Hemiarthroplasty and femoral neck fractures

Nye fremskritt i norsk forskning om protesekirurgi ved lårhalsbrudd Overlege og forsker Paul Wender Figved og medarbeidere viser i en ny doktoravhandling gode resultater ved bruk av to forskjellige typer hofteprotese ved behandling av lårhalsbrudd. Forskere fra den samme gruppen har tidligere fått internasjonal anerkjennelse for å vise at de fleste lårhalsbrudd bør behandles med protese og ikke med skruer. Hvilken type hofteprotese som egner seg best til behandling av lårhalsbrudd er gjenstand for videre forskning. Gjennomsnittsalderen for pasienter med lårhalsbrudd i Norge er rundt 82 år og ca 80% er kvinner. Rundt 10.000 pasienter med brudd i hoften opereres ved norske sykehus hvert år, og rundt halvparten av disse er rene lårhalsbrudd. Diagnosen er forbundet med høy komplikasjonsrate og dødelighet. Bruk av sement ved innsetting av protese er forbundet med sjeldne men svært alvorlige komplikasjoner. Avhandlingen Hemiarthroplasty and femoral neck fractures består av fire vitenskaplige artikler. En klinisk studie med 220 pasienter som ble behandlet med enten en protese festet med sement eller en protese festet uten sement, viste like gode resultater med hensyn til smerter etter operasjonen, grad av fornøydhet og komplikasjoner. Tidligere forskning har vist at det finnes en rekke usementerte proteser som fungerer dårlig ved behandling av lårhalsbrudd, men protesen som ble brukt i denne studien synes å være bedre og er nå i økende bruk i Norge. Pasientene som fikk protese uten sement hadde kortere operasjonstid og mindre blodtap, men dette ga ikke utslag på resultatet av behandlingen. En klinisk studie med en nyutviklet målemetode viste at slitasjen en protese påfører brusken i hofteskålen er så liten at den ikke lar seg måle det første året etter operasjonen. To studier viste at behandlingen av komplikasjoner etter operasjon med protese er vanskelig, at utfallet etter ytterligere kirurgi er særdeles usikkert og forbundet med en rekke ytterligere komplikasjoner

Implementering, etterlevelse og resultater av et forbedringsprosjekt for hoftebruddbehandling ved Bærum sykehus.

Kvalitetsforbedring i helsetjenesten er en kontinuerlig prosess. Systematiske kunnskapsoppsummeringer og faglige retningslinjer er nødvendige for at helsetjenesten skal kunne endre prosessene sine til det vi kaller «beste praksis». I et forbedringsprosjekt for bedre hoftebruddbehandling ble idéutvikling, implementering, målinger av etterlevelse og til slutt måling av resultater, utført ved Ortopedisk avdeling, Bærum sykehus, i perioden 2013 til i dag. Et forbedringsteam valgte ut seks forbedringstiltak som ville være et vesentlig kvalitetsløft dersom et gap mellom før-situasjonen og beste praksis ble lukket. De seks tiltakene var 1) tidlig kirurgi (innen 48 timer), 2) korrekt administrering av antibiotikaprofylakse, 3) kirurgi med godt dokumenterte metoder, 4) kirurger med god nok ekspertise, 5) tverrfaglig behandling gjennom oppholdet, og 6) sekundær forebygging av brudd. De to første var allerede godt etablert, mens de fire siste krevde betydelige endringer. Etterlevelse før, under og etter implementering ble målt med statistisk prosesskontroll (SPC). Forskjeller i komplikasjoner, reoperasjoner og død opp til 5 år etter operasjon ble sammenliknet mellom en pasientgruppe før (n=293) og en etter (n=182) implementering, med overlevelseskurver og log-rank (Mantel-Cox) test, rapportert som hazard ratio (HR) med 95% konfidensintervall (KI). Forbedringsarbeidet oppnådde et vedvarende gjennomsnittlig etterlevelsesnivå på over 90% i de fem måleperiodene etter implementering, fra 2014 til 2021. Den siste perioden er målt fem år etter den forrige, og tyder på høy vedvarende etterlevelse. I løpet av 5 år etter operasjon fant vi 57% reduksjon i komplikasjoner i gruppen etter at alle forbedringstiltakene var implementert, fra 19,1% til 8,2% (HR: 2,66 (95% KI: 1,6 til 4,3, p=0,0007). Behovet for reoperasjon i forbindelse med en komplikasjon falt fra 12,6% til 4,9% (HR: 2,70 (95% KI: 1,5 til 4,9, p=0,0054). Vi fant ingen forskjell i dødelighet mellom gruppene (HR: 1,1 (95% KI: 0,8 til 1,3, p=0,645). Etterlevelsen av forbedringene var over 90% gjennom og etter implementering, og vedvarende etter 5 år. Kvaliteten og sikkerheten i pasientforløpet ble forbedret, og førte til en betydelig reduksjon i komplikasjoner og reoperasjoner

