Treatment for Fixation Complications Femoral Neck Fractures John P.
Albright, MD, Stuart
L.
Weinstein, MD
Of 102 hips with femoral neck fracture complications, 75 required major secondary procedures such as total hip replacement, femoral prosthesis, cup arthroplasty, tibial bone grafting, and head and neck resection. The method chosen depended on the specific problem: nonunion, aseptic necrosis, infection, degenerative arthritis, or a failed primary prosthesis. Other factors influencing treatment were the patient's chronological and physiological age, his general health, his life pattern, and the familiarity of the surgeon with the technique and the advantages and disadvantages of the various salvage procedures.
improved techniques Despite fractures, complications
for managing femoral neck remain commonplace. At the University of Iowa we see nearly 34 examples each year. Between January 1970 and January 1973 there were 155 operations for fresh femoral neck fractures and 102 sec¬ ondary or salvage procedures. An increasing acceptance of high-angled sliding nail or pin systems, complete with lat¬ eral fixation devices, and the principle of early impaction should enable us to nearly eliminate the 36 nonunions we saw during this period.1-' Of the 102 hips, 75 needed major salvage procedures requiring more than mere removal of hardware or local debridement. These figures are some¬ what biased in that complications tend to be more readily referred to us than fresh fractures. Table 1 lists the reasons for primary treatment failures and subsequent corrective procedures at Iowa during the past three years. These statistics are presented merely to put this problem in perspective and to illustrate alterna¬ tive methods of treatment recently used at the University of Iowa. The numbers represent a conglomerate for the entire staff and do not reflect individual preferences for Accepted
for publication July 25, 1974. From the Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City. Reprint requests to Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242 (Dr. Albright).
specific cases. The table does indicate, however, that no procedure is a panacea for homeotypical complica¬ tions. In each case, many factors must be considered by one
the surgeon before a decision about the best choice of treatment can be made. EVALUATION OF FEMORAL NECK FRACTURE COMPLICATIONS I. Patient information A. Physiologic age 1. Patient's chronologic age 2. General medical status a.
Cardiorespiratory
b. Neuromuscular 3. Mental status a. Alertness b. Attitude B. Functional expectations 1. Patient's requirements, ie, pain relief, ability to walk 2. Preoperative ambulatory status 3. Postoperative expectations: functional demands, ie, house confinement, return to work 4. Effect of specific complication on expected results C. Status of other joints, ie, hip, knees, upper extremities 1. Future degree of pain or disability 2. Ability to use crutches D. Procedure survivance requirement, ie, life expectancy of patient modified in terms of physiologic age II. Knowledge of salvage procedures A. Alternative procedures 1. Girdlestone 2. Arthrodesis 3. Bone graft 4. Femoral prosthesis 5. Cup arthroplasty 6. Total replacement B. Chances of good result (regarding success of each proce¬ dure for specific complications) 1. Short-term
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2.
C.
risks (death, infection, and
so
on) of each al¬
ternative D. Limitations of procedure 1. Postoperative management requirements 2. Technical difficulties of operation and associated E.
population at large in this age group, which 90%. The addition of a femoral neck fracture to the former reduced this survival rate to 33%. An estimation of the activity level and life expectancy of an individual may influence the choice of salvage procedure, eg, a 50-year-old woman expected to live 29 additional years should ideally receive the procedure offering the best, predictable life¬ time guarantee. rate in the
Long-term
Operative
operative problems Specific advantages of each procedure 1. Functional 2. Alternative if
post¬
was
procedure fails
RESULTS OF SALVAGE PROCEDURES
Femoral neck fracture complications are related to age.1 The additional medical problems often seen in people over age 65 lead to a high immediate mortality of 10% to 15%, with an additional 10% to 15% in the ensuing year." Pa¬ tients over 90 are clearly at greater risk than those closer to 65. Most of the serious problems are attributable to car¬ diac, pulmonary, and neuromuscular disorders as well as a suppressed mental status secondary to cerebral anoxia. In the seventh and eighth decades a majority of patients ap¬ pear to have associated cardiorespiratory problems and are thus poor operative risks. However, patients surviving femoral neck fracture long enough to develop complica¬ tions usually demonstrate stable support systems and are more likely to survive a salvage procedure. The choice of treatment may be predicated on the pa¬ tient's chief complaint. His prime concern may be the abil¬ ity to move about on his own, or merely relief of constant pain. Knowledge of the patient's ambulatory status prior to the operation is important. Niemann and Mankin4 re¬ ported that 17% of nursing home patients were unable to walk preoperatively. Only 40% of the ambulatory patients in this age group' who survived the primary procedure were ever able to walk again. The mental attitude and expectations of the patient and his family can clarify realistic goals toward which the surgeon should aim. A functional assessment should in¬ clude such questions as: Does the patient merely need to walk to the bathroom and the dining room table? Could the patient be independently ambulatory? Is it likely that he will return to work? Extremely important in reaching a conclusion as to functional expectations is the evaluation of the other joints involved in postoperative ambulation. For instance, disease in the contralateral hip or either knee may alter the expected results. One would not desire to electively resect the head and neck in a patient who had a painful degenerated hip on the opposite side and who desired to return to work in a job that required much walking. Strength of the upper extremities is also impor¬ tant if the patient is expected to use assistive devices
In order to offer a yardstick for comparing the relative merits of the alternative operations, the data most heavily relied on stem from patients treated at the University of Iowa who were given numerical hip ratings (Figure). The 100-point rating scale developed by Larson" offers an ob¬ jective quantitative evaluation of hip disabilities that is reproducible by different examiners. It is most valuable in comparison of preoperative versus postoperative results for an individual patient. It is also useful in comparing re¬ sults between groups of patients. From its use, we can ex¬ amine results of the following reconstructive procedures and thereby offer an aid for use in the selection of the most appropriate treatment for each individual patient. The patient's satisfaction is not part of this system, but is information obviously valuable to obtain. In general, patients whose score is over 90 would be classed as having an excellent result by any method. Sim¬ ilarly a score of less than 70 would fall into an unsatis¬ factory or poor category. Scores between 80 and 90 are reported as good results. Caution should be used in at¬ tempting to apply the general scores to making a decision on an individual patient. The expected improvement in the specific deficit most affecting that patient is far more
postoperatively. One should always arrive at a conclusion of the patient's physiologic age from his chronologic age and the associ¬ ated medical problems that exist. This will give an idea of the life expectancy anticipated for the individual by modi¬ fying national vital statistics (Table 2). Our patients fit into these national age categories as seen in Table 3. An example of the use of such a table is illustrated by Niemann and Mankin.1 Their nursing home patients' oneyear survival rate
was
71%
versus
the one-year survival
important.
