132 Injury,11,132-135
Printedin GreatBritain
Treatment of subcapital femoral fractures by primary total hip replacement Roger L. Coates Nuffield Orthopaedic Centre, Oxford
Paul Armour Christchurch H o s p i t a l Christchurch, N e w Zealand
Summary Primary total hip replacement for displaced subcapital fractures may be performed with an acceptable mortality. The majority of a series of patients who were reviewed after operation experienced few symptoms and 87 per cent were able to walk independently. These results compared favourably with other forms of management, and deterioration was seldom observed. INTRODUCTION IT has long been recognized that patients with subcapital fractures treated by prolonged immobilization have a significant mortality and this was again confirmed by Riska (1971a). Current methods of management aim at early restoration of function and mobility, either by internal fixation after reduction of the fracture or by primary prosthetic replacement of the femoral head. Treatment by reduction and internal fixation of the more displaced subcapital fractures has been reported as unsatisfactory in 37 per cent of patients owing to non-union or the development of avascular necrosis (Barnes et al., 1976). In displaced fractures both these complications can therefore be anticipated by primary prosthetic replacement. Long term follow-up of patients treated by primary hemi-arthroplasty for displaced subcapital fractures, however, demonstrates that disability may occur in as many as one-third of individuals so treated (Burwell, 1967; Riska, 1971b; Bracey, 1977), principally as a result of
TableI. Distribution of patients Age" (yr)
No. of patients
%
5 19 37 19 5 85
6"5 22 43 22 6"5 1O0
-60 60-69 70-79 80-89 90+ Total "Average age 76 years.
acetabular erosion (Johnston and Crothers, 1975; d'Arcy and Devas 1976). In order to restore function and relieve pain, total hip replacement has then been the operation of choice and can therefore be considered as an initial management of displaced subcapital fractures. PATIENTS AND METHODS Eighty-five patients with 86 Garden's grade 3 or 4 (Garden, 196]) subcapita] fractures were treated by primary total hip replacement between 1 January 1 9 7 4 and 31 December ]9?6. There were 14 men and 7] women whose average age on admission was 76 years (Table I). In five of the patients the fractures were caused by metastatic neoplastic disease and in a sixth by gross osteoporosis from massive corticosteroid therapy.
Coates and Armour: Femoral Fractures
Apart from those patients with fractures resulting from metastatic disease, total hip replacement was reserved for patients over 60 years of age with significantly displaced subcapital fractures of Garden's grade 3 and 4. All patients were independently mobile before admission, although some used a stick. Total hip replacement was performed where possible within the first two days following admission. Immediately before operation most patients received prophylactic antibiotics which were continued for seven to ten days after operation. In 84 cases the anterolateral approach to the hip joint without osteotomy of the greater trochanter was used and in the remainder the posterior approach was used. The Charnley prosthesis was used in 29 patients and the Mtiller prosthesis in 56 patients. The operations were carried" out in ordinary operating theatres. No particular measures were used to avoid thromboembolic disease. The patients were all assessed, either by a telephone interview (15 per cent) or by post with a written questionnaire (85 per cent), six months following operation on the last patient to be included in this review. In their postoperative management many patients were seen and examined periodically, but information recorded at these times was not included in this review, nor were any patients recalled for examination for this review. The degree of any pain experienced by the patient was rated as mild if it was intermittent and did not require analgesics. It was considered severe if it was continuous and/or required analgesics and/or limited mobility. Mobility and independence were also assessed. If the assistance of another person was required to walk or if there was an increase in the number or complexity of walking aids required, it was considered that the mobility and independence were impaired. The case records were examined and the presence of bacteriologically-proven wound infections, prosthetic dislocations and the mortality.at one month were recorded.