Prosthetic joint infection—a devastating complication of hemiarthroplasty for hip fracture

Background and purpose — Hemiarthroplasty is the most common treatment in elderly patients with displaced femoral neck fracture. Prosthetic joint infection (PJI) is a feared complication. The infection rate varies in the literature, and there are limited descriptive data available. We investigated the characteristics and outcome of PJI following hemiarthroplasty over a 15-year period. Patients and methods — Patients with PJI were identified among 519 patients treated with hemiarthroplasty for a femoral neck fracture at Oslo University Hospital between 1998 and 2012. We used prospectively registered data from previous studies, and recorded additional data from the patients’ charts when needed. Results — Of the 519 patients, we identified 37 patients (6%) with early PJI. 20 of these 37 patients became free of infection. Soft tissue debridement and retention of implant was performed in 35 patients, 15 of whom became free of infection with an intact arthroplasty. The 1-year mortality rate was 15/37. We found an association between 1-year mortality and treatment failure (p = 0.001). Staphylococcus aureus and polymicrobial infection were the most common microbiological findings, each accounting for 14 of the 37 infections. Enterococcus spp. was found in 9 infections, 8 of which were polymicrobial. There was an association between polymicrobial infection and treatment failure, and between polymicrobial infection and 1-year mortality. Interpretation — PJI following hemiarthroplasty due to femoral neck fracture is a devastating complication in the elderly. We found a high rate of polymicrobial PJIs frequently including Enterococcus spp, which is different from what is common in PJI after elective total hip arthroplasty

60% Reduction of reoperations and complications for elderly patients with hip fracture through the implementation of a six-item improvement programme

Introduction Hip fractures are common, serious and costly fractures in the elderly population. Several guidelines seeking to ensure best practice have been introduced. Although our institution complied with national guidelines for early surgery of hip fractures, no assessment of other evidence-based measures existed. We wanted to assess, test, implement and measure the impact of a quality improvement (QI) programme consisting of key elements proven to be important in the treatment of hip fractures. Methods We formed a multidisciplinary QI team, consisting of several specialists in different fields. The QI team assessed multiple possible process measures for inclusion in the programme and selected six measurable interventions for implementation: early surgery, correct administration of prophylactic antibiotics, surgery using proven methods and expertise, a multidisciplinary patient pathway and secondary fracture prevention. The improvement process was monitored by a statistical process control chart (SPC). Complications, reoperations and mortality were compared before (n=293) and after (n=182) the intervention. Results The SPC analyses indicated increasing adherence with all interventions throughout the improvement programme, and sustainability 7 years later. The last four periods showed a stable adherence above 90%. We found 60% reduction in major complications after the implementation of the improvement programme, from 19.1% to 7.7% (HR: 0.38 (95% CI: 0.23 to 0.61, p=0.0007). The need for reoperations due to complications fell from 12.6% to 4.9% (HR: 0.37 (95% CI: 0.21 to 0.67, p=0.0054). We did not find a difference in post-operative mortality after the implementation of the QI programme (HR: 0.95 (95% CI: 0.74 to 1.2, p=0.645). Conclusion Our multiprofessional improvement programme achieved almost full adherence within 2 years and was sustainable 7 years later. The quality and safety of the care process were improved and led to a substantial and sustainable decrease in complications and reoperations

