Bipolar or Unipolar Hemiarthroplasty after Femoral Neck Fracture in the Geriatric Population

Abstract

Background: The choice of prosthesis in hemiarthroplasty is controversial for geriatric patients after femoral neck fracture. We hypothesised that selection criteria for unipolar or bipolar prostheses could be constructed based on factors affecting mortality. Aims: The aims of this retrospective study were: (1) to determine the factors affecting mortality of femoral neck fracture patients ≥65 years of age; (2) to compare patient mortality rates, radiological findings, and functional outcomes according to prosthesis type (unipolar or bipolar); and (3) to evaluate the persistence of inner bearing mobility of bipolar prostheses. Study Design: Retrospective comparative study. Methods: In total, 144 patients operated for hemiarthroplasty and aged ≥65 were included. We classified the patients into either unipolar or bipolar prosthesis groups. To reveal factors that affected mortality, age, sex, delay in surgery, and American Society of Anesthesiologists score were obtained from folders. Barthel Daily Living, Harris hip, and acetabular erosion scores were calculated and bipolar head movement was analysed for live patients. Results: One-year mortality was 31.94%. Age ≥75 (p=0.029), male sex (p=0.048), and delay in surgery ≥6 (p=0.004) were the patient characteristics that were related to increased mortality. There were no significant differences in sex, age, American Society of Anesthesiologists score, delay in surgery, mortality, or Barthel, Harris, acetabulum scores between the two groups. Twenty patients from each group were admitted for last follow-up. Bipolar head movement was preserved for 33.3% of patients. They were inactive patients with low Barthel and Harris scores. Conclusion: Although bipolar head movement was preserved in inactive patients, we suppose that this conferred no advantage to these patients, who could hardly walk. In this study, male patients, those aged ≥75 years, and those operated at ≥6 days had an increased risk of mortality. Also, although not significant in multivariate analysis, high American Society of Anesthesiologists score (≥3) was related to increased mortality. Considering that one of three patients died during the first postoperative year, we think that these patients should be operated as soon as possible, and expensive bipolar prostheses must be used selectively in regard to patient characteristics. Turkish Başlık:Geriatrik Nüfusta Femur Boyun Kırıkları Sonrası Bipolar veya Unipolar Hemiartroplasti Anahtar Kelimeler:Femur boyun kırığı, mortalite, hemiartroplasti Arkaplan: Yaşlı hastalarda hemiartroplasti ile femur boyun kırığı tedavisinde protez tipi tercihi tartışmalıdır. Biz çalışmamızda mortaliteyi etkileyen faktörleri baz alarak unipolar veya bipolar protez için tercih ölçütleri oluşturabileceğimizi düşündük. Amaç: Bu retrospektif çalışmanın amaçları; (1) 65 yaş ve üstü hastalarda femur boyun kırığı sonrası mortaliteyi etkileyen faktörleri belirlemek, (2) protez tipine (unipolar veya bipolar) göre hastaların mortalite oranlarını, radyolojik bulgularını ve fonksiyonel sonuçlarını karşılaştırmak, (3) bipolar protezlerde iç taşıyıcı yüzey hareketinin sebatını değerlendirmektir. Çalışma Tasarımı: Retrospektif karşılaştırmalı çalışma Yöntemler: Çalışmamıza hemiartroplasti ameliyatı yapılan 65 yaş ve üstü toplam 144 hasta dâhil edildi. Hastaları unipolar ve bipolar protez grupları olarak sınıflandırdık. Mortaliteyi etkileyen faktörleri ortaya koymak için hasta dosyalarından yaş, cinsiyet, cerrahi bekleme süresi ve American Society of Anesthesiologists (ASA) skorları belirlendi. Sağ olan hastaların Barthel günlük yaşam aktivite, Harris kalça ve asetabuler erozyon skorları hesaplandı ve radyografilerle bipolar baş hareketi incelendi. Bulgular: Bir yıllık mortalite oranı % 31.94 hesaplandı. Yaşın ≥75 olması (p=0.029), erkek cinsiyet (p=0.048) ve cerrahi bekleme süresinin ≥6 gün olması (p=0.004) artmış mortalite ile ilişkili hasta karakterleriydi. İki grup arasında cinsiyet, yaş, ASA skoru, cerrahi bekleme süresi, mortalite, Barthel, Harris ve asetabulum skorları arasında anlamlı fark yoktu. Her iki gruptan yirmişer hasta son kontrol için başvurdu. Bipolar baş hareketi bu hastaların % 33.3'ünde mevcuttu. Onlar düşük Barthel ve Harris skorları olan inaktif hastalardı. Sonuç: Bipolar baş hareketi inaktif hastalarda korunmuş olsa da, bunun zorlukla yürüyebilen hastalar için bir avantaj sağlamadığını düşünmekteyiz. Bu çalışmada erkek hastalar, 75 yaş ve üstü olanlar, cerrahi bekleme süresi ≥6 gün olanlar yüksek mortalite riskine sahipti. Çok değişkenli analizlerde anlamlı bulunmamasına rağmen yüksek ASA skoru (≥3) da artmış mortalite riski ile ilişkiliydi. Her üç hastadan birinin ameliyat sonrası ilk yılda öldüğü düşünüldüğünde, bu hastaların olabildiğince erken zamanda ameliyat edilmesi gerektiğini ve pahalı bipolar protezin hasta karakterleri dikkate alınarak seçilmiş hastalarda kullanılması gerektiğini düşünmekteyiz.

