2230

Selected

Instructional Course Lectures

The American Academy of Orthopaedic Surgeons
R OBERT A. H ART
EDITOR, VOL. 63

C OMMITTEE R OBERT A. H ART

CHAIR

C RAIG J. D ELLA V ALLE M ARK W. P AGNANO T HOMAS W. T HROCKMORTON P AUL T ORNETTA III E X -O FFICIO D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academys Annual Meeting, will be available in March 2014 in Instructional Course Lectures, Volume 63. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

2231
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

Geriatric Trauma: The Role of Immediate Arthroplasty

Andrew H. Schmidt, MD, Jonathan P. Braman, MD, Paul J. Duwelius, MD, and Michael D. McKee, MD, FRCS(C)
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Periarticular fractures in the elderly are difcult to stabilize, and nonoperative treatment is not well tolerated. Surgery is usually indicated, but standard techniques of internal xation often fail in this age group because of osteopenic bone and fracture comminution. These factors often prevent sufcient xation to allow early weight-bearing, which is of critical importance in the geriatric patient. In contrast, immediate arthroplasty of periarticular fractures in the elderly allows immediate mobilization of the patient. The purpose of this Instructional Course Lecture is to review the role of immediate arthroplasty in four common fractures that occur in the elderly: the proximal and distal end of the humerus, the acetabulum, and the proximal part of the femur. Shoulder Arthroplasty for Proximal Humeral Fractures Proximal humeral fractures are the third most common fracture in the elderly after wrist and hip fractures. They have a substantial impact on quality of life even when they are minimally displaced and

do not require surgery1. Factors consistently associated with poor outcomes after either nonoperative management or open reduction and internal xation (ORIF) are advanced patient age, fracture comminution, varus angulation of the humeral head, and osteoporosis2-7. Appropriate indications for shoulder arthroplasty in patients with a complex proximal humeral fracture are a dysvascular humeral head, a patient who cannot tolerate the limitations that accompany nonsurgical treatment, and a comminuted and/or varus displaced fracture pattern, especially when associated with poor bone quality that precludes ORIF. Shoulder function following hemiarthroplasty depends on anatomic reduction and secure, stable tuberosity xation8. Reverse total shoulder arthroplasty is an attractive option for elderly patients with displaced proximal humeral fractures since restoration of rotator cuff function is not as critical. Expected patient activity level and longevity are the primary considerations for choosing between reverse total shoulder

arthroplasty and shoulder hemiarthroplasty: reverse total shoulder arthroplasty is better for sedentary and elderly patients, while shoulder hemiarthroplasty is better for patients with higher activity levels (Figs. 1-A and 1-B)9,10. Although short and intermediate-term results of reverse total shoulder arthroplasty are reasonable, no long-term data that estimate the longevity of these devices in these patients are available, and salvage options are limited. Hemiarthroplasty of the Shoulder Surgery is performed using a long (15-cm) deltopectoral approach with the patient in the beach-chair position. The coracoacromial ligament is preserved since this is an important secondary restraint preventing anterosuperior escape of the humeral head if the greater tuberosity does not heal. We tenodese the biceps tendon. Large sutures are placed at the bone-tendon interface of the greater and lesser tuberosities to provide control of the greater and lesser tuberosity fragments. External rotation of the arm improves reduction of the greater

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a nancial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to inuence or have the potential to inuence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to inuence or have the potential to inuence what is written in this work. The complete Disclosures of Potential Conicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2013;95:2231-9

2232
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

Fig. 1-A

Fig. 1-B

Figs. 1-A and 1-B A seventy-ve-year-old woman who sustained a four-part fracture of the proximal part of the humerus, including comminution of the humeral head and displacement of the tuberosities, in a fall from a standing height that involved her nondominant arm. Fig 1-A Preoperative anteroposterior radiograph of the injured shoulder. Fig. 1-B Radiograph made after reverse total shoulder arthroplasty.

tuberosity. If there is a periosteal sleeve that remains in place, we attempt to leave it to facilitate reduction and stability. However, in fractures that are more than a few days old, contracture of the periosteum can preclude reduction of the tuberosities and release may be needed. A fracture-specic stem may improve the outcome and should allow conversion to a reverse total shoulder arthroplasty if necessary11-13. Suture xation must provide interfragmentary compression xation between tuberosity fragments, between the tuberosities and the humeral shaft, and around the neck of the implant14. Proper positioning of the stem can be difcult because the normal osseous landmarks of the proximal part of the humerus no longer exist. Achieving both the correct retroversion and height of the humeral head are critical for restoration of shoulder biomechanics and function. Typically, the prosthetic humeral head should be placed in slightly less than anatomic retroversion (20) to