RESULTS Follow-up information was available on 54 patients; 6 patients could not be traced and 25 patients had died (Table II). The interval between operation and assessment averaged 17 months (range 6-32 months). Mortality At follow-up 25 patients (29 per cent) were
133
Table II. Results at follow-up Fractures
Pathological (6) Non-pathological (80)
Outcome
1 patient living 5 patients dead 53 patients living 20 patients dead 6 patients fate unknown
%
1 6 62 24 7
known to have died, 5 (7 per cent) within the first month. Two of these patients died of ischaemic heart disease, one patient diedfrom a clinically diagnosed pulmonary embolus, one patient from septicaemia complicating a wound infection and the other patient died from associated cancer. Only one patient with a fracture caused by cancer was alive at follow-up. No significant age difference was observed between the living and dead group of patients.
Complications Dislocation of the prosthetic components occurred in 7 patients (8 per cent), all but one before discharge from hospital. Of the 29 Charnley prostheses inserted, 5 dislocated; of the 57 Mtiller prostheses inserted, 2 dislocated. The difference in the dislocation rate between the two types of prostheses is not statistically significant (P > 0"05) and dislocation did not affect the mortality. Technical errors contributed to the dislocations. I nfection Bacteriologically-proven infection occurred in 6 patients (7 per cent) and in one patient the infection was directly responsible for her death. In one of the surviving patients with a persistently infected total hip replacement Girdlestone's pseudarthrosis was performed. Infection occurred in 2 of the surviving patients (4 per cent) and in 4 of the patients who died (16 per cent). This difference is not statistically significant (P > 0"05). Rehabilitation The evaluation of mobility and the assessment of pain was possible in 54 patients. Thirty-three patients (61 per cent) were pain-free, 15 patients (28 per cent) experienced mild pain and 6
134
Injury: the British Journal of Accident Surgery Vol. 11/No.2
Table II1. Comparative review of complications and results following hemi-arthroplasty
Average age
Mortality
Infection rate
Satisfactory on review
(yr)
(%)
(%)
(%)
12"9 at 1 mth 13'7 at 1 mth 6'5 at 6 wk 41 '0 at 6 mth 22"4 at 1 mth 10"9 at 1 mth 9 " 8 a t 1 mth 9'0 at 6 w k 16"0 at 1 mth
4"7 3"9 6-5 8'5 4"0 1'8 4"9 -9"0
81"1 41"3 -39-0 38'0 64"5 61"5 77"0 63-0
7 ' O a t 1 mth
7"1
87"0
Author
Date
No. of patients
d'Arcy Burwell Chan Hunter Lunt .Polyzoides Riska Tillberg Wrighton Coates and Armour
1976 1967 1975 1969 1971 1971 1971 1976 1971
361 127 243 94 98 110 112 163 153
81"3 73'8 76-9 79"0 -73"0 77-4 78"0 --
1979
85
76
patients (I1 per cent) had severe pain which limited function and for which they required analgesics. The mobility of 47 patients (87 per cent) was unchanged, but 7 (13 per cent) experienced a major decline and were unable to walk without the support of another person or a frame. Twenty-eight patients (52 per cent) walked with the aid of a stick or elbow crutches and 19 patients (35 per cent) were walking without aids. DISCUSSION
Long term follow-up of patients with displaced subcapital fractures treated by primary hemiarthroplasty has shown that as many as onethird has symptoms attributable to acetabular erosion and pelvic migration. With uncemented prostheses distal femoral migration also occurs, so adding to disability (Wrighton and Woodyard, 1971). Salvage of these painful hips by total replacement may be difficult and there is an increased risk of infection when total replacement has been preceded by previous operations (Fitzgerald et al., 1977). Although accurate reduction and secure internal fixation may achieve a satisfactory rate of union without avascular necrosis (Garden, 1961; Deyerle, 1973), most large series note that at least onethird of patients so treated have an unsatisfactory result (Barnes et al., 1976; Chapman et al., 1975). Salvage by total hip replacement may be necessary in these patients if they have persistent pain and disability. The mortality of 7 per cent at one month compares favourably with that recorded in other series in which hemi-arthroplasties were used primarily (Table III). The 7 per cent post-
operative infection rate does not differ much from that reported in most series in which hemiarthroplasties were used (Chart and Hoskinson, 1975; d'Arcy and Devas, 1976), but is higher than experienced when elective total hip replacement is performed under optimal conditions (Charnley and Eftekhar, 1969). The dislocation rate is high compared to previously published figures (Eftekhar, 1976), but the introduction of the long posterior wall Charnley acetabular component and improvement in operative technique may be expected to lower the incidence of dislocation. As pre-existing hip disease with stiffness was not present in any patient, the immediate postoperative range of movement was large and this may have contributed to the dislocations. The role of total hip replacement in the primary treatment of displaced fractures of the femoral neck requires further evaluation, but the results suggest that in selected patients their interests may best be served by primary total replacement.
