Arthroplasty in patients with femoral neck fractures

The aim of this thesis was to analyze hip function and the health-related quality of life (HRQoL) in patients with a displaced fracture of the femoral neck treated with a cemented total hip arthroplasty (THA) or a hemiarthroplasty (HA), unipolar or bipolar. Moreover, the purpose was to analyze factors influencing the stability of the THA with special reference to the surgical approach and to evaluate the responsiveness of the Short Musculoskeletal Function Assessment (SMFA), i.e. the instrument’s ability to capture clinically important changes, in patients with femoral neck fractures. A four-year follow-up of a randomized controlled trial (RCT) of 120 elderly patients (mean age 81 years) with a displaced femoral neck fracture randomly allocated to treatment by either THA or bipolar HA (Study I). The results confirmed the better outcome regarding hip function and HRQoL after THA as compared to HA in the longer time perspective. In an RCT, 120 elderly patients (mean age 86 years) with a displaced fracture of the femoral neck were randomly allocated to treatment by either unipolar HA or bipolar HA (Study II). The study showed that unipolar HA and bipolar HA appeared to produce equivalent clinical outcomes regarding hip function and HRQoL after one year, but with a significantly higher incidence of acetabular erosion in the unipolar HA group. In a cohort study, 713 consecutive hips in a series of 698 patients having undergone a primary THA (n = 311) for a displaced femoral neck fracture or a secondary THA (n = 402) due to a fracture healing complication after a femoral neck fracture were included (Study III). The results showed that the anterolateral surgical approach was associated with a significantly lower risk of dislocation than the posterolateral approach with or without posterior repair. In order to evaluate the responsiveness of the SMFA, the 120 patients from Study I were included (Study IV). To evaluate the internal responsiveness of the SMFA, the observed change and the Standardized Response Mean (SRM) in relation to the change in the Dysfunction Index and the Bother Index were calculated. In order to calculate external responsiveness, an External Criterion (EC) was constructed by using the Harris Hip Score. Receiver Operating Characteristic (ROC) curves and logistic regression analysis were used in the evaluation. The results of the study showed that the SMFA indices had good internal responsiveness and acceptable external responsiveness in patients with femoral neck fractures. In conclusion, THA is recommended as the primary treatment for the active, healthy elderly patient with a femoral neck fracture and long life expectancy. In the most elderly patients, bipolar HA and unipolar HA seem to produce equally good clinical results in the shorter time perspective, but the significantly higher incidence of acetabular erosion in the unipolar HA group may imply that bipolar HA should be the preferred treatment. Moreover, in order to minimize the risk of dislocation, we recommend the use of the anterolateral approach for THA in patients with femoral neck fractures. Finally, the SMFA can be recommended for use as one of the measures to evaluate the outcome after a femoral neck fracture

Dislocation of total hip replacement in patients with fractures of the femoral neck: A prospective cohort study of 713 consecutive hips

Background Total hip replacement is increasingly used in active, relatively healthy elderly patients with fractures of the femoral neck. Dislocation of the prosthesis is a severe complication, and there is still controversy regarding the optimal surgical approach and its influence on stability. We analyzed factors influencing the stability of the total hip replacement, paying special attention to the surgical approach

At mid- to long-term follow-up after proximal hamstring tendon avulsion; there was greater fatty infiltration, muscle atrophy and strength deficit in the hamstring muscles of the injured leg than in the uninjured leg

BackgroundProximal hamstring tendon avulsions (PHAs) may be treated nonoperatively or operatively. Little is known about the result of the injury, and its treatment, on the quality and function of the hamstring muscle after healing and rehabilitation. We hypothesized that the injured leg would have greater fatty infiltration and atrophy than the uninjured leg at follow-up and that these findings would correlate to muscle weakness.MethodsIn a cross-sectional cohort study, 48 patients treated for PHA, either operatively or nonoperatively, were re-examined 2-11 years post-treatment. We measured muscle strength with isokinetic strength tests, and muscle volume and fatty infiltration with MRI.Primary outcomes were hamstring muscle quality, quantified by outlining the cross-sectional area slice-by-slice, and the degree of fatty infiltration estimated using the Goutallier grading method. Secondary outcome was concentric isokinetic hamstring muscle strength measured using BioDex at 60 degrees/sec and tendon attachment assessed on MRI. Comparisons with the outcomes of the uninjured leg were made.ResultsThe total hamstring muscle volume was on average reduced by 9% (SD +/- 11%, p < 0.001) compared to that of the uninjured leg. Fatty infiltration was significantly more severe in the injured hamstrings than in the uninjured hamstrings (p < 0.001). This was also true when only analyzing operatively treated patients. The reduction in muscle volume and increase in fatty infiltration correlated significantly (r = 0.357, p = 0.013), and there was also a statistically significant correlation with muscle atrophy and reduction in isokinetic strength (r = 494, p < 0.001).ConclusionPHA injuries result in fatty infiltration and muscle atrophy and the muscle quality impairment correlates with residual muscle weakness

