Abstract OBJECTIVE:
To identify trends related to surgical procedure for the management of neck of femur fracture to see how the choice is changing over time in relation to different age groups.  METHODS:
The retrospective audit was conducted at Aga Khan University Hospital, Karachi, and comprised data of all patients who presented with neck of femur fracture from 1995 to 2014. Patients with open fractures and those having external fixators were excluded. Data was retrieved from the hospital database, and analysed using SPSS 17.  RESULTS:
Records of 1039 patients were reviewed. The proportion of patients in the 70+ years age group significantly increased from 45% to 52% over the two decades (p=0.033). Proportion of patients undergoing total hip replacement increased by more than 3 times from 2.6% to 8% (p50 years (p  CONCLUSIONS:
There is apparently a rising trend in number of patients presenting with neck of femur fracture. Total hip replacement has a rising trend and partial hip arthroplasties have a decreasing trend when it comes to treatment of neck of femur fractures

Abdul Muhammad, Zehra

Ahmad, Tashfeen

Ashraf, Umair

Irfan, Omar

English

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryNovember 2015Trends in management of neck of femur fractureTashfeen AhmadAga Khan University, tashfeen.ahmad@aku.eduUmair AshrafAga Khan University, umair.ashraf@aku.eduOmar IrfanAga Khan UniversityZehra Abdul MuhammadAga Khan University, zehra.abdul@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Orthopedics Commons, and the Surgery CommonsRecommended CitationAhmad, T., Ashraf, U., Irfan, O., Abdul Muhammad, Z. (2015). Trends in management of neck of femur fracture. JPMA: Journal ofPakistan Medical Association, 65(11), S-163-165.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/149IntroductionHip fractures are common in the elderly and haveconsequences extending into the domains of medicine,rehabilitation, psychiatry, social work and medicaleconomics. Despite improvements in patient care,advances in surgical technique and implant technology,hip fractures continue to pose a substantial economicburden on the medical systems in the developed and thedeveloping world. In 1995, 15 European Union (EU)countries had about 382,000 hip fractures with anestimated care cost of 9 billion Euros.1 Its estimated thatabout 250,000 hip fractures occur in the United Stateseach year. The number of fractures is projected to doubleby 2050 as the population ages.2There are several factors contributing to an ever-increasing number of femoral neck fractures, including anincreased patient lifespan, activity level and incidence ofosteoporosis.3 The decrease in bone mass in the elderly iscaused by a number of factors including reduced functionof osteoblasts, increased osteoclast activity, reducedphysical activity, genetic predisposition, decreasedcalcium intake and hormonal influences.3 This results inbone resorption outpacing bone building.Postmenopausal women are especially at risk because ofoestrogen deficiency.3Surgical treatmenthasbeenestablishedas thegold standard,with the main aim being early mobilisation in order toprevent morbidity associated with recumbency. However,choice of the surgical option remains a topic of debate.Surgical options mostly revolve around internal fixation,hemiarthroplasty (such as Austin-Moore) and total hipreplacement (THR). Each of these has its own merits anddemerits.The current study was conducted to audit the trends inmanagement of neck of femur fracture at our institution tosee how the choice of surgical procedure is changing overtime in relation to different age groups.Materials andMethodsThe retrospective audit was conducted at Aga KhanUniversity Hospital, Karachi, and comprised data of allpatients who presented with neck of femur fracture from1995 to 2014. Patients with open fractures and those havingexternal fixators were excluded.Data was retrieved from the hospital database, and analysedusing SPSS 17 Chi square test was used to comparecategories. P<0.05 was considered statistically significant.Vol. 65, No.11 (Suppl. 3), November 201529th Pak Orthocon 2015 S-163Department of Surgery, Aga Khan University, Karachi, Pakistan.Correspondence: Tashfeen Ahmad. Email: tashfeen.ahmad@aku.eduORIGINAL ARTICLETrends in management of neck of femur fractureTashfeen Ahmad, Umair Ashraf, Omar Irfan, Zehra Abdul MuhammadAbstractObjective: To identify trends related to surgical procedure for themanagement of neck of femur fracture to see howthe choice is changing over time in relation to different age groups.Methods: The retrospective audit was conducted at Aga Khan University Hospital, Karachi, and comprised data ofall patients who presented with neck of femur fracture from 1995 to 2014. Patients with open fractures and thosehaving external fixators were excluded. Data was retrieved from the hospital database, and analysed using SPSS 17.Results: Records of 1039 patients were reviewed. The proportion of patients in the 70+ years age group significantlyincreased from 