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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Hemiarthroplasty of the Hip                 

 - See: Bipolar Arthroplasty:

- Discussion:
    - indications: indicated for patients w/ a femoral neck frx who meet the following criteria:
             - poor general health thay would prevent a second operation;
             - pathologic hip fractures:
             - parkinson's disease, hemiplegia, or other neurological disease;
             - physiologic age > 70 yrs;
             - severe osteoporosis w/ loss of primary trabeclae in femoral head (see Sigh Index);
             - inadequate closed reduction;
             - displaced frx which is several days old;
             - pre-existing hip disease (DJD, RA, AVN);
    - contraindications:
             - preexisting sepsis
             - young patient
             - failure of internal fixation devices;
             - pre-existing dz of the acetabulum;
                   - even w/ normal preoperative cartilagenous space, many patients will become symptomatic at 5 years due to metal induced degradation;
     - basic science:
             -
Hemiarthroplasty of hip joint: An experimental validation using porcine acetabulum
             - Fluid load support and contact mechanics of hemiarthroplasty in the natural hip joint.
             - The response of articular cartilage to weight-bearing against metal. A study of hemiarthroplasty of the hip in the dog 
             - Effect of hip hemiarthroplasty on articular cartilage and bone in a canine model
             - Acetabular involvement in osteonecrosis of the femoral head.
             - Degeneration of Acetabular Articular Cartilage to Bipolar Hemiarthroplasty

- Pre Op Planning: 
     - checklist
     - femoral head size:
            - if too large, equatorial contact occurs, resulting in a tight joint with a decreased motion and pain;
            - if head is too small, polar contact occurs with increased stress over reduced area; leads to erosion, superomedial prosthetic migration & pain; 
            - references:
                     - Hemiarthroplasty of the hip for fracture-What is the appropriate sized femoral head?
                     - Femoral head measurement in hemiarthroplasty: assessment of interobserver error using 3 measuring systems.
                     - Degenerative changes in normal femoral heads in the elderly
                     - Acetabular Diameter Measurement Determines Proper Prosthetic Head Size in Hemiarthroplasty for Femoral Head Osteonecrosis

     - neck length:
            - if the neck is left excessively long, reduction may be difficult and pressure on acetabular cartilage is increased;
            - prostheses should be inserted so that the distance between the greater trochanter and center of the femoral head is restored;
                     - alternatively, attempt to restore the distance between the lesser trochanter and the acetabulum;
            - this will restore the length of the abductor mechanism and thereby help to prevent postoperative limp;
     - to cement or to not cement ? (cemented femoral stem and  cement technique
            - pro-cement argument 
                     - patients w/ a "stove pipe" type of femur (w/ no tapering of medullary canal) are the best candidates for cemented stems, since there
                              will be a higher risk of fracture with press fit stems in these patients;
                      - risks of cement in hip fractures:
                               - main risk of cementing is methylmethacrylate embolism (leading to death);
                               - best ways to avoid cement emobism is thoroughly irrigate the canal and to thoroughly vaccum mix the cement;
                                       - references:
                                              - [Reduction of severe cardiac complications during implantation of cemented total hip endoprostheses in femoral neck fractures].
                                              - Transesophageal echo and clinical features of fat embolism during cemented total hip arthroplasty. A randomized study in patients with a femoral neck fracture.
                                              - Prophylaxis against fat and bone-marrow embolism during total hip arthroplasty reduces the incidence of postoperative deep-vein thrombosis: a controlled, randomized clinical trial.
                                              - Cardiac output during hemiarthroplasty of the hip. A prospective, controlled trial of cemented and uncemented prostheses.

            - pro-press fit argument
                      - some studies indicate that cemented stems are superior to press fit but the later are often low quality DRG stems (not plasma
                                spray titanium - see surface coating) - hence comparing apples to oranges;
                      - main risk of press fit is periprosthetic fracture;
                      - if a press fit stem is to be used, then consider using a lateral approach since the fragile osteoporotic bone requires
                                that the stem be placed in the patients native anteversion (which may or may not provide sufficient stability);
            - references:
                     - Moore hemiarthroplasty with and without bone cement in femoral neck fractures: a clinical controlled trial.  
                     - Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty
                     - Hemiarthroplasty of the Hip with and without Cement: A Randomized Clinical Trial
                     - Cement emerges as the most predictable option for hip hemiarthroplasty: commentary on an article by Fraser Taylor, BSc, MBChB, FRACS, et al.
                     - Is there a difference in perioperative mortality between cemented and uncemented implants in hip fracture surgery?
                     - Periprosthetic fractures around hip hemiarthroplasty performed for hip fracture.
                     - Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture: 12- to 19-year follow-up of patients aged 75 years or more.
                              12- to 19-year follow-up of patients aged 75 years or more

