Arthroplasty in Hip Arthroplasty in Hip FractureFracture

Seminar on Management of Hip FractureSeminar on Management of Hip FractureAsian Association for Dynamic OsteosynthesisAsian Association for Dynamic Osteosynthesis

Dr. KW CheungDr. KW CheungJuly 8, 2007July 8, 2007

IndicationsIndicationsAcuteAcute

Displaced intracapsular transcervical fracture in old Displaced intracapsular transcervical fracture in old patientpatientIntracapsular transcervical fracture with concomitant Intracapsular transcervical fracture with concomitant hip pathology e.g. prehip pathology e.g. pre--existing avascular necrosis of existing avascular necrosis of femoral headfemoral headDelayed presentation of displaced intracapsular Delayed presentation of displaced intracapsular transcervical fracture in young patient (> 48 to 72 transcervical fracture in young patient (> 48 to 72 hours)hours)Pathological fracture of femoral head or neckPathological fracture of femoral head or neckAbnormal sized femoral canal (too wide or too Abnormal sized femoral canal (too wide or too narrow)narrow)

Subcapital #NOFSubcapital #NOF

Subcapital #NOF with preSubcapital #NOF with pre--existing existing AVNAVN

LateLateComplications of previous endoprothesisComplications of previous endoprothesis

LooseningLooseningInfectionInfectionAcetabular protrusioAcetabular protrusio

Complications of previous internal fixationComplications of previous internal fixationScrew protrusion into hip jointScrew protrusion into hip jointAvascular necrosis of femoral headAvascular necrosis of femoral headNonNon--union of fractureunion of fracture

Acetabular protruisoAcetabular protruiso

PostPost--traumatic AVNtraumatic AVN

NonNon--union after #NOFunion after #NOF

Pathological #NOFPathological #NOF

Types of arthroplasty in hip fractureTypes of arthroplasty in hip fracture

HemiarthroplastyHemiarthroplastyAustin Moore HemiarthroplastyAustin Moore HemiarthroplastyThompsonThompson’’s prosthesiss prosthesis

Unipolar and Bipolar hemiarthroplastyUnipolar and Bipolar hemiarthroplastyCemented vs. cementlessCemented vs. cementless

Total hip arthroplastyTotal hip arthroplastyCemented, cementless or hybridCemented, cementless or hybridDifferent bearing surfacesDifferent bearing surfaces

Metal or ceramic on polyethyleneMetal or ceramic on polyethyleneCeramicCeramic--onon--ceramicceramicMetalMetal--onon--metalmetal

HemiarthroplastyHemiarthroplasty

AdvantagesAdvantagesCheapCheapLess technical demandingLess technical demandingLow dislocation rate (large head)Low dislocation rate (large head)Suitable in fragile, old patientsSuitable in fragile, old patients

DisadvantagesDisadvantagesInsecure fixation of femoral stemInsecure fixation of femoral stemAcetabular erosion and protrusioAcetabular erosion and protrusioHigh reoperation rate in relatively young patient (between 60 High reoperation rate in relatively young patient (between 60 to 80 yo)to 80 yo)

Unipolar hemiarthroplastyUnipolar hemiarthroplasty

Bipolar HemiarthroplastyBipolar Hemiarthroplasty

Unipolar and bipolar hemiarthroplastyUnipolar and bipolar hemiarthroplasty

AdvantagesAdvantagesLow dislocation rateLow dislocation rateMore secure femoral stem fixationMore secure femoral stem fixationLow reoperation rateLow reoperation rateOne more motion interface in bipolar One more motion interface in bipolar hemiarthroplastyhemiarthroplastyConversion to THA is simple (if femoral stem is well Conversion to THA is simple (if femoral stem is well fixed, can perform acetabular side only)fixed, can perform acetabular side only)

DisadvantagesDisadvantagesAcetabular erosion and protrusioAcetabular erosion and protrusioTechnical demandingTechnical demanding

