Intraoperative Dissociation and Migration of the Trial Bipolar Cup in Hip Hemiarthroplasty: A Rare Case.

Femoral neck fractures are an ever-increasing pathology, and with the elderly population on the rise, cases of cemented bipolar hemiarthroplasties are also on the rise. This is a rare case of intraoperative dissociation and migration of the trial components of bipolar hemiarthroplasty. Considering the current literature, all junior surgeons should be aware of this possible development during trial reduction. We present the case of an 82-year-old Caucasian woman suffering from a left femoral neck fracture due to a fall. She was treated surgically with a cemented bipolar hemiarthroplasty, but after trial reduction, the trial components dissociated and migrated inside the pelvis. The attempts at recovery through the current approach failed, and a new incision and approach were needed. A small ilioinguinal incision was performed, and the recovery of the trial cup was successful. The patient recovered with no considerable problems. As the reasons for this rare complication are largely unknown, the surgeon should be careful and take measures to prevent this scenario. Moreover, it is wise to weigh the pros and cons of retrieval through other approaches and choose the best course of action for the patient.

Trends in managing femoral neck fractures with arthroplasty in the ≥ 50 years age group.

Objective: To know about the trends in the management of neck of femur fractures with arthroplasty in patients ≥ 50 years. Methods: It is a retrospective cross-sectional study with data collection from Hospital Management Information System from 1st January 2020 to 31st July 2023. SPSS version 25 was used for data analysis. Mean & standard deviation was reported for quantitative variable & frequency and proportion were reported for qualitative variables. The cross- tabulations were performed to evaluate the association between the variables. Results: Total number of patients in this study was 305. Mean age was 67.80 ± 10.5 SD. Male to female ratio was 150:155. Co-morbidities were found in 126 patients. The surgical options used were Austin Moore prosthesis (64), Cemented Bipolar (36), Hybrid Total Hip Replacement (7), Non-cemented Total Hip Replacement (86), Cemented Total Hip Replacement (32), Uncemented Bipolar (71). Garden Type-2 fracture was noted in 33 patients, Type-3 in 170 patients and Type-4 in 87 patients. Cemented stem was used in 74 patients while 222 patients had non-cemented stem. Conclusion: One quarter of the patients had cemented stem implanted compared to three quarter of the patients who had non-cemented stem.

Does total hip arthroplasty in elderly patients with femoral neck fractures reduce complications?: A Japanese DPC study.

BACKGROUND: The global increase in femoral neck fractures due to aging and osteoporosis is a major clinical challenge. The debate on the optimal surgical intervention for femoral neck fractures remains unresolved. This large-scale study explores femoral neck fractures among the elderly, focusing on the comparative outcomes of Total Hip Arthroplasty (THA) versus Bipolar Hemiarthroplasty (BHA) in Japanese patients. METHODS: Using the Japanese National Administrative Diagnosis Procedure Combination (DPC) database, we studied cases of femoral neck fracture from April 2016 to March 2023, and after propensity score matching by age, sex, and comorbidities, we examined the association between THA, complications, and clinical outcomes, and the usefulness of THA for elderly patients with femoral neck fracture. RESULTS: One-to-one propensity score matching identified 7741 pairs of THA and BHA cases. There was no difference in length of stay between the THA and BHA groups. Significantly more blood transfusions were required in the THA group. There was no significant difference in mortality between the THA and BHA groups, but there was a reduced risk of pneumonia in the THA group, with a ratio of 0.547 (95% CI: 0.418-0.715). On the other hand, the THA group had a higher risk of pulmonary embolism, with a ratio of 1.607 (95% CI: 1.379-1.874). The THA group shows improved discharge rates directly home from the facility where the operation was performed, with a ratio of 1.798 (95% CI: 1.675-1.929). CONCLUSION: The findings of this research indicate that THA is more effective than BHA in enabling elderly Japanese patients with femoral neck fractures to be discharged directly home and in preventing pneumonia, despite concerns about pulmonary embolism. These findings suggest that THA may improve functional prognosis in elderly patients with femoral neck fractures, although there is a trade-off with an increased risk of pulmonary embolism.