45% to 52% over the two decades (p=0.033). Proportion of patients undergoing total hipreplacement increased by more than 3 times from 2.6% to 8% (p<0.001).Internal fixation was the most commonprocedure in patients aged <50 (p<0.001), and hemiarthroplasty for those aged >50 years (p<0.001). Total hipreplacement was seen in its highest proportion (15%) in patients aged 40-49 years (p=0.006). Hemiarthroplastyshowed a dramatic decrease in the age group 50-59 years (from 57% to 40%). Total hip replacement showed a steadyincreasing trend over the last 20 years, most prominently in people in their 50s and 60s (from 1% to 18%; p<0.001).Conclusion: There is apparently a rising trend in number of patients presenting with neck of femur fracture. Totalhip replacement has a rising trend and partial hip arthroplasties have a decreasing trendwhen it comes to treatmentof neck of femur fractures.Keywords: Fracture neck of femur, Intracapsular fractures, Internal fixation, Hemiarthroplasty, Total hipreplacement, Management trends. (JPMA65: S-163 (Suppl. 3); 2015)ResultsRecords of 1039 patients were reviewed. Hemiarthroplastywas the most common procedure in 68% patients (Table-1).Internal fixationwas themost commonprocedure in patientsaged<50 (p<0.001), andhemiarthroplasty for thoseaged>50years (p<0.001). THRwas seen in its highest proportion (15%)in patients aged 40-49 years (p=0.006) (Figure-1).The age group forming the highest proportion was 70-79years, accounting for 31% patients (Table-2). However,there was a shift in the age towards older age group overthe 20-year study period. The proportion of patients in the70+ age group compared to <70 group significantlyincreased from 45% to 52% (p=0.033).In terms of choice of procedure, internal fixation remainedmoreor less consistent across the years, beingmore commonin yournger age groups (Figure-2). Hemiarthroplasty showedadecreasing trendbelow70 years. The greatest decreasewasin the 50-59 age group, decreasing from 57% to 40%. THRshowedan increasing trend. In the last 10 yearsTHR increasedfrom 2.5% before 2010 to over 12.9% after 2010 (p<0.001).The increase was the greatest in patients in their 50s and 60s;from 1% to 18% (p<0.001).Gender distributiondidnot showany changeover time,withJ Pak Med Assoc (Suppl. 3)S-164 29th Pak Orthocon 2015Figure-1: Stacked bar chart and data table depicting age distribution and proportionof each procedure within age groups. Significantly higher proportion of patients aged<50 years underwent internal fixation (76%; p<0.001), while those aged >50 yearsunderwent hemiarthroplasty (76%; p<0.001). A narrow bracket (15%) of patientsaged 40-49 years underwent total hip replacement (THR) in a significantly higherproportion (p=0.006) than other age groups.Figure-2: Trend of choice of procedure across 20 years, according to age group. In the 50s internal fixation was done in about 40% patients, while in the >80 age grouphemiarthroplasty remained the most common procedure. In 50s and 60s, there was a progressive increase in proportion of total hip replacement (THR) (from 1% to 18%; p<0.001) anda corresponding decrease in proportion of hemiarthroplasty (78% to 55%; p<0.005).Table-1: Hemiarthroplasty was the most common procedure in 68% patients.Characteristic n (%)GenderMale 476 (46%)Female 563 (54%)Year1995-1999 199 (19%)2000-2004 231 (22%)2005-2009 283 (27%)2010-2014 326 (31%)ProcedureHemiarthroplasty 707 (68%)Internal fixation 272 (26%)Total hip replacement 60 (6%)Table-2: Differences in age groups over time. Proportion of older patients (70+ years)is increasing across the time periods.Age group 1995-1999 2000-2004 2005-2009 2010-2014< 30 8(4%) 11(5%) 14(5%) 19(6%)30-39 6(3%) 11(5%) 4(1%) 10(3%)40-49 14(7%) 16(7%) 12(4%) 18(6%)50-59 23(12%) 34(15%) 42(15%) 42(13%)60-69 58(29%) 54(23%) 63(22%) 68(21%)70-79 49(25%) 73(32%) 98(35%) 100(31%)80+ 41(21%) 32(14%) 50(18%) 69(21%)slight female preponderance by about 4-8%. Proportion ofpatients undergoing internal fixation and hemiarthroplastydecreased by 8% and 5% respectively (p>0.05). On the otherhand, proportion of patients undergoing THR increased bymore than 3 times from 2.6% to 8% (p<0.001).DisscussionOur study showed that in patients presenting with neck offemur fractures therewas aprogressive rise in theproportionof patients undergoing THR, and a fall in the proportion ofhemiarthroplasty. There has conventionally been a singlefactor that determined surgical treatment of these injuries:whether the fracture is displaced or not. When fractures arerelatively undisplaced they are fixed and when displaced,hemiarthroplasty was the recommended treatment. THRwas seldom performed because of a higher dislocation ratecompared to hemiarthroplasty4-6 because of greatercomplexity and cost of the procedure. Internal fixation withcannulated screws is minimally invasive, simple andeconomical. However, the related complications of internalfixation, including possibility of avascular necrosis (AVN) ornon-union (requiring revision surgery) and malunion(causing shortening and limp) are considerations