Proximally Coated Cementless Bipolar Hemiarthroplasty in Dorr Type C Bone

Transcription

1 Proximally Coated Cementless Bipolar Hemiarthroplasty in Dorr Type C Bone Peter M. Bonutti, MD; Alex D. Stroh, MD; Kimona Issa, MD; Steven F. Harwin, MD; Dipak V. Patel, MD; Michael A. Mont, MD abstract Full article available online at Healio.com/Orthopedics. Search: The current study was conducted to examine the clinical and radiographic outcomes of cementless bipolar arthroplasty in patients who had type C bone at the time of the procedure. A total of 87 patients (105 hips) who had type C femora and had undergone cementless bipolar hemiarthroplasty with a proximally coated cementless prosthesis for the treatment of displaced femoral neck fractures at a single institution were reviewed. Patients included 83 women and 4 men who had a mean age of 84 years (range, years) and were followed for a mean of 6 years (range, 2-11 years). Outcomes evaluated included aseptic implant survivorship, surgical complications, Harris Hip scores, and radiographic findings. At final follow-up, there were no revisions for aseptic implant loosening. The overall aseptic implant survivorship was 95%, with 5 patients undergoing revision surgery for aseptic reasons. Three revisions were because of periprosthetic fractures after falls, 1 revision was because of intractable groin pain, and 1 revision was because of recurrent dislocations. The surgical complication rate was 8.5%, which included 3 septic revisions, 2 avulsion fractures of the greater trochanter after falls, 2 superficial wound infections, 1 recurrent dislocation, and 1 wound hematoma. The mean Harris Hip score had improved to 80 points (range, points) at final follow-up. Despite generally poor bone quality and medical comorbidities, elderly patients with displaced femoral neck fractures achieved excellent clinical outcomes, with few perioperative complications, through the use of proximally coated cementless bipolar hemiarthroplasty. Figure: Preoperative hip radiograph of a patient who had Dorr type C bone. The authors are from the Bonutti Clinic (PMB), Effingham, Illinois; Department of Orthopaedic Surgery (ADS, KI) and the Center for Joint Preservation and Reconstruction (MAM), Sinai Hospital of Baltimore, Maryland; Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New York (SFH); and the Department of Orthopaedic Surgery (DVP), Seton Hall University, Saint Joseph Regional Medical Center, Paterson, New Jersey. Drs Stroh, Issa, and Patel have no relevant financial relationships to disclose. Dr Bonutti receives royalties from Stryker and Joint Active Systems, Inc; is on the speakers bureau of Stryker; is a paid consultant for Stryker and Biomet; and has stock or stock options in Joint Active Systems, Inc. Dr Harwin receives royalties from Stryker; is on the speakers bureau of Stryker and Convatec; is a paid consultant for Stryker and Convatec; and has stock or stock options in Stryker. Dr Mont receives royalties from Stryker; is a paid consultant for Johnson & Johnson, Sage Products, Salient Surgical Technologies, TissueGene, Stryker, OnGoing Care Solutions, Inc, and Wright Medical Technologies, Inc; and receives research support from the National Institutes of Health (NIAMS and NICHD), Sage Products, Stryker, TissueGene, and Wright Medical Technologies, Inc. Correspondence should be addressed to: Michael A. Mont, MD, Center for Joint Preservation and Reconstruction, Sinai Hospital of Baltimore, 2401 W Belvedere Ave, Baltimore, MD (mmont@ lifebridgehealth.org). Received: August 30, 2013; Accepted: September 26, 2013; Posted: April 15, doi: / APRIL 2014 Volume 37 Number 4 e345

2 Displaced fractures of the femoral neck are common morbid orthopedic injuries, especially in the elderly population. With approximately 300,000 hip fractures per year 1 and more than $3 billion spent annually on their management, 1,2 these injuries constitute an important medical issue. Furthermore, the incidence of osteoporosis or low bone mineral density is on the rise, as noted in a press release by the Surgeon General suggesting that 50% of Americans will be at risk for osteoporosis by As the US population continues to age and becomes increasingly at risk for poor bone quality, care must be taken to select the optimal treatment option to re-establish prefracture functionality while minimizing perioperative risk. The optimal arthroplasty treatment method for displaced femoral neck fractures in elderly patients has been a point of debate for decades, 4 and the decision has become more complicated as newer technologies and implants have been adopted. A common treatment algorithm for this injury suggests open reduction and internal fixation for younger patients and hemiarthroplasty vs total hip arthroplasty (THA) in older patients, depending on the condition of the acetabular cartilage. 5 The choice of cemented or cementless femoral components is less well established. Although some reports have suggested cemented fixation as the gold standard in patients who have poor bone quality, 6 cemented fixation has been associated with a higher 30-day mortality rate in the elderly compared with cementless fixation (4% vs 2%, respectively). 