REFERENCES
d'Arcy J. C. and Devas M. (1976) Treatment of fractures of the femoral neck by replacement with Thompson prosthesis. J. Bone Joint Surg. 58B, 279. Barnes R., Brown J. T., Garden R. S. et al. (1976) Subcapital fractures ofthe femur. J. Bone Joint Surg. 58B, 2.
Bracey D. J. (1977) A comparison of internal fixation and prosthetic replacement in the treatment of displaced subcapital fractures. Injury 9, 1. Burwell H. N. (1967) Replacement of the femoral head
Coates and Armour: Femoral Fractures
by prosthesis in subcapital fractures. Br. J. Surg. 54, 741. Chan R. N. W. and Hoskinson J. (1975) Thompson prosthesis for fractured neck of femur. J. Bone Joint Surg. 57B, 437. Chapman M. W., Stehr J. H., Eberle C. F. et al. (1975) Treatment of intracapsular hip fractures by the Deyerle method. J, Bone Joint Surg. 57A, 735. Charnley J. and Eftekhar N. S. (1969) Postoperative infection in total prosthetic replacement of the hip joint with special reference to the bacterial content of the air of the operating room. Br. J. Surg. 56, 641. Deyerle W. M. (1973) Present concepts in fixation of fractures of the neck of the femur. Instructional course lecture 96. Annual Meeting of the American Academy of Orthopaedic Surgeons, Las Vegas, Nevada. Eftekhar N. S. (1976) Dislocation and instability complicating low friction arthroplasty of the hip joint. Clin. Orthop. 121,120. Fitzgerald R. H., Nolan D. R., llstrup D. M. et al. (1977) Deep wound sepsis following total hip arthroplasty. J. Bone Joint Surg. 59A, 847. Garden R. S. (1961) Low angle fixation in fractures of the femoral neck. J. Bone Joint Sztrg. 43B, 647.
135
Hunter G. A. (1969) A comparison of the use of internal fixation and prosthetic replacement for fresh fractures of the neck of the femur. Br. J. Surg. 56,229. Johnston J. T. H. and Crothers O. (1975) Nailing versus prosthesis for femoral neck fractures. J. Bone Joint Surg. 57A, 686. Lunt H. R. W. (1971) The role of prosthetic replacement of the head of the femur as primary treatment for subcapital fractures. Injury 3, 107. Polyzoides A. J. (1971) Prosthetic replacement after femoral neck fractures (short term and long term follow-up). Injury 2, 283. Riska E. B. (1971a) Factors influencing the primary mortality in hip fractures. Injur.v 2, 107. Riska E. B. (1971b) Prosthetic replacement in the treatment of subcapital fractures of the femur. Acta Orthop. Scand. 42, 281. Tillberg B. (1976) Treatment of fractures of the femoral neck by primary arthroplasty. Acta Orthop. Scand. 47, 209. Wrighton J. D. and Woodyard J. E. (1971) Prosthetic replacement for subcapital fractures of the femur: a comparative study. Injury 2, 287.
Requests for reprints sho,M be addressed to: R. I. Coates, NuffJeldOrthopaedicCentre,Oxford.
