SHORT TERM OUTCOME CEMENTLESS TOTAL HIP REPLACEMENT With

SHORT ROTATOR SPARRING FOR FRACTURE NECK FEMUR IN ELDERLY : A

Indri Pratiwi Tobing MD, Noha R,Soekarno SpOT

RS Hermina Grand Wisata, Tambun Selatan, Indonesia

Abstract

When dealing Femoral Neck Femur in elderly with limited activity, hemiarthroplasty has been a
preferred choice to make the patient return to mobillity soon with less bleeding during the surgery and
speedy recovery and ambulatory.

Currently elderly might have longer life expectation and live expectancy, still want to enjoy the
communal and recreational sport.

We present a case of elderly, fracture neck femur, 74 years old male with recreational sports and
commnunal activity, and a hobby of travelling around Indonesia. The patient underwent a cementless
total hip replacement with piriformis sparring technique.

The case was reviewed and followed for 4 months and scorring with Harris Hip Score and WOMAC
index score to address the outcome and function of this case on both the neck femur correction and
patient daily activity.

Keywords

Total Hip Replacement, Hip arthtroplasty ,Cementless, Fracture neck femur, Elderly

Introduction

Total hip arthroplasty (THA) has been deemed as “the operation of the century” due to its excellent
clinical outcome and patient satisfaction rates 1. THA is preffered on young and active patients, with
end-stage osteoarthritis of the hip, providing patients with early return to their activities with
significant improvement in their quality of life2.

According to United Nations elderly or older persons are the people aged 60+ years. They are further
classified as oldest old (80+ years), centenarian (100+) and super-centenarian (110+). The population
of elderly is expected to reach 1.2 billion by 2025 globally3. Currently elderly might have different
life expectation and longer live expectancy.

Femoral neck fractures, are common injuries sustained by older patients who are both more likely to
have unsteadiness of gait and reduced bone mineral density, predisposing to fracture. In elderly
patients, the mechanism of injury varies from falls directly onto the hip to a twisting mechanism in
which the patient’s foot is planted and the body rotates.
The treatment of older patients with intracapsular femoral neck fractures depends on local conditions,
patient profiles, personal preferences and training of the surgeon9. In geriatric populations, an overall
reduced bone quality is more frequently observed, Thus cemented prosthesis can be an option in less
density bone, according DOOR classification type B or C. (ref). The uncemented prosthesis can
shorten the operation time and reduce the incidence of pulmonary embolism, however it does not
reduce mortality, blood loss, and hospital stay. The incidence of prosthetic-related complications was
higher in uncemented patients20.

Dislocation is one common complication in fracture neck femur in active elderly treated with total hip
arthroplasty posterior approach. The choice of hemiarthroplasty may increased stability with risk of
acetabular erosion. Thus it is reserved in less active patient. The cause of the dislocation is varied.
From the patient, surgeon, or technical factor. Posterior approach is common among orthopaedic with
higher risk of posterior dislocation. With proper implant position, and novel technique, using
technique of short rotator sparring, will help retain stability by adding soft tissue restraint. (ref)

This study then try to evaluate the short rotator sparring, with cementless implant for an
usually active elderly (Which, may be common in the future)

Methodology

Surgical Technique:

The operation was performed under spinal anesthesia, the patient was posititioned in lateral decubitus.
The operation was performed via posterolateral approach

The incision was done in standard fashion of posterior approach. The gluteus was protected
with Hohman retractor. The short rotator was indentifed. 3 tendon of short rotator was
resected with remaining piriformis tendon. The quadratus femoris is left intact. The neck was
extracted. After capsule resection and osteotomy of the femoral neck, the head-neck fragment was
removed and inspected. The acetabular is prepared for cementless cup. the acetabulum is
progressively reamed to the appropriate size and depth to correcting the leg length, and the final
component is place and cementless in proper anteversion and abduction angles based on preoperative
functional assessment. Continued with Femoral cementless stem. evaluation was done and
remaining short rotators are secured. The incision-suture time was 120 min. intraarticular drain was
inserted.

