Aims

Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

In 1975, Sweden started registering primary knee replacement surgeries based on the personal identity number. Individual-based registrations of primary total hip replacements started in 1992 and for hemiarthroplasties the registration started in 2006. The completeness of these registrations is estimated at 98% during the last 10-year period. The long history and high completeness allow for accurate calculations of population-based prevalence of joint replacement and trends over time.

We used all data on primary joint replacements available in the Swedish Arthroplasty Register. The prevalence was calculated using number of alive patients with 1) at least one joint replacement 2) at least one hip replacement 3) at least one knee replacement at the end of each year from 2010 – 2021. Publicly available population numbers were retrieved from Statistics Sweden. We calculated total prevalence and prevalence per age in years.

By the end of 2021, 3.2% of the Swedish population had at least one hip or knee replacement. This was an increase from 2.5% in 2010. Among 80-year-old, the prevalence was 17.5% for any joint replacement. For both hip and knee replacement and all ages, the prevalence was higher for women. For knee replacement, the 2021 prevalence peaked at the age of 89 (9,4%) while the prevalence continuously increased with age for hip replacements.

A considerable proportion of the Swedish elderly population is living with at least one hip or knee replacement. The prevalence has increased during the last 12-year period for both hips and knees. An increasing prevalence may also affect the incidence of fractures and infections. Knowledge about the prevalence is fundamental for planning future demand for primary and revision hip and knee replacement.

Aims

Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied.

Aims

The aim of this study was to investigate the potentially increased risk of dislocation in patients with neurological disease who sustain a femoral neck fracture, as it is unclear whether they should undergo total hip arthroplasty (THA) or hemiarthroplasty (HA). A secondary aim was to investgate whether dual-mobility components confer a reduced risk of dislocation in these patients.

Dislocation after total hip arthroplasty in individuals treated for acute hip fracture is up to 10 times more frequent than in elective patients. Whilst approach plays a role, the effect of head sizes in conventional THA and dual mobility cups (DMC) is less studied in fracture cases.

The total dislocation rate at 1-year and 3-year revision rates were recorded in this observational study on 8,031 patients with acute hip fracture, treated with a THA 2005–2014. Swedish Arthroplasty Register data were linked with the National Patient Register. Cox multivariable regression models were fitted to calculate adjusted hazard ratios stratified by approach and head size.

The cumulative risk of dislocation during year 1 was 2.7% (95% CI 2.2–3.2) with lateral approach and 8.3% (7.3–9.3) with posterior approach (KM estimates).

In the posterior approach group DMC was associated with a lower risk of dislocation compared to cTHA=32mm (HR=0.21; 0.07–0.68), whilst a head size <32mm carried a higher risk (HR=1.47; 1.10–1.98). These differences were no longer visible when revision in general was used as outcome.

Neither of the implant designs influenced the dislocation risk when direct lateral approach was used. Male gender and severe comorbidity increased the risk. DMC with lateral approach was associated with a reduced risk of revision in general (HR=0.36; 0.13–0.99). Head size did not influence the revision risk.

When aiming to reduce the risk of any dislocation, lateral approach – regardless of cup/head design – is referable. If, for any reason, posterior approach is used, DMC is associated with the lowest risk of dislocation. This is not reflected in analysing revision in general as outcome. An interpretation could be that there are different thresholds for dislocation prompting revision.

Aims

Our aim was to examine the Elixhauser and Charlson comorbidity indices, based on administrative data available before surgery, and to establish their predictive value for mortality for patients who underwent hip arthroplasty in the management of a femoral neck fracture.

The Swedish Hip Arthroplasty Register started in 1979 and celebrates its 40^th anniversary in 2019. The Swedish Hip Arthroplasty Register is not primarily a device register or research database; we strive to provide an overall assessment of the care provided with a multidimensional approach, and to disseminate knowledge on best practices in our network of participating hospitals. Since the inception of the register, there has been a marked change in trends and outcomes.

The completeness of registrations has been 97–99% for primary THA, 93–95% for revisions, and 95–98% for HA over the last 10 years. The register contains 371,125 primary THAs, 55,893 HAs, 83,233 reoperations, and 408,110 PROM responses registered in 352,585 unique patients. All outcome measures have improved over time; primary THA has 0.71% 90-day mortality, 94.3% 10-year implant survival, and 2.2% 2-year reoperation rate. At 1-year follow up, 91% of the patients report a clinically significant pain reduction, 76% report a substantial improvement in health-related quality of life, and 89% are satisfied with the result of the operation.

