JOURNAL CLUB ON 27-02-08

JOURNAL CLUB ON 27-02-08WEDNESDAY : 

JOURNAL CLUB ON 27-02-08WEDNESDAY PRESENTED:DR. CHETAN MODERATOR: DR. SUDESH SHARMA{PROFESSOR}

TOTAL HIP ARTHROPLASTY Vs HEMIARTHOROPLASTY FOR DISPLACED INTRA-CAPSULAR FEMORAL NECK FRACTURES. : 

TOTAL HIP ARTHROPLASTY Vs HEMIARTHOROPLASTY FOR DISPLACED INTRA-CAPSULAR FEMORAL NECK FRACTURES. BY R.P. BAKER ET. AL INVESTIGATED AT SOUTHMEAD HOSPITAL, FRENCHAY HOSPITAL AND BRISTOL ROYAL INFIRMIRY, BRISTOL U.K. JOURNAL OF BONE AND SURGERY DECEMBER 2006 VOL. 88 NO.12

BACKGROUND : 

BACKGROUND HEMIARTHROPLASTY AND THR BOTH HAVE BEEN USED EXTENSIVELY TO TREAT FEMORAL NECK FRACTURE BUT EACH HAS ITS PROS AND CONS. THIS ARTICLE DISCUSSES THIS ISSUE BASED ON A RCT.

EARLIER REPORTS COMPARED ARTHROPLASTY WITH INTERNAL FIXATION FOR DISPLACED NECK FRACTURES. : 

EARLIER REPORTS COMPARED ARTHROPLASTY WITH INTERNAL FIXATION FOR DISPLACED NECK FRACTURES. THESE REPORTS HAD SHOWN THAT ARTHROPLASTY HAD AN EDGE OVER INTERNAL FIXATION IN THAT LESSER NO. OF SURGERIES WERE REQUIRED FOR REVISION. THE MAJOR PROBLEM ASSOSCIATED WITH HEMIARTHROPLASTY WAS THAT OF ACETABULAR EROSIONS. THEY DEVELOPED IN UPTO 30% IN SOME SERIES. MAJOR PROBLEM WITH THR IS DISLOCATION WHICH INCREASES WITH USE OF POSTERIOR APPROACH AND A SMALLER HEAD DESIGN.

MATERIALS AND METHODS : 

MATERIALS AND METHODS THIS STUDY HAD BEEN APPROVED BY EHICS COMMITTEE OF ALL PARTICIPATING HOSPITALS. PATIENTS WERE ADMITTED TO THIS STUDY WITH DIAGNOSIS OF DISPLACED FEMORAL NECK FRACTURES. PATIENTS WERE ASESSED WITH OXFORD HIP SCORE AND ABBREVITED MM SCORE. OXFORD HIP SCORE IS A VALIDATED 12 POINT QUESTIONAIRE WITH LOW SCORE INDICATING BEST HIP FUNCTION AND VICE VERSA.PATIENTS WERE THEN PROSPECTIVELY RANDOMIZED TO TWO TREATMENT ARMS.85 PATIENTS WERE RECRUITED. 45 WERE CHOSEN TO UNDERGO HEMIARTHROPLASTY AND 40 WERE MANAGED BY THR.

INCLUSION CRITERIA : 

INCLUSION CRITERIA INCLUSION CRITERIA WERE : 1. AGE MORE THAN 60. 2.NORMAL MMS EXAMINATION. 3.ABILITY TO WALK >0.8 KM 4. ABILITY TO LIVE INDEPENDENTLY. 5.NON PATHOLOGICAL FRACTURE. EXCLUSION CRITERIA:- 1.AGE LESS THAN 60 YRS. 2.MEDICAL OR PHYSICAL CO MORBIDITIES THAT RESULTED IN INABILITY TO WALK MORE THAN 0.8 KM OR LESS. 3. PRE EXISTING HIP PATHOLOGY REQUIRING THR 4. PATHOLOGICAL THR.

