prospective study was carried out in Referral Rustaq Hospital
Oman to determine the functional results and complications in
elderly patients (above 65 yrs) with fracture neck femur treated
by hemiarthroplasty Austin Moore Prosthesis from March 1999 to
February 2003. The patients were followed for 18 months. The
study design was descriptive and analytical. Statistical
analysis was done with chi-square test.
Results : The total number of patients were 52 with
average age of 71 years and above. Male to female ratio was
1:3. There were 57.6% patients with associated one or more
co-morbidity. The median duration of hospital stay was 7 days
and surgery time 45 min. Overall mortality at 15 months was
23%. Wound infection was present in 5.7% cases. The
dislocation of prosthesis was seen in 3.8% patients. Periprosthetic fracture was seen in 3.8% cases. The morbidity
and mortality was high in patients with systemic co-morbidity
and those above 70 years of age but statistically was not
significant ( p value > 0.05). In surviving patients at 18
months functional assessment was graded excellent / good in
Conclusion : We recommend primary hemiarthroplasty
for all elderly patients above 65 years with fracture neck femur
as overall functional results are unsatisfactory in patients
less than 65 years.
Austin Moore Prosthesis (AMP), Hemiarthroplasty, Fracture neck
The best treatment for fracture of femoral
neck is still to be determined (Masson et al 2004 1. Studies by (Johansson et al 20002, Rogmark
et al 2002 a, b3,4 Roden et al 20035)
have shown a 30 40 % rate of reoperation after internal
fixation and superior function after primary hemi or total
Internal fixation was associated with non
union and avascular necrosis and need for frequent revision.
With introduction of Austin Moore Prosthesis in 1992, the
problem of non union and avascular necrosis was improved as the
femoral head was replaced by metallic implant. The common
complications and mortality in elderly patients with femoral
neck fractures are mostly related to their age and other
systemic co-morbidities. The surgical procedure further
adds to their depleting health status
The Austin Moores Prostheis is commonly
performed in our hospital in elderly patients with fracture neck
femur. The factors considered in selecting treatment
modalities are age of the patient, general medical condition,
type of fracture, availability of facilities and socio economic
conditions of the patient 5,9 .
No results of early hemiarthroplasty for hip
fractures have been reported in literature from any Gulf Medical
Centres, although the procedure is commonly performed all over
hospitals in Gulf region.
Material and Methods :
This prospective analytical
study was conducted in Orthopaedic Department of Rustaq Referral
Hospital, Oman from March 1999 to February 2003.
52 patients with fracture neck
femur treated by hemiarthroplasty (Austin Moore Prosthesis) were
followed on average for 15 months to assess the functional
results and complications. Inclusion criteria were age 65
years and above, Bedridden patients and those with rheumatoid
arthritis, pathological fractures or any form of infection or a
life threatening medical conditions were excluded from the
All patients history and
clinical examination findings were recorded on a performa.
Patients variables such as demographic data mechanism of injury,
duration of fracture, side of fracture and any associated
systemic illness was noted. (Table I) Appropriate
Radiographs of the affected hip were taken to classify the type
of fracture. Relevant laboratory investigations, chest
radiographs and ECG were done in all cases.
Patients who were fit underwent
surgery under general anesthesia, only in five cases spinal
anesthesia was used. Patients were operated through
Moores porterior approach in lateral position. In all
cases appropriate size Austin Moores Prosthesis was used.
Patients were routinely started as prophylactic injection 1st/2nd
generation cephalosparins which was continued post-operatively
for 5 days as per the department protocol.
Patients were started on
physiotherapy while in hospital and mobilized early. After
discharge from hospital the patient was followed at interval of
02 weeks, 08 weeks, 06 months, 12 months and 15 months to record
any complications and at last follow up all the surviving
patients were functionally assessed to grade
data was analyzed for frequencies of various variables.
Statistical analysis was done with chi-square test.
total number of patients was 52 with female to male ratio of
3:1. The average age of patients was 72 years. 47 patients
were operated under general anesthesia and only 5 patients
underwent surgery under spinal anesthesia. 57% (30) of patients
had one or more systemic co-morbidity such as hypertension,
Ischaemic heart disease, Diabetes Mellitus, Chronic Obstructive
airway disease, Parkinsonism, chronic renal dysfunction. The
median duration of surgery was 45 min. (30-105) and hospital
stay 7 (5-37) days. Blood transfusion was given to 46 patients
and 16 needed 2 or more units.
In 15 months follow up only. 3 patients had wound
infection (5.7%). Two patients (3.8%) had dislocation of
the prosthesis and in both of them it was defected during first
week. Seven of surviving (13.4%) patients had complaints
of persistent thigh or groin pain sometimes radiating to the
knee causing significant discomfort to the patients.
patients (3.8%) had peri prosthetic fracture which was managed
conservatively. No neurovascular complication was noted.
patients with co-morbidities the mortality at 15 months was 25%
(8/30) and 40% patients had complications while 30% (9/30) were
mobile independently at 15 months period. Compared to 18%
(4/22) deaths and 27.2% (6/22) complications in patients without
prexisting co-morbidities. The results were however not
significant statistically (p value < 0.05).
overall mortality at 15 months was 23%. Most of these patients
were having one or more co-morbidities and their age was above
70 years. The cause of mortality was mostly medical.
