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Femoral neck fractures in the elderly: A changing paradigm

Max Vaynrub, MDn, and Jay R. Lieberman, MD

Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA

A R T I C L E I N F O

Keywords:

femoral neck fracture

hip fracture

total hip arthroplasty

hemiarthroplasty

internal fixation

bipolar

unipolar

527/$ - see front matter Published by Edx.doi.org/10.1053/j.sart.2013.08.002

ress reprint requests to Max Vaynrub, Mne of USC, 1520 San Pablo Street, Suitail address: Maksim.Vaynrub@med.u

A B S T R A C T

Femoral neck fractures are often life-changing events, and maximizing the patient’s post-

injury outcome hinges on optimal surgical management. The goal is to minimize pain and

disability, and restore as much as possible of the patient’s pre-injury functional capacity,

with a single procedure. It is helpful to approach the surgical management of femoral neck

fractures with an algorithm. A decision must first be made between internal fixation and

arthroplasty; internal fixation is usually chosen for younger patients or for nondisplaced

femoral neck fractures at any age, while arthroplasty is generally beneficial for displaced

femoral neck fractures in the elderly. If arthroplasty is chosen, then the type of

arthroplasty to be used is decided upon based on the patient’s health and functional

status, with total hip arthroplasty being the preferred intervention in healthy, active

patients that live at home. Finally, there is no evidence in the recent literature that

indicates that bipolar hip hemiarthroplasty has a better functional outcome than the

unipolar variety, and therefore the use of unipolar implants would probably reduce the

economic burden on the healthcare system without compromising patient care.

Published by Elsevier Inc.

1. Introduction

Femoral neck fractures are often life-changing events, asso-ciated with significant mortality, pain, disability, and declinein independent function. Maximizing the patient’s post-injury outcome hinges on optimal surgical management,which requires a judicious assessment of the fracture andthe patient. The goal is to minimize pain and disability, andrestore as much as possible of the patient’s pre-injury func-tional capacity, with a single procedure. A comprehensiveunderstanding of the available options for fixation or recon-struction, as well as the variables that influence the ultimateoutcome of these options, is critical when deciding on thesurgical intervention that will maximize the patient’s chan-ces for a successful outcome.It is helpful to approach the surgical management of

femoral neck fractures with an algorithm. The first decisionswill be whether to treat the fracture with internal fixation or

lsevier Inc.

D, University of Southere 2000, Los Angeles, CA 9sc.edu (M. Vaynrub).

an arthroplasty. If arthroplasty is appropriate, one mustdecide between a total hip arthroplasty versus hemiarthro-

plasty. When pursuing hemiarthroplasty, one must further

choose either a unipolar or bipolar component. There isevidence in the orthopedic literature that can guide the

surgeon at each decision point in the algorithm in order to

arrive at the management option that will maximize the

chances for success.It must be remembered that hip fracture patients represent

a heterogeneous patient population. Some patients will berelatively healthy and will be living in the community, whileothers may have significant medical comorbidities, includingdementia. These patients often are low demand and reside inassisted-living facilities, such as nursing homes. Therefore, itis essential to evaluate the patient’s overall health, mentalstatus, activity level, and residential status before making adecision with respect to surgical management of a femoralneck fracture.

n California, Department of Orthopaedic Surgery, Keck School of0033.

S E M I N A R S I N A R T H R O P L A S T Y 2 4 ( 2 0 1 3 ) 5 6 – 6 0 57

2. Internal fixation versus arthroplasty

While the treatment of choice for a stable, nondisplacedfracture of the femoral neck (Garden type I or II) is usuallyscrew fixation [1], the management of a displaced fracture(Garden type III or IV) is more variable. The management ofdisplaced femoral neck fractures is clearly influenced by thepatient’s age. The age cutoff varies, but many studies con-sider patients under 60 years of age to be in the young cohortand patients over 70 years to be in the elderly cohort.However, one should determine the patient’s physiologicage when making management decisions for this group ofpatients [2].Reduction and internal fixation with either screws alone or

screws with a sideplate is a viable option for the youngpatient with a displaced femoral neck fracture. However, inthe elderly population, the results of internal fixation are lesssuccessful. A number of randomized controlled trials andmeta-analyses have compared the results of internal fixationversus arthroplasty for the treatment of femoral neck frac-tures in the elderly population (Table 1). Patients with severecognitive impairment or loss of independent function weregenerally excluded in these studies, and thus the results areapplicable only to patients who are healthy and are com-munity ambulators.The general consensus among these studies is that arthro-

plasty is beneficial over internal fixation for treatment of

Table 1 – RCTs Comparing Results of Internal Fixation versus

Studies Study Type YearFollow-

up(months)

