Displaced femoral neck fractures in the elderly : treatment with arthroplasties

Treatment of displaced femoral neck fractures in the elderly with arthroplasties has become standard practice during the last decade and results in good and predictable outcomes regarding hip function and health-related quality of life (HRQoL). There is, however, a lack of evidence concerning certain types of arthroplasties and different subgroups of patients. Patients with severe cognitive dysfunction have a very limited life expectancy after a hip fracture and low functional demands, as well a low HRQoL before the injury. Many surgeons have concerns regarding arthroplasties in these patients. The bipolar hemiarthroplasty (HA) is designed to reduce stress and erosion on the patient`s natural acetabulum and should, in theory, render a better functional outcome and HRQoL than the unipolar HA. Patients with arthroplasties after displaced femoral neck fractures are at higher risk of sustaining a late periprosthetic fracture (PPF) compared to patients treated due to degenerative joint disease. In addition, some prosthetic designs have been pointed out as being a risk factor for PFF. Uncemented arthroplasties are widely used for various indications and show excellent clinical results. In addition, there are concerns about cementing in older frail patients with multiple comorbidities. All patients in Studies I to IV have been treated with arthroplasties because of a displaced femoral neck fracture. Study I is a randomised controlled trial (RCT) comparing treatment with internal fixation (IF) and treatment with HA in patients with severe cognitive dysfunction. Compared to treatment with IF, HAs appear to result in a better HRQoL and fewer reoperations. Study II is an RCT with a 48-month follow-up comparing bipolar and unipolar HAs. Treatment with a bipolar HA resulted in a better HRQoL after four years. In Study III a cohort of 2757 patients with primary or secondary arthroplasties after femoral neck fractures were investigated. A single cemented femoral implant was used. The incidence of PPFs was high (2.3%) in the cohort, but the surgical outcome after reoperation for a PFF was better compared to previous reports. Study IV is an RCT with a 12-month follow-up comparing uncemented arthroplasties with cemented arthroplasties. The uncemented arthroplasties showed inferior results regarding functional outcome and HRQoL. The main conclusions of this thesis are: Treatment of displaced femoral neck fractures with arthroplasties is safe, even for patients with severe cognitive dysfunction; the use of uncemented arthroplasties should be avoided and there are still controversies regarding the use of bipolar Has

Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: A pooled analysis of 30,250 participants data

PURPOSE: To assess the clinical outcomes of unipolar versus bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures in older patients and to report whether bipolar implants yield better long-term functional results. METHODS: We searched PubMed, Scopus, EBSCO, and Cochrane Library for relevant randomized clinical trials (RCTs) and observational studies, comparing unipolar and bipolar hemiarthroplasty. Data were extracted from eligible studies and pooled as relative risk (RR) or mean difference (MD) with corresponding 95% confidence intervals (CI) using RevMan software for Windows. RESULTS: A total of 30 studies were included (13 RCTs and 17 observational studies). Analyses included 30,250 patients with a mean age of 79 years and mean follow-up time of 24.6 months. The overall pooled estimates showed that bipolar was superior to unipolar hemiarthroplasty in terms of hip function, range of motion and reoperation rate, but at the expense of longer operative time. In the longer term the unipolar group had higher rates of acetabular erosion compared to the bipolar group. There was no significant difference in terms of hip pain, implant related complications, intraoperative blood loss, mortality, six-minute walk times, medical outcomes, and hospital stay and subsequently cost. CONCLUSIONS: Bipolar hemiarthroplasty is associated with better range of motion, lower rates of acetabular erosion and lower reoperation rates compared to the unipolar hemiarthroplasty but at the expense of longer operative time. Both were similar in terms of mortality, and surgical or medical outcomes. Future large studies are recommended to compare both methods regarding the quality of life

A systematic review of Vancouver B2 and B3 periprosthetic femoral fractures

Aims The aim of this study was to investigate the outcomes of Vancouver type B2 and B3 fractures by performing a systematic review of the methods of surgical treatment which have been reported. Materials and Methods A systematic search was performed in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. For inclusion, studies required a minimum of ten patients with a Vancouver type B2 and/or ten patients with a Vancouver type B3 fracture, a minimum mean follow-up of two years and outcomes which were matched to the type of fracture. Studies were also required to report the rate of re-operation as an outcome measure. The protocol was registered in the PROSPERO database. Results A total of 22 studies were included based on the eligibility criteria, including 343 B2 fractures and 167 B3 fractures. The mean follow-up ranged from 32 months to 74 months. Of 343 Vancouver B2 fractures, the treatment in 298 (86.8%) involved revision arthroplasty and 45 (12.6%) were treated with internal fixation alone. A total of 37 patients (12.4%) treated with revision arthroplasty and six (13.3%) treated by internal fixation only underwent further re-operation. Of 167 Vancouver B3 fractures, the treatment in 160 (95.8%) involved revision arthroplasty and eight (4.8%) were treated with internal fixation without revision. A total of 23 patients (14.4%) treated with revision arthroplasty and two (28.6%) treated only with internal fixation required re-operation. Conclusion A significant proportion, particularly of B2 fractures, were treated without revision of the stem. These were associated with a higher rate of re-operation. The treatment of B3 fractures without revision of the stem resulted in a high rate of re-operation. This demonstrates the importance of careful evaluation and accurate characterisation of the fracture at the time of presentation to ensure the correct management. There is a need for improvement in the reporting of data in case series recording the outcome of the surgical treatment of periprosthetic fractures. We have suggested a minimum dataset to improve the quality of data in studies dealing with these fractures