Treatment of displaced femoral neck fractures in the elderly

Femoral neck fracture (FNF) in elderly patients is a common cause of suffering and premature death in individuals with osteoporotic bones. This fracture type is more common in women after menopause, and the associated patients are often osteoporotic, which contributes to a higher incidence of fractures. FNFs can be undisplaced or displaced, with the latter representing 70-75% of cases. The treatment of displaced FNF in the elderly is still controversial. Optimizing the treatment for improved outcomes and reducing the need for secondary surgery are mandatory for humanitarian and economic reasons. Various options for the surgical treatment of patients with FNF are available, including internal fixation (IF), hemiarthroplasty (HA) and total hip arthroplasty (THA). Each treatment has its advantages and disadvantages. IF is not controversial for the treatment of undisplaced FNF and represents the method of choice for displaced FNF in young patients (less than 65-70 years old) and the frailest elderly patients who are not medically fit for prosthesis surgery. HA is the most common surgical procedure in elderly patients with low functional demands, whereas THA is the preferred method for healthy, active and lucid elderly patients. HA is still the dominant procedure for the treatment of displaced FNF. In Sweden, 64% of all patients with displaced FNF are treated with HA, 22% are treated with THA and 14% are treated with internal fixation. The most common method of performing prosthesis fixation in elderly patients is with bone cement, although concerns over performing this method in older frail patients with multiple comorbidities have been noted. Bone cement implantation syndrome (BCIS) is more prevalent in cemented stems than uncemented stems in patients with FNF. Severe BCIS has a substantial impact on early and late mortality. Thus, the use of uncemented hydroxyapatite stems for this patient group may be justified. Recent reports on modern hydroxyapatite-coated femoral stems used in FNF patients have shown promising early results. However, a more direct comparison between uncemented and cemented stems is required because recent register data suggest a significant increased risk of reoperation with uncemented stems. The functional outcome and the rate of complications and reoperation after modern HA in patients with displaced FNF in combination with cognitive dysfunction are relatively unknown. This patient group has not been sufficiently analysed, and a few studies have recommended IF for this patient group. Moreover, some studies have reported improved post-operative functional outcomes and a lower rate of complications and reoperation after cemented HA compared to IF, even in the presence of severe cognitive dysfunction. The aim of this thesis was to define the optimal treatment for elderly patients with a displaced FNF with respect to their age, functional demands and cognitive function. Study I: This study is a randomized controlled trial (RCT) of 100 patients ≥65 years of age with a displaced FNF, and it was designed to compare THA and IF. Follow-up evaluations were performed at three months and at one, two, four, eleven, and seventeen years. We found a higher Harris hip score and a lower rate of reoperations for patients who were treated with THA. Study II: This study is a RCT of 69 patients aged 65-79 years with a displaced FNF, and it was designed to compare uncemented and cemented stems in patients treated with THA. The patients were followed up at three months and one and two years. Patients who were treated with the uncemented stems showed more complications than patients who were treated with the cemented stems without affecting the functional outcome. Study III: This study is a RCT of 120 patients ≥80 years of age with a displaced FNF, and it was designed to compare THA and HA. The one-year results showed that THA did not present superior outcomes to those of HA. Study IV: This study is a prospective observational cohort study of 160 patients with displaced FNFs, and it was designed to compare the results after HA in 100 patients aged ≥65 years with cognitive dysfunction with that of 60 patients aged ≥80 years without cognitive dysfunction. The patients were followed up at three months and one year. HA in patients with cognitive dysfunction was associated with higher mortality and a higher prevalence of the inability to walk. Patients with cognitive dysfunction who did not receive geriatric rehabilitation had worse patient-reported outcomes and were almost 9-times more likely to be confined to a wheelchair or bedridden. The main conclusions of this thesis are as follows: • THA is the treatment of choice for a displaced FNF in healthy and lucid elderly patients with good hip function preoperatively. • Uncemented femoral stems should be avoided in patients older than 65 years with a displaced FNF. • THA yields no benefits over HA in octa- and nonagenarians treated for a displaced FNF. • HA is a safe option as a treatment for displaced FNF in patients with dementia or cognitive dysfunction

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

External Validity of the HOPE-Trial Hemiarthroplasty Compared with Total Hip Arthroplasty for Displaced Femoral Neck Fractures in Octogenarians

Background: Randomized controlled trials (RCTs) are the most reliable way of evaluating the effect of new treatments by comparing them with previously accepted treatment regimens. The results obtained from an RCT are extrapolated from the study environment to the general health care system. The ability to do so is called external validity. We sought to evaluate the external validity of an RCT comparing the results of total hip arthroplasty with those of hemiarthroplasty for the treatment of displaced femoral neck fractures in patients ≥80 years of age. Methods: This prospective, single-center cohort study included 183 patients ≥80 years of age who had a displaced femoral neck fracture. All patients were screened according to the inclusion and exclusion criteria for an RCT comparing total hip arthroplasty and hemiarthroplasty. The population for this study consisted of patients who gave their informed consent and were randomized into the RCT (consenting group, 120 patients) as well as those who declined to give their consent to participate (non-consenting group, 63 patients). The outcome measurements were mortality, complications, and patient-reported outcome measures. Follow-up was carried out postoperatively with use of a mailed survey that included patient-reported outcome questionnaires. Results: We found a statistically significant and clinically relevant difference between the groups, with the non-consenting group having a higher risk of death compared with the consenting group. (hazard ratio, 4.6; 95% confidence interval, 1.9 to 11.1). No differences were found between the groups in terms of patient-reported outcome measures or surgical complications. Conclusions: This cohort study indicates a higher mortality rate but comparable hip function and quality of life among eligible non-consenters as compared with eligible consenters when evaluating the external validity of an RCT in patients ≥80 years of age with femoral neck fracture. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence

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

The pleasure of the eighteenth-century texts: The conflation of literary and critical discourse in the early novelistic tradition

One of the prominent characteristics of contemporary literature is its assimilation to critical discourse. The self-reflexivity in literature, which transforms literary texts into acts of criticism, is paralleled by theory’s tendency to encroach on the literary domain. One of the findings of the poststructuralist literary theory is that descriptions of reading experience elude scientific language and are more aptly conveyed by metaphors. (A good example is Roland Barthes’ The pleasure of the text.) The conflation of literary and critical discourse is not, however, peculiar to postmodernity only. The same phenomenon is observable in the eighteenth-century writings. It turns out that the self-reflexivity evident at the times of the proclaimed “death of the novel” is manifest also in the times of its birth. The aim of my paper is to analyse the metafictional reflection on readerly pleasure incorporated in early novelistic texts