DEMOGRAPHIC DATA : 

DEMOGRAPHIC DATA HEMIARTHROPLASTY THR FEMALE:MALE RATIO 32:9 32:8 WALKING DISTANCE(KM) 2.17 2.17 MMS EXAMINATION SCORE 9.98 9.83 OXFORD HIP SCORE 12.12 12.90 SHORT FORM-36 SCORE(POINTS) PHYSICAL 44.35 48.01 MENTAL 54.76 55.52 MEDIAN ASA grade 2(1 to 3) 2(1 to 3)

OPERATIVE PROCEDURE : 

OPERATIVE PROCEDURE ALL PATIENTS received SAME CEMENTED FEMORAL COMPONENT, THE CPT COLARLESS POLISHED TAPERED STEM. ALL OPERATIONS WERE PERFORMED THROUGH TRANS GLUTEAL LATERAL APPROACH. HEMIARTHROPLASTY GROUP received ENDO FEMORAL HEAD.PROSTHETIC HEAD WAS AVAILABLE IN 2mm INCREMENTS. THR GROUP received 28 mm FEMORAL HEAD ARTICULATING WITH ALL POLYETHYLENE CEMENTED ACETABULAR COMPONENT. ALL PATIENTS WERE MOBILIZED 2nd DAY POST- OP.PATIENTS WERE EVALUATED AT 3 MONTHS, ONE YEAR AND 3 YEARS AFTER SURGERY.WALKING DISTANCE AT FINAL FOLLOW UP WAS REPORTED BY PATIENTS THEMSELVES.

RESULTS : 

RESULTS 36 OF 40 PATIENTS IN THR GROUP AND 33 OUT OF 45 PATIENTS WITH PROSTHESIS WERE AVAILABLE FOR FINAL STUDY. AT TIME OF FINAL FOLLOW UP HEMIARTHROPLASTY GROUP HAD GREATER DISABILITY, GREATER OXFORD HIP SCORE, SHORTER SELF REPORTED WALKING DISTANCE. BOTH GROUPS HAD SIGNIFICANTLY LOWER PERFORMANCE WHEN COMPARED TO THEIR PRE-OP STATUS. NONE OF FINAL RADIOGRAPHS IN THR GROUP SHOWED ANY SIGNS OF WEAR OFF OF ACETABULAR COMPONENT IN THR GROUP.IN HEMIARTHROPLASTY GROUP 66% SHOWED SIGNS OF ACETABULAR WEAR OUT.

POST OP COMPLICATIONS WITHIN 30 DAYS OF TREATMENT. : 

POST OP COMPLICATIONS WITHIN 30 DAYS OF TREATMENT. HEMIARTHROPLASTY THR DISLOCATION O 3 WOUND INFECTION 1 3(1 NEEDED DEBRID.) THROMOEM. EVENT 3(2 FATAL) 4 DVTS(2 DISTAL TO KNEE) \PNEUMONIA 2 3 ATRIAL FIBRILLATION 1 O HAEMATEMESIS 1 O PRESSURE SORES O 1 HYPO NATREMIA O 1

REVISIONS : 

REVISIONS IN HEMI-ARTHROPLASTY GROUP, 2 HIPS WERE REVISED TO TOTAL HIP ARTHROPLASTY BECAUSE OF SEVERE PAIN ASSOSCIATED WITH ACETABULAR EROSION. AFTER REVISION PROCEDURE, BOTH IMPROVED. ONE MORE PATIENT WITH GRADE 2 EROISION WAS AWAITING REVISION TO THR AT TIME OF PUBLISHING.ONE MORE PATIENT REQUIRED REVISION BECAUSE OF PERI-PROSTHETIC FRACTURE. IN THR GROUP ONE PATIENT REQUIRED REVISION SECONDARY TO MASSIVE FEMORAL SUBSIDENCE.