Anders Enocson

Comparison of bipolar hemiarthroplasty with total hip arthroplasty for displaced femoral neck fractures: a concise four-year follow-up of a randomized trial.

We performed a four-year follow-up of a randomized controlled trial involving 120 elderly patients with an acute displaced femoral neck fracture who were randomized to treatment with either a bipolar hemiarthroplasty or a total hip arthroplasty. The difference in hip function (as indicated by the Harris hip score) in favor of the total hip arthroplasty group that was previously reported at one year persisted and seemed to increase with time (mean score, 87 compared with 78 at twenty-four months [p < 0.001] and 89 compared with 75 at forty-eight months [p < 0.001]). The health-related quality of life (as indicated by the EuroQol [EQ-5D(index)] score) was better in the total hip arthroplasty group at the time of each follow-up, but the difference was significant only at forty-eight months (p < 0.039). These results confirm the better results in terms of hip function and quality of life after total hip arthroplasty as compared with hemiarthroplasty in elderly, lucid patients with a displaced fracture of the femoral neck.

Dislocation of hemiarthroplasty after femoral neck fracture: Better outcome after the anterolateral approach in a prospective cohort study on 739 consecutive hips

Background and purpose Hip replacement using a hemiarthroplasty is a common surgical procedure in elderly patients with fractures of the femoral neck. The optimal surgical approach regarding the risk of dislocation is controversial. We analyzed factors influencing the stability of the hemiarthroplasty, with special regard to the surgical approach. Patients and methods We studied 720 consecutive patients on whom 739 hemiarthroplasties were performed between 1996 and 2003, either as a primary operation for a displaced fracture of the femoral neck or as a secondary procedure after failed internal fixation of a fracture of the femoral neck. Logistic regression analyses were performed in order to evaluate factors associated with prosthetic dislocation. Results The multivariate regression analysis showed that the posterolateral approach was the only factor associated with a significantly increased risk of dislocation: OR 3.9 (CI: 1.6–10) for the posterolateral approach with posterior repair and OR 6.9 (CI: 2.6–19) for the posterolateral approach without posterior repair. Age, sex, indication for surgery, the surgeons experience, and type of HA had no statistically significant effect on the dislocation rate. Interpretation Compared to the anterolateral approach, the posterolateral approach was associated with a significantly increased risk of dislocation in patients with femoral neck fractures treated with HA. A posterior repair appears to reduce the rate of dislocation, although not to the same low level as in patients operated using the anterolateral approach.

Dislocation of total hip replacement in patients with fractures of the femoral neck: A prospective cohort study of 713 consecutive hips

Background Total hip replacement is increasingly used in active, relatively healthy elderly patients with fractures of the femoral neck. Dislocation of the prosthesis is a severe complication, and there is still controversy regarding the optimal surgical approach and its influence on stability. We analyzed factors influencing the stability of the total hip replacement, paying special attention to the surgical approach. Patients and methods We included 713 consecutive hips in a series of 698 patients (573 females) who had undergone a primary total hip replacement (n = 311) for a non-pathological, displaced femoral neck fracture (Garden III or IV) or a secondary total hip replacement (n = 402) due to a fracture-healing complication after a femoral neck fracture. We used Cox regression to evaluate factors associated with prosthetic dislocation after the operation. Age, sex, indication for surgery, the surgeon’s experience, femoral head size, and surgical approach were tested as independent factors in the model. Results The overall dislocation rate was 6%. The anterolateral surgical approach was associated with a lower risk of dislocation than the posterolateral approach with or without posterior repair (2%, 12%, and 14%, respectively (p < 0.001)). The posterolateral approach was the only factor associated with a significantly increased risk of dislocation, with a hazards ratio (HR) of 6 (2–14) for the posterolateral approach with posterior repair and of 6 (2–16) without posterior repair. Interpretation In order to minimize the risk of dislocation, we recommend the use of the anterolateral approach for total hip replacement in patients with femoral neck fractures.

Minimum 5-Year Follow-Up of a Cementless, Modular, Tapered Stem in Hip Revision Arthroplasty

Hip revision surgery with a cementless tapered femoral component can provide axial and rotational stability in patients with compromised proximal bone stock. This study includes 90 cases revised with the Link MP (Waldemar Link, Hamburg, Germany) prosthesis. The median age at surgery was 72 (38-89) years. Aseptic loosening (70%) and periprosthetic fracture (22%) were common indications for surgery. Sixty-three patients (70%) were followed clinically with a median of 6 (5-11) years of follow-up. All other patients were followed through the Swedish Hip Register. The 5-year survival rate was 98% with stem removal and 90% with any reoperation as the end point. Complications included hip dislocation in 17 (19%) patients. The median Harris hip score was 78 (16-100) points, and the median radiographic stem migration was 2.7 mm at follow-up.