Functional assessments of the 46 patients who were alive at 15
months was done according to the grading system adopted in Table
(II) adopted as comparable to that of Arcy and Devas(10)
. The result scoring showed that 20 patients (43.5%) were
graded excellent with no pain and full mobility while 18
patients (39.2%) were graded good, the remaining 8 patients
(17.3%) had poor results with restricted mobility and pain.
Fracture neck femur in elderly patients is a challenging
problems. The treatment depends on many factors including the
type of fracture, functional demands and presence of any
preexisting medical problems.
past few years a broader consensus has been reached as regards
treatment of fracture femoral neck in active, independent,
elderly patients, they benefit from a primary arthroplasty. (Dorr
et al 198611, Skinner et al 1989 12,
Ravi Kumar and Marsh 2000 13). Austin Moore
Prosthesis is most commonly performed procedure in developing
countries. This is especially indicated in patients with
relatively shorter life expectancy. Although Austin Moores
prosthesis eliminates the chances of non union and avascular
necrosis, other complications still occur. The complications
include deep vein thrombosis, chest infection, renal failure and
bed sores. The more specific complications associated with
hemiarthroplasty are infection, dislocation of implant, peri
prosthetic fractures, protrusion, thigh pain and neurovascular
injury 7,9 .
results of our study have shown overall mortality of 23% at 15
months which is comparable with other studies. There is slight
difference in patient characteristics, surgical approach,
implant design but these factors are not related to mortality.
and Devas10 has also reported mortality of 23% in
patients undergoing hemiarthroplasty at one year follow up.
Nather et al 19857, have reported mortality of 15%
in elderly patients undergoing Austin Moore prosthesis. Lee et
al have reported 6% mortality in patients with fracture neck of
femur treated by total hip replacement (THA). But they had
slected relatively fit patients for THR14 .
Dislocation of prosthesis is a common mechanical complications
in patient undergoing Arthroplasty. There were two dislocations
(3.8%) in present study.
al in their meta-analysis of literature on femoral neck
fractures found dislocation rate of 2.1% in hemiarthroplasty
group6 . Tellizi and Wahab in their series
reported dislocation rate of 3.4% 15 .
the present study the infection rate was 5.7% which is
comparable with other studies. The rate of infection was kept
low by routine are of antibiotics. The infection rate has been
reported to be high when posterior approach is used for
arthroplasty due to proximity of incision to the perineum.
of our patients had post operative deep vein thrombosis (DVT).
Routine use of low molecular weight Heparin prophylaxis is
routine in our hospital. DVT is less common in Asians and in
Middle East population compared to western population. Early
mobilization and use of prophylactic anti thrombotic agents
could explain the low incidence of DVT in these patients.
the present study the rate of complications and mortality was
high in patients above 70 years and with preexisting underlying
medical problems. But this was not statistically significant.
Contrary to this other authors have found significant difference
in mortality and morbidity in two groups (6,16,17) .
This could be due to small sample size.
percent of patients in our series had persistent thigh pain of
various severity. This is in concurrence with reported thigh
pain in literature ranging from 15% to 50%. Various factors may
be responsible for thigh pain, implant size/design, loosening,
infection. Use of cement as in Thompson Prosthesis has been
associated with less frequency of pain.
Functional assessment of 46 patients at 15 months follow up have
shown excellent to good results in 82.7% of our cases which is
comparable to the study of Arcy and Devas(10) who
reported 82% excellent good results.
present series has certain limitations as the study was based
on small sample size and vague hip scoring system for functional
assessment of surviving patients. Moreover the exact cause of
mortality could not be ascertained in absence of post mortem.
However this study was conducted for commonly performed
orthopaedic procedure to ascertain the results and complications
in most commonly occurring fracture in elderly patients and
approach to treatment of this condition where systemic and
medical co-morbidities compound the inherent risks.
Hemiarthroplasty Austin Moore Prosthesis for acute fracture
neck femur in elderly patients is associated with certain
complication inherent to the procedure and mortality and
morbidity which is due to associated systemic medical condition
most of the rime rather than due to the fracture itself.
Functional grading excellent to good was seen in 82.7% of our
cases at 15 months follow up. However large sample size and
longer follow up is advisable.
Demographic Data of Patients
Total Patients : 52
Variables For Grading Results
Side of Fracture
Duration of Fracture
0 7 days
7 14 days
Patients with Systemic co-morbidities
FFD < 10°
FFD > 20°
Moderate to Severe discomfort
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