Hip fractures and its aftereffects continue to be on the rise as our society ages and becomes more and more geriatric. Ageing is the main risk factor for these fractures and proximal femur intracapsular fractures account for a large portion of fractures in the elderly. The basic objective of treating a femoral neck fracture is to return function to that which it had before the fracture, without any accompanying morbidity. This forsake complete immobilisation to obtain a bone union, or to resort early ambulatory operations by surgery with arthroplasty, since extended immobilisation during such fracture in the elderly will jeopardise the life span and further worsen the problem [1,2].

Modern bipolar hip prostheses with cement, particularly those with modular stems, are the greatest alternative for people who want to be more active. The bipolar prosthesis consists of a femoral head that is undersized and snap-fits into a polyethylene liner (the inner bearing) of a metal acetabular shell. The metal acetabular shell then articulates within the anatomic acetabulum (the outer bearing) through suction-fit. The advantage of this device is that it should result in less acetabular wear because it permits motion at both the inner and exterior bearing surfaces. As a result, surgical intervention is the gold standard and a modular cemented hemiarthroplasty is frequently the best way to achieve this [2,3].

These patients have been receiving modular bipolar hip arthroplasty from the Department of Orthopaedic Surgery for several years. At Indira Gandhi Medical College in Shimla, it was deemed important to assess the degree of osteoporosis and the classification of fracture in elderly patients who had had bipolar hip arthroplasty.

Aims and Objectives

To assess the Classification of Fracture and Degree of osteoporosis among elderly cases of fracture neck of femur and undergone bipolar hip arthroplasty at Indira Gandhi Medical College, Shimla.

The present study was conducted in Department of Orthopaedic Surgery Indira Gandhi Medical College, Shimla. It included both prospective and retrospective cases. A prospective cases included 35 patients from May 2016 onwards and retrospective cases included 25 traceable operated patients in last 5 years at Department of Orthopaedic Surgery Indira Gandhi Medical College, Shimla.

Inclusion Criteria

• Patients with physiological age more than 70 years of either sexes

• Elderly patients with displaced fracture neck of femur

• Neglected fracture neck of femur more than 3-4 weeks old in elderly patients

Exclusion Criteria

• Patients less than 70years of age

• Poly trauma patients

• Undisplaced fracture neck femur

Methods

Prospective Regimen: After reporting to the hospital, history was obtained from the patient and attendants. Assessment of patient was done for physiological age by physiological status score when found less than 20 were included in study. Fracture neck of femur was classified along with other associated injuries and the general condition of the patient was assessed. Below knee skin traction was applied while waiting for surgery with the aim of relieving pain, to prevent shortening and to immobilize the involved lower limb. Oral and parental non-steroidal anti-inflammatory drugs were given to relieve the pain.

Radiological Evaluation

Regardless of the mechanism of injury following X-rays were taken with tube to film distance of 40 inches to get standard magnification for templating of patients having fracture neck of femur and patient was planned for surgery:

• X-ray pelvis with both hips with upper half of femora antero-posterior views

• Lateral views of affected hip with thigh

• Both hips with upper half femora in15 degree of internal rotation to bring the neck parallel to X-ray film

• Chest X-ray

All fractures were classified as per Anatomical/Garden/Pauwel/Simple working classification. Degree of osteoporosis was assessed in accordance with Singh’s index and DEXA scan. The patients who fulfill the inclusion criteria were included in the study.

Laboratory Investigations

Included complete haemogram, blood sugar, liver function tests, renal function tests, lipid profile, serum electrolytes, blood group, CRP, ESR, PT-INR, Viral markers for HIV, HBsAg, HCV, Urine routine and microscopy, Urine C/S, EKG were also done and medical consultation was sought for co-morbid conditions and were evaluated and treated before taking them to surgery.

Patient counseling was done regarding rehabilitation programme to be followed subsequent to surgery. Patients and attendants were told about their expectations out of surgery and were detailed about outcome, limitations, preoperative and postoperative complications.

Preanaesthetic assessment was done for all patients and fitness for surgery was sought from anaesthesiologist.

Preoperative Regimen

Patient once fit for anaesthesia and surgery was taken up for surgery. Patients were shaved off all hairs from nipples to toes both anteriorly and posteriorly on the day of surgery. Nails were cut short. Patient kept empty stomach after 10 P.M. of preoperative day. Enema was given in evening of preoperative day. Injectable antibiotic was given an hour before surgery after test dose. 

Patient positioning was in true lateral position, a large sized K-nail firmly in contact with both ASIS was used and position secured, with anterior pubic pad and a large posterior pad. 

Anaesthesia eithersubarachnoid block or as decided by anaesthetist.

