Intraoperative periprosthetic fractures around Austin Moore

International Journal of Advanced Joint Reconstruction 2015; 2(2): 38-42
ORIGINAL
ISSN 2385 - 7900
Intraoperative periprosthetic fractures around Austin
Moore hemiarthroplasty performed for hip fracture
Iker Uriarte, Jesus Manuel Moreta, Borja Muñoz, Javier Mosquera, Jose Luis Martínez de los Mozos
Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Bizkaia, Spain
Copyright © 2015 I. Uriarte et al. This is an open access article. distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 20 July 2015/ Accepted 15 October 2015 / Published online 16 October 2015.
ABSTRACT
Displaced femoral neck fractures in the elderly are usually treated with hemiarthroplasty. Published literature suggests
more complications with uncemented implants.
Our study was designed to detail our complication rate with the Austin Moore prosthesis (AMP). We performed a
retrospective study of the AMP implanted in our unit from January 2010 to February 2014. From the 177 cases recorded,
in 22 of them (12.4%) an intraoperative periprosthetic fracture occurred and in 5 of them (2.8%) loosening was seen. 8 of
the fractures and 2 cases of loosening required to change the indication to a bipolar cemented hemiarthroplasty.
Subsidence of the stem was seen in 7 patients (5.1%) in the first visit at one month from surgery.
Our findings represent a high rate of early complications when using AMP in this population, especially due to
intraoperative periprosthetic fractures. More studies are needed to establish the causes of these complications in order to
minimize them.
KEYWORDS
Hip fracture, hemiarthroplasty, Austin Moore, periprosthetic fracture
Correspondence:
Iker Uriarte
Department of Orthopaedic Surgery and Traumatology,
Hospital Galdakao-Usansolo, Barrio Labeaga s/n,
48960 Bizkaia, Spain
Tel.: +34 944 00 70 00; fax: +34 944 00 71 32.
E-mail [email protected]
Conflict of interest statement The authors declare no
conflict of interest related to the publication of this
manuscript
How to cite this article
Uriarte I, Moreta J, Muñoz B, MosqueraJ, Martínez de
los Mozos JL. Intraoperative periprosthetic fractures
around Austin Moore hemiarthroplasty performed for
hip fracture. Int J Adv Jt Reconstr. 2015;2(2): 38-42.
INTRODUCTION
Hemiarthroplasty is considered to be the treatment of
choice in elderly patients with a displaced fracture of the
femoral neck, but there is still controversy about the type of
prosthesis preferred. Recent literature shows increased rate of
complications with uncemented hemiarthroplasty compared to
cemented implants, in particular due to periprosthetic
fractures. [1,2] Accordingly, the NICE guidelines (2011)
recommend that arthroplasties for hip fracture should be
cemented. [3]
Revision surgery is associated with increased morbidity
and mortality in elderly patients, so it is particularly important
to reduce complications in these population.
Uriarte I et al. Intraoperative periprosthetic fractures around Austin Moore hemiarthroplasty performed for hip fracture
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International Journal of Advanced Joint Reconstruction 2015; 2(2): 38-42
ORIGINAL
ISSN 2385 - 7900
The objective of this study is to address the incidence of
complications in patients with femoral neck fractures treated
with the Austin Moore prosthesis (AMP) at our institution.
METHOD
A retrospective review of patients who had undergone
Austin Moore hemiarthroplasty at our hospital from January
2010 to February 2014 was performed. This prosthesis was
used to treat displaced femoral neck fractures in low demand
elderly patients, according to surgeon preferences. Medical
records of these patients were reviewed and the data collected
included age, sex, date of operation and discharge day,
surgical approach, ASA grade [4], previous function,
intraoperative complications and medical or surgery related
complications during hospital stay.
