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Comparison of outcomes after total hip arthroplasty in hip fracture versus elective cases in patients over 60 years of age
⁎Corresponding author: Dae Hee Lee. todayzic@nate.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Total hip arthroplasty (THA) allows for the replacement of impaired parts of the hip joint with artificial ones. This study aimed to compare the differences in preoperative patient profiles, postoperative complications, and clinical outcomes of two patient groups: those who underwent THA for fractures and those who underwent THA electively for diseases such as osteoarthritis (OA) and avascular necrosis (AVN).
We retrospectively analyzed the data of patients who underwent THA between March 2012 and December 2021. Of 232 patients, 173 patients who met the exclusion and inclusion criteria were included. Patients were divided into two groups (Group 1: 113 patients diagnosed with OA or AVN; Group 2: 60 patients diagnosed with hip fracture). Pre- and postoperative Visual Analogue Scale (VAS), Koval scores, and postoperative modified Harris Hip Score (mHHS) were used to assess clinical outcomes. Demographic data and postoperative complications of the two groups were compared. After surgery, a rehabilitation protocol was initiated.
Patients in Group 2 (fracture) had more preoperative comorbidities than those in Group 1 (elective). Follow-up months are 26.22 ± 19.78 (Group 1), and 27.42 ± 17.02 (Group 2) respectively (P > 0.05). There were no statistical differences in the prevalence of postoperative complications between two groups (P > 0.05). Compared with Group 1(elective), Group 2(fracture) showed lower VAS (P < 0.01) at last follow-up, and no difference in Koval score (P = 0.77) and mHHS (P = 0.96) at last follow-up.
Considering the characteristics of the two groups and their perioperative multidisciplinary care, THA for hip fractures can provide good clinical results compared to those with elective THA.
Keywords
Hip
Trauma
Avascular necrosis
Degenerative arthritis
Total hip arthroplasty
1 Introduction
The proportion of older adults is increasing as the world population ages, resulting in an increase in the incidence of hip joint problems, including avascular necrosis (AVN), osteoarthritis (OA), and osteoporotic hip fractures.1 Total hip arthroplasty (THA) is an ideal surgical procedure for patients with hip joint diseases, such as OA and AVN, as well as hip fractures.2 Although there is some debate, THA has been the preferred treatment for displaced femoral neck fractures in patients aged over 60 years who are relatively physiologically young.3 In addition, THA is a highly reproducible procedure and has shown excellent long-term outcomes.3 Although THA can improve pain and range of motion, it may also be related to several postoperative medical complications and mortality.4 Also, although pre- and postoperative progressions for patients with hip joint diseases and fractures differ, many national healthcare systems underestimate or misinterpret the perioperative plans of these two groups.2 There are several studies that elective THA resulted in better outcomes including postoperative morbidity, mortality, and readmission than fracture THA.5–9 However, it is not clear that fracture THA also results in worse outcomes than elective THA in age or preoperative morbidity matched studies. In this study, in patients aged over 60 years, we aimed to compare the demographic data, postoperative complications, and clinical outcomes of the two groups-those who underwent THA for fractures and those who underwent THA electively for diseases such as osteoarthritis (OA) and avascular necrosis (AVN).
2 Materials and methods
2.1 Patient selection
The study design was approved by the Institutional Research Ethics Committee of our center. We retrospectively reviewed the data of patients who had undergone THA between March 2012 and December 2021. Patients who underwent THA and were followed-up for at least 12 months after surgery were included. Patients with a history of hip surgery or trauma in the affected hip, concomitant injury in the adjacent pelvic structure, or history of infection or vascular problems were excluded. In addition, all surgeries were conducted by a single orthopaedic surgeon specialized in hip surgery. Cementless femoral stems were used in all cases.