Surgical approach was posterolateral approach with posterior dislocation of hip i.e. Marcy and Fletcher’s modification of Gibson’s approach was used in all the surgeries and were performed on an elective basis using standard aseptic precautions. 

Postoperative Regimen

On first post-operative day, patient was allowed sitting with the help of back rest and check X-rays were done when patient was comfortable. Wound was inspected on second day and negative suction drains were removed, injectable antibiotics were continued depending on wound condition then patient was shifted onto oral antibiotics on 6^th postoperative day. Patient was allowed knee bending and quadriceps exercises. Patient was allowed assisted walking whenever patient was comfortable with axillary crutch/walker usually within a week time. Skin sutures were removed on 14^th postoperative day and oral antibiotics were stopped. By this time those patients who were allowed to walk early were able to walk confidently and comfortably in hospital premises were discharged from hospital.

On discharge, patient was advised not to squat and sit cross legged, avoid low-level chairs/sofas and sleeping on the operated limb. Patient were advised to use western type of seat in toilet, keep limb abducted, not to adduct, not to flex more than 90⁰ and internally rotate the hip. Active quadriceps, hip and knee bending exercises, flexion stretches were advised to patient.

On day of discharge antero-posterior X-ray of both hip with upper half femur were taken. Every patient was advised to come for followup at every 6 weeks for 6 months. Further followup was done every 3 months in first year. On every followup patient were X-rayed and were evaluated for subjective complaints like limb length discrepancy, gait, range of motion. 

Retrospective Evaluation

Records of all patients who underwent Modular Bipolar hip arthroplasty in elderly patients above 70 years of age were traced from the Medical Records Department. The case files were obtained from hospital record section and relevant desired information was recorded from these as per performas. Patients were called for follow-up in OPD on specified days. Patients were examined thoroughly, detailed information was obtained from them and X-rays were taken of pelvis with bilateral hips with upper half of femora antero-posterior views and hip with thigh lateral views.

This study was conducted in Department of Orthopaedic Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh. Sixty patients were included in the study, 35 prospective and 25 retrospective. The following observations were obtained (Table 1):

Table 1: Distribution of Participants According to Age, Gender, Side and

Mode of Injury

• About 52% of patients were aged between 70-80 years followed by 38% patients between 81-90 years. Six patients were aged more than 90 years. Females outnumbered males by a ratio of 2:1 (Table 2)

Table 2: Garden Type

• All the patients who underwent replacement were unstable and Garden Type III & IV (Table 3)

Table 3: Pauwel Type

• Majority of fractures (78.3%) were Pauwel Type III while 21.7% patients had Pauwel Type II (Table 4)

Table 4: Anatomic Type

• Majority of fractures were Subcapital and Transcervical type in 86.7% (Table 5)

Table 5: DEXA Scan

• All patients except one had osteoporosis as revealed by DEXA scan (Table 6)

   

Table 6: Singh’s Index

• About 78% of patients had Type 4 and Type 5 osteoporosis pattern as documented by Singh’s index

Hip fractures are the most devastating injuries in the elderly. The impact goes well beyond immediate clinical consideration and extends into the domains of medicine, rehabilitation, psychiatry, social work and medical economics. Fractures of neck of femur have always presented great challenge. The present study was aimed to evaluate the Classification of Fracture and Degree of osteoporosis among elderly cases of fracture neck of femur and undergone bipolar hip arthroplasty at Indira Gandhi Medical College, Shimla

Depending upon degree of displacement, Garden classified fractures as type I incomplete, type II complete undisplaced, type III complete partially displaced and type IV complete fully displaced.

In our study, depending on anteroposterior radiographic view, we were very selective in choosing patients. Garden I and Garden II fracture patients were subjected to internal fixation and all the patients who had displaced femoral neck fractures i.e. Garden III (41.67%) and Garden IV (58.33%) were subjected to arthroplasty. Barnes et al. [4] reported 19.6% Garden type I and 1.2% Garden type II fractures and Garden type III was seen in 37.2% while Type IV in 41.2% of the patients. Haidukewych et al. [5] in their study of 72 cases reported undisplaced fracture in 30% of cases and displaced fractures in 70% of cases. In both of series preservation of native hip joint was preferred for undisplaced fractures and arthroplasty for displaced types.

Similarly after grouping Garden type III and Garden type IV into ‘displaced fractures’ Kulkarni [6] found 82.5% and Mukerjee and Puri [7] found 85% patients respectively of displaced types who were subjected to arthroplasty. It was concluded from various studies that fracture displacement (Garden type) is not only factor taken into consideration for management in elderly as final functional outcome is do affected by age, premorbidity, preoperative activity level, physiological age and time since injury.