 - Surgical Approaches:
      - Anterolateral Approach to Hip Joint: (Watson Jones)
            - difficult to perform w/ straight femoral stems, esp if patient is even slightly obese;
      - Lateral Approach:
            - may be associated w/ limp unless care is taken to minimize dissection of the medius off of the trochanter;
            - main advantage of this approach is that there is virtually no risk of posterior instability, and therefore, patients do not need hip precautions;
            - probably the approach of choice in patients who are demented or who have neurological disorders;
            - may be the approach of choice when the stem is to be press fitted since the fragile osteoporotic bone requires that the stem be placed in the
                     patients native anteversion (which may or may not provide sufficient stability);
      - Posterior Approach to the Hip Joint
            - attempt to re-approximate hip capsule to reduce dislocation;
            - note that w/ a displaced femoral neck fracture, the trochanter may be shifted slightly anteriorly, and therefore, consider making the incision
                    slightly more posterior than usual;
                    - further, it will be easier to broach the femoral canal thru a smaller incision, if the incision is curved more posterior than usual (towards 
                             sciatic notch rather than the PSIS);
            - ref: The Moore self locking Vitallium prosthesis in femoral neck frx: a new low posterior approach. AT Moore. Instr Course Lectures 1959;16:309-321.    

- Complications after Hemiarthroplasty:
     - mortality:
           - Kenzora et. al. report: 14% mortality during first year after hip frx compared to the 9% mortality rate in normal population of similar age;
                 - mortality after hemiarthroplasty is 10 to 40%; 
                 ref: Outcome after hemiarthroplasty for femoral neck fractures in the elderly
    - fracture of the Femur: 4.5%
           - almost all frx occur when surgeon attempts to reduce prosthesis;
           - most are non displaced and involve either greater troch or neck;
           - w/ femoral shaft frx consider methy methacrylate combined w/ a long stem prosthesis;
    - dislocation:
           - less than 10%.
           - more common w/ too much anteversion or retroversion, posterior capuslectomy, & excessive postoperative flexion or rotation w/ hip adducted; 
           - reference:
                  - Botulinum Toxin as a Solution in Voluntary Hip Dislocation After Modular Unipolar Hemiarthroplasty
    - post op: sepsis: 2% to 20%
           - more common w/ posterior surgical approach;
           - infections may be superficial or deep
           - ref:  Relationship between haematoma in femoral neck fractures contamination and early postoperative prosthetic joint infection.
    - loosening and migration:
           - presence of a radiolucent zone around the prosthesis;
           - if clinical signs and symptoms are present and loosening or migration is present, then consider revision to THR;
           - erosion tends to occur in active pts with cemented Thompson hemiarthroplasty; 
   - pain: 
           - painful hemiarthroplasty - conversion to THR
           - reference:
                    - Capsular impingement as a source of pain following bipolar hip arthroplasty. 





Clinical and X-ray comparison between a reamed versus an unreamed acetabulum in hip hemiarthroplasty

Thompson hemiarthroplasty and acetabular erosion

Hemireplacement Arthroplasty with Unipolar vs Bipolar Prosthesis for Displaced Hip Fractures in Elderly

Clinical Results for Bipolar Hemiarthroplasty of the Hip in Patients Under 65 Years Old

Acetabular revision with a bipolar prosthesis.
 
Long-term results of bipolar hemiarthroplasty for osteoarthritis of the hip and idiopathic osteonecrosis of the femoral head

Rate of degeneration of human acetabular cartilage after hemiarthroplasty.

Total Hip Arthroplasty and Hemiarthroplasty in Mobile, Independent Patients with a Displaced Intracapsular Fracture of the Femoral Neck. A randomized, controlled trial 

[Stress analysis on the acetabular side of bipolar hemiarthroplasty by the two-dimensional finite element method incorporating the boundary friction layer]

Bipolar Arthroplasty as a Treatment in Osteoarthritis of the Hip. Preliminary Report

Capsular impingement as a source of pain following bipolar hip arthroplasty.

Bipolar hemiarthroplasty in degenerative arthritis of the hip. 100 consecutive cases.

Precision-fit surface hemiarthroplasty for femoral head osteonecrosis. Long-term results

Bipolar Hemiarthroplasty for Primary Osteoarthritis of the Hip: A Review of 41 Cases With 8 to 10 Years of Follow-Up




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, August 19, 2013 1:54 pm