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CASE PRESENTATION

INTRA-CAPUSULAR FEMORAL NECK FRACTURES Emmanuel Illical, Adult Reconstruction Fellow Dr. Paul Kim MD, FRCSC. CASE PRESENTATION. CASE PRESENTATION. OUTLINE. Background Garden Classification “Young” Patient Management ORIF Issues “Older” Patient Management ORIF vs. arthroplasty

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CASE PRESENTATION

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  1. INTRA-CAPUSULAR FEMORAL NECK FRACTURESEmmanuel Illical, Adult Reconstruction FellowDr. Paul Kim MD, FRCSC

  2. CASE PRESENTATION

  3. CASE PRESENTATION

  4. OUTLINE • Background • Garden Classification • “Young” Patient Management • ORIF • Issues • “Older” Patient Management • ORIF vs. arthroplasty • Unipolar vs. Bipolar Hemiarthoplasty • Cemented vs. Uncemented • Hemiarthroplasty vs. THA • Choice of Approach • Ongoing Studies • Summary

  5. BACKGROUND: BURDEN OF DISEASE • Significant mortality • Moran et al. JBJS Am 2005. Early mortality after hip fracture: is delay before surgery important? • Mortality at 30 days = 9% • Mortality at 3 months = 19% • Mortality at 1 year = 30% • Significant morbidity • Johnell et al. CORR 2004. An estimate of the worldwide prevalence, mortality and disability associated with hip fracture. • 1.75 million disability adjusted life years lost • 1.4% of burden among women from established market economies • #9 of all causes of disability globally • Osnes et al. Osteoporos Int 2004. Consequences of hip fracture of ADLs and resedential needs. • % of patients living in nursing homes doubles • 33% of pts >85 living on their own had to move into nursing home post # • 43% of pts lost their pre-fracture ability to move outside on their own

  6. BACKGROUND: BURDEN OF DISEASE • Significant strain on the system • Papadimitropoulos et al. CMAJ 1997. Current and projected rates of hip fracture in Canada. • number of proximal femoral #s will increase exponentially over next 40 years • length of stay in acute care setting increased with advancing age • rate of death during acute care stay increased exponentially with increasing age • AAOS Bull 1999. AAOS urges hip fracture care reform. • more hospital days than any other MSK injury • > 2/3 of all hospital days due to fracture • Cummings et a. CORR 1990. The future of hip fractures in the United States. • estimated annual cost of at least $9.8 billion US

  7. GARDEN CLASSIFCATION I II III IV Garden RS. Low-angle fixation in fractures of the femoral neck. JBJS Br 1961. 43(B): 647-663.

  8. “YOUNG” PATIENT MANAGMENT • Literature generally defines “young” patient as < 60 y/o • Duckworth et al. JBJS Br. 2011. Fixation of ICFNF in young pts. Risk factors for failure. • significant predictors: age > 40, alcohol excess, pre-existing renal / resp / liver disease • approaching significance: pre-existing mobility problems, CP, learning difficulties • General consensus for ORIF for all types of FNF: screw vs. SHS • No consensus on type of fixation • Parker MJ and Gurusamy KS. Cochrane Database Syt Rev 2011. Internal fixation of intracapsular hip fractures in adults. • 30 studies involving 6334 participants (6339 fractures) • SHS vs. multiple screws: • less AVN & lower fixation failure rate  but no difference for re-op • longer OR time & increased blood loss • no difference in mortality

  9. “YOUNG” PATIENT MANAGMENT: ISSUES • Timing of intervention: no difference in rates of nonunion / AVN • Damany et al. Injury 2005. Complications after ICHF in young adults meta-analysis • meta-analysis: pts < 50, 18 retrospective cohort studies, 547 fractures • non-union: DFNF 6% vs. NDFNF 0.9% • AVN: DFNF 22.5% vs. NDFNF 5.9% • no sig difference in AVN rate for #s reduced within 12 hours (13.6% vs. 15%) • no sig difference in non-union rate for #s reduced within 12 hours (11.8% vs. 5%) • Upadhyay et al. JBJS Br 2004. Delayed IF of FNF in young adults. • 92 patients btwn 15-50 y/o randomised to ORIF vs. CRIF w/ 2 year f/u • no difference in AVN rate for #s reduced within 48 hours (14% vs. 19%) • no difference in nonunion rate for #s reduced within 48 hours (18% vs. 16.7%) • 2 case series of neglected DFNF in young adults • results equal or better than fractures fixed on an urgent basis

  10. “YOUNG” PATIENT MANAGMENT: ISSUES • No role for decompression of intra-capsular hematoma • Maruenda et al. CORR 1997. Intracapsular hip pressure after FNF. • consecutive series of 34 pts w/ FNF; mean age 75; 22 pts int fix • scintigraphy scan prior to surgery to evaluate blood flow • ICP recorded continuously at time of surgery before & after aspiration • mean f/u 7 years • NO differece in ICP btwn DFNF and NDFNF • NO relation btwn intra-capsular pressure and • reduction blood supply to femoral head • devleopment of AVN • Upadhyay et al. JBJS Br 2004. • no difference in AVN / non-union for #s treated w/ CRIF vs. ORIF

