Background: The femoral neck fracture is one the most important traumatic event in the elderly, because of its high rate and terrible complications. The most frequently used surgical option for the management of displaced intracapsular femoral neck fractures is the bipolar hemiarthroplasty. This study examines the incidence of early complications following bipolar hemiarthroplasty procedures for the management of femoral neck fractures using posterior approach.Methods: We retrospectively reviewed 1 year follow up of 150 patients with displaced femoral neck fracture who underwent hemiarthroplasty at our institution between 2007 and 2012. Several variables including age, sex, medical comorbidities, type of fracture, operation time, intraoperative complications, hospitalization time, surgical site infection, systemic infection, prosthesis dislocation periprosthetic fracture, pulmonary thromboembolism, mortality and Harris Hip score were examined.Results: There were 82 males and 68 females in this study. Mean age of patients was 71.4 years. There were no intraoperative mortality, however, one year follow up mortality rate was 7.33%. There were 6.66% early dislocation and surgical site infection was seen in 2.66% of patients. Venous thromboembolic events occurred in 2.66% of patients. The average HHS improved significantly at one year follow up.Conclusions: Our study showed that bipolar hemiarthroplasty through posterior approach is associated with a modest rate of complications

Arabzadeh, Aidin

Berehnegard, Edris

Khomeisi, Bijan

Mortazavi, SM Javad

Saberi, Sadegh

English

Academic Journal of Surgery (AJS - Tehran University of Medical Sciences)

