A femoral neck fracture, recognized since the time of Hippocrates, still remains a vexing clinical problem for orthopaedic surgeons. It has always presented great challenges to orthopaedic surgeons and even today it remains an unsolved as far as treatment is concerned. Intracapsular femoral neck fractures account for about 50% of all these fractures. The lifetime risk of sustaining a hip fracture is high and lies within range of 40% to 50% in women and 13% to 22% in men. Life expectancy is increasing worldwide and these demographic changes can be expected to increase the number of hip fractures occurring worldwide [1-3].

Hip fractures represent an enormous socioeconomic and medical problem and challenge orthopaedic surgeons and anaesthetist to find the cheapest and most cost effective way to treat them. Hoogendoorn et al. amongst other authors pointed out that there was a rise of age-specific incidence as well, possibly caused by osteoporosis, diminished muscle volume and neuromuscular response. Moreover, many frail patients are kept going, even after serious illness, operations and fracture treatments [4,5].

With our society becoming more and more a geriatric society, the burden of this fracture and its sequelae continues to be on the rise. As most important risk factor for these fractures is advancing age and intracapsular fractures of proximal femur form a major share of fractures in elderly. The main goal of the treatment of femoral neck fracture is restoration of pre-fracture function without associated morbidity. As prolonged immobilization during such fracture in elderly will jeopardise the life span and further complicates the problem, this abandon complete immobilization to achieve a bony union, or to resort early ambulatory procedures by surgery with arthroplasty [6,7].

Attempting to salvage the femoral neck often leads to healing complications, while the more predictable operation (prosthetic replacement) is associated with poorer function and has significant complications of its own. Added to this dilemma is the high mortality rate of patients in the age group that most often sustains these fractures [4,6].

Bipolar prosthesis consist of undersized femoral head that is snap-fit into polyethylene liner (inner bearing) of a metal acetabular shell, which articulates within the anatomic acetabulum (outer bearing) via suction-fit. By allowing motion at the inner and at outer bearing surfaces, this device has theoretical advantage of causing less acetabular wear. Therefore surgical treatment is considered gold standard and a modular cemented hemiarthroplasty often accomplish this the best [5-7].

Department of Orthopaedics Surgery is doing modular bipolar hip arthroplasty in these patients since decades. It was thought worthwhile to evaluate the post-operative complications, Limb Length Discrepancy and Weight Bearing among fracture neck femur patients above 70 years of age and treated by bipolar hip arthroplasty at Indira Gandhi Medical College, Shimla.

Aims and Objectives

To evaluate the post-operative complications, Limb Length Discrepancy and Weight Bearing among fracture neck femur patients above 70 years of age and treated by 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 in 15 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 inall 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 14th 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 90° 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 and Gender

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: Post-Operative Complications

*2 patients who had more than one type of infection. One patient had UTI and pneumonia and other patient had bed sore and pneumonia

Results could be assessed in 56 patients only as 4 patients died in postoperative period while at hospital secondary to multiple systemic co-morbidities, 78% patients had uneventful post-operative period secondary to early mobilization. Whereas only 6 patients who declined to be mobilized from bed developed Grade 1 bed sores following surgery (Table 3).

Table 3: Limb Length Discrepancy

*6 patients died before first follow up and were excluded

In our clinical observation, it was found that from our 54 patients most patients (87%) had limb length discrepancy of less than 1 cm (Table 4).

Table 4: Stem Placement

On X-ray examination of 54 patients were available, stem was found to be in valgus placement (37%) or central (46.3%) in majority. Small number had stem in varus. All stem placements were considered after considering stem tip placement on plane X-rays AP and lateral views. None of patients had heterotrophic ossification or calcification or dislocation (Table 5).

Table 5: Partial Weight Bearing in Weeks

Patient mobilization was started only once the patients were comfortable. Most patients (52) were mobilized by 2nd week with weight bearing to tolerance (96.2%) i.e. 15 patients in 1st week and 37 patients in 2nd week. Only 2 prospective patients failed to mobilize after 2 week hospital stay, among which one patient had Alzheimer's disease while another had renal dysfunction (Table 6).

Table 6: Full Weight Bearing in Weeks

In present study, 54 patients were available for final assessment and were allowed full weight bearing after 3 weeks. Most of the patients started almost full weight bearing with walker at the time of 1^st mobilization but were very comfortable in doing full weight bearing after 3 weeks.

The present study was aimed to evaluate the post-operative complications, Limb Length Discrepancy and Weight Bearing among fracture neck femur patients above 70 years of age and treated by bipolar hip arthroplasty at Indira Gandhi Medical College, Shimla. The complications following hemiarthroplasty for fracture neck femur was reported in varying incidences. Majority of patients 78.33% reported uncomplicated postoperative period. 