7 It has been suggested that patients who have tenuous cardiovascular status may be at particularly greater risk for adverse outcomes. 5 Many of the previous studies of cementless hemiarthroplasty in patients with poor bone stock have focused on older implants than those currently available, 8-10 whereas modern technologies for cementless fixation have allowed surgeons to use such implants with less quality bone in elective arthroplasty with favorable results. 11,12 With this controversy in mind, the authors evaluated the performance of a modern cementless implant in patients who had femoral neck fractures with Dorr type C bone, which is characterized by wide femoral canals, thin cortices, and poor bone quality. More specifically, this study evaluated (1) aseptic implant survivorship, (2) clinical outcomes measured by Harris Hip scores, (3) complication rates, (4) operation times, (5) estimated intraoperative blood loss, and (6) radiographic outcomes. Materials and Methods The database of all cementless hemiarthroplasties performed as primary treatment for isolated displaced femoral neck fracture by an experienced arthroplasty surgeon (P.M.B.) at a high-volume institution between January 1992 and December 2006 were reviewed. All available preoperative radiographs were analyzed by P.M.B. according to previously reported definitions 6 to identify patients who had Dorr type C bone at the time of the procedure (Figure 1). A total of 95 patients who had undergone 113 hemiarthroplasties and who met the inclusion criteria were identified. Eight patients (8 hips) died during the 30-day postoperative period and were excluded from the study. Additionally, 38 patients died of nonsurgical causes distant from the index procedure, but these patients were not excluded from this report and their last follow-up was used for statistical analysis of clinical outcomes. The final study population included 83 women and 4 men who had undergone 105 hemiarthroplasties. They had a mean age of 84 years (range, years) and were followed for a mean of 6 years (range, 2-11 years). The most common comorbidities included neurologic disorders (32%), osteoporosis (31%), and endocrine diseases (17%). Demographic features are summarized in Table 1. Prospectively collected data were assembled from both inpatient Figure 1: Preoperative hip radiograph of a patient who had Dorr type C bone. charts and clinic notes, including age at surgery, operative time, estimated blood loss, components used, operative approach, Harris Hip scores, and all available radiographs. Appropriate institutional review board approval was obtained for this study. The indications for surgery (isolated displaced fracture of the femoral neck in a medically stable patient) remained constant throughout the course of the study. In each case, a standard posterior approach was selected. All patients had received Secure-Fit (Stryker Orthopaedics, Mahwah, New Jersey) prostheses (Figure 2). Unless otherwise noted, all discussions of hemiarthroplasty in this report refer to bipolar components. The prosthesis was inserted in a cementless, press-fit, and fill fashion, and sized by preoperative planning as well as intraoperative testing of stability. On discharge, all patients were followed at approximately 6 weeks, 6 months, and yearly thereafter. At each postoperative visit, both clinical (pain level, Harris Hip score, functional range of motion) and radiographic outcomes were assessed. Patients were monitored for the e346 ORTHOPEDICS Healio.com/Orthopedics

3 development of complications, including superficial and deep infections, hematoma formation, dislocation, implant loosening, and hardware failure. Postoperative anteroposterior and lateral radiographs were obtained and evaluated by P.M.B. specifically for the presence of subsidence, radiolucencies, fracture, component malposition, and hardware failure. Data were recorded in an Excel spreadsheet (Microsoft Corp, Redmond, Washington), which was also used to calculate summary data statistics (eg, mean, range, standard deviation). Results At final follow-up, there were no revisions for implant loosening (100% survivorship). The overall aseptic implant survivorship was 95.5% (n=100 of 105), with 5 patients undergoing revision surgery for other aseptic reasons, 3 revisions for periprosthetic fractures after falls, 1 revision for intractable groin pain, and 1 revision for recurrent dislocation (Table 2). For the 3 revisions performed for periprosthetic fractures, the falls had occurred within 2 months after the index hemiarthroplasty procedure. These patients achieved Harris Hip scores of 74, 78, and 80 points at minimum follow-up of 24 months. Another patient underwent 1-stage aseptic revision for intractable groin pain that was refractory to nonoperative management 4 months postoperatively. This patient achieved a Harris Hip score of 76 points at 43 months of follow-up. Recurrent dislocation was noted in another patient who was treated with 1-stage revision 2 months postoperatively and achieved a Harris Hip score of 78 points at 49 