Reduced periprosthetic fracture rate when changing from a tapered polished stem to an anatomical stem for cemented hip arthroplasty : an observational prospective cohort study with a follow-up of 2 years

Background and purpose - Straight collarless polished tapered stems have been linked to an increased risk for periprosthetic femur fractures in comparison with anatomically shaped stems, especially in elderly patients. Therefore, we evaluated the effect of an orthopedic department's full transition from the use of a cemented collarless, polished, tapered stem to a cemented anatomic stem on the cumulative incidence of postoperative periprosthetic fracture (PPF). Patients and methods - This prospective single-center cohort study comprises a consecutive series of 1,077 patients who underwent a cemented hip arthroplasty using either a collarless polished tapered stem (PTS group, n = 543) or an anatomic stem (AS group, n = 534). We assessed the incidence of PPF 2 years postoperatively and used a Cox regression model adjusted for age, sex, ASA class, cognitive impairment, BMI, diagnosis, and surgical approach for outcome analysis. Results - Mean age at primary surgery was 82 years (49-102), 73% of the patients were female, and 75% underwent surgery for a femoral neck fracture. The PPF rate was lowered from 3.3% (n = 18) in the PTS group to 0.4% (n = 2) in the AS group. The overall complication rate was also lowered from 8.8% in the PTS group to 4.5% in the AS group. In the regression model only cognitive dysfunction (HR 3.8, 95% CI 1.4-10) and the type of stem (PTS vs AS, HR 0.1, CI 0.0-0.5) were correlated with outcome. Interpretation - For elderly patients with poor bone quality use of cemented anatomic stems leads to a substantial reduction in periprosthetic fracture rate without increasing other complications

HOPE-Trial: Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians : A Randomized Controlled Trial

Background: The choice of primary hemiarthroplasty or total hip arthroplasty in patients ≥80 years of age with a displaced femoral neck fracture has not been adequately studied. As the number of healthy, elderly patients ≥80 years of ageis continually increasing, optimizing treatments for improving outcomes and reducing the need for secondary surgery is an important consideration. The aim of the present study was to compare the results of hemiarthroplasty with those of totalhip arthroplasty in patients ≥80 years of age. Methods: This prospective, randomized, single-blinded trial included 120 patients with a mean age of 86 years (range, 80 to 94 years) who had sustained an acute displaced femoral neck fracture <36 hours previously. The patients were randomized to treatment with hemiarthroplasty (n = 60) or total hip arthroplasty (n = 60). The primary end points were hip function and health-related quality of life at 2 years. Secondary end points included hip-related complications and reoperations, mortality, pain in the involved hip, activities of daily living, surgical time, blood loss, and general complications.The patients were reviewed at 3 months and 1 and 2 years. Results: We found no differences between the groups in terms of hip function, health-related quality of life, hip-related complications and reoperations, activities of daily living, or pain in the involved hip. Hip function, activities of daily living,and pain in the involved hip deteriorated in both groups compared with pre-fracture values. The ability to regain previous walking function was similar in both groups. Conclusions: We found no difference in outcomes after treatment with either hemiarthroplasty or total hip arthroplasty inactive octogenarians and nonagenarians with a displaced femoral neck fracture up to 2 years after surgery. Hemiarthroplastyis a suitable procedure in the short term for this group of patients. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence

Patient-reported outcomes after surgical and non-surgical treatment of proximal hamstring avulsions in middle-aged patients

