Authors: Tashfeen Ahmad ( Department of Surgery, Aga Khan University, Karachi, Pakistan. )
Umair Ashraf ( DepartmenDepartment of Surgery, Aga Khan University, Karachi, Pakistan.t of Surgery, Aga Khan University, Karachi, Pakistan. )
Omar Irfan ( Department of Surgery, Aga Khan University, Karachi, Pakistan. )
Zehra Abdul Muhammad ( Department of Surgery, Aga Khan University, Karachi, Pakistan. )
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% (p<0.001).Internal fixation was the most common procedure in patients aged <50 (p<0.001), and hemiarthroplasty for those aged >50 years (p<0.001). Total hip replacement was seen in its highest proportion (15%) in patients aged 40-49 years (p=0.006). Hemiarthroplasty showed a dramatic decrease in the age group 50-59 years (from 57% to 40%). Total hip replacement showed a steady increasing 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. 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.
Keywords: Fracture neck of femur, Intracapsular fractures, Internal fixation, Hemiarthroplasty, Total hip replacement, Management trends. (JPMA 65: S-163 (Suppl. 3); 2015)
Hip fractures are common in the elderly and have consequences extending into the domains of medicine, rehabilitation, psychiatry, social work and medical economics. Despite improvements in patient care, advances in surgical technique and implant technology, hip fractures continue to pose a substantial economic burden on the medical systems in the developed and the developing world. In 1995, 15 European Union (EU) countries had about 382,000 hip fractures with an estimated care cost of 9 billion Euros.1 Its estimated that about 250,000 hip fractures occur in the United States each year. The number of fractures is projected to double by 2050 as the population ages.2
There are several factors contributing to an ever-increasing number of femoral neck fractures, including an increased patient lifespan, activity level and incidence of osteoporosis.3 The decrease in bone mass in the elderly is caused by a number of factors including reduced function of osteoblasts, increased osteoclast activity, reduced physical activity, genetic predisposition, decreased calcium intake and hormonal influences.3 This results in bone resorption outpacing bone building. Postmenopausal women are especially at risk because of oestrogen deficiency.3
Surgical treatment has been established as the gold standard, with the main aim being early mobilisation in order to prevent 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 hip replacement (THR). Each of these has its own merits and demerits.
The current study was conducted to audit the trends in management of neck of femur fracture at our institution to see how the choice of surgical procedure is changing over time in relation to different age groups.
Materials and 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 Chi square test was used to compare categories. P<0.05 was considered statistically significant.
Records of 1039 patients were reviewed. Hemiarthroplasty was the most common procedure in 68% patients (Table-1). Internal fixation was the most common procedure in patients aged <50 (p<0.001), and hemiarthroplasty for those aged >50 years (p<0.001). THR was 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 70-79 years, accounting for 31% patients (Table-2). However, there was a shift in the age towards older age group over the 20-year study period. The proportion of patients in the 70+ age group compared to <70 group significantly increased from 45% to 52% (p=0.033).
In terms of choice of procedure, internal fixation remained more or less consistent across the years, being more common in yournger age groups (Figure-2).
Hemiarthroplasty showed a decreasing trend below 70 years. The greatest decrease was in the 50-59 age group, decreasing from 57% to 40%. THR showed an increasing trend. In the last 10 years THR increased from 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 distribution did not show any change over time, with slight female preponderance by about 4-8%. Proportion of patients undergoing internal fixation and hemiarthroplasty decreased by 8% and 5% respectively (p>0.05). On the other hand, proportion of patients undergoing THR increased by more than 3 times from 2.6% to 8% (p<0.001).