  11. “YOUNG” PATIENT MANAGMENT: ISSUES • Risk factors for poor prognosis • Posterior comminution • ? significant damage to posterior retinacular vessels • may influence ability to obtain good quality of reduction • may decrease stability of fixation post-operatively • Difficulty of reduction • Quality of reduction • Varus • Shortening • Quality of fixation

  12. “OLDER” PATIENT MANAGMENT: ORIF vs. ARTHOPLASTY • Parker MJ and Gurusamy KS. Cochrane Database Syst Rev 2011. Internal fixation versus arthroplasty for intracapsular proximal femur fractures in adults • 19 trials (randomised & quasi-randomised) w/ 3044 participants • arthroplasty associated with significantly • longer length of surgery • more operative blood loss & need for blood transfusion • higher risk of deep wound infection • lower re-operation rate (11% vs. 40% for IF) • no differences for • superficial wound infection & major medical post-op complications • hospital stay • mortality

  13. “OLDER” PATIENT MANAGMENT: ORIF vs. ARTHOPLASTY • Dai et al. JSR 2011. Meta-analysis comparing arthroplasty with internal fixation for DFNF in the elderly. • 19 published RCTs involving 3505 pts > 60 y/o • no difference in mortality at 1 year post-op (OR 1.10) • arthroplasty superior to int fixation with regards to major method related complications (OR 0.11) • arthroplasty associated with greater risk of hip dislocation & wound infection • arthroplasty associated w/ less pain & better function • arthroplasty is superior to int fixation with regards to surgical revision (OR 0.10) • Several studies have shown arthoplasty to be more cost effective than IF • Iorio et al. Clin Orthop 2001. • Rogmark et al. Acta Orthop Scand 2003. • Keating et al. JBJS Am 2006.

  14. “OLDER” PATIENT MANAGMENT: UNIPOLAR vs. BIPOLAR • Parker et al. Cochrane Database Syst Rev 2010. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. • 7 trials (randomised & quasi-randomised) w/ 857 pts (863 fractures) • no statistically significant differences for following outcomes • acetabular erosion • re-operations • dislocation • mobility • mortality • other: DVT, deep wound infection • inadequate evidence to support or refute use of bipolar

  15. “OLDER” PATIENT MANAGMENT: UNIPOLAR vs. BIPOLAR • Hedbeck et al. Int Orthop 2011. Unipolar HA versus bipolar HA in the most elderly pts w/ DFNF: a RCT. • 120 pts w/ mean age of 80 w/ 4 and 12 month f/u; observer not blinded • randomisation to unipolar vs. bipolar heads using an identical modern femoral stem (Exeter) • no difference btwn groups • regarding surgical complications (p =0.30) • unipolar 5% (2 dislocations, 1 deep infection) • bipolar 10% (1 dislocation, 2 deep infections, 3 periprosthetic #) • general medical complications • 1 year mortality rate (unipolar 12% vs. bipolar 22% p =0.14) • functional outcome at 4 and 12 months (Harris Hip Score, ADLs) • significant difference at 1 year with regards to acetabular erosion • unipolar 20% vs. bipolar 5% (p=0.03) • trend towards worse hip function, lower quality of life, lower ADL function

  16. “OLDER” PATIENT MANAGMENT: CEMENTED VS. UNCEMENTED HEMI • Parker et al. Cochrane Database Syst Rev 2010. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. • 6 trials (randomised & quasi-randomised) w/ 899 patients • cemented prosthesis associated with • longer operative time (mean difference 7.24 minutes) • reduced risk of operative femur fracture (5.6% vs. 0%; RR 0.09) • less loss of mobility (lower reduction of a mobility score; RR -0.80) • fewer patients w/ residual pain at 3 months and longer f/u • lower pain scores • NO difference in mortality at any time interval

  17. “OLDER” PATIENT MANAGMENT: CEMENTED VS. UNCEMENTED HEMI • Luo et al. Arch Orthop Trauma Surg 2011. Systematic review of cemented versus uncemented HA for DFNF in older pts. • 8 RCTs, 1 175 hips • no difference between • peri-operative mortality: cemented = 7.5% vs. uncemented 8.3% • 1 year mortality: cemented 24.4% vs. uncemented 27.2% • re-operation rate: cemented 6.1% vs. uncemented 8.0% • general medical complications: cemented 14.5% vs. uncemented 17.5% • local complications (RR 0.85) • residual pain at 3 month (RR 0.84) • significant difference of residual pain at 1 year • cemented 23.6% vs. uncemented 34.4% • random-effect meta-analysis showed so difference

  18. “OLDER” PATIENT MANAGMENT: CEMENTED VS. UNCEMENTED HEMI • Figved et al. CORR 2009. Cemented vs. Uncemented HA for DFNF. • pts w/ DFNF > 70, randomised to cemented stem (Spectron) or uncemented hydroxyapatite coated stem (Corail) • HA coated stem found to have: • shorter length of surgery (12.4 minutes) • less operative blood loss (89 mL) and total blood loss • no other outcomes had statistical difference • blood transfusion, wound infection, medical complications, hospital stay • dislocation, intra-op / post-op femur #, mortality • outcome measures • possible that previous noted differences may not exist with modern implants