Acad J Surg, Vol. 1, No. 3-4 (2014)  Corresponding Author: SM Javad Mortazavi Department of Orthopedic Surgery, Imam University Hospital, Tehran University of Medical Sciences, AND Joint Reconstruction Research Center, Tehran University of Medical Sciences, End of Keshavarz Blvd, 1419733141 Tehran, Iran. Tel: +98 21 66935512, Fax: +98 21 6658 1586, E-mail: smjmort@yahoo.com ORIGINAL ARTICLEEarly Complications Following Bipolar Hemiarthroplasty for Femoral Neck Fracture in Elderly Patients Sadegh Saberi1, Aidin Arabzadeh1, Bijan Khomeisi1, Edris Berehnegard1, SM Javad Mortazavi1 1 Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran Received: 19 Oct. 2013; Received in revised form: 2 Dec. 2013; Accepted: 4 Jan. 2014 ________________________________________________________________________________________________________ Abstract Background: The femoral neck fracture is one the most important traumatic event in the elderly, because of its high rate and terrible complications. The most frequently used surgical option for the management of displaced intracapsular femoral neck fractures is the bipolar hemiarthroplasty. This study examines the incidence of early complications following bipolar hemiarthroplasty procedures for the management of femoral neck fractures using posterior approach. Methods: We retrospectively reviewed 1 year follow up of 150 patients with displaced femoral neck fracture who underwent hemiarthroplasty at our institution between 2007 and 2012. Several variables including age, sex, medical comorbidities, type of fracture, operation time, intraoperative complications, hospitalization time, surgical site infection, systemic infection, prosthesis dislocation periprosthetic fracture, pulmonary thromboembolism, mortality and Harris Hip score were examined. Results: There were 82 males and 68 females in this study. Mean age of patients was 71.4 years. There were no intraoperative mortality, however, one year follow up mortality rate was 7.33%. There were 6.66% early dislocation and surgical site infection was seen in 2.66% of patients. Venous thromboembolic events occurred in 2.66% of patients. The average HHS improved significantly at one year follow up. Conclusions: Our study showed that bipolar hemiarthroplasty through posterior approach is associated with a modest rate of complications.  Citation: Saberi S, Arabzadeh A, Khomeisi B, Berehnegard E, Mortazavi SMJ. Early Complications Following Bipolar Hemiarthroplasty for Femoral Neck Fracture in Elderly Patients. Acad J Surg, 2014; 1(3-4): 45-48. Keywords: Hemiarthroplasty, Femoral Neck Fractures, Aged, Patients, Complications. Introduction The femoral neck fracture is one of the most important traumatic event in the elderly, because of its high rate and terrible complications (1). Femoral neck fractures occur most frequently in elderly female patients following fall from standing height and may be associated with osteoporosis. Undisplaced femoral neck fractures account for 15% of femoral neck fractures in elderly and are usually treated with internal fixation. There are several surgical options for displaced femoral neck fractures with regard to patient’s age, functional status and cognitive function (11). In this group of patients, reduction and internal fixation is associated with significant complications. Therefore, hip arthroplasty is the treatment of choice. However, there is a current debate on whether hemiarthroplasty or total hip arthroplasty is the best option. Hemiarthroplasty is the more often surgical option currently used for the management of displaced intracapsular femoral neck fractures in elderly patients to restore their mobility and prevent of complications related to decreased ambulation following fracture (3). However, this surgical intervention is not without morbidity and mortality during perioperative period (1,2,3,6,10).  This study examines the incidence of early complications following bipolar hemiarthroplasty procedures for the management of femoral neck fractures using posterior approach. Methods We retrospectively reviewed one year follow up of 150 patients with displaced femoral neck fracture who underwent bipolar hemiarthroplasty through posterior approach at our institution between 2007 and 2012. All patients were referred to our emergency room (ER) department with displaced femoral neck fracture. We tried to optimize medical issues in 48 hours preoperatively. Patients underwent surgery through a posterior approach by single surgeon (SS). Venous thromboembolism prophylaxis was started preoperatively with low molecular weight heparin (LMWH) and continued for 4 weeks postoperatively. We held LWWH 12 hours before surgery and restarted 12 hours after surgery. Patients were mobilized on the Bipolar hemiarthroplasty complications for Femoral Neck Fracture 46  Acad J Surg, Vol. 1, No. 3-4 (2014) second postoperative day using a walker frame. Follow-up visits were at 2nd and 4th weeks and 2nd, 6th &12th months after surgery. Several variables including age, sex , medical comorbidities, type of fracture, operation time, intraoperative complications, postoperative length of stay, postoperative complications and functional outcomes (Harris Hip score: HHS) were examined.  