Volar Locking Plate Versus Dorsal Locking Nail-Plate Fixation for Dorsally Displaced Unstable Extra-Articular Distal Radial Fractures: Functional and Radiographic Results from a Randomized Controlled Trial

Background: The use of low-profile dorsal and volar locking plates for distal radial fracture surgery has improved results and lowered the complication rate compared with older plate designs. The purpose of the present randomized controlled trial was to compare patient-reported outcomes as well as radiographic and functional results between patients who underwent stabilization with a volar locking plate or a dorsal locking nail-plate for the treatment of dorsally displaced unstable extra-articular distal radial fractures. Methods: One hundred and twenty patients ≥55 years of age were randomized to surgery with either a volar locking plate or a dorsal locking nail-plate and were assessed at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. The primary outcome was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Secondary outcomes were the Patient-Rated Wrist Evaluation (PRWE), EuroQol 5 Dimensions (EQ-5D) index and visual analog scale (VAS), range of motion, grip strength, radiographic measurements, and complication rate. Results: The median age was 66 years (range, 55 to 88 years). The rate of follow-up was 97%. There was no clinically important difference between the groups at any point during follow-up. Patients in the volar locking plate group had better mean QuickDASH scores at 6 weeks, 6 months, and 1 year. However, the differences were small (5.8 vs. 11.3 points at 1 year; mean difference, −5.5 points [95% confidence interval (CI), −9.9 to 1.2]; p = 0.014), which is lower than any proposed minimum clinically important difference (MCID). The difference in PRWE scores was also lower than the MCID (1.0 vs. 3.5 at 1 year; mean difference, −2.5 [95% CI, −4.4 to 0.6]; p = 0.012). The dorsal locking nail-plate group had slightly better restoration of volar tilt (p = 0.011). EQ-5D index, EQ-5D VAS, range of motion, grip strength, and complication rates were similar. Conclusions: We found no clinically relevant difference between the volar locking plate and dorsal locking nail-plate groups after 1 year or in the time period up to 1 year. A dorsal locking nail-plate can therefore be an alternative method for the treatment of these unstable fractures or in cases in which a dorsal approach is preferable over a volar approach

Higher cartilage wear in unipolar than bipolar hemiarthroplasties of the hip at 2 years: A randomized controlled radiostereometric study in 19 fit elderly patients with femoral neck fractures

Background and purpose: The use of unipolar hemi­arthroplasties for femoral neck fractures is increasing in some countries due to reports of higher reoperation rates in bipolar prostheses. On the other hand, it has been proposed that bipolar hemiarthroplasties have clinical advantages and less cartilage wear than unipolar hemiarthroplasties. We compared cartilage wear between bipolar and unipolar hemiarthroplasties using radiostereometric analyses (RSA), in patients aged 70 years or older. Patients and methods: 28 ambulatory, lucid patients were randomized to treatment with a unipolar or a bipolar hemiarthroplasty for an acute femoral neck fracture. Migration of the prosthetic head into the acetabulum was measured using RSA. Secondary outcomes were Harris Hip Score (HHS), and EQ-5D scores. Patients were assessed at 3, 12. and 24 months. Results: 19 patients were available for follow-up at 2 years: mean proximal penetration was 0.83 mm in the unipolar group and 0.24 mm in the bipolar group (p = 0.01). Mean total point movement was 1.3 mm in the unipolar group and 0.95 mm in the bipolar group (p = 0.3). Median HHS was 78 (62–96) in the unipolar group and 100 (70–100) in the bipolar group (p = 0.004). Median EQ-5D Index Score was 0.73 (0.52–1.00) in the unipolar group and 1.00 (0.74–1.00) in the bipolar group (p = 0.01). Median EQ-5D VAS was 70 (50–90) in the unipolar group and 89 (70–95) in the bipolar group (p = 0.03) Interpretation: Patients with unipolar hemiarthroplasties had higher proximal cartilage wear and lower functional outcomes. Unipolar hemiarthroplasties should be used with caution in ambulatory, lucid patients