Hybrid THAHybrid THA

THATHA

AdvantagesAdvantagesLow reoperation rateLow reoperation rateSecure femoral stem fixationSecure femoral stem fixationLess acetabular protrusioLess acetabular protrusio

DisadvantagesDisadvantagesTechnical demandingTechnical demandingHigher dislocation rate than hemiarthroplasties Higher dislocation rate than hemiarthroplasties (small femoral head)(small femoral head)Disruption of relatively normal acetabular cartilageDisruption of relatively normal acetabular cartilage

Cemented THACemented THA

Bone cementBone cement

Polymethylmethacrylate (PMMA)

in use for 40 yearsin use for 40 yearspopularized by Charnleypopularized by Charnleyadvances in cementing techniqueadvances in cementing techniquetoxic effectstoxic effects

Contents of cementContents of cementPacketPacket

PMMA powderPMMA powder10% Radiopaque barium sulphate (occ. Zirconium dioxide)10% Radiopaque barium sulphate (occ. Zirconium dioxide)Polymerization initiator (1% benzoyl peroxide)Polymerization initiator (1% benzoyl peroxide)

Vial of liquidVial of liquidMethylmethacrylate monomerMethylmethacrylate monomerActivator (3% DMP toluidine)Activator (3% DMP toluidine)Trace amount of retardant to prevent monomer Trace amount of retardant to prevent monomer polymerization during storagepolymerization during storage

Cement mixingCement mixingDough timeDough time

Beginning of mixing until cement not stick to gloves Beginning of mixing until cement not stick to gloves ~ 2 ~ 2 –– 3 minutes3 minutes

Working timeWorking timeTime from the end of dough time to until cement Time from the end of dough time to until cement too stiff to manipulate ~ 5 too stiff to manipulate ~ 5 –– 8 minutes8 minutes

Setting timeSetting timeDough time + working time ~ 8 Dough time + working time ~ 8 –– 10 minutes10 minutes

Cement MixerCement Mixer

•

Cementing techniqueCementing technique

First generation (Charnley)First generation (Charnley)unplugged medullary canalunplugged medullary canalfingerfinger--packingpacking

•• SecondSecond

generationgenerationmedullary plugmedullary plugcement guncement gun

Third generation (Harris)Third generation (Harris)medullary plugmedullary plugcement guncement gunpulsatile lavagepulsatile lavagereduction of cement porosity (vacuum mix)reduction of cement porosity (vacuum mix)pressurizationpressurizationprecoatingprecoating

Toxic effect of Toxic effect of MethylmethacrylateMethylmethacrylate

Animal studiesAnimal studiesdosedose--dependent depression of left ventricular dependent depression of left ventricular function function →→ ↓↓ blood pressure and pulse rateblood pressure and pulse rateinduces pulmonary hypertension and increases induces pulmonary hypertension and increases lung vascular permeability lung vascular permeability

Human studiesHuman studiesWenda K et al Arch Ortho Trauma Surg Wenda K et al Arch Ortho Trauma Surg

107:316,1985107:316,1985MMA found in pulmonary artery, radial artery and MMA found in pulmonary artery, radial artery and SVCSVCBP BP ↓↓ during first 3 minduring first 3 minpulmonary arterial pressure pulmonary arterial pressure ↑↑ during first to 10 during first to 10 minminno correlation between MMA concentration & no correlation between MMA concentration & ↓↓BP or BP or ↑↑ pulmonary arterial pressurepulmonary arterial pressure

Cementless THACementless THA

Alternate bearing surfacesAlternate bearing surfaces

Ceramic-on-ceramic

Ceramic-on-ceramic

Metal-on-metal

Results of arthroplasty Results of arthroplasty in hip fracturein hip fracture

Outcome of intracapsular Outcome of intracapsular transcervical fracturetranscervical fracture

NonNon--unionunion5% in undisplaced fracture5% in undisplaced fracture21 21 –– 32% in displaced fracture32% in displaced fracture