Keywords

• Femoral neck fracture, mortality, hemiarthroplasty

Bipolar or Unipolar Hemiarthroplasty after Femoral Neck Fracture in the Geriatric Population

Öz

References

1. Vestergaard P, Rejnmark L, Mosekilde L. Has mortality after a hip fracture increased? J Am Geriatr Soc 2007;55:1720-6. [CrossRef]
2. Aharonoff GB, Koval KJ, Skovron ML, Zuckerman JD. Hip fractures in the elderly: predictors of one year mortality. J Orthop Trauma 1997;11:162-5. [CrossRef]
3. Kesmezacar H, Ayhan E, Unlu MC, Seker A, Karaca S. Predictors of mortality in elderly patients with an intertrochanteric or a femoral neck fracture. J Trauma 2010;68:153-8. [CrossRef]
4. Parker MJ. Internal fixation or arthroplasty for displaced subcapital fractures in the elderly? Injury 1992;23:521-4. [CrossRef]
5. 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. J Bone Joint Surg Am 1994;76:15-25.
6. Drinker H, Murray WR. The universal proximal femoral endoprosthesis. A short-term comparison with conventional hemiarthroplasty. J Bone Joint Surg Am 1979;61:1167-74.
7. Ong BC, Maurer SG, Aharonoff GB, Zuckerman JD, Koval KJ. Unipolar versus bipolar hemiarthroplasty:functional outcome after femoral neck fracture at a minimum of thirty-six months of follow-up. J Orthop Trauma 2002;16:317-22. [CrossRef]
8. Wathne RA, Koval KJ, Aharonoff GB, Zuckerman JD, Jones DA. Modular unipolar versus bipolar prosthesis:a prospective evaluation of functional outcome after femoral neck fracture. J Orthop Trauma 1995;9:298-302. [CrossRef]

9. Calder SJ, Anderson GH, Jagger C, Harper WM, Gregg PJ. Unipolar or bipolar prosthesis for displaced intracapsular hip fracture in octogenarians:a randomised prospective study. J Bone Joint Surg Br 1996;78:391-4.
10. Wetherell RG, Hinves BL. The Hastings bipolar hemiarthroplasty for subcapital fractures of the femoral neck. J Bone Joint Surg Br 1990;72:788-93.
11. Raia FJ, Chapman CB, Herrera MF, Schweppe MW, Michelsen CB, Rosenwasser MP. Unipolar or bipolar hemiarthroplasty for femoral neck fractures in the elderly? Clin Orthop Relat Res 2003;(414):259-65. [CrossRef]
12. LaBelle LW, Colwill JC, Swanson AB. Bateman bipolar hip arthroplasty for femoral neck fractures. A five- to ten-year follow-up study. Clin Orthop Relat Res 1990;(251):20-5.
13. Davison JN, Calder SJ, Anderson GH, Ward G, Jagger C, Harper WM, et al. Treatment for displaced intracapsular fracture of the proximal femur. A prospective, randomised trial in patients aged 65 to 79 years. J Bone Joint Surg Br 2001;83:206-12. [CrossRef] Bateman JE. The classic: single-assembly total hip prosthesispreliminary report. 1974. Clin Orthop Relat Res 2005;441:16-8. [CrossRef]
14. Chen SC, Badrinath K, Pell LH, Mitchell K. The movements of the components of the Hastings bipolar prosthesis. A radiographic study in 65 patients. J Bone Joint Surg Br 1989;71:186-8.
15. Verberne GH. A femoral head prosthesis with a built-in joint. A radiological study of the movements of the two components. J Bone Joint Surg Br 1983;65:544-7.
16. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J 1965;14:61-5.
17. Mahomed NN, Arndt DC, McGrory BJ, Harris WH. The Harris hip score: comparison of patient self-report with surgeon assessment. J Arthroplasty 2001;16:575-80 [CrossRef]
18. Phillips TW. Thompson hemiarthroplasty and acetabular erosion. J Bone Joint Surg (Am), 1989;71-A:913-917.
19. Phillips TW. The Bateman bipolar femoral head replacement. A fluoroscopic study of movement over a four-year period. J Bone Joint Surg Am 1989;71:913-7.
20. Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE. Survival experience of aged hip fracture patients. Am J Public Health 1989;79:274-8. [CrossRef]
21. Michel JP, Klopfenstein C, Hoffmeyer P, Stern R, Grab B. Hip fracture surgery: is the pre-operative American Society of Anesthesiologists (ASA) score a predictor of functional outcome? Aging Clin Exp Res 2002;14:389-94. [CrossRef]
22. Sircar P, Godkar D, Mahgerefteh S, Chambers K, Niranjan S, Cucco R. Morbidity and mortality among patients with hip fractures surgically repaired within and after 48 hours. Am J Ther 2007;14:508-13. [CrossRef]
23. Parker MJ, Gurusamy K. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2006;19;3:CD001706.
24. Bochner RM, Pellicci PM, Lyden JP. Bipolar hemiarthroplasty for fracture of the femoral neck. Clinical review with special emphasis on prosthetic motion. J Bone Joint Surg Am 1988;70:1001-10.
25. Dalldorf PG, Banas MP, Hicks DG, Pellegrini VD Jr. Rate of degeneration of human acetabular cartilage after hemiarthroplasty. J Bone Joint Surg Am 1995;77:877-82.
26. Tsukamoto Y, Mabuchi K, Futami T, Kubotera D. Motion of the bipolar hip prosthesis components. Acta Orthop Scand 1992;63:648-52. [CrossRef]