Our study showed that in patients presenting with neck of femur fractures there was a progressive rise in the proportion of patients undergoing THR, and a fall in the proportion of hemiarthroplasty. There has conventionally been a single factor that determined surgical treatment of these injuries: whether the fracture is displaced or not. When fractures are relatively undisplaced they are fixed and when displaced, hemiarthroplasty was the recommended treatment. THR was seldom performed because of a higher dislocation rate compared to hemiarthroplasty4-6 because of greater complexity and cost of the procedure. Internal fixation with cannulated screws is minimally invasive, simple and economical. However, the related complications of internal fixation, including possibility of avascular necrosis (AVN) or non-union (requiring revision surgery) and malunion (causing shortening and limp) are considerations against the choice of internal fixation, especially in the elderly.7
The procedure of Austin-Moore hemiarthroplasty is commonly carried out in all hospitals of Pakistan catering to patients with fractures,8-10 but the long-term results of these patients has not been reported previously. According to a recent study,11 Austin Moore arthroplasty has proved a good option in terms of low complication rate and an acceptable functional result (33% Excellent and 43% Good), though there was no comparison group in the study. Hemiarthroplasty may be done using either a monopolar or so called bipolar heads. The theoretical advantage of a bipolar head is that with two articulating surfaces, there is reduced friction upon the native acetabular cartilage, possibly leading to a slower progression of cartilage wear and lesser pain as well as lower dislocation rate.12
In the last few decades, there appears to be a trend towards THR because of evidence of better functional outcomes and a lower revision rate than hemiarthropalsty.13-15 With the wide use of larger diameter heads and improving surgical techniques, the dislocation rate is going down. Abroad, it is becoming a common procedure for active people in middle and elderly age groups suffering from femoral neck fractures.
Internal fixation is the favoured option in patients below 50 years of age, though it is practised in all age groups. THR is becoming more common, especially in patients in their 50s and 60s. Hemiarthroplasty, which used to be the most common procedure in the elderly, is showing a decline in people aged less than 70 years. Better reported functional results after THR compared to hemiarthroplasty, and a general increase in recognition of the role of, and experience in, THR in fracture patients are likely to be responsible for this trend.
1. Gennari C. Calcium and vitamin D nutrition and bone disease of the elderly. Public Health Nutr 2001; 4: 547-9.
2. Koval KJ, Zuckerman JD. Functional recovery after fracture of the hip. J Bone Joint Surg Am 1994; 76: 751-8.
3. Yoon BH, Lee YK, Kim SC, Kim SH, Ha YC, Koo KH. Epidemiology of proximal 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 Joint J 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. J Arthroplasty 2008; 23: 867-872.
6. Poignard A, Bouhou M, Pidet O, Flouzat-Lachaniette CH, Hernigou P. High dislocation cumulative risk in THA versus hemiarthroplasty for fractures. Clin Orthop Relat Res 2011; 469: 3148-53.
7. Hailer NP, Weiss RJ, Stark A, Kärrholm J. The risk of revision due to dislocation after total hip arthroplasty depends on surgical approach, femoral head size, sex, and primary diagnosis. An analysis of 78,098 operations in the Swedish Hip Arthroplasty Register. Acta Orthop 2012; 83: 442-8.
8. Ahmad I. Mortality and morbidity in elderly patients with fracture neck of 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 with Hemiarthroplasty During One Year Post-Operative Followup Period. [Dissertation Orthopaedic Surgery] College of Physicians and Surgeons Pakistan; 2004.
10. Mustafa Y, Aysha H, Avraham G, Abdalla B. The orthopaedic quandry of hip fractures in patients with Alzheimer\\\'s disease require appropriate prevention strategy. Merit Research J 2014; 2: 12-18. (Online) (Cited 2015 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 fracture treated by Austin-Moore hemiarthoplasty in elderly patients. Med Forum 2015; 26:45-49. (Online) (Cited 2015 April 30). Available from URL: 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 bipolar endoprosthesis. 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 hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. Int Orthop 2012; 36: 1549-60.
14. Yu L, Wang Y, Chen J. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures: meta-analysis of randomized trials. Clin Orthop Relat Res 2012; 470: 2235-43.
15. Macaulay W, Nellans KW, Garvin KL, Iorio R, Healy WL, Rosenwasser MP, et al. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. J Arthroplasty 2008; 23(6Suppl): 2-8.