The outcomes of conversion of hemiarthroplasty to total hip arthroplasty, a systematic review and meta-analysis.

INTRODUCTION: Acetabular erosion is an important complication in hemiarthroplasty and may lead to total hip arthroplasty as a conversion. The results of total hip arthroplasty as a conversion remain unclear. We performed a systematic review and meta-analysis to compare the outcome of total hip arthroplasty as a conversion with primary total hip arthroplasty. MATERIALS AND METHODS: PRISMA guidelines were used and Pubmed, Embase and the Cochrane libraries were searched. Both, studies comparing the outcome of total hip arthroplasty as a conversion with the outcome of primary total hip arthroplasty and the outcome of cohort studies limited to total hip arthroplasty as a conversion, were included. Risk of bias was assessed using the Methodological Index for Non Randomized Studies checklist. Meta-analysis was performed concerning pooled annual revision, dislocation and infection rates. RESULTS: A total of 27 studies were available for analysis; four comparative studies and 23 cohort studies. Comparative studies were defined as high quality and cohort studies as medium quality. Analysis revealed a significantly higher overall revision risk (Hazard Ratio 1.72, 95% confidence interval 1.39 to 2.14) after total hip arthroplasty as a conversion compared to primary total hip arthroplasty. The annual revision rate of total hip arthroplasty as a conversion was 1.63% (95% confidence interval 1.14 to 2.33) in the comparative studies and 1.40% (95% confidence interval 1.17 to 1.66) in the cohort studies. A pooled infection rate of 4.34% (95% confidence interval 2.66 to 7.01) and dislocation rate of 4.79% (95% confidence interval 3.02 to 7.53), was found. CONCLUSIONS: Literature concerning the results of total hip arthroplasty as a conversion is limited. The risk of revision after conversion of hemiarthroplasty is higher compared to primary total hip arthroplasty.

Controversies around hip fracture treatment: clinical evidence versus trends from national registries.

PURPOSE: Several controversies in the optimal treatment of femoral neck fractures persist, together with large variations in clinical practice. METHODS: A narrative literature review covering 4 current controversies in the surgical management of femoral neck fractures (total hip arthroplasty (THA) versus hemiarthroplasty (HA), cemented versus uncemented HA, internal fixation versus arthroplasty, operative versus non-operative) was performed. Available literature was balanced against annual trends in the management of femoral neck fractures from the public domain of several national registries (Sweden, Norway, The Netherlands, Australia and New Zealand). RESULTS: For most controversies, the literature provides stronger evidence than is reflected by variations encountered in daily practice. Implementation of clinical evidence tends to lag behind and important differences exist between countries. CONCLUSIONS: Trends of clinical practice from national registries indicate that implementation of available clinical evidence needs to be improved.

Revision risk of salvage compared with acute total hip arthroplasty following femoral neck fracture: an analysis from the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: There is no consensus on the treatment of patients with femoral neck fractures between internal fixation (IF) or directly treated with a total hip arthroplasty (fracture-THA) in particular for the age group 60-70 years. Failure of IF is not uncommon, resulting in salvage total hip arthroplasty (salvage-THA). The aim of our study was to compare revision rates of salvage-THA with fracture-THA and osteoarthritis (OA)-THA. PATIENTS AND METHODS: Revision rates and reasons for revision were compared. Data collected in the Dutch Arthroplasty Register (LROI) between 2007 and 2018 was used. The study included 4,310 salvage-THAs, 12,159 fracture-THAs, and 274,147 OA-THAs. We performed Kaplan-Meier survival analyses and Cox regression to evaluate THA survival. RESULTS: No statistically significant difference in revision rates between salvage-THAs and fracture-THAs was found (HR 1.0, 95% CI 0.7-1.3) whereas the revision rate was higher compared with OA-THAs (HR 1.3, CI 1.0-1.5). The 5-year revision rate was 5.0% (CI 4.4-5.8) in salvage-THAs, 4.5% (CI 4.1-5.0) in fracture-THAs, and 3.1% (CI 3.0-3.2) in OA-THAs. A higher revision rate for infection was found in salvage-THAs in comparison with fracture-THAs (HR 1.6, CI 1.0-2.3). CONCLUSION: We found no difference in revision rates for salvage-THAs compared with fracture-THAs. The risk of revision for infection was higher for salvage-THA.

Increased failure rates after the introduction of the TFNA proximal femoral nail for trochanteric fractures: implant related or learning curve effect?