Interventions

Arthroplasty

Ravikumarand Marsh[3]

RCT 2000 156 Hemi/THA

Parker et al.[4]

RCT 2002 12 Hemi

Rogmarket al. [5]

RCT 2002 24 Hemi/THA

Tidermarket al. [6]

RCT 2003 24 THA

Keating et al.[7]

RCT 2005 24 Hemi/THA

Blomfeldtet al. [8]

RCT 2005 48 THA

Heetveldet al. [9]

RCT 2007 24 Hemi

Leonardssonet al. [10]

RCT 2010 120 Hemi/THA

Gao et al.[11]

Meta-analysis 2012 12–156 Hemi/THA

displaced femoral neck fractures in healthy, independentelderly patients. Arthroplasty was associated with signifi-cantly higher intraoperative blood loss and operating roomtime, and a trend towards higher mortality in the first 4months (RR ¼ 1.27) [12]. However, the mortality rates at oneyear were equivalent in both treatment groups. Notably, therewas a significantly higher failure rate in the internal fixationgroup (36–43%) compared with the arthroplasty group (4–9%)[5–7]. It follows that the rates of reoperation proved to besignificantly lower in the arthroplasty group compared withthe internal fixation group (42–47% versus 4%, respectively,RR ¼ 0.08–0.23) [1,6]. Throughout the postoperative periodand up to 5 years after surgery, the arthroplasty groupconsistently proved to have a significantly lower degree ofpain, higher level of function, and lesser magnitude ofdecreased function as compared to the pre-injury state. Aneconomic analysis of cumulative admission costs over 2postoperative years indicated that total hip arthroplastyconferred a cost advantage over hemiarthroplasty, and hemi-arthroplasty over internal fixation [7].

3. Total arthroplasty versus hemiarthroplasty

Once the decision to pursue arthroplasty has been made, thesurgeon must decide between total arthroplasty versus hemi-arthroplasty. Each type of implant is associated with its ownset of advantages, and the choice of implant must be tailored

Arthroplasty

Numberof Patients

OutcomeInternalFixation

Compressionscrew andplate

271THA with lower revision rate,

less pain, and better function

3 AO screws 455Hemi with lower revision rate

and less limb shorteningHansson

hook pinsor Olmedscrews

409Arthroplasty with lower failure

rate, less pain, and betterfunction

2 cannulatedscrews

102THA with lower revision rate,

less pain, and better functionCancellous

screws orsliding hipscrew

298Arthroplasty with lower

revision rate, better function,and lower long-term cost

2 cannulatedscrews

102Arthroplasty with lower

revision rate and betterfunction

Screws 224 Hemi with lower revision rate

Hanssonhook pinsor Olmedscrews

409Arthroplasty with lower

revision rate and nodifference in pain or function

Various 4508Arthroplasty with lower

revision rate, less pain, andbetter function

Table 2 – RCTs Comparing Results of Total Arthroplasty versus Hemiarthroplasty

Studies Study Type YearFollow-up(months)

Interventions Numberof

PatientsOutcome

THA Hemi

Ravikumarand Marsh[3]

RCT 2000 156 Cemented Uncemented 180

THA with lower failure rate,less pain, better function,and higher early dislocationrate

Keating et al.[7]

RCT 2005 24 Cemented Cemented 180THA with lower failure rate,

better outcome scores, andless costs over time

Baker et al.[13]

RCT 2006 36 Cemented Cemented 81THA with better function and

fewer complicationsBlomfeldt

et al. [14]RCT 2007 12 Cemented Cemented 120

THA with better Harris HipScores (HHS)

Yu et al. [15] Meta-analysis 2012 24–156Cemented/

uncementedCemented/

uncemented1320

THA with lower revision rate,higher dislocation rate, andhigher HHS

Zi-Shenget al. [16]

Meta-analysis 2012 12–156Cemented/

uncementedCemented/

uncemented1208

THA with lower revision rate,higher dislocation rate, andless pain

Liao et al.[17]