Patients were seen at clinic 1 month after surgery for
clinical and radiological evaluation and cases that required
revision surgery were recorded. At the time of the study a
telephone interview was carried out to the surviving patients
for clinical assessment and a radiograph was offered. At this
telephone consultation an assessment of pain and mobility was
done. Pain was evaluated by asking either they had no pain,
mild pain or severe pain. Mobility was assessed with regard to
ambulation without assistance, with assistance of either a cane
or walker or inability to walk. In relation to radiographic
analysis the next were evaluated: subsidence of the stem, signs
of loosening, acetabular protrusion and/or erosions,
heterotopic ossification and dislocations.
RESULTS
During the studied period, 199 Austin Moore
hemiarthroplasties were initially planned to implant in our unit
for displaced femoral neck fractures. In 22 cases hospital
records were missing or incomplete and they were excluded
from analysis. From the remaining 177 cases, in 10 of them,
indication was changed to cemented bipolar hemiarthroplasty
because of intraoperative complications, in eight cases due to
intraoperative femoral fracture and in two to poor fixation.
These cases were only included to rate intraoperative
complications.
A total of 167 AMP were implanted, in 57 males and 110
females. The average age was 87 years (range 71-100 years).
The mean delay between the admission and operation was
2,46 days (1-12) and average hospital stay was 11.2 days
(5-36). The mean length of follow up for these patients was 24
months (range 4-50). Posterior approach was used in 134
cases (80,2%), and lateral transgluteal approach in 33 (19.8%).
At the time of the study, 82 patients (49%) were dead: 14
patients died within 30 days from surgery, 54 in the first year
and 28 after the first year.
According to the American Society of
Anaesthesiologists’ (ASA) classification of Physical Health
[4], 26 cases were classified as grade II, 78 cases as grade III,
62 cases as grade IV and 1 case as grade V. 58 patients were
able to walk without any help before sustaining the fracture,
106 patients needed some kind of help (cane or walker), and 3
were unable to walk.
Figure 1. Intraoperative periprosthetic femoral fracture managed with cerclage wire.
Uriarte I et al. Intraoperative periprosthetic fractures around Austin Moore hemiarthroplasty performed for hip fracture
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International Journal of Advanced Joint Reconstruction 2015; 2(2): 38-42
ORIGINAL
ISSN 2385 - 7900
Figure 2. Subsidence of the stem one month from surgery.
Intraoperative periprosthetic fractures were sustained in 22
of the 177 initial cases (12.4%). 13 cases were treated with
cerclage wires (Fig. 1), 8 cases required to change the implant
to a cemented bipolar hemiarthroplasty and 1 case did not
require any additional treatment.
In 5 cases (2.8%) poor primary fixation of the prosthesis
was observed during surgery so in 2 of them a cemented
bipolar hemiarthroplasty was implanted but the other 3 cases
were left untreated.
During hospital stay 42 patients (25%) sustained medical
problems but no complication related to the prosthesis was
seen. 136 patients were seen at clinic 1 month after surgery. In
7 cases (5.1%) subsidence of the stem (Fig. 2) was observed
(not related to any documented fracture), 3 patients sustained a
traumatic femoral periprosthetic fracture, 2 developed an
infection and 1 suffered subsidence of the prosthesis after a
simple fall.
Revision surgery was done in 5 cases. 3 of them were due
to periprosthetic fracture (two cases were Vancouver B1
treated with plate and cerclage wiring and one Vancouver B2
treated with prosthetic revision) (Fig. 3) [5], one to infection
(irrigation and debridement) and the other case to subsidence
(revision to a bipolar hemiarthroplasty).
Only 65 patients answered the questionnaire about pain
and function at the time for the final follow-up. 4 patients
referred to have no pain, 14 mild pain and 47 severe pain. In
terms of mobility 25 patients could walk without any
assistance, 37 needed some help and 3 were unable to walk.
These patients were offered to take a radiograph of the
affected hip but only 30 of them accepted it. In 9 cases a
subsidence of the stem > 3mm was seen and in 14 cases signs
of loosening were appreciated. No acetabular changes,
heterotopic ossifications or dislocations were observed.
