Open access peer-reviewed chapter
Abstract
Hemiarthrroplasty is a procedure in which the head and neck of femur are only replaced with prosthesis. Currently, almost exclusively used now for displaced intracapsular femur neck fracture in older adults and is the surgery of choice for hip fracture in patients who minimally ambulate or do not function at a very high level. This surgical procedure(arthroplasty) eliminates the risk of non-union, fixation failure, and reoperation in the treatment of femur neck fracture. There are two forms of HA: unipolar and bipolar, as well as conventional and dual-mobility THA. Both HA types have comparable results in terms of stability, but there is a danger of acetabular wear that may eventually need conversion to THA. HA is indicated in patients whose self-sufficiency and physical activity are limited. A unipolar implant should be used, as no evidence exist that bipolar implants provide additional benefits. THA is associated with better functional outcomes and a lower risk of revision surgery in self-sufficient, physically active patients. Instability is the leading complication of conventional THA and occurs with a higher incidence compared to HA. Because of the potential for instability, the posterior approach should be avoided while doing HA. In the hands of a skilled surgeon employing a dual-mobility cup, the posterior route is a solid alternative for THA. Cement fixation of the stem is advised to reduce the possibility of peri-prosthetic fracture.
Keywords
- hemiarthroplasty
- femur neck
- internal fixation
- total hip replacement
- bipolar hemiarthroplasty
- unipolar hemiartroplasty
- cemented
- uncemented hemiartroplasty
1. Introduction
Hip arthroplasty is a surgical procedure where the entire or part of the hip joint is replaced with a prosthetic implant. Hip arthroplasty comes in a wide range of variations. There are two types of procedures involving femoral head replacement: total hip arthroplasty and hemiarthroplasty. The femoral head is replaced with a prosthesis while the native acetabulum and acetabular cartilage are kept in hemiarthroplasty. The acetabulum, as well as the femoral head, are both replaced during total hip replacement.
A hip or proximal femoral fracture in an elderly patient is the most common reason for hemiarthroplasty. The displaced intracapsular fracture is the most common type of hip fracture treated with arthroplasty. The majority of extracapsular fractures are treated with fracture internal fixation. There is still debate about the best treatment for displaced intracapsular fractures in the elderly. Internal fixation reduces operative trauma, but complications such as fracture displacement, nonunion, and avascular necrosis may necessitate revision. Although internal fixation is still preferred in some countries, most surgeons now treat this fracture with arthroplasty.
The Moore prosthesis (1952) and the FR Thompson Hip Prosthesis (1954) are the most well-known early hemiarthroplasty designs (1954). Both of these implants are monoblocks that were designed prior to the development of poly (methyl methacrylate) bone cement, so they were initially inserted as a “press fit.” The Moore prosthesis has a fenestrated femoral stem as well as a square stem with a shoulder to allow for stability within the femur and to resist rotation within the femoral canal. It is commonly used without cement, and bone in-growth into the fenestrations can occur over time. Thompson prostheses have a smaller stem with no fenestrations and are frequently used in conjunction with cement. There are numerous other designs of unipolar hemiarthroplasties that are based on stems used for total hip replacements [1].
In bipolar prostheses, there is an articulation in the femoral head component itself. In this type of prosthesis, there is a spherical inner metal head with a size of between 22 and 36 millimeters in diameter. This fits into a polyethylene shell, which in turn is enclosed by a metal cap. The objective of these condjoints is to reduce acetabular wear by promoting movement at the interprosthetic articulation rather than with the native acetabulum. There are a number of different types of prostheses with different stem designs. Examples of bipolar prostheses are the Charnley-Hastings, Bateman, Giliberty, and Monk prostheses, but many other types with different stem designs exist [1].
The femoral stem can be fixed during hip arthroplasty using cement or by bone growth into a porous-coated implant, depending on the surgeon’s inclination. In elective total hip arthroplasty for osteoarthritis, some orthopedic surgeons now use uncemented femoral components, whereas some prefer cemented stems [2].
Hemiarthroplasty requires different considerations than complete hip arthroplasty. In the latter, clear exposure of both the femur and the acetabulum is essential, necessitating a very long exposure. Because patients are often older and more sensitive to anesthetics and surgical procedures, hemiarthroplasty requires a quick yet successful surgery with the least amount of stress and physiological disruption. There have been several surgical methods for the hip documented [3].