Unipolar versus bipolar Exeter hip hemiarthroplasty: a prospective cohort study on 830 consecutive hips in patients with femoral neck fractures

BackgroundHip replacement using a hemiarthroplasty (HA) is a common surgical procedure in elderly patients with fractures of the femoral neck. Data from the Swedish Hip Arthroplasty Register suggest that there is a higher risk for revision surgery with the bipolar HA compared with the unipolar HA.Purpose In this study we analysed the reoperation and the dislocation rates for Exeter HAs in patients with a displaced femoral neck fracture, comparing the unipolar and bipolar prosthetic designs. Additionally, we compared the outcome for HAs performed as a primary intervention with those performed secondary to failed internal fixation.MethodsWe studied 830 consecutive Exeter HAs (427 unipolar and 403 bipolar) performed either as a primary operation for a displaced fracture of the femoral neck or as a secondary procedure after failed internal fixation of a fracture of the femoral neck. Cox regression analyses were performed to evaluate factors associated with reoperation and prosthetic dislocation. Age, gender, the surgeon’s experience, indication for surgery (primary or secondary) and type of HA (unipolar or bipolar) were tested as independent variables in the model.ResultsThe prosthetic design (uni- or bipolar) had no influence on the risk for reoperation or dislocation, nor had the age, gender or the surgeon’s experience. The secondary HAs were associated with a significantly increased risk for reoperation (HR 2.6, CI 1.5–4.5) or dislocation (HR 3.3, CI 1.4–7.3) compared to the primary HAs. We found no difference in the risk for reoperation or dislocation when comparing Exeter unipolar and bipolar HAs, but special attention is called for to reduce the risk of prosthesis dislocation and reoperation after a secondary HA.

Cemented versus uncemented arthroplasty in patients with a displaced fracture of the femoral neck: a randomised controlled trial.

The aim of this randomised controlled study was to compare functional and radiological outcomes between modern cemented and uncemented hydroxyapatite coated stems after one year in patients treated surgically for a fracture of the femoral neck. A total of 141 patients aged > 65 years were included. Patients were randomised to be treated with a cemented Exeter stem or an uncemented Bimetric stem. The patients were reviewed at four and 12 months. The cemented group performed better than the uncemented group for the Harris hip score (78 vs 70.7, p = 0.004) at four months and for the Short Musculoskeletal Function Assesment Questionnaire dysfunction score at four (29.8 vs 39.2, p = 0.007) and 12 months (22.3 vs 34.9, p = 0.001). The mean EQ-5D index score was better in the cemented group at four (0.68 vs 0.53, p = 0.001) and 12 months (0.75 vs 0.58, p = < 0.001) follow-up. There were nine intra-operative fractures in the uncemented group and none in the cemented group. In conclusion, our data do not support the use of an uncemented hydroxyapatite coated stem for the treatment of displaced fractures of the femoral neck in the elderly.

Acetabular fractures in the elderly treated with a primary Burch-Schneider reinforcement ring, autologous bone graft, and a total hip arthroplasty: a prospective study with a 4-year follow-up.

Objectives: To investigate the clinical and radiologic outcomes in elderly patients suffering from an acetabular fracture operated with an acute primary acetabular reinforcement ring, autologous bone graft, and a total hip arthroplasty (THA). Design: Prospective cohort study. Setting: Tertiary care university hospital. Patients: Fifteen elderly patients (7 women) with a mean age of 76 years and a displaced acetabular fracture after a low-energy trauma were included. The fractures involved the anterior column, but no patients with associated both column fractures were included. All the patients were able to walk independently before the fracture occurred. Intervention: Primary operation with a Burch–Schneider reinforcement ring, autologous bone graft, and a THA. Main Outcome Measurements: The patients were reviewed at 4, 12, 24, and 48 months after the fracture occurred. The outcome assessments included complications, reoperations, activity of daily living function, functional scores (Harris hip score and short musculoskeletal function assessment), health-related quality of life [EuroQol (EQ-5D) index score], and radiologic evaluation. Results: There were no prosthetic dislocations, periprosthetic fractures, deep infections, or other adverse events. There were no radiologic signs of loosening of the reinforcement ring or the prosthesis components at any of the follow up sessions, and the autologous bone graft was well incorporated in all the patients at the final follow-up. At 48 months, the mean Harris hip score was 88, the mean short musculoskeletal function assessment dysfunction score was 30, the bother score was 25, and the mean EQ-5D index score was 0.65. All the patients were able to walk independently at the final follow-up. Conclusions: Treatment of displaced anterior column, anterior column posterior hemitransverse and transverse acetabular fractures in elderly patients using a primary reinforcement ring, autologous bone graft, and a THA seems to be a safe option with good functional and radiologic outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Internal fixation versus cemented hemiarthroplasty for displaced femoral neck fractures in patients with severe cognitive dysfunction: a randomized controlled trial.