Among the 232 patients who had undergone THA, 59 were excluded, and a total of 173 patients aged >60 years were divided into two groups: 113 patients who were diagnosed with OA or AVN (Group 1, elective group), and 60 patients who were diagnosed with femoral head and displaced femoral neck fractures (Group 2, fracture group). Clinical outcomes, including the Visual Analog Scale (VAS) and Koval scores (Table 1) were evaluated preoperatively and at the last follow-up for between-group comparisons. The preoperative Koval scores for the fracture group were estimated prior to the trauma. Additionally, the modified Harris Hip Score (mHHS) was evaluated at the last follow-up. Intraoperative variables such as blood loss and operation time; and demographic data including age, body mass index (BMI), and underlying comorbidities (diabetes mellitus, hypertension, cardiac disease, pulmonary disease, tumor, neurologic disorder, rheumatoid disease, chronic renal failure, chronic anemia, thyroid disease, and liver disease) were evaluated. American Society of Anesthesiologists (ASA) score was also evaluated, which was divided into low (ASA I + II), and high (III + IV).10 Postoperative complications were investigated both within the hospital and after discharge. Complications such as pneumonia, pulmonary embolism, urinary tract infection (UTI), deep vein thrombosis (DVT), hip joint dislocation, and surgical site infection were compared between the two groups.
| Ambulatory ability | Score |
| Independent community ambulatory | 7 |
| Community ambulatory with cane | 6 |
| Community ambulatory with walker | 5 |
| Independent household ambulatory | 4 |
| Household ambulatory with cane | 3 |
| Household ambulatory with walker | 2 |
| Nonfunctional ambulator | 1 |
2.2 Surgical techniques and postoperative management
All procedures were performed using a posterolateral approach under general or spinal anesthesia with lateral decubitus position. An incision was made along the intertrochanteric crest, followed by the division of short external rotator and piriformis muscles. While being careful of damage of the sciatic nerve, exposure and dislocation of the hip joint were conducted by external rotation and abduction of the femoral head posterior to the acetabulum. For OA or AVN, the femoral neck was cut and excised using an oscillating saw. In cases of hip fracture, additional femoral neck cutting was performed according to the extent and location of the fracture line. After insertion of guide pins into the acetabulum, reaming was performed using a power reamer and after measurement of the femoral head, an acetabular cup was inserted. The femoral neck was exposed by hip adduction and flexion. Using the starting reamer, reaming of the femoral shaft and neck was performed, and an appropriately sized femoral stem was inserted. After insertion of the femoral stem, the femoral head and liner were inserted. After reducing the prosthesis to a satisfactory range of motion, the surgical site was closed. After layer-by-layer suturing of the fascia to the skin, a compressive dressing was applied.
The day after surgery, with cooperation from a rehabilitation specialist, a rehabilitation protocol including hip range of motion, muscle strengthening exercises, and ambulation aided by a walker was initiated while maintaining abduction of the affected side to prevent dislocation.
2.3 Statistical analysis
Between the two groups, the preoperative and postoperative measurements were compared using a paired t-test for continuous variables, according to the normality of the data. And the chi-squared test was used for categorical variables. Between group differences were analyzed using an independent t-test for independent samples, according to the normality of the data. Statistical significance was set at P < 0.05 Statistical analyses were performed using IBM SPSS 2019 version 26.0 software (IBM Co., Armonk, NY, USA).
3 Results
The groups were compared using four categories: demographic variables, comorbidities, postoperative complications, and clinical outcomes. In demographic variables, the average age of Group 1 (elective) was 68.84 ± 6.79 years, and 48.7 % of the patients were female. The average age of Group 2 (fracture) was 70.27 ± 5.88 years, and 55.0 % of the patients were female. The average follow-up period after surgery was 26.22 ± 19.78 months for Group 1 (elective) and 27.42 ± 17.02 months for Group 2 (fracture) (P = 0.69). There were no statistical differences in demographic data, except for intraoperative blood loss (Group 1, 545.13 ml vs Group 2, 806.67 ml; P = 0.04) (Table 2).
| Group 1 (elective) | Group 2 (fracture) | P-value | |
| (N = 113) | (N = 60) | ||
| Age (years) | 68.84 ± 6.79 | 70.27 ± 5.88 | 0.17 |
| Sex, N (%) | 0.43 | ||
| Men | 55(48.7) | 33(55.0) | |
| Women | 58(51.3) | 27(45) | |
| Follow-up (months) | 26.22 ± 19.78 | 27.42 ± 17.02 | 0.69 |
| Body mass index (BMI, kg/m2) | 24.17 ± 3.53 | 25.32 ± 4.02 | 0.43 |
| Smoking (Yes: No, N) | 27:86 | 13:47 | 0.11 |
| Operative time (min) | 91.57 ± 20.8 | 90.65 ± 19.05 | 0.75 |
| Length of stay (days) | 23.76 ± 11.88 | 26.25 ± 14.81 | 0.29 |
| Blood loss (ml) | 545.13 ± 759.81 | 806.67 ± 563.24 | 0.04 |
Generally, the patients in Group 2 (fracture) had more preoperative comorbidities than those in Group 1 (elective); these included diabetes mellitus (DM) (Group 1, 14.2 % vs. Group 2, 31.7 %; P < 0.05), neurological disorders (Group 1, 6.2 % vs. Group 2, 25.0 %; P < 0.05), and chronic renal failure (Group 1, 8.8 % vs. Group 2, 23.3 %; P < 0.05). However, ASA grade showed no statistical difference between two groups(P = 0.60) (Table 3). In postoperative complications, the differences between the groups were not statistically significant (Table 4).