A Case of a Failed Hemiarthroplasty of the Hip Treated by an Extended Trochanteric Osteotomy.

Hip bipolar hemiarthroplasty, a widely employed surgical intervention for managing hip fractures and degenerative hip diseases, can pose significant challenges when revisions become necessary due to complications such as implant loosening, instability, or breakage. This case report presents the intricate management of a 58-year-old male who presented with worsening left hip pain a decade after undergoing hip replacement surgery. Despite a thorough preoperative assessment ruling out infection, intraoperative complexities included the necessity for extended trochanteric osteotomy (ETO) to address a broken stem and associated metallosis. Successful revision surgery was meticulously executed, incorporating techniques for implant removal, femoral shaft augmentation, and postoperative rehabilitation. The ensuing discussion explores the multifaceted aspects of failed hemiarthroplasty, emphasizing the critical roles of surgical precision, judicious patient selection, and ongoing research endeavors aimed at refining surgical strategies to optimize patient outcomes. This case underscores the imperative of a multidisciplinary approach and the continued imperative for advancements in surgical methodologies for effectively managing revision hip arthroplasty cases, thus enhancing the quality of patient care in this intricate clinical domain.

Long-Term Outcomes of Cementless Bipolar Hemiarthroplasty in Young Patients With Osteonecrosis of the Femoral Head: The Impact of Implant Improvements and Preoperative Stage.

Introduction Advancements in bipolar hemiarthroplasty (BHA) implants in the mid-1990s contributed to favorable short-term outcomes for osteonecrosis of the femoral head (ONFH), particularly in cases without acetabular cartilage lesions. Nevertheless, long-term results remain unclear. In this study, we investigated (i) the impact of new-generation BHA implants and (ii) the effect of the preoperative stage on long-term outcomes in young patients with ONFH. Methods The records of consecutive patients with ONFH who underwent cementless BHA were retrospectively reviewed. Patients aged ≥60 years, with <10 years of follow-up, or who underwent acetabular reaming during surgery were excluded. Radiographical and clinical outcomes of patients who received first-generation BHAs and new-generation BHAs (developed after 1998) were compared by stratifying based on preoperative stage 2/3A and 3B/4, according to the Japanese Investigation Committee classification. Results Overall, 50 hips from 39 patients (mean age: 44.6 years; 64% male) with an average follow-up of 18.6 years were included. The frequency of advanced-stage patients was significantly higher in the first-generation BHA group than in the new-generation group. Regarding postoperative outcomes, the first-generation BHA group had higher acetabular erosion grades (p<0.001) and more femoral component loosening than those in the new-generation group (p<0.001). Revisions were performed in eight hips (seven in the first-generation and one in the new-generation BHA groups, p<0.001). In the new-generation BHA group, there were no significant differences in patient background between stage 2/3A and 3B/4 groups, and only one case in the stage 3B/4 group required revision. In the new-generation group, the grade of acetabular erosion was significantly higher for stage 3B/4 than stage 2/3A (p<0.001); other radiographical and clinical outcomes did not differ significantly between stages. Conclusion New-generation BHAs have significantly better implant survival rates for early-stage ONFH than those of first-generation BHAs. These findings indicate that BHA is an acceptable treatment option for early-stage ONFH in young patients.

Evaluating Pain Management from Peripheral Nerve Block for Geriatric Patients following Bipolar Hemiarthroplasty for Displaced Femoral-Neck Fracture.

