Prosthetic Treatment of Intracapsular Hip Fractures in the Elderly Patient

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Prosthetic Treatment of Intracapsular Hip
Fractures in the Elderly Patient

• Riyaz Jinnah, MD
• Jonathan York, BS
• Pamela Allen, MD
• Beth Smith, PhD

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Background

• More than 250,000 femoral neck fractures occur in
  patients in the United States each year, and the
  prevalence of these fractures is expected to
  double by the year 2050. (Koval et al.)
• Annual health care expenditures for hip fractures
  will soon exceed 15 billion. (Ray et al.)

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Background

• Only 2-3 of hip fractures will occur in patients
  under the age of fifty. (Zetterberg et al.)
• Excellent results have been shown in patients
  younger than age fifty who have been treated with
  reduction and internal fixation. (Tooke et al.)

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Background

• The young and active patient with
• Good bone quality
• A reducible fracture
• And a low degree of comminution
• Should be treated with reduction and internal
  fixation in an attempt to preserve the natural
  hip.
• Shah et al.

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Background

• In the elderly patient, there is little doubt
  that arthroplasty is the preferred treatment.
• However, the choice between hemiarthroplasty and
  total hip arthroplasty remains contested.

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Background

• Historically
• THA has been shown to have dislocation rates as
  high as 18 in the past. (Dorr et al).
• Multiple studies have shown excellent results
  with THA in the treatment of osteoarthritis.
  (Older et al.)
• The primary indication for THA has been
  concurrent acetabular disease.

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Background

• Conventional wisdom would suggest the treatment
  algorithm is seen on the next slide.

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However

• Several other considerations necessitate further
  evaluation when choosing the appropriate
  treatment for displaced femoral neck fractures in
  the elderly, including
• Costs
• Complications
• Postoperative health-related quality of life.

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Cost
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Hemiarthroplasty vs. THA
Iorio et al.
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Hemiarthroplasty
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Hemiarthroplasty

• Acetabular Erosion
• Acetabular erosion can be a serious long term
  postoperative complication, resulting in pain and
  functional disability.
• Young age and high activity level are generally
  accepted as the most important factors leading to
  acetabular erosion. (Phillips et al., Warwick et
  al.)

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Hemiarthroplasty

• Acetabular Erosion
• 26 of patients younger than age 70 had evidence
  of acetabular erosion, compared with only 1.5 of
  patients older than age 80. (DArcy and Devas).

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Hemiarthroplasty

• Kofoed and Kofod
• 71 patients followed for 2 yrs.
• 37 required or had undergone conversion to THA
• Of those living independently, 55 required
  revision to THA because of pain.

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Hemiarthroplasty

• Dislocation Rate
• Varies in the literature, from 0.4 to 14.

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Hemiarthroplasty

• Rogmark et al.
• 103 hemiarthroplasties
• Patients over age 80
• One year failure rate 7. Dislocation rate 1.9.
• Authors recommend primary hemiarthroplasty for
  demented and/or institutionalized patients over
  80 years with displaced femoral neck fractures

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Hemiarthroplasty

• Parker et al.
• 229 hemiarthroplasties
• Patients over age 70 (mean age 82.4)
• 83 of patients returned to their pre-injury
  status at one year follow-up.

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Summary Hemiarthroplasty

• Hemiarthroplasty generally is recommended in
  older patients who are less active and have a
  shorter life expectancy.

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Total Hip Arthroplasty
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Total Hip Arthroplasty

• THA often limited to patients with concurrent
  acetabular disease.
• However, a retrospective analysis comparing THA
  in femoral neck fractures and THA in
  osteoarthritis found no statistically significant
  difference between the two groups with regards
  to perioperative morbidity, physical examination,
  or Harris Hip Score. (Abboud et al.)

