Hip fractures are frequent and account for 20% of an orthopaedic trauma unit's surgical burden. About 50% of all these fractures are intracapsular femoral neck fractures. Hip fractures have a high lifetime risk that ranges from 40% to 50% for women and 13% to 22% for males. Since life expectancy is rising globally, it is reasonable to anticipate that global hip fracture rates will rise as a result of these demographic trends [1,2].

Being a common, relatively uniform injury that afflicts a population with low demands, the orthopaedic community has tended to be indifferent towards hip fractures. But for the afflicted patient, on the other hand, a hip fracture is a major physiological and psychological trauma, which threatens a continued independent life [3-5].

In modern days the bipolar hip prosthesis with cementis best option wherein they can be more active, especially the prosthesis with modular stem. Bipolar prosthesis consists 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 [6-9].             

Department of Orthopaedics Surgery is doing modular bipolar hip arthroplasty in these patients since decades. It was thought worthwhile to evaluate the results of bipolar hip arthroplasty in fracture neck femur in elderly patient above 70 years of age using Oxford Hip score at Indira Gandhi Medical College, Shimla.

Aims and Objectives

To evaluate the Oxford Hip scores 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

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 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, HBs, Ag, 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 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 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 follow up at every 6 weeks for 6 months. Further follow up was done every 3 months in first year. On every follow up 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 Oxford 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 Oxford 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 (Table 1).

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).

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

The comparison of prospective patients on preoperative and postoperative Oxford 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 was found to be statistically not significant (except in age group of 70-80 years). Sex based comparison between males and females of Oxford Hip score were found to be statistically significant (p<0.05) (Table 5).

Table 1: Distribution of Participants According to Age and Gender

Table 2: Oxford Hip Score

*Out of 60 patients, 4 patients died while 2 patients could not be followed-up; hence, score were calculated only for 54 patients. Oxford Hip score was found to be excellent in 81.5%, good in 16.7%, fair in 1.8% and none of patient had poor outcome.

Table 3: Age and Gender Distribution of Oxford Hip Score at Final Follow-Up

Table 4: Oxford Hip Score in Prospective Patients

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

The present study was aimed to evaluate the Oxford Hip scores among fracture neck femur patients above 70 years of age and treated by modular bipolar hip arthroplasty at Indira Gandhi Medical College, Shimla. 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 Oxford Hip score in our study. 

In our study, Oxford Hip score was found to be excellent in 81.5%, good in 16.7%, fair in 1.8% and none of patient had poor outcome. In all 54 patients Oxford Hip Score in different age groups and in males & females were more or less similar. The age group based comparison between preoperative and postoperative score in prospective patients of different age groups was found to be statistically not significant (except in age group of 70-80 years). Sex based comparison between males and females of Oxford Hip score were found to be statistically significant (p<0.05). The evaluation of final functional outcome by Oxford Hip score in this age group has not been done before.

Patients with advanced age of above 70 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 came to the conclusion that the best treatment choice in advanced age with good functional outcomes is modular bipolar hip arthroplasty for displaced fracture neck of femur.

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