INTRODUCTION: The purpose of this study was to evaluate peripheral nerve block (PNB) effectiveness in postoperative pain management and surgical outcomes for displaced femoral-neck fracture in geriatric patients (>70 years) who underwent bipolar hemiarthroplasty (BHA). METHODS: From January 2017 to December 2021, 231 geriatric patients with displaced femoral-neck fracture who consecutively underwent BHA were retrospectively reviewed. Patients were divided into two groups: the patient-controlled analgesia (PCA) group (n = 132) who received only intravenous (IV) PCA for postoperative pain management, and all others who received PNB with IV PCA (PNB+PCA) such as femoral nerve block or fascia iliaca compartment block after surgery (n = 99). Primary outcomes were postoperative visual analog scale (VAS) at rest and during activity at 6, 24, and 48 h postoperatively. Secondary outcomes were postoperative complications, changes in hemoglobin, length of hospital stay, and total morphine usage after surgery. RESULTS: Postoperative resting VAS at 6 h and 48 h was significantly lower in the PNB+PCA group compared with the PCA group (p = 0.075, p = 0.0318, respectively). However, there was no significant difference in either resting VAS at 24 h or active VAS. Complications of pneumonia and delirium until 1 month postoperative were significantly lower in the PNB + PCA group than the PCA group (p = 0.0022, p = 0.0055, respectively). CONCLUSION: PNB with IV PCA seems to have a beneficial effect on geriatric femoral-neck patients who underwent BHA with postoperative analgesia for reducing postoperative resting pain and complications, especially pneumonia and delirium.

Persistent Pain and Purulent Discharge: A Case of Infected Bipolar Hemiarthroplasty.

Prosthetic joint infection (PJI) remains a significant complication following joint arthroplasty, necessitating prompt recognition and intervention to optimize patient outcomes. This case report describes a 65-year-old male who presented with persistent pain, swelling, and purulent discharge from the right hip, three years post-bipolar hemiarthroplasty following a road traffic accident. Clinical examination revealed signs suggestive of PJI, prompting surgical intervention with total hip arthroplasty. Postoperatively, the patient experienced resolution of symptoms and satisfactory recovery. This case underscores the challenges associated with infected joint arthroplasty and highlights the importance of a multidisciplinary approach for effective management. Early diagnosis, appropriate surgical intervention, and comprehensive postoperative care are essential for minimizing morbidity associated with PJIs and optimizing patient outcomes.

Treatment of Failed Proximal Femoral Nail Anti-rotation Asia (PFNA2) in a Severely Osteoporotic Patient With a Revision Stem.

An intertrochanteric fracture is a prevalent and perilous kind of fracture that often affects older persons. A customized implant, proximal femoral nail anti-rotation Asia (PFNA2) is being used expressly in unstable intertrochanteric fractures in people with osteoporosis. In this case report, we examined a female osteoporosis patient, age 74, who underwent a failed PFNA2 procedure. Subsequently, the patient had bipolar hemiarthroplasty as a treatment. To prevent mechanical failure, it is crucial to strive for a high level of reduction quality and precise alignment of the central blade throughout hip X-ray procedures. Improved surgical proficiency and skill are crucial for managing patients with severe osteoporosis and prolonged weight-bearing requirements, hence reducing the occurrence of postoperative problems. Depending on the cause of the failure and the individual circumstances of the patient when internal fixation fails, it is recommended to either replace the joint with a prosthetic or reapply fixation. These interventions may facilitate the production of beneficial healing outcomes.

Clinical Outcomes of Bipolar Hemiarthroplasty with a Conjoined Tendon-Preserving Posterior Approach for Femoral Neck Fractures.