2. Indication
There is little doubt, and the evidence is convincing, that arthroplasty surgery, instead of internal fixation, should be performed for the elderly suffering from displaced intracapsular hip fractures.
This decision is often influenced not only by whether one implant is superior to another, but as surgeons, we must also take into account patient’s medical comorbidities, functional demands, premorbid ambulatory status, and, inevitably, financial considerations. The debate on the choice of implant is, however, never-ending.
2.1 Arthroplasty vs internal fixation
The surgical treatment of patients with a femoral neck fracture should be based on the patient’s age, walking ability, comorbidities, and life expectancy. Internal fixation or different types of hip arthroplasties are the available treatment modalities.
The degree of fracture displacement, the patient’s age, functional demands, and risk profile, such as level of cognitive function and degree of physical fitness, should all be considered when deciding whether to treat displaced femoral neck fractures in the elderly with internal hemiarthroplasty, total hip artroplasty, or internal fixation [4].
For elderly patients with few functional demands who have displaced intracapsular fractures, unipolar or bipolar hemiarthroplasty appears to be the optimum technique, according to the orthopedic surgeon. However, treatment for the generally healthy, active, and cognitively alert old patient is still debatable [4].
Internal fixation is uncontroversial in patients with undisplaced fractures (Garden I-II), with a reasonable incidence of fracture healing problems and a favorable outcome in terms of function and health-related quality of life. Internal fixation is also seen to be the best treatment option for young patients with displaced fractures (Garden III-IV) [5].
Internal fixation causes less operative stress, but sequelae such as fracture displacement, non-union, and avascular necrosis may necessitate revision. Most surgeons now treat this fracture with arthroplasty, while internal fixation is still preferred in some countries.
A meta-analysis 1 of over 100 reports of displaced fractures of the neck of the femur reported a mean rate of nonunion of 33%, avascular necrosis of 16%, and a reoperation rate of 20–36% after internal fixation compared with 6–18% after hemiarthroplasty.
Randomized controlled trials (RCTs) have shown that a primary THR provides superior results to internal fixation in relation to the need for secondary surgery, hip function, and health-related quality of life for the active alert patient fractures(Garden III-IV) [6].
A recent multicenter randomized controlled trial shows THR should be thought of as the therapy of choice for the older patient in excellent condition with a displaced intracapsular fracture of the femoral neck when compared to internal fixation, bipolar hemiarthroplasty, and THR [7].
2.2 Hemiarthroplasty versus total hip arthroplasty
Hemiarthroplasty (HA) and total hip arthroplasty (THA) are still the most often used procedures of hip replacement following fracture. In the long term, some HA patients will require THA conversion owing to activity-limiting thigh discomfort caused by acetabulum wear. Reduced dislocation rates, less difficult surgery, shorter operation times, less blood loss, and cheaper initial expenditures are reported benefits of HA over THA [8].
THA yields superior functional outcomes than HA in the treatment of femoral neck fractures [9] and is, therefore, increasingly performed, notably in physically active patients. Nevertheless, the outcomes of THA used to treat a fracture differ from those of THA for osteoarthritis; blood transfusion is more often required; both the operative time and the hospital stays are longer; and the risks are higher for perioperative complications, infection, re-admission, and mortality [10].
Instabilities are more prevalent during total hip arthroplasty than hemiarthroplasty. The surgeon’s competence, surgical approach, component alignment, and implant selection are all factors that influence hip arthroplasty outcomes [11] A femur neck fracture is a risk factor for instability in and of itself. Dislocation is also substantially more prevalent following THA to treat a fracture than in osteoarthritis patients [12] As a result, choosing an implant for THA for fracture treatment requires extraordinary prudence. Dual-mobility cups have been found to lower dislocation risk, outperforming large-diameter heads and Constrained implants [13].
The most serious long-term issue with hemiarthroplasty is severe acetabular erosion. Acetabular erosion rates have been observed to range from 0–26% for bipolar designs and from 2.2–36% for unipolar designs. According to one study, acetabular erosion necessitated the revision of 38% of unipolar prosthetic hips. Contrarily, dislocation is the most frequent early complication of total hip arthroplasty, and it is more likely when a posterior approach is used, and the prosthetic head size is smaller. After a complete hip replacement for a displaced intracapsular femoral neck fracture, dislocation rates have ranged from 2–20% [14].