Follow up:

A Clinical follow up including the assesment of the Harris Hip Score, WOMAC index and the Visual
Analogue Scaale (VAS) for pain at rest and on load as well as overall patient satisfation and also
radiological follow up was assessed using a standardized and callibrated AP-View pelvis radiograph.

Case Presentation

We present the case of a 74-year-old male patient, 177 cm in height and weighing 90 kg, presented at
our orthopedic clinic due to pain in the right hip. He described inguinal symptoms upon weight-
bearing and at rest, with pain radiating into the thigh and down to the knee over a period of
approximately six weeks.
six weeks ago the patient was incidentally fell down from a 1 meter height stairs in his house.

Mobility in the right hip was markedly impaired, at extension/flexion (Ex/Flex) 0/0/90°, ext/int
rotation (ER/IR) 20/0/0° and abduction/adduction (Abd/Add) 20/0/10°. The Harris Hip Score
modified according to Haddad was 37, the WOMAC score was 103. The contralateral hip showed
neither pain nor restriction of mobility.

X-ray was taken as a pelvic survey with a low ap setting and laterally of the right hip. This revealed a
right femoral neck fracture, with the joint gap obliterated centrocaudally (Fig. 1)

The surgery was then, performed

Day-1 Post Op : The perioperative blood loss within the first 24 hours was 250 ml. the serial
blood test revealed no need of blood transfusion. The wound healed primarily. The serial X-ray
showed a normal position of the cementless THA, with a correctly adjusted leg length and
offset. (Fig.2)

Day-2 Post Op : patient was still immobilized, drain was removed with minimum amount of
proudtion.

Day-4 Post Op : patient was conducted to walking and followed up by the Physiotherapy team,
the inflammatory parameters showed a trend toward normal values (leukocytes 8640 g/dl).

Day-5 Post Op : The patient was discharged, patient was ambulatory with a walker device.

Week 2, healed

Walking with cane, the patient insist walk without cane.

Month 1, jalan2 keliling..

Two,3 and 4 months after the operation, the patient attended our outpatient department for routine
followup. The wound had healed completely, was free of irritation and dry. The follow-up X-ray
showed findings Subsidence or a periprosthetic fracture were not present, the prosthesis was now seen
to be securely integrated in the bone. (Fig.3)

Functionally, the patient was fully mobilized and very satisfied, without symptoms.

The range of motion (ROM) showed a good postoperative outcome, with Ex/Flex =0/0/90°, ER/IR
25/0/15°, and Abd/Add 25/0/15°. The HHS increased by 58 points to now 95 points and the
WOMAC dropped from 103 points to now 0 points postoperatively…. (-20)

Discussion

The aim of this case report was to investigate complications and the clinical and radiological outcome
followed for this elderly patient who had been received the cementless total hip arthroplasty.
We asked the question if this particular cementless THA, which to date still is mainly used in young
and active patients, can be implanted safely in elderly patients. And whether preserving the short
rotator quadratus, may help stability of the patient. (Bahasa).

There are some potential benefits that cementless THA can offer to very active, geriatric populations.
For this reason, they can particularly benefit from approaches or implants that are less invasive and
thus associated with less intraoperative blood loss and postoperative transfusions, which can interfere
with early mobilization after THA. The early clinical outcome of this patient is encouraging.
We marked zero scale found for the mean VAS values of rest pain, load pain, two week after
surgery.

Finally, since this report investigated only one case of short term, the present results cannot be
generalized to other fracture neck femur elderly, further study is recommended.

Conclusions

Treating fracture neck femur in elderly should be tailored to individual needs. There are shifting
trends of elderly becoming more active and longer expectancy. These report results indicate that the
treatment femoral neck fracture in elderly following cementless total hip arhtroplasty,when using
posterior approach, combined with short rotator sparring is achieveable and might give desirable
clinical outcome, and patient satisfaction.

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