SPSS statistical software (SPSS Inc., Chicago, IL, USA) was used for the analysis of data. The level of significance was set at 0.05. A paired t-test was used for analyzing the effects of surgery before and after arthroplasty in each groups.  Results  There were 82 males and 68 females in our study. Mean age of patients was 71.4 years at the time of surgery (range, 49 to 93). A number of 139 patients had Garden type 4 fracture and 11 patients had Garden type 3 fracture. Demographic data and hospital outcomes are shown in Table 1. There was at least one comorbid condition in 58 patients. Female patients had significantly more comorbidity than male patients (p=0.02). Cardiovascular disease was the most common comorbid condition in our patients (Table 2). We did not have any significant intraoperative complications, other than excessive blood loss. Twenty nine patients needed blood transfusion at the time of surgery. No intraoperative mortality was observed. Thirty four complications occurred in 34 patients during the first postoperative year (Table 3). Of these complications, 22 took place in the first month following surgery (p=0.03). One-year mortality rate was 7.33%. The rate of complications was the same in female and male patients (p=0.2). There was a significant improvement in HHS at one year follow up. The average HHS increased from 74.5 at 6 months to 80.7 at 12 months (p=0.001). The functional score was significantly higher in female patients; however, HHS was the same in both gender in 12th month (Figure 1). Figure 2 shows that younger patients had significantly better HHS measures during follow up (p=0.001). Discussion  This study showed that bipolar hemiarthroplasty for displaced femoral neck fracture in elderly patients through posterior approach improved functional outcome, however, it was associated with modest rate of complications. We found an overall rate of 23% complications including infection, dislocation, pulmonary emboli (PE), heterotopic ossification and death. Shah et al. reviewed the results of 173508 patients managed with Table 2. Demographic data & hospital outcomes.0.7% 1 Rheumatoid arthritis 4.7% 7 Kidney disease 3.3% 5 Pulmonary disease 1.3% 2 Gastrointestinal disorders 11.4% 17 Neurological disease 38% 57 Cardiovascular disease 21.3% 32 Diabetes mellitus 6% 9 Malignancies Figure 1. Harris Hip Score in males and females. 72.5677.0579.3882.3566687072747678808284Male FemaleHHS.6th month HHS.12th monthTable 1. Demographic data and hospital outcomes. Male Female TotalNo (percentage) 82(54.8%) 68(45.2%) 150(100%) Average age (years) 71.65(8.85) 71.14(8.85) 71.42(8.69) Duration of operation (minutes) 72.74(7.62) 71.13(13.4) 72.01(10.63) Post-operative length of stay (days) 7.2(3.27) 6.15(2.5) 6.72(2.98)Table 3. Complications at one-year follow-up. Male Female TotalMortality 8(5.33%) 3(2%) 11(7.33%)Prosthesis dislocation 6(4%) 4(2.66%) 10(6.66%) Infection Wound infection Systemic infection 3(2%) 3(2%) 6(4%)2(1.33%) 2(1.33%) 4(2.66%)1(0.66%) 1(0.66%) 2(1.33%)Pulmonary Emboli (PE) 2(1.33%) 2(1.33%) 4(2.66%) Bed sore 2(1.33%) 0(0%) 2(1.33%) Heterotopic ossification 0(0%) 1(0.66%) 1(0.66%) Total 21(14%) 13(8.6%) 34(22.66%)Saberi S et al. Acad J Surg, Vol. 1, No. 3-4 (2014)  47the bipolar prosthesis and reported similar rate of complications (20%). The incidence of PE, wound infection, urinary tract infection (UTI) and pneumonia were 1.5%, 0.1%, 15.8% and 2.8%, respectively (3). Lu-Yao G et al. reported deep infection and PE rates 1.7% and 2%, respectively (4). We found almost the same rate of complications in our patients. Femoral neck fractures treated with bipolar hemiarthroplasty result in a significantly increased mortality. During the first year after femoral neck fractures a mortality of 11–36 % is reported (14-17). With 11% one-year mortality rate this study is comparable to the literature mentioned above. D'Angelo et al. reported 25% one year follow up mortality rate following hemiarthroplasty (1). Eiskjar reported 20% mortality rate at six months and 28% mortality rate at one-year. They found cardiac factors other than previous myocardial infarction; status as a nursing home patient; chronic pulmonary disease; serum creatinine level greater than 1.7 mg/100 ml; pneumonia; previous myocardial infarction; duration of surgery; and gender had significant influence on mortality. However, factors such as age, time delay from admission to surgery, mode of anesthesia, and cerebrovascular diseases had no