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Femoral head replacement following fracture: an analysis of the surgical approach
Injury, 11,3 17-320 Printedin Great Britain
317
Femoral head replacement following fracture: an analysis of the surgical approach Michael R. Wood Senior Orthopaedic Registrar, Black Notley Hospital, Braintree, Essex
Summary
The early results of 276 femoral head replacements for displaced fractures of the neck of the femur are described. The procedure was performed in the same hospital by two similar groups of surgeons. Either an anterior or a posterior approach was used. Although there was no statistical difference between the rates of infection and dislocation in the two groups, infection and dislocation occurred more commonly in the posterior approach. Misplacement of the prosthesis and fracture of the upper part of the femoral shaft occurred statistically more frequently in the anterior group. INTRODUCTION
THOMPSON(1954) advised the use of an anterior approach for replacement of the femoral head after fracture, but Moore (1959), having had dislocations following the anterior approach, described a low posterior exposure, the Southern approach. Since then individual preference has dictated the method used. Addison (1959) Bolton (1961) and King (1964) used a posterior approach, while Chan and Hoskinson (1975) and Devas and D’Arcy (1976) favoured an anterior or anterolateral approach. It was the purpose of this study to investigate the early results following replacement of the head of the femur and to compare the anterior and posterior approaches. PATIENTS
AND METHODS
Between 1972 and 1977 276 patients at Black Notley Hospital underwent replacement of the head of the femur after displaced fracture. Adequate information was available for review from a study of the case notes in 235 patients. In this group 104 prostheses had been inserted
Table 1. The age and sex distribution groups
Mean age Standard deviation Range Males : Females
of the two
Anterior (n= 104)
Posterior (n= 131)
77.5 yr 8.7 yr 55-95 yr 19:85
79.9 yr 8.2 yr 58-99 yr 23: 108
through an anterior or anterolateral approach and 13 1 through a posterior approach. The 23 5 prostheses included 174 Thompson’s prostheses and 61 Moore’s prostheses, which had been randomly distributed between the two groups. All the patients had been operated upon in the same theatre suite and had identical pre- and postoperative care. In all, 41 surgeons were involved, 28 using the posterior approach and 13 using the anterior approach with the proportion of consultants to trainee surgeons equal. The age and sex distributions of the patients are shown in Table I. The relationships between the incidences of infection, dislocation, misplacement of the prosthesis, fracture of the upper femur and mortality were studied and analysed statistically, using a 2 x 2 contingency table and the x2 test. RESULTS Infection
Infections were diagnosed with the culture of pathogenic organisms from a swab taken of wound discharge (Table II). The differences
318
Table Il.
Injury:the British Journal of Accident Surgery Vol. 1 1/No. 4
Infections
Infection
Table III. Dislocations A n terior (n= 104)
Posterior (n= 131)
(42%)
(9?%,
Total infection
Deep infection resulting in removal of prosthesis
Posterior (n= 131)
Total dislocations
0
Fig.
I. Lateral radiograph showing the posterior cortex breached.
between the groups is not statistically significant either in the total infection rate or in the group needing removal of the prosthesis (PcO.2 and < 0.25 respectively). The mortality associated with infection was high. Three patients in the anterior group and 8 patients in the posterior group died in the six months following operation. Of the 22 infections the organism cultured was Staphylococcus pyogenes in 18 and Staphylococcus albus in 4 patients. Dislocations
There were 5 dislocations
Anterior (n= 104)
in the anterior group
Unstable hips requiring prosthetic removal
0
Fig. 2. Anteroposterior radiograph showing fracture of the upper part of the femoral shaft produced during an anterior approach. and I3 in the posterior group (Table III). All 5 hips in the anterior group were reduced by closed manipulation and none re-dislocated. Of the 13 in the posterior group, 8 were stable after closed reduction, 5 needed open reduction and 3 were so unstable that they eventually had to be removed. The difference between the two dislocation rates is not statistically significant (P~0.25). Again, the associated mortality for the two groups is high-3 patients of the anterior group and 8 patients of the posrerior group died within six weeks of the dislocation.