Avascular necrosisAvascular necrosis10% in undisplaced fracture10% in undisplaced fracture12 12 –– 16% in displaced fracture16% in displaced fracture

Problems encountered during Problems encountered during conversion of failed osteosynthesis to conversion of failed osteosynthesis to

arthroplastyarthroplastyBone loss caused by implant protrusioBone loss caused by implant protrusioMedullary cavity sclerotic especially previous Medullary cavity sclerotic especially previous intraintra--medullary devicemedullary device

Difficult to insert cementless prosthesis and prone Difficult to insert cementless prosthesis and prone to femoral shaft fractureto femoral shaft fractureCement interdigitation very difficultCement interdigitation very difficult

Multiple holes in proximal femurMultiple holes in proximal femurDifficult to achieve good pressurization of cementDifficult to achieve good pressurization of cement

Osteosynthesis vs. primary Osteosynthesis vs. primary arthroplasty in displaced femoral arthroplasty in displaced femoral

neck fractureneck fracture

Rogmark et al Rogmark et al Acta Orthopaedica77(3): 359Acta Orthopaedica77(3): 359--67, 200667, 2006

MetaMeta--analysis of 14 RCTs, 2289 patientsanalysis of 14 RCTs, 2289 patientsPrimary arthroplasty has significantly less major Primary arthroplasty has significantly less major methodmethod--related complications and reoperationsrelated complications and reoperationsBetter function and less pain after primary Better function and less pain after primary arthroplastyarthroplasty70 to 80 yo should have THA70 to 80 yo should have THA>80 yo should have hemiarthroplasty>80 yo should have hemiarthroplasty

BjBjØØrugl et al rugl et al Acta Orthopaedica 77(3): 368Acta Orthopaedica 77(3): 368--74, 200674, 2006

228 osteosynthesis, 455 bipolar hemiarthroplasty, all 228 osteosynthesis, 455 bipolar hemiarthroplasty, all had displaced #NOFhad displaced #NOF2% revision surgery after bipolar hemiarthroplasty2% revision surgery after bipolar hemiarthroplasty24% revision surgery after osteosynthesis24% revision surgery after osteosynthesisNo significant difference in mortality between 2 No significant difference in mortality between 2 groups at 30 days postgroups at 30 days post--opop

Parker et al Parker et al JBJS 84B:1150JBJS 84B:1150--5, 20025, 2002

RCTRCT226 osteosynthesis, 229 hemiarthroplasty226 osteosynthesis, 229 hemiarthroplastyAv age 82 yoAv age 82 yoSignificantly less patient require reoperation after Significantly less patient require reoperation after hemiarthroplastyhemiarthroplastyTendency for improved survival in patients > 90 yoTendency for improved survival in patients > 90 yoOsteosynthesis reserved for old fragile patientOsteosynthesis reserved for old fragile patient

Results of AMAResults of AMA

Roberts et al Roberts et al Injury 33(5): 423Injury 33(5): 423--426, 2002426, 2002

Compare 100 failed hip screws with conversion to Compare 100 failed hip screws with conversion to AMA (group 1) and 730 primary hip fracture with AMA (group 1) and 730 primary hip fracture with AMA done (group 2)AMA done (group 2)Significantly higher revision surgery in group 1Significantly higher revision surgery in group 1Group 1 has significantly more dislocation, infection Group 1 has significantly more dislocation, infection and painand pain

Yau WP, Chiu KY Yau WP, Chiu KY Injury 35(10):1020Injury 35(10):1020--4, 20044, 2004

44 patients44 patientsAge < 73 at the time of operation has significantly Age < 73 at the time of operation has significantly more subsidencemore subsidence<70% fill of prosthesis within proximal femur was <70% fill of prosthesis within proximal femur was associated with subsidenceassociated with subsidence

