Arthroplasty

 

Type III gardenCemented unipolar

 

Indications

 

Patient > 50

Displaced fractures

 

Issues

 

Fixation versus arthroplasty

Hemiarthroplasty versus THA

Hemiarthroplasty (HA)

- bipolar versus monopolar

- cemented versus uncemented

- surgical approach

 

Fixation versus arthroplasty of displaced fractures

 

Ramadanov et al J Orthop Surg Res 2023

- systematic review and meta-analysis

- both displaced and non displaced fractures

- 33 RCTs with 5700 patients

- THA and HA had the best functional outcome

- cannulated screws and DHS had highest reoperation rates

 

Gjertsen et al JBJS Am 2010

- Norwegian Hip Fracture registry

- 4335 patients > 70 with displaced subcapital fractures

- screw fixation versus bipolar HA

- 1 year mortality same in each group (25%)

- reoperation rate: 23% screw fixation v 3% in hemiarthroplasty

- more pain / higher dissatisfaction / lower quality life in screw fixation group

 

Hemiarthroplasty versus THA

 

HEALTH investigators NEJM 2019

- RCT of 1495 patients > 50 with displaced femoral neck fracture

- HA versus THA

- reoperation rate same in both groups (8%)

- dislocation: 2% HA versus 5% THA

- serious adverse events: 37% HA verus 42% THA

- modest improvement in function for THA over HA, clinically unimportant

 

Australian Joint Registry 2023

- 15 year revision rate THA for OA 6%

- 15 year revision rate THA for fracture 9%

 

Hemiarthroplasty

 

Hemiarthroplasty Design Options

 

Unipolar

- single articulation between prosthesis and acetabulum

 

Unipolar monoblock

- Austin Moore press fit

- Thompson cemented

- no offset options

 

Hip Austin MooreThompsons Hemiarthroplasty

Austin Moore                                         Thompson

 

Modular unipolar

 

Based on standard THR concepts

- alternative offset options

- neck length options

- cemented or uncemented

 

Cemented unipolar

 

Bipolar modular

 

Concept

- second articulation between inner smaller head and polyethylene liner

- reduce wears on acetabulum

- improved function and less pain

- may reduce dislocation

- may have better ROM

 

Issues

- higher cost

- may need open reduction in dislocation if femoral head disassociates from socket

- loss of motion interface / becomes unipolar

Zimmer bipolarZimmer bipolarBipolar hemi

 

 

Unipolar HA verus Bipolar HA

 

Papavasiliou et al Eur J Orthop Surg Traumatol 2023

- systematic review of 16 RCTs and 1800 patients

- unipolar versus bipolar

- reduced acetabular erosion with bipolar

- improved function and reduced pain with bipolar

- no difference in reoperation or dislocation

 

Australian Joint Registry 2023

- 45,000 unipolar modular

- 28,000 bipolar modular

- 10 year revision rate unipolar 7%

- 10 year revision rate bipolar 5%

 

Australian Joint Registry 2023

- patients < 75

- 10 year revision rate unipolar 14%

- 10 year revision rate bipolar 8%

 

AJRR uniAJS unipolar

Revision rate AJRR all ages                                                                    Revision rate AJRR < 75 years

 

Cemented versus uncemented HA

 

Modular HemiarthroplastyUncemented hip

Cemented unipolar hemiathroplasty                  Uncemented bipolar hemiarthroplasty

 

Cement

- minimizes fracture risk in osteoporotic patients

- reduced risk thigh pain

- slightly increased cardiac risk with cement

 

Parker et al BJJ 2023

- RCT of 400 patients

- cemented vs uncemented

- cemented HA had better early mobility

- cemented HA had significantly lower mortality

- no difference in complication or revision rate

 

He et al Orthop Surg 2023

- systematic review of 24 RCTs and 3500 patients

- cemented versus uncemented HA

- cemented had less pain and better function

- cemented had fewer fracture / loosening / revision

 

Uncemented HAUncemented HA fracture

 

Technique

 

Vumedi lateral approach hemiarthroplasty

 

Vumedi posterior approach hemiarthroplasty

 

Approach

 

Posterior approach

- increased short-term morbidity

- may increase dislocation risk

 

Hardinge

- take off anterior 1/3 abductor tendons

 

Complications

 

Infection

 

Dislocation

 

Hemiarthoplasty dislocatedBipolar Dislocation

 

Fracture

 

Hip Hemiarthroplasty GT FractureHemi fracture

 

Leg length discrepancy

 

Hip Hemiarthroplasty LLDLLD hemi

 

Groin pain from acetabular cartilage erosion

 

Severe acetabular wear

 

Acetabular erosion

 

Bipolar Acetabular Destruction 1Bipolar Acetabular Destruction 2Bipolar Acetabular Destruction Revision 1Bipolar Acetabular Destruction Revision 2

 

 

Loosening

 

Cement implantation syndrome

 

Hypoxia, hypotension and loss of consciousness concurrent with cementing

 

Olsen et al, Br J Anaesth 2014

- 1016 cemented hemiarthroplasties

- 28% incidence in neck fracture

- higher early mortality

 

Total hip arthroplasty

 

Indications

 

Young, active, mobile patient with neck of femur fracture

 

Issues

 

THA

- better functional outcome in young mobile patient

- higher cost

- higher dislocation rates

 

Results

 

HEALTH investigators NEJM 2019

- RCT of 1495 patients > 50 with displaced femoral neck fracture

- HA versus THA

- reoperation rate same in both groups (8%)

- dislocation: 2% HA versus 5% THA

- serious adverse events: 37% HA verus 42% THA

- modest improvement in function for THA over HA, clinically unimportant

 

Tang et al J Orthop Surg Res 2020

- systematic review of 25 RCTs and 3200 patients

- THA better functional outcomes in mid term

- higher dislocation with THA

 

Australian Joint Registry 2023

- 27,500 primary THA for fracture hip

- revision rate 9% at 15 years

- revision for dislocation 1.5%

- revision for fracture 2%

- revision for infection 1%

- revision for loosening 1.5%