| Group 1 (elective)(N = 113)(N, %) | Group 2 (fracture)(N = 60)(N, %) | P-value | |
| Diabetes Mellitus | 16(14.2) | 19(31.7) | 0.01 |
| Hypertension | 66(58.4) | 27(45.0) | 0.09 |
| Cardiac disease | 12(10.6) | 12(20.0) | 0.09 |
| Pulmonary disease | 9(8) | 9(15) | 0.15 |
| Tumor | 3(2.7) | 6(10.0) | 0.07 |
| Neurological disorder | 7(6.2) | 15(25.0) | <0.01 |
| Rheumatoid disease | 7(6.2) | 5(8.3) | 0.75 |
| Chronic renal failure | 10(8.8) | 14(23.3) | 0.01 |
| Chronic anemia | 6(5.3) | 2(3.3) | 0.56 |
| Thyroid disease | 6(5.3) | 3(5.0) | 1.00 |
| Liver disease | 7(6.2) | 5(8.3) | 0.75 |
| ASA∗ | 0.60 | ||
| -low (I + II) | 94(83.2) | 48(80) | |
| -high (III + IV) | 19(16.8) | 12(20) |
| Group 1 (elective)(N = 113)(N, %) | Group 2 (fracture)(N = 60)(N, %) | P-value | |
| Pneumonia | 3(2.7) | 4(6.7) | 0.42 |
| Deep vein thrombosis | 3(2.7) | 1(1.7) | 1.00 |
| Pulmonary embolism | 2(1.8) | 2(3.3) | 0.61 |
| Urinary tract infection | 6(5.3) | 6(10.0) | 0.35 |
| Dislocation | 3(2.7) | 4(6.7) | 0.24 |
| Surgical site infection | 1(0.9) | 2(3.3) | 0.28 |
| Periprosthetic fracture | 1(0.9) | 2(3.3) | 0.28 |
| Heterotophic ossification | 0(0.0) | 1(1.7) | 0.35 |
In clinical outcomes, both groups showed significant improvements in VAS scores at the last follow-up (Table 5). Group 2 (fracture) showed statistically higher VAS score preoperatively (Group 1, 6.09 ± 0.73 vs. Group 2, 7.52 ± 0.50; P < 0.01), and lower VAS score at the last follow-up (Group 1, 1.22 ± 0.81 vs. Group 2, 0.70 ± 0.50; P < 0.01) than Group 1 (elective). Group 1 (elective) showed a significant improvement in Koval score postoperatively (P < 0.01), while Group 2 (fracture) showed no significant difference in pre-trauma versus postoperative Koval scores (P = 0.18). Although Group 2 (fracture) showed higher Koval scores (Group 1, 5.08 ± 0.86 vs. Group 2, 5.89 ± 0.32; P < 0.01) than Group 1 (elective), there was no significant difference in the last follow-up Koval score (Group 1, 5.76 ± 0.93 vs. Group 2, 5.78 ± 0.45; P = 0.18). At the last follow-up, the differences in the mHHS between the groups were not statistically significant (Group 1: 71.28 ± 9.38 vs. Group 2: 70.50 ± 11.75; P = 0.96).
| Group 1 (elective) | Group 2 (fracture) | p-value | |
| VAS∗ score (preoperative) | 6.09 ± 0.73 | 7.52 ± 0.50 | <0.01 |
| VAS score (last follow-up) | 1.22 ± 0.81 | 0.7 ± 0.50 | <0.01 |
| Koval score (preoperative) | 5.08 ± 0.86 | 5.89 ± 0.32 | <0.01 |
| Koval score (last follow-up) | 5.76 ± 0.93 | 5.78 ± 0.45 | 0.77 |
| mHHS∗∗ (last follow-up) | 71.28 ± 9.38 | 70.50 ± 11.75 | 0.96 |
4 Discussion
In this study, we compared clinical outcomes after THA for fracture and elective cases. There were no statistical differences in demographic data between the two groups. Additionally, there were no significant differences in postoperative complications. At the last follow-up, the VAS scores in Group 2 (fracture) were better than Group 1(elective), and clinical scores of Group 2 (fracture) were comparable with Group 1 (elective) in Koval scores and mHHS.