AMA vs. cemented ThompsonAMA vs. cemented Thompson’’s s prosthesisprosthesis

Singh et al Singh et al Injury 77(4):638Injury 77(4):638--43, 200643, 2006

54 hip fractures, 25 Thompson54 hip fractures, 25 Thompson’’s prosthesis, 29 s prosthesis, 29 AMAAMAPatients with ThompsonPatients with Thompson’’s prosthesis has s prosthesis has significantly less pain and shorter hospital stay than significantly less pain and shorter hospital stay than patients with AMApatients with AMA

Results of unipolar hemiarthroplastyResults of unipolar hemiarthroplasty

Wachtl et al Wachtl et al J Arthroplasty 18(5), 587J Arthroplasty 18(5), 587--591, 2003591, 2003162 patients, average age 84 yo162 patients, average age 84 yoModular MModular Müüller selfller self--locking straight stemlocking straight stemProsthesis survivalProsthesis survival

98% at 1 year98% at 1 year94% at 5 and 10 years94% at 5 and 10 years

Patient survivalPatient survival73% at 1 year73% at 1 year23% at 5 years23% at 5 years6% at 10 years6% at 10 years

Overall complication rate requiring repeat surgery was 10%Overall complication rate requiring repeat surgery was 10%Preferred for patient older than 70 yearsPreferred for patient older than 70 years

Results of bipolar hemiarthroplastyResults of bipolar hemiarthroplasty

Bezwada et al Bezwada et al J Arthroplasty 19(7) Suppl 2: 73J Arthroplasty 19(7) Suppl 2: 73--7, 20047, 2004

168 patients, cementless stem168 patients, cementless stemAv age: 77, av FU 3.5 yearsAv age: 77, av FU 3.5 years5% need revision surgery5% need revision surgery

6 patients revised due to acetabular erosion 6 patients revised due to acetabular erosion 2 patients revised due to femoral stem loosening2 patients revised due to femoral stem loosening

Dixon et al Dixon et al Injury 35(2): 152Injury 35(2): 152--6, 20046, 2004

53 patients, cemented bipolar hemiarthroplasty53 patients, cemented bipolar hemiarthroplastyAv FU 32 monthsAv FU 32 monthsNo dislocationNo dislocation2 revision surgeries2 revision surgeries

1 with femoral stem loosening1 with femoral stem loosening1 with acetabular erosion1 with acetabular erosion

Unipolar vs. bipolar hemiarthroplastyUnipolar vs. bipolar hemiarthroplasty

Raia et al Raia et al Clin Orth Rel Res 414: 259Clin Orth Rel Res 414: 259--65, 200365, 2003

RCTRCT40 unipolar, 38 bipolar, all had cemented stem40 unipolar, 38 bipolar, all had cemented stemNo significance difference in functional outcome No significance difference in functional outcome and quality of life at 1 year postand quality of life at 1 year post--opop

Results of primary THA in displaced Results of primary THA in displaced #NOF#NOF

Wazir et al Wazir et al J Orth Surg 14(1):43J Orth Surg 14(1):43--6, 20066, 2006

38 patients, av FU 21 months38 patients, av FU 21 monthsAv. age 75 yoAv. age 75 yoCemented THACemented THA30 patients no pain30 patients no pain2 dislocation2 dislocation2 deep infection with Girdle Stone operation2 deep infection with Girdle Stone operationNo aseptic looseningNo aseptic loosening

Mishra et al Mishra et al Injury 35(2): 157Injury 35(2): 157--60, 200460, 2004

51 patients, av FU 33 months51 patients, av FU 33 monthsAv age 74 yoAv age 74 yoCemented THACemented THA2 revision surgeries2 revision surgeries

1 recurrent dislocation1 recurrent dislocation1 deep infection with Girdle Stone operation1 deep infection with Girdle Stone operation