reduce tension on the greater tuberosity repair. Restoration of the height of the humeral head is also challenging. Krishnan et al. described the Gothic arch to help to obtain the correct hemiarthroplasty height15. Fortunately, the pectoralis major tendon is rarely torn in this injury, and both Murachovsky et al.16 and Greiner et al.17 described its use as a landmark for the assessment of humeral head height. According to Murachovsky et al., the mean distance (and 95% condence interval) between the top of the humeral head and the top of the pectoralis major tendon is 5.6 0.5 cm, which will help in the accurate restoration of the humeral head position. Stems should be cemented to obtain rotational control. Total Shoulder Arthroplasty Many surgeons perform reverse total shoulder arthroplasty through the deltopectoral interval because of their comfort with this approach. Additionally, ORIF can be performed using the same

approach, facilitating conversion from one procedure to the other if intraoperative ndings warrant. Other authors have preferred the superolateral approach for reverse total shoulder arthroplasty18. This approach releases the anterior deltoid muscle from the acromion and uses a split in the anterolateral raphe of the deltoid for access to the humeral shaft. The humerus is exposed and reamed, and the glenoid is addressed. Excellent en face glenoid access is imperative for reverse total shoulder arthroplasty. The height of the implant is determined by assessing tension in the deltoid and coracobrachialis muscles, which should be tight enough so that the implants do not dislocate, but are not difcult to reduce. Tuberosity xation is important in reverse total shoulder arthroplasty following fracture as it allows proper rotational control of the arm after healing. Consequently, secure suture repair of the tuberosities to the humeral shaft, humeral stem, and to each other is performed. Humeral stems should be cemented in

2233
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

reverse total shoulder arthroplasty to provide rotational stability of the construct. Overview Reverse total shoulder arthroplasty and shoulder hemiarthroplasty are both surgical options for comminuted fractures of the proximal part of the humerus in elderly patients with a dysvascular humeral head and/or severe fracture comminution. Younger patients should be treated with ORIF whenever possible. Patients who are more active or physiologically younger should undergo shoulder hemiarthroplasty with a convertible implant. Reverse total shoulder arthroplasty may be more predictable for restoring the ability to perform the activities of daily living for elderly or sedentary patients with this injury, especially those with an expected life span of less than ten years. Total Elbow Arthroplasty for Fractures of the Distal End of the Humerus Improved surgical techniques, tricepssparing approaches, and anatomic pre-

contoured plates have improved outcomes following ORIF of intraarticular distal humeral fractures. However, complications remain frequent in elderly patients with severe fracture comminution and poor bone quality. Suboptimal plate xation in osteopenic bone often leads to nonunion and more complications. Nonunion or malunion of the distal end of the humerus causes substantial impairment in the functional ability and level of independence of a patient19. Total elbow arthroplasty is an alternative to ORIF for comminuted, intra-articular distal humeral fractures in elderly patients (Figs. 2-A and 2-B). Total elbow arthroplasty is reserved for elderly patients only; it is not an option for younger, higher-demand individuals. Primary total elbow arthroplasty for elbow fracture was rst reported, to our knowledge, in 1997 by Cobb and Morrey, who described twenty-one elbows in twenty patients (mean age, seventy-two years) with comminuted distal humeral fractures that were managed with a primary total elbow

arthroplasty, resulting in a good or excellent outcome in 95% of the twenty elbows with complete data and only one reoperation in the entire cohort20. Other retrospective reviews from single centers have conrmed similar, consistently reliable results21,22. In the rst comparative study, Frankle et al. performed a retrospective comparison of ORIF and total elbow arthroplasty for intra-articular distal humeral fractures in twenty-four women older than sixtyve years23. At the time of the shortterm follow-up, the patients who had total elbow arthroplasty had excellent or good results, with improved range of motion and less need for physical therapy than those who had ORIF, and 25% of patients treated with ORIF had a mechanical failure that required revision to total elbow arthroplasty. Recently, in a randomized prospective trial comparing ORIF and total elbow arthroplasty for comminuted intraarticular distal humeral fractures in elderly patients, McKee et al. reported that total elbow arthroplasty improved functional outcome compared with

Fig. 2-A

Fig. 2-B

Figs. 2-A and 2-B A ninety-year-old man with an intra-articular distal humeral fracture. Fig. 2-A Preoperative axial computed tomographic image showing the displaced distal humeral fragments. Fig. 2-B Lateral elbow radiograph made three months after total elbow reconstruction.

