Results of displaced subcapital fractures treated by primary total hip replacement

doi:10.1016/S0020-1383(03)00075-5

Injury

Volume 35, Issue 2, February 2004, Pages 157-160

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Abstract

We present morbidity, mortality and functional outcome in mobile, socially independent and alert patients with displaced subcapital hip fractures, treated by primary total hip replacement (THR).

Fifty-one consecutive socially independent and mentally alert patients with displaced subcapital fractures were treated by primary THR, from April 1997 to March 2000, at a single hospital. Most patients were female (45/51) with an average age of 74 years. Patient hospital records were reviewed and patients interviewed by telephone. Functional outcome was assessed using Oxford hip score (OHS), short form 12 (SF12), and patient satisfaction. This study had a mean follow-up of 33 months (range 20–54).

One patient with early dislocation went on to have recurrent dislocations. Two patients underwent revision surgery. Three patients died within 1 year of sustaining fracture. Function was comparable to elective THR in osteoarthritic patients. OHS correlated well with both SF12 and patient satisfaction.

This study has the lowest reported dislocation rate (2%) and an acceptable 1-year mortality (6%) confirming the place of primary THR in treatment of these selected patients with a displaced hip fracture. The OHS proved a valuable instrument to assess function following THR in fracture patients.

Introduction

Total hip replacement (THR) as primary treatment for displaced intracapsular neck of femur fractures in the elderly patients, remains controversial.⁹ Two recent long-term prospective randomised trials have shown that THR results in decreased pain and improved physical function, as compared to internal fixation and hemiarthroplasty.10., 11. They suggest primary THR for treatment of physiologically active elderly patients with displaced subcapital fracture who are presently treated either by internal fixation or hemiarthroplasty. However primary THR remains unacceptable to many because, besides being expensive and time consuming, it results in a very high dislocation rate in non-arthritic, previously mobile, fracture patients.1., 4., 6., 10., 11., 12., 13., 14. Our challenge to this concern stems from our view that a low dislocation rate along with good function can be achieved by using modern operative techniques in physiologically active elderly patients with displaced subcapital fracture.

We therefore reviewed our patients with displaced subcapital fracture, treated by THR, to assess morbidity, mortality and functional outcome.

Section snippets

Patients and methods

We identified 51 consecutive patients with displaced neck of femur fractures, treated by THR, during a period of 3 years from April 1997 to March 2000. In our hospital, patients above physiological age of 65 years were treated by arthroplasty for displaced subcapital fractures (Garden 3 and 4). THR was given preference over hemiarthroplasty to treat socially independent, mobile and alert patients. In this retrospective clinical study, the first author reviewed the patient hospital records to

Morbidity

Eleven out of 51 patients suffered early in-patient post-operative morbidity, including one dislocation (Table 2). Two patients had late complications resulting in revision surgery. The patient with early dislocation went on to have recurrent dislocations and underwent revision surgery. One patient developed a deep infection and underwent surgical debridement twice, before final revision to a Girdlestone excision arthroplasty.

Mortality

At the time of review 5/51 patients were dead. Of these two died

Discussion

This study shows that in carefully selected patients with displaced intracapsular hip fractures, primary THR resulted in minimal late morbidity (2% dislocation rate and 4% revision rate) in contrast to other series in the literature.4., 6., 10., 11., 12., 13., 14. A high early in-patient morbidity (22%) recorded in this study is comparable with other reports.

Several clinical trials have compared THR to hemiarthroplasty and internal fixation for treating displaced hip fracture.10., 11., 12., 13.

Conclusion

Our study confirms the place of primary THR in treatment of socially independent, mobile, alert patients with displaced hip fracture. We found OHS valuable in functional assessment of THR following hip fracture.

References (14)

I.J Cartlidge
Primary total hip replacement for displaced subcapital femoral fractures
Injury
(1981)
J Dawson et al.
Issues relating to long-term follow-up in hip arthroplasty surgery: a review of 598 cases at 7 years comparing 2 prostheses using revision rates, survival analysis, and patient-based measures
J. Arthroplasty
(2000)
R.J.H Gregory et al.
Treatment of subcapital femoral fractures with total hip replacement
Injury
(1992)
K.J Ravikumar et al.
Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur—13 year results of a prospective randomised study
Injury
(2000)
P Skinner et al.
Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement
Injury
(1989)
B Squires et al.
Displaced intracapsular neck of femur fractures in mobile independent patients: total hip replacement or hemiarthroplasty?
Injury
(1999)
J Dawson et al.
Questionnaire on the perceptions of patients about total hip replacement
J. Bone Joint Surg. Br.
(1996)

There are more references available in the full text version of this article.