319
Wood: Femoral Head Replacement Table IV. Causes of death
O-6 wk Bronchopneumonia Myocardial infarct CVA
8
CCF Uraemia Pulmonary embolus Carcinomatosis Liver failure
1 1 :
Anterior 6 wk-6
:
Total
15
CVA, cerebrovascular
6 weeks 6 months
15 20
14 19.2
Posterior No. % 17 36
12.9 27.4
Misplacement
The posterior or lateral femoral cortex was breached in 3 patients (Fig. 1), all in the anterior group. All left hospital walking well. One patient subsequently complained of persistent pain and later underwent total hip replacement. Fracture of the upper part of the shaft of the femur occurred in 6 patients, all in the anterior group, and this delayed rehabilitation. The most severe fracture is shown in Fig. 2 and this was the only one that required replacement with a long-stemmed prosthesis. The incidence of these complications, compared with those after the posterior approach, is statistically significant (P
The commonest causes of death in the first six months were bronchopneumonia and congestive cardiac failure (Table IV). The mortality rates at six weeks and six months were compared, but there was no statistical difference between the two groups (PcO.9 at six weeks and co.25 at six months) (Table v). DISCUSSION
The best approach
for routine
O-6 wk
Posterior 6 wk-6
4 0 :,
9 0 0
10 3 1
: 0 0
2 0 4 1 1
: 2 0 0
5
17
19
mths
accident; CCF, congestive cardiac failure.
Tab/e V. Comparison of mortality rates at six weeks and six months Anterior No. %
mths
use for replacing
Table VI. Differences between two series
Present series Numbers Anterior 104 Posterior 13 1
Chan and Hoskinson (19751 Numbers Anterior 107 Posterior 136
Infections Anterior 5 Posterior 13
(4.8%) (19.9%)
Infections Anterior 7 Posterior 25
(6.5%) (18.5%)
Dislocations Anterior 5 Posterior 13
(4.8%) (9.9%)
Dislocations Anterior 1 Posterior 19
(0.9%) (14.0%)
Death at 6 weeks Anterior 15 (14.0%) Posterior 17 (12.9%)
Death at 6 weeks Anterior 7 (6.5%) Posterior 28 (20.6%)
the head of the femur following fracture remains debatable and the present study was undertaken to try to elucidate the subject. We find that our conclusions do not confirm the work of Chan and Hoskinson (1975) (Table VI), since the more even distribution of results in the present study meant that statistical significance could not be achieved. The infection rate of 9.3 per cent, though comparable with Chan and Hoskinson (1975), remains unacceptably high, although the use of the criterion of a positive wound swab may give an artiftcially high infection rate. Although there was no statistical difference between the two groups, infections did occur twice as commonly in the posterior group and on four occasions were of sufficient severity to
320
Injury: the British Journal of Accident Surgery Vol. 1 1/No. 4
require removal ofthe prosthesis. This must be a cause for concern. Although it is often harder and sometimes impossible to dislocate a test prosthesis inserted though an anterior approach, statistical analysis showed no difference between the two groups. However, the dislocation rate in the posterior series was twice that in the anterior group. No prosthesis inserted through an anterior approach was so unstable as to require removal eventually, while in the posterior group 3 prostheses were removed. This implies that the posterior approach is less stable. Misplacement of the prosthesis was more likely with the anterior approach. This may be due to greater difficulty in reaming the femoral shaft after this approach. One of the 3 misplacements in the anterior group needed removal, followed by total joint replacement. Such misplacement occurred in 8 patients in the Hastings series in which an anterolateral approach was used (Devas, 1976); 3 patients had to have the tip of the prosthesis removed with a diamond saw. Six patients in the present study sustained fractures of the upper part of the shaft of the femur, one needed a long-stemmed prosthesis and another died two weeks after the original operation. This complication was significantly higher after the anterior approach (P
approach to appear to be more likely to become infected and to appear to be more unstable. This favours an anterior approach. There is defmitely, however, a statistically increased risk of misplacement of the prosthesis using the anterior approach. Both approaches have their own particular problems and the decision as to which to use must remain the choice of the individual surgeon.