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Total Hip Arthroplasty

• Accepted treatment for femoral neck fractures
• Taine and Armour
• 163 independently mobile patients
• gt65 yrs of age
• Treated with THA
• Mean duration of follow-up 42 months
• 4 revision rate

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Total Hip Arthroplasty

• Results of Lee et al. exemplified the current
  concerns with THA.
• Retrospective analysis
• 126 patients treated with THA for femoral neck
  fractures
• Mean age 75
• Mean duration of follow 8.8 yrs.
• Dislocation Rate 10
• 1 year postoperatively 99 of patients reported
  no pain, and 69 regained or improved their
  preoperative level of function.

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Summary THA

• THA has been associated with a high dislocation
  rate, but yields excellent results.

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Hemiarthroplasty vs. THA

• Randomized clinical trials offer the most
  definitive comparison between total hip
  arthroplasty and hemiarthroplasty.

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Hemiarthroplasty vs. THA

• Skinner et al.
• 278 patients over 65 yrs of age
• Randomized to hemiarthroplasty or THA
• No difference in post-operative mortality
• THA resulted in the least pain and most mobility
• Conversion rate for hemiarthroplasty 13
• Revision rate for THA 4

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Hemiarthroplasty vs. THA

• Blomfeldt et al.
• 120 patients, mean patient age 81
• Randomized to hemiarthroplasty or THA
• Follow-up at 4 and 12 months
• No difference in morbidity between the two
  groups.
• No dislocations in either group.
• Hip function (measured by Harris Hip Score)
  significantly better in the THA group.

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Hemiarthroplasty vs. THA

• Baker et al.
• 81 previously mobile patients
• Randomized to either hemiarthroplasty or THA
• Mean duration of follow-up 3 yrs.
• Patients randomized to THA had lower average
  Oxford Hip Scores and longer walking distances.

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Hemiarthroplasty vs. THA

• Ravikumar and Marsh
• 290 patients over age 65
• Randomized to either closed reduction and
  internal fixation, unipolar hemiarthroplasty, or
  THA

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Summary Hemi vs. THA

• Total hip arthroplasty is superior to
  hemiarthroplasty with regards to revision rates,
  hip function, and pain.
• THA is, however, associated with a higher
  dislocation rate than hemiarthroplasty

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What is the solution?
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Large Femoral Heads
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Large Femoral Heads

• Crowninshield et al., Amstutz et al.
• Increasing the femoral head size can
  concomitantly increase joint stability.

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Large Femoral Heads

• Cuckler et al.
• Compared incidence of dislocation in 28mm vs.
  38mm. femoral heads in the first 3 post-operative
  months following THA.
• 28mm heads
• 78 patients
• 2.5 dislocation rate.
• 38 mm heads
• 616 patients
• NO DISLOCATIONS

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Smith et al - CORR 2005

• 327 patients
• 91.8 primaries
• 8.2 revisions
• Large heads reduce dislocation risk

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Summary Large Femoral Heads

• With the use of large femoral heads, the risk of
  dislocation associated with THA can be virtually
  eliminated.

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Current Treatment Preferences
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Current Treatment Preferences

• Iorio et al.
• Survey sent to AAHK
• Treatment choice in patients older than 65
• Hemiarthroplasty 85
• THA 13
• Risk of dislocation most important factor in
  choice

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Current Treatment Preferences

• Large disparity between treatment practices and
  literature.

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Recommended Preoperative Scoring System
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Recommended Preoperative Scoring System

• This scoring system favors the use of THA in
• Young
• Alert
• Community ambulatory patients
• With or without acetabular disease

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Recommended Preoperative Scoring System

• The hallmark of this scoring system is the
  discretion left to the surgeon for patients whose
  score falls within the midrange (5-7).

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Recommended Preoperative Scoring System

• This scoring system is not designed to replace
  the surgeons experience or judgment.

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Recommended Preoperative Scoring System

• Instead, this algorithm is meant to serve as a
  practical guide to the surgeon based upon the
  current literature.

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