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Survival Rate and Application Number of Total Hip Arthroplasty in Patients With Femoral Neck Fracture: An Analysis of Clinical Studies and National Arthroplasty Registers
2020, Journal of Arthroplasty
Citation Excerpt :
One hundred twenty-seven full-text articles were assessed for eligibility. A total of 22 studies [3,11,12,17–35] published from 1999 to 2018 met all predetermined inclusion criteria and were assessed in this review. The systematic literature search and the reference search revealed 19 studies with 24 study cohorts [36–54], which were published from 2003 to 2019.
Total hip arthroplasty (THA) is an increasingly popular treatment option for fractured neck of femur (NOF). The primary aim of this study is to systematically review all literature on primary THA and hemiarthroplasty (HA) after fractured NOF to calculate an overall revision rate. Furthermore, we wanted to compare primary THA implantations after fractured NOF between different countries in terms of THA number per inhabitant.
All clinical studies on THA and HA for femoral neck fractures between 1999 and 2019 were reviewed and evaluated with a special interest on revision rate. Revision rate was calculated as “revision per 100 component years.” THA registers were compared between different countries with respect to the number of primary implantations per inhabitant.
THA studies showed a mean revision rate of 11.8% after 10 years, which was lower than a 24.6% 10-year revision rate for HA. We identified 8 arthroplasty registers that revealed an annual average incidence of THA for fractured NOF of 9.7 per 100,000 inhabitants.
This study showed that patients with THA were less likely to be revised at 10 years compared to HA. We found similar annual numbers of THAs for fractured NOF per inhabitant across countries. The results of this analysis can be used to rank present and future national THA numbers within an international context.
Clinical outcomes of total hip arthroplasty for fractured neck of femur in patients over 75 years
2015, Journal of Arthroplasty
Citation Excerpt :
However, if one excluded the patient with the lowest OHS, who was severely limited by contralateral hip and bilateral knee osteoarthritis, then the mean score in this study would be 42 and therefore equivalent to elective results. The mean score was still comparable to other THA for hip fracture papers looking at a younger population [36] and preferable to those obtained in populations undergoing hemiarthroplasty for NOF fracture with studies quoting a mean score from 35 to 38 [37–39]. We know that hip function peaks approximately 12 months following a TH, therefore if a THA provides a better functioning joint at 12 months then this is a significant advantage over hemiarthoplasty [12,40,41].
To date, there has been little research into the clinical outcomes of total hip arthroplasty (THA) for intracapsular neck of femur (NOF) fracture in the very elderly. 44 patients over 75 years underwent THA for an intracapsular NOF fracture over a two year period. Oxford Hip Scores were obtained from 37 patients with a mean score of 39.7 (range 11–47). Katz Index Scores were collected from 36 patients with a mean pre-operative score of 5.9 and post operative score of 5.7. THA in this population gives patients the best opportunity to return to premorbid function. When complications occur there is a catastrophic effect on independence. Therefore it is important to select these patients' appropriately and to optimise their medical condition peri-operatively.
The results of total hip arthroplasty for fractured neck of femur in octogenarians
2014, Journal of Arthroplasty
Citation Excerpt :
The benefits of THA over Hemiarthroplasty are balanced by an increased risk of dislocation, greater operative time and higher implant cost [14]. The dislocation rate after THA ranges from 2% to 20% [1,13,15–21] following fracture although this may be reducing as the use of larger head sizes becomes commonplace [22]. There were no dislocations in the group of patients we studied.
The role of total hip arthroplasty (THA) for fracture in octogenarians remains unclear. Over a two-year period, 354 patients aged > 80 years were admitted with a displaced intracapsular hip fracture. Using defined clinical guidelines, 38 patients underwent THA with a median age of 84 years, mean follow-up of 20 months. Primary outcomes were dislocation, 30-day and one-year mortality, revision surgery and periprosthetic fracture. There were no dislocations or periprosthetic fractures and patient survival was 97% at 30 days and 87% at one year. There was one revision for deep infection. This study demonstrates that THA for selected octogenarians can be performed safely, allows the majority of patients to return to independent living and has a low complication rate.
Proximal femoral fractures in the elderly: How are we measuring outcome?
2011, Injury
Citation Excerpt :
The OHS has been demonstrated to be consistent, reproducible and sensitive for patients undergoing primary and revision hip arthroplasty, and has been validated against SF-36, Eq5D and the arthritis impact measurement scale.144 Three studies used the OHS as timing points from one month to five years post injury, both as a single measure,99,157 and as a comparative measure over time.9 In one study, the OHS correlated well with estimated pre-injury mobility and SF-12, but showed differences not seen with simultaneous use of SF-36.9
Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature.
Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation.
ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population.
A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups.
There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.
Preoperative planning of prosthetic replacement in hip fractures in the elderly
2010, Revista Espanola de Cirugia Ortopedica y Traumatologia
Existen numerosas publicaciones sobre la planificación preoperatoria en los reemplazos de cadera electivos con resultados satisfactorios. Sin embargo, ninguna de ellas se ha enfocado para el tratamiento de las fracturas de cadera. La planificación aumenta su importancia en estos pacientes debido a que la reconstrucción de la biomecánica de la cadera se ve dificultada por la ausencia de un fémur intacto.
En este trabajo se describe un método de planificación preoperatoria basado en la reproducción de la biomecánica de la cadera contralateral no fracturada, siempre y cuando ésta sea anatómicamente normal. El plan registra medidas radiológicas que se reproducen durante la cirugía para lograr una reconstrucción de la biomecánica normal de la cadera fracturada.
There are numerous reports on successful results for total hip replacement being achieved through preoperative planning. However, none of these reports have been focused on the treatment of hip fractures. Preoperative planning has increased importance in this group of patients as the correct biomechanical reconstruction of the hip is made more difficult by the absence of an intact femur.
This report describes a method for preoperative planning based on the reproduction of the biomechanics of the intact contralateral hip, if and when it is anatomically normal. The plan is based on radiological measurements that are reproduced during surgery to achieve normal biomechanical reconstruction for the fractured hip.
Acetabular erosion after bipolar hip hemiarthroplasty for femoral neck fracture in elderly patients: a retrospective study
2023, HIP International

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Results of displaced subcapital fractures treated by primary total hip replacement

Abstract

Introduction

Section snippets

Patients and methods

Morbidity

Mortality

Discussion

Conclusion

Injury

J. Arthroplasty

Injury

Injury

Injury

Injury

Questionnaire on the perceptions of patients about total hip replacement

J. Bone Joint Surg. Br.