Requests .fbr reprinrs should be addreswd Downsview, Ontario, M3L IGB, Canada.
10: Mr M. R. Wood,
Acknowledgements
The author wishes to thank the consultant staff at Black Notley Hospital for permission to study their patients. Special thanks are due to Mr D. M. Dunn and Mrs Sheila Upson at Black Notley Hospital, and to Mr D. Dandy and Dr Trevor Rae of Addenbrooke’s Hospital for their help in the preparation ofthis manuscript. REFERENCES
Addison J. R. (1959) Prosthetic replacement in the primary treatment of fracture of the femoral neck. Proc. R. Sot. Med. 52,908. Bolton H. (1961) Treatment of displaced fractures of the femoral neck by immediate replacement arthroplasty. J, Bone Joint Surg. 43B, 606. Chan R. N. and Hoskinson J. (1975) Thomoson prosthesis for fractured neck of fkmurla combarison of surgical approaches. J. Bone Joint Surg. 57B, 431. Devas M. and D’Arcy J. (1976) Treatment of fractures of the femoral neck by replacement with the Thomnson nrosthesis. tl. Bone Joint Sum. 58B. 279. King D: (19i4) Discussion of prima{ prosthetic replacement in femoral neck fractures. J. Bone Joint Surg. 46A, 240. Moore Austin T. (1959) The Moore Self Locking Vitallium prosthesis in fresh femoral neck fractures. A new low posterior approach-the Southern exposure. Am. Acad. Orthop. Instruct. Course Lect. 16,309. Thompson F. R. (1954) Two and a half years’ experience with a Vitallium intramedullary hip prosthesis. J. Bone Joint Surg. 36A, 489.
The Workmen’s
Compensation
Board,
I 15 Torbarrle
Road,
317
Femoral head replacement following fracture: an analysis of the surgical approach Michael R. Wood Senior Orthopaedic Registrar, Black Notley Hospital, Braintree, Essex
Summary
The early results of 276 femoral head replacements for displaced fractures of the neck of the femur are described. The procedure was performed in the same hospital by two similar groups of surgeons. Either an anterior or a posterior approach was used. Although there was no statistical difference between the rates of infection and dislocation in the two groups, infection and dislocation occurred more commonly in the posterior approach. Misplacement of the prosthesis and fracture of the upper part of the femoral shaft occurred statistically more frequently in the anterior group. INTRODUCTION
THOMPSON(1954) advised the use of an anterior approach for replacement of the femoral head after fracture, but Moore (1959), having had dislocations following the anterior approach, described a low posterior exposure, the Southern approach. Since then individual preference has dictated the method used. Addison (1959) Bolton (1961) and King (1964) used a posterior approach, while Chan and Hoskinson (1975) and Devas and D’Arcy (1976) favoured an anterior or anterolateral approach. It was the purpose of this study to investigate the early results following replacement of the head of the femur and to compare the anterior and posterior approaches. PATIENTS
AND METHODS
Between 1972 and 1977 276 patients at Black Notley Hospital underwent replacement of the head of the femur after displaced fracture. Adequate information was available for review from a study of the case notes in 235 patients. In this group 104 prostheses had been inserted
Table 1. The age and sex distribution groups
Mean age Standard deviation Range Males : Females
of the two
Anterior (n= 104)
Posterior (n= 131)
77.5 yr 8.7 yr 55-95 yr 19:85
79.9 yr 8.2 yr 58-99 yr 23: 108
through an anterior or anterolateral approach and 13 1 through a posterior approach. The 23 5 prostheses included 174 Thompson’s prostheses and 61 Moore’s prostheses, which had been randomly distributed between the two groups. All the patients had been operated upon in the same theatre suite and had identical pre- and postoperative care. In all, 41 surgeons were involved, 28 using the posterior approach and 13 using the anterior approach with the proportion of consultants to trainee surgeons equal. The age and sex distributions of the patients are shown in Table I. The relationships between the incidences of infection, dislocation, misplacement of the prosthesis, fracture of the upper femur and mortality were studied and analysed statistically, using a 2 x 2 contingency table and the x2 test. RESULTS Infection
Infections were diagnosed with the culture of pathogenic organisms from a swab taken of wound discharge (Table II). The differences
318
Table Il.