2234
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

ORIF on the basis of both objective elbow performance scores and patientrated upper extremity disability and symptoms24. They emphasized that the mean age of the patients in their study was close to eighty years of age, and that this procedure is not suitable for younger patients. Indications and Contraindications While total elbow arthroplasty produces reliably good results in the appropriate patient, careful adherence to patient selection and surgical technique are critical.
Indications

A low-demand patient with an age of more than sixty-ve years Preexisting, symptomatic arthritis of the elbow Articular comminution (typically three or more articular fragments) A closed or type-1 open fracture25 (if the arthroplasty is done within eight to twelve hours of injury and satisfactory debridement is obtained) Delayed presentation with articular fragmentation rendering reconstruction unfeasible Associated severe ligamentous damage and/or elbow instability
Contraindications

Active infection or insufcient soft-tissue coverage Advanced dementia or noncompliance issues (e.g., substance abuse) Extensor mechanism disruption (a relative contraindication) A type-2 or 3 open fracture A young, active, high-demand patient Simple fracture pattern (i.e., two articular fragments) Technique Total elbow arthroplasty for a fracture requires the correct implant, equipment, and an experienced operatingroom staff and surgeon. The fracture is splinted until conditions are optimized for surgery; a wait of up to fourteen days is rarely detrimental if required. A cemented, linked, or semiconstrained prosthesis is the treatment of choice for

total elbow arthroplasty following a distal humeral fracture. While some promising preliminary results are available for distal humeral hemiarthroplasty (typically with an anatomic distal humeral replacement) that may extend the indications for this procedure to younger patients, such an approach should be considered experimental at present26. The patient is placed in the lateral decubitus position with the affected arm free-draped over a bolster, with a tourniquet applied. A posterior approach is used; the ulnar nerve is identied and protected. The olecranon is not osteotomized; this compromises the insertion and stability of the ulnar component. When the fractured articular fragments or condyles are excised, this creates a socalled working space allowing the humerus and ulna to be instrumented and the components inserted without detaching the triceps. Condylar resection does not appear to negatively affect forearm or wrist strength, and the condyles are not required for ligament attachment or stability when a linked prosthesis is used27. If greater exposure is required, the triceps can be split or peeled from the olecranon28,29. Following insertion of the prosthesis, thorough irrigation and standard closure are performed: the ulnar nerve remains in a tension-free position medially. A major benet of the linked total elbow arthroplasty in general and the so-called triceps-on approach in particular is the ability to allow immediate full range of active motion postoperatively. This enhances the elbow-specic outcome, rapidly restores independent function to the patient, and minimizes hospital and rehabilitation time. Overview Primary semiconstrained total elbow arthroplasty has a role in the treatment of comminuted intra-articular fractures of the distal end of the humerus in selected elderly patients. In this specic group, it results in improved patient outcome compared with ORIF, enhances the return to independent function, and minimizes

hospital stay and rehabilitation time. ORIF and Immediate Total Hip Replacement for the Management of Selected Displaced Acetabular Fractures in the Elderly The recommended treatment for most displaced acetabular fractures is ORIF30,31. Acetabular fractures in the elderly are an increasingly common injury pattern32-34. In the elderly, these fractures are more likely the result of a low-energy fall than high-energy trauma34,35, yet they are often comminuted with major displacement and impaction of the articular surface32,33,36. Early mobilization of these fragile patients is of primary importance in restoring them to their preinjury level of function, as well as preventing complications from prolonged recumbency37. The difculty of obtaining a satisfactory result with internal xation and the common need for a delayed total hip replacement to treat failed internal xation in these patients makes initial prosthetic replacement attractive38-43. One approach is to initially manage these patients nonoperatively, performing delayed total hip replacement once the fracture has healed in symptomatic patients36. However, delayed arthroplasty following acetabular fracture in the elderly has inferior results compared with primary arthroplasty for degenerative disease41. Immediate total hip replacement with acetabular reconstruction allows early mobilization and lessens the risk of subjecting the patient to two major surgical procedures in a relatively short time period (Figs. 3-A and 3-B). The challenge of immediate total hip replacement is to obtain stable acetabular component xation, and to be able to allow the patients early activity without compromising xation of the implants or hip stability. In fact, reports of this approach published several decades ago noted problems with xation of the cemented acetabular component44. In the last decade, there has been renewed interest in treating selected acetabular fractures with early total hip replace et al. reported the ment33,42,45-48. Beaule cases of ten patients managed with open reduction and acute total hip replacement

2235
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

immobilization. The average Merle and Postel score was 16, indidAubigne cating a good outcome. More recently, Boraiah et al. described eighteen patients who were treated by a protocol very similar to ours and were followed for at least one year; those authors also reported one early acetabular failure requiring revision surgery, while 81% of their patients had good or excellent results according to the Harris hip score48. ORIF of the acetabulum and immediate total hip replacement is a complex procedure that should be performed by surgeons adept at both surgical xation of acetabular fractures and total hip replacement. Published results have indicated that functional outcomes are similar to those after primary total hip replacement for osteoarthritis35,46. Technique Patients undergo surgery as soon as possible after admission and thorough evaluation by the orthopaedic, trauma, and/or internal medicine services as indicated by their injuries and medical comorbidities (if any). Surgical procedures are usually done within two to four days. Patients with fracturedislocations have their hip reduced immediately in the emergency department with deep intravenous sedation. If the hip is unstable following closed reduction, skeletal traction is placed, typically through the distal end of the femur. Subcutaneous heparin (5000 units three times daily) and pneumatic compression stockings are routinely used for prophylaxis against venous thromboembolism. We initially repair the acetabular fracture using standard techniques of internal xation as appropriate for the fracture pattern. The goal of the internal xation is to reduce and stabilize the anterior and/or posterior columns, not to restore the articular surface. In patients with major displacement of the anterior column, an ilioinguinal approach or Stoppa approach with the patient supine is used to reduce and plate the pelvic brim (Figs. 3-A and 3-B). Next, or for fractures primarily involving the posterior wall and/or column, a Kocher-Langenbeck

