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Trauma: R. Blomfeldt, H. Törnkvist, S. Ponzer, A. Söderqvist, and J. Tidermark Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment J Bone Joint Surg Br 2005; 87-B: 523-529 [Abstract] [Full text] [PDF]

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Reply to Dr Abbas from Dr Tidermark

Jan Tidermark   (29 June 2005)

The treatment of femoral neck fractures in elderly patients

Dawar Abbas   (15 June 2005)

Reply to Dr Abbas from Dr Tidermark 29 June 2005
Jan Tidermark, MD, PhD, Consultant Orthopaedic Surgeon Karolinska Institute, Department of Orthopaedics at Stockholm Söder Hospital, Sweden Send letter to journal: Re: Reply to Dr Abbas from Dr Tidermark jan.tidermark{at}sodersjukhuset.se Jan Tidermark	Sir, We thank Dr Abbas for his valuable comments. Firstly, we would like to emphasise that the aim of our paper was not to compare hemiarthroplasty with internal fixation in the treatment of displaced fractures of the femoral neck in the elderly population in general. The aim was to evaluate these treatments in a highly selected group of patients with severe cognitive impairment. The results in both groups with a very high rate of mortality, significant deterioration in activities of daily living function, reduced walking ability and health-related quality of life show the major impact on outcome of the severe cognitive dysfunction. These results are also supported by the only previous study on the same selected group of patients by van Dortmont et al.1 The high rate of complication after internal fixation of displaced fractures of the femoral neck is not unique to this trial nor to this patient cohort. Almost all prospective trials with at least a two-year follow-up have a rate of complication of fracture healing of between 35% and 50%.2,3 In our opinion, it is not justifiable to recommend post-operative non-weight bearing in elderly patients after a hip fracture, especially not in this group of patients, which by definition was non-compliant. At the start of this trial, the uncemented Austin Moore prosthesis was still an accepted implant in Sweden for this group of patients and is still recommended for the majority of elderly patients with displaced fractures of the femoral neck.4 We share Dr Abbas' opinion that a cemented prosthesis would probably create less pain and better mobility; an opinion also supported by a recent meta-analysis.5 However, the cementing procedure may increase the risk for serious peri-operative complications, especially in this selected cohort of fragile patients.6 We chose to report both the number of patients requiring re-operation and the number of such procedures needed in each group. The total number of revision procedures needed reflects the severity of the complication and also the burden for the health care system. The tendency for a reduced number of re-operated patients in the hemiarthroplasty group, although not confirmed in the number of re-operations, must be balanced against the better outcome regarding hip function and health-related quality of life in the internal fixation group. Clinicians may come to a different conclusion in this aspect. Our conclusion is that there does not seem to be any obvious advantage in performing an uncemented Austin Moore hemiarthroplasty compared with internal fixation in patients with severe cognitive dysfunction. We agree with Dr Abbas that the role of a cemented hemiarthroplasty in this selected patient group needs to be evaluated in future trials. We are currently performing a randomised controlled trial comparing a modern cemented hemiarthroplasty with internal fixation using the same inclusion criteria as in the present paper. J. TIDERMARK, MD, PhD Stockholm Söder Hospital Stockholm, Sweden. 1. van Dortmont LM, Douw CM, van Breukelen AM, et al. Cannulated screws versus hemiarthroplasty for displaced intracapsular femoral neck fractures in demented patients. Ann Chir Gynaecol 2000;89:132-7. 2. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck: a meta-analysis of one hundred and six published reports. J Bone Joint Surg [Am] 1994;76-A:15-25. 3. Tidermark J. Quality of life and femoral neck fractures. Acta Orthop Scand Suppl 2003;74(309):1-42. 4. Parker MJ, Khan RJ, Crawford J, Pryor GA. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly: a randomised trial of 455 patients. J Bone Joint Surg [Br] 2002;84-B:1150-5. 5. Parker MJ, Gurusamy K. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2004;(2):CD001706. 6. Parvizi J, Holiday AD, Ereth MH, Lewallen DG. The Frank Stinchfield Award. Sudden death during primary hip arthroplasty. Clin Orthop 1999;369:39-48.
The treatment of femoral neck fractures in elderly patients 15 June 2005
Dawar Abbas, Orthopaedic Surgeon Milton Keynes General Hospital Send letter to journal: Re: The treatment of femoral neck fractures in elderly patients dawarabbas{at}yahoo.co.uk Dawar Abbas	Sir, I read this article with interest. In their study the authors have shown an overall rate of failure of 41% in the internal fixation group, which although comparable with other similar series1,2 is unacceptably high. Among the survivors at two years there was a very high rate of re-operation in the internal fixation group (9 out of 17) compared with the hemiarthroplasty group (3 out of 18). The high rate of nonunion may be partly attributed to non-compliance of the patients to remain non-weight-bearing on the affected hip after internal fixation. On the other hand, hemiarthroplasty requires no such compliance and dislocation of the prosthesis is very uncommon (no dislocation in the present series). The reason for sudden deterioration in the HRQOL of the hemiarthroplasty group between one and two years after surgery remains unclear. Other studies have shown that a cemented hemiarthroplasty is associated with much less pain and better mobility compared with uncemented prostheses.3 The risk of periprosthetic fractures has also been shown to be less after cemented rather than uncemented hemiarthroplasty.4 Cemented hemiarthroplasty does carry a slightly higher risk of deep infection.1 The authors may have reached a different conclusion had they concentrated on the number of patients requiring re-operation rather than on the number of revision procedures needed in each group. Although uncemented hemiarthroplasty may not be ideal for all elderly patients, there is no doubt that cemented hemiarthroplasty is a better option in the majority of cases as the outcome is more predictable and the risk of failure requiring re-operation is much smaller. A randomised trial would certainly help in resolving the controversy. D. ABBAS, MS (Orth), MSc, FRCS Milton Keynes General Hospital, Milton Keynes, UK. 1. Parker MJ, Khan RJK, Crawford J, Pryor GA. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. J Bone Joint Surg [Br] 2002;84-B:1150-5. 2. Rogmark C, Carlsson A, Johnell O, Sernbo I. A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur: Functional outcome for 450 patients at two years. J Bone Joint Surg [Br] 2002;84-B:183-8. 3. Parker MJ, Gurusamy K. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev. 2004;(2):CD001706. 4. Foster AP, Thompson NW, Wong J, Charlwood AP. Periprosthetic femoral fractures-a comparison between cemented and uncemented hemiarthroplasties. Injury 2005;36(3):424-9.