Girdlestone Procedure
The classic "last resort" in modern hip surgery, other than the extreme of disarticulation, is a procedure remov¬ ing the head and neck, as described in the 19th century for the treatment of infection. The observation that a patient with a Girdlestone procedure can function fairly well free of significant pain is often assumed. A long-term look at how patients actually fare after this procedure has re¬ cently been reviewed by Parr et al.7 Table 4 presents a summary of these results. The overall results were encouraging, with 81% of the patients satisfied. Poor results were usually due to poor general medical status. From this study we can conclude that a Girdlestone procedure is most effective at per¬ manently relieving pain. However, these people cannot expect a normal hip. They will have a short leg, unstable hip, and will walk with a limp. They may require a shoe lift and at least a cane for support. Patients needing bilat¬ eral procedures should be warned of a poor prognosis. The procedure itself is simple but does require several weeks before the limb can comfortably tolerate weight bearing. Traction is frequently used for the first two to three weeks but does not appear to prevent shortening. Instability may be lessened by a pelvic support osteotomy.
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Table 1.—Three-Year
(1970 to 1973) Operative
Records for
Complications of
Femoral Neck Fractures
Treatment
Removal Hardware No. of Patients 36
Diagnosis Nonunion
Second-degree aseptic necrosis
12 15 12 18
Infection Failed Austin-Moore Painful nail/pins
Total
Bone
Hip
Graft 11
Femoral Prosthesis 11
Girdlestone
and/or
Cup Arthroplasty
Debridement
10 17
Second-degree degenerative arthritis Total
102
29
16
13
10
Average age at second procedure, yr
61.9
65.3
58.1
68.7
56.0
These results must be used as a basis for comparison with the more sophisticated procedures discussed below. Any procedure chosen over this one should yield better than a 70-point average on the Iowa scale, or an average gain of more than 35 points per patient.
Table
Fusion of the hip is only briefly mentioned as it is rarely elected by patients in our institution. Although this can be a reliable procedure in a child, the average age of the fem¬ oral neck fracture patient we are seeing with complica¬ tions is the sixth decade. We believe this procedure is con¬ traindicated in this age group because of the lack of adaptability of the lower part of the back, which is re¬ quired for successful arthrodesis.8 Also the prolonged (three to six months) immobilization necessary to obtain a good result could lead to the high mortality seen long ago when the fresh fractures were treated with cast immobili¬ zation. Tibial Bone
Grafting
In 1968, Bonfiglio and Voke" reported the effects of 116 tibial grafts to the femoral head and neck observed for two to 15 years. Ninety-three procedures were done for aseptic necrosis and/or nonunion secondary to femoral neck fractures. Table 5 summarizes the overall ratings for these patients. Nonunion.—When done for nonunion, threaded pins are also inserted for stability. All but five (84%) of the pa¬ tients in this category had a satisfactory result with decreased pain, improvement in function, and increased range of motion. In those instances where manipulation was required to realign the neck-shaft relationship, there was less chance of a good result (79%) than when a graft¬ ing in situ was done (92%). A long interval between fracture and bone grafting did not affect the result; the average lapse in this study was nine months. Aseptic Necrosis With Nonunion.—Seventy-six percent of the patients in this group had a satisfactory result, mak¬ ing this syndrome the most difficult to overcome with a bone graft. Most of the failures in this group occurred in
2.—Abridged
60.3
Life Table*
71.2 53.3 44.0 34.8 29.0 18.6 12.3 9.7 7.5 5.8
20 30 40 50 60 70 75
80 85 + *
49.9
Average Life Remaining, yr
Age, yr Birth
Arthrodesis
27
Data from Vital Statistics Report: Annual Summary for the United
States, 1972.
instability was a problem at the time of grafting, ie, requiring reduction of fragments be¬ cause of malalignment or those where grafting was per¬ formed less than one year after primary surgery. Aseptic Necrosis With Union.—Eighty-one percent of these patients had satisfactory results. Early diagnosis is difficult and is rarely made sooner than six months after fracture. The average time from onset of pain to grafting was 25 months and often ranged as high as four years. This delay did not substantially affect the results. In these patients there was no direct correlation between the de¬ gree of the collapse and the chance of success. Also, the roentgenographic presence of degenerative changes did not necessarily correlate with clinical symptoms. However it does seem reasonable that eventual secondary de¬ generative arthritis is more likely when substantial de¬ formity of the femoral head is present. Pain is often relieved immediately postoperatively, a phenomenon sim¬ ilarly noted with osteotomy at the hip or knee. The range of motion, muscle strength, and so forth improve with an exercise program. But, those people with at least 90° flex¬ ion and less than a 30° flexion contracture preoperatively tend to have more satisfactory results than those with stiffer hips·. In order to obtain an idea of the longevity of a success¬ ful grafting, we selected only those patients evaluated at least seven years postoperatively. Twenty-two of the 93 cases
where
those
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patients qualified; the time at examination ranged from seven to 15 years. Fifteen patients originally had nonun¬ ion and aseptic necrosis, four had aseptic necrosis alone,
and three had nonunion alone. The average age was 59.9 years. The preoperative hip rating was 49 and the postop¬ erative hip rating was 86 (gain of 37). All but four main¬ tained their hip ratings. Each of these patients had had nonunion with aseptic necrosis. One patient with an 82 fating at 4.5 years lost points to 77 by seven years. Two other patients noted moderate pain secondary to degen¬ erative changes at seven and 12 years after grafting. The fourth patient had developed a mild secondary collapse and fatigue pain only. Two patients required a second grafting procedure before desired results were obtained and continued to do well 7.6 and 8.0 years later. As noted in Table 1, the bone grafting procedure re¬ mains an attractive choice at the University of Iowa, espe¬ cially for the younger, more active patients. It saves the One hundred
A. Function
femoral head while providing the relatively good chance of long-lasting success in the posttraumatic cases. The procedure also carries a low morbidity and mortality. It is a conservative procedure in that, if it is not successful, any of the other reconstructive procedures can still be performed. Also, even if painful degenerative changes emerge beyond the 15-year time span studied, it shortens the years an implant will be required to function. However, inserting a tibial graft is a technically de¬ manding procedure where poor attention to detail is likely to lead to a poor result. It also requires a cooperative pa¬ tient who will carry out the postoperative program of pro¬ tected weight bearing and hip strengthening exercises for about ten to 12 months. Major postoperative complications are fewer than those seen with implant surgery, but they do exist. Fifteen of the 93 patients required a second oper¬ ation during this study period. In 2.7% of these patients, an infection necessitated a Girdlestone procedure. Some
point scale for hip evaluation.