Background and Objectives: The conventional posterior approach in the lateral decubitus position is widely used for femoral neck fractures in femoral hemiarthroplasty. Postoperative dislocation is the major problem with this approach. The conjoined tendon-preserving posterior (CPP) approach is a less invasive surgical approach than the conventional posterior approach to the hip, maintains posterior stability, and preserves short external rotators and joint capsules. However, the mention was required to avoid muscle damage and whether muscle damage affects postoperative dislocation or not. The current study aimed to evaluate the clinical results of the CPP approach in hemiarthroplasty for femoral neck fractures and identify muscle damage risk factors. Materials and Methods: This study was a retrospective cohort study and included 170 hips in 168 patients. The mean age at the operation was 81.2 years. The preservation rate of the internal obturator muscle and gemellus inferior muscle and factors related to intraoperative short rotator muscle injury were investigated retrospectively. The postoperative complications and the relation between muscle damage and postoperative dislocation were investigated. Results: In the four hips (2.3%) with the obturator internus muscle damage, thirty-eight hips (22.4%) with gemellus inferior muscle damage were detected; in the muscle-damaged cases, the high body mass index (BMI) was significantly higher. The complication occurred in four hips (2.3%), including postoperative posterior dislocation in one hip without muscle damage (0.6%). Postoperative infection occurred in one hip (0.6%), and peroneal or sciatic nerve paralysis was suspected in two hips (1.1%). Conclusions: Compared to the conventional posterior approach in previous reports, the CPP approach reduces postoperative dislocation. A higher BMI is a risk factor for muscle damage, and the gemellus inferior muscle damage has no effect on postoperative dislocation. The CPP approach for BHA appeared to be an effective treatment method.

Cemented bipolar hemiarthroplasty for unstable intertrochanteric fracture in elderly patients over 70 years: Boon or bane?

INTRODUCTION: The surgical management of intertrochanter femur fracture in elderly patient is still under debate. Various implants can be utilised but prosthetic replacement is gaining popularity. This study was performed to evaluate the functional and clinical outcomes of cemented bipolar arthroplasty as a primary treatment for unstable intertrochanteric fracture in elderly patients (> 70 years). MATERIALS AND METHODS: Thirty-seven patients with unstable intertrochanteric fracture in elderly patient (> 70 years) who underwent cemented bipolar hemiarthroplasty. Intra-operative and post-operative complications were noted; functional outcomes were assessed using Harris hip score (HHS). All patients were followed up for a minimum of 12 months. RESULTS: Overall 90% of patients has some minor or major intra or post-operative complication. One year mortality rate was 16% (6/37). Cardiopulmonary events were the most common life threatening incident. Mean fall in Haemoglobin was 1.6 gm/dL. The average time for full weight bearing mobilisation with the help of walker was 2.8 ± 1.2 days (1-8 days). The average duration of surgery was 58 ± 6 min (44-96 min) with an average blood loss of 126 ± 24 mL (90-380 mL). HHS at the end of 12 months was 77. CONCLUSIONS: The use of bipolar hemiarthroplasty in senile patient with unstable hemiarthroplasty gives an advantage of early weight bearing. However, it is associated with risk of significant intra or post-operative morbidity due to intra-operative trauma, surgical time and blood loss during the surgery. Although hemiarthroplasty can be a single-time solution to the complexities of intertrochanter fracture in elderly patients but should be performed in selected patients only.

Retrospective Analysis of Ultrasound-Guided Serial-Injection Triple Nerve Block Efficacy in Cementless Bipolar Hemiarthroplasty for Femoral Neck Fracture.

BACKGROUND: Femoral neck fractures are effectively treated with bipolar hemiarthroplasty (BHA) surgery, yet postoperative pain management remains a challenge. This study explores the efficacy of multimodal pain management in minimizing opioid use and enhancing recovery. METHODS: A retrospective analysis of 87 patients who underwent BHA between September 2016 and September 2020 was conducted. Patients were analyzed in two groups: Group I (n = 42), receiving serial-injection nerve blocks (SINBs) before and after surgery, and Group II (n = 41), with no SINB. Notably, all nerve blocks for Group I were performed after November 2017, following the implementation of this technique in our protocol. Pain and analgesic medication usage were assessed over 72 h post-surgery, along with hospitalization duration and perioperative complications. RESULTS: Group I patients exhibited significantly lower pain scores at 6, 12, 24, and 48 h post-surgery, alongside reduced incidences of postoperative nausea and vomiting (PONV) and delirium compared with Group II (p < 0.05). CONCLUSIONS: Utilizing sequential lower limb nerve blocks under ultrasound guidance in BHA surgeries effectively reduces early postoperative pain and associated adverse effects. This approach demonstrates potential benefits in pain management, leading to diminished narcotic usage and lower risks of PONV and delirium.

Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases.

OBJECTIVE: Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population. METHODS: A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves. RESULTS: Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039). CONCLUSION: Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Short-Term Outcomes of Uncemented Bipolar Hemiarthroplasty Using Stainless Steel Fully Hydroxyapatite-Coated Stem in Transcervical Fracture of the Femur.

Background: Bipolar hemiarthroplasty is the standard of care for transcervical fracture in the elderly. Stainless steel being cheaper is preferred over titanium in developing nations for implants and prostheses. This study was conducted for assessing the short-term outcomes of uncemented bipolar hemiarthroplasty done using hydroxyapatite-coated stainless steel prosthesis. Methods: Sixty-five patients, >60 year of age operated between 2018 and 2020 at tertiary care centre with stainless steel (316L) completely coated with hydroxyapatite bipolar hemiarthroplasty implants were retrospectively followed up. Radiological outcomes were assessed based on pedestal formation, stem position, radiological limb length discrepancy, sinkage of stem, spot welds and stress shielding. Clinical and functional outcomes were assessed based on mean Harris Hip score. Results: Mean Harris Hip score at baseline, 3-week follow-up, 6-week follow-up, 3-month follow-up and 1-year follow-up was 45.9 (SD 2.5), 63.2 (SD 6.5), 75.1 (SD 9.9), 83.9 (SD 9.8) and 87.1 (SD 9.9), respectively. Excellent, good, fair, poor results were seen in 32.31, 40, 18.46, 9.23 of the patients, respectively. Valgus, central and varus stem position was seen in 49.23, 40, 10.77 percent of the patients, respectively. Pedestal formation, radiological limb length discrepancy, sinkage, spot welds, stress shielding was seen in 6.15, 32.31, 3.07, 53.85, 40 percent of the patients, respectively. Conclusion: Short-term outcomes of this study provides evidence that using a more affordable fully hydroxyapatite-coated stainless steel prosthesis for uncemented bipolar hemiarthroplasty is an appropriate treatment option for the transcervical femur fracture.

Correlation between Inflammatory Systemic Biomarkers and Surgical Trauma in Elderly Patients with Hip Fractures.

The treatment for hip fractures consists of a wide variety of orthopedic implants ranging from prosthesis to intramedullary nails. The purpose of this study is to determine the correlation between blood-count-derived biomarkers such as the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the monocyte-to-lymphocyte ratio (MLR) and the systemic immune-inflammation index (SII) and the level of aggression sustained by elderly patients during these surgical procedures. A total of 129 patients aged over 70 and diagnosed with acute hip fractures who underwent surgical treatment between November 2021 and February 2023 were included in our observational retrospective cohort study. Two groups were formed depending on the anatomic location of the fracture for statistical comparison: group 1 with extracapsular fractures, who received a closed reduction internal fixation (CRIF) with a gamma nail (GN) as treatment, and group 2 with intracapsular fractures, who received a bipolar hemiarthroplasty (BHA) as treatment. The length of hospital stay (LHS), duration of surgery, preoperative days, pre- and postoperative red blood count (RBC) and hemoglobin (HGB) levels and postoperative NLR, PLR and SII were significantly different between the two groups (p < 0.05). Furthermore, the multivariate analysis indicated that the postoperative NLR (p = 0.029), PLR (p = 0.009), SII (p = 0.001) and duration of surgery (p < 0.0001) were independently related to the invasiveness of the procedures. The ROC curve analysis demonstrated that a postoperative SII > 1564.74 is a more reliable predictor of surgical trauma in terms of specificity (58.1%) and sensitivity (56.7%). Postoperative SII as a biomarker appears to be closely correlated with surgical trauma sustained by an older population with hip fractures.

Outcomes of Osteosynthesis Versus Hemiarthroplasty in Elderly Patients With Arbeitsgemeinschaft Fur Osteosynthesefragen-Orthopedic Trauma Association (AO-OTA) 31A2 Hip Fractures.