Baker’s findings suggest that for the treatment of individuals who are cognitively capable, independent, and active, total hip arthroplasty is preferred to hemiarthroplasty. After a three-year average follow-up, complete hip arthroplasty was associated with superior functional results, fewer problems, and fewer revisions. Both groups had functional decline postoperatively when compared to preoperative levels; however, individuals in the total hip arthroplasty group saw less deterioration and maintained their walking distances [14].
Meta-Analysis and systemic review of randomized trials comparing all forms of THA and hemiarthroplasty done by burger shows that total hip arthroplasty for displaced femoral neck fractures in the fit elderly may lead to higher patient-based outcomes but has higher dislocation rates compared with hemiarthroplastysty in a selected group of patients suffering displaced femoral neck fractures. This review, including the most recent evidence, shows that total hip arthroplasty may be advantageous over hemiarthroplasty [8].
Hedbeck’s randomized controlled trial shows that complete hip arthroplasty produces superior results in terms of hip function and health-related quality of life than bipolar hemiarthroplasty in older, lucid patients with a displaced femoral neck fracture. The findings of this study and earlier research indicate that total hip arthroplasty should be the preferred form of treatment for this fracture in an active older patient with a long-life expectancy [9].
3. Types of hemiarthroplasty
3.1 Based on prosthesis head component
3.1.1 Bipolar vs unipolar hemiartroplasty
Hemiarthroplasty can be unipolar (the head is attached to the stem) or bipolar (in which there is an additional polyethylene bearing between the stem and the endoprosthetic head component). Previous systems, like the Moore, were unipolar arthroplasties with no modularity between the head and stem. Modularity is available in modern hip fracture arthroplasty systems for both unipolar and bipolar arthroplasties. In a bipolar arthroplasty, the second articulation ought to broaden the range of motion and reduce wear on the natural acetabulum, in principle. The production of particle wear debris as a result of the polyethylene might potentially result in osteolysis [15].
It is debatable that prosthesis should be used in hemiarthroplasty. Bipolar prosthesis is preferred by certain authors over unipolar prostheses by others. The motion at the inner bearing of the bipolar prosthesis, in addition to the prosthesis-acetabulum interface, is its potential benefit. The quantity of acetabular erosion should be reduced as a result. According to radiological proof and clinically proven pain reduction, however, investigations have revealed that the bipolar prosthesis acts similarly to the unipolar prosthesis and that the inner bearing loses mobility with time. Additionally, the bipolar prosthesis’ two- to five-fold higher price tag than that of the unipolar prosthesis raises the question of whether it has an impact on older patients’ quality of life and functional outcomes following fractures with high death rates [16].
Less wear on the acetabular cartilage is a putative benefit of the bipolar design. This has led to the suggestion that it might be a better option for patients who are more active and have longer life expectancies. Although there is a chance that the stem will become looser, and synovitis will develop as a result of polyethylene wear on the inner surface of the bipolar head covered in polyethylene. Despite the fact that several RCTs have failed to produce conclusive results on differences in clinical outcomes between the unipolar and the bipolar designs, there are few studies that report on acetabular wear using a grading system [17].
The results of unipolar and bipolar hemiarthroplasty procedures following femoral neck fracture have also been shown to be indistinguishable in several recent prospective investigations. Parker et al. revealed no variations in mortality or complication rates between unipolar and bipolar hemiarthroplasty treatment in a recent evidence-based Cochrane study [16].
3.2 Based on prostesis assembly
3.2.1 Monoblock vs modular
Monoblock and modular prostheses are the two main types of prosthesis assembly that can be used in hip hemiarthroplasty. The diameter of the patient’s femoral head affects the prosthesis size for a monoblock hemiarthroplasty. The most popular monoblock hemi-arthroplasty is the collared Thompson. These implants usually fail to correctly restore the patient’s original hip geometry because of the pre-fabricated design of the prosthesis, which limits its ability to be modified intra-operatively to accommodate for variations in femoral neck offset or leg length [18].