(35 points)
Does most of housework or job that requires moving about Dresses unaided (includes tying shoes and putting on socks) Walks enough to be independent Sits without difficulty at table or toilet Picks up objects from floor by squatting Bathes without help Negotiates stairs foot over foot Negotiates stairs in any manner Carries objects comparable to suitcase Gets into car or public conveyance unaided and rides comfortably Drives a car B. Freedom from
pain (35 points)
No pain Pain only with fatigue Pain only with weight bearing Pain at rest but not with weight Pain sitting or in bed Continuous pain
D. Absence of
No fixed No fixed No fixed Not over
Muscle
5 5 5 4 3 3 3 2 2 2 1
C. Gait (10 points)
bearing
No limp; no support No limp using cane Abductor limp Short leg limp Needs two canes Needs two crutches Cannot walk
35 30 20 15 10 0
E.
deformity (10 points) 3 3 2 2
flexion over 30° adduction over ten degrees rotation over ten degrees 2.5 cm shortening
Range
of motion (10
10 8
points)
Flexion-extension (normal 140°) Abduction-adduction (normal 80°) External-internal rotation (normal 80° Total degrees Points (1 point/30o)
strength (No points)
Straight leg raising:
Abduction: Extension:
Less than Less than Less than
gravity gravity gravity
Gravity Gravity Gravity
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Gravity + resistance Gravity +resistance GravÍty+ resistance
pin migration was seen in 24 of 36 (66%) of the patients with nonunion. But this did not always require later re¬ moval of the hardware. The technique appears most successful when nonunion exists without malalignment fragments or when aseptic necrosis exists alone. Femoral Head Prosthesis The long-term results of 237 consecutive femoral head prostheses done at Iowa for neck fractures have been re¬ ported.10 One hundred three prostheses were inserted as salvage procedures some 14 months postfracture. As seen in Table 6, the often prohibitive mortality of prosthetic re¬ placement for fresh neck fractures does not appear to be a major factor in the salvage procedure for reasons men¬ tioned previously. Complications were frequent in the overall prosthesis series, with the most serious being infection. In 2.5% of the cases, deep infection necessitated removal of the pros¬ thesis. Such infections can increase the mortality drasti¬ cally.4 In another 7.5%, a wound hematoma with or with¬ out superficial infection was present. Femoral shaft frac¬ tures occurred frequently (6.8%) at the time of reduction or during insertion of the medullary stem. This is a much greater problem in the salvage procedures where disuse osteoporosis has weakened the bone strength. Another problem inherent to this salvage procedure and total re¬ placement is incorrect placement of the metal stem. In 3.4% of these cases the stem protruded from the shaft at the site of the old nail hole. Shaft fracture, stem protru¬ sion, or early dislocation did not affect the late results if they were treated properly. Forty-three of the patients having salvage procedures were still alive over one year postoperatively, mentally alert, and available for follow-up examination. The aver¬ age time from surgery at follow-up was four years and four months. The average hip rating for this group was Table
Totals
Age (yr) Range Under 50
3.—Age
35 21
Total
average of nine years
Necrosis
Infection
Pins/Nail
Failed First Prosthesis
Painful
Second-Degree Degenerative Arthritis
10 12
102
36
12
15
18
12
61.9
62.9
62.6
51.8
69.7
62.5
Average age, yr
Table 4.—Hip
All patients Infected patients
Two additional
over an
21
50-59 60-69 70-79 80-89 90 +
*
were best in patients nonunion when the acetabular necrosis or aseptic cartilage was intact. Anderson et al1- reported 79.5% good to excellent results in treatment of traumatic aseptic necrosis. Their poor re¬ sults were seen when care was not taken to avoid cutting too much bone from the femoral neck, causing looseness. For nonunion they also reported a 71.4% overall success rate, with an 82% satisfactory result using the AustinMoore prosthesis versus the Thompson. Late complications were not substantial in the Iowa pa¬ tients but were noted in as many as 10% of Salvati and Wilson's study. The three potential problems worth men¬ tioning in this category are (1) loosening of the stem in the femoral shaft; (2) distal migration of the prosthesis; and (3) proximal (acetabular) migration with intrusion of the prosthesis into the pelvis. Of these three, proximal mi¬ gration is the most likely to alter the chance of a good long-term result. It occurred in as many as 15% of AustinMoore prostheses.1- It can also occur despite the presence of normal acetabular cartilage at the time of surgery. The type of surgical approach does not seem to affect the complication rate or the long-term results. Currently at Iowa, the posterior approach is used most frequently because it leaves the greater trochanter intact and allows early ambulation. The anterior approach is indicated occa¬ sionally when a flexion contracture exists that needs re¬ leasing at the time of prosthetic insertion. The fenestrated stem Austin-Moore prosthesis is usu¬ ally selected from diverse prosthetic designs because there appears to be less chance of stem loosening and distal mi¬ gration. The Thompson prosthesis, however, is recom¬ mended for those cases where less than 1.3 cm of the fem¬ oral neck is left above the lesser trochanter because it does have a greater height. Presently no well-documented
sults with
Distribution of 102 Patients
Aseptic
Nonunion
83.7, with 86% of the individuals having satisfactory re¬ sults ( < 80 points). Salvati and Wilson" noted that the re¬
patients
No. of Patients 38 10* were not
Age, yr 65 56.9
65.2
Rating for Head-Neck Resections Follow-up,
mo
42 58.3
Hip Rating Preoperative Postoperative 35 31
rated; both apparently had poor results.
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70 79
Heel lift, cm 2.5 2.7
long-term results of cementing the Thompson prosthesis
available. Such data could well show elimination of the shaft loosening and distal migration, but could also show an increase in the likelihood of proximal migration. are
Cup Arthroplasty In 1969, Johnston and Larson1' reported the results of 543 cup arthroplasties performed at the University of Iowa and observed from three to 16 years, with an aver¬ age of eight years. Of these operations, 76 were for com¬ plications of femoral neck fractures. We reviewed the records of 26 patients in this group who had a normal op¬
posite hip (Table 7). The ratings are not quite as good as those for the larger group (77-point average) or for the more recent results re¬ ported by Collis and Johnston (80- to 90-point average).11
This is attributable to the evolution of the biomechanical principles during the early cases.1'' Subsequently, as far as possible, the acetabulum has been moved medially and in¬ feriorly while the greater trochanter has been transferred laterally and distally through a lateral approach. This is probably most important in those patients with nonunions where shaft arthroplasties are frequently performed. The symptom for which relief is most often requested and most successfully relieved with this operation is pain. Nearly two thirds of the patients will experience complete relief of pain and can hope to walk without a detectable limp, most likely using a cane. They will have an improved but not normal range of motion, similar to that achieved with total hip replacement.16 Poorer preoperative hip rating scores are listed for this group than for patients selected for tibial bone grafting. Cup arthroplasty does tend to give a greater improvement in hip rating for the more disabled preoperative hips when compared to tibial graftings. Complications were substan¬ tial with this procedure. The infection rate in all 543 oper¬ ations was 3.8%; mortality was 1.5%; thrombophlebitis rate was 5.8%, with pulmonary emboli seen in 3.6%. Subluxa¬ tions and dislocations occurred in 7% of all procedures, but many of these occurred in those nonunion cases with the early reconstructive attempts done before trochanteric transfers became routine. Greater trochanter problems (ie, nonunion) were noted in 9.4% of the operations. Surgical revisions were required in about 4% of the 76 procedures done postfemoral neck fracture. When revision is required for any reason, the final result is likely to be poor. Only 36% in this series had a rating of 80 or better after revision. Shortening of 2.5 cm occurred and was related to the amount of bone already missing at surgery as in the non¬ union cases. Occasionally, settling of the cup on the femur also occurred. It can be seen from these statistics that patients with late complications of femoral neck fractures can improve with cup arthroplasties; almost all improved their rating in the pain category. Like bone grafting, cup arthroplasty is an acceptable means of treatment for this problem, as¬ suming one has a patient who is not only capable of, but willing to follow through with the lengthy postoperative
cup arthroplasty rehabilitation program. We also know that if a cup succeeds, it can last the life of the patient; and if it fails, we are left with many alternatives, ie, re¬ vise the cup, insert a femoral prosthesis, replace the entire hip joint, or resect the head and neck. Like the bone graft¬ ing procedure, this is a difficult operation that requires ex¬ perienced hands for good, long-lasting results.
