Summary A review of recent advances in the treatment of intracapsular hip fractures in the elderly patient is offered to provide some guidelines on choosing the appropriate treatment for a given patient. Alternatives discussed include open reduction and internal fixation versus arthroplasty; unipolar versus bipolar hemiarthroplasty versus total hip arthroplasty; cemented versus cementlless prostheses; and a surgical approach. These recommendations are based upon a review of the substantial literature on the subject and the author's own experience. It is recommended that patients more than 60-years-old with a femoral neck fracture be treated in the following manner: Patients with undisplaced, stable fractures perform an ORIF, patients with displaced fractures, replace the head of the femur, the use of a Moore or Thompson prostheses should be relegated to the medically infirm, minimally ambulatory patient, modular unipolar or bipolar (cemented stem) hemiarthroplasty has the most reliable and predictable outcome in most patients, an uncemented modular hemiarthroplasty should be considered in patients with significant cardiovascular risk factors, THA perhaps recommended for the “active elderly patient”. The use of large heads and meticulous capsular repair techniques will reduce the early dislocation rate while still allowing excellent long-term functional outcomes.

Advances in the treatment of intracapsular hip fractures in the elderly.

Background In Australia the most frequently employed hemiarthroplasty prosthesis for the management of displaced intracapsular femoral neck fractures is the Uncemented Austin Moore (UAM). Despite concerns regarding poor functional outcomes and increased early revision rates associated with the UAM prosthesis, apprehension regarding the systemic side effects of polymethylmethacrylate cement implantation in the elderly patient continues to influence prosthesis selection. This study examines the incidence of early prosthesis related complications after UAM and Cemented Thompson (CT) hemiarthroplasty procedures for the management of femoral neck fractures. Methods A multicentre retrospective review of charts and radiographs was conducted in order to determine early prosthetic complications associated with the CT and UAM prostheses over a 6 year period in five Queensland public hospitals. Results Intraoperative periprosthetic fractures were sustained in 11.8% of UAM and 1.8% of CT implantations (p<0.0001). Intraoperative periprosthetic fractures were associated with an increased requirement for reoperation within 1 month of the index procedure (p=0.05). No statistical difference in the incidence of intraoperative periprosthetic fractures could be observed between the hospitals participating, regardless of the proportional use of each prosthesis. Early dislocation rates were similar for the UAM and CT prostheses. The intraoperative mortality rate attributable to the use of polymethylmethacrylate cement during hip hemiarthroplasty was 1/ 738 (0.14%). Conclusions The results of this study support the use of the CT prosthesis for the management of femoral neck fractures to reduce the high incidence of intraoperative periprosthetic fractures and associated requirements for early reoperation experienced with the UAM.

Early prosthetic complications after unipolar hemiarthroplasty

Displaced intracapsular fractures of the neck of femur are routinely treated in the elderly with either cemented or uncemented hemiarthroplasty Recent evidence suggests a superior outcome with the use of cement, but uncemented prostheses are still employed for those with multiple co-morbidities or particular frailty In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) recommendations are used to identify which patients should receive a cemented prosthesis These are simply based upon the presence of cardiorespiratory disease, particularly in the frail elderly patient Between January 2007 and June 2010, a total of 1397 patients with neck-of-femur fractures presented to our unit Retrospective analysis was performed with particular attention given to the rate of postoperative periprosthetic fracture As many as 546 fractures were treated with hemiarthroplasty, of which 183 were treated with a cemented Exeter Trauma Stem (ETS) and 363 were treated with an uncemented Austin-Moore prosthesis (AMP) At the time of our retrospective analysis, we found that 15 (4%) patients treated with an uncemented prosthesis went on to sustain a periprosthetic fracture There were no periprosthetic fractures in the cemented group (p=0004) Data analysis by case-note review of those patients sustaining a periprosthetic fracture was then performed Seven (50%) suffered from confusion secondary to dementia, six (43%) had a history of significant cardiac disease (recent myocardial infarction (MI) or cardiac failure) and two (14%) had known renal impairment The mean time to fracture after uncemented hemiarthroplasty was 2 years The majority (80%) were fractures which required further surgery Revision surgery in these patients was associated with an overall complication rate of 42% (mainly deep infection and haemorrhage requiring transfusion) Two of the patients had a fracture that could be treated conservatively It is concluded that, in conjunction with the treating senior anaesthetist, cemented implants should be considered in all patients, especially those who are deemed to be frail and with multiple co-morbidities A periprosthetic fracture rate of 14% at a mean of 2 years after uncemented hemiarthroplasty represents a potentially unacceptable risk for such a frail population In particular, we feel that the AMP should not be used for treating displaced intracapsular neck-of-femur fractures