Fig. 3-A

Fig. 3-B

Figs. 3-A and 3-B A seventy-six-year-old woman with osteoporosis who sustained a displaced acetabular fracture on the right side. Fig. 3-A Preoperative anteroposterior pelvic radiograph showing the displaced acetabular fracture with the femoral head protruding into the fracture site. Fig. 3-B Anteroposterior pelvic radiograph after internal xation and immediate total hip replacement.

utilizing a direct anterior surgical approach for anterior wall or column fractures in the elderly46. At an average follow-up of three years, none of the

patients had nonunion or component loosening or migration. One patient had an anterior dislocation that was treated successfully with closed reduction and

2236
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

approach is used with the patient in the lateral decubitus position. Following exposure of the greater trochanter, the short external rotators are released and tagged with suture for later repair. A hip capsulotomy is performed, maintaining capsular aps for later repair. The femoral head is dislocated, the femoral neck cut, and the femoral head removed in the standard fashion. A cobra retractor is placed over the anterior wall of the acetabulum, and any posterior wall fragments are identied. The acetabular labrum is excised. If there is a fracture of the posterior column, the posterior column is carefully exposed and reduced with clamps. If the posterior wall requires reconstruction, an acetabular trial that is similar in size to the resected femoral head is selected and placed in the acetabulum for use as a template for reconstruction. The posterior wall fragment(s) are repositioned against the acetabular trial component, and the posterior wall and column of the acetabulum are stabilized with a posterior buttress plate. After the posterior wall and/or column are stabilized, any residual bone defects resulting from articular impaction or comminution are bone-grafted using cancellous bone from the patients femoral head. Following repair of the acetabulum, total hip arthroplasty is then performed through the same incision. The acetabulum is prepared with standard reaming with medialization of the cup to the oor of the cotyloid fossa. For uncemented cups, once bleeding subchondral bone is reached, a cup 1 mm larger than the outside diameter of the last reamer is selected and implanted with an interference t. The acetabular component is anchored with additional screw xation into the ilium. Standard femoral canal preparation and femoral stem placement are employed, using uncemented, proximally porous-coated implants in most patients (Figs. 3-A and 3-B). Postoperative Treatment Patients receive prophylactic antibiotics for twenty-four hours and are started on warfarin or low-molecular-weight heparin postoperatively, which is continued for four weeks following discharge.

Prophylaxis against heterotopic ossication using low-dose radiation (a single dose of 600 Gy) is recommended for male patients who have a posterior fracture-dislocation. Patients with displaced anterior or posterior column fractures are mobilized with crutches or a walker for six weeks. Patients with isolated posterior wall fractures are allowed full weight-bearing immediately. Patients are instructed to avoid hip exion beyond 90 and to sleep with a pillow between their legs. Displaced Femoral Neck Fractures: The Case for Total Hip Replacement Total hip replacement for the treatment of displaced femoral neck fractures (Fig. 4) in the elderly leads to improved outcomes, fewer complications, and decreased cost compared with other treatment techniques of internal xation or hemiarthroplasty. The incidence of hip fractures in the United States in 1996 was approximately 250,000 cases, with projections that this

would increase to 500,000 fractures per year by 204049. Thus, the management of femoral neck fractures in a costeffective manner is of societal importance, not to mention the consequences for the individual patient when complications of care occur. This section reviews the role of arthroplasty in the management of fractures of the femoral neck: when to replace the hip, which device to use, and whether to cement or press-t the implant. Hemiarthroplasty has been the preferred management for femoral neck fractures that are not ideal for internal xation because of advanced patient age and/or osteopenia. Advantages of hemiarthroplasty compared with total hip arthroplasty are the quick and relatively simple surgical technique and a documented low risk of dislocation50. The main disadvantages of hemiarthroplasty include the potential for rapid wear of acetabular articular cartilage (requiring conversion to total hip replacement) and pain related to the metallic femoral head

Fig. 4

Preoperative (left) and postoperative (right) radiographs of a displaced femoral neck fracture in a seventy-three-year-old woman who was treated with primary total hip arthroplasty.