Total
Hip Replacement
Several hundred Charnley total hip replacements have been done at the University of Iowa since 1969."·15·" Fol¬ low-up in this large series of patients indicates that there is no substantial difference in the final outcome no matter what the preoperative diagnosis. The overall, fairly shortterm results indicate a hip rating averaging from 90 to 95 with patients preponderantly satisfied. Prospective com¬ parison of 90 more recent cup arthroplasties with 183 re¬ cent total joint replacements indicates reliably superior results of the latter.14 The total hip replacement allows a
rapid postoperative recovery, greater endurance, pain, and less limp than does the cup procedure. Long-term results have recently been reported by Charn¬ ley.'8 In 379 operations extending from four to seven years, 90% of the patients appeared to have excellent re¬ sults regarding relief of pain, range of motion, and ability to walk. These early good results have apparently not de¬ teriorated with time. In Charnley's series of 582 cases, an 11.5% complication rate was reported. This included non¬ union of the greater trochanter (4.2%), infection (3.8%, half of these occurring late), death (2.1%), and mechanical failure (1.4%). We have had fewer infections but more dis¬ more
less
locations and
subluxations, as well as greater trochanteric
problems.
DuPont and Charnley also recently discussed technical difficulties in total hip replacements after failures of pre¬ vious operations.11' Forty-one out of a total of 217 oper¬ ations were performed on patients who had originally fractured the neck of the femur. It was found that the most difficult implant to replace was the Austin-Moore prosthesis because of the diminished size of the greater trochanter and the difficulty of extraction of the fenestrated stem from the medullary canal. Conversion from cup arthroplasty was apparently the easiest technically. In this group of salvage procedures, 84.5% of the patients were totally relieved of pain, whereas 3.5% still had signif¬ icant pain. As seen in Table 1, total hip replacement has been done more than any other major salvage procedure at our insti¬ tution in the last three years. However, it has been re¬ served for older patients with circumscribed life expec¬ tancies and for patients in whom a good result with any of the alternative procedures could not be anticipated. It is currently our thinking that successful total hip replace¬ ment can be expected to last for at least ten years. More time will be needed to establish the maximum longevity of such a procedure. Its attractive early results must be weighed against its potential complications, and the pa¬ tients' prognosis if for some reason the xlevice must be re¬ moved.
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Table
5.—Hip Rating for Tibial
Hip Rating
Diagnosis Nonunion
Follow-up
Preop-
Postop¬
No. of Cases 31
yr 66.6
Time 4 yr 3 mo
erative 54
46
60.4
6 yr
47
81
16
54.0
6 yr 11
57
79 (+22)
Age,
erative 84 (+30)
Aseptic
necrosis* & nonunion
Second-degree aseptic
(+34)
Aseptic necrosis
=
30%
Diagnosis Primary prosthesis Salvage prosthesis (nonunion and/or aseptic necrosis)
mo
of head.
in Femoral Head Prostheses
6.—Mortality
No. of Patients
Average Age, yr
in First Year
63
79
41
103
71
10
% Mortality
yr
Time, yr
tive
tive
61.5
6.7
32.0
75.0 (+43)
61.9
8.0
54.0
75.0
Nonunion necrosis
Aseptic
necrosis
15
(+21)
COMMENT at the University of Iowa, we have no pan¬ for the treatment of femoral neck fracture complica¬ tions. Our recent statistics (Table 1) reflect our continous reappraisal of accumulated clinical experience. Each alternative treatment method carries a combination of advantages, disadvantages, and uncertainties that are unique to it. Total hip replacement is employed in a large number of salvage situations (29 of 75). It is used predominantly for patients with less than a 15-year physiologic life expec¬ tancy who are good operative risks and who are poten¬ tial walkers. The patients are uncomfortable and limited enough to stand in need of a Girdlestone procedure, the al¬ ternative in the event of a total hip replacement failure. Tibial bone grafting is often chosen for nonunion and avascular necrosis in comparatively younger patients (life expectancy > 20 years) in whom the preservation of bone appears wisest in the long-term picture. The presence of a fairly good preoperative Iowa hip rating, < a 30° flexion contracture and about 90° of flexion, makes this procedure an even more attractive choice. The Austin-Moore prosthesis has been performed less frequently since the introduction of whole joint replace-
Currently
acea
References
Fielding
J:
Displaced femoral
neck fractures.
2. Massie W: Treatment of femoral neck fractures
Age, Follow-up Preopera- Postopera¬
and/or aseptic
last resort for in¬ to
walk preoperatively. The surgeon who attempts to deal with femoral neck fixations should be (1) familiar with the patient's oper¬ ative fragility, physiologic life expectance, and projected functional needs; (2) knowledgeable about and technically capable to perform each of the available procedures; and (3) able to compute this comprehensive judgment and skill into the appropriate operation for his patient, ex natura rei.
2:11-17, 1973.
Hip Rating No. of Patients
as a
fections, failed implants, and/or for patients unable
1.
7.—Hip Ratings for Posttraumatic Cup Arthroplasties (Normal Opposite Hip)
Table
Diagnosis
prosthesis.
Head and neck resection is done
necrosis
Table
mainly used for nonunion patients with a phys¬ life iologic expectancy of 15 years or less or in cases where the acetabular cartilage remains intact. Cup arthroplasty is now performed infrequently, but is still considered desirable in comparative young patients with poor preoperative hip ratings, in cases of collapsed avascular heads, or unstable nonunion sites. These pa¬ tients present a poor prognosis for a bone graft or femoral ment. It is
Bone Grafts
Orthop
Rev
emphasizing
long-term follow-up observations on aseptic necrosis. Clin Orthop 92:16-62, 1973. 3. Metz CW Jr, Sellers TD, Feagin JA, et al: The displaced intracapsular fracture of the neck of the femur: Experiences with the Dyerly method of fixation in 63 cases. J Bone Joint Surg 52\x=req-\ A:113-127, 1970. 4. Niemann K, Mankin H: Fractures about the hip in an institutionalized patient population: II. Survival and ability to walk again. J Bone Joint Surg 50-A:1327-1340, 1968. 5. Goldstein M, Beye C, Bonfiglio M, et al: Treatment of fractures of the neck of the femur in the aged. J Am Geriatr Soc 4:75\x=req-\ 81, 1956. 6. Larson C: Rating scale for hip disabilities. Clin Orthop 31:85\x=req-\ 93, 1963. 7. Parr P, Croft C, Enneking W: Resection of the head and neck of the femur with and without angulation osteotomy: A follow-up study of 38 patients. J Bone Joint Surg 53-A:935-944, 1971. 8. Stenchfield F, Cavallaro W: Arhtrodesis of the hip joint: A follow-up study. J Bone Joint Surg 32-A:48-58, 1950. 9. Bonfiglio M, Voke E: Aseptic necrosis of the femoral head and non-union of the femoral neck: Effect of treatment by drilling and bone grafting (Phemister technique). J Bone Joint Surg 50\x=req-\ A:48-66, 1968. 10. Hawkins L: Hip prostheses: Fifteen years' experience. J Iowa Med Soc 56:465-471, 1966. 11. Salvati E, Wilson P: Long-term results of femoral-head replacements. J Bone Joint Surg 54-A:1355-1356, 1972. 12. Anderson L, Hamsa W, Waring T: Femoral-head prostheses: A review of 356 operations and their results. J Bone Joint 46-A:1049-1065, 1964. Surg 13. Johnston R, Larson C: Results of treatment of hip disorders with cup arthroplasty. J Bone Joint Surg 51-A:1461-1479, 1969. 14. Collis D, Johnston R: Comparative evaluation of the results of cup arthroplasty and total hip replacement. Clin Orthop 86:102\x=req-\ 1972. 15. Johnston
114,
R, Larson C: Biomechanics of cup arthroplasty. Clin Orthop 66:56-69, 1969. 16. Stauffer RN, Johnston RC: Total hip replacement: First
year's experience.
