Total Hip Replacement for the Femoral Neck Fracture: It is the Right - PowerPoint PPT Presentation

Total Hip Replacement for the Femoral Neck Fracture: It is the Right Answer - When to Pull the Plug? Simon C. Mears, MD, PhD Orthopaedic Summit 2017 University of Arkansas for Medical Services

Disclosure • Deputy Editor: Geriatric Orthopaedic Surgery and Rehabilitation • Past President: International Geriatric Fracture Society

Total hip replacement • Is it the right answer? • Yes!! • When to pull the plug??? • All the time!!

The older active individual with a displaced fracture • No brainer • THA give the best outcomes • Less pain and reoperations • Vastly superior to internal fixation

How young is too young for THA • A cost-effective option for a displaced femoral neck fracture in an: – Otherwise healthy patient who is >54 years old – A patient with mild comorbidity who is >47 years old – A patient with multiple comorbidities who is >44 years old. Swart E, Roulette P, Leas D, Bozic KJ, Karunakar M. ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis. J Bone Joint Surg Am. 2017 Jan 4;99(1):65-75.

How non-active is too non- active for THA • Dementia • Low life expectancy • Do not ambulate without walker • Pull the plug but do a hemi

Displacement • Data suggest that patients are more satisfied with THA than fixation • Can weightbear as tolerated and not worry about fracture healing • No late osteonecrosis or shortening

Tips for THA in fracture patients • Avoid – Fracture – Dislocation • Consider – Approach – Stem type – Surgeon

Periprosthetic fractures • Norwegian hip fracture registry 5 year survival • Uncemented stems 91% • Cemented stems 97% • Cemented stem lower reoperation rates

Use a cemented stem • Reliable – Cement embolization – Intra-operative hypotension – 26 of 8639 patients in Norwegian hip fracture registry

Be prepared for intraoperative fractures • Look for calcar cracks • Cable if found • Consider strongly cemented stem • Be very careful with anterior approach

Acetabular side • Careful with reaming and cup impaction • Do not break the acetabulum either • Low threshold for additional screws

THA dislocation risk • Much higher in hip fracture population: 8% ?? Non expert surgeons or Laxity of capsule in non- arthritic hip

Prevent dislocation • Proper anteversion of stem • Correct acetabular positioning

Prevent dislocation • Anterolateral approach has less dislocation • Consider its use particularly in patients at high risk of dislocation • Repair the capsule if you do posterior approach

Prevent dislocation • Use the largest head available • Consider the use of a dual mobility type head to give the biggest size available

The surgeon: When and who should pull it • Hip fractures do best with surgery as quickly as possible • If you are on call and never do a THA you will need to get someone who does to do the surgery

Conclusion: Pull the plug! • Total hip replacement less pain and better outcomes in several randomized studies • THA for active patients – Live alone – Under 80 – No ambulatory aids

Technique is important Reduce fracture risk cement the stem Reduce dislocation risk correct position large head anterolateral approach Early surgery with the best surgeon

Thank You

References • Swart E, Roulette P, Leas D, Bozic KJ, Karunakar M. ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis. J Bone Joint Surg Am. 2017 Jan 4;99(1):65-75. • Hansson S, Nemes S, Kärrholm J, Rogmark C. Reduced risk of reoperation after treatment of femoral neck fractures with total hip arthroplasty. Acta Orthop. 2017 Oct;88(5):500-504. doi: 10.1080/17453674.2017.1348095. Epub 2017 Jul 10. • Rogmark C, Fenstad AM, Leonardsson O, Engesæter LB, Kärrholm J, Furnes O, Garellick G, Gjertsen JE. Posterior approach and uncemented stems increases the risk of reoperation after hemiarthroplasties in elderly hip fracture patients. Acta Orthop. 2014 Feb;85(1):18-25. doi: 10.3109/17453674.2014.885356. Epub 2014 Jan 24. • Leonardsson O, Sernbo I, Carlsson A, Akesson K, Rogmark C. Long-term follow-up of replacement compared with internal fixation for displaced femoral neck fractures : results at ten years in a randomised study of 450 patients. J Bone Joint Surg Br. 2010 Mar;92(3):406-12. doi: 10.1302/0301-620X.92B3.23036. Erratum in: J Bone Joint Surg Br. 2010 Jun;92(6):901. • Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R, Törnkvist H, Ponzer S, Tidermark J. Comparison of bipolar hemiarthroplasty with total hip arthroplasty for displaced femoral neck fractures: a concise four-year follow-up of a randomized trial. J Bone Joint Surg Am. 2011 Mar 2;93(5):445-50. doi: 10.2106/JBJS.J.00474. • Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg Am. 2006 Dec;88(12):2583-9. • Lu Q, Tang G, Zhao X, Guo S, Cai B, Li Q. Hemiarthroplasty versus internal fixation in super-aged patients with undisplaced femoral neck fractures : a 5-year follow-up of randomized controlled trial. Arch Orthop Trauma Surg. 2017 Jan;137(1):27-35. doi: 10.1007/s00402-016-2591-9. Epub 2016 Nov 11. • Gjertsen JE, Fevang JM, Matre K, Vinje T, Engesæter LB. Clinical outcome after undisplaced femoral neck fractures . Acta Orthop. 2011 Jun;82(3):268-74. doi: 10.3109/17453674.2011.588857. • Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, Kreder HJ, Jenkinson RJ, Wodchis WP. Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery . JAMA. 2017 Nov 28;318(20):1994- 2003. doi: 10.1001/jama.2017.17606.