Injury:the British Journal of Accident Surgery Vol. 1 1/No. 4
Infections
Infection
Table III. Dislocations A n terior (n= 104)
Posterior (n= 131)
(42%)
(9?%,
Total infection
Deep infection resulting in removal of prosthesis
Posterior (n= 131)
Total dislocations
0
Fig.
I. Lateral radiograph showing the posterior cortex breached.
between the groups is not statistically significant either in the total infection rate or in the group needing removal of the prosthesis (PcO.2 and < 0.25 respectively). The mortality associated with infection was high. Three patients in the anterior group and 8 patients in the posterior group died in the six months following operation. Of the 22 infections the organism cultured was Staphylococcus pyogenes in 18 and Staphylococcus albus in 4 patients. Dislocations
There were 5 dislocations
Anterior (n= 104)
in the anterior group
Unstable hips requiring prosthetic removal
0
Fig. 2. Anteroposterior radiograph showing fracture of the upper part of the femoral shaft produced during an anterior approach. and I3 in the posterior group (Table III). All 5 hips in the anterior group were reduced by closed manipulation and none re-dislocated. Of the 13 in the posterior group, 8 were stable after closed reduction, 5 needed open reduction and 3 were so unstable that they eventually had to be removed. The difference between the two dislocation rates is not statistically significant (P~0.25). Again, the associated mortality for the two groups is high-3 patients of the anterior group and 8 patients of the posrerior group died within six weeks of the dislocation.
319
Wood: Femoral Head Replacement Table IV. Causes of death
O-6 wk Bronchopneumonia Myocardial infarct CVA
8
CCF Uraemia Pulmonary embolus Carcinomatosis Liver failure
1 1 :
Anterior 6 wk-6
:
Total
15
CVA, cerebrovascular
6 weeks 6 months
15 20
14 19.2
Posterior No. % 17 36
12.9 27.4
Misplacement
The posterior or lateral femoral cortex was breached in 3 patients (Fig. 1), all in the anterior group. All left hospital walking well. One patient subsequently complained of persistent pain and later underwent total hip replacement. Fracture of the upper part of the shaft of the femur occurred in 6 patients, all in the anterior group, and this delayed rehabilitation. The most severe fracture is shown in Fig. 2 and this was the only one that required replacement with a long-stemmed prosthesis. The incidence of these complications, compared with those after the posterior approach, is statistically significant (P
The commonest causes of death in the first six months were bronchopneumonia and congestive cardiac failure (Table IV). The mortality rates at six weeks and six months were compared, but there was no statistical difference between the two groups (PcO.9 at six weeks and co.25 at six months) (Table v). DISCUSSION
The best approach
for routine
O-6 wk
Posterior 6 wk-6
4 0 :,
9 0 0
10 3 1
: 0 0
2 0 4 1 1
: 2 0 0
5
17
19
mths
accident; CCF, congestive cardiac failure.