2237
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

against the host acetabulum (chondrolysis). The justication for prosthetic replacement in the treatment of femoral neck fractures resides in the fact that arthroplasty provides optimal functional recovery. The literature overwhelmingly supports arthroplasty for the treatment of the displaced femoral neck fracture in the elderly51-65. Complications and the need for multiple procedures are decreased when total hip replacement is utilized over other treatment options. Schmidt et al. recently provided a comprehensive review of the literature regarding the optimal arthroplasty for displaced femoral neck fractures63. Iorio et al. conducted a survey in 2006 that revealed that most surgeons preferred treating geriatric patients with displaced femoral neck fractures with bipolar arthroplasty66. However, at the time of their survey, surgical practice was changing because of the recent introduction of highly cross-linked polyethylene and larger femoral heads to decrease dislocation rates. Newer stem designs also were proven to be successful in elderly patients with femoral neck fractures67. The Displaced Femoral (neck fracture) Arthroplasty Consortium for Treatment and Outcomes reported the results of their prospective, multicenter randomized clinical trial comparing hemiarthroplasty and total hip arthroplasty in 2008, nding that total hip replacement had superior results58. Treatment choices for displaced femoral neck fractures might differ depending on which outcome criteria we consider. Possible criteria include complication rates, cost-effectiveness, and short and long-term outcomes. Iorio et al. presented a cost-effectiveness analysis of four surgical treatments for a displaced femoral neck fracture68. This series considered initial hospital costs, rehabilitation costs, and costs of reoperations and complications. Those authors determined that cemented total hip replacement was the most cost-effective treatment and that internal xation was the most expensive option68. A highly compelling study is the Scottish Trial of Arthroplasty or Reduc-

tion (STARS) for subcapital femoral neck fractures57. This multicenter randomized study showed that long-term function was best after total hip replacement. The STARS study revealed an incidence of osteonecrosis of 20% and nonunion rates of 30% in the ORIF group, consistent with prior studies. The reoperation rate was much higher for the internal xation group, which had a failure rate of 37%. Chondrolysis, which generally manifested itself as pain, occurred in 20% of the bipolar-monopolar treatment group, with a reoperation rate of 5%. A systematic review of xation options indicated that cemented hip replacement is associated with less pain than uncemented hip replacement in patients with a hip fracture69. This nding was further substantiated in a recent study supporting cemented stems as being superior to bone ingrowth stems70. In the STARS study, the total hip replacement treatment group had the best functional outcome and the least pain, the lowest cost, and a reoperation rate of 9%. Healy and Iorio also reported better results and lower cost with total hip replacement71. Several randomized prospective series lend credence to the fact that arthroplasty leads to better results than internal xation of displaced femoral neck fractures55-58,60,62,64. Displaced femoral neck fractures pose certain problems for the treating surgeon. The randomized controlled trial by Blomfeldt et al., which compared bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients, revealed superior results in the total hip replacement group in all outcomes parameters compared with the bipolar group, utilizing the anterolateral approach in all cases to reduce the risk of dislocation typically associated with posterior approaches72. However, capsular repair and use of a large femoral head may mitigate the dislocation risk when posterior approaches are done61,73. Berry et al. further described how the dislocation rate can be decreased with careful attention to detail, such as using larger femoral heads, highly cross-linked polyethylene, and capsular closure74. The surgeon may

therefore use whatever surgical approach he or she is most comfortable with. Surgical techniques are more difcult in displaced femoral neck fractures compared with elective total hip replacement. Poor bone quality, intraoperative instability, and difculties with abnormal anatomy due to the displaced fracture present unique problems. The surgeon can base his or her preoperative plan on the nonfractured side to best evaluate for stem size, head center, limb length, and offset. Technical pearls include the use of a larger femoral head, careful reaming, restoration of appropriate limb length and offset, repair of the hip capsule, and use of multiple acetabular screws with compromised bone quality. Controversy remains about whether to cement or press-t the femoral component53,70,72. Treatment of these difcult fractures involves certain parameters that are outside the surgeons control such as the patients age, mental status, bone quality, fracture pattern, time to diagnosis, and comorbidities. However, the surgeon does have control over many factors that are critical in the treatment of these fractures. These include the timing of surgery, choice of surgical approach, restoration of hip center, use of larger femoral heads to decrease the prevalence of dislocation, capsular closure, and surgical experience. No single approach works best for all fracture types. However, for displaced femoral neck fractures, the surgeon should give strong consideration to the treatment of these difcult fractures with a total hip replacement to decrease cost, lower complications, and restore the best postoperative function.