Meta-analysis 2012 12–156Cemented/

uncementedCemented/

uncemented828

THA with lower revision rateand better functionaloutcome

S E M I N A R S I N A R T H R O P L A S T Y 2 4 ( 2 0 1 3 ) 5 6 – 6 058

to the clinical picture and demands of the patient. There isa clear contraindication to hemiarthroplasty in patients withsignificant acetabular erosion or a history of inflammatoryarthritis, but the choice of implant in patients with arelatively preserved acetabulum is more controversial.A number of recent randomized controlled trials and meta-

analyses have explored this topic, with fairly consistentresults (Table 2). The patients in these studies are generallywithout severe cognitive impairment and are functionallyindependent prior to injury. Total hip arthroplasty is asso-ciated with greater operative time and intraoperative bloodloss. There is no significant difference in mortality, infections,or general complications between the two groups. Patientsundergoing total hip arthroplasty are more likely to experi-ence a dislocation (RR ¼ 1.99), though with the availability oflarger femoral heads, the risk of dislocation is expected todecrease. Moreover, the total hip arthroplasty group is sig-nificantly less likely to require a reoperation (RR ¼ 0.53) [15].The most common indication for reoperation in the hemi-arthroplasty group is pain due to progressive acetabularerosion. Radiographic evidence of erosion is present in 66%of hemiarthroplasty patients at 3 years, and 8.6–14.6% ofhemiarthroplasty patients required revision [13,15]. Further-more, total hip arthroplasty patients had a better functionaloutcome compared with hemiarthroplasty, with respect toHarris Hip Scores at 1 year (WMD ¼ 3.81) and 3–4 years (WMD¼ 10.07).Although there is a general consensus amongst recent

studies that total hip arthroplasty leads to improved functionand lower reoperation rates in cognitively intact, independ-ent, elderly patients, there is no consensus as to the bestchoice of implant for patients with cognitive decline or loss ofindependent function. The senior author’s preference is touse a total hip arthroplasty for healthy and active patientsthat live at home. Thus, when deciding between arthroplasty

and hemiarthroplasty, the surgeon must take into accountthe patient’s physiologic age, life expectancy, functionaldemands, tolerance of increased EBL and OR time with totaljoint arthroplasty, and ability to comply with activity restric-tions to prevent dislocation.

4. Bipolar versus unipolar hemiarthroplasty

Bipolar hemiarthroplasty is marketed as a superior implantcompared with unipolar hemiarthroplasty due to the partialabsorption of shear forces by the additional articulatingprosthetic surface, leading to lower acetabular erosion rates(5.6% in bipolar versus 11% in unipolar) [18]. This advantagecomes at a price premium of approximately four times thecost of a unipolar implant [19]. However, the difference inacetabular erosion rates may be irrelevant in the short- tomedium-term and in low-demand patients.Recent studies comparing bipolar versus unipolar hemi-

arthroplasty for displaced femoral neck fractures in elderlypatients have not shown a significant difference in outcomes.Though Cornell et al [20] showed increased range of abduc-tion, rotation, and walking speed in patients receiving bipolarversus unipolar hemiarthroplasty, there have not been anysignificant differences in complications, length of stay, mor-tality, dislocation, ambulatory status, or functional outcomescores between the two groups with short- to medium-termfollow-up [19,21–26]. An analysis of trends in Californiahospitals from 1995–1996 showed that 73% of hemiarthro-plasties placed were of the bipolar variety. Given the lack ofevidence for improved clinical outcomes with bipolar hemi-arthroplasty in elderly patients with femoral neck fractures,the choice of unipolar implants in this patient populationwould reduce the economic burden on the healthcare systemwithout compromising patient care.

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5. Conclusions

With the wealth of recent data on surgical outcomes inelderly patients with femoral neck fractures, it is possible todevelop a treatment algorithm that will maximize functionaloutcomes and minimize reoperation rates, avoidable opera-tive risks, and unnecessary costs. While nondisplaced femo-ral neck fractures can safely be stabilized with internalfixation, displaced fractures have a high rate of failure offixation and should undergo primary arthroplasty in cogni-tively intact, independent, elderly patients. In these studies,total hip arthroplasty was associated with a higher disloca-tion rate, but this should be less of a problem with theavailability of larger femoral heads. Total hip arthroplastyconfers a significant advantage with respect to functionaloutcome and revision rates in comparison to hemiarthro-plasty, and is the treatment of choice in patients who arephysiologically intact enough to attain these benefits andcomply with postoperative activity restrictions. When choos-ing hemiarthroplasty, the theoretical benefit of decreasednative acetabular wear rate has not been born out in clinicaloutcomes and is unlikely to justify the significantly increasedcost of the bipolar implant.

r e f e r e n c e s

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