Team approach: Multidisciplinary treatment of hip fractures in elderly patients: Orthogeriatric care

Patients with hip fractures are best managed by a multidisciplinary team. The multidisciplinary team consists of an orthogeriatrician, orthopaedic surgeon, aanesthesiologist, orthopaedic and/or geriatric nurse, occupational therapist, physical therapist, and clinical pharmacologist and may also include other professions, such as endocrinologist, nutritional therapist, and social worker. Key factors include perioperative assessment and minimal delay to surgery; comprehensive geriatric assessment; multidisciplinary in-ward assessment including discharge planning, treatment, and rehabilitation; and secondary fracture prevention. Current evidence shows that older people receiving multidisciplinary treatment for a hip fracture, comprehensive geriatric assessment, and systematic secondary fracture prevention have reduced morbidity and mortality and a lower risk of subsequent fractures and are more likely to return to the same location in which they lived before hospital admission

Cemented versus Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures

Hemiarthroplasty is the most commonly used treatment for displaced femoral neck fractures in the elderly. There is limited evidence in the literature of improved functional outcome with cemented implants, although serious cement-related complications have been reported. We performed a randomized, controlled trial in patients 70 years and older comparing a cemented implant (112 hips) with an uncemented, hydroxyapatite-coated implant (108 hips), both with a bipolar head. The mean Harris hip score showed equivalence between the groups, with 70.9 in the cemented group and 72.1 in the uncemented group after 3 months (mean difference, 1.2) and 78.9 and 79.8 after 12 months (mean difference, 0.9). In the uncemented group, the mean duration of surgery was 12.4 minutes shorter and the mean intraoperative blood loss was 89 mL less. The Barthel Index and EQ-5D scores did not show any differences between the groups. The rates of complications and mortality were similar between groups. Both arthroplasties may be used with good results after displaced femoral neck fractures

Early aseptic loosening of a mobile-bearing total knee replacement

Background and purpose - Registry-based studies have reported an increased risk of aseptic tibial loosening for the cemented Low Contact Stress (LCS) total knee replacement compared with other cemented designs; however, the reasons for this have not been established. We made a retrieval analysis with the aim of identifying the failure mechanism. Patients and methods - We collected implants, cement, tissue, blood, and radiographs from 32 failed LCS Complete cases. Damage to the tibial baseplate and insert was assessed. Exposure to wear products was quantified in 11 cases through analysis of periprosthetic tissue and blood. Implant alignment and bone cement thickness was compared with a control group of 43 non-revised cases. Results - Loosening of the tibial baseplate was the reason for revision in 25 retrievals, occurring at the implant-cement interface in 16 cases. Polishing was observed on the lower surface of the baseplate and correlated to the level of cobalt, chromium, and zirconium in the blood. No evidence of abnormally high polyethylene wear was present. For each 1 mm increase in cement thickness the odds of failure due to aseptic loosening decreased by 61%. Greater varus alignment was associated with a shorter time to failure. The roughness, Ra, of a new LCS baseplate's lower surface was 3.7 (SD 0.7) microm. Interpretation - Debonding of the tibial component at the implant-cement interface was the predominant cause of tibial aseptic loosening. A thin cement layer may partly explain the poor performance. Furthermore, the comparatively low tibial surface roughness and the lack of a keeled stem may have played a role in the failures observed