In 2005, the leading international medical journal, the Journal of Bone and Joint Surgery (JBJS), published an international survey [1] that revealed the treatment choices of North American orthopaedic surgeons at the time for displaced femoral neck fractures (Garden types III and IV) in the elderly. The survey found that physicians surveyed agreed on the relationship between patient age and internal fixation/arthroplasty, choosing internal fixation for displaced femoral neck fractures in patients <60 years of age and prosthetic arthroplasty for patients >80 years of age; parallel hollow nails (Multiple screws) were the most widely used option for internal fixation and unipolar hemiarthroplasty was the most widely used option for arthroplasty. In terms of technical difficulty of surgery, total hip replacement is considered the most difficult, and the relatively easy ones are sliding compression system internal fixation and unipolar hemiarthroplasty; in terms of difficulty of revision of surgical failure, total hip replacement revision is still considered the most difficult, and the relatively easy ones are hollow nail internal fixation and hemiarthroplasty revision. Most physicians believe that internal fixation surgery is superior to prosthetic arthroplasty in terms of operative time, blood loss, and infection rate; prosthetic arthroplasty is considered superior to internal fixation in terms of function and pain. In addition, there is a wide divergence of opinion regarding the surgical approach, type of internal fixation, type of artificial joint, and many other aspects. An earlier study [2] showed that in patients with good pre-injury mobility, 41% of the treatments chosen by physicians were bipolar hemiarthroplasty, 37% were internal fixation, 32% were unipolar hemiarthroplasty, 16% were total hip, and 74% were cemented; in patients with poor mobility, 94% were unipolar hemiarthroplasty, 8% were bipolar hemiarthroplasty, 1% were internal fixation, and 46% were cemented. 46%. What are the latest research advances on internal fixation and artificial joints today? This article attempts to review the review.
1. Internal fixation and artificial joints
The age of the patient is one of the most important factors influencing the choice of treatment. Younger patients with femoral neck fractures have milder underlying disease, good bone quality, and often require better functional recovery. In these patients, it has been reported that internal fixation of the fracture should be performed within 8 h of diagnosis to minimize the incidence of femoral head necrosis [3,4]. In younger patients with femoral neck fractures, internal fixation of the fracture is still the main treatment of choice, while in older patients there is often a trade-off between internal fixation and artificial arthroplasty.
Older patients have poorer bone quality, and studies have found that older patients with osteoporotic femoral neck fractures treated with internal fixation have a nonhealing rate of more than 30% [5]. Even if the fracture heals well, this does not mean a good functional recovery: in approximately 66% of cases the limb heals shortened, in 39% of cases the neck stem angle heals inward, and lower limb shortening of more than 5 mm is accompanied by impaired hip function [6,7]. Even though pain and function after internal fixation were similar to those of arthroplasty [8], the forced revision rate by year 13 was 33% for failed internal fixation compared to 24% and 6.75% for hemi- and total hip replacement, respectively [9], making the revision rate worse for internal fixation than for arthroplasty [8,10,11]. Although the initial cost of total hip arthroplasty is higher, considering the cost of secondary surgery for internal fixation and the poor functional recovery of the hip, total hip arthroplasty is more cost-effective than resurfacing internal fixation in the long term [10].
Elderly patients with femoral neck fractures may achieve better hip function and fewer complications with prosthetic arthroplasty, with no difference or slightly increased mortality at 1 year compared with reduction internal fixation [8,10,12]. Artificial arthroplasty is accompanied by a higher risk of infection, bleeding and prolonged operative time [8]. Therefore, the current study of Garden I femoral neck fractures and Garden
III IV patients under 65 years of age are mostly given internal fixation treatment, and arthroplasty is mostly chosen for Garden III IV patients older than 80 years of age [1]. The choice between internal fixation and arthroplasty for Garden III IV patients between 65 and 80 years of age requires a combination of factors such as whether the fracture site occurs under the head, in the neck, or at the base, as well as the patient’s physical condition and pre-existing disease. New evidence on the choice between internal fixation and arthroplasty will be reported in future studies of large multicenter randomized controlled clinical trials, such as the Hip Fracture Preference for Total Hip Arthroplasty or Femoral Head Arthroplasty Study (HEALTH), the Hip Fracture Treatment Internal Fixation implant selection study (FAITH)”.