months of followup. In addition, 2 other revisions were performed for deep periprosthetic infections. One of these infections, diagnosed 1 month postoperatively, was unsuccessfully treated with irrigation and debridement before a 1-stage revision was performed. The other 2 infections were diagnosed 2 months and 2 years postoperatively, and Characteristics Table 1 Patient Demographics All Patients Total no. of patients (hips) 87 (105) Men 4 (4) Women 83 (101) Mean age (range), y 84 (72-100) Mean time from injury to surgery (range), d 1.9 (0-26) Mean follow-up (range), y 6 (2-11) Surgical approach Posterior 100% Comorbidities Neurologic (Alzheimer s, dementia, CVA) 32 Osteoporosis (diagnosed) 31 Endocrine (DM, hypothyroid) 17 Cardiovascular (CHF, CABG, prosthetic valves) 15 Cancer 9 Respiratory (COPD, severe asthma) 8 Abbreviations: CABG, coronary artery bypass graft; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; DM, diabetes mellitus. because of patients low functional needs, component removal and Girdlestone procedures were performed. All of these patients had achieved Harris Hip scores of greater than 70 points at minimum followup of 24 months. There were no reported intraoperative complications or adverse events. Despite the poor bone stock of the group, there were no intraoperative femur fractures. Postoperative complications included multiple dislocations in a patient who was treated twice with closed reductions. These occurred approximately 1 and 3 weeks postoperatively, and the patient has remained free of complications since his last relocation and had achieved a Harris Hip score of 78 points at 29 months of follow-up. Two other patients, both with moderate cognitive impairment, sustained subsequent falls that led to avulsion fragments from the greater trochanter. With nonoperative treatment they achieved final Harris Hip scores of 79 and 74 points at follow-up of 36 and 42 months, respectively. Also, 2 superficial wound infections were treated adequately with oral antibiotics and a wound hematoma was treated with evacuation and irrigation and debridement. These patients had achieved Harris Hip scores of 80 points at 49 and 68 months of follow-up. The mean final Harris Hip scores had improved to 80 points (range, points) postoperatively, with a mean improvement of 64 points (range, points). All patients reported or were reported to have had the ability to ambulate either with or without a variety of assistive devices after surgical treatment. Intraoperative results showed that the procedure was generally well tolerated and expeditious. Mean estimated blood loss was 176 ml (range, ml), and mean operative time was 47 minutes (range, minutes). APRIL 2014 Volume 37 Number 4 e347

4 Table 2 Outcomes for Cementless Hemiarthroplasty in Type C Bone Figure 2: Postoperative hip radiograph of a patient who had Dorr type C bone and underwent primary total hip arthroplasty. Except for patients who had undergone revision for any reason, radiographic evaluation of the remaining patients showed that all components were well fixed and in good alignment, with no evidence of symptomatic progressive radiolucencies or implant loosening. Discussion The use of proximally coated stems for femoral fixation was historically discouraged in patients with osteoporosis, metabolic bone disease, or Dorr type C bone. 13 Recent attempts using cementless fixation in poor bone have been favorable ; however, some authors have attributed the historically poor track record of cementless hemiarthroplasty in these patients to the limitations of the early cementless Austin-Moore prosthesis. 18,19 The potential advantages of cementless fixation include avoidance of the systemic effects of pressurized cement and local cement toxicity, potentially greater ease of revision if required, and often reduced costs and operating times. 15 The current study adds to the evidence showing that cementless fixation, even in traumatic injuries in elderly patients with osteoporosis, as described in this study, can yield Outcome excellent clinical outcomes, with low complications and a low revision rate at mid-term follow-up. This study had several limitations. The patient cohort was composed almost entirely of women, and although this injury preferentially occurs in women, the results may be less generalizable to broader populations. There was no concomitant comparison group. All surgery was performed by an experienced arthroplasty surgeon, which may not be applicable to the experience of an on-call orthopedist with general training who is tasked with covering such an injury. Patients who died of causes unrelated to the procedure and at a distant time were included in the analyses. Nevertheless, despite these shortcomings, because there are few reports on this topic, the authors believe that the outcomes of this study are valuable to evaluate the mid-term clinical and radiographic outcomes of this procedure in this difficult-to-treat population of elderly patients with type C bone. More prospective Value Total no. of revisions (% of total) 8 (7.1%) Periprosthetic fracture 3 (2.7%) Recurrent dislocation 1 (0.9%) Intractable