Cognitive complications appear in approximately 10% of patients after hip fracture more so in elderly. The pathophysiology has not been clearly elucidated. Probably, its responsible mechanisms are heterogenous and multifactorial and may be related to preoperative health status, level of cognition, neurotoxic effects of anaesthetic agents and perioperative events related to surgery itself [8].The use of acrylic cement for prosthetic implantation can cause inflammatory response that may possibly be associated with occurrence of postoperative cognitive complications [9]. 

Postoperative delirium in patients with hip fracture appears normally after surgery and affects 13.5% to 33% of these patients [9-10]. In our study it was found in 12.5% patients, lower incidence in our series was due to adequate postoperative care and probably because cementation was done in early dough phase therefore reducing the monomer vapours and intramedullary pressure thus reducing risk of embolism. Postoperative delirium can present as hyperactive, hypoactive and mixed cognitive and motor status type. While hyperactive patients present augmented psychomotor activity (pressured speech, irritability and uneasiness), hypoactive ones normally exhibit quiet appearance, carelessness, reduced mobility and trouble to answer simple questions. Hypoactive delirium may be misdiagnosed as depression or fatigue. With our experience over years we have found reduced incidence of delirium with spinal anaesthesia and supplemental oxygenation (3-4 L/min) is continued till 2^nd post surgery day at our centre. Since pain can contribute to delirium, an adequate postoperative analgesia minimizing the use of sedative drugs and anticholinergics seemed to decrease its risk.

Hip fracture has an overall 1 year mortality rate that varies from 14% to 36% among the patients above 65 years, which is found to be higher in men as compared to women, especially after 5 to 10 years after fracture and in addition the survivors have shorter life expectancy. Mortality is significantly influenced by preoperative cognitive state, medical comorbidities and mobility. However in medically unstable patients, a delay of surgery does not result in statistically significant difference in mortality compared to patients treated surgically.

In our series of prospective patients, 4 patients (11.4%) died in immediate post-operative period. Two prospective died within 4 weeks discharge from hospital. At end of 6 months and one year total of only 6 prospective patients died, as we reported 17% mortality at end of 12 month period. Moore [7] reported 16.67%, Salvatti et al. [11] 14.3%, C.M Robinson et al. [12] 11% one year mortality. Mortality was higher in our study because all of our patients were of advanced age (>70 years) and patients who succumbed were having multiple comorbidities.

Six patients (10%) developed Grade 1 bedsore following brief interval secondary to unwillingness to mobilize in uncooperative active patients following surgery which recovered completely once patients were mobilized depending upon effort tolerance and did not need any other treatment. Another study by Shivanand et al. [13,14] quoted 10.5% incidence of Grade 1 bedsores.

DVT was reported in 1 patient (1.7%) in our series, which was also reported by C.M Robinson et al. [12] in 2% patients and 5% patients by Shivanand et al. [14] which resolved with adequate medical attention and care. None of our patient had DVT during their stay at hospital as physiotherapy was advised for all and anticoagulant were initiated wherever indicated. From our clinical experience we instituted anticoagulation in 11 patients only from total 56 patients, this was because rest of patients were cooperative and did physiotherapy well right from the day of hospitalization. Among these 11 patients, 6 had preexisting cardiovascular illness for which they were already on anticoagulation (i.e. 3 patients were on aspirin, one on clopidogrel, one on low molecular weight heparin and one on fondaparinux) and rest 5 patients had prolonged hospital stay with poor cooperation were managed on low molecular weight heparin. In all 11 cases they were managed on LMWH, 24 hours following surgery till patients were mobilized from bed. Only patient who reported DVT was at 6 weeks following discharge from hospital and was optimally managed medically following admission for same. Ennis et al. [15] found DVT after hip fracture in 30% to 60%, with 30% to 36% incidence of proximal DVT. The frequency of pulmonary embolism after hip fracture ranges from 4.3% to 24% with incidence of fatal pulmonary embolism in 0.5% to 12.9%. Currently, there are 2 approaches for prevention of fatal pulmonary embolism. First approach involves primary prevention through use of pharmacological and mechanical prophylaxis and second is early detection through screening of high risk patients and subsequent anticoagulant treatment when thrombosis discovered.

