Hip fractures are among the most serious fragility fractures affecting older adults and represent a major cause of hospitalization, disability, loss of independence, and mortality worldwide. The global burden is expected to rise substantially with population ageing, making effective surgical treatment and prevention of postoperative morbidity increasingly important. ¹ Intracapsular fractures of the femoral neck constitute an important proportion of hip fractures in elderly patients. Age-related osteoporosis, deterioration of bone microarchitecture, reduced muscle strength, impaired balance, and increased susceptibility to falls collectively contribute to their occurrence, frequently following relatively trivial trauma. ² The burden is particularly relevant in Asian countries, including India, because of rapid demographic transition and increasing longevity. Indian prospective data have demonstrated that fragility hip fractures represent an important geriatric orthopaedic problem, while limitations in registries and standardized care pathways make their true national burden difficult to quantify. ²

George et al., in an Indian prospective study, emphasized that hip fractures are associated with considerable morbidity and mortality and estimated an annual incidence exceeding 120 per 100,000 persons aged over 50 years in India, with higher rates among women.³ The combination of a large ageing population, osteoporosis, nutritional deficiencies, comorbid illnesses, and variable access to timely surgical care makes geriatric hip-fracture management particularly challenging in the Indian setting.³ Displaced intracapsular femoral neck fractures are biologically problematic because disruption of the femoral head blood supply predisposes to non-union and avascular necrosis. Consequently, primary arthroplasty is commonly preferred over internal fixation in elderly patients with displaced fractures, particularly when early mobilization and avoidance of fixation failure are priorities. ⁴ Hemiarthroplasty replaces the femoral head and neck while retaining the native acetabulum and remains an established surgical treatment for displaced femoral neck fractures in elderly patients. Bipolar hemiarthroplasty incorporates an additional inner articulation within the prosthetic head, theoretically permitting movement at both the prosthesis and acetabular interfaces and potentially reducing acetabular wear. ⁴

Large pooled evidence comparing bipolar and unipolar hemiarthroplasty has evaluated more than 30,000 patients and demonstrated that both remain clinically established options for displaced femoral neck fractures, while differences in specific outcomes such as acetabular erosion may favour bipolar designs in some settings.⁴ The advantages of hemiarthroplasty in elderly patients include immediate structural stability, early weight bearing, relatively rapid mobilization, and avoidance of complications associated with fracture non-union and osteonecrosis. However, successful implantation does not eliminate the possibility of perioperative and postoperative complications. Important early complications following bipolar hemiarthroplasty include surgical-site infection, dislocation, periprosthetic fracture, nerve injury, thromboembolic events, wound complications, and cardiopulmonary complications. Cemented procedures may additionally be associated with bone cement implantation syndrome, characterized by varying degrees of hypoxia, hypotension, cardiac arrhythmia, cardiovascular collapse, or rarely death around the time of cementation. ⁵

The choice between cemented and cementless fixation has therefore remained clinically relevant. While cemented stems may provide reliable immediate fixation in osteoporotic bone, cementless stems avoid cement-related physiological complications. Indian experience with cementless bipolar hemiarthroplasty has demonstrated satisfactory clinical and radiological performance in elderly patients with femoral neck fractures.⁵ Marya et al., in an Indian series of elderly patients treated with cementless bipolar hemiarthroplasty, demonstrated that the procedure could provide satisfactory mobility and implant stability, supporting its usefulness in the management of geriatric femoral neck fractures.⁵ Such findings are particularly relevant to Indian practice, where osteoporosis and multiple medical comorbidities may influence both implant selection and postoperative recovery.

Apart from clinical complications, radiological evaluation constitutes an essential component of follow-up after hemiarthroplasty. Postoperative radiographs permit assessment of femoral stem alignment, implant position, subsidence, periprosthetic fracture, loosening, acetabular changes, and other mechanical abnormalities that may influence long-term prosthesis survival. The position of the femoral component in the frontal plane is particularly relevant because varus or excessive valgus positioning may alter load transmission across the proximal femur and potentially affect implant biomechanics. Consequently, systematic radiographic evaluation can identify technically important abnormalities even before they produce clinically evident symptoms.

Recent Indian evidence has further investigated the relationship between radiological parameters and recovery following hemiarthroplasty, emphasizing that postoperative radiographs provide useful information regarding implant positioning and structural outcomes in addition to routine clinical assessment. ⁶ Long-term studies have demonstrated the durability of bipolar hemiarthroplasty when satisfactory implant fixation is achieved. Von Roth et al. reported that cemented bipolar hemiarthroplasty provided durable treatment extending beyond 20 years in elderly patients with femoral neck fractures, with a cumulative 20-year revision incidence of only 3.5%. ⁷ Therefore, evaluation of hemiarthroplasty should extend beyond functional scores alone and include systematic documentation of early postoperative complications and radiological outcomes. Such evaluation can identify preventable adverse events, assess the quality of implant positioning, and provide information relevant to surgical technique and postoperative surveillance.

AIM

To evaluate the early postoperative complications and radiological outcomes following bipolar hemiarthroplasty for intracapsular fracture neck of femur in elderly patients.

OBJECTIVES

Primary Objective

1. To determine the incidence and pattern of early postoperative complications following bipolar hemiarthroplasty in elderly patients with intracapsular fracture neck of femur.

Secondary Objective

2. To assess the radiological outcome and femoral component position at 6 months following bipolar hemiarthroplasty.

Study Design The study was conducted as a prospective observational study. Study Setting The study was conducted in the Department of Orthopaedics, Mahadevappa Rampure Medical College, Basaveshwar Teaching and General Hospital, Kalaburagi, Karnataka. Study Period The study was conducted from March 2021 to August 2022. Study Population The study population consisted of elderly patients aged more than 60 years, irrespective of sex, who were diagnosed with intracapsular fracture neck of femur and underwent hemiarthroplasty using a bipolar endoprosthesis. Sample Size A total of 40 patients were included in the study. The sample size was estimated based on hospital records, which showed an