2. Choice of internal fixation
The ideal internal fixation implant should provide compression of the broken end, resistance to displacement and rotational stability, and the options are multiple compression screws (CS), sliding hip screws and lateral plates (SHS-P), and proximal femoral locking plates (LPFP), etc. CS and SHS-P allow the broken end to slide along the longitudinal axis of the internal fixation, translating weight into compression of the broken end; LPFP is a strong fixation of the fracture end.
The CS technique is the most widely used internal fixation technique, with the advantages of providing compression of the severed end and resistance to rotation, minimal trauma, protection of residual blood supply, and ease of secondary remedial surgery after failure; the disadvantages are the tendency for the screws to penetrate the femoral head during the surgical operation, frequent retraction of the nail leading to non-union of the fracture, and possible shortening of the lower extremity [13]. This technique requires parallel inverted zigzag shape between the three screws and the posterior and inferior nails should be close to the cortical bone within 3 mm [14]. It has been reported [15] that the CS technique is more suitable for Pauwel type I fractures, where the severed end is pressure-dominant and the screws can be easily placed at right angles to the section, whereas for Pauwel type III fractures, where the severed end is shear-dominant, the incidence of nonunion with internal fixation systems such as SHS-P is significantly lower than with the CS technique (8% versus 19%).
SHS-P and other similar internal fixation systems are classified as “the fixed-angle implant”. As mentioned previously, Pauwel type III fractures are more suitable for SHS-P [13,15]. SHS-P may require less secondary revision than CS [16]. Short-term follow-up results show that SHS-P results in higher healing rates and lower revision rates compared to CS, but there appears to be a trend toward higher rates of femoral necrosis [20, 21].The disadvantages of SHS-P include poor resistance to rotation, disruption of the blood supply, and shortening of the lower extremity [17].
LPFP differs from the above 2 internal fixation techniques in that it does not provide dynamic compression, but rather strong fixation of the severed end. Some experimental biomechanical studies [18,19] found that LPFP can withstand greater stresses, including compressive and rotational forces, compared with CS and fixed-angle internal fixation. However, it has also been reported [22] that LPFP, although better at maintaining fixed repositioning, has a higher risk of internal fixation fracture and subrotor fracture with poor hip function scores, possibly due to overly pronounced stress masking that impedes micromovement of the disconnected end.
In general, CS technique is still the most classic and widely used technique for treating femoral neck fractures in the elderly; SHS and other fixed-angle internal fixation techniques may be superior to CS technique in some cases, but further research is still needed; LPFP applied to femoral neck fractures in the elderly still lacks strong clinical evidence.
3.Artificial joint
Complications of artificial hip replacement for elderly femoral neck fractures mainly include infection, prosthesis dislocation, periprosthetic fracture, acetabular wear, and aseptic loosening. According to the Swedish National Hip Arthroplasty Registry (SHAR) database [23], the 18-month follow-up reoperation rate for hemiarthroplasty for elderly femoral neck fractures between 2005 and 2010 was 3.8% and the revision rate was 3.0%, including 1.68% prosthetic dislocation, 1.18% infection, 0.56% periprosthetic fracture, 0.18% acetabular wear, pain 0.07%, aseptic loosening 0.04%, and other complications 0.09%. Risk factors for reoperation were male, history of local surgery (second-stage arthroplasty after failed internal fixation), <85 years, non-cemented fixation, and bipolar prosthesis; risk factors for prosthesis dislocation were history of local surgery, <75 years, and bipolar prosthesis, whereas cemented polished prosthesis and anterior surgery significantly reduced the risk of dislocation; risk factors for infection were history of local surgery, <75 years, and bipolar prosthesis; and 1 year postoperatively Risk factors for death were male, cognitive impairment, while <85 years of age and low American Society of Anesthesiologists (ASA) score significantly reduced the risk of death at 1 year postoperatively.
