Elsevier

Injury

Volume 47, Issue 10, October 2016, Pages 2060-2064
Injury

Review
Total hip replacement for hip fracture: Surgical techniques and concepts

https://doi.org/10.1016/j.injury.2016.06.034Get rights and content

Abstract

When treating a hip fracture with a total hip replacement (THR) the surgical technique may differ in a number of aspects in comparison to elective arthroplasty. The hip fracture patient is more likely to have poor bone stock secondary to osteoporosis, be older, have a greater number of co-morbidities, and have had limited peri-operative work-up. These factors lead to a higher risk of complications, morbidity and perioperative mortality.

Consideration should be made to performing the THR in a laminar flow theatre, by a surgeon experienced in total hip arthroplasty, using an anterolateral approach, cementing the implant in place, using a large head size and with repair of the joint capsule. Combined Ortho-geriatric care is recommended with similar post-operative rehabilitation to elective THR patients but with less expectation of short length of stay and consideration for fracture prevention measures.

Introduction

The incidence of hip fracture is increasing year on year [1], [2], [3]. The total number of recorded intra-capsular hip fractures in the United Kingdom for 2014 was 64,102 [4]. The surgical options for an intracapsular fracture include internal fixation, hemiarthroplasty or total hip replacement (THR).

The United Kingdom National Institute for Clinical Excellent (NICE) [5] stipulates that patients with displaced intra-capsular fractures should have the option of a THR discussed if—

  • They are able to walk independently outdoors with no more than one stick

  • They are not cognitively impaired

  • And are medically fit for the anaesthetic and the procedure

Partly as a consequence of these guidelines there has been a steady increase in the number of total hip replacements performed for hip fracture patients in the UK. In 2011 10.7% of eligible hip fracture patients received THR. This increased to 19.1% in 2013 and 26% in 2015 [4]. The figures from the UK National Joint Registry of England, Wales (NJR) also corroborate this with 1698 THR in 2011 for hip fracture compared to 3246 THR in 2014 (NJR 2011–14) [6].

A number of randomised trials and case series reports have to date shown favourable outcomes for THR in comparison to hemiarthroplasty [7], [8], [9], [10], [11]. These reports have however highlighted the potential for an increased risk of specific complications, particularly dislocation [11]. This has led to the suggestion that the surgical technique used for a standard patient with an arthritic hip should be modified for a THR in a hip fracture patient. The authors believe that a THR for a hip fracture is a different operation and has different challenges to that of a primary elective THR for arthritis (Fig. 1). This review draws attention to the possible operative modifications that may differ from a standard ‘elective’ THR.

We recommend performing the THR in a laminar flow theatre [12]. All of these cases should be performed or supervised by surgeons regularly performing hip arthroplasty. There is evidence that dislocation rates are higher in surgeons performing less than 5 THR per year in the elective population [13]. It is no longer acceptable for occasional hip surgeons to be undertaking these cases. The same study also found an association between dislocation and an operative duration of over 180 min [13]. Units should have a policy of calling for senior assistance if the case is not in line for completion within 90 min total surgical time.

We recommend using an antero-lateral approach. This is primarily due to the reduction in risk of hip dislocation, which has been demonstrated in the hip fracture population [14], [15], [16]. In elective hip arthroplasty it is accepted that there is a small but definite difference in dislocation rate between the anterolateral and posterior approach [6]. Stafford et al. reviewed the THR records for hip fracture patients submitted to the National Joint Registry (NJR) [15]. They reported that revision rates were significantly higher in hip fracture patients treated with THR by the posterior approach compared to other approaches (anterior/lateral) (3.5% vs 1.3%, p = 0.02). In a series of 713 hips Enocson et al. suggested an increased rate of dislocation in fractured hip THR using the posterior approach in comparison to the anterolateral approach 12% versus 2% p < 0.001 respectively [16].

There is however an increasing trend towards elective hip replacement being inserted via the posterior approach [6], and it is unknown if it is better to have an experienced arthroplasty surgeon use a posterior approach with which they are familiar than an inexperienced one using an antero-lateral approach. If the posterior approach is used then capsular repair and repair of the short external rotators with a strong non-absorbable suture using trans-osseous sutures in the greater trochanter should always be performed. We suspect a surgeon will achieve the best results using the approach they are most familiar with. However, whatever approach is chosen outcomes should be regularly audited, specifically surgeon, approach and dislocation rate. This should also include formal training of THR in hip fracture patients by senior arthroplasty surgeons.