Moving forward, we are developing enhanced online applications for surgeons, patients and the implant industry to access real-time information. This work involves constructing a shared decision-making tool that helps clinicians assessing the future benefits and risks of THA by offering individualized outcome predictions. Further steps forward include randomized clinical trials and nested studies through the registry's platform. The trends and changes in Swedish arthroplasty practice have largely been promoted and facilitated by the register over the last 40 years.

Aims

Hemiarthroplasty of the hip is usually carried out through either a direct lateral or posterior approach. The aim of this prospective observational study was to determine any differences in patient-reported outcomes between the two surgical approaches.

This review summarises the evidence for the treatment of displaced fractures of the femoral neck in elderly patients. Results from randomised clinical trials and national register studies are presented when available.

The advantages of arthroplasty compared with internal fixation are supported by several studies. A number of studies contribute to the discussions of total hip arthroplasty (THA) versus hemiarthroplasty and unipolar versus bipolar hemiarthroplasty, but no clear-cut evidence-based recommendation can be made. THA may be particularly advantageous for active, lucid patients with a relatively long life expectancy. For patients who are physiologically older, hemiarthoplasty is probably satisfactory, and for the oldest patients with more comorbidities, unipolar implants are considered to be sufficient. If the hospital can support emergency THA surgery in sufficient numbers and quality, there may be few patients who warrant bipolar hemiarthroplasty.

The direct lateral approach reduces the risk of dislocation compared with the posterior approach. Cemented implants lower the risk of periprosthetic fracture and its subsequent morbidity and mortality. As the risk of peri-operative death related to bone cement can be reduced by adequate measures, cemented implants are recommended in fracture cases.

Take home message: There remains a great variation in the surgical management of patients with a hip fracture, and an evidence-based approach should improve the outcomes for this vulnerable patient group.

Cite this article: Bone Joint J 2016;98-B:291–7.

Background

In Sweden approximately 6000 patients yearly sustain displaced femoral neck fractures. During the last decade there has been a shift towards more arthroplasties at the expense of internal fixation. In 2008 approximately 75% of the dislocated femoral neck fractures in Sweden were treated with arthroplasties. Those patients are typically elderly and frail and the vast majority of them receive hemiarthroplasties. In 2005 a national hemiarthroplasty registration was established as part of the Swedish Hip Arthroplasty Register (SHAR).

Introduction: During the last decade the treatment regime for dislocated femoral neck fractures has switched towards more arthroplasties. There has been apprehensions regarding long-term results for arthroplasties. The opinion has been put forward that preserving the femoral head is preferable to performing total hip arthroplasty.

Methods: 409 of the 450 patients in a randomized study 1995–97 had valid follow-up at 4 months, 1, 2, 5, and 10 years (or until deceased). Mentally intact, independently living and walking patients over 70 years were included and randomized to osteosynthesis (n=217) or arthroplasty (n=192).

Results: After 10 years 168 patients (77 percent) were deceased and there were 99 failures (46 percent) in the osteosynthesis group. In the arthroplasty group 145 patients (76 percent) were deceased and there were 17 failures (9 percent) after 10 years. Both groups had the same rate of failure between 2 and 10 years.

There was significantly better results regarding pain and function in the arthroplasty group at 4 months. At 10 years the results were still not superior for osteosynthesis.

A Cox regression analysis regarding sex, age, time to surgery, smoking, osteoporosis, trauma type, preoperative function and choice of skin incision comparing the patients without hip complications at 10 years with the patients with failures in each group revealed no risk factor for failure.

Discussion: Arthroplasty for hip fracture show a reliable long-term result while osteosynthesis leads to a high rate of complications and is not superior regarding pain and function even when successful. Both methods have the same mortality.

Background: Hemiarthroplasty of the hip is a common procedure, but information about implants and outcome is scarce. In Sweden the number of hemiarthroplasties has increased from 200 in 1998 to 4181 in 2007.

Material and Methods: Nationwide registration started in 2005. 100% of the hospitals participates, and 96% of the hemi-procedures are registrered. An analysis of 12 245 cases operated 2005–07 is presented.

Results: In the Register the mean age at surgery is 84 years (SD 7.0, 73% female). 93% are operated due to acute fracture and 6% due to failed internal fracture fixation. Cemented fixation has been used in 92% and a posterior approach in about half of the cases (52%). The Lubinus and Exeter stems are most common (41 and 23%). The Austin-Moore design has decreased from 9 to 2% during the study period.