According to the National Artificial Joint Replacement Registry (NJR) database [24], a total of 4323 elderly patients with good mobility of femoral neck fractures underwent total hip arthroplasty between 2003 and 2010, with 42.4% cemented, 28.9% uncemented, and 26.2% hybrid prostheses; 49.5% with 28 mm femoral head, 30 mm The 5-year revision rate was 3.25%, and the reasons for revision were 30% dislocation, 16% infection, aseptic loosening, 11% peri-prosthetic fracture and 8% peri-prosthetic fracture. 11%, and 8% for periprosthetic fractures. The 5-year survival rate of the prosthesis was close to 98% for cemented prostheses and close to 95% for non-cemented prostheses. Risk factors for revision were non-cemented prosthesis, <75 years of age, and non-metal-polyethylene prosthesis, whereas weight-bearing surface size and femoral head diameter were not risk factors for revision. The risk factor for 90-d postoperative mortality was 3.2%. risk factors for 90-d mortality included higher ASA score, male, >75 years of age, metal-polyethylene prosthesis, and posterior approach surgery. The above data suggest that total hip arthroplasty is a good option for patients <75 years of age with femoral neck fractures and low ASA scores; cemented fixation of the femoral stem prosthesis did not affect perioperative mortality but reduced mid-term prosthetic survival.
Information from the Australian Orthopaedic Society-National Artificial Joint Replacement Registry database [25] showed that the 9-year revision rate for artificial arthroplasty was 4.3% for bipolar hemiarthroplasty compared with 7.7% for unipolar hemiarthroplasty and 8% for total hip. The reasons for failure of unipolar hemiarthroplasty were 50.6% for loose prosthesis, 17.3% for fracture, 10.4% for dislocation, 9.3% for infection, 6.9% for pain, and 3% for cartilage wear; the reasons for failure of bipolar hemiarthroplasty were 23.5% for loose prosthesis, 22.1% for fracture, 17.4% for dislocation, 18.8% for infection, 8.7% for pain, and 4.7% for cartilage wear. percent.
Data from the Italian National Artificial Joint Replacement Registry [25] showed that the 9-year revision rate after arthroplasty was 3% in the hemiarthroplasty and 7% in the total hip. The causes of prosthesis failure in the hemi hip were 16.7% for prosthesis loosening, 5.3% for fracture, 42.7% for dislocation, 7.62% for infection, and 17.5% for cartilage wear.
Data from a small sample of two hospitals in the United States [26,27] showed that the mean age of patients undergoing total hip arthroplasty in one report was 78 years, with a mean follow-up of 15.8 months, an overall mortality rate of 58%, and an overall revision rate of 1.3%, due to infection and acetabular wear, respectively; the overall complication rate of patients undergoing hemiarthroplasty in the other report was 16.1% (most of which were prosthesis In another report, the overall complication rate of patients who underwent hemiarthroplasty was 16.1% (most of which were dislocated), and the mortality rate at 2 years after surgery was 8.1%, while the smaller head to neck ratio was a risk factor for dislocation.
4.Hemiprosthesis and total hip prosthesis
Many studies [1,9,28-30] have confirmed that hemi-acetabular prostheses are superior to total hip prostheses in terms of operative time, bleeding, and dislocation; however, they are inferior to total hip prostheses in terms of revision rate, local pain, hip function, overall patient health, and 1-year mortality. There was no difference between the two in other aspects. One study [31] even reported that a 20-year prosthetic survival rate of 84% was achieved in patients with femoral neck fractures treated with total hip arthroplasty without a history of local surgery. Although the incidence of prosthetic dislocation after total hip arthroplasty appears to be higher than that of hemiarthroplasty, most dislocations of total hip prostheses can be repositioned with nonoperative treatment, whereas a significant proportion of bipolar hemiarthroplasties need to be repositioned with secondary surgery. Notably, a randomized controlled clinical trial study on this issue [32] found that cemented total hip prostheses were slightly worse than cemented bipolar hemiarthroplasties in terms of bleeding and operative time, but had more significant improvements in postoperative hip function, with no significant differences in various other complications and mortality rates, so cemented bipolar hemiarthroplasties may not be significantly worse than total The non-cemented hemiarthroplasty is worse than the total hip prosthesis in terms of local pain, so there is no conclusive evidence to confirm whether these differences between the total and hemiarthroplasty are due to the use of bone cement. However, some studies [25] have also concluded that total hip prostheses result in higher revision rates than hemi-acetabular prostheses and have recommended anterior approach hemi-acetabular arthroplasty for patients with femoral neck fractures aged >75 years. By summarizing different studies [10,12,34] reports suggest that total hip arthroplasty should be given to patients with femoral neck fractures aged 70 to 80 years with good mobility and mental status and in general health, while hemi hip arthroplasty should be given to patients aged 80 years or older with poor mobility or mental status.
