Session X - Geriatrics

Sun., 10/10/04 Geriatrics, Paper #57, 8:06 am

Internal Fixation or Hemiarthroplsty for Displaced Femoral Neck Fractures: Can an Individual Physiologic Status Score Aid in Treatment Choice? A Dutch Prospective Multicenter Study

Martin J. Heetveld, MD1 (n); Ernst L. F. B. Raaymakers, PhD1 (n);
Jan S. K. Luitse, MD1 (n); Marc Nijhof, PhD2 (*); Gerrolt N. Jukema, MD3 (*);
Andreas J. M. Karthaus, PhD4 (*); Jan Biert, PhD5 (*); Sven van Helden, MD6 (*);
Maarten van der Elst, PhD7 (*); Huub van der Meulen, MD8 (*);
Jan Ultee, MD9 (*); Rob Leemans, MD10 (*); J. Carel Goslings, PhD1 (*);
Kees-Jan Ponsen, MD1 (*); Dirk J. Gouma, PhD1 (*);
1 Academic Medical Center, Amsterdam;
2 Medisch Spectrum Twente, Enschede;
3 University Medical Center Leiden, Leiden;
4Deventer Hospital, Deventer;
5 University Medical Center Radboud, Nijmegen;
6 University Hospital Groningen, Groningen;
7 Reinier de Graaff Hospital, Delft;
8 Leyenburg Hospital, The Hague;
9 Sint Lucas Andreas Hospital, Amsterdam;
10 Leeuwarden Medical Center-Zuid, Leeuwarden, The Netherlands

Purpose: There is continuing debate about the optimal treatment of patients between the ages of 60 and 90 who have a displaced femoral neck fracture (FNF). Meta-analysis data show a fracture nonunion rate of 29% and an avascular necrosis rate of 8% following internal fixation (IF). After hemiarthroplasty (HA), pooled data show a dislocation rate of 4%, stem loosening of 5%, and acetabular wear of 3%. A modified Physiologic Status Score (PSS), which quantifies the individual qualities of walking ability, accommodation, bone density, mental status, and medical condition could aid in selecting patients for IF or HA. The hypothesis is that active, healthy patients with a high PSS have less need for revision procedures after IF, and patients with a lower PSS would benefit more from HA because of lesser revision risk. The aim of this study was to validate the PSS treatment protocol as a preoperative selection strategy.

Methods: After obtaining Institutional Review Board consent, 10 Dutch hospitals participated in the study. Patients between 60 and 90 years of age with a displaced FNF were included prospectively. The PSS was used as a selection criterion for performing either IF or HA; a maximum of 26 points could be achieved. Bone density was measured with dual energy X-ray absorptiometry. The cut-off point for IF was 20 points. The study protocol defined fracture reduction and IF principles. Cannulated screws or sliding hip screws were recommended for IF. Only cemented hemiarthroplasty implants were allowed. Operations were performed under the supervision of a surgeon with experience in both treatment modalities. An independent expert panel rated the IF technique. The Harris Hip Score and hip radiographs were evaluated at 8 weeks, 1 year, and 2 years postoperatively. End points were revision, mortality and Harris Hip Score (HHS). Power analysis expected a 10% reduction in IF revisions compared with meta-analysis data; 243 patients were required. A 35% dropout rate, primarily from mortality, was anticipated.

Results: A total of 252 patients were included over an 18-month period. Twenty-eight patients were excluded because of violation of protocol, leaving 224 patients for evaluation. Of these, 115 patients received IF (PSS, 20 points) and 109 received HA (PSS, <20 points). The two-year follow-up rate was 98% of surviving patients. Excluding 15 technically inadequately rated cases, the revision rate in the IF group was 31% and in the HA group 3%. Two-year mortality was 16% in the IF and 50% in the HA group. Two-year mean HHS was significantly higher in both successful IF (79 ± 15) and revised IF (78 ± 16) patients compared with HA patients (71 ± 12, P = 0.007 and 0.001 respectively). Mortality of revised IF patients was also similar to successful IF patients (P = 0.94).

Conclusion/Significance: Selection of active and ambulatory patients with the aid of the PSS for IF led to similar revision rates compared with recent meta-analysis data. The PSS protocol was useful in selecting patients with very low risk of revision after HA. As pain, function, and mortality of successful and revised IF patients are comparable, a revision rate of 31% may be acceptable in an attempt to retain the femoral head in elderly patients with a quantified high functional demand.