groin pain 1 (0.9%) Loosening 0 Infection 3 (2.7%) Mean Harris Hip score (range), points Preoperative 16 (3-30) Postoperative 80 (30-97) Intraoperative parameters Estimated blood loss (range), ml 176 ( ) Mean operative time (range), min 47 (20-113) Intraoperative femur fractures 0 Radiographic follow-up Periprosthetic fracture 3 Progressive radiolucency >2 mm 0 multicenter studies are necessary to better evaluate these outcomes. The results of the current study are in agreement with reports on the use of cementless hemiarthroplasty overall and for cementless fixation of stems for elective THA. 12,17,20-22 Bezwada et al 17 compared the clinical outcomes of 248 patients (256 hips) with a mean age of 77 years (range, years) who sustained displaced femoral neck fractures treated with cementless bipolar hemiarthroplasties. At a mean follow-up of 3.5 years (range, 3-5 years), the revision rate was 5% and the mean Harris Hip score improved to 82 points (range, points). Two components were revised for loosening and 6 were revised to THA for intractable groin pain. Eschen et al 20 compared the clinical outcomes after cementless, hydroxyapatite-coated hemiarthroplasty for displaced femoral neck fractures in 47 patients who had a mean age of 81 years. At a mean 2-year follow-up, the mean EuroQol 5D score (a patient-reported score similar to e348 ORTHOPEDICS Healio.com/Orthopedics

5 SF-36, from 0 to a maximum of 1) was 0.7 (range, ). Of 37 hips that had radiographic follow-up, there were no signs of implant loosening. Dalury et al 12 analyzed the outcomes of 53 patients (60 hips) with osteoarthritis and Dorr type C bone who underwent primary THA with a proximally coated, tapered, cementless stem. At 6-year follow-up, the 40 patients (43 hips) who were available experienced no thigh pain, no revisions, and no radiographic evidence of loosening or stress shielding. Figved et al 21 described similar results with cementless (108 hips) compared with cemented hemiarthroplasty (112 hips) for the treatment of displaced femoral neck fractures in patients who had a mean age of 83 years (range not given). At 1-year follow-up, both groups had similar mean Harris Hip scores (71 points in cemented vs 72 points in cementless, respectively). The rates of early reoperation for any reason were similar in cemented and cementless groups (8 vs 11 reoperations, respectively). The results of the current study are not concordant with some previously published reports that discouraged using cementless fixation in displaced femoral neck fractures. 6,18,21,23 Dorr et al 6 randomized 89 patients who sustained displaced femoral neck fractures to receive either cemented THA (39 patients), cemented hemiarthroplasty (37 patients), or cementless hemiarthroplasty (13 patients). Of the 13 cementless stems, 9 showed proximal femur radiolucency on follow-up radiographs. Based on their experience, Dorr et al 6 advised against the use of cementless stems in type C bone because of inability to obtain a stable press-fit and subsequent risk of subsidence. One potential reason for the difference between the current results and the results of Dorr et al 6 may be the use of older-generation prostheses in their study. Gjertsen et al 18 reviewed the Norwegian Hip Fracture Register to compare displaced femoral neck fractures treated with cemented (8639 hips) or cementless (2477 hips) hemiarthroplasty. At 5-year follow-up, they found that implant survivorship was better for cemented vs cementless implants (97% vs 91%, respectively). Furthermore, a significantly greater number of patients in the cementless group were cognitively impaired at baseline. Viberg et al 23 evaluated the reoperation rate for 4 different treatment methods for femoral neck fracture, including 180 patients who had undergone internal fixation/dynamic hip screw, 203 patients who had received an uncemented bipolar prosthesis, 209 patients who had received a cemented bipolar prosthesis, and 158 patients who had received an uncemented hydroxyapatite-coated bipolar prosthesis (all patients were aged years at the time of surgery). At follow-up of 12 to 19 years, the authors reported a significantly lower reoperation rate for the cemented hemiarthroplasty group (5%) compared with the uncemented hemiarthroplasty group (11%-16%) or the internal fixation group (18%). Thus, they concluded that the cemented bipolar prosthesis had superior long-term survivorship and was the best treatment option for this patient group. A recent review by Figved et al 21 of cemented and cementless arthroplasties for proximal femoral fractures reviewed 23 randomized trials in 2861 patients and found that cementing may reduce pain and lead to better postoperative mobility. The 6 studies included in this review all used outcomes from older-generation implants, whereas studies of modern proximally coated prostheses were analyzed separately and were not included in this analysis. Conclusion The management of displaced femoral neck fractures in patients with poor bone stock remains challenging, with potentially high rates of mortality. 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