The cost of this fracture and its consequences is increasing 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 snaps into a polyethylene liner of a metal acetabular shell (the inner bearing). The metal acetabular shell then articulates within the anatomic acetabulum (the outer bearing) via 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 [1,2].

The 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 Modified Harris Hip score among fracture neck femur patients over the age of 70 who were receiving modular bipolar hip arthroplasty.

Aims and Objectives

To evaluate the Modified Harris Hip score among fracture neck femur patients above 70 years of age and treated by modular 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

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 either subarachnoid 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 6th 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 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 and scoring was done according to Modified Harris Hip score and Oxford Hip score. 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. Final functional score was done according to Modified Harris Hip score.

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. Subsequently patients were scored on the basis of Modified Harris Hip score.

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 retrospectives. The following observations were obtained.

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 1).

Out of a total 54 patients in our study, 2 (3.8%) had excellent results with Modified Harris Hip Sores of more than 90, 22 (40.7%) had good results with scores 80 to 89, 22 (40.7%) patients had fair outcomes with scores 70 to 79 and 8 patients (14.8%) had poor results with scores <70 (Table 2).

The final follow-up Modified Harris Hip score in different age group were found to be almost similar. Similarly, the final Modified Harris Hip score were found to be almost similar between males and females (Table 3).

The comparison of prospective patients on preoperative and postoperative Modified Harris Hip score was found to be statistically insignificant (Table 4).

The age group based comparison between preoperative and postoperative score in prospective patients of different age groups were found to be statistically not significant Similarly, Sex based comparison between males and females of Modified Harris Hip score were found to be statistically insignificant (p>0.05) (Table 5).

Table 1: Distribution of Participants According to Age and Gender

Table 2: Modified Harris Hip Score

Table 3: Age and Sex distribution of Modified Harris Hip Score at Final Follow-up

Table 4: Modified Harris Hip Score in Prospective Patients

Table 5: Age and Gender Distribution of Modified Harris Hip Score in Prospective Patients

Modified Harris Hip Score notably has been mainly used in the past to assess the functional outcome following hemiarthroplasty. In simplified terms the return of patient to pre-injury status remains the best outcome possible both for the patient and surgeon. The final results were analyzed using Modified Harris Hip score in our study. Out of a total 54 patients in our study, 2 (3.8%) had excellent results with Modified Harris Hip Scores of more than 90, 22 (40.7%) had good results with scores 80 to 89, 22 (40.7%) patients had fair outcomes with scores 70 to 79 and 8 patients (14.8%) had poor results with scores <70. The poor result in these patients was because these patients were not leading an active lifestyle before fracture. 

Our study included patients 70 years and above; our series had relatively older age group with mean of 78.5±6.87 years compared to previous studies by La Belle  et al. [3], with mean age of 72.5 years and Gallinaro  et al. [4], had mean age of 75 years. Majority (85%) patients had excellent to fair outcome of Modified Harris Hip score in our study. This was similar to previous studies by Hinchey and Day [5], with satisfactory result in 72.8%. Saxena and Saraf  et al. [6], reported satisfactory results in 90.9%, Mukherjee  et al. [7], had desired outcome in 78%. 

In all 54 patients Modified Harris Hip score in males and females were more or less similar. While in prospective patients Modified Harris Hip score was higher in females compared to males but was found to be statistically not significant. 

Final follow up Modified Harris Score in patients above 90 years was 77.80±11.08 which was more or less similar to patients in 70-90 years of age group (Modified Harris Hip score 78.83±8.57). 

This difference though was not found to be statistically significant. Patients with advanced age of above 90 years had lesser comorbid conditions possibly resulting in increased longevity of life which contributed to improved and better functional outcome albeit their number was less. So this can be recommended as procedure of choice even in advanced age with good functional results.

We therefore concluded that modular bipolar hip arthroplasty for displaced fracture neck of femur is the best available treatment option in advanced age with good functional results.

1. Holmberg, S.  et al. “Treatment and outcome of femoral neck fractures: An analysis of 2418 patients admitted from their own homes.” Clinical Orthopaedics and Related Research, no. 218, 1987, pp. 42–52.

2. Loro, R.  et al. “Displaced femoral fractures in elderly: Outcomes and cost effectiveness.” Clinical Orthopaedics and Related Research, no. 383, 2001, pp. 229–242.

3. La Belle, L.W. and J.C. Colwill. “Bateman bipolar hip arthroplasty for neck femur fracture, five to ten-year study.” Clinical Orthopaedics and Related Research, no. 251, February 1990, pp. 20.

4. Gallinaro, P.  et al. “Experience with bipolar prosthesis in femoral neck fractures in elderly and dilapidated.” Clinical Orthopaedics and Related Research, no. 251, February 1990, pp. 26–30.

5. Hinchey, J.J. and P.L. Day. “Primary prosthetic replacement in fresh femoral neck fractures.” The Journal of Bone and Joint Surgery. American Volume, vol. 42, 1960, pp. 633–640.

6. Saxena, P.S. and J.K. Saraf. “Moore prosthesis in fracture neck of femur.” Indian Journal of Orthopaedics, vol. 2, 1978, pp. 138–145.

7. Mukherjee, D.L. and H.C. Puri. “Early hemiarthroplasty for fresh fractures of the neck of the femur in geriatric patients.” Indian Journal of Surgery, vol. 48, 1986, pp. 77–80.