**3. Hemiarthroplasty versus total hip replacement**

acetabular wear, which is the leading cause [27]. Uncertainty remains as to which type of prosthesis is most appropriate for the treatment of fractures in these elderly patients. This leads to significant regional variations in treatment: THR is up to three times more likely to be performed in the treatment of hip fractures in Sweden than in England and twice as likely

A detailed history and clinical examination is necessary in all cases of hip fractures. Particular care must be made to identify pre-existing medical comorbidities and regular anticoagulants being taken by the patient. A comprehensive discussion should take place with the patient and their relatives in relation to any proposed management strategy. Morbidity and mortality associated with femoral neck fracture care should be discussed. Mortality is 10% within the first 30 days reflecting the compromised status of many of these patients. Mortality rates rise

Examination may reveal a shortened, externally rotated lower extremity. The neurovascular status of the lower limb should be evaluated and documented, and a secondary survey should

Appropriate imaging should take the form of plain film radiographs of the pelvis and femur in anterior-posterior and lateral planes. The pelvis should be held in neutral with both femurs clearly visible and the feet held in internal rotation. Preoperative estimates of magnification on X-rays are frequently incorrect and can lead to mismatching of implant sizes, limb length discrepancies, and disturbance of the biomechanical parameters of the hip joint. The magnification factor for pelvic imaging normally ranges from 109 to 128%. Radioopaque calibration spheres can be sited midline to femurs and proximally towards the pubic symphysis to aid in digital templating of the preoperative X-rays. The contralateral hip should be used as a surrogate for templating in the trauma setting. Digital templating is essential to determine the location of the neck cut, size of the prosthesis, appropriate offset, and depth of insertion. If there is a concern for pathological fracture, appropriate imaging of the whole femur should be obtained in the first instance, and intraoperative histological samples should be sent for

All patients with a hip fracture should have a preoperative electrocardiogram, and in those over the age of 65, a chest X-ray should also be performed. It has been determined by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) that a preoperative echocardiogram should not delay the passage of a patient with a hip fracture to theatre and should rather be performed, if necessary, during the postoperative period. Routine preoperative blood tests may reveal preoperative anaemia which occurs in 30–40% of patients and may be attributable to the fracture itself, haemodilution or a pre-existing condition. The acute response to trauma may lead to neutrophilia or leucocytosis. It is noteworthy that electrolyte imbalances are not uncommon in this cohort of patients, especially hyponatremia and hypokalemia. Hyperkalemia may also be an indicator of rhabdomyolysis occurring secondary to a

prolonged period of immobilisation following the initial traumatic event.

as in Canada [28].

86 Total Hip Replacement - An Overview

analysis.

**2. Preoperative evaluation**

to approximately 40% at 12 months.

be completed to rule out associated injuries.

In the vast majority of cases, the accepted treatment for displaced neck of femur fractures in the elderly is a unipolar or bipolar hemiarthroplasty, especially in elderly patients with low functional demands. Compared with THR, hemiarthroplasty has the advantage of being a simpler, standardised procedure with shorter operating times, and less blood loss. In the acute trauma setting, many orthopaedic surgeons are more comfortable performing hemiarthroplasty rather than THR. Therefore, THR may not be readily available to the trauma patient, and surgical delay is likely to increase morbidity and mortality. Recent studies conclude that THR in the trauma setting is associated with improved functional outcomes and lower reoperation rates when compared with hemiarthroplasty, albeit with a higher dislocation rate [30–32]. Instability post THR is multifactorial, and contributory factors include surgical approach, bearing diameter, restoration of hip biomechanics, cognitive dysfunction, and presence of neuromuscular disease. Where the posterior approach has been utilised, meticulous capsular repair is essential to minimise instability. Some authors advocate the anterolateral approach when treating a femoral neck fracture with THR. This reduces the dislocation rate at the expense of potential abductor dysfunction and a postoperative Trendelenburg gait. The use of large head sizes has also reduced dislocation rates, with the literature suggesting that the benefit is greatest when utilising the posterior approach.

It is essential to adhere to strict selection criteria when determining suitability of patients with hip fractures for THR in order to minimise complication rates. In 2011 the National Institute for Health and Care Excellence (NICE) published their guidelines and recommended THR for patients with adequate cognitive and physical function who are fit to undergo anaesthesia and major surgery. Perry et al. evaluated UK Hip Fracture Database information to ascertain compliance with NICE guidelines for THR [33]. Their study evaluated patients over the age of 60 presenting acutely with displaced intracapsular femoral neck fractures. They determined that only 32% of ostensibly eligible patients underwent THR, and, of those who had surgery, 42% did not qualify under the NICE eligibility criteria. Inclusion and exclusion criteria for THR in trauma need to be defined more accurately based on specific rather than arbitrary parameters.

THR performed for trauma has equivalent results to those performed electively. Anakwe et al. matched 100 trauma patients with an elective cohort and demonstrated equivalent functional outcomes [34]. THR may appear as a more expensive treatment for trauma in terms of implant cost, but the overall costs associated with unipolar and bipolar hemiarthroplasties (including revision surgeries) are higher in the long term [35]. Maceroli et al. demonstrated lower mortality rates in patients undergoing THR for femoral neck fractures in centres that performed large numbers of such procedures [36]. Uhler et al. demonstrated that a patient will gain more cumulative utility over the course of 2 years by waiting 48 hours for a THR, despite an increase in short-term morbidity associated with delayed surgery [37]. It seems reasonable therefore to advocate THR for suitable patients where dedicated arthroplasty services are available. **Figure 1** demonstrates a left basicervical neck of femur fracture, with subsequent treatment with a hybrid THR shown in **Figure 2**.

**4. THR for failed neck of femur internal fixation**

in **Figure 6**.

union [39].

neck of femur fracture.

formed at an appropriate later date.

Following initial treatment with internal fixation, the neck of femur fractures may develop nonunion and osteonecrosis, with reoperation rates of up to 40% reported in the literature. Nikolopoulos et al. demonstrated in a prospective study that patients with displaced neck of femur fractures who underwent internal fixation had a higher rate of avascular necrosis than those that were undisplaced [38]. This group of patients may develop disabling secondary degenerative symptoms necessitating arthroplasty. We highlight this with examples of clinical cases. **Figure 3** shows the collapse of the femoral head following initial sliding screw fixation of a basicervical neck of femur fracture. This was subsequently revised to a hybrid THR as demonstrated in **Figure 4**. **Figure 5** describes the case of screw cut-out post ORIF of the neck of femur fracture, which was subsequently revised to a modular prosthesis as seen

Arthroplasty for Proximal Femur Fracture http://dx.doi.org/10.5772/intechopen.77053 89

Tidermark et al. demonstrated suboptimal outcomes in patients with displaced neck of femur fractures treated with internal fixation, showing impaired functional outcomes when compared with a cohort of undisplaced fractures despite radiographic and clinical evidence of

In treating nonunion the surgical team must consider the presence of infection. Clinical evaluation and serial erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are useful diagnostic tools and if abnormal might prompt joint aspiration or bone biopsy and culture. If preoperative or intraoperative findings suggest infection, a two-stage revision with removal of metalwork and excision of the femoral head is usually performed. An antibioticimpregnated spacer is implanted in the first instance, and subsequent arthroplasty is per-

**Figure 3.** AP radiograph of pelvis demonstrating collapse of femoral head post dynamic hip screw fixation of basicervical

**Figure 1.** AP radiograph of pelvis showing left basicervical neck of femur fracture.

**Figure 2.** AP pelvis demonstrating subsequent treatment with a hybrid THR in the acute setting.