  19. “OLDER” PATIENT MANAGMENT: HEMIARTHOPLASTY vs. THA • Parker et al. Cochrane Database Syst Rev 2010. • 7 trials (randomised & quasi-randomised) w/ 734 patients • THA associated with: • longer surgical time (mean 18.53 mins, range 13-23 mins) • increased risk of dislocation (7.9% vs. 4.3% for hemi) • more “minor” re-operations (9.3% vs. 4.7% for hemi) • less “major” re-operations (3.2% vs. 7.9% for hemi) • less residual pain at 1 year vs. uncemented hemi • better functional outcome scores (Oxford, Harris Hip, Barthel, EuroQol) • no difference in mortality • Remember patient selection • acute (< 48 hours) non-pathologic fracture, • good cognitive fnc & physically healthy • non-institutionalized independent living & pre-injury walking capability • pre-existing hip pain (arthrosis / inflammatory arthropathy)

  20. “OLDER” PATIENT MANAGMENT: CHOICE OF APPROACH • Varley J and Parker MJ. Int Orthop 2004. Stability of hip hemiarthoplasties. • systematic review from 1974-2004  133 articles, 23 107 cases • dislocation statistically significant for approach (p =0.0.003) • anterior approach = 2.4% vs. posterior approach = 5.1% • Enocson et al. Acta Orthop 2008. Dislocation of HA after FNF. • 739 HA either as 1* or 2* procedure for FNF • posterolateral approach = increased risk of dislocation • anterior = 3.0% vs. PL + repair = 8.5% vs. PL – repair = 13% • only factor which affected dislocation rate • Garellick et al. Swedish Hip Arthoplasty Register Annual Report 2009. • anterior approach associated w/ lower risk of re-operation 2* dislocation for hemiarthroplasty and THA • use of anterolateral approach increased from 47% to 56%

  21. “OLDER” PATIENT MANAGMENT: CHOICE OF APPROACH • Enocson et al. JBJS Br 2010. Dislocation of THR in pts w/ FNF • 532 consecutive THRs prospectively followed • compared to anterolateral approach • significantly higher risk of dislocation for posterior approach w/o post repair • strong trend for higher risk of dislocaiton for posterior approach + repair • Ricci et al. Hip Int 2011. THA for acute DFNF via posterior approach: a protocol to minimise hip dislocation risk • 29 consecutive patients; > 50 y/o; acute, non-pathological #; congnitively lucid; independent community ambulator; w/o Parkinson; w/o prior instrumentation • posterior approach, largest possible femoral head size, modern components, standardized approach for stability testing, repair of posterior hip capsule + ext rot, posterior hip precautions • only 1 dislocation in a non-compliant patient

  22. CURRENT STUDIES: FAITH TRIAL • Fixation using Alternative Implants for the Treatment of Hip fractures • multi-centre randomised trial: sliding hip screws vs cancellous screws • Inclusion criteria: • age > 50, any degree of displacement that can be closed reduced, operative treatment within 48 hours / 7 of presenting to ER for DFNF / NDFNF, pt ambulatory prior to #, low energy #, no other trauma • Exclusion criteria: • pts no suitable for IF (e.g. RA), associated major injuries of L/E, retained h/w around hip, infection, bone metabolism d/o (e.g. Paget’s), mod/severe congitive impairment (MMSE), Parkinson’s / dementia that will limit post op rehab • Primary outcome: • revision surgery at 12 months • Secondary outcomes: • health related quality of life (SF-12), functional outcomes (WOMAC), health outcomes (EQ-5D), complications

  23. CURRENT STUDIES: HEALTH TRIAL • Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty • multi-centre randomised trial: THA vs. hemi • Inclusion criteria: • age > 50, DFNF, operative treatment within 3 days of presenting to, pt ambulatory prior to #, low energy #, no other trauma • Exclusion criteria: • pts no suitable for HA (e.g. RA), associated major injuries of L/E, retained h/w around hip, infection, bone metabolism d/o (e.g. Paget’s), mod/severe congitive impairment (MMSE), Parkinson’s / dementia that will limit post op rehab or f/u • Primary outcome: • revision surgery at 24 months • Secondary outcomes: • health related quality of life (SF-12), functional outcomes (WOMAC), functional mobility (TUG), health outcomes (EQ-5D), cost-utlity ratio, complications

  24. SUMMARY • ORIF for patients < 60 (w/o risk factors) w/ SHS or cannulated screws • Posterior comminution, difficulty of reduction quality of reduction, quality of fixation • consider arthroplasty for patients > 60 w/ DFNF • lower re-operation rate despite longer surgical time and more blood loss • more cost effective • if choosing hemiarthoplasty • unipolar or bipolar effective • cemented prosthesis may have better pain scores at 1 year • patient selection important for THA • anterior approaches have lower dislocation rate for HA and THA • patient selection & surgical technique when considering other approaches

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