3.2% of the patients (hips) have been reoperated, most commonly because of dislocation. Multiple reoperations are common. Male gender, secondary procedure and uncemented stem are associated with increased reoperation risk with 1.2, 1.7 and 1.8 times (1.2, CI: 1.0–1.6; 1.7, 1.3–2.3; 1.8 1.4–2.5). Use of uncemented fixation resulted in increased risk of reoperation, also with exclusion of uncemented Austin-Moore prostheses (1.8 times, 1.1–2.8).

In a separate analysis of the two most frequent designs, use of bipolar head increased the risk of revision twice (1.4–2.8) compared to unipolar head when adjusting for other risk factors. This may reflect that fitter and more active individuals get a bipolar prosthesis and are more prone to become revised should complications occur or a true increase of complications when using bipolar head. A further analysis is in progress.

Use of dorsal approach (1.6, 1.2–2.2), Austin-Moore (1.8, 1.1–3.1) and Thompson prostheses (1.8, 1.5–2.8) increased the risk of revision because of dislocation.

Summary: When treating fracture patients with hemi-arthroplasty we recommend that a well documented cemented implant with different off-set options should be used via an anterolateral approach. Use of bipolar heads may increase the risk of revision.

In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function.

Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck.

Between 1999 and 2005, 10 264 patients who had undergone total hip replacement (THR) for subcapital fracture of the hip were compared with 76 520 in whom THR had been performed for other reasons. All the cases were identified through the Swedish Hip Arthroplasty Register. The THRs performed as primary treatment for fracture were also compared with those done after failure of internal fixation.

After seven years the rate of revision was higher in THR after fracture (4.4% vs 2.9%). Dislocation and periprosthetic fracture were the most common causes of revision. The risk was higher in men than in women. The type of femoral component and the surgical approach influenced the risk. After correction for gender, type of component and the surgical approach the revision rates were similar in the primary and secondary fracture THR groups.

Total hip replacement is therefore a safe method for both the primary and secondary management of fracture of the hip.

Aims: To evaluate a new treatment protocol for femoral neck fractures based on our own and other authorsñ randomised studies concerning choice of surgical treatment. Methods: Consecutive study of 358 patients, 1-year follow-up. According to our new program all undisplaced fractures and all fractures in patients under 70 years were treated with close reduction and Hansson hook pins. Active, independent patients aged 70 Ð 80 years with displaced fractures received a total arthroplasty, the frailer patients in this age group and all those over 80 years received a hemi-arthroplasty. Internal þxation could be chosen for patients with life threatening diseases. Results: Introducing primary arthroplasty in our new program instead of internal þxation for a majority of the displaced fractures reduced the failure rate for patients over 70 years from 42% to 5%. Internal þxation for displaced fractures in patients under 70 years had a 48% failure rate, but risk factors for failure were frequent among these patients. Undisplaced fractures had a failure rate of 14%. The study compromises the þrst year with this new protocol and in 4% of the cases the surgeon did not adhere to the protocol. Mortality for women was 5% at 1 month and 21% at 1 year; for men 12 and 32% respectively. Conclusions: We consider the treatment regime successful and feasible and 1 year follow up shows adherence to the new program. Primary arthroplasty for displaced fractures for a great majority of all patients over 70 years has signiþcantly reduced the failure rate compared to earlier results after internal þxation.

It remains a matter of debate whether displaced fractures of the neck of the femur should be treated by internal fixation or arthroplasty. We have compared the two methods with regard to complications, mortality and functional outcome.

We studied 409 patients, aged 70 years and over, with subcapital fractures graded as Garden 3 or 4, in a two-year prospective multicentre study from 12 Swedish hospitals. They were randomised to internal fixation or arthroplasty. Patients who were mentally confused, bedridden or in a nursing-home were excluded from the survey.

After two years the rate of failure was 43% in the internal fixation (IF) and 6% in the arthroplasty group (p < 0.001). In the IF group 36% had impaired walking and 6% had severe pain compared with 25% and 1.5%, respectively, in the arthroplasty group (both p < 0.05). There was no difference in mortality.

With a high rate of failure and poor functional outcome after IF, we recommend primary arthroplasty for displaced fractures of the neck of the femur in patients over 70 years of age.