OUTCOME OF UNCEMENTED BIPOLAR HEMIARTHROPLASTY IN FRACTURE

NECK OF FEMUR - A RETROSPECTIVE STUDY

Background: Among all hip fractures, femur neck fractures account for a
significant portion. It is typical in the female-dominated geriatric age group
and may also be linked to other injuries. The therapy of older patients with
unstable osteoporotic fractures is complicated due to difficult anatomical
reduction, poor bone quality, and occasionally a requirement to shield the
fracture from weight-bearing pressures. Aim: The purpose of this study
was to evaluate the safety, efficacy, and radiographic and functional
outcomes of uncemented bipolar hemiarthroplasty in the treatment of
fracture neck of femur. Method: Clinical information about patients was
gathered from Kasturba Medical College Manipal's computerised medical
records. The medical records division was used to locate patients who
received un-cemented bipolar hemiarthroplasty for fracture neck of femur
between January 2011 and December 2020. After getting their
postoperative xrays from PACS, radiological parameters were measured.
Results: According to the results of our study, women are more likely to
develop it, with the left side being the most commonly affected. Better than
good functional scoring was reported by 83.7%. The position of the
femoral stem showed no discernible alteration in the subsequent x-rays.
Conclusion: Uncemented modular hemiarthroplasty provides a good
primary anchorage with equally promising results to treat Bipolar
hemiarthroplasty for femoral neck fractures.
Keywords: femoral neck fractures, Bipolar hemiarthroplasty, uncemented,
cemented.
Introduction
Elderly patients frequently experience femoral neck fractures, which are
linked to lower mobility, greater mortality rates, and higher healthcare
costs. Femoral neck fractures are more common in female patients over
60 than in male patients.(1) The fracture is the primary cause of the
patient's more than two-thirds hospital stay.(2) When compared to the
senior population, younger people are more likely to sustain high energy
trauma, which can lead to femoral neck fractures and other severe
injuries.(3) In adults (those under 60), these fractures are regarded as
medical emergencies that need for immediate care in order to reestablish
blood flow to the femoral head.(4) The femoral head's avascular necrosis
(AVN) and non-union are the two main outcomes for patients with this
fracture.(5)
Cemented hip arthroplasty is the normal treatment for femoral neck
fractures in the mobile elderly, however there have been worries that this
technique raises the risk of cardiovascular issues. When the cement is
pressured, it can result in bone cement implantation syndrome, a
potentially fatal complication that raises intramedullary pressure and raises
the chance of fat embolisation, especially in individuals with pre-existing
disorders. Although it may reduce mortality, the cement-less stem
treatment is technically difficult and demands careful planning and
execution.(6) Another disadvantage of cemented hemiarthroplasty is that
revision hemiarthroplasty will be more difficult.(7) The advantages of
hemiarthroplasty for displaced femoral neck fractures with a modular un-
cemented bipolar prosthesis include pain relief, greater range of motion,
and a quicker return to independent activity.
Implants used in hemiarthroplasty might be unipolar, bipolar, modular, or
nonmodular in design. Although cement is generally used during modular
hemiarthroplasty, it can potentially be performed without cement and still
produce good results. (8) Studies have shown that bipolar prostheses had
a lower rate of acetabular degradation and protrusion than unipolar
prostheses, which are used in traditional (9) hemiarthroplasty. Although
the functional outcomes were the same in both groups in terms of the
dislocation rate, the bipolar prosthesis also provided a longer symptom-
free period than the Austin Moore prosthesis. Currently, there is insufficient
evidence from randomised trials to determine whether cemented or
uncemented bipolar hemiarthroplasty is preferable. As a result, the
orthopaedic surgeon must make difficult decisions while treating some of
these very sick, elderly patients.
Materials and method
Clearance from the Institutional Ethical Committee was obtained for the
study. Hospital numbers of the patients who underwent un-cemented
bipolar hemiarthroplasty for fracture neck of femur from January 2011 to
December 2020 were retrieved from the medical records department.
Radiological parameters were measured after retrieving their
postoperative xrays from PACS. Patient’s clinical data were collected from
the electronic medical records available at Kasturba Medical College
Manipal. Inclusion criteria was patients who underwent uncemented
Bipolar hemiarthroplasty for femoral neck fractures performed between
January 2011 and December 2020 at Kasturba Hospital, Manipal Exclusion
criteria was any fractures (in ipsilateral or contralateral limb) that might
affect Modified Harris Hip Score Any intertrochanteric fractures which
underwent coxa-femoral bypass surgery. The radiological parameters
which were measure included: Cortical Index, Stem Positioning, Acetabular
Erosion, Subsidence, modified harris hip score. Data obtained was stored
and analysed using the statistical package for social sciences software
(SPSS) version v 21.0 IBM corporation (SPSS Inc., Chicago, Illinois).
Results
Radiological measurements were calculated using Corel Draw software.