Andrew H. Schmidt, MD Department of Orthopedic Surgery, Hennepin County Medical Center, 701 Park Avenue, Mailcode G2, Minneapolis, MN 55415. E-mail address: schmi115@umn.edu Jonathan P. Braman, MD Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South,

2238
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

#R200, Minneapolis, MN 55454. E-mail address: brama011@umn.edu Paul J. Duwelius, MD Orthopedic and Fracture Specialists, 11782 SW Barnes Road, Suite 300, Portland, OR 97225. E-mail address: pduwelius@gmail.com

Michael D. McKee, MD, FRCS(C) Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, St. Michaels Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address: mckeem@smh.ca

Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academys Annual Meeting, will be available in March 2014 in Instructional Course Lectures, Volume 63. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

References
1. Calvo E, Morcillo D, Foruria AM, Redondoa E, Osorio-Picorne F, Caeiro JR; GEIOSSantamar SECOT Outpatient Osteoporotic Fracture Study Group. Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception. J Shoulder Elbow Surg. 2011 Jul;20(5):795-801. Epub 2010 Dec 31. 2. Brorson S, Rasmussen JV, Frich LH, Olsen BS, Hr objartsson A. Benets and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: a systematic review. Injury. 2012 Jul;43(7):999-1005. Epub 2011 Oct 2. 3. Hardeman F, Bollars P, Donnelly M, Bellemans J, Nijs S. Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus. Injury. 2012 Feb;43(2):153-8. Epub 2011 May 12. 4. Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical xation of proximal humerus fractures. Injury. 2011 Nov;42(11):1283-8. Epub 2011 Feb 9. 5. Ong C, Bechtel C, Walsh M, Zuckerman JD, Egol KA. Three- and four-part fractures have poorer function than one-part proximal humerus fractures. Clin Orthop Relat Res. 2011 Dec;469(12):3292-9. 6. Osterhoff G, Hoch A, Wanner GA, Simmen HP, Werner CML. Calcar comminution as prognostic factor of clinical outcome after locking plate xation of proximal humeral fractures. Injury. 2012 Oct;43(10):1651-6. Epub 2012 May 12. 7. S udkamp NP, Audig e L, Lambert S, Hertel R, Konrad G. Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures. J Shoulder Elbow Surg. 2011 Dec;20(8): 1207-16. Epub 2011 Sep 14. 8. Liu J, Li SH, Cai ZD, Lou LM, Wu X, Zhu YC, Wu WP. Outcomes, and factors affecting outcomes, following shoulder hemiarthroplasty for proximal humeral fracture repair. J Orthop Sci. 2011 Sep;16(5):565-72. Epub 2011 Jul 13. 9. Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. Orthop Traumatol Surg Res. 2009 Feb;95(1):48-55. Epub 2009 Feb 6. 10. Garrigues GE, Johnston PS, Pepe MD, Tucker BS, Ramsey ML, Austin LS. Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. Orthopedics. 2012 May;35(5):e703-8. 11. Dines DM, Warren RF. Modular shoulder hemiarthroplasty for acute fractures. Surgical considerations. Clin Orthop Relat Res. 1994 Oct;(307):18-26. 12. Aaron DL, Neviaser AS, Mulcahey MK, Flatow EL, Parsons BO, Blaine TA. Functional and radiographic outcomes using a tantalum porous implant in the treatment of three and four part proximal humerus fractures. Presented as a paper at the American Shoulder Elbow Society Closed Meeting; 2011 Oct 12-15; White Sulfur Spring, WV. Paper no. 18. 13. Krishnan SG, Reineck JR, Bennion PD, Feher L, Burkhead WZ Jr. Shoulder arthroplasty for fracture: does a fracture-specic stem make a difference? Clin Orthop Relat Res. 2011 Dec;469(12):3317-23. 14. Boileau P, Pennington SD, Alami G. Proximal humeral fractures in younger patients: xation techniques and arthroplasty. J Shoulder Elbow Surg. 2011 Mar;20(2)(Suppl):S47-60. 15. Krishnan SG, Bennion PW, Reineck JR, Burkhead WZ. Hemiarthroplasty for proximal humeral fracture: restoration of the Gothic arch. Orthop Clin North Am. 2008 Oct;39(4):441-50, vi. 16. Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2006 Nov-Dec;15(6): 675-8. Epub 2006 Oct 19. oning I, Scheibel M, 17. Greiner SH, K aa b MJ, Kr Perka C. Reconstruction of humeral length and centering of the prosthetic head in hemiarthroplasty for proximal humeral fractures. J Shoulder Elbow Surg. 2008 Sep-Oct;17(5):709-14. Epub 2008 Jul 14. 18. Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. Orthop Traumatol Surg Res. 2009 Feb;95(1):48-55. 19. McKee M, Jupiter J, Toh CL, Wilson L, Colton C, Karras KK. Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults. J Bone Joint Surg Br. 1994 Jul;76(4):614-21. 20. Cobb TK, Morrey BF. Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am. 1997 Jun;79(6):826-32. 21. Garcia JA, Mykula R, Stanley D. Complex fractures of the distal humerus in the elderly. The role of total elbow replacement as primary treatment. J Bone Joint Surg Br. 2002 Aug;84(6):812-6. 22. Lee KT, Lai CH, Singh S. Results of total elbow arthroplasty in the treatment of distal humerus fractures in elderly Asian patients. J Trauma. 2006 Oct;61(4):889-92. 23. Frankle MA, Herscovici D Jr, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal xation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma. 2003 Aug;17(7):473-80. 24. McKee MD, Veillette CJH, Hall JA, Schemitsch EH, Wild LM, McCormack R, Perey B, Goetz T, Zomar M, Moon K, Mandel S, Petit S, Guy P, Leung I. A multicenter, prospective, randomized, controlled trial of open reductioninternal xation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):3-12. Epub 2008 Sep 26. 25. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-ve open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4): 453-8. 26. Adolfsson L, Nestorson J. The Kudo humeral component as primary hemiarthroplasty in distal humeral fractures. J Shoulder Elbow Surg. 2012 Apr;21(4):451-5. Epub 2011 Oct 17. 27. McKee MD, Pugh DM, Richards RR, Pedersen E, Jones C, Schemitsch EH. Effect of humeral condylar resection on strength and functional outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg Am. 2003 May;85-A(5):802-7. 28. Morrey BF, Sanchez-Sotelo J. Approaches for elbow arthroplasty: how to handle the triceps. J Shoulder Elbow Surg. 2011 Mar;20(2)(Suppl):S90-6. 29. Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am. 2011 Apr 6;93(7):686-700. 30. Letournel E. Acetabulum fractures: classication and management. Clin Orthop Relat Res. 1980 Sep;(151):81-106. 31. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996 Nov;78(11):1632-45. 32. Anglen JO, Burd TA, Hendricks KJ, Harrison P. The Gull Sign: a harbinger of failure for internal xation of geriatric acetabular fractures. J Orthop Trauma. 2003 Oct;17(9):625-34. 33. Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg. 1999 Mar-Apr;7(2):128-41. 34. Vanderschot P. Treatment options of pelvic and acetabular fractures in patients with osteoporotic bone. Injury. 2007 Apr;38(4):497-508. Epub 2007 Mar 30. 35. Mears DC, Velyvis JH. Acute total hip arthroplasty for selected displaced acetabular fractures: two to twelve-year results. J Bone Joint Surg Am. 2002 Jan;84-A(1):1-9. 36. Spencer RF. Acetabular fractures in older patients. J Bone Joint Surg Br. 1989 Nov;71(5):774-6. 37. Helfet DL, Borrelli J Jr, DiPasquale T, Sanders R. Stabilization of acetabular fractures in elderly patients. J Bone Joint Surg Am. 1992 Jun;74(5):753-65. 38. Bellabarba C, Berger RA, Bentley CD, Quigley LR, Jacobs JJ, Rosenberg AG, Sheinkop MB, Galante JO. Cementless acetabular reconstruction after acetabular fracture. J Bone Joint Surg Am. 2001 Jun;83A(6):868-76. 39. Boardman KP, Charnley J. Low-friction arthroplasty after fracture-dislocations of the hip. J Bone Joint Surg Br. 1978 Nov;60-B(4):495-7. 40. Huo MH, Solberg BD, Zatorski LE, Keggi KJ. Total hip replacements done without cement after acetabular fractures: a 4- to 8-year follow-up study. J Arthroplasty. 1999 Oct;14(7):827-31. 41. Romness DW, Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. Long-term results. J Bone Joint Surg Br. 1990 Sep;72(5):761-4. 42. Sermon A, Broos P, Vanderschot P. Total hip replacement for acetabular fractures. Results in 121 patients operated between 1983 and 2003. Injury. 2008 Aug;39(8):914-21. Epub 2008 Jul 2. 43. Weber M, Berry DJ, Harmsen WS. Total hip arthroplasty after operative treatment of an