DISCUSSION
Hemiarthroplasty is the recommended treatment for
displaced femoral neck fractures in the elderly, but the optimal
design continues to be controversial. Recent studies
comparing cemented and uncemented prostheses have shown
higher risk of complications with the uncemented implants,
particularly due to periprosthetic fractures [1,2], but there are
few series documenting intraoperative fractures.
In our study we found a 12.4% rate of intraoperative
periprosthetic femoral fractures while inserting the AMP.
Published literature shows an incidence that ranges from 0 to
14%.
Uriarte I et al. Intraoperative periprosthetic fractures around Austin Moore hemiarthroplasty performed for hip fracture
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International Journal of Advanced Joint Reconstruction 2015; 2(2): 38-42
ORIGINAL
ISSN 2385 - 7900
Figure 3. Periprosthetic femoral fracture after a fall (Vancouver type B2) treated with revision to
THA (cemented dual mobility cup and uncemented modular revision stem with cerclages).
Fernández-Valencia et al [6] identified an intraoperative
periprosthetic femoral fracture rate of 6.8% in a study of 365
consecutive Austin-Moore arthroplasties. 80% of them where
detected during the surgery and the 20% in the postoperative
radiology, but considered to be unnoticed fractures during the
surgery. Weinrauch et al [7] showed 14% of intraoperative
fractures during implantation of 147 consecutive Austin
Moore prostheses.
uncemented AMP compared to none fracture in the cemented
Austin Moore group.
Foster et al [8] reviewed 244 patients who had undergone
hip hemiarthroplasty. 7% of patients where AMP was
implanted sustained a periprosthetic fracture (2 intraoperative
and 3 postoperative), while in the Thompson cemented group
no periprosthetic fracture was seen. A multicentre
retrospective review published by Weinrauch et al [9] reported
that 11.8% of AMP sustained an intraoperative periprosthetic
fracture compared to 1.8% in the cemented Thompson group.
Singh et al [10] found an incidence of 3.4% of intraoperative
periprosthetic fractures in the AMP group compared to 0% in
the cemented Thompson group. Khan et al [11] described three
iatrogenic periprosthetic fractures (2.5%) while inserting
Periprosthetic femoral fractures around a hip arthroplasty
are a serious complication that becomes a challenge for the
orthopedic surgeon and worsens the prognosis of the patient.
Some studies like the recently published by Moreta et al [12],
have showed marked functional deterioration and high rate of
complications in spite of correct treatment of postoperative
periprosthetic femoral fractures.
In addition to the intraoperative periprosthetic fractures
observed, our study revealed 2.8% of cases of loosening when
AMP was inserted and 5.1 % of subsidence of the stem during
the first month after surgery. These findings represent a high
rate of early complications when using Austin Moore
hemiarthroplasty in this population.
Literature shows that the Austin Moore is a technical
demanding prosthesis. Weinrauch et al [7] found that the most
common error was the inadequate length of femoral neck.
Additionally they recommended to have the narrow stem
available in case it was required. In any case, Yau et al [13]
Uriarte I et al. Intraoperative periprosthetic fractures around Austin Moore hemiarthroplasty performed for hip fracture
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International Journal of Advanced Joint Reconstruction 2015; 2(2): 38-42
ORIGINAL
ISSN 2385 - 7900
advised a minimum of 70% canal filling by the stem at the
level of the lesser trochanter to avoid subsidence of the
prosthesis. Sharif et al [14] emphasized the importance of
technical aspects when inserting this implant, in particular the
correct seating of the collar of the prosthesis on the calcar.
Based on National Joint Replacement Registers orthopedic
surgeons have decreased their use of Austin Moore implants in
Australia [15] and Sweden. Rogmark et al [16] analyzed the
data from Swedish Hip Arthroplasty Register between
2005-2009 and found that uncemented monoblock implants,
as Austin Moore implants, leaded to an increased risk of reoperation, in particular due to periprosthetic fracture and
suggested that should not be used in modern orthopaedic care.