The stem, neck, and head components of a modular hemiarthroplasty are all manufactured separately. The surgeon can modify component size while assembling these intra-operatively, allowing for a more accurate restoration of the patient’s original hip.
3.3 Based on technique of femoral stem insertion
3.3.1 Cemented vs uncemented hemiarthroplasty
According to the method of implant fixation, hemiarthroplasty prosthesis can be divided into two different types: cemented and uncemented hemiarthroplasty. However, controversy still exists regarding whether cemented or uncemented implant fixation is preferable in this patient population [19].
During hip arthroplasty, fixation of the femoral stem can be accomplished with cement or via bony growth into a porous-coated implant [2].
Design-wise, hemiarthroplasty stems can be either cemented or uncemented, both of which have a track record of effectiveness. Comparable to the debate over cement- or cementless-prostheses in primary hip arthroplasty, the controversy over cemented or non-cemented hemiar-throplasty is similar. Although each has advantages and disadvantages of its own, it is not clear which is better. Uncemented stems, which operate using the press-ft approach, may offer advantages in terms of less invasive and shorter surgery time, but they also carry a risk of periprosthetic fractures and thigh discomfort from implant loosening because they perform poorly when it comes to osteointegration with osteoporotic bone [20]. Due to the quality of younger patient bone stock, cementless hip arthroplasties are generally considered to be more suitable for them [21].
There is insufficient evidence from randomized studies to declare one method of hemiarthroplasty to be better than the other in hip fracture surgery. According to some researchers, patients with cemented stems recover more quickly and with less discomfort than those who had non-cemented press fits [22] Primary cementless complete hip arthroplasties usually result in reports of mid-thigh discomfort.
Bone quality is crucial for non-cemented prostheses, in elderly people, it is typically subpar. Inability to create a congruent fit and interference with bone in-growth are two relative contraindications for non-cemented total hip prostheses, both of which prevent the formation of rigid initial stability [21].
The use of a cemented stem, on the other hand, results in better implant fixation because the cement improves the anchor-age, with fewer chances of loosening and thigh pain but higher risks of cardiovascular and respiratory problems because of cement-related toxicity and embolization of cement monomer, or “cement disease.” [23]. Furthermore, in cemented situations, revision procedures become quite challenging [24].
Cement implantation has a well-established impact on the cardiopulmonary system, ranging from temporary hypotension and hypoxemia to abrupt mortality [25]. Uncertainty surrounds the pathogenic mechanism behind this. The majority of experts feel that it is a direct result of fat and marrow emboli [26]; other ideas include cement toxicity, reflex autonomic effects, prostaglandin-induced vasodilatation, and thromboplast in activating the clotting cascade, lowering platelet count and oxygen tension [27]. No of the underlying mechanism, the small cardiopulmonary alterations seem to be temporary and not clinically meaningful. The prevalence of unexpected intraoperative death appears to be less than (0.2%) [28].
In choosing between these techniques, there is limited evidence contrasting the functional outcomes, morbidity, and mortality with cemented or uncemented stems [29]. The cemented group has been shown to be associated with greater blood loss and operative time, the revision rate is lower, with significantly less thigh pain and better mobility [29]. In some investigation, the cemented prosthesis provided stable early fixation with good functional outcomes at 1-year follow-up [30].
There are no differences between using current cemented and uncemented hemiarthroplasty for the treatment of intracapsular hip fractures in terms of mortality risk. The frequency of intraoperative and periprosthetic fractures is much lower with modern cemented hemiarthroplasty, but anesthesia and surgical time are prolonged [31].
4. Surgical approach
Hemiarthroplasty requires different considerations than complete hip arthroplasty. In the latter, clear exposure of both the femur and the acetabulum is essential, necessitating a very lengthy exposure. Because patients are often older and more sensitive to anesthetics and surgical procedures, hemiarthroplasty requires a quick yet successful surgery with the least amount of stress and physiological disruption. There have been several surgical methods to the hip documented [3].
Surgical approaches to the hip for hip hemiarthroplasty can be divided into three main categories: lateral approaches (LA), posterior approaches (PA), and anterior approaches (AA) [18].
According to the few national registers that collect data on surgical approaches for hemiarthroplasty, the direct lateral approach(DLA) and posterior approach(PA) are commonly used internationally. Anterior and anterolateral approaches are also used, but less often. Internationally, it appears that the choice of approach is frequently based on surgeon preference, as a result of training and experience, rather than rigid adherence to guidelines or evidence guide [32].