2239
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 5-A N U M B E R 24 D E C E M B E R 18, 2 013
d d d

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

acetabular fracture. J Bone Joint Surg Am. 1998 Sep;80(9):1295-305. 44. Coventry MB. The treatment of fracture-dislocation of the hip by total hip arthroplasty. J Bone Joint Surg Am. 1974 Sep;56(6):1128-34. 45. Mears DC, Shirahama M. Stabilization of an acetabular fracture with cables for acute total hip arthroplasty. J Arthroplasty. 1998 Jan;13(1):104-7. 46. Beaul e PE, Grifn DB, Matta JM. The Levine anterior approach for total hip replacement as the treatment for an acute acetabular fracture. J Orthop Trauma. 2004 Oct;18(9):623-9. 47. Tidermark J, Blomfeldt R, Ponzer S, S oderqvist A, T ornkvist H. Primary total hip arthroplasty with a Burch-Schneider antiprotrusion cage and autologous bone grafting for acetabular fractures in elderly patients. J Orthop Trauma. 2003 Mar;17(3):193-7. 48. Boraiah S, Ragsdale M, Achor T, Zelicof S, Asprinio DE. Open reduction internal xation and primary total hip arthroplasty of selected acetabular fractures. J Orthop Trauma. 2009 Apr;23(4):243-8. 49. Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States. Numbers, costs, and potential effects of postmenopausal estrogen. Clin Orthop Relat Res. 1990 Mar;(252):163-6. 50. Carroll C, Stevenson M, Scope A, Evans P, Buckley S. Hemiarthroplasty and total hip arthroplasty for treating primary intracapsular fracture of the hip: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2011 Oct;15(36):1-74. 51. Bhandari M, Matta J, Ferguson T, Matthys G. Predictors of clinical and radiological outcome in patients with fractures of the acetabulum and concomitant posterior dislocation of the hip. J Bone Joint Surg Br. 2006 Dec;88(12):1618-24. 52. Cho MR, Lee HS, Lee SW, Choi CH, Kim SK, Ko SB. Results after total hip arthroplasty with a large head and bipolar arthroplasty in patients with displaced femoral neck fractures. J Arthroplasty. 2011 Sep;26(6):893-6. Epub 2010 Mar 23. 53. Dorr LD, Glousman R, Hoy AL, Vanis R, Chandler R. Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty. J Arthroplasty. 1986;1(1):21-8. 54. Haidukewych GJ, Israel TA, Berry DJ. Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res. 2002 Oct;(403):118-26.

55. Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R, T ornkvist H, Ponzer S, Tidermark J. Comparison of bipolar hemiarthroplasty with total hip arthroplasty for displaced femoral neck fractures: a concise four-year follow-up of a randomized trial. J Bone Joint Surg Am. 2011 Mar 2;93(5):445-50. 56. Johansson T, Jacobsson SA, Ivarsson I, Knutsson A, Wahlstr om O. Internal xation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips. Acta Orthop Scand. 2000 Dec;71(6):597-602. 57. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and xation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006 Feb;88(2):249-60. 58. Macaulay W, Nellans KW, Garvin KL, Iorio R, Healy WL, Rosenwasser MP; other members of the DFACTO Consortium. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. J Arthroplasty. 2008 Sep;23(6)(Suppl 1):2-8. 59. Parker MJ, Khan RJ, Crawford J, Pryor GA. Hemiarthroplasty versus internal xation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. J Bone Joint Surg Br. 2002 Nov;84(8):1150-5. 60. Ravikumar KJ, Marsh G. Internal xation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur13 year results of a prospective randomised study. Injury. 2000 Dec;31(10):793-7. 61. Ricci WM, Langer JS, Leduc S, Streubel PN, Borrelli JJ. Total hip arthroplasty for acute displaced femoral neck fractures via the posterior approach: a protocol to minimise hip dislocation risk. Hip Int. 2011 Jun 8;21(3):344-50. Epub 2011 Jun 8. 62. Rogmark C, Carlsson A, Johnell O, Sernbo I. A prospective randomised trial of internal xation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years. J Bone Joint Surg Br. 2002 Mar;84(2):183-8. 63. Schmidt AH, Leighton R, Parvizi J, Sems A, Berry DJ. Optimal arthroplasty for femoral neck fractures: is total hip arthroplasty the answer? J Orthop Trauma. 2009 Jul;23(6):428-33.

oderqvist A, 64. Tidermark J, Ponzer S, Svensson O, S T ornkvist H. Internal xation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br. 2003 Apr;85(3):380-8. 65. Zi-Sheng A, You-Shui G, Zhi-Zhen J, Ting Y, ChangQing Z. Hemiarthroplasty vs primary total hip arthroplasty for displaced fractures of the femoral neck in the elderly: a meta-analysis. J Arthroplasty. 2012 Apr;27(4):583-90. Epub 2011 Sep 15. 66. Iorio R, Schwartz B, Macaulay W, Teeney SM, Healy WL, York S. Surgical treatment of displaced femoral neck fractures in the elderly: a survey of the American Association of Hip and Knee Surgeons. J Arthroplasty. 2006 Dec;21(8):1124-33. 67. Klein GR, Parvizi J, Vegari DN, Rothman RH, Purtill JJ. Total hip arthroplasty for acute femoral neck fractures using a cementless tapered femoral stem. J Arthroplasty. 2006 Dec;21(8):1134-40. 68. Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ. Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness. Clin Orthop Relat Res. 2001 Feb;(383):229-42. 69. Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD001706. 70. Taylor F, Wright M, Zhu M. Hemiarthroplasty of the hip with and without cement: a randomized clinical trial. J Bone Joint Surg Am. 2012 Apr 4;94(7):577-83. 71. Healy WL, Iorio R. Total hip arthroplasty: optimal treatment for displaced femoral neck fractures in elderly patients. Clin Orthop Relat Res. 2004 Dec;(429):43-8. 72. Blomfeldt R, T ornkvist H, Eriksson K, S oderqvist A, Ponzer S, Tidermark J. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br. 2007 Feb;89(2):160-5. 73. Sierra RJ, Raposo JM, Trousdale RT, Cabanela ME. Dislocation of primary THA done through a posterolateral approach in the elderly. Clin Orthop Relat Res. 2005 Dec;441(441):262-7. 74. Berry DJ, von Knoch M, Schleck CD, Harmsen WS. Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Nov;87(11):2456-63.