There are several limitations in our study including that the
data are retrospective and the absence of a control group. No
conclusion about the results obtained can be done due to the
important loss of patients and the associated comorbidity of
this population. A large prospective randomized trial may be
needed to establish definite conclusions.
More studies are necessary in order to identify the causes
of early complications with AMP and to minimize them.
10.
Singh GK, Deshmukh RG. Uncemented Austin–Moore and cemented
Thompson unipolar hemiarthroplasty for displaced fracture neck of
femur-Comparison of complications and patient satisfaction. Injury
2006;37:169-74.
11.
Khan RJ, MacDowell A, Crossman P, Datta N, Jallali N, Arch BN,
Keene GS. Cemented or uncemented hemiarthroplasty for displaced
intracapsular femoral neck fractures. International Orthopaedics
2002;26:229-232.
12.
Moreta J, Aguirre U, Sáez de Ugarte O, Jáuregui, Martínez De Los
Mozos JL. Functional and radiological outcome of periprosthetic
femoral fractures after hip arthroplasty. Injury 2015;46:292-98.
13.
Yau WP, Chiu KY. Critical radiological analysis after Austin Moore
hemiarthroplasty. Injury 2004;35:1020-4.
14.
Sharif KM, Parker MJ. Austin Moore hemiarthroplasty: technical
aspects and their effects on outcome, in patients with fractures of the
neck of the femur. Injury 2002;33:419-22.
15.
Graves S, Davidson D, de Steiger R, Tomkins A. Australian Orthopaedic
Association national joint replacement registry. Annual report. Adelaide.
AOA 2011.
16.
Rogmark C, Leonardsson O, Garellick G, Kärrholm J. Monoblock
hemiarthroplasties for femoral neck fractures- A part of orthopaedic
history? Analysis of national registration of hemiarthroplasties
2005-2009. Injury 2012;43:946-49.
REFERENCES
1.
McGraw IWW, Spence SC, Baird EJ, Eckhardt SM, Ayana GE.
Incidence of periprosthetic fractures after hip hemiarthroplasty: Are
uncemented prostheses unsafe? Injury 2013;44:1945-48.
2.
Phillips JRA, Moran CG, Manktelow ARJ. Periprosthetic fractures
around hip hemiarthroplasty performed for hip fracture. Injury
2013;44:757-62.
3.
National Clinical Guidance Centre. The management of hip fracture in
adults. London: National Clinical Guidance Centre; 2011.
4.
Owens WD, Felts JA, Spitznagel EL. ASA physical status classification:
a study of consistency ratings. Anaesthesiology 1978;49:239-43.
5.
Duncan CP, Masri BA. Fractures of the femur after hip replacement.
Instructional Course Lectures 1995;44:293-304.
6.
Fernández-Valencia JA, Llobet F, Pons N, López-Zabala I, Gallart X,
Bori G, Riba J. Intraoperative periprosthetic femoral fractures related to
Austin Moore hemiarthroplasty-A retrospective review of 365 patients.
Open Journal of Orthopedics, 2013,3,189-92.
7.
Weinrauch P. Intraoperative error during Austin Moore hemiarthroplasty.
Journal of Orthopaedic Surgery 2006;14(3):249-52.
8.
Foster AP, Thompson NW, Wong J, Charlwood AP. Periprosthetic
femoral fractures – a comparison between cemented and uncemented
hemiarthroplasties. Injury 2005;36(3):424-9.
9.
Weinrauch PC, Moore WR, Shooter DR, Wilkinson MP, Bonrath EM,
Dedy NJ, McMeniman TJ, Jabur MK, Crawford RW. Early prosthetic
complications after unipolar hemiarthroplasty. ANZ J Surg
2006;76(6)432-5.
Uriarte I et al. Intraoperative periprosthetic fractures around Austin Moore hemiarthroplasty performed for hip fracture
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