ObjectivesIn the literature on proximal hamstring avulsions, only two studies report the outcomes of non-surgically treated patients. Our objective was to compare subjective recovery after surgical and non-surgical treatment of proximal hamstring avulsions in a middle-aged cohort.MethodsWe included 47 patients (33 surgically and 14 non-surgically treated) with a mean (SD) age of 51 (±9) years in a retrospective cohort study. Follow-up time mean (SD) of 3.9 (±1.4) years. The outcome variables were the Lower Extremity Functional Scale (LEFS) and questions from the Proximal Hamstring Injury Questionnaire. Outcome variables were adjusted in regression models for gender, age, American Society of Anestesiologits (ASA) classification and MRI findings at diagnosis.ResultsThe baseline characteristics showed no differences except for the MRI result, in which the surgically treated group had a larger proportion of tendons retracted ≥ 2 cm. The mean LEFS score was 74 (SD±12) in the surgically treated cohort and 72 (SD±16) in the non-surgically treated cohort. This was also true after adjusting for confounders. The only difference in outcome at follow-up was the total hours performing physical activity per week, p=0.02; surgically treated patients reported 2.5 hours or more (5.2 vs 2.7).ConclusionThis study on middle-aged patients with proximal hamstring avulsions was unable to identify any difference in patient-reported outcome measures between surgically and non-surgically treated patients. The vast majority of patients treated surgically had complete proximal hamstring avulsions with ≥ 2 cm of retraction. We conclude that to obtain an evidence-based treatment algorithm for proximal hamstring avulsions studies of higher scientific level are needed

HOPE-trial : hemiarthroplasty compared to total hip arthroplasty for displaced femoral neck fractures in the elderly-elderly, a randomized controlled trial

Background: A femoral neck fracture (FNF) is a common cause of suffering and premature death in the elderly population. Optimizing the treatment for improved outcome and a reduced need for secondary surgery is important both for the patient and the society. The choice of primary total or hemiarthroplasty in patients over eighty years are controversial. We hypothesized that total hip arthroplasty has an equal or better outcome in patient-reported outcome compared with hemiarthroplasty. Methods/Design: A prospective, randomized, single-blinded trial will be conducted. We will include 120 patients, 80 years of age and over with an acute (<36 h) displaced femoral neck fracture. The patients will be randomized in a 1: 1 ratio to either total hip arthroplasty or hemiarthroplasty. The primary endpoints are Harris hip Score and EQ-5D. Secondary endpoints include pain measured with visual analogue scale, surgical time, reoperations, complications and radiological measurement of erosion in patients operated with hemiarthroplasty. Follow-up will be performed postoperatively after three months, 1, 2, 4 and 10 years. Discussion: To our knowledge, this is the first randomized controlled trial comparing total hip arthroplasty and hemiarthroplasty for displaced femoral neck fracture in patients age 80 years and over

Primary hemiarthroplasty for the elderly patient with cognitive dysfunction and a displaced femoral neck fracture : a prospective, observational cohort study

Background: At least one-third of hip fracture patients have some degree of impaired cognitive status, which may complicate their postoperative rehabilitation. Aim: We aimed to describe the outcome for elderly patients with cognitive dysfunction operated with hemiarthroplasty (HA) for a femoral neck fracture and to study the impact postoperative geriatric rehabilitation has on functional outcome up to 1 year after surgery. Methods: 98 patients with a displaced femoral neck fracture with a mean age of 86 years were included and followed up to 1 year. The outcomes were hip-related complications and reoperations, the capacity to return to previous walking ability, health-related quality of life, hip function and mortality. Results: The prevalence of hip complications leading to a major reoperation was 6% and the 1-year mortality rate was 31%. The lack of geriatric rehabilitation was correlated with poorer outcomes overall and those who receive geriatric rehabilitation were less likely to be confined to a wheelchair or bedridden at the 1-year follow-up. Conclusions: Hemiarthroplasty is an acceptable option for elderly patients with a displaced femoral neck fracture and cognitive dysfunction. A lack of structured rehabilitation is associated with a significant deterioration in walking ability despite a well-functioning hip. However, the causality of this could be due to selection bias of healthier patients being sent to geriatric rehabilitation