significant influence on mortality (12). Schneppendahl et al showed that mortality after femoral neck fracture treated with bipolar arthroplasty has significantly decreased during last twenty years (13). They concluded that significant decrease in mortality over recent years suggests that bipolar hemiarthroplasty is an increasingly secure treatment option for elderly patients sustaining a femoral neck fracture. We think that our low mortality rate could be related to younger age of our patients. Dislocation of hip hemiarthroplasties has been a concern for orthopedic surgeons since the advent of the procedure. Furthermore, early dislocation is associated with increased mortality rate (19-20). Manoj Kumar Rajak et al. reported 3% prosthesis dislocation following bipolar hemiarthroplasty (10). Unwin et al. reported a 6.5% dislocation rate among all their patients, with those having posterior approaches being three times more likely to dislocate (21). We observed 6.6% early dislocation in our series which is comparable to the other series. Though some authors reported no association between surgical approach and dislocation following bipolar hemiarthroplasty (22), an increased risk of dislocation has been shown for the posterolateral surgical approach compared with lateral approaches (23,24,25,26). This increased risk may be reduced by posterior capsule repair and short external rotator reattachment (27,28). We attribute our high rate of dislocation to posterolateral approach we administered in our patients. As the number of patients might not be enough to do more analysis, we could not show if there is any association between patient's age, gender and risk of dislocation. We also were unable to show if dislocation would increase the mortality rate. Early surgical complications after bipolar hemiarthroplasty may be the origin of cascades leading to general complications and increased mortality. This is why their prevention is especially important. Surgical approach can affect the type of complication. Though there is no significant difference in overall complication rate, the dislocation rate is higher after a posterior approach while hematoma is higher in anterior approaches. The rates for infection, seroma and perioperative fracture did not differ significantly (29). In our study, postoperative complications were seen in %22.6 of patients. Infection was the third most common complication in our series. The significant improvement of HHS was seen at one-year follow up. This is along with previous studies that showed good functional outcome for patients who received bipolar hemiarthroplasty for displaced femoral neck fracture (30). We also showed that the younger patients had better functional outcome at the final follow up which related to their better physical and functional status of health at the time of surgery. It is also very important that the functional outcome significantly improved during the first year after surgery. In conclusion, bipolar hemiarthroplasty in elderly patients with displaced femoral neck fracture through posterior is associated with modest rate of complications. Mortality during the first postoperative year, dislocation and infection are the most frequently encountered complications. However, bipolar hemiarthroplasty has a significant effect on patients' functional status after disabling femoral neck fracture. Therefore, further studies are required to see if modification in surgical techniques and approaches could influence the rate of complications.  References 1. D’Angelo F, Giudici M, Molina M, Margaria G. Mortality rate after hip hemiarthroplasty: analysis of risk factors in299 consecutives cases. J. of Orthop. and Traumatol..2005;6(3):111-6.2. Weinrauch PC, Moore WR, Shooter DR, Wilkinson MP,Bonrath EM, Dedy NJ, et al. Early prostheticcomplications after unipolar hemiarthroplasty. ANZ J. ofSurg. 2006;76(6):432-5.3. Shah SN, Wainess RM, Karunakar MA. Hemiarthroplasty for Femoral Neck Fracture in the Elderly: Surgeon andHospital Volume− Related Outcomes. The J. ofarthroplasty. 2005;20(4):503-8.4. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE.Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports.The J. of Bone & Joint Surg. 1994;76(1):15-25.5. Macaulay W, Nellans KW, Garvin KL, Iorio R, HealyWL, Rosenwasser MP. Prospective randomized clinicaltrial comparing hemiarthroplasty to total hip arthroplastyBipolar hemiarthroplasty complications for Femoral Neck Fracture 48  Acad J Surg, Vol. 1, No. 3-4 (2014) in the treatment of displaced femoral neck fractures: winner of the Dorr Award. The J. of arthroplasty. 2008;23(6):2-8. 6. Tanous T, Stephenson KW, Grecula MJ. Hiphemiarthroplasty after displaced femoral neck fracture: asurvivorship analysis. Orthopedics. 2010;33(6):385.7. Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, Chang-Qing Z. Hemiarthroplasty vs Primary Total HipArthroplasty For Displaced Fractures of the FemoralNeck in the Elderly: A Meta-Analysis. The J. ofArthroplasty. 2012;27(4):583-90.8. Enocson A, Hedbeck CJ, Törnkvist H, Tidermark J,Lapidus LJ. Unipolar versus bipolar Exeter hiphemiarthroplasty: a prospective cohort study on 830consecutive hips in patients with femoral neck fractures.Int. orthop. 2012;36(4):711-7.9. Ahn J, Man L-X, Park S, Sodl JF, Esterhai JL. Systematicreview of cemented and uncemented hemiarthroplastyoutcomes for femoral neck fractures. Clin. Orthop. andRelat. Res. 2008;466(10):2513-8.10. Rajak MK, Jha R, Kumar P, Thakur R. Bipolarhemiarthroplasty for intracapsular femoral neck fracturesin elderly patients. J. of orthop. Surg. (Hong Kong).2013;21(3):313-6.11. Bucholz R,Court-Brown C,Heckman J,TornettaP.Rockwood and Green'S FRACTURES INADULTS.Seventh edition. Wolters Kluwer LippincottWilliams & Wilkins 2010;Volume 2:1561-1596.12. EISKJAER S, ØSTGÅRD SE. Risk factors influencingmortality after bipolar hemiarthroplasty in the treatmentof fracture of the femoral neck. Clin. Orthop. and Relat.Res. 1991;270:295-300.13. Schneppendahl J, Grassmann JP, Petrov V, Bottner F,Korbl B, Hakimi M, et al. Decreasing mortality afterfemoral neck fracture treated with bipolarhemiarthroplasty during the last twenty years. Int. Orthop. 2012;36(10):2021-6.14. Miyamoto RG, Kaplan KM, Levine BR, Egol KA,Zuckerman JD. Surgical management of hip fractures: anevidence-based review of the literature. I: femoral neckfractures. The J. of the Am. Acad. of Orthop. Surg.2008;16(10):596-607.15. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hipfracture mortality. Relation to age, treatment,preoperative illness, time of surgery, and complications.Clin. Orthop. and Relat. Res. 1984(186):45-56.16. Sexson SB, Lehner JT. Factors affecting hip fracturemortality. J. of orthop. trauma. 1987;1(4):298-305.17. Lim YW, Kwon SY, Han SK, Sun DH, Choi SP, Kim YS. Postoperative mortality and factors related to mortalityafter bipolar hemiarthroplasty in patients with femoralneck fractures. J Arthroplasty. 2009;24(8):1277-80. 18. Ions GK, Stevens J. Prediction of survival in patients with femoral neck fractures. The J. of bone and joint surg. Br.vol. 1987;69(3):384-7.19. Petersen MB, Jorgensen HL, Hansen K, Duus BR. Factors affecting postoperative mortality of patients withdisplaced femoral neck fracture. Injury. 2006;37(8):705-11.20. Ninh CC, Sethi A, Hatahet M, Les C, Morandi M, VaidyaR. Hip dislocation after modular unipolarhemiarthroplasty. J Arthroplasty. 2009;24(5):768-74.21. Unwin AJ, Thomas M. Dislocation after hemiarthroplasty of the hip: a comparison of the dislocation rate afterposterior and lateral approaches to the hip. Ann. of theRoy. Coll. of Surg. of Engl.. 1994;76(5):327-9.22. Sierra RJ, Schleck CD, Cabanela ME. Dislocation ofbipolar hemiarthroplasty: rate, contributing factors, andoutcome. Clin. Orthop. and Relat. Res. 2006;442:230-8.23. Pajarinen J, Savolainen V, Tulikoura I, Lindahl J,Hirvensalo E. Factors predisposing to dislocation of theThompson hemiarthroplasty: 22 dislocations in 338patients. Acta. Orthop. Scand. 2003;74(1):45-8.24. Enocson A, Hedbeck CJ, Tornkvist H, Tidermark J,Lapidus LJ. Unipolar versus bipolar Exeter hiphemiarthroplasty: a prospective cohort study on 830consecutive hips in patients with femoral neck fractures.Int. Orthop. 2012;36(4):711-7.25. Keene G, Parker M. Hemiarthroplasty of the hip—theanterior or posterior approach? A comparison of surgicalapproaches. Injury. 1993;24(9):611-3.26. Bush JB, Wilson MR. Dislocation after hiphemiarthroplasty: anterior versus posterior capsularapproach. Orthopedics. 2007;30(2):138-44.27. Suh KT, Park BG, Choi YJ. A posterior approach toprimary total hip arthroplasty with soft tissue repair. Clin.Orthop. and Relat. Res. 2004;418:162-7.28. Ko C, Law S, Chiu K. Enhanced soft tissue repair usinglocking loop stitch after posterior approach for hiphemiarthroplasty. The J. of Arthroplasty. 2001;16(2):207-11.29. Biber R, Brem M, Singler K, Moellers M, Sieber C, BailHJ. Dorsal versus transgluteal approach for hiphemiarthroplasty: an analysis of early complications inseven hundred and four consecutive cases. Int. Orthop.2012;36(11):2219-23.30.  Renken F, Renken S, Paech A, Wenzl M, Unger A, Schulz AP. Early functional results after hemiarthroplasty forfemoral neck fracture: a randomized comparison between a minimal invasive and a conventional approach. BMCMusculoskelet Disord. 2012;13:141.

Early Complications Following Bipolar Hemiarthroplasty for Femoral Neck Fracture in Elderly Patients

https://ajs.tums.ac.ir/index.php/ajs/article/download/11/11

Early Complications Following Bipolar Hemiarthroplasty for Femoral Neck Fracture in Elderly Patients

Abstract

Similar works

Full text

Available Versions

Academic Journal of Surgery (AJS - Tehran University of Medical Sciences)