Several studies have reported worse clinical outcomes in patients requiring urgent THA for hip fracture than in those undergoing elective THA, particularly in readmission, postoperative morbidity, and mortality.5–9 Sassoon et al. reported that the incidences of in-hospital mortality, pulmonary embolism, hematoma, infection, and dislocation were higher in the immediate peri-operative period in the fracture group than in the elective group.3 Additionally, Yannick et al. found that THA for hip fracture was related to a higher risk of in-hospital mortality than elective THR.4 Several factors, including pain, bleeding, and trauma caused by hip fracture, result in catabolic, stress, and inflammatory status11–14 that lead to postoperative complications such as pneumonia, pulmonary embolism, myocardial infarction, stroke, and major bleeding.15,16
In this study, in the demographic data, there were no statistical differences except for intraoperative blood loss. There was more intraoperative blood loss in Group 2 (fracture) than in Group 1 (elective) (Group 1, 545.13 ml vs Group 2, 806.67 ml; P = 0.04). The cause of this difference would be bone bleeding or hematoma created by the fracture. In underlying comorbidities, although statistical differences were observed in the prevalence of several underlying diseases, comparison of ASA score showed no significant difference between the two groups. There were no statistical differences in postoperative complication. In addition, there was a significant improvement in the VAS score of postoperative 1 year in both groups. Group 2 (fracture) reported worse VAS score preoperatively and better VAS score at 1 year after surgery than Group 1 (elective). Regarding the Koval score, Group1 showed significant improvement whereas Group 2 showed no significant difference, indicating that the ambulatory ability of Group 2 was similar to that before trauma. Also, there was no significant difference in Koval score at 1 year after surgery between the two groups. Unlike other studies mentioned above, THA for hip fractures achieved comparable clinical results with THA for elective cases.
Similarly, Lim, J.W. et al. conducted a prospective study comparing clinical outcomes of THA for 41 trauma and 41 elective cases.17 The two groups were matched for age, sex, surgeon's grade, etc. The study reported that THA for trauma cases can produce comparable functional clinical scores and postoperative complication rates with THA for elective cases under well-matched patient selection. Although the present study was retrospective, there were no significant differences in demographic data including age, sex, BMI, surgeon's grade, ASA, and we included 173 patients (elective - 113, fracture - 60) in this study. The study of Lim, J.W. et al. supports the findings of this study in some ways.17 However, the study of Lim, J.W. et al. did not describe any after surgery rehabilitation and exercise programs. In the present study, multidisciplinary preoperative care and postoperative aggressive rehabilitation protocol could be advantages to achieve comparable clinical results for both groups.
Vidán M. et al. suggested that early multidisciplinary geriatric care reduces postoperative complications and mortality in patients aged ≥65 years with hip fractures.18 Other studies recommended that earlier surgery within 48 h after hip fracture was associated with a lower risk of postoperative complications and mortality.19–21 Many studies have shown that THA for fractures is viewed differently from THA for elective cases; we focused on shortening the time from admission to surgery, thorough preoperative examinations for presurgical preparation, and postoperative rehabilitation including earlier ambulation. In Group 2 (fracture), earlier surgeries (within 48 h) were performed in 33 of the 60 patients (55 %). Because surgeries are often delayed for many reasons, including patient age, admission on holidays, and correction of laboratory abnormalities,22,23 there were difficulties in performing surgeries within 48 h in some patients with underlying conditions that required investigation. Under thorough multidisciplinary evaluation by anesthesiologists, cardiologists, etc., we attempted to perform surgeries as promptly as possible. In addition, patients who underwent THA either for fractures or elective reasons started ambulation using a walker and thigh muscle strengthening exercises within 24 h after surgery. Mathesis C. et al. stated that strength training and mobilization of hip muscles in addition to standard physiotherapy within one week after THA improves hip mobility and gait performance.24 Cooperating with a rehabilitation specialist, physiotherapy focusing on the hip joint and adjacent muscles started within 5 days after THA in our study. We thought that these rehabilitation procedures could have aided in preventing postoperative complications.
