Surgical Approach and Dislocation Risk After Hemiarthroplasty in Geriatric Patients With Femoral Neck Fracture With and Without Cognitive Impairments—Does Cognitive Impairment Influence Dislocation Risk?

Abstract

Objectives: To determine whether there is an association between surgical approach and dislocation risk in patients with cognitive impairment compared with those without cognitive impairment treated with hemiarthroplasty for femoral neck fracture. Design: Retrospective study. Setting: Large, multicenter health system. Patients/Participants: One thousand four hundred eighty-one patients who underwent hemiarthroplasty for femoral neck fractures. 828 hips met inclusion criteria, 290 (35.0%) were cognitively impaired, and 538 (65.0%) were cognitively intact. Intervention: Hemiarthroplasty. Main Outcome Measure: Prosthetic hip dislocation. Results: The overall dislocation rate was 2.1% (17 of 828), 3.4% (10 of 290) in the cognitively impaired group, and 1.3% (7 of 538) in the cognitively intact group with a median time to dislocation of 20.5 days (range 2–326 days), 24.5 days (range 3–326 days), and 19.0 days (range 2–36 days), respectively. In the entire cohort, there were no dislocations (0 of 58) with the direct anterior approach (DA); 1.1% (6 of 553) and 5.1% (11 of 217) dislocated with the modified Hardinge (MH) and posterior approaches (PA), respectively. In the cognitively impaired group, there were no dislocations with the DA (0 of 19); 1.5% (3 of 202) and 10.1% (7 of 69) dislocated with the MH and PA, respectively. In the cognitively intact group, there were no dislocations (0 of 39) with the DA; 0.85% (3 of 351) and 2.7% (4 of 148) dislocated with the MH and PA, respectively. There were statistically significant associations between surgical approach and dislocation in the entire cohort and the cognitively impaired group when comparing the MH and PA groups. This was not observed in the cognitively intact group. Patients who dislocated had 3.2 times (95% CI 1.2, 8.7) (P = 0.0226) the hazard of death compared with patients who did not dislocate. Dislocation effectively increased the risk of death by 221% (HR 3.2 95% CI 1.2, 8.7) (P = 0.0226). Conclusions: In this patient population, the PA has a higher dislocation rate than other approaches and has an especially high rate of dislocation when the patients were cognitively impaired. The authors of this study suggest careful consideration of surgical approach when treating these injuries. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Incidence rate, risk factors and patient reported outcome in patients with a dislocation following hip hemiarthroplasty after acute femoral neck fracture; a scoping review

“…Unfortunately, dislocation of the HA lacks an ICD-10 diagnosis code, why it is difficult to find the precise number of people affected. The existing literature is unclear of the dislocation rates of the hip HA, ranging from 1 -12% (1)(2)(3)(4)(5)(6)(7)(8). Many studies describing prevalence, incidence or incidence rate base their dislocation rate on patients treated at their facility or insurance data.…”

“…Knowledge of reasons for dislocation of the hip HA would help surgeons choose, or opt out, on the implant when the patient is deemed too high-risk for dislocation, or we might be able to warn the patients' of the possible risks and push them to be more careful. Thus, there are several studies suggesting some risk factors for dislocation of the hip HA, such as surgical approach (1,5,6), cognitive impairment (2,(5)(6)(7)(8), prosthesis type(4) and uncemented vs cemented implant (3). However, such studies often contradict each other, and there is a lack of conclusive evidence and the hierarchy of the proposed risk factors are unknown.…”

Cognitive assessment to optimize prediction of functional outcome in subacute hip fracture: a short-term prospective study

“…Recent prospective studies have emphasized the long known unfavorable prognostic role exerted by cognitive impairment after hip fracture in older people. Impaired cognition has been significantly associated with high mortality rates, 1 , 2 increased risk of recurrent fractures and prosthetic hip dislocations, 3 , 4 blunted ability to function in activities of daily living, 5 , 6 impaired mobility, 7 low likelihood of discharge home and reduced number of days alive and at home, a combined patient-centered outcome measure. 8 , 9 The recent results are in agreement with a lot of previous original studies and various systematic reviews: on the whole, the wider literature has consistently reported poor outcomes in cognitively impaired subjects with a fragility fracture of the hip.…”