Background Intertrochanteric femur fractures account for more than half of the cases of hip fractures. These injuries are among the most common fractures in elderly individuals. Elderly patients suffer from other comorbidities such as diabetes mellitus or hypertension and are prone to low surgical tolerance with increased postoperative morbidity and mortality. Although the ideal choice of treatment for intertrochanteric femur fractures in the elderly remains debatable, the use of hemiarthroplasty in elderly patients provides an early mobilization and decreased postoperative morbidity. In this study, we aimed to assess the functional outcomes of bipolar hemiarthroplasty and osteosynthesis in Arbeitsgemeinschaft Fur Osteosynthesefragen-Orthopedic Trauma Association (AO-OTA) 31A2 hip fractures using the Harris Hip Score. Methodology A total of 60 elderly patients with AO/OTA 31A2 hip fractures were divided into two groups and treated with bipolar hemiarthroplasty and osteosynthesis using proximal femoral nail (PFN). Functional scores were assessed at two months, four months, and six months postoperatively using the Harris Hip Score. Results The mean age of the patients was 73.03 ± 7.57 years in the study. The majority of the patients were females, 38 (63.33%), with 18 females in the osteosynthesis group and 20 females in the hemiarthroplasty group. The average operative time was 144.93 ± 9.76 minutes in the hemiarthroplasty group and 86.07 ± 11 minutes in the osteosynthesis group. Blood loss was 263.67 ± 42.95 mL in the hemiarthroplasty group and 84.5 ± 15.05 mL in the osteosynthesis group. The average Harris Hip Score at two months, four months, and six months was 64.77 ± 4.33, 72.67 ± 3.54, and 79.72 ± 2.53, respectively, for the hemiarthroplasty group and 57.83 ± 2.83, 64.13 ± 3.89, and 72.83± 3.89, respectively, for the osteosynthesis group (p < 0.001 for all follow-up scores). One death was encountered in the hemiarthroplasty group. Other complications included superficial infection noted in two (6.67%) patients in both groups. There was one episode of hip dislocation in the hemiarthroplasty group. Conclusions The use of bipolar hemiarthroplasty in intertrochanteric femur fractures in elderly patients can prove to be better in comparison to osteosynthesis, but the use of osteosynthesis can be effective for patients who cannot tolerate major blood loss and longer surgical times.

Uncemented hemiarthroplasty may have a role in the treatment of unstable intertrochanteric fractures in elderly patient. A survival complications and functional outcomes analysis.

BACKGROUND: Fractures of the proximal femur account for 30% of all fractures requiring surgical treatment. The optimal treatment for per- and intertrochanteric fractures, particularly associated with trochanter instability, is still open to debate. For these reasons, some authors have recently supported the use of bipolar arthroplasty or hemiarthroplasty as a treatment capable of reducing the risk of complications and obtaining a better functional result. The purpose of this study was to evaluate the functional and clinical outcomes at minimum six months of follow up of bipolar hemiarthroplasty as the primary treatment for intertrochanteric fracture in older patients. A secondary objective was to study the risk of early and intraoperative complications. METHODS: From November 2020 to April 2022, 102 patients with lateral proximal femur fracture underwent surgical operation with implant of a long-stemmed bipolar hemiarthroplasty. 86 patients were enrolled. The average age at the time of fracture was 87.4 ± 4.6 (range 77-98) years. Of the patients, 76.7% were female. For all patients intra- and perioperative data were extracted. All available patients were evaluated at a minimum 6-months follow-up to investigate: Charlson Comorbidity Index, autonomy (Barthel Index), use of walking aids (Koval Grade), memory quality or dementia (Mental Score), subsequent hospitalizations for surgical operations relating to the operated hip. RESULTS: The average time from trauma to surgery was 1 ± 0.7 days. The surgical time was 78.9 ± 21.9 minutes. At least one cerclage was used in 73.3% of patients. 87.5% of patients were verticalized on the first day. The average hospitalization time was 5.5 ± 2.9 days. During follow-up 20 deaths occurred, with a distance to surgery of 6.6 ± 7.2 (range 0.3-22.7) months. Six months after surgery, out of 86 patients, 12 deaths occurred, corresponding to 13.95%. 12 months after surgery, out of 57 patients, 15 deaths occurred, corresponding to 26.31%. CONCLUSIONS: Long stemmed bipolar hemiarthroplasty following intertrochanteric fracture can be considered a safe procedure, especially in patients over 80 with associated comorbidities and short life expectancy.