5.Bone cemented prosthesis and non-bone cemented prosthesis
It should be noted that all studies on cemented versus uncemented prosthesis fixation have used hemi-acetabular prostheses, including bipolar and unipolar prostheses. Noncemented prosthetic fixation has a higher rate of complications, including periprosthetic fractures, thigh pain, prosthetic subsidence, and secondary revision surgery, and postoperative recovery of hip function is worse than with cemented prosthetic fixation; there is no difference between the two in terms of mortality, although cement particles have been reported to significantly cause pulmonary obstruction and decreased blood oxygen levels [35]; noncemented prosthetic fixation has a shorter operative time and less bleeding [ 11,23,30,33,36-44]. Some studies [45-47] have also reported that the overall complication rate after uncemented hemiarthroplasty is close to the local pain rate. Overall, the cemented type is significantly better than the uncemented type as far as hemiacetabular prostheses are concerned.
6.Hemip unipolar and bipolar prosthesis
Currently, bipolar prostheses are mostly used for hemiarthroplasty in elderly patients with femoral neck fractures, and surveys have shown that nearly 90% of patients can obtain similar hip function and standard of living as before the injury through bipolar hemiarthroplasty [48,49]. Comparative studies between bipolar and unipolar prosthesis replacements [36,50-56] found that unipolar prostheses did not differ from bipolar prostheses in terms of postoperative dislocation and reoperation rates, while gender, age, and operator experience were not risk factors; bipolar prostheses had lower acetabular wear rates; patients with fractures with a history of local surgery had an elevated risk of postoperative dislocation and secondary surgery after hemiarthroplasty; and both had a higher risk of prosthesis loosening, There was no difference in deep infection, revision rate, deep vein thrombosis, or mortality; improvement in hip function after bipolar prosthesis replacement may be better than unipolar prosthesis, but it is controversial. However, some studies [57] reported that the risk of dislocation was lower with bipolar prosthesis replacement than with unipolar prosthesis replacement, that the revision rate was significantly lower with bipolar prosthesis replacement than with unipolar prosthesis [25,51,52], and that the 5-year survival rate was better with bipolar prosthesis than with unipolar prosthesis (62.9% versus 40.0%) [58], especially in patients <75 years of age, where this difference was more significant. Bipolar prosthesis replacement has better acetabular wear than unipolar prosthesis, but has a higher risk of prosthesis dislocation, infection, periprosthetic fracture, and revision [24]. Combining the above research evidence, bipolar hemi hip prosthesis may not have significant advantages over unipolar prosthesis, and more in-depth research is needed in the future; even if it does have some advantages in terms of hip function and acetabular wear, its cost-effectiveness profile needs to be considered, and there is no research evidence on the cost-effectiveness of bipolar prosthesis replacement compared with unipolar prosthesis replacement.
Summary
In summary, we believe that for patients younger than 65 years of age with good mobility and no osteoporotic arthritis, and for patients without significant displacement of the fracture, priority should be given to internal fixation treatment, with specific internal fixation selected with reference to the fracture. For patients older than 80 years old, with poor mobility and osteoporotic arthritis disease, a cemented hemi hip prosthesis should be considered, and the choice of unipolar and bipolar can be based on the patient’s mobility and economic conditions; for patients between 65-80 years old, with obvious displacement of subhead type fractures, good mobility and economic conditions, total hip replacement can be considered. In conclusion, to obtain good results, we need to choose the most suitable treatment for the patient according to the patient’s specific conditions, including general condition, age, coexisting diseases, living ability, local fracture type, bone quality and other factors, and if surgery is needed, we must have good surgical conditions, excellent surgical techniques and comprehensive perioperative treatment to obtain good results, not just Do a surgery.