Anita Söderqvist

A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients

The best treatment for the active and lucid elderly patient with a displaced intracapsular fracture of the femoral neck is still controversial. Randomised controlled trials have shown that a primary total hip replacement is superior to internal fixation as regards the need for secondary surgery, hip function and health-related quality of life. Despite good results achieved with total hip replacement in this group, most orthopaedic surgeons still advocate hemiarthroplasty for this injury. We studied 120 patients with a mean age of 81 years (70 to 90) with an acute displaced intracapsular fracture of the femoral neck. They were randomly allocated to be treated with either a bipolar hemiarthroplasty or total hip replacement. Outcome measurements included peri-operative data, general and hip-specific complications, hip function and health-related quality of life. The patients were reviewed at four and 12 months. The duration of surgery was longer in the total hip replacement group (102 minutes (70 to 151)) versus 78 minutes (43 to 131) (p<0.001), and the intra-operative blood loss was increased 460 ml (100 to 1100) versus 320 ml (50 to 850) (p<0.001), but there were no differences between the groups regarding any complications or mortality. There were no dislocations in either group. Hip function measured by the Harris hip score was significantly better in the total hip replacement group at both follow-up periods (p=0.011 and p<0.001, respectively). The health-related quality of life measure was in favour of the total hip replacement group but did not reach statistical significance (p=0.818 at four months and p=0.636 at 12 months). These results indicate that a total hip replacement provides better function than a bipolar hemiarthroplasty as soon as one year post-operatively, without increasing the complication rate. We recommend total hip replacement as the primary treatment for this group of patients.

Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly: A RANDOMISED, CONTROLLED TRIAL

The treatment algorithms for displaced fractures of the femoral neck need to be improved if we are to reduce the need for secondary surgery. We have studied 102 patients of mean age 80 years, with an acute displaced fracture of the femoral neck. They were randomly placed into two groups, treated either by internal fixation (IF) with two cannulated screws or total hip replacement (THR). None showed severe cognitive dysfunction, all were able to walk independently, and all lived in their own home. They were reviewed at four, 12 and 24 months after surgery. Outcome measurements included hip complications, revision surgery, hip function according to Charnley and the health-related quality of life (HRQoL) according to EuroQol (EQ-5D). The failure rate after 24 months was higher in the IF group than in the THR group with regard to hip complications (36% and 4%, respectively; p < 0.001), and the number of revision procedures (42% and 4%, p < 0.001). Hip function was significantly better in the THR group at all follow-up reviews regarding pain (p < 0.005), movement (p < 0.05 except at 4 months) and walking (p < 0.05). The reduction in HRQoL (EQ-5D index score) was also significantly lower in the THR group than in the IF group, comparing the pre-fracture situation with that at all follow-up reviews (p < 0.05). The results of our study strongly suggest that THR provides a better outcome than IF for elderly, relatively healthy, lucid patients with a displaced fracture of the femoral neck.

Comparison Of Internal Fixation With Total Hip Replacement For Displaced Femoral Neck Fractures: Randomized, Controlled Trial Performed At Four Years

BACKGROUND Recent randomized, controlled trials performed at two years postoperatively have shown that a primary total hip replacement is superior to internal fixation for the treatment of a displaced femoral neck fracture in a relatively healthy, mentally competent, elderly patient. The primary aim of the present study was to evaluate the outcomes at four years. METHODS One hundred and two patients (mean age, eighty years) who had an acute displaced femoral neck fracture were randomly allocated to be treated with total hip replacement or internal fixation. The inclusion criteria were an age of at least seventy years, absence of severe cognitive dysfunction, an independent living status, and the ability to walk independently. The main outcome measurements were hip complications, reoperations, hip function, and health-related quality of life. RESULTS The mortality rate was 25% in both groups. At the forty-eight-month follow-up evaluation, the rate of hip complications was 4% in the patients treated with total hip replacement and 42% in those treated with internal fixation (p < 0.001) and the reoperation rates were 4% and 47%, respectively (p < 0.001). The arthroplasty group had no additional hip complications or reoperations between the twenty-four and forty-eight-month follow-up visits. In the fixation group, the percentage of hip complications increased from 36% to 42% and the percentage of reoperations increased from 42% to 47% during the same period. The hip function was significantly better and the decline in health-related quality of life was less pronounced in the arthroplasty group than it was in the fixation group at the four, twelve, and twenty-four-month follow-up evaluations. Ninety-seven percent of the patients in the arthroplasty group and 57% of the patients in the fixation group who were available for follow-up at forty-eight months had no hip complications (p < 0.001). CONCLUSIONS Compared with internal fixation, primary total hip replacement provides a better outcome for mentally competent elderly patients with a displaced femoral neck fracture. The complication and reoperation rates were significantly lower and hip function and health-related quality of life were at least as good at four years after the surgery.

Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment

We studied 60 patients with an acute displaced fracture of the femoral neck and with a mean age of 84 years. They were randomly allocated to treatment by either internal fixation with cannulated screws or hemiarthroplasty using an uncemented Austin Moore prosthesis. All patients had severe cognitive impairment, but all were able to walk independently before the fracture. They were reviewed at four, 12 and 24 months after surgery. Outcome assessments included complications, revision surgery, the status of activities of daily living (ADL), hip function according to the Charnley score and the health-related quality of life (HRQOL) according to the Euroqol (EQ-5D) (proxy report). General complications and the rate of mortality at two years (42%) did not differ between the groups. The rate of hip complications was 30% in the internal fixation group and 23% in the hemiarthroplasty group; this was not significant. There was a trend towards an increased number of re-operated patients in the internal fixation group compared with the hemiarthroplasty group, 33% and 13%, respectively (p = 0.067), but the total number of surgical procedures which were required did not differ between the groups. Of the survivors at two years, 54% were totally dependent in ADL functions and 60% were bedridden or wheelchair-bound regardless of the surgical procedure. There was a trend towards decreased mobility in the hemiarthroplasty group (p = 0.066). All patients had a very low HRQOL even before the fracture. The EQ-5D(index) score was significantly worse in the hemiarthroplasty group compared with the internal fixation group at the final follow-up (p < 0.001). In our opinion, there is little to recommend hemiarthroplasty with an uncemented Austin Moore prosthesis compared with internal fixation, in patients with severe cognitive dysfunction.

The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures: A RANDOMISED, CONTROLLED TRIAL

We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D). The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D(index) score) was significant in both groups compared with that before the fracture (p < 0.005). Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures. The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method.

Nutritional status, insulin-like growth factor-1 and quality of life in elderly women with hip fractures

AIM To evaluate nutritional status and its relation to cognitive and physical function and quality of life in elderly female patients with hip fractures. METHODS Nutritional status was assessed in 42 women (80+/-7 years old) using the body mass index (BMI), triceps skin fold, arm muscle circumference and serum levels of insulin-like growth factor (IGF-1) and its binding protein (BP) IGFBP-1. Handgrip strength was measured. The Short Portable Mental Status Questionnaire was used to assess cognitive function and the Nottingham Health Profile to asses quality of life. RESULTS Low BMI (<== 20) and reduced IGF-1 and IGFBP-1 levels were detected in 50% of the patients. BMI correlated with IGF-1 (p<< 0.02) and with hand grip strength (P<< 0.001). Hand grip strength correlated with arm muscle circumference (P<< 0.05). Cognitive dysfunction was detected in 18% of the patients, and a correlation was found between cognitive function and BMI (P<< 0.01). The Nottingham Health Profile assessment indicated a lower quality of life in underweight patients as compared to others (P<< 0.05). CONCLUSIONS Half of the elderly women with hip fractures displayed signs of protein-energy malnutrition. Underweight was associated with reduced serum levels of IGF-1, muscle fatigue, cognitive dysfunction and a low quality of life rating, i.e. a cluster of factors which may unfavourably influence the postoperative course in a large proportion of hip fracture patients.

The Influence of Cognitive Function on Outcome After a Hip Fracture

BACKGROUND Previous studies have indicated that patients with a hip fracture who have impaired cognitive function have an increased risk for complications, poor long-term outcome, and an increased mortality rate. An assessment of cognitive function is often lacking in nursing and medical records. We investigated whether an assessment of cognitive function obtained with use of a validated instrument would be a useful patient management adjunct. METHODS We studied 213 patients with a hip fracture who had a mean age of eighty-four years and were entered in a prospective trial with a follow-up evaluation at four and twelve months. On admission to the orthopaedic ward, the patients were evaluated with use of the Short Portable Mental Status Questionnaire to assess their cognitive function. The outcome for patients with severe cognitive dysfunction, i.e., those with a score of <3 on the questionnaire, was compared with the outcome for patients with higher scores. The main outcome measurements were the Charnley hip score, activities of daily living status, health-related quality of life, and mortality. RESULTS A Short Portable Mental Status Questionnaire score of <3 and male gender were associated with an increased mortality rate during the first twelve months. Moreover, patients with a score of <3 had a significantly worse outcome with regard to the ability to walk and to perform the activities of daily living, with 36% of these patients confined to a wheelchair and almost 39% totally dependent with regard to daily living functions at the time of the final follow-up (p < 0.001). CONCLUSIONS The systematic use of the Short Portable Mental Status Questionnaire upon admission to the orthopaedic ward identifies patients with a hip fracture who have severe cognitive dysfunction and effectively predicts their outcome with regard to the ability to walk, ability to perform the activities of daily living, and mortality, and it can be recommended for use in the care of elderly patients with a hip fracture.