Posterior approaches commonly include the Moore, the Southern, the true posterior and the posterolateral approaches [18]. The division of the piriformis, and the short external rotators while preserving the hip abductor muscles are the major characteristics of this method. The approach permits the acetabulum and femur to be clearly visualized and exposed for as long as needed. There are advantages such as a lower risk of femoral shaft fracture, a shorter recovery period, a functional abductor, and reduced blood loss. The posterior technique can be used with or without the posterior joint capsule being repaired, along with additional muscle- and tendon-sparing adjustments [32].
There are two types of anterior approaches used to access the anterior part of the hip joint: direct anterior and Smith Peterson approach l. Both of them used the internervous plane in superficial dissection b/n sartorious muscle inervated by the femoral nerve and tensor facsia lata inervated by the superior gluteal nerve and in deep dissection bln gluteas medius muscle inervated by the superior gluteal nerve and rectus femoris muscle which is inerveted by the femoral nerve [18].
The major advantage of the anterior approach is that it has a lower risk of dislocation than other approaches; this advantage makes the rehabilitation program easier for the patient. There is also a minimal chance of sciatic nerve damage. The most common obstacle most surgeons face during an anterior approach is a restricted surgical field, which can result in extensive dissection of soft tissue, particularly the gluteas medius, as well as trouble reaming the femoral medulary cavity, which can result in femur fracture [32].
Lateral approaches commonly involve (partial or complete) division or retraction of the hip abductor muscles (gluteus medius and minimus) to enable access to the hip capsule. These include the Hardinge (direct lateral), the trans gluteal, and the Watson-Jones (anterolateral) approach [18].
There is solid evidence that the method affects the frequency and character of the complications. In individuals with FNF, the most commonly employed techniques are posterolateral and lateral or anterolateral. Data show that, as compared to the lateral or trans-gluteal approaches, the posterior route is linked with a significantly greater incidence of dislocation following both HA and conventional THA. When it comes to bipolar HA, the posterior approach is associated with an 8-fold increase in the risk of dislocation when compared to the lateral approach [12].
The risk of dislocation following traditional THA is also influenced by the surgical approach: documented dislocation rates are 2% for the anterolateral approach, 12% for the posterior approach, and 14% for the posterior technique without re-attachment of the posterior capsule (p 0.001) [12].
The combination of a dual-mobility cup with the posterior approach remains a reliable option, with a dislocation rate similar to that seen when conventional THA is performed via the antero lateral approach [12].
5. Conclusions
Hip fractures are classified according to their location: intracapsular and extracapsular, with intra-capsular fractures being the most common, accounting for over 60% of all hip fractures. The patient’s age and fracture displacement are taken into account when determining the procedure for a specific case. Fracture displacement raises the probability of femoral head blood supply interruption and, as a result, is associated with higher rates of non-union, fracture fixation failure, delayed union, and AVN of the femoral head. In old age (> 65 years), there is a high risk of non-union and fixation failure that leads to a high reoperation rate, which is not recommended in geriatric patients. As a result, current hip fracture treatment recommendations state that “displaced intracapsular neck of femur fractures in old age patients should be treated with arthroplasty.”
There are two types of hip replacement procedures for the treatment of displaced femoral neck fractures of the intracapsular type: THA and HA. Its indication depends on the patient’s age and the physiological as well as the general cognitive status of the patient. Hemiarthroplasty is recommended for the frail, low-preoperative mobility patient, and total hip arthroplasty is recommended for physically active and demanding patients.
Bipolar hemiarthroplasty and unipolar hemiarthroplasty showed comparable intraoperative blood loss, operative time, acetabular wear development, risk of instability, reoperation rates, systemic complications, mortality, and functional results. Given the lack of clinical data to support the superiority of either HA type, economic concerns should take precedence; bipolar implants are 2–5 times more expensive than unipolar implants; hence, unipolar implants are the preferable option when conducting HA [18].
Acronyms and abbreviations
Total Hip Arthroplasty Hemiarthroplasty Direct Lateral Approach Posterior Approach Anterior Approach Femoral Neck Fracture
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