We recommend using a cemented cup and stem for hip fracture patients. Evidence from the NJR has demonstrated an increased rate of revision in patients treated with un-cemented versus cemented prosthesis for hip fracture (hazard ratio (HR) 1.33, p = 0.021) [15], [17]. We therefore recommend using a cemented cup and a cemented stem for hip fracture patients.

An increased risk of bone cement implantation syndrome exists in hip fracture patients. This is reflected in the higher mortality in hip fracture patients treated with a cemented implant at 24 h. However, this difference has disappeared at 7 days and uncemented implants have a higher mortality at 3 months [19], [20]. The authors take the view that where a patient is felt to be at significantly increased risk if the bone cement were to be pressurised, this would suggest they are not medically fit enough to have a THR rather than a hemiarthroplasty. The use of bone cement should always be discussed with the anaesthetic team at the pre-operative theatre briefing and at a ‘time out’ check prior to cementing [21]. Full precautions and an appropriate cementing technique should be used, as recommended by the AAGBI/BOA/BGS guidelines [22].

There is no evidence as to which bearing surfaces to use for the hip articulation. However, in this age group with a relatively limited life expectancy, it is difficult to justify anything except a metal head articulating with a polythene cup.

We recommend careful planning of the hip replacement using preoperative templates either directly from hard copy X-rays or using digital planning software. The contralateral (intact hip) can be used to estimate femoral implant size, offset and positioning as the fracture usually distorts the anatomy on the affected side.

The acetabulum should be reamed gently and with great care due to the soft bone and absence of any floor (curtain) osteophyte. This makes it unnecessary to ream medially and attempting to do so poses a real risk of breaching the floor of the acetabulum. We recommend measuring the diameter of the extracted femoral head and starting with a reamer 4 mm smaller than the native femoral head size and then enlarging by 2 mm increments until breaking into cancellous bone. It should not normally be necessary to ream beyond 4 mm larger than the measured diameter of the femoral head. If the extracted femoral head is not measured the starting reamer should not be less than 44 mm as this also reduces the risk of over reaming or breaching the medial wall into the pelvis.

Great care should always be taken with the reamers, particularly if they are new and sharp. During the first few turns with the reamer it may feel as though the bone is fairly firm but as soon as the sub-chondral bone plate has been reamed, the underlying cancellous bone is usually very soft. The point at which the cortical bone has been reamed through can often be identified by a change in note in the rotating reamer at which point reaming should cease immediately.

If a small (1 cm) defect is inadvertently made in the medial wall of the acetabulum, part of the extracted femoral head may be used to fill this. First using a bone nibbler or a saw blade as a burr, scrape off the majority of the articular cartilage from the top part of the femoral head. Then cut off the top of the femoral head, creating a curved disc of bone 3–4 mm thicker in the middle and large enough to overlap the hole by 0.5–1 cm all the way around. Place this over the defect, add some bone reamings, or morcellised cancellous graft from the remains of the femoral head to help seal the edges, and cement in a standard cup. If the defect is any larger then advice and assistance from a hip surgeon with experience in acetabular reconstruction should always be sought. Options then include use of a rim fitting uncemented cup and screws with graft from the femoral head in the floor, a mesh and impacted graft onto which a cup is cemented or in extreme cases an acetabular cage.

After preparation of the acetabulum, make key holes in the ilium, pubis and ischium and superiorly, being careful not to remove too much cancellous bone, particularly where this is of very poor quality in the ilium. Thorough lavage of the bone surface should be performed then pressurise the cement well (as for an elective THR) before inserting the cup.

The acetabular cup alignment should normally lie parallel to the transverse acetabular ligament [23] and/or in the orientation of the acetabular bony mouth (which will not be distorted by the presence of osteophytes), which is approximately 20° of anteversion for the anterolateral approach (30° if using the posterior approach). Aim for approximately 40–45° of inclination (abduction).