Prediction of Mortality in Elderly Patients with Hip Fractures: A Two-Year Prospective Study of 1,944 Patients

Background: Hip fracture patients are reported to have an increased mortality rate compared to the general population. In order to be able to reduce the morbidity and mortality after a hip fracture, our efforts to identify the patients at risk already upon admission to the hospital need to be increased. For such a risk assessment, robust, validated, and reproducible criteria are mandatory. Objective: To determine preoperative factors associated with mortality and to evaluate the combined use of the American Society of Anesthesiologists (ASA) and the Short Portable Mental Status Questionnaire (SPMSQ) to identify patients with an increased mortality rate and to create a predictive model to assess the mortality risk after hip fracture surgery. Methods: A total of 1,944 consecutive patients aged 66 years or older admitted for a hip fracture were included in a prospective cohort study with a 24-month follow-up. The patients were assessed with regard to gender, age, type of hip fracture, smoking habits, comorbidities, general physical health according to the ASA classification, and cognitive function according to the SPMSQ. A higher ASA score indicates an increasingly severe systemic disease and a lower SPMSQ score indicates an increasingly severe cognitive dysfunction. We used Cox proportional hazard models and classification trees to identify the factors associated with mortality. The predictive model was created based on factors that were significantly associated with death and all readily accessible upon admission. Results: The mortality rate during the acute hospitalization period was 4%, at 4 months 16%, and at 24 months 38%. The most prominent factors associated with mortality were high ASA scores, low SPMSQ scores, high age and male gender. The SPMSQ score provided additional information about the survival time, compared to when the ASA score was used alone. Conclusion: The combined use of the ASA classification for assessing physical health and the SPMSQ for assessing cognitive function effectively identified hip fracture patients with an increased mortality rate. We present a predictive model including age, gender, ASA, and SPMSQ that can be used to assess the mortality risk after hip fracture surgery.

Primary total hip arthroplasty with a Burch-Schneider antiprotrusion cage and autologous bone grafting for acetabular fractures in elderly patients.

Objectives To investigate the clinical and functional outcome in an elderly population with acetabular fractures after low-energy trauma treated acutely with a total hip arthroplasty supported by a reinforcement ring (Burch-Schneider antiprotrusion cage) and autologous bone grafting of the acetabulum. Setting University hospital. Design Retrospective clinical study. Patients Ten patients (7 males) available for follow-up, with a mean age at the time of surgery of 73 years (range 57–87). The mean time to follow-up was 38 months (range 11–84). Intervention Primary total hip arthroplasty supported by a reinforcement ring (Burch-Schneider Antiprotrusion Cage) and autologous bone grafting of the acetabulum. Main Outcome Measurements Surgical data, complications, radiographic assessment, pain, walking ability, Harris Hip Score, activities of daily living, health-related quality of life according to EuroQol (EQ-5D). Results The mean operating time was 159 minutes (range 125–185). The mean intraoperative blood loss was 1100 mL (700–1600 mL). The reinforcement ring was stable and there were no signs of loosening of the acetabular component or stem in any of the patients. The bone graft was completely incorporated in all cases. Four patients presented slight (Brooker I-II) heterotopic bone formation. All patients were still independent walkers at follow-up but with a slightly increased need for walking aids. The mean Harris Hip Score was 85 (range 69–99). The mean EQ-5Dindex score was 0.62. Conclusion Primary total hip replacement with a reinforcement ring and bone grafting of the socket seems to be a promising treatment alternative in displaced acetabular fractures in elderly patients with osteoporotic bone, except in those with an increased risk of dislocation.

Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly

The treatment algorithms for displaced fractures of the femoral neck need to be improved if we are to reduce the need for secondary surgery. We have studied 102 patients of mean age 80 years, with an acute displaced fracture of the femoral neck. They were randomly placed into two groups, treated either by internal fixation (IF) with two cannulated screws or total hip replacement (THR). None showed severe cognitive dysfunction, all were able to walk independently, and all lived in their own home. They were reviewed at four, 12 and 24 months after surgery. Outcome measurements included hip complications, revision surgery, hip function according to Charnley and the health-related quality of life (HRQoL) according to EuroQol (EQ-5D). The failure rate after 24 months was higher in the IF group than in the THR group with regard to hip complications (36% and 4%, respectively; p < 0.001), and the number of revision procedures (42% and 4%, p < 0.001). Hip function was significantly better in the THR group at all follow-up reviews regarding pain (p < 0.005), movement (p < 0.05 except at 4 months) and walking (p < 0.05). The reduction in HRQoL (EQ-5D index score) was also significantly lower in the THR group than in the IF group, comparing the pre-fracture situation with that at all follow-up reviews (p < 0.05). The results of our study strongly suggest that THR provides a better outcome than IF for elderly, relatively healthy, lucid patients with a displaced fracture of the femoral neck.