Printedin GreatBritain
Treatment of subcapital femoral fractures by primary total hip replacement Roger L. Coates Nuffield Orthopaedic Centre, Oxford
Paul Armour Christchurch H o s p i t a l Christchurch, N e w Zealand
Summary Primary total hip replacement for displaced subcapital fractures may be performed with an acceptable mortality. The majority of a series of patients who were reviewed after operation experienced few symptoms and 87 per cent were able to walk independently. These results compared favourably with other forms of management, and deterioration was seldom observed. INTRODUCTION IT has long been recognized that patients with subcapital fractures treated by prolonged immobilization have a significant mortality and this was again confirmed by Riska (1971a). Current methods of management aim at early restoration of function and mobility, either by internal fixation after reduction of the fracture or by primary prosthetic replacement of the femoral head. Treatment by reduction and internal fixation of the more displaced subcapital fractures has been reported as unsatisfactory in 37 per cent of patients owing to non-union or the development of avascular necrosis (Barnes et al., 1976). In displaced fractures both these complications can therefore be anticipated by primary prosthetic replacement. Long term follow-up of patients treated by primary hemi-arthroplasty for displaced subcapital fractures, however, demonstrates that disability may occur in as many as one-third of individuals so treated (Burwell, 1967; Riska, 1971b; Bracey, 1977), principally as a result of
TableI. Distribution of patients Age" (yr)
No. of patients
%
5 19 37 19 5 85
6"5 22 43 22 6"5 1O0
-60 60-69 70-79 80-89 90+ Total "Average age 76 years.
acetabular erosion (Johnston and Crothers, 1975; d'Arcy and Devas 1976). In order to restore function and relieve pain, total hip replacement has then been the operation of choice and can therefore be considered as an initial management of displaced subcapital fractures. PATIENTS AND METHODS Eighty-five patients with 86 Garden's grade 3 or 4 (Garden, 196]) subcapita] fractures were treated by primary total hip replacement between 1 January 1 9 7 4 and 31 December ]9?6. There were 14 men and 7] women whose average age on admission was 76 years (Table I). In five of the patients the fractures were caused by metastatic neoplastic disease and in a sixth by gross osteoporosis from massive corticosteroid therapy.
Coates and Armour: Femoral Fractures
Apart from those patients with fractures resulting from metastatic disease, total hip replacement was reserved for patients over 60 years of age with significantly displaced subcapital fractures of Garden's grade 3 and 4. All patients were independently mobile before admission, although some used a stick. Total hip replacement was performed where possible within the first two days following admission. Immediately before operation most patients received prophylactic antibiotics which were continued for seven to ten days after operation. In 84 cases the anterolateral approach to the hip joint without osteotomy of the greater trochanter was used and in the remainder the posterior approach was used. The Charnley prosthesis was used in 29 patients and the Mtiller prosthesis in 56 patients. The operations were carried" out in ordinary operating theatres. No particular measures were used to avoid thromboembolic disease. The patients were all assessed, either by a telephone interview (15 per cent) or by post with a written questionnaire (85 per cent), six months following operation on the last patient to be included in this review. In their postoperative management many patients were seen and examined periodically, but information recorded at these times was not included in this review, nor were any patients recalled for examination for this review. The degree of any pain experienced by the patient was rated as mild if it was intermittent and did not require analgesics. It was considered severe if it was continuous and/or required analgesics and/or limited mobility. Mobility and independence were also assessed. If the assistance of another person was required to walk or if there was an increase in the number or complexity of walking aids required, it was considered that the mobility and independence were impaired. The case records were examined and the presence of bacteriologically-proven wound infections, prosthetic dislocations and the mortality.at one month were recorded.