Background and purpose - Trochanteric fractures are often treated using intramedullary fixation. In our institution, the TFN-Advanced Proximal Femoral Nailing System (TFNA) was introduced as replacement for the Gamma Trochanteric Nail (GTN3) for the treatment of these fractures as a result of a hospital-driven change of trauma implant supplier. We compared trochanteric fracture fixation failure rate between these 2 intramedullary nails. Patients and methods - All trochanteric fractures treated surgically from 2011 to 2019 were retrospectively reviewed for fixation failure. From 2016 only the TFNA was used. Fixation failure was defined as implant cut-out, implant breakage, non-union, malpositioning of the screw/blade requiring reoperation, new fracture around the nail, or miscellaneous. Propensity score matching was used to balance distribution of covariates and to compare failure rates between TFNA and GTN3 groups. Learning curve analyses were performed. Results - After exclusion, 797 GTN3s (779 patients) and 542 (536 patients) TFNAs were available for analysis. A higher risk of fixation failure was found in the TFNA group (14%) compared with the GTN3 group (7.0%) (hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.2-3.5). This was mainly attributed to a higher risk of cut-out (HR 2.2; CI 0.9-5.7), malpositioning (HR 4.7; CI 0.7-34), and new fracture around the nail (HR 4.0; CI 1.0-16). Learning curve analyses indicated no clear learning curve effect. Interpretation - Failure of fixation increased after a switch from the GTN3 to the TFNA proximal femoral nail for the treatment of trochanteric fractures. Cut-out and malpositioning of the calcar screw or blade appeared to be the most dominant failure mechanisms. Modifications in implant design may have played a role in this increased risk of failure of fixation. In our institution a new implant device was introduced without solid clinical evidence behind it. This study may help to underline the need for medical doctors with a critical and scientific background to be involved in implant choices.

Nonoperative management of hip fractures in very frail elderly patients may lead to a predictable short survival as part of advance care planning.

Background and purpose - Surgical treatment is still the mainstay of care even in very frail elderly hip fracture patients. However, one may argue whether surgery is in the best interest of all patients. We elucidated mortality rates of nonoperative management (NOM) of a hip fracture after shared decision-making in a cohort of very frail elderly patients.Patients and methods - Orthogeriatric patients (age > 70 years) admitted with a hip fracture between 2011 and 2019 were included. In the presence of fragility features the motivation for surgery or NOM was supported by advance care planning (ACP) and shared decision-making through geriatric assessment. Mortality rates after NOM were assessed and also presented for the remaining surgical group for reference.Results - In 1,279 out of 3,467 patients, geriatric assessment was indicated and subsequently 1,188 (93%) had surgery versus 91 (7%) NOM. The motivation for NOM was based on patient and family preferences in only 20% of patients, medical grounds in 54%, and a combination of both in 26%. The 30-day and 1-year mortality in the frail NOM group was 87% and 99% respectively, whereas this was 7% and 28% in the surgery group. No statistical comparison between groups was performed due to profound bias by indication.Interpretation - This study provides further insight into the predictable and high short-term mortality after NOM in carefully selected very frail elderly hip fracture patients. This information may help to consider NOM as an alternative treatment option to surgery when no significant gain from surgery is anticipated.

A Swallowing Screening Test Enhances a Better Recognition of Patients with a Hip Fracture at Risk for Oropharyngeal Dysphagia.

Oropharyngeal dysphagia (OD) is commonly encountered in elderly patients with hip fracture. It is easily overlooked and predisposes patients to life-threatening postoperative pneumonia. The aim of this study was to evaluate whether OD screening by nurses results in a better recognition of patients at risk for OD. After the introduction of the Standardized Swallowing Assessment by nurses, the incidence of increased risk for OD and the prevention of OD complications were monitored (intervention group; N = 92) and compared with a historical control group (N = 81). The risk for OD was diagnosed in 27 patients (29%) in the intervention group in comparison with 12 patients (15%) in the control group (p < .05). The number of diet modifications increased from 12 (15%) in the control group to 25 (27%) in the intervention group (p < .05). A simple screening test results in better recognition of increased OD risk and, in turn, the early initiation of measures to avoid aspiration.

The (un)necessity of regular postoperative follow-up of hemiarthroplasty for femoral neck fractures.

BACKGROUND: Postoperative follow-up after hemiarthroplasty is part of routine based practice. However, these visits appear to be a significant burden since it concerns a frail population. The aim of this study was to confirm the current common practice regarding postoperative visits of patients treated with hemiarthroplasty and to evaluate the complication detection rate at these visits. METHODS: A national short survey was conducted among orthopedic surgeons working in 26 large Dutch teaching hospitals to test the hypothesis that postoperative follow-up is indeed common practice. Furthermore, a retrospective patient review was performed in all hemiarthroplasties implanted between January 2014 and December 2019. RESULTS: The response of the national survey was complete and showed that postoperative follow-up in patients treated with hemiarthroplasty is part of standard care according to 89% of respondents. A total of 1055 hips (1026 patients) were implanted with hemiarthroplasty during the studied period. Implant-related complications were identified in 68 hemiarthroplasties, with 31 of these hips going on to reoperation. Only 2 of these complications were picked up at standard planned follow-up leading to a complication detection rate of 0.3%. In contrast, complication detection rates of 47% and 16% were found at unplanned visits at the Emergency Department and the outpatient department, respectively. CONCLUSIONS: Postoperative follow-up in patients treated with hemiarthroplasty is still the standard of care. However, this study revealed that the majority of implant-related complications are detected at unplanned visits and almost no at standard follow-up visits. Postoperative follow-up of patients treated with hemiarthroplasty could be abandoned in this frail population.