Majority of patients in our study had Pauwel type 3 (78%). As these elderly patients are with high chances of fixation failure and nonunion and are best suited for hemiarthroplasty. Parker and Dynan [8] studied if Pauwel classification is valid. They revealed no significant difference in the incidence of non-union related to the Pauwel angle for displaced fractures and supported that Pauwel angle for displaced fractures is unnecessary.

In our series, majority were transcervical fractures in about 67% patients whereas subcapital in 12 patients (20%) and basal in 8 patients (13%). Similar results were found by Adapureddi et al. [9] where they analyzed the results of surgical management of fracture neck of femur using modular bipolar hemiarthroplasty. Out of 50 patients, majority of the patients (80%) had a transcervical fracture while 8 patients had a basicervical and 2 had sub-capital fracture.

In a study by Crabtree et al. [10] found that cancellous bone is reported to contribute over 70% of bone strength in immediate subcapital region declining to 50% at mid neck. Therefore it was predicted that transcervical fractures are more dependent than subcapital fractures on the loss of cortical bone with age.

It was found that anatomical type of fracture (subcapital, transcervical, basal) did not have any bearing on the final function. Age [7] and time since fracture [6] are taken into consideration while selecting hemiarthroplasty. Bavadekar and Manelkar [11], emphasized not to choose hemiarthroplasty in Garden type I and II fractures even in old individuals. We had followed same criterion while selecting the patients for hemiarthroplasty.

Almost all patients (98.3%) were DEXA proven osteoporotic. The decrease in bone mass in elderly is caused by a number of factors, including reduced biosynthetic and replicative potential of osteoblasts, increased osteoclast activity, reduced physical activity (a stimulus for bone remodeling), genetic predisposition, decreased calcium intake and hormonal influences. The net result is that bone resorption outpaces bone building.

About 78% of patients had type 4 and type 5 osteoporosis pattern according to Singh’s index. It has been suggested by Crabtree et al. [12] that femoral neck fractures originate in cortical rather than spongiosa bone. They found that cortical bone mass was reduced by a quarter in case of intracapsular hip fracture. This was a result of combination of cortical thinning, as shown by reduction in cortical area and decreased density either due to increase in porosity or decrease in mineralization density. In a study conducted by Shivanand et al. [13], all 19 patients were found to be osteoporotic therefore cements the pathological nature of fracture neck femur.

In our study, all the patients had displaced fractures. This is in concordance with previous studies where it has been reported that displaced intracapsular fractures in elderly are associated with osteoporosis and with an increased incidence of osteonecrosis. We had this special consideration in mind while elderly were admitted, therefore beside focusing on additional nutritional support with help of attendant education we also gave oral Vitamin D once a week (60,000U) to all patients and oral bisphosphonate once a month therapy with attention to renal and hepatic profile. Therefore bipolar hemiarthroplasty was found well suited for our patients as treatment largely dependent on the general physical condition and mental capacity of the patient which was also observed by Antapur et al. [14].

Present study concluded that among majority of the elderly cases of fracture neck of femur who undergone bipolar hip arthroplasty were classified as Garden Type III and IV, Pauwel Type III and were Subcapital and Transcervical type. All these cases had osteoporosis on DEXA scan and had Type 4 and Type 5 osteoporosis pattern in Singh’s index.

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9. Adapureddi, Hanu T. et al. “Prospective study of management of fracture neck of femur by hemiarthroplasty with cemented bipolar.” Journal of Evolution of Medical and Dental Sciences, vol. 4, 2015, pp. 16309–16314.

10. Crabtree, N. et al. “Intracapsular hip fracture and region-specific loss of cortical bone: Analysis by peripheral quantitative computed tomography.” Journal of Bone and Mineral Research, vol. 16, 2001, pp. 1318–1328.

11. Bavadekar, A.V. “A review of internal fixation and prosthetic replacement for fresh fracture of the femoral neck.” Clinical Orthopaedics India, 1987, pp. 43–52.

12. Crabtree, N. et al. “Intracapsular hip fracture and region-specific loss of cortical bone: Analysis by peripheral quantitative computed tomography.” Journal of Bone and Mineral Research, vol. 16, 2001, pp. 1318–1328.

13. Mayi, Shivanand C. et al. “Evaluation of functional outcome of cemented bipolar hemiarthroplasty for treatment of osteoporotic proximal femoral fractures in elderly people.” International Orthopaedics, vol. 2, no. 3, 2016, pp. 180–183.

14. Antapur, P. et al. “Fractures in the elderly: When is hip replacement a necessity?” Clinical Interventions in Aging, vol. 6, 2011, pp. 1–7.