Objectives: To compare the outcome of internal fixation (IF) versus a cemented hemiarthroplasty (HA) in patients with a displaced femoral neck fracture and a severe cognitive dysfunction. Design: A prospective randomized controlled trial. Setting: A tertiary care university hospital. Patients: Sixty patients with a displaced femoral neck fracture were randomized to IF (n = 30) or HA (n = 30). All patients suffered from severe cognitive dysfunction but were able to walk before the fracture. Intervention: IF using 2 cannulated screws or HA using a cemented Exeter unipolar arthroplasty. Main Outcome Measurements: Patients were reviewed at 4, 12, and 24 months after the fracture. Outcome assessments included complications, reoperations, hip function (Charnley score), and health-related quality of life (EQ-5Dindex score). Results: A total of 8 patients were reoperated (14%); 7 in the IF group and 1 in the HA group. The EQ-5Dindex score at the follow-ups were generally lower in the IF group compared with the HA group with a significant difference at 12 months (P = 0.03). No difference was seen in hip function, general complications, or mortality between the groups. Conclusions: HA seems to provide a safe option with better health-related quality of life and less risk for reoperations compared with IF for these patients. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The vertical hip fracture - a treatment challenge. A cohort study with an up to 9 year follow-up of 137 consecutive hips treated with sliding hip screw and antirotation screw.

BackgroundFemoral neck fractures with a vertical orientation have been associated with an increased risk for failure as they are both axial and rotational unstable and experience increased shear forces compared to the conventional and more horizontally oriented femoral neck fractures. The purpose of this study was to analyse outcome and risk factors for reoperation of these uncommon fractures.MethodsA cohort study with a consecutive series of 137 hips suffering from a vertical hip fracture, treated with one method: a sliding hips screw with plate and an antirotation screw. Median follow-up time was 4.8 years. Reoperation data was validated against the National Board of Health and Welfare’s national registry using the unique Swedish personal identification number.ResultsThe total reoperation rate was 18%. After multivariable Logistic regression analysis adjusting for possible confounding factors there was an increased risk for reoperation for displaced fractures (22%) compared to undisplaced fractures (3%), and for fractures with poor implant position (38%) compared to fractures with adequate implant position (15%).ConclusionsThe reoperation rate was high, and special attention should be given to achieve an appropriate position of the implant.

Direction of hip arthroplasty dislocation in patients with femoral neck fractures

In order to prevent hip arthroplasty dislocations, information regarding the direction of the dislocation is important for accurate implant positioning and for optimising the postoperative regimens in relation to the surgical approach used. The aim of this study was to analyse the influence of the surgical approach on the direction of the dislocation in patients treated by a hemiarthroplasty (HA) or total hip arthroplasty (THA) after a femoral neck fracture. Fracture patients have a high risk for dislocations, and this issue has not been previously studied in a selected group of patients with a femoral neck fracture. We analysed the radiographs of the primary dislocation in 74 patients who had sustained a dislocation of their HA (n = 42) or THA (n = 32). In 42 patients an anterolateral (AL) surgical approach was used and in 32 a posterolateral (PL). The surgical approach significantly influenced the direction of dislocation in patients treated with HA (p < 0.001), while no such correlation was found after THA (p = 0.388). For THA patients there was a correlation between the mean angle of anteversion of the acetabular component and the direction of dislocation when comparing patients with anterior and posterior dislocations (p = 0.027). These results suggest that the surgical approach of a HA has an influence on the direction of dislocation, in contrast to THA where the position of the acetabular component seems to be of importance for the direction of dislocation in patients with femoral neck fractures.