Osteosynthesis vs. THAOsteosynthesis vs. THA

Johansson et al Johansson et al Int Orthop 30:1Int Orthop 30:1--6, 20066, 2006

RCT, 145 patientsRCT, 145 patientsSocioeconomic comparison between primary THA Socioeconomic comparison between primary THA and osteosynthesis in displaced #NOFand osteosynthesis in displaced #NOF

Significantly more patients after osteosynthesis need Significantly more patients after osteosynthesis need reoperation than THAreoperation than THANo significant difference in socioNo significant difference in socio--economic cost between economic cost between 2 groups2 groups

Unipolar hemiarthroplasty vs. THAUnipolar hemiarthroplasty vs. THA

Baker et al Baker et al JBJS 88A(12):2583JBJS 88A(12):2583--88, 200688, 2006

RCT, 41 hemiarthroplasties, 40 THAsRCT, 41 hemiarthroplasties, 40 THAsAv. FU 3 years, all had cemented stemAv. FU 3 years, all had cemented stem66% of unipolar hemiarthroplasty showed acetabular 66% of unipolar hemiarthroplasty showed acetabular erosion radiographically, none in THAerosion radiographically, none in THAMore dislocation after THA More dislocation after THA Revision surgeryRevision surgery

14.6% in unipolar group14.6% in unipolar group2.5 % in THA group2.5 % in THA group

Bipolar hemiarthroplasty vs. THABipolar hemiarthroplasty vs. THA

Narayan et al Narayan et al Arch Orth Trau Surg 126: 545Arch Orth Trau Surg 126: 545--8, 20068, 2006

29 THAs, 32 bipolar hemiarthroplasties29 THAs, 32 bipolar hemiarthroplastiesAv FU 58.5 monthsAv FU 58.5 monthsNo difference in function and pain between 2 No difference in function and pain between 2 groups groups More dislocation after THA than bipolar More dislocation after THA than bipolar hemiarthroplastyhemiarthroplasty

Preference of surgeonsPreference of surgeons

Bhandari et al Bhandari et al JBJS 87A: 2122JBJS 87A: 2122--30, 200530, 2005

International survey of 298 North America and International survey of 298 North America and European surgeonEuropean surgeon

<60 yo<60 yo89% opted for osteosynthesis in Garden type III #89% opted for osteosynthesis in Garden type III #75% opted for osteosynthesis in Garden type IV #75% opted for osteosynthesis in Garden type IV #

>80 yo>80 yo6% opted for osteosynthesis in Garden type III #6% opted for osteosynthesis in Garden type III #4% opted for osteosynthesis in Garden type IV #4% opted for osteosynthesis in Garden type IV #

Patients between 60 to 80 yoPatients between 60 to 80 yoGarden type III #Garden type III #

34% opted for bipolar hemiarthroplasty34% opted for bipolar hemiarthroplasty28% opted for unipolar hemiarthroplasty28% opted for unipolar hemiarthroplasty15% opted for THA15% opted for THA25% opted for osteosynthesis25% opted for osteosynthesis

Garden type IV #Garden type IV #41% opted for bipolar hemiarthroplasty41% opted for bipolar hemiarthroplasty32% opted for unipolar hemiarthroplasty32% opted for unipolar hemiarthroplasty17% opted for THA17% opted for THA11% opted for osteosynthesis11% opted for osteosynthesis

ConclusionConclusion

Young patient (< 65 yo)Young patient (< 65 yo)Try osteosynthesisTry osteosynthesisIf osteosynthesis fail, convert to bipolar If osteosynthesis fail, convert to bipolar hemiarthroplasty hemiarthroplasty ±± THATHA

Relatively young patient (65 to 80 yo)Relatively young patient (65 to 80 yo)Bipolar hemiarthroplasty Bipolar hemiarthroplasty ±± THATHA

Old, fragile patient (>80 yo)Old, fragile patient (>80 yo)Hemiarthroplasty (AMA or ThompsonHemiarthroplasty (AMA or Thompson’’s prosthesis)s prosthesis)

Displaced femoral neck fracture

Thank youThank you