RESULTS Follow-up information was available on 54 patients; 6 patients could not be traced and 25 patients had died (Table II). The interval between operation and assessment averaged 17 months (range 6-32 months). Mortality At follow-up 25 patients (29 per cent) were
133
Table II. Results at follow-up Fractures
Pathological (6) Non-pathological (80)
Outcome
1 patient living 5 patients dead 53 patients living 20 patients dead 6 patients fate unknown
%
1 6 62 24 7
known to have died, 5 (7 per cent) within the first month. Two of these patients died of ischaemic heart disease, one patient diedfrom a clinically diagnosed pulmonary embolus, one patient from septicaemia complicating a wound infection and the other patient died from associated cancer. Only one patient with a fracture caused by cancer was alive at follow-up. No significant age difference was observed between the living and dead group of patients.
Complications Dislocation of the prosthetic components occurred in 7 patients (8 per cent), all but one before discharge from hospital. Of the 29 Charnley prostheses inserted, 5 dislocated; of the 57 Mtiller prostheses inserted, 2 dislocated. The difference in the dislocation rate between the two types of prostheses is not statistically significant (P > 0"05) and dislocation did not affect the mortality. Technical errors contributed to the dislocations. I nfection Bacteriologically-proven infection occurred in 6 patients (7 per cent) and in one patient the infection was directly responsible for her death. In one of the surviving patients with a persistently infected total hip replacement Girdlestone's pseudarthrosis was performed. Infection occurred in 2 of the surviving patients (4 per cent) and in 4 of the patients who died (16 per cent). This difference is not statistically significant (P > 0"05). Rehabilitation The evaluation of mobility and the assessment of pain was possible in 54 patients. Thirty-three patients (61 per cent) were pain-free, 15 patients (28 per cent) experienced mild pain and 6
134
Injury: the British Journal of Accident Surgery Vol. 11/No.2
Table II1. Comparative review of complications and results following hemi-arthroplasty
Average age
Mortality
Infection rate
Satisfactory on review
(yr)
(%)
(%)
(%)
12"9 at 1 mth 13'7 at 1 mth 6'5 at 6 wk 41 '0 at 6 mth 22"4 at 1 mth 10"9 at 1 mth 9 " 8 a t 1 mth 9'0 at 6 w k 16"0 at 1 mth
4"7 3"9 6-5 8'5 4"0 1'8 4"9 -9"0
81"1 41"3 -39-0 38'0 64"5 61"5 77"0 63-0
7 ' O a t 1 mth
7"1
87"0
Author
Date
No. of patients
d'Arcy Burwell Chan Hunter Lunt .Polyzoides Riska Tillberg Wrighton Coates and Armour
1976 1967 1975 1969 1971 1971 1971 1976 1971
361 127 243 94 98 110 112 163 153
81"3 73'8 76-9 79"0 -73"0 77-4 78"0 --
1979
85
76
patients (I1 per cent) had severe pain which limited function and for which they required analgesics. The mobility of 47 patients (87 per cent) was unchanged, but 7 (13 per cent) experienced a major decline and were unable to walk without the support of another person or a frame. Twenty-eight patients (52 per cent) walked with the aid of a stick or elbow crutches and 19 patients (35 per cent) were walking without aids. DISCUSSION
Long term follow-up of patients with displaced subcapital fractures treated by primary hemiarthroplasty has shown that as many as onethird has symptoms attributable to acetabular erosion and pelvic migration. With uncemented prostheses distal femoral migration also occurs, so adding to disability (Wrighton and Woodyard, 1971). Salvage of these painful hips by total replacement may be difficult and there is an increased risk of infection when total replacement has been preceded by previous operations (Fitzgerald et al., 1977). Although accurate reduction and secure internal fixation may achieve a satisfactory rate of union without avascular necrosis (Garden, 1961; Deyerle, 1973), most large series note that at least onethird of patients so treated have an unsatisfactory result (Barnes et al., 1976; Chapman et al., 1975). Salvage by total hip replacement may be necessary in these patients if they have persistent pain and disability. The mortality of 7 per cent at one month compares favourably with that recorded in other series in which hemi-arthroplasties were used primarily (Table III). The 7 per cent post-
operative infection rate does not differ much from that reported in most series in which hemiarthroplasties were used (Chart and Hoskinson, 1975; d'Arcy and Devas, 1976), but is higher than experienced when elective total hip replacement is performed under optimal conditions (Charnley and Eftekhar, 1969). The dislocation rate is high compared to previously published figures (Eftekhar, 1976), but the introduction of the long posterior wall Charnley acetabular component and improvement in operative technique may be expected to lower the incidence of dislocation. As pre-existing hip disease with stiffness was not present in any patient, the immediate postoperative range of movement was large and this may have contributed to the dislocations. The role of total hip replacement in the primary treatment of displaced fractures of the femoral neck requires further evaluation, but the results suggest that in selected patients their interests may best be served by primary total replacement.