against thechoice of internal fixation, especially in the elderly.7TheprocedureofAustin-Moorehemiarthroplasty is commonlycarried out in all hospitals of Pakistan catering to patients withfractures,8-10 but the long-term results of thesepatientshasnotbeen reportedpreviously. According toa recent study,11 AustinMoore arthroplasty has proved a good option in terms of lowcomplication rate and an acceptable functional result (33%Excellent and 43% Good), though there was no comparisongroup in thestudy.Hemiarthroplastymaybedoneusingeithera monopolar or so called bipolar heads. The theoreticaladvantage of a bipolar head is that with two articulatingsurfaces, there is reduced friction upon the native acetabularcartilage, possibly leading to a slower progression of cartilagewear and lesser pain aswell as lower dislocation rate.12In the last few decades, there appears to be a trend towardsTHRbecauseof evidenceof better functional outcomes andalower revision rate than hemiarthropalsty.13-15 With the wideuse of larger diameter heads and improving surgicaltechniques, the dislocation rate is going down. Abroad, it isbecoming a common procedure for active people in middleand elderly age groups suffering from femoral neck fractures.ConclusionInternal fixation is the favoured option in patients below 50years of age, though it is practised in all age groups. THR isbecoming more common, especially in patients in their 50sand 60s. Hemiarthroplasty, which used to be the mostcommon procedure in the elderly, is showing a decline inpeople aged less than 70 years. Better reported functionalresults afterTHR compared tohemiarthroplasty, and ageneralincrease in recognitionof the role of, and experience in,THR infracture patients are likely to be responsible for this trend.References1. Gennari C. Calcium and vitamin D nutrition and bone disease of theelderly. Public Health Nutr 2001; 4: 547-9.2. Koval KJ, Zuckerman JD. Functional recovery after fracture of the hip. JBone Joint Surg Am 1994; 76: 751-8.3. Yoon BH, Lee YK, Kim SC, Kim SH, Ha YC, Koo KH. Epidemiology ofproximal femoral fractures in South Korea. Arch Osteoporos 2013; 8:157. doi: 10.1007/s11657-013-0157-9.4. Su EP, Su SL. Femoral neck fractures: a changing paradigm. Bone JointJ 2014; 96 (11 Suppl A): 43-7.5. Conroy JL, Whitehouse SL, Graves SE, Pratt NL, Ryan P, Crawford RW.Risk factors for revision for early dislocation in total hip arthroplasty. JArthroplasty 2008; 23: 867-872.6. Poignard A, Bouhou M, Pidet O, Flouzat-Lachaniette CH, Hernigou P.High dislocation cumulative risk in THA versus hemiarthroplasty forfractures. Clin Orthop Relat Res 2011; 469: 3148-53.7. Hailer NP, Weiss RJ, Stark A, Kärrholm J. The risk of revision due todislocation after total hip arthroplasty depends on surgical approach,femoral head size, sex, and primary diagnosis. An analysis of 78,098operations in the Swedish Hip Arthroplasty Register. Acta Orthop2012; 83: 442-8.8. Ahmad I.Mortality andmorbidity inelderlypatientswith fractureneckof femur treated by hemiarthroplasty. J Coll Physicians Surg Pak 2006;16: 655-8.9. Ahmad I. A Study on Mortality and Morbidity in Elderly Patients withHemiarthroplasty During One Year Post-Operative Followup Period.[Dissertation Orthopaedic Surgery] College of Physicians andSurgeons Pakistan; 2004.10. MustafaY,AyshaH,AvrahamG,AbdallaB.Theorthopaedicquandryofhip fractures in patients with Alzheimer's disease require appropriateprevention strategy. Merit Research J 2014; 2: 12-18. (Online) (Cited2015 April 30). Available from URL: http://meritresearchjournals.org/mms/content/2014/January/Yassin%20et%20al.pdf.11. Shah SA, Memon A, Pirwani M. Outcome of femural neck fracturetreated by Austin-Moore hemiarthoplasty in elderly patients. MedForum 2015; 26:45-49. (Online) (Cited 2015 April 30). Available fromURL: http://www.medforum.pk/index.php/article-database/9-articles/112-outcome-of-femural-neck-fracture-treated-by-austin-moor-hemiarthoplasty-in-elderly-patients.12. Giliberty RP. Hemiarthroplasty of the hip using a low-friction bipolarendoprosthesis. Clin Orthop Relat Res 1983; 175: 86-92.13. Burgers PT, Van Geene AR, Van den Bekerom MP, Van Lieshout EM,Blom B, Aleem IS, et al. Total hip arthroplasty versus hemiarthroplastyfor displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. Int Orthop 2012;36: 1549-60.14. YuL,WangY,Chen J.Total hip arthroplasty versushemiarthroplasty fordisplaced femoral neck fractures: meta-analysis of randomized trials.Clin Orthop Relat Res 2012; 470: 2235-43.15. MacaulayW,Nellans KW,GarvinKL, Iorio R,HealyWL, RosenwasserMP,et al. Prospective randomized clinical trial comparinghemiarthroplasty to total hip arthroplasty in the treatment ofdisplaced femoral neck fractures: winner of the Dorr Award. JArthroplasty 2008; 23(6Suppl): 2-8.Vol. 65, No.11 (Suppl. 3), November 201529th Pak Orthocon 2015 S-165

Trends in management of neck of femur fracture

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Trends in management of neck of femur fracture

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