Superficial infection was reported in just 1.7% patient as compared to Salvatti et al. [11] 8.3 and 5% in series of Robinson et al. [12] Which responded adequately well to medication. Superficial infection was wound erythema with no altered discharge from surgical site for which prompt attention was given with daily antiseptic dressing and later that resolved completely. We used broad spectrum injectable antibiotic prophylaxis starting half an hour before incision at induction of anaesthesia and for about 5 days, followed by oral antibiotic till removal of stitches. This may have accounted for low infection rate in our series and this was coupled with meticulous surgical technique like sparing use of electric cautery and mostly to cauterize vessels so as to avoid dead tissue inside. One of prospective patient had urinary tract infection postoperatively with E. coli, which was treated with Nitrofurantoin after urine culture sensitivity versus 2 patients in series by Shivanand et al. [14] Urinary tract infections are leading hospital acquired infections and affect 12-61% of all patients with hip fractures. Urinary catheter are the single most important risk related to this type of postoperative infection. Therefore indwelling catheters should be removed within 24 h after insertion. In all other patients early catheter removal protocols were followed. Patient who got urinary infection was because of non-cooperative, unhygenic patient and attendents insisting for continued indwelling catheter for better bladder hygiene.

Dislocation of bipolar prosthesis is a rare phenomenon. It has been reported inliterature ranging from 1.1% at one year followup to 5% at 20 years [16]. Stinchfield and Coopermann reported 4% dislocation rate and 6% fractures in proximal femur, C.M Robinson¹² had 3% dislocation. Salvatti et al.[11] believed that excessive postoperative flexion or rotation with hip adducted is the main cause for dislocation and they also observed that dislocation was commonly caused while shifting the patient from operation theatre to ward. Kenzora et al. [17] noted that all six dislocation in their series were followed by posterior approach, which is well known complication of posterior approach. Maruthi et al. [18] noted only one dislocation. However, in our series, no dislocation has occurred till final followup. This was because of properly balancing soft tissues around hip joint, careful trial reductions, meticulous attention to suturing the posterior capsule and short external rotators and keeping the limb in slight abduction and in below knee skin traction for 2-3 days after surgery. Patients and their attendants were educated and well informed about the risk of dislocation with excessive flexion, adduction and internal rotation of hip. Not only this, they were advised not to squat and sit cross-legged throughout rest of their life.

No patient in our series sustained periprosthetic fractures. Hinchey and Day [19] emphasized that all fractures occur when the surgeon attempts to reduce the prosthesis. Maruthi et al. [18] had one patient with periprosthetic fracture which was reoperated and stabilized with stainless steel wire. In these patients, in presence of osteoporosis, bone need to be handled very delicately like soft tissue. Forceful trial reductions essentially need to be discouraged and Gluteus maximus release and adductor tenotomy was done where ever indicated. Cemented stems appear to perform better in the presence of osteroporosis as one does not need to impact it forcefully into the medullary canal of femur.

Amongst 54 patients 27% had equal limb length postoperatively whereas around 60% had limb length discrepency of 0.5cm-1.5cm, which was very well tolerated by patients. Adapureddi et al. [20 had two patients of old neglected fractures who had gross shortening (6cm-7cm) preoperatively with persisting limb shortening (1cm-1.5cm) postoperatively. LLD after Bipolar replacement has not been reported in literature while incidence of limb length discrepancy after primary THA has been reported from 1-27% and in literature LLD is reported to vary from 3mm to 70mm with a mean from 3mm to 17mm. LLD has been associated with back pain, sciatica, neuritis, gait disorders, dissatisfaction, dislocation and early loosening of components and therefore revision surgery. In elderly patients this is not of much concern because of low demand on hip and lower extremities. The patients needs to have painless hip, painless range of movements, ability to walk and perform daily life activities unobstructed, which he or she is able to do. Our target is to bring the patient back to preinjury status, which is easily accomplished by surgery.

Stem position was neutral in 25 cases (46.3%) patients, valgus in 20 patients (37%) and varus in 9 patients (16.7%). They all were considered after considering the stem tip on X-ray AP and lateral view. Central and valgus placement was favoured as varus position acts as a stress riser and pre-dates a periprosthetic fracture.

We were not very aggressive in ambulating the patients. Patient were allowed walking depending on their effort tolerance, confidence and general well-being. Fifty two patients were allowed weight bearing to tolerance with walking aids either crutches or walker before 2 weeks postoperatively while all patients were allowed side sitting and standing with support by bed side within 7 days after surgery. Patients were persuaded to do physiotherapy as advised, hamstring and static quadriceps on bed for relatively easy rehabilitation in postoperative period. Full weight bearing with support was initiated only once patient was confident.

Present study concluded that only minor complications were observed in our series. Grade 1 bedsore, DVT, superficial infection, UTI and Pneumonia were the common complications among elderly cases of fracture neck of femur who undergone bipolar hip arthroplasty. All the complications were managed satisfactorily. Since the morbidity was minimal, weight bearing was started early in all patients.

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