutaneous
multiple screw fixation using intravenous sedation and
generous amounts of local lidocaine infiltration anesthesia.
9. Patients with psychoses or mental deterioration.
Elderly patients with fractures of the intertrochanter
femoral neck often already have Alzheimer's disease,
and protected weight-bearing in such patients may be
unreliable, with immediate unprotected weight-bearing
resulting in possible loss of fixation, especially in
severely comminuted fractures. A primary prosthesis
may in these circumstances be justified.
CONCLUSION
Cemented hemiarthroplasty
is a successful procedure for the elderly population
over 70 years with femoral neck fractures. Return to
pre-morbid level of activity and independent functions
occur early, avoiding the hazards of prolonged incumbency,
to prevent implant failure secondary to osteoporosis.
This might result in higher chances of complications
like pulmonary embolism, deep vein thrombosis, pneumonia,
and decubitus ulcer. Good functional results were obtained
by early cemented hemiarhroplasty, although further
prospective randomized trials are required to support
our conclusion.
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