REFERENCES
d'Arcy J. C. and Devas M. (1976) Treatment of fractures of the femoral neck by replacement with Thompson prosthesis. J. Bone Joint Surg. 58B, 279. Barnes R., Brown J. T., Garden R. S. et al. (1976) Subcapital fractures ofthe femur. J. Bone Joint Surg. 58B, 2.
Bracey D. J. (1977) A comparison of internal fixation and prosthetic replacement in the treatment of displaced subcapital fractures. Injury 9, 1. Burwell H. N. (1967) Replacement of the femoral head
Coates and Armour: Femoral Fractures
by prosthesis in subcapital fractures. Br. J. Surg. 54, 741. Chan R. N. W. and Hoskinson J. (1975) Thompson prosthesis for fractured neck of femur. J. Bone Joint Surg. 57B, 437. Chapman M. W., Stehr J. H., Eberle C. F. et al. (1975) Treatment of intracapsular hip fractures by the Deyerle method. J, Bone Joint Surg. 57A, 735. Charnley J. and Eftekhar N. S. (1969) Postoperative infection in total prosthetic replacement of the hip joint with special reference to the bacterial content of the air of the operating room. Br. J. Surg. 56, 641. Deyerle W. M. (1973) Present concepts in fixation of fractures of the neck of the femur. Instructional course lecture 96. Annual Meeting of the American Academy of Orthopaedic Surgeons, Las Vegas, Nevada. Eftekhar N. S. (1976) Dislocation and instability complicating low friction arthroplasty of the hip joint. Clin. Orthop. 121,120. Fitzgerald R. H., Nolan D. R., llstrup D. M. et al. (1977) Deep wound sepsis following total hip arthroplasty. J. Bone Joint Surg. 59A, 847. Garden R. S. (1961) Low angle fixation in fractures of the femoral neck. J. Bone Joint Sztrg. 43B, 647.
135
Hunter G. A. (1969) A comparison of the use of internal fixation and prosthetic replacement for fresh fractures of the neck of the femur. Br. J. Surg. 56,229. Johnston J. T. H. and Crothers O. (1975) Nailing versus prosthesis for femoral neck fractures. J. Bone Joint Surg. 57A, 686. Lunt H. R. W. (1971) The role of prosthetic replacement of the head of the femur as primary treatment for subcapital fractures. Injury 3, 107. Polyzoides A. J. (1971) Prosthetic replacement after femoral neck fractures (short term and long term follow-up). Injury 2, 283. Riska E. B. (1971a) Factors influencing the primary mortality in hip fractures. Injur.v 2, 107. Riska E. B. (1971b) Prosthetic replacement in the treatment of subcapital fractures of the femur. Acta Orthop. Scand. 42, 281. Tillberg B. (1976) Treatment of fractures of the femoral neck by primary arthroplasty. Acta Orthop. Scand. 47, 209. Wrighton J. D. and Woodyard J. E. (1971) Prosthetic replacement for subcapital fractures of the femur: a comparative study. Injury 2, 287.
Requests for reprints sho,M be addressed to: R. I. Coates, NuffJeldOrthopaedicCentre,Oxford.