(Table 1) Mean femoral diameter was found to be 13.53mm and
Intramedullary canal diameter being 7.63mm Cortical index was calculated
using the formula (Z – X)/(Z). Cut off points are 0.58 between type A and B
and 0.49 between type B and C on the anteroposterior radiograph"(10)
Stem alignment was calculated using the longitudinal axis of the proximal
femur and the longitudinal axis of the femoral component.(11) Stem
alignment was calculated using the longitudinal axis of the proximal femur
and the longitudinal axis of the femoral component.(11) (Shown in figure
1&2) Standard deviation was 1.676 and 2.39 for immediate post-operative
alignment and followup. No significant difference was observed as p value
was >0.05. Average immediate post-operative stem alignment was + 0.64
degrees varus. Average stem alignment in last follow up was + 0.57
degrees varus. There was no significant change in the alignment of femoral
stem in the follow up x-rays. (Shown in table 2 and figure 3)
Average difference from top of the stem to the greater trochanter in the
distance was 0.57mm. No significant subsidence was observed as there
needed to be a difference of more than 2mm to be deemed significant.
(Shown in table 3 & figure 4)
83.7% reported better than good functional scoring. (Shown in table 4).
Complication rates were very low with <1% showing post-operative
infections, peri-prosthetic fractures. (Shown in table 5).
Discussion
A typical procedure for displaced femur neck fractures is hemiarthroplasty.
There are two types of hemiarthroplasty: unipolar and bipolar. More often
than not, unipolar is linked to a rapid rate of acetabular erosion. There is
less likelihood of articular wear with a bipolar prosthesis because hip
motion occurs primarily at the prosthetic joint and secondarily at the metal
-cartilage interface. However, numerous research comparing the functional
outcomes of AMP and Bipolar prostheses have found that the outcome is
identical. Hemiarthroplasty can either be un-cemented with press-fit
technique or cemented into the femoral canal. Less pain is left over after
cementing the prosthesis, which also improves function and offers a more
stable fixation. But the introduction of cement into the proximal femur's
medullary canal raises the morbidity of the operation and carries the risk of
cardiovascular collapse.
The cementless stem technique may reduce this mortality risk but it is
technically demanding and needs precise planning and execution. Marya
SK et al (12), Thukral R et al (13) report the perioperative mortality and
morbidity of cementless bipolar hemiarthroplasty in a series of mobile
elderly patients (age >70 years) with femoral neck fractures. All study
patients were ambulatory and had painless hips; the mean Harris hip score
was 85 (range: 69– 96). Conclusion of the study was that cementless
bipolar hemiarthroplasty for femoral neck fractures in the very elderly
permits early return to premorbid life and is not associated with any
untoward cardiac event in the perioperative period. It can be considered a
treatment option in this select group. Femoral neck fractures in the elderly
are associated with high morbidity and mortality. The optimal treatment
remains controversial regarding the use of cement in hemiarthroplasty
when treating a displaced femoral neck fracture in elderly patients. The
primary hypothesis of this study was that the use of cement would afford
better visual analogue pain and activity scores in elderly patients. Similar
study like us was done by Rai SK et al (14) in cemented vs uncemented
modular bipolar hemiarthroplasty treatment for femoral neck fracture in
elderly patients. They found no statically significant between-groups
differences in terms of length of hospital stay, Harris Hip Score and
complications
In our study Average Femoral diameter was 13.53mm, average Canal
diameter was 7.63mm and average Cortical index was 0.43mm. Which
shows most of the femurs were Dorr type B. In our study Telephonic
interview done for the patients post operatively. Total patients called were
168. In our study HHS test was excellent for 32.43 % , fair for 27.03% ,
good for 24.32% and poor for 16.22 %. Thus showing more than 83.7%
better than good functional scoring. Similar results were seen in study
done by Hinchey Day et al (15) they studied 225 patients in which HHS test
was excellent for 52.4%, good for 20.4% , fair for 10.7 % and poor for
16.4%. Lanceford et al (16) they studied 210 patients in which HHS test
was excellent for 30%, good for 51% , fair for 9 % and poor for 10%.
Anderson et al (17) they studied 356 patients in which HHS test was
excellent for 51.9 %, good for 28.4% , fair for 14.8 % and poor for 4.9 %.
Salvatti et al (18) they studied 251 patients in which HHS test was excellent
for 31 %, good for 26% , fair for 25 % and poor for 8 %. Mukherjee et al (19)
they studied 55 patients in which HHS test was excellent for 49%, good for
29% , fair for 18 % and poor for 4.0 %. Saxena et al (20) they studied 82
patients in which HHS test was excellent for 46.1 %, good for 44.8% , fair
for 6.5 % and poor for 2.6 %. Bavadekar et al (21) they studied 328
patients in which HHS test was excellent for 60 %, good for 0% , fair for 30
% and poor for 10 %.
Conclusion
This leads to the conclusion that although uncemented modular
hemiarthroplasty is not commonly performed in a cemented manner, it
offers a good primary anchorage and equally encouraging outcomes for
the treatment of bipolar hemiarthroplasty for femoral neck fractures.
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List of tables & graphs