From the Guidelines
Revision surgery with a new prosthesis, specifically a total hip arthroplasty (THA), is the recommended treatment for a fracture of a prosthetic hip joint at the neck of femur (NOF) level, as it offers a functional benefit over hemiarthroplasty, although with a risk of increased complications. The decision to proceed with THA is based on the patient's age, comorbidities, level of function, and underlying osteoarthritis, as supported by the American Academy of Orthopaedic Surgeons (AAOS) management of hip fractures in older adults evidence-based clinical practice guideline 1.
When considering the type of surgery, several factors come into play, including:
- The type of existing prosthesis
- Fracture pattern
- Bone quality
- Patient factors, such as age and functional demands The surgery typically involves removing the broken components and replacing them with a new prosthesis, with options including revision to another THA or conversion to a hemiarthroplasty in elderly patients with limited functional demands 1.
The use of cemented femoral stems in arthroplasty for the treatment of hip fractures in older adults is strongly recommended, as supported by the AAOS clinical practice guideline summary: management of hip fractures in older adults 1. Additionally, the use of venous thromboembolism (VTE) prophylaxis and an interdisciplinary care program are strongly recommended to improve functional outcomes and decrease complications 1.
In terms of perioperative care, patients will need:
- Perioperative antibiotics, typically cefazolin 2g IV preoperatively and continued for 24 hours postoperatively
- DVT prophylaxis
- A structured rehabilitation program This approach is necessary because internal fixation alone is rarely successful for periprosthetic fractures, as the presence of the prosthesis compromises blood supply to the fracture site and the metal-on-metal interface creates an unstable environment for healing.
From the Research
Surgical Options for Fracture of Prosthetic Hip Joint at NOF Level
The type of surgery recommended for a fracture of a prosthetic hip joint at the neck of femur (NOF) level depends on various factors, including the type of prosthesis, the extent of the fracture, and the patient's overall health.
- Revision surgery using a new prosthesis, such as the Solution prosthesis, may be necessary in cases of prosthesis loosening or fracture 2.
- Total hip arthroplasty (THA) is a common treatment option for fractured NOF, with a lower revision rate compared to hemiarthroplasty (HA) 3, 4, 5.
- The choice of surgical approach, such as the modified Hardinge approach or the modified SPAIRE approach, may depend on the patient's individual needs and risk factors 6.
Considerations for Surgical Decision-Making
When deciding on the type of surgery, the following factors should be considered:
- The type and extent of the fracture
- The type of prosthesis and its condition
- The patient's overall health and mobility
- The risk of complications, such as dislocation or infection
- The potential need for revision surgery in the future
Available Evidence
Studies have shown that THA is a effective treatment option for fractured NOF, with a lower revision rate compared to HA 3, 4, 5. However, the choice of surgical approach and prosthesis should be individualized based on the patient's specific needs and circumstances 2, 6.