Oleh Mohammad Zaim Chilmi Department of Orthopaedic & Traumatology

1. HEMIARTHROPLASTY ( Debate in orthopaedic trauma displaced femoral neck fracture in 60 years Famale Patient ) Oleh Mohammad Zaim Chilmi Department of Orthopaedic & Traumatology School of Medicine Airlangga University Dr. Soetomo General Hospital Surabaya

2. Overview • 350,000 Hip fractures annually • Expected to double by 2050 ( William Macaulay MD et al: AAOS 2006;14:287-293) • At risk populations • Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition • Fracture rates doubles for each decade after the 5thdecade. • Incidence is highest in >65 years of age but also in young adults due to RTA Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

3. Blood Supply • Lateral epiphysel artery • terminal branch MFC artery • predominant blood supply to weight bearing dome of head • Artery of ligamentumteres • from obturator artery • supplies anteroinferior head • Lateral femoral circumflex artery • less contribution than MFC Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

4. Blood Supply • Greater fracture displacement = greater risk of vascular disruption to femoral head  AVASCULAR NECROSES • Revascularization of the head • intact vessels • vascular ingrowth across fracture site • importance of quality of reduction • metaphyseal vessels Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

5. Femoralneck Intertrochanteric subtrochanteric General types of Hip fractures Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

6. General types of Hips fractures • Femoral Neck fractures are all intracapsularcan be further divided into • Subcapital • Transcervical • Basical Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

7. Mechanism of injury • Femoral Neck and Intertrochanteric fractures – mostly low-energy fractures osteoporotic elderly patients. Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

8. Mechanism of injury • Weak, slow muscle contraction in the elderly. • Muscle atrophy and slow neurological response to fall. • Increased Axial forces on the bone after a fall – load on the greater trochanter • In extreme external rotation – impingement of the head in the acetabular rim. Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

9. Treatment Elderly Patients • Operative vs. Non-operative • Displaced fractures • Unacceptable rates of mortality, morbidity, and poor outcome with non-operative treatment [Koval 1994] • Non-displaced fractures • Unpredictable risk of secondary displacement • AVN rate 2X • Standard of care is operative for all femoral neck fractures • Non-operative tx may have developing role in select patients with impacted/ non-displaced fractures [Raaymakers 2001] Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

10. Timing of Surgery • Often elderly patients with co-morbidities • do not tolerate prolonged bed-rest • Increased waiting period (> 3 days) double mortality in the first post-surgical year (Zuckerman 1990) • Method of anesthesia spinal, epidural, General do not alter prognosis. Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

11. Operative treatment • More surgical complications and reoperations occur after internal fixation than after arthroplasty. • Reoperation rates after arthroplasty of 7%, 11%, and 11% compared with 40%, 35%, and 33% for internal fixation. • Postoperative pain, function, and quality of life, without showing any difference between the treatment groups. ( BMJ. 2007 December 15; 335(7632): 1251–1254) Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

12. Operative treatment • In Meta-analysis – re-operation after ORIF due to AVN or non-union 22-36% • Hemiarthroplasty is the preferred treatment option for older patients. Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

13. Hemiarthroplasty • Advantages • One definite procedure (immediate weight bearing). • Disadvantages • prosthetic joint (dangerous infections) • bigger operation (risk for dislocations, and late mechanical complications). Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

14. Hemiarthroplasty • Hemi associated with • Lower reoperation rate (6-18% vs. 20-36%) • Improved functional scores • Less pain • More cost-effective • Slightly increased short term mortality • Literature supports hemiarthroplasty for displaced fractures ( Lu-yao JBJS,1994 ) ( Iorio et al; ClinOrthopRelat Res 2001;383:229-242) Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

15. Unipolar Endoprosthesis(Austin Moore) • Cheap • Can cause acetabular erosion and protrusion • Loosening of stem • NOT EASY be converted to THR Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

16. Bipolar Endoprosthesis • Inner plastic shell “joint within joint” (the prosthesis-prosthesis articulation) • Decreases acetabular protrusion • Better Biomechanics • EASY to be converted to THR • Expensive Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

17. HemiarthroplastyUnipolar vs. Bipolar • Bipolar theoretical advantages • Lower dislocation rate • Less acetabular wear/ protrusio • Less Pain • More motion Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

18. HemiarthroplastyUnipolar vs. Bipolar • Bipolar • Disadvantages • Cost • Dislocation often requires open reduction • Loss of motion interface (effectively unipolar) • Polyethylene wear/ osteolysis not yet studied for Bipolars Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

19. HemiarthroplastyUnipolar vs. Bipolar • Complications / Mortality / Length of stay • No Difference • Hip Scores / Functional Outcomes • No significant difference • Bipolar slightly better walking speeds, motion, pain • Revision rates • Unipolar 20% vs. Bipolar 10% (7 years) • Unipolar more cost-effective • Literature supports use of either implant Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

20. HemiarthroplastyCemented vs. Non-cemented • Cement (PMMA) • Improved mobility, function, walking aids • Most studies show no difference in morbidity / mortality • Sudden Intra-op cardiac death risk slightly increased: • 1% cemented hemi for fx vs. 0.015% for elective arthroplasty • Non-cemented (Press-fit) • Pain / Loosening higher • Intra-op fracture (theoretical) Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

21. HemiarthroplastyCemented vs. Non-cemented • Cement gives better results • Function • Mobility • Implant Stability • Pain • Cost-effective • Low risk of sudden cardiac death • Use cement with caution Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

22. Complication of Hemiarthroplasty • Hemiarthroplasty may cause dislocation, loosening, and peri-prosthetic fracture, which together have an overall incidence of 5–15%. (BMJ. 335(7632):1220-1221, December 15, 2007). Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

23. Unipolar & Bipola Prosthesis - complication Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

24. Conclusion • In Adult patients >65 – Bipolar Hemiarthroplasty • >75 very-low demand or morbid pt. – Unipolar hemiarthroplasty Orthopaedi & Traumatology Department Airlangga University - Dr. Soetomo General Hospital

25. Thank You Terima kasih