Incidence of periprosthetic fractures after hip hemiarthroplasty: Are uncemented prostheses unsafe?

Between 2002 and 2007, fifty elderly patients with displaced femoral neck fractures were treated with hip replacement at Emergency Hospital, Mansoura University Patients were randomly selected, 25 patients had either cemented or cementless bipolar prosthesis, and another 25 patients had either cemented or cementless fixed-head prosthesis There were 34 women and 16 men with an average age of 635 years (range between 55 and 72 years) All patients were followed up both clinically and radiologically for an average 44 years (range between 2 and 6 years) At the final follow-up, the average Harris hip score among the bipolar group was 92 points (range between 72 and 97 points), while the fixed-head group was 84 points (range between 65 and 95 points) Radiologically, joint space narrowing more than 2 mm was found in only 8% (2 patients) among the bipolar group, and in 28% (7 patients) of the fixed-head group Through the follow-up period, total hip replacement was needed in two cases of the bipolar group and seven cases of the fixed-head group Bipolar hemiarthroplasty offered a better range of movement with less pain and more stability than the fixed-head hemiarthroplasty in elderly patients with displaced femoral neck fractures

https://link.springer.com/content/pdf/10.1007%2Fs11751-010-0100-1.pdf

Bipolar versus fixed-head hip arthroplasty for femoral neck fractures in elderly patients

Pure lateral elbow dislocation is rare, and a successful closed reduction is even rarer. Reduction can be hindered by swelling, soft tissue interposition or associated fractures. We present a pure lateral traumatic dislocation of the elbow joint in a 40-year-old man. This was successfully manipulated and reduced in casualty using a modification of the gravity-aided 'hanging arm' technique originally described for shoulder dislocations by Stimson. We strongly recommend the use of this simple technique in these rare yet difficult injuries, in order to avoid potential complications with general anaesthesia and surgery.

/pdf/successful-closed-manipulation-of-a-pure-lateral-traumatic-260tee3e0j.pdf

Successful closed manipulation of a pure lateral traumatic dislocation of the elbow joint using a modified Stimson's technique: a case report

Forty cases of Austin Moore Replacement done for transcervical fractures of the femur in patients were reviewed after a period of 12 to 48 months postoperatively (mean 26 mth). 30 cases (75%) had mild to severe pain of non-infective origin, starting as early as 6 months postoperatively. This was irrespective of the make, size or position (varus/valgus) of the prosthesis. Though the Aufranc and Sweet clinical scoring was satisfactory in 65% cases, radiological evidence of complications like sinking, protrusion, etc. were seen in majority of the cases. Calcar resorption was seen in 34 cases (85%) as early as 4 months postoperatively. Results of THR and bipolar replacement done for transcervical fractures in recent literature show 85% pain-free cases at 5 years. We feel that Austin Moore Replacement should be reserved for patients more than 65 years of age and those who are less active or debilitated because of other factors, because of increased acetabular wear with time in the younger individual. This is corroborated by unsatisfactory results in patients less than 65 years of age (p < 0.05).

Results of Austin Moore replacement.

A rare case of an irreducible post-traumatic lateral dislocation of elbow is presented. The mechanism of injury was fall on a flexed elbow with trauma on its medial aspect resulting in pronation of the forearm. At open reduction, the brachialis muscle was in the form of a tight band which prevented reduction. The ulnar nerve was entrapped in the joint.

MM Divekar

Papers

Results of Austin Moore replacement.

Irreducible lateral dislocation of the elbow.