We advocate the use of a larger head size (32 or 36 mm head), when the size of acetabular component allows this. Although, Jameson et al. in a large retrospective review of 4323 THR for hip fracture from the NJR found that revision was independent of head size and bearing surface [17]. Malkani et al. in a series of 39,271 THR, found that both early and late dislocation risk was significantly higher in patients treated with smaller (<32 mm) diameter heads compared to those treated with large diameter heads (>32 mm) [13]. Larger diameters heads resulted in a 35% reduction in early dislocation and a 43% reduction in late dislocation. The NJR also demonstrates a lower dislocation rate with a head size of 36 mm or larger in elective THR [17].

Using a dual mobility prosthesis may be a way to try and reduce the dislocation rate and the use of this type of cup has increased recently. However, there are potential weaknesses with this design of prosthesis in relation to wear characteristics and component dislocation. They are also much more expensive than conventional cemented components. The authors do not, at this time, recommend their routine use in hip fracture patients.

The use of a double tapered polished cemented stem of the ‘Exeter’ type has become widespread in the UK in line with the NICE recommendations to use a cemented stem with good evidence of effectiveness from long term follow-up studies. This type of prosthesis is now widely available and relatively easy to use. It also has the additional benefit of being easy to remove and allowing the possibility of a ‘cement in cement’ revision to be undertaken in the future if necessary, which is particularly useful when the bone is thin and fragile [24].

Before cementation the authors advocate a thorough lavage of fat from the canal and insertion of a cement restrictor. A suction catheter must be used and cement should always be inserted retrograde using a cement gun. The anaesthetist must always be warned before insertion of cement into the femoral canal and prior to any cement pressurisation [22].

We recommend the femoral component be inserted in a position of 5–10° of anteversion (15–20 if doing a posterior approach) and that stability be assessed using a trial prosthesis before definitive cementation takes place.

The soft tissue envelope provides secondary stability to the hip joint to reinforce the inherent stability of the ball and socket joint [25]. The joint capsule should be preserved and repaired to aid stability of the THR. In hip fracture patients the capsule is not tight and restrictive as it can be in hip arthritis, so retention and repair should aid stability rather than limit range of motion. Kakar et al. report that 80% of surgeons questioned accordingly repaired the capsule during arthroplasty for femoral neck fractures [26].

Current evidence indicates that Tranexamic acid use in elective arthroplasty reduces the need for blood transfusion without increasing the risk of thrombotic complications [27]. However, there is no conclusive evidence to date for its use in hip fracture patients [28]. In view of this we would cautiously recommend the use of tranexamic acid in THR for hip fracture patients but not necessarily for hemiarthroplasty patients at present.

There is some evidence to suggest that patients undergoing hip fracture surgery do marginally benefit from spinal anaesthesia [29]. However, we suggest it would be best to use local preference and expertise in deciding upon spinal or general anaesthesia.

There is no evidence to date to support a change to the standard policies for antibiotic and thromboembolism prophylaxis in these patients compared to patients undergoing similar elective procedures.

We see no need to change the hip precautions used to those following THR for hip arthritis. For most surgeons this will involve recommending limiting flexion of the hip to 90° for bending and sitting and avoidance of crossing the legs and twisting the hip for 6–8 weeks.

Post-operatively patients should be encouraged to fully weight bear as soon as possible. They should receive post-operative physiotherapy as with elective arthroplasty. However, hip fracture patients are likely to have a longer length of stay, more co-morbidity and require more rehabilitation support compared to elective THR [30]. Combined care with an Ortho-geriatrician is strongly recommended.

Section snippets

Discussion

THR following hip fracture has been established as an effective treatment option for fit patients with displaced intra-capsular fractures with favourable outcomes in relation to pain and mobility compared to hemiarthroplasty [7], [8], [9], [10], [11], [31], [32]. These results have similar outcomes at short and medium term follow-up with Baker et al. reporting improved function (further walking distance and Oxford hip score) at three years with THR compared to hemiarthroplasty [11]. Some

Summary

Hip fracture patients are a different population to elective arthroplasty patients and as such the THR has unique challenges. We therefore recommend performing the THR in a laminar flow theatre, by a surgeon competent in arthroplasty, via the anterolateral approach with preservation and repair of the capsule. We suggest using a cemented cup, tapered, polished cemented stem and large femoral head, using a contemporary cementing technique. Post-operatively combined ortho-geriatric care is advised

Conflict of interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Ethical approval

Nil required. We did not seek ethical approval for this study because there were no patients involved in the research.

Funding

Nil.

Acknowledgement

Nil to declare.

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