Outcomes of Geriatric Hip Fractures in a Tertiary Referral Center in Malaysia During the COVID-19 Pandemic.

Introduction With the advancing age of the population, there are an increasing number of patients with geriatric hip fractures. Despite the advancement of surgical knowledge and improvement of implant designs to treat geriatric hip fractures, mortality and morbidity remain high among these frail patients. In conjunction with the COVID-19 pandemic, the collateral damage dealt to these patients remains unknown as scarce resources are funneled to deal with the pandemic. This study is geared to investigate the surgical outcomes of patients with geriatric hip fractures who were admitted during the initial phase of the COVID-19 pandemic. Methods This retrospective study was carried out at Hospital Kuala Lumpur, the largest public hospital in the capital of Malaysia, from March 1, 2020, to March 1, 2021. All patients of age 60 years and above were screened for suitability. Only patients who had undergone surgical intervention during the study period were included in this study. Patients' demographic data, mechanism of injury, waiting time for surgery, type of surgery, complications and ambulatory status were obtained from the medical records. Univariate analysis was performed to determine the factors associated with complications as well as the post-operative ambulatory status of the patients. Results A total of 52 patients were included in this study, with a median age of 72 years. The majority of the patients were Chinese (n=21, 40.4%). This was followed by Malay and Indian (n=14, 26.9% each) and other ethnicity (n=3, 5.8%). More than three-quarters of the patients had a trivial injury such as a fall due to a miss-step (n=16, 30.8%) and slip (n=16, 30.8%) and a fall due to dizziness (n=8, 15.4%). Only 12 patients (23.1%) sustained hip fractures due to trauma. The median time to surgery for these patients was 5 days (interquartile range: 4 days). Most of these patients underwent total hip replacement (n=30, 57.7%). This was followed by unipolar hemiarthroplasty (n=11, 21.2%), bipolar hemiarthroplasty (n=10, 19.2%) and internal fixation (n=1, 1.9%). Among these patients, six of them had documented complications. There were periprosthetic joint infection (n=2, 3.8%), dislocation (n=2, 3.8%), hematoma formation (n=1, 1.9%) and seroma (n=1, 1.9%). Six months after the surgery, most of the patients were able to ambulate, albeit some patients required walking aid such as walking stick and walking frame. Univariate analysis showed that all the factors were not associated with the complications and the post-operative ambulatory status of the patients. Conclusion  The incidence of geriatric hip fractures remains high during the COVID-19 pandemic despite the movement control order (MCO) being enforced in Malaysia. With prompt surgical intervention, most of the patients can regain ambulatory status, albeit with a walking aid.

Bipolar Hemiarthroplasty in Unstable Intertrochanteric Fractures with an Effective Wiring Technique.

Purpose: Bipolar hemiarthroplasty has recently been acknowledged as an effective option for treatment of unstable intertrochanteric fracture. Trochanteric fragment nonunion can cause postoperative weakness of the abductor muscle and dislocation; therefore, reduction and fixation of the fragment is essential. The purpose of this study was to perform an evaluation and analysis of the outcomes of bipolar hemiarthroplasty using a useful wiring technique for management of unstable intertrochanteric fractures. Materials and Methods: A total of 217 patients who underwent bipolar hemiarthroplasty using a cementless stem and a wiring technique for management of unstable intertrochanteric femoral fractures (AO/OTA classification 31-A2) at our hospital from January 2017 to December 2020 were included in this study. Evaluation of clinical outcomes was performed using the Harris hip score (HHS) and the ambulatory capacity reported by patients was classified according to Koval stage at six months postoperatively. Evaluation of radiologic outcomes for subsidence, breakage of wiring, and loosening was also performed using plain radiographs at six months postoperatively. Results: Among 217 patients, five patients died during the follow-up period as a result of problems unrelated to the operation. The mean HHS was 75±12 and the mean Koval category before the injury was 2.5±1.8. A broken wire was detected around the greater trochanter and lesser trochanter in 25 patients (11.5%). The mean distance of stem subsidence was 2.2±1.7 mm. Conclusion: Our wiring fixation technique can be regarded as an effective additional surgical option for fixation of trochanteric fracture fragments during performance of bipolar hemiarthroplasty.

