Postoperative periprosthetic fractures in patients with an Exeter stem due to a femoral neck fracture: cumulative incidence and surgical outcome.

PURPOSE: The purpose of this study is to report on the cumulative incidence and the outcome of surgically-treated postoperative PPFs in patients with femoral neck fractures treated with a THA or HA using an Exeter stem. METHODS: A consecutive series of patients operated during 1998-2010 due to a non-pathological femoral neck fracture using an Exeter stem were included in this cohort study. Patients were followed until 2012, or death, in order to obtain information about reoperations due to postoperative PPFs, and subsequent re-operations after surgery due to PPFs. In addition to local audit data the Swedish National Board of Health and Welfare's registry was used to identify patients who had been re-operated upon elsewhere in Sweden. RESULTS: A total of 2,757 patients (median age 82 years, 2,019 females) were identified and included in the study. Of these patients, 63 (2.3%) sustained a postoperative PPF that was treated surgically. The majority of the Vancouver B1 (n = 21/23) and C (n = 14/14) fractures were treated using open reduction and internal fixation (ORIF), whereas most of the B2 (n = 16/25) fractures and the only B3 fracture were treated with stem revision. Three (4.8%) patients were subsequently re-operated upon due to fracture-related complications, all B2 fractures, and were treated with ORIF (n = 2) or stem revision (n = 1). CONCLUSION: The cumulative incidence of surgically treated PPFs was considerable among patients with Exeter stems operated due to a femoral neck fracture. The re-operation rate due to fracture-related complications was highest among patients with B2 fractures.

Unipolar hemiarthroplasty versus bipolar hemiarthroplasty in patients with displaced femoral neck fractures: a four-year follow-up of a randomised controlled trial.

PURPOSE: The treatment of choice for a displaced femoral neck fracture in the most elderly patients is a cemented hemiarthroplasty (HA). The optimal design, unipolar or bipolar head, remains unclear. The possible advantages of a bipolar HA are a better range of motion and less acetabular wear. The aim of this study was to evaluate hip function, health related quality of life (HRQoL), surgical outcome and acetabular erosion in a medium-term follow-up. METHODS: One hundred and twenty patients aged 80 or more with a displaced fracture of the femoral neck (Garden III and IV) were randomised to treatment with a cemented Exeter HA using a unipolar or a bipolar head. All patients were able to walk independently, with or without aids, before surgery. Follow-ups were performed at four, 12, 24 and 48 months postoperatively. Assessments included HRQoL (EQ-5D index score), hip function (Harris hip score [HHS]) and radiological acetabular erosion. RESULTS: The mean EQ-5D index score was generally higher among the patients with bipolar hemiarthroplasties at the follow-ups with a significant difference at 48 months: unipolar HAs 0.59 and bipolar HAs 0.70 (p = 0.04). There was an increased rate of acetabular erosion among the patients with unipolar hemiarthroplasties at the early follow-ups with a significant difference at 12 months (unipolar HAs 20% and bipolar HAs 5%, p = 0.03). At the later follow-ups the incidence of acetabular erosion accelerated in the bipolar group, and there were no significant differences between the groups at the 24- and 48-month follow-ups. There was no difference in HHS or reoperation rate between the groups at any of the follow-ups. CONCLUSION: The bipolar HAs seem to result in better HRQoL beyond the first two years after surgery compared to unipolar HAs. Bipolar HAs displayed a later onset of acetabular erosion compared to unipolar HAs.

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.