Fri., 10/17/08 Geriatrics/Reconstruction, Paper #40, 4:40 pm OTA-2008
Anterior Hip Arthroplasty for Treatment of Acute Displaced Elderly Femoral Neck Fractures
Kurtis Staples, MD (n); Philip J. Kregor, MD (a-AO Research Foundation, Synthes);
Vanderbilt Orthopaedic Institute, Nashville, Tennessee, USA
Purpose: This study reviewed the initial consecutive series of anterior hip arthroplasty performed in the setting of an acute displaced femoral neck fracture in elderly patients (>65 years age). The hypothesis was that anterior hip arthroplasty is associated with more accurate positioning of components than historical controls, less dislocations, and an easier postoperative rehabilitation than traditional hip arthroplasty.
Methods: Between July 2005 and January 2008, 33 patients (20 females, 13 males) with a mean age of 73.5 years were treated by a single surgeon with an anterior total hip arthroplasty for an acute displaced femoral neck fracture. The same surgeon also treated 23 other patients (14 females, 9 males) during this time period with anterior hemiarthroplasty for an acute displaced femoral neck fracture. All patients were allowed to immediately bear weight as tolerated without any hip precautions postoperatively.
Results: All arthroplasties were performed via an anterior Heuter (modified Smith-Peterson) approach averaging 10 cm in length. For total hip arthoplasty, large femoral heads were utilized (32 mm or greater) in all cases. Acetabular cups were inserted under direct vision and confirmed with fluoroscopy. Each hemiarthroplasty was performed with a bipolar head implant sized according to the individual patient. All femoral stems were placed in a press-fit manner. A Depuy Corail hydroxyapitite femoral component was utilized in all cases. There were three intraoperative fractures: one acetabular fracture that occurred during cup impaction and two nondisplaced greater trochanter fractures. There were no wound or deep infections requiring operative intervention. There were no dislocations. Postoperative radiographs demonstrated an average leg-length inequality of 1.1 mm (range, 3 to –4) and 1.4 mm (range, 4 to –4) for total hip arthoplasty and hemiarthroplasty, respectively. Acetabular cup abduction, as measured on the postoperative radiograph, averaged 39° (range, 32° to 45°).
Conclusions: Advantages of the anterior approach for arthroplasty in elderly patients with a femoral neck fracture include: (1) decreased rate of dislocation (0%), (2) low infection (0%), (3) accurate restoration of leg length (average limb-length discrepancy = 1 mm), (4) avoidance of abductor devitalization, and (5) supine positioning, which may be beneficial in medically unstable patients. There is increasing evidence that functional outcomes are improved with a total hip arthroplasty versus a hemiarthroplasty in the elderly patient with a displaced femoral neck fracture. However, a major concern with the use of total hip arthroplasty in this setting is dislocation (6.9%; Bhandari et al [2006]). The use of the anterior approach negates the need for any hip flexion precautions or activity restrictions and is associated with a low rate of dislocation. In addition, the early return of function without assistive aids may be particularly helpful in the elderly patient population. Prospective randomized studies comparing the anterior and posterior/anterolateral approaches for this clinical problem are underway.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.