Our study had several limitations. First, it was a non-randomized retrospective study conducted at a single medical center. Data from the two groups were collected at different periods to eliminate patient selection bias; however, doing so might have influenced the clinical results. Second, relatively small numbers of patients were included in this study (Group 1, 113; Group 2, 60).
5 Conclusion
Considering the characteristics of the two groups and focusing on perioperative multidisciplinary care, THA for hip fractures can produce clinical results comparable with those of elective THA for AVN and OA. These results can help surgeons make informed choices when choosing surgical options for hip fractures.
Funding
None.
Ethical statement
The study design was approved by the Institutional Research Ethics Committee of our center and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki.
Guardian/patient's consent
Because this study is a retrospective study conducted by chart review, consent of guardian or patient is not needed.
CRediT authorship contribution statement
Ki-Choul Kim: Conceptualization, Methodology, Validation. Joo Han Kwon: Software, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Young Chae Park: Resources, Data curation, Investigation. Dae Hee Lee: Supervision, Project administration, Funding acquisition.
References
- Comparison of bipolar hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis. BMC Muscoskel Disord. 2015;16(1):1-13.
- [Google Scholar]
- A review of total hip arthroplasty comparison in FNF and OA patients. Advances in Orthopedics.. 2021;2021
- [Google Scholar]
- Total hip arthroplasty for femoral neck fracture: comparing in-hospital mortality, complications, and disposition to an elective patient population. J Arthroplasty. 2013;28(9):1659-1662.
- [Google Scholar]
- Outcomes after hip fracture surgery compared with elective total hip replacement. JAMA. 2015;314(11):1159-1166.
- [Google Scholar]
- Hip arthroplasty for fracture vs elective care: one bundle does not fit all. J Arthroplasty. 2017;32(8):2353-2358.
- [Google Scholar]
- Complications following total hip arthroplasty: a nationwide database study comparing elective vs hip fracture cases. J Arthroplasty. 2020;35(8):2144-2148. e3.
- [Google Scholar]
- Not all hip arthroplasties are created equal: increased complications and re-admissions after total hip arthroplasty for femoral neck fractures compared with osteoarthritis. Bone Joint Lett J. 2019;101-b(6_Supple_B):84-90.
- [Google Scholar]
- Hip fracture does not belong in the elective arthroplasty bundle: presentation, outcomes, and service utilization differ in fracture arthroplasty care. J Arthroplasty. 2018;33(7s):S56-s60.
- [Google Scholar]
- The frank stinchfield award : total hip arthroplasty for femoral neck fracture is not a typical drg 470: a propensity-matched cohort study. Clin Orthop Relat Res. 2017;475(2):353-360.
- [Google Scholar]
- Cytokines and C-reactive protein production in hip-fracture-operated elderly patients. J Gerontol A Biol Sci Med Sci. 2007;62(4):420-426.
- [Google Scholar]
- Vascular endothelial growth factor (VEGF) in plasma increases after hip surgery. J Clin Anesth. 2004;16(6):435-439.
- [Google Scholar]
- Hip fracture and increased short-term but not long-term mortality in healthy older women. Arch Intern Med. 2011;171(20):1831-1837.
- [Google Scholar]
- Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: pulmonary Embolism Prevention (PEP) trial. Lancet. 2000;355(9212):1295-1302.
- [Google Scholar]
- A prospective study on total hip arthroplasty outcome in hip fracture compared with matched elective cohort. Current Orthopaedic Practice. 2022;10:1097.
- [Google Scholar]
- Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005;53(9):1476-1482.
- [Google Scholar]
- Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ (Can Med Assoc J). 2010;182(15):1609-1616.
- [Google Scholar]
- Accelerated versus standard care in hip fracture patients: does speed save lives? J Comp Eff Res. 2014;3(2):115-118.
- [Google Scholar]
- Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth. 2008;55(3):146-154.
- [Google Scholar]
- Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155(4):226-233.
- [Google Scholar]
- Strength and mobilization training within the first week following total hip arthroplasty. J Bodyw Mov Ther. 2018;22(2):519-527.
- [Google Scholar]