Tab/e V. Comparison of mortality rates at six weeks and six months Anterior No. %
mths
use for replacing
Table VI. Differences between two series
Present series Numbers Anterior 104 Posterior 13 1
Chan and Hoskinson (19751 Numbers Anterior 107 Posterior 136
Infections Anterior 5 Posterior 13
(4.8%) (19.9%)
Infections Anterior 7 Posterior 25
(6.5%) (18.5%)
Dislocations Anterior 5 Posterior 13
(4.8%) (9.9%)
Dislocations Anterior 1 Posterior 19
(0.9%) (14.0%)
Death at 6 weeks Anterior 15 (14.0%) Posterior 17 (12.9%)
Death at 6 weeks Anterior 7 (6.5%) Posterior 28 (20.6%)
the head of the femur following fracture remains debatable and the present study was undertaken to try to elucidate the subject. We find that our conclusions do not confirm the work of Chan and Hoskinson (1975) (Table VI), since the more even distribution of results in the present study meant that statistical significance could not be achieved. The infection rate of 9.3 per cent, though comparable with Chan and Hoskinson (1975), remains unacceptably high, although the use of the criterion of a positive wound swab may give an artiftcially high infection rate. Although there was no statistical difference between the two groups, infections did occur twice as commonly in the posterior group and on four occasions were of sufficient severity to
320
Injury: the British Journal of Accident Surgery Vol. 1 1/No. 4
require removal ofthe prosthesis. This must be a cause for concern. Although it is often harder and sometimes impossible to dislocate a test prosthesis inserted though an anterior approach, statistical analysis showed no difference between the two groups. However, the dislocation rate in the posterior series was twice that in the anterior group. No prosthesis inserted through an anterior approach was so unstable as to require removal eventually, while in the posterior group 3 prostheses were removed. This implies that the posterior approach is less stable. Misplacement of the prosthesis was more likely with the anterior approach. This may be due to greater difficulty in reaming the femoral shaft after this approach. One of the 3 misplacements in the anterior group needed removal, followed by total joint replacement. Such misplacement occurred in 8 patients in the Hastings series in which an anterolateral approach was used (Devas, 1976); 3 patients had to have the tip of the prosthesis removed with a diamond saw. Six patients in the present study sustained fractures of the upper part of the shaft of the femur, one needed a long-stemmed prosthesis and another died two weeks after the original operation. This complication was significantly higher after the anterior approach (P
approach to appear to be more likely to become infected and to appear to be more unstable. This favours an anterior approach. There is defmitely, however, a statistically increased risk of misplacement of the prosthesis using the anterior approach. Both approaches have their own particular problems and the decision as to which to use must remain the choice of the individual surgeon.
Requests .fbr reprinrs should be addreswd Downsview, Ontario, M3L IGB, Canada.
10: Mr M. R. Wood,
Acknowledgements
The author wishes to thank the consultant staff at Black Notley Hospital for permission to study their patients. Special thanks are due to Mr D. M. Dunn and Mrs Sheila Upson at Black Notley Hospital, and to Mr D. Dandy and Dr Trevor Rae of Addenbrooke’s Hospital for their help in the preparation ofthis manuscript. REFERENCES
Addison J. R. (1959) Prosthetic replacement in the primary treatment of fracture of the femoral neck. Proc. R. Sot. Med. 52,908. Bolton H. (1961) Treatment of displaced fractures of the femoral neck by immediate replacement arthroplasty. J, Bone Joint Surg. 43B, 606. Chan R. N. and Hoskinson J. (1975) Thomoson prosthesis for fractured neck of fkmurla combarison of surgical approaches. J. Bone Joint Surg. 57B, 431. Devas M. and D’Arcy J. (1976) Treatment of fractures of the femoral neck by replacement with the Thomnson nrosthesis. tl. Bone Joint Sum. 58B. 279. King D: (19i4) Discussion of prima{ prosthetic replacement in femoral neck fractures. J. Bone Joint Surg. 46A, 240. Moore Austin T. (1959) The Moore Self Locking Vitallium prosthesis in fresh femoral neck fractures. A new low posterior approach-the Southern exposure. Am. Acad. Orthop. Instruct. Course Lect. 16,309. Thompson F. R. (1954) Two and a half years’ experience with a Vitallium intramedullary hip prosthesis. J. Bone Joint Surg. 36A, 489.
The Workmen’s
Compensation
Board,
I 15 Torbarrle
Road,