Outcomes of Total Hip Replacement for Failed Hemiarthroplasty.

Aim: Our study aims to analyze the outcomes of conversion total hip replacement (THR) done for failed hemiarthroplasty. Patients and Methods: We retrospectively analyzed 104 consecutive patients who underwent conversion THR for failed hemiarthroplasty between January 2012 and December 2018. The patient's records were analyzed for demographic information, index surgery details, preoperative functional status, and perioperative complications. Patients were analyzed according to the various modes of failure of hemiarthroplasty. The radiographs were analyzed for any progressive osteolysis, cup migration and stem subsidence. All the patients were evaluated using the modified Harris hip score (HHS) for clinical outcome. Complications, revision or reoperation in the follow-up period was recorded. Results: A total of 73 patients were included in the study for final analysis after exclusion criteria. The average follow-up was 48.2 ± 29.6 months. There was a significant improvement in mean HHS from 38.5 ± 9.1 preoperatively to 80.9 ± 4.3 at the last follow-up (p < 0.05). The different modes of failure had no statistically significant difference in the postoperative Harris hip score (p = 0.393). None of the patients had progressive radiolucent lines more than 2 mm or significant subsidence in the final follow-up compared to the initial postoperative radiograph. There was one deep infection, one patient had grade 2 heterotopic ossification, intraoperative calcar fracture was fixed with cerclage wiring in 11 patients, and postoperative periprosthetic fracture in two patients was treated with plate osteosynthesis. There were no neurovascular complications or dislocation during the follow-up. Conclusion: Conversion THR for failed hemiarthroplasty is a challenging procedure and results in good functional outcome and provides reliable pain relief. Conversion THA for septic loosening by two stage revision have comparable postoperative outcomes like THA for aseptic loosening. Caution is required owing to high incidence of peri-prosthetic fracture during conversion THA. Dislocation rate is negligible even with smaller head provided the prosthesis is implanted in the proper orientation and adequate soft tissue balancing is achieved.

Chronic posterior dislocation of the right hip treated with bipolar hemiarthroplasty in resource limited environment- a case report.

INTRODUCTION AND IMPORTANCE: Chronic traumatic posterior dislocation of the hip is one of the uncommon conditions that surgeons in developing countries have to treat due to continued unvetted patronage of traditional bone setters by patients. It usually treatment challenges due to limitation in option available because resource constraints. CASE PRESENTATION: We present the case of 42-year-old male patient who presented to our hospital one and half years after sustaining road traffic accident. He had initial failed treatment with the traditional bone setters that left him with persistent right hip pain, limp, shortening and limitation of movement. He had initial heavy skeletal traction before an uneventful right bipolar hemiarthroplasty was done. His Harris hip score improved from 40.6 (preoperative) to 90.4 (postoperative). CLINICAL DISCUSSION: Chronic posterior dislocation is a rarity in developed countries but is gradually becoming a common occurrence in developing countries. While total hip replacement is advocated in developed countries this may not be readily available due to financial constraints, poor access to the hospital, and fewer Orthopaedic surgeons to population ratios. This makes bipolar hemiarthroplasty used in this a readily available option that yielded a comparatively good outcome. CONCLUSION: We propose that bipolar hemiarthroplasty is viable alternative to total Hip replacement in chronic posterior hip dislocation in resource limited environment where access to this procedure may not be easily available.