Arch Surg 103:668-671, 1971. 17. Johnston R: Clinical follow-up of total hip replacement. Clin Orthop 95:118-126, 1973. 18. Charnley J: The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg 54-B:61-76, 1972. 19. DuPont J, Charnley J: Low-friction arthroplasty of the hip for the failures of previous operations. J Bone Joint Surg 54-B:77\x=req-\ 87, 1972.
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Albright, MD, Stuart
L.
Weinstein, MD
Of 102 hips with femoral neck fracture complications, 75 required major secondary procedures such as total hip replacement, femoral prosthesis, cup arthroplasty, tibial bone grafting, and head and neck resection. The method chosen depended on the specific problem: nonunion, aseptic necrosis, infection, degenerative arthritis, or a failed primary prosthesis. Other factors influencing treatment were the patient's chronological and physiological age, his general health, his life pattern, and the familiarity of the surgeon with the technique and the advantages and disadvantages of the various salvage procedures.
improved techniques Despite fractures, complications
for managing femoral neck remain commonplace. At the University of Iowa we see nearly 34 examples each year. Between January 1970 and January 1973 there were 155 operations for fresh femoral neck fractures and 102 sec¬ ondary or salvage procedures. An increasing acceptance of high-angled sliding nail or pin systems, complete with lat¬ eral fixation devices, and the principle of early impaction should enable us to nearly eliminate the 36 nonunions we saw during this period.1-' Of the 102 hips, 75 needed major salvage procedures requiring more than mere removal of hardware or local debridement. These figures are some¬ what biased in that complications tend to be more readily referred to us than fresh fractures. Table 1 lists the reasons for primary treatment failures and subsequent corrective procedures at Iowa during the past three years. These statistics are presented merely to put this problem in perspective and to illustrate alterna¬ tive methods of treatment recently used at the University of Iowa. The numbers represent a conglomerate for the entire staff and do not reflect individual preferences for Accepted
for publication July 25, 1974. From the Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City. Reprint requests to Department of Orthopedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242 (Dr. Albright).
specific cases. The table does indicate, however, that no procedure is a panacea for homeotypical complica¬ tions. In each case, many factors must be considered by one
the surgeon before a decision about the best choice of treatment can be made. EVALUATION OF FEMORAL NECK FRACTURE COMPLICATIONS I. Patient information A. Physiologic age 1. Patient's chronologic age 2. General medical status a.
Cardiorespiratory
b. Neuromuscular 3. Mental status a. Alertness b. Attitude B. Functional expectations 1. Patient's requirements, ie, pain relief, ability to walk 2. Preoperative ambulatory status 3. Postoperative expectations: functional demands, ie, house confinement, return to work 4. Effect of specific complication on expected results C. Status of other joints, ie, hip, knees, upper extremities 1. Future degree of pain or disability 2. Ability to use crutches D. Procedure survivance requirement, ie, life expectancy of patient modified in terms of physiologic age II. Knowledge of salvage procedures A. Alternative procedures 1. Girdlestone 2. Arthrodesis 3. Bone graft 4. Femoral prosthesis 5. Cup arthroplasty 6. Total replacement B. Chances of good result (regarding success of each proce¬ dure for specific complications) 1. Short-term
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2.
C.
risks (death, infection, and
so
on) of each al¬
ternative D. Limitations of procedure 1. Postoperative management requirements 2. Technical difficulties of operation and associated E.
population at large in this age group, which 90%. The addition of a femoral neck fracture to the former reduced this survival rate to 33%. An estimation of the activity level and life expectancy of an individual may influence the choice of salvage procedure, eg, a 50-year-old woman expected to live 29 additional years should ideally receive the procedure offering the best, predictable life¬ time guarantee. rate in the
Long-term
Operative
operative problems Specific advantages of each procedure 1. Functional 2. Alternative if
post¬
was
procedure fails
RESULTS OF SALVAGE PROCEDURES
Femoral neck fracture complications are related to age.1 The additional medical problems often seen in people over age 65 lead to a high immediate mortality of 10% to 15%, with an additional 10% to 15% in the ensuing year." Pa¬ tients over 90 are clearly at greater risk than those closer to 65. Most of the serious problems are attributable to car¬ diac, pulmonary, and neuromuscular disorders as well as a suppressed mental status secondary to cerebral anoxia. In the seventh and eighth decades a majority of patients ap¬ pear to have associated cardiorespiratory problems and are thus poor operative risks. However, patients surviving femoral neck fracture long enough to develop complica¬ tions usually demonstrate stable support systems and are more likely to survive a salvage procedure. The choice of treatment may be predicated on the pa¬ tient's chief complaint. His prime concern may be the abil¬ ity to move about on his own, or merely relief of constant pain. Knowledge of the patient's ambulatory status prior to the operation is important. Niemann and Mankin4 re¬ ported that 17% of nursing home patients were unable to walk preoperatively. Only 40% of the ambulatory patients in this age group' who survived the primary procedure were ever able to walk again. The mental attitude and expectations of the patient and his family can clarify realistic goals toward which the surgeon should aim. A functional assessment should in¬ clude such questions as: Does the patient merely need to walk to the bathroom and the dining room table? Could the patient be independently ambulatory? Is it likely that he will return to work? Extremely important in reaching a conclusion as to functional expectations is the evaluation of the other joints involved in postoperative ambulation. For instance, disease in the contralateral hip or either knee may alter the expected results. One would not desire to electively resect the head and neck in a patient who had a painful degenerated hip on the opposite side and who desired to return to work in a job that required much walking. Strength of the upper extremities is also impor¬ tant if the patient is expected to use assistive devices
In order to offer a yardstick for comparing the relative merits of the alternative operations, the data most heavily relied on stem from patients treated at the University of Iowa who were given numerical hip ratings (Figure). The 100-point rating scale developed by Larson" offers an ob¬ jective quantitative evaluation of hip disabilities that is reproducible by different examiners. It is most valuable in comparison of preoperative versus postoperative results for an individual patient. It is also useful in comparing re¬ sults between groups of patients. From its use, we can ex¬ amine results of the following reconstructive procedures and thereby offer an aid for use in the selection of the most appropriate treatment for each individual patient. The patient's satisfaction is not part of this system, but is information obviously valuable to obtain. In general, patients whose score is over 90 would be classed as having an excellent result by any method. Sim¬ ilarly a score of less than 70 would fall into an unsatis¬ factory or poor category. Scores between 80 and 90 are reported as good results. Caution should be used in at¬ tempting to apply the general scores to making a decision on an individual patient. The expected improvement in the specific deficit most affecting that patient is far more
postoperatively. One should always arrive at a conclusion of the patient's physiologic age from his chronologic age and the associ¬ ated medical problems that exist. This will give an idea of the life expectancy anticipated for the individual by modi¬ fying national vital statistics (Table 2). Our patients fit into these national age categories as seen in Table 3. An example of the use of such a table is illustrated by Niemann and Mankin.1 Their nursing home patients' oneyear survival rate
was
71%
versus
the one-year survival
important.
Girdlestone Procedure
The classic "last resort" in modern hip surgery, other than the extreme of disarticulation, is a procedure remov¬ ing the head and neck, as described in the 19th century for the treatment of infection. The observation that a patient with a Girdlestone procedure can function fairly well free of significant pain is often assumed. A long-term look at how patients actually fare after this procedure has re¬ cently been reviewed by Parr et al.7 Table 4 presents a summary of these results. The overall results were encouraging, with 81% of the patients satisfied. Poor results were usually due to poor general medical status. From this study we can conclude that a Girdlestone procedure is most effective at per¬ manently relieving pain. However, these people cannot expect a normal hip. They will have a short leg, unstable hip, and will walk with a limp. They may require a shoe lift and at least a cane for support. Patients needing bilat¬ eral procedures should be warned of a poor prognosis. The procedure itself is simple but does require several weeks before the limb can comfortably tolerate weight bearing. Traction is frequently used for the first two to three weeks but does not appear to prevent shortening. Instability may be lessened by a pelvic support osteotomy.
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Table 1.—Three-Year
(1970 to 1973) Operative
Records for
Complications of
Femoral Neck Fractures
Treatment
Removal Hardware No. of Patients 36
Diagnosis Nonunion
Second-degree aseptic necrosis
12 15 12 18
Infection Failed Austin-Moore Painful nail/pins
Total
Bone
Hip
Graft 11
Femoral Prosthesis 11
Girdlestone
and/or
Cup Arthroplasty
Debridement
10 17
Second-degree degenerative arthritis Total
102
29
16
13
10
Average age at second procedure, yr
61.9
65.3
58.1
68.7
56.0
These results must be used as a basis for comparison with the more sophisticated procedures discussed below. Any procedure chosen over this one should yield better than a 70-point average on the Iowa scale, or an average gain of more than 35 points per patient.
Table
Fusion of the hip is only briefly mentioned as it is rarely elected by patients in our institution. Although this can be a reliable procedure in a child, the average age of the fem¬ oral neck fracture patient we are seeing with complica¬ tions is the sixth decade. We believe this procedure is con¬ traindicated in this age group because of the lack of adaptability of the lower part of the back, which is re¬ quired for successful arthrodesis.8 Also the prolonged (three to six months) immobilization necessary to obtain a good result could lead to the high mortality seen long ago when the fresh fractures were treated with cast immobili¬ zation. Tibial Bone
Grafting
In 1968, Bonfiglio and Voke" reported the effects of 116 tibial grafts to the femoral head and neck observed for two to 15 years. Ninety-three procedures were done for aseptic necrosis and/or nonunion secondary to femoral neck fractures. Table 5 summarizes the overall ratings for these patients. Nonunion.—When done for nonunion, threaded pins are also inserted for stability. All but five (84%) of the pa¬ tients in this category had a satisfactory result with decreased pain, improvement in function, and increased range of motion. In those instances where manipulation was required to realign the neck-shaft relationship, there was less chance of a good result (79%) than when a graft¬ ing in situ was done (92%). A long interval between fracture and bone grafting did not affect the result; the average lapse in this study was nine months. Aseptic Necrosis With Nonunion.—Seventy-six percent of the patients in this group had a satisfactory result, mak¬ ing this syndrome the most difficult to overcome with a bone graft. Most of the failures in this group occurred in
2.—Abridged
60.3
Life Table*
71.2 53.3 44.0 34.8 29.0 18.6 12.3 9.7 7.5 5.8
20 30 40 50 60 70 75
80 85 + *
49.9
Average Life Remaining, yr
Age, yr Birth
Arthrodesis
27
Data from Vital Statistics Report: Annual Summary for the United
States, 1972.
instability was a problem at the time of grafting, ie, requiring reduction of fragments be¬ cause of malalignment or those where grafting was per¬ formed less than one year after primary surgery. Aseptic Necrosis With Union.—Eighty-one percent of these patients had satisfactory results. Early diagnosis is difficult and is rarely made sooner than six months after fracture. The average time from onset of pain to grafting was 25 months and often ranged as high as four years. This delay did not substantially affect the results. In these patients there was no direct correlation between the de¬ gree of the collapse and the chance of success. Also, the roentgenographic presence of degenerative changes did not necessarily correlate with clinical symptoms. However it does seem reasonable that eventual secondary de¬ generative arthritis is more likely when substantial de¬ formity of the femoral head is present. Pain is often relieved immediately postoperatively, a phenomenon sim¬ ilarly noted with osteotomy at the hip or knee. The range of motion, muscle strength, and so forth improve with an exercise program. But, those people with at least 90° flex¬ ion and less than a 30° flexion contracture preoperatively tend to have more satisfactory results than those with stiffer hips·. In order to obtain an idea of the longevity of a success¬ ful grafting, we selected only those patients evaluated at least seven years postoperatively. Twenty-two of the 93 cases
where
those
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patients qualified; the time at examination ranged from seven to 15 years. Fifteen patients originally had nonun¬ ion and aseptic necrosis, four had aseptic necrosis alone,
and three had nonunion alone. The average age was 59.9 years. The preoperative hip rating was 49 and the postop¬ erative hip rating was 86 (gain of 37). All but four main¬ tained their hip ratings. Each of these patients had had nonunion with aseptic necrosis. One patient with an 82 fating at 4.5 years lost points to 77 by seven years. Two other patients noted moderate pain secondary to degen¬ erative changes at seven and 12 years after grafting. The fourth patient had developed a mild secondary collapse and fatigue pain only. Two patients required a second grafting procedure before desired results were obtained and continued to do well 7.6 and 8.0 years later. As noted in Table 1, the bone grafting procedure re¬ mains an attractive choice at the University of Iowa, espe¬ cially for the younger, more active patients. It saves the One hundred
A. Function
femoral head while providing the relatively good chance of long-lasting success in the posttraumatic cases. The procedure also carries a low morbidity and mortality. It is a conservative procedure in that, if it is not successful, any of the other reconstructive procedures can still be performed. Also, even if painful degenerative changes emerge beyond the 15-year time span studied, it shortens the years an implant will be required to function. However, inserting a tibial graft is a technically de¬ manding procedure where poor attention to detail is likely to lead to a poor result. It also requires a cooperative pa¬ tient who will carry out the postoperative program of pro¬ tected weight bearing and hip strengthening exercises for about ten to 12 months. Major postoperative complications are fewer than those seen with implant surgery, but they do exist. Fifteen of the 93 patients required a second oper¬ ation during this study period. In 2.7% of these patients, an infection necessitated a Girdlestone procedure. Some
point scale for hip evaluation.
(35 points)
Does most of housework or job that requires moving about Dresses unaided (includes tying shoes and putting on socks) Walks enough to be independent Sits without difficulty at table or toilet Picks up objects from floor by squatting Bathes without help Negotiates stairs foot over foot Negotiates stairs in any manner Carries objects comparable to suitcase Gets into car or public conveyance unaided and rides comfortably Drives a car B. Freedom from
pain (35 points)
No pain Pain only with fatigue Pain only with weight bearing Pain at rest but not with weight Pain sitting or in bed Continuous pain
D. Absence of
No fixed No fixed No fixed Not over
Muscle
5 5 5 4 3 3 3 2 2 2 1
C. Gait (10 points)
bearing
No limp; no support No limp using cane Abductor limp Short leg limp Needs two canes Needs two crutches Cannot walk
35 30 20 15 10 0
E.
deformity (10 points) 3 3 2 2
flexion over 30° adduction over ten degrees rotation over ten degrees 2.5 cm shortening
Range
of motion (10
10 8
points)
Flexion-extension (normal 140°) Abduction-adduction (normal 80°) External-internal rotation (normal 80° Total degrees Points (1 point/30o)
strength (No points)
Straight leg raising:
Abduction: Extension:
Less than Less than Less than
gravity gravity gravity
Gravity Gravity Gravity
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Gravity + resistance Gravity +resistance GravÍty+ resistance
pin migration was seen in 24 of 36 (66%) of the patients with nonunion. But this did not always require later re¬ moval of the hardware. The technique appears most successful when nonunion exists without malalignment fragments or when aseptic necrosis exists alone. Femoral Head Prosthesis The long-term results of 237 consecutive femoral head prostheses done at Iowa for neck fractures have been re¬ ported.10 One hundred three prostheses were inserted as salvage procedures some 14 months postfracture. As seen in Table 6, the often prohibitive mortality of prosthetic re¬ placement for fresh neck fractures does not appear to be a major factor in the salvage procedure for reasons men¬ tioned previously. Complications were frequent in the overall prosthesis series, with the most serious being infection. In 2.5% of the cases, deep infection necessitated removal of the pros¬ thesis. Such infections can increase the mortality drasti¬ cally.4 In another 7.5%, a wound hematoma with or with¬ out superficial infection was present. Femoral shaft frac¬ tures occurred frequently (6.8%) at the time of reduction or during insertion of the medullary stem. This is a much greater problem in the salvage procedures where disuse osteoporosis has weakened the bone strength. Another problem inherent to this salvage procedure and total re¬ placement is incorrect placement of the metal stem. In 3.4% of these cases the stem protruded from the shaft at the site of the old nail hole. Shaft fracture, stem protru¬ sion, or early dislocation did not affect the late results if they were treated properly. Forty-three of the patients having salvage procedures were still alive over one year postoperatively, mentally alert, and available for follow-up examination. The aver¬ age time from surgery at follow-up was four years and four months. The average hip rating for this group was Table
Totals
Age (yr) Range Under 50
3.—Age
35 21
Total
average of nine years
Necrosis
Infection
Pins/Nail
Failed First Prosthesis
Painful
Second-Degree Degenerative Arthritis
10 12
102
36
12
15
18
12
61.9
62.9
62.6
51.8
69.7
62.5
Average age, yr
Table 4.—Hip
All patients Infected patients
Two additional
over an
21
50-59 60-69 70-79 80-89 90 +
*
were best in patients nonunion when the acetabular necrosis or aseptic cartilage was intact. Anderson et al1- reported 79.5% good to excellent results in treatment of traumatic aseptic necrosis. Their poor re¬ sults were seen when care was not taken to avoid cutting too much bone from the femoral neck, causing looseness. For nonunion they also reported a 71.4% overall success rate, with an 82% satisfactory result using the AustinMoore prosthesis versus the Thompson. Late complications were not substantial in the Iowa pa¬ tients but were noted in as many as 10% of Salvati and Wilson's study. The three potential problems worth men¬ tioning in this category are (1) loosening of the stem in the femoral shaft; (2) distal migration of the prosthesis; and (3) proximal (acetabular) migration with intrusion of the prosthesis into the pelvis. Of these three, proximal mi¬ gration is the most likely to alter the chance of a good long-term result. It occurred in as many as 15% of AustinMoore prostheses.1- It can also occur despite the presence of normal acetabular cartilage at the time of surgery. The type of surgical approach does not seem to affect the complication rate or the long-term results. Currently at Iowa, the posterior approach is used most frequently because it leaves the greater trochanter intact and allows early ambulation. The anterior approach is indicated occa¬ sionally when a flexion contracture exists that needs re¬ leasing at the time of prosthetic insertion. The fenestrated stem Austin-Moore prosthesis is usu¬ ally selected from diverse prosthetic designs because there appears to be less chance of stem loosening and distal mi¬ gration. The Thompson prosthesis, however, is recom¬ mended for those cases where less than 1.3 cm of the fem¬ oral neck is left above the lesser trochanter because it does have a greater height. Presently no well-documented
sults with
Distribution of 102 Patients
Aseptic
Nonunion
83.7, with 86% of the individuals having satisfactory re¬ sults ( < 80 points). Salvati and Wilson" noted that the re¬
patients
No. of Patients 38 10* were not
Age, yr 65 56.9
65.2
Rating for Head-Neck Resections Follow-up,
mo
42 58.3
Hip Rating Preoperative Postoperative 35 31
rated; both apparently had poor results.
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70 79
Heel lift, cm 2.5 2.7
long-term results of cementing the Thompson prosthesis
available. Such data could well show elimination of the shaft loosening and distal migration, but could also show an increase in the likelihood of proximal migration. are
Cup Arthroplasty In 1969, Johnston and Larson1' reported the results of 543 cup arthroplasties performed at the University of Iowa and observed from three to 16 years, with an aver¬ age of eight years. Of these operations, 76 were for com¬ plications of femoral neck fractures. We reviewed the records of 26 patients in this group who had a normal op¬
posite hip (Table 7). The ratings are not quite as good as those for the larger group (77-point average) or for the more recent results re¬ ported by Collis and Johnston (80- to 90-point average).11
This is attributable to the evolution of the biomechanical principles during the early cases.1'' Subsequently, as far as possible, the acetabulum has been moved medially and in¬ feriorly while the greater trochanter has been transferred laterally and distally through a lateral approach. This is probably most important in those patients with nonunions where shaft arthroplasties are frequently performed. The symptom for which relief is most often requested and most successfully relieved with this operation is pain. Nearly two thirds of the patients will experience complete relief of pain and can hope to walk without a detectable limp, most likely using a cane. They will have an improved but not normal range of motion, similar to that achieved with total hip replacement.16 Poorer preoperative hip rating scores are listed for this group than for patients selected for tibial bone grafting. Cup arthroplasty does tend to give a greater improvement in hip rating for the more disabled preoperative hips when compared to tibial graftings. Complications were substan¬ tial with this procedure. The infection rate in all 543 oper¬ ations was 3.8%; mortality was 1.5%; thrombophlebitis rate was 5.8%, with pulmonary emboli seen in 3.6%. Subluxa¬ tions and dislocations occurred in 7% of all procedures, but many of these occurred in those nonunion cases with the early reconstructive attempts done before trochanteric transfers became routine. Greater trochanter problems (ie, nonunion) were noted in 9.4% of the operations. Surgical revisions were required in about 4% of the 76 procedures done postfemoral neck fracture. When revision is required for any reason, the final result is likely to be poor. Only 36% in this series had a rating of 80 or better after revision. Shortening of 2.5 cm occurred and was related to the amount of bone already missing at surgery as in the non¬ union cases. Occasionally, settling of the cup on the femur also occurred. It can be seen from these statistics that patients with late complications of femoral neck fractures can improve with cup arthroplasties; almost all improved their rating in the pain category. Like bone grafting, cup arthroplasty is an acceptable means of treatment for this problem, as¬ suming one has a patient who is not only capable of, but willing to follow through with the lengthy postoperative
cup arthroplasty rehabilitation program. We also know that if a cup succeeds, it can last the life of the patient; and if it fails, we are left with many alternatives, ie, re¬ vise the cup, insert a femoral prosthesis, replace the entire hip joint, or resect the head and neck. Like the bone graft¬ ing procedure, this is a difficult operation that requires ex¬ perienced hands for good, long-lasting results.
Total
Hip Replacement
Several hundred Charnley total hip replacements have been done at the University of Iowa since 1969."·15·" Fol¬ low-up in this large series of patients indicates that there is no substantial difference in the final outcome no matter what the preoperative diagnosis. The overall, fairly shortterm results indicate a hip rating averaging from 90 to 95 with patients preponderantly satisfied. Prospective com¬ parison of 90 more recent cup arthroplasties with 183 re¬ cent total joint replacements indicates reliably superior results of the latter.14 The total hip replacement allows a
rapid postoperative recovery, greater endurance, pain, and less limp than does the cup procedure. Long-term results have recently been reported by Charn¬ ley.'8 In 379 operations extending from four to seven years, 90% of the patients appeared to have excellent re¬ sults regarding relief of pain, range of motion, and ability to walk. These early good results have apparently not de¬ teriorated with time. In Charnley's series of 582 cases, an 11.5% complication rate was reported. This included non¬ union of the greater trochanter (4.2%), infection (3.8%, half of these occurring late), death (2.1%), and mechanical failure (1.4%). We have had fewer infections but more dis¬ more
less
locations and
subluxations, as well as greater trochanteric
problems.
DuPont and Charnley also recently discussed technical difficulties in total hip replacements after failures of pre¬ vious operations.11' Forty-one out of a total of 217 oper¬ ations were performed on patients who had originally fractured the neck of the femur. It was found that the most difficult implant to replace was the Austin-Moore prosthesis because of the diminished size of the greater trochanter and the difficulty of extraction of the fenestrated stem from the medullary canal. Conversion from cup arthroplasty was apparently the easiest technically. In this group of salvage procedures, 84.5% of the patients were totally relieved of pain, whereas 3.5% still had signif¬ icant pain. As seen in Table 1, total hip replacement has been done more than any other major salvage procedure at our insti¬ tution in the last three years. However, it has been re¬ served for older patients with circumscribed life expec¬ tancies and for patients in whom a good result with any of the alternative procedures could not be anticipated. It is currently our thinking that successful total hip replace¬ ment can be expected to last for at least ten years. More time will be needed to establish the maximum longevity of such a procedure. Its attractive early results must be weighed against its potential complications, and the pa¬ tients' prognosis if for some reason the xlevice must be re¬ moved.
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Table
5.—Hip Rating for Tibial
Hip Rating
Diagnosis Nonunion
Follow-up
Preop-
Postop¬
No. of Cases 31
yr 66.6
Time 4 yr 3 mo
erative 54
46
60.4
6 yr
47
81
16
54.0
6 yr 11
57
79 (+22)
Age,
erative 84 (+30)
Aseptic
necrosis* & nonunion
Second-degree aseptic
(+34)
Aseptic necrosis
=
30%
Diagnosis Primary prosthesis Salvage prosthesis (nonunion and/or aseptic necrosis)
mo
of head.
in Femoral Head Prostheses
6.—Mortality
No. of Patients
Average Age, yr
in First Year
63
79
41
103
71
10
% Mortality
yr
Time, yr
tive
tive
61.5
6.7
32.0
75.0 (+43)
61.9
8.0
54.0
75.0
Nonunion necrosis
Aseptic
necrosis
15
(+21)
COMMENT at the University of Iowa, we have no pan¬ for the treatment of femoral neck fracture complica¬ tions. Our recent statistics (Table 1) reflect our continous reappraisal of accumulated clinical experience. Each alternative treatment method carries a combination of advantages, disadvantages, and uncertainties that are unique to it. Total hip replacement is employed in a large number of salvage situations (29 of 75). It is used predominantly for patients with less than a 15-year physiologic life expec¬ tancy who are good operative risks and who are poten¬ tial walkers. The patients are uncomfortable and limited enough to stand in need of a Girdlestone procedure, the al¬ ternative in the event of a total hip replacement failure. Tibial bone grafting is often chosen for nonunion and avascular necrosis in comparatively younger patients (life expectancy > 20 years) in whom the preservation of bone appears wisest in the long-term picture. The presence of a fairly good preoperative Iowa hip rating, < a 30° flexion contracture and about 90° of flexion, makes this procedure an even more attractive choice. The Austin-Moore prosthesis has been performed less frequently since the introduction of whole joint replace-
Currently
acea
References
Fielding
J:
Displaced femoral
neck fractures.
2. Massie W: Treatment of femoral neck fractures
Age, Follow-up Preopera- Postopera¬
and/or aseptic
last resort for in¬ to
walk preoperatively. The surgeon who attempts to deal with femoral neck fixations should be (1) familiar with the patient's oper¬ ative fragility, physiologic life expectance, and projected functional needs; (2) knowledgeable about and technically capable to perform each of the available procedures; and (3) able to compute this comprehensive judgment and skill into the appropriate operation for his patient, ex natura rei.
2:11-17, 1973.
Hip Rating No. of Patients
as a
fections, failed implants, and/or for patients unable
1.
7.—Hip Ratings for Posttraumatic Cup Arthroplasties (Normal Opposite Hip)
Table
Diagnosis
prosthesis.
Head and neck resection is done
necrosis
Table
mainly used for nonunion patients with a phys¬ life iologic expectancy of 15 years or less or in cases where the acetabular cartilage remains intact. Cup arthroplasty is now performed infrequently, but is still considered desirable in comparative young patients with poor preoperative hip ratings, in cases of collapsed avascular heads, or unstable nonunion sites. These pa¬ tients present a poor prognosis for a bone graft or femoral ment. It is
Bone Grafts
Orthop
Rev
emphasizing
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