Management of Elderly #

NOF

Dr. Pyae Phyo Maung (Resident Year 3 )

Supervisor- AP. Dr. Chan Mya Ohn
Introduction
Femoral neck fractures are a commonly encountered injury in
orthopaedic practice and result in significant morbidity and mortality
According to age, Elderly # NOF means
• > 50 yrs in developing countries
• > 65 yrs in developed countries
• > 80 yrs in US, UK, Europe, Japan
Introduction
As the count of the elderly population increases, the annual number of hip
fractures is globally expected to exceed 7 million in the next 40 to 50 years
# NOF is a major cause of morbidity and mortality in the elderly and associated
with an overall mortality rate averaging 7.5% within 1 mnth and 30% at one year
The relative risk of mortality increases 4% per year
 Increased mortality rate is more related with the presence of co-morbidities
and bed bound complications such as DVT, pulmonary embolism, pneumonia,
bed sores, congestive heart disease, UTI , Decubitus ulcer etc..
(The Open Orthopaedics Journal, 2017, 11, 309-315)
 Surgical Timing
• Numerous studies have reported the correlation between
time to surgery and increased mortality
• Shiga and colleagues’ meta-analysis of 16 observational
studies demonstrated increased mortality rates at 30 days
and one year of 41% and 32 % respectively when surgery
was delayed more than 48 hrs
• In the patients who are fit for surgery that had delays of
more than 4 days had a mortality rate of 10.7 % at one
month
• In the patients who require medical optimization
preoperatively had a 30 day mortality nearly 2.5 times
greater (17 %) than fit patients (Moran et al)
Surgical Timing
Rapid medical optimization and prompt surgery significantly improve outcomes
in patients with hip fractures

(David A Curr Rev Musculoskelet Med (2012) 5:214–221

DOI 10.1007/s12178-012-9127-x)
Introduction
A geriatric hip fracture clinical pathway, led by an orthopedic surgeon, was
developed in 2007
This clinical pathway team is multidisciplinary and consists of surgeons,
physicians, anesthetists, nurses, physiotherapists, occupational therapists,
medical social workers, dieticians as well as voluntary support groups
This pathway is an excellent approach to the geriatric hip fracture service.
The most significant improvement is the dramatic shortening of the length of
hospital stay and 30 days mortality rate Geriatric Orthopaedic
Surgery

& Rehabilitation

4(1) 3-9

ª The Author(s) 2013

Figure. The model of geriatric
hip fracture clinical pathway
Risk factors
•Older patients- Osteoporosis or Osteomalacia
•Elderly women (low estrogen level)
•Poor health
• Excessive smoking and alcohol use
•Previous fracture (fall history)
•Mental problems (dementia, depression)
•Major trauma in young adults like RTA, Fall etc.
Mechanism of injury
•Trivial fall- direct blow over the greater trochanter
•Lateral rotation of extremity- posterior communition of neck
•Cyclical loading due to muscle force and torsion
Clinical features
•H/O of fall
•Pain
•Restriction of movements
P/E
•Tenderness over ant hip joint line
•Minimal shortening
•External rotation deformity
Investigation
Radiography
1. Extent of fracture (complete or incomplete)
2. Fracture angle
3. Break in Shenton’s line
4. Posterior wall comminution
5. Prominent lesser trochanter
6. Degree of osteoporosis
Treatment plan
Depends on
1. Patient factors ( Age, Activity level, Cognitive level, compliance, associated
comorbidities, and Life expectancy )
2. Fracture factors ( Degree of displacement, Degree of comminution, Pattern of
the fracture, and the quality of bone )
 Age historically is considered major determinant in a treatment plan
•Definitive age cutoff difficult, Often arbitrarily set at physiologic age 65 given
differences in physiologic vs chronologic age
•Sernbo Scoring System ( Age, Habit, Walking aids, Mental status )
The Sernbo score is a simple non-specialist tool that may be used as part of a
routine orthopaedic assessment to identify high-risk patients prior to
surgery for an intracapsular hip fracture.
This may have a role as a screening test for transferring patients to a
preoperative optimization area
High risk patients- < 15
points
Low risk patients - ≥ 15 points

High risk group – one-year

survival rate 65 %
Low risk group- one-year
survival rate 92 %
Pre-operative considerations
•The bone quality in the proximal femur is always a concern when the surgeon
considers which fixation method (cemented or non-cemented) to use in the
treatment of # NOF
•Dual-energy x-ray absorptiometry (DEXA) is considered to be the gold standard
for measuring the bone mineral density (BMD) over the proximal femur.
•However, DEXA may not be readily available in every institution, and it may not
be practical to do it for every patient.
• Several authors proposed that the changes in the plain radiographs could be
used to predict the bone quality in the proximal femur
The Journal of Arthroplasty Vol. 21 No. 4 2006
Pre-operative considerations
Singh et al quantified the degree of osteoporosis by observing the trabecular
pattern of proximal femur in the plain anteroposterior (AP) radiograph.
However, other authors found that it had poor correlation with the degree of
osteoporosis.
 Singh Index
Grade Description
1 Even the principal compressive trabeculae
are markedly reduced in number and are no
longer prominent.
2 Only the principal compressive trabeculae
stand out prominently, the others have been more or
less completely resorbed.
3 There is a break in the continuity of the
principal tensile trabeculae.
4 Principal tensile trabeculae are markedly
reduced in number but can still be traced from the
lateral cortex to the upper part of the femoral neck.
5 The structure of principal tensile and
principal compressive trabeculae is accentuated. Ward’s
triangle appears prominent.
6 All the normal trabecular groups are
visible and the upper end of the femur seems completely
occupied by cancellous bone.
Pre-operative considerations
Dorr et al classified bone quality as A, B, or C, and based the findings in both
the AP and the lateral radiographs.
The parameters assessed included the thickness of the cortices, especially the
posterior one, the shape of the medullary canal, and the width of the canal at
the diaphyseal part.
These were descriptive and could not be accurately measured.
Dorr classification
Treatment
Goals

 Decrease the rates of mortality

 Minimize risks and avoid complications
 Return to pre-injury level of function
 Provide cost-effective treatment

Early mobilization and decreasing the risks associated with

prolong bed rest ( pneumonia, decubiti, UTI, DVT, etc) are
the primary goals for the physiologically older patients
Treatment
Options
 Non-operative
◦ very limited role
◦ Activity modification
◦ Skeletal traction
 Operative
◦ Internal Fixation
◦ Hemiarthroplasty
◦ Total Hip Replacement
Also consider biological age > chronological age
Impacted/Non-displaced
Fractures
Fractures of the femoral neck are considered to be impacted when they do not
displace during normal hip movement.
This implies that the fragments are in close apposition so that they move as one
 Mean - Garden stage 1 and 2
Impacted/Non-displaced
Fractures
Criteria of impaction- The diagnosis of impacted femoral neck fracture was
based on the following clinical and radiographic features:
(1) absence of deformity at the affected hip
(2) ability to rotate medially at the hip and to raise the straight leg actively
(3) painless passive movements at the hip
(4) radiographic appearances of a fracture of the femoral neck showing close
apposition of the fragments on the A-P and lateral radiographs with a varying
degree of valgus at the fracture site.
Impacted/ Non-displaced
Fractures
Up to 40% of impacted or non-displaced fractures will displace without internal
fixation
The treatment of choice of fresh impacted femoral neck fractures is primary
internal fixation.
Surgical fixation for non-displaced fractures allows early patient mobilization
and ensures that a non-displaced fractures does not subsequently displace
Exceptions are pathologic fractures, severe osteoarthritis/ rheumatoid arthritis,
Paget disease, and other metabolic conditions
These conditions may require prosthetic replacement
Internal Fixation
Minimally invasive dynamic hip screw (MIDHS), Sliding Compression hip screw (SCHS),
and Multiple cannulated screws (MCS) can be used for treating the un-displaced femoral
neck fractures

• Predictable healing
• Nonunion < 5%
• AVN < 8%
• Infection < 5%
• Minimal complications
• Relatively quick procedure
• Minimal blood loss
• Early mobilization
• Unrestricted weight bearing with assistive device
Internal Fixation
Sliding Compression Hip Screw (SCHS ) had more disadvantages related to
more soft tissue stripping than either minimally invasive dynamic hip
screw( MIDHS) or multiple cannulated screws (MCS).
MIDHS showed a trend of an increased rate of overall success (stable fixation
without need to change the implant) in an elderly patient with un-displaced
femoral neck fracture when compared with MCS.
 MCS fixation could loosen with time if the lateral cortex was osteopenic with
poor bone quality.

(Yih-Shiunn Lee et al The Journal of TRAUMA Injury, Infection, and Critical Care 2008)
 Minimally Invasive Dynamic Hip Screw

Fig. 2. The mini-invasive technique: incision and guide Fig. 3. The mini-invasive technique: Insertion of
plate use. A 3-cm long incision is made at an incision point the guide wire and retractor use. (A) The guide
approximately 4 cm below the vastus lateralis ridge. (A) A, wire is inserted through the side plate and
vastus lateralis ridge; B, upper incision point; C, lower the lag screw. GW, guide wire; S, skin. (B) A
incision point; GW, guide wire; S, skin. (B) A lag screw is retractor is used and the 3 screw holes are viewed
inserted, and the guide wire is then removed. A 7-cm long clearly. R, retractor; S, skin.
side plate (3 holes) is placed into a 3-cm incision wound in
an oblique and 180-degree rotation position. When the
plate is completely inserted to the incision wound, return
the plate to a normal position. P, side plate; S, skin
Fig. 5. A 78 year-old male patient with un-displaced
femoral neck fracture was treated with MIDHS. (A)
Preoperative pelvis AP view showed an un-displaced
fracture of left femoral neck (arrow). P, a line parallel to
the fracture; H, a horizontal line; the Pauwels angle 60
degrees (Pauwels type III). (B) Postoperative 2-year pelvis
AP view showed fracture healing with a slight valgus but
no evidence of mechanical failure.
Internal Fixation
Multiple screw fixation:
•The common accepted method of fixation
 Three parallel screws are the usual number of fixation
 No advantage to > 3 screws
 Uniform compression across fracture
 In-situ pin impacted fractures
 * ↑ AVN with disimpaction [Crawford 1960]
 Fixation most dependent on bone density
Multiple Cannulated Screw Fixation
 Screw Fixation
Screw location
◦ Avoid posterior/ superior quadrant
◦ Blood supply
◦ Cut-out
◦ Biomechanical advantage to inferior/ calcar screw
[Booth 1998]
Sliding Compression Screw
Fixation
Compression Hip Screws
◦ Sacrifices large amount of bone
◦ May injury blood supply
◦ Biomechanically superior in cadavers
◦ Anti-rotation screw often needed
◦ Increased cost and operative time

No clinical advantage over parallel

screws
* May have role in high energy/ vertical
shear fractures
Complications of Internal Fixation
In Un-displaced Fracture
Failure of Internal Fixation
◦ Inadequate / unstable reduction
◦ Secondary displacement/ Disimpaction
◦ Poor bone quality
◦ Poor choice of implant

Treatment
◦ Elderly: Arthroplasty
 Displaced Fractures
ORIF vs.
Hemiarthroplasty
Hemiarthroplasty associated with
◦ Lower reoperation rate (6-18% vs. 20-36%)
◦ Improved functional scores
◦ Less pain
◦ More cost-effective
◦ Slightly increased short term mortality
Literature supports hemiarthroplasty for displaced
fractures [Lu-yao JBJS 1994]
[Iorio CORR 2001]
Unipolar Hemiarthroplasty
THOMPSON PROSTHESIS (CEMENTED)
Head
Neck
INDICATIONS
Acutely
1. Non union angled Collar

2. Age > 60 yrs

3. Inadequate femoral calcar
Stem
4. Pathological fracture
5. Osteoporosis
Unipolar Hemiarthroplasty
AUSTIN MOORE PROSTHESIS Eye for Head
(CEMENTLESS) removal
Transverse collar
Fenestrations facilitate
INDICATIONS bony ingrowth and
anchor the prosthesis
1. Non union through the shaft
2. Age > 60 yrs
3. Adequate femoral calcar
Advantages of Unipolar
Hemiarthroplasty
1. Relatively low cost
2. Short duration of operation
3. Acceptable intra-operative bleeding
4. Reasonable clinical outcomes
Disadvantages of Unipolar
Hemiarthroplasty
1. Hip pain
2. Prosthetic loosening
3. Dislocation
4. Periprosthetic fracture
5. Acetabular protusion
6. Leg length discrepancy
These may lead to the need for revision, and the re-operation rate ranges from
4.5 to 24%.
The philosophy of Austin Moore Prosthesis

 Austin Moore hemiarthroplasty was originally designed for cementless

application.
Its initial stability inside the proximal femur depends on the principle of three
point fixation with bone metal contact at multiple points
Proximal fixation of the implant is crucial in the success of the surgery a tight
fixation gives mechanical stability and allow the grafts in the fenestration to
consolidate, making it a self-locking device -this prevents over-loading of calcar,
no subsidence, no loosening, no failure
The philosophy of Austin
Moore Prosthesis
Impaction grafting: the most important area is the medial side near calcar
 Graft should be inserted when nearly half of the prosthesis has gone inside
Fill the fenestrations of the prosthesis with bone grafts, as the prosthesis
advances into the canal the collar of the implant should not over-hang on the
calcar-if done properly, it should rest on the neck and will compress the grafts
Concepts about Complication Of
Austin Moore Prosthesis
Symptomatic femoral loosening is one of the causes which lead to revision.
The possible signs of femoral loosening include varus pivoting, subsidence, osteolysis along
the stem of prosthesis and lack of ossification in the fenestration hole of prosthesis.
Initial stability of Austin Moore hemiarthroplasty depends on multiple points of bone metal
contact.
 Adequate fill of the prosthetic stem within the femur is important to ensure the prosthesis
is sitting on the good quality cancellous bone in the periphery or even the cortical bone
We advocated a minimum of 70% canal fill by the stem of the prosthesis at the level of
lesser trochanter on AP X-ray to avoid excessive subsidence of the prosthesis and pain
W.P. Yau*, et al at 2004
 Figure : Relative fill of the stem of prosthesis
to the
medullary canal of femur at the level of lesser
trochanter on AP X-ray (A and B).

 It was concluded that the fill of AMA within the shaft

of femur should be greater than 70% to avoid early
loosening
Bipolar Hemiarthroplasty
INDIACTIONS Bipolar head
1. Non union Inner head
variable
2. Young patients (50-55 yrs) neck length

Taper

Femoral stem
 Hemiarthroplasty
Unipolar vs. Bipolar

Bipolar theoretical advantages

◦ Lower dislocation rate
◦ Less acetabular wear/ protrusio
◦ Less Pain
◦ More motion
 Hemiarthroplasty
Unipolar vs. Bipolar
Bipolar
◦ Disadvantages
◦ Cost
◦ Dislocation often requires open
reduction
◦ Loss of motion interface (effectively
unipolar)
◦ Polyethylene wear/ osteolysis not yet
studied for Bipolars
 Hemiarthroplasty
Unipolar vs. Bipolar
 Complications / Mortality / Length of stay
◦ No Difference
 Hip Scores / Functional Outcomes
◦ No significant difference
◦ Bipolar slightly better walking speeds, motion, pain
 Revision rates
◦ Unipolar 20% vs. Bipolar 10% (7 years)
Unipolar more cost-effective
Literature supports use of either implant
The Bonding Of Prosthesis
To Bone By Cement
BY JOHN CHARNLEY, From the Centre for Hip Surgerv, Wrightington Hospital.
1.The use of acrylic cement in bonding femoral head prostheses to bone is
described.
2. No sign of deterioration of the bond between the cement and bone has been
seen in histological preparations up to three and a quarter years after operation,
and no harmful effects have been recognized, or suspected, in 455 patients in
whom it has been used.
3. The technique is considered justifiable in elderly patients where the medullary
canal is large and the cortex of the femur is thin and brittle.
 Hemiarthroplasty
Cemented vs. Non-
cemented
Cement (PMMA)
◦ Improved mobility, function, walking aids
◦ Most studies show no difference in morbidity / mortality
◦ Sudden Intra-op cardiac death risk slightly increased:
(1% cemented hemi for fx vs. 0.015% for elective
arthroplasty)
Non-cemented (Press-fit)
◦ Pain / Loosening higher
◦ Intra-op fracture (theoretical)
Hemiarthroplasty
Cemented vs. Non-cemented
Conclusion:
Cement gives better results
◦ Function
◦ Mobility
◦ Implant Stability
◦ Pain
◦ Cost-effective
◦ Low risk of sudden cardiac
death
Use cement with caution Tao Li et al at 2013
Cemented vs. Non-cemented
Hemiarthroplasty
Total Hip Arthroplasty
INDICATIONS
1. Pre-existing acetabular disease
2. Non inflammatory degenerative joint disease (OA, RA)
3. Displaced fracture in old age > 60 yrs
4. Avascular necrosis of femoral head
5. Neglected non-union femoral neck fractures
6. Revision procedures where other treatments or devices have failed
 Total Hip Arthroplasty
CONTRAINDICATIONS
1. Active infection or suspected latent infection in or about the hip joint
2. Bone stock that is inadequate for support or fixation of the prosthesis;
3. Skeletal immaturity
4. Any mental or neuromuscular disorder that would create an unacceptable risk of
prosthesis instability, prosthesis fixation failure, or complications in post-operative care
5. Obesity. An overweight or obese patient can produce loads on the device that can lead

to failure of the fixation of the device or to failure of the device itself

Displaced Fractures
Total Hip Replacement vs. Hemiarthroplasty
Dislocation rates:
◦ Hemi 2-3% vs. THR 11% (short term)
◦ 2.5% THR recurrent dislocation [Cabanela Orthop 1999]
Reoperation:
◦ THR 4% vs. Hemi 6-18%
DVT / PE / Mortality
◦ no difference
Pain / Function / Survivorship / Cost-effectiveness
◦ THR better than Hemi [Lu –Yao JBJS 1994]
[Iorio CORR 2001]
Post-operative assessment of
Arthroplasty
The technical adequacy of the procedure was judged on four radiological
criteria (Kwok and Cruess, 1982): on AP radiograph
1. Appropriate head size of the prosthesis. This was judged by comparing the
normal femoral head and measuring the diameter of the acetabulum (allowing
for the thickness of articular cartilage). A difference of <2 or > 3 mm was
considered inappropriate.
2. Neck length. As stated by Moore, ‘the neck is cut with a saw one-half to
three-quarters of an inch above the lesser trochanter’ (Moore, 1957). The
centre of the head of the prosthesis should be approximately level with the tip
of the greater trochanter.
Post-operative assessment of
Arthroplasty
3. Prosthesis stem-shaft angle. This was assessed in relation to the long axis of
the femur. If the prosthesis stem was angled greater than 5 ˚, with the tip in
contact with the lateral cortex, it was judged to be in varus (Figure I).
4. Calcar seating. This was rated satisfactory if there was a flat, weight bearing
surface without bony spikes in contact with the prosthesis (Figure 2).
.

Figure 1. Moore prosthesis inserted in varus. Figure 2. Moore prosthesis with satisfactory
calcar seating and neck length
Figure 3. Example of poor calcar seating and short neck in patient
with no symptoms.
Complications of Arthroplasty
Rehabilitation after Internal
Fixation
Walking aids should be used for 8 to 12 weeks after injury.
Many older patients are unable to comply with restricted weight bearing, and
this restriction seems to be of limited additional benefit, especially after internal
fixation of un-displaced fractures.
Most patients can be mobilized safely, with weight bearing as tolerated, using
external support for the first 4 to 6 weeks after fixation.
 Long-term follow up is advisable because of the risk of avascular necrosis,
which may not manifest for 2 or 3 years.
Rehabilitation After Arthroplasty
Postoperatively, the hips are maintained in abduction by two pillows placed
between the knees.
The patient should be out of bed in a chair two to three times daily beginning
on the first postoperative day.
 Physical therapy generally begins on the second or third postoperative day and
the patient is instructed in touch-down weight bearing using a walker or
crutches.
.
Rehabilitation After Arthroplasty
Adduction, flexion, and internal-rotation exercises are not permitted for three
weeks.
The abductor muscles are intact and can be exercised immediately after surgery.
Crutch-walking is begin in two to ten days, allowing partial weight-bearing.
 Patients are encouraged to use the limb and to bear the amount of body weight
that does not cause pain.
Treatment Outline For Elderly # NOF

Boot Camp
2013
Phoenix, AZ
Summary
Existing debates regarding issues such as timing of surgery, implant of choice,
and perioperative management, the primary goals for elderly # NOF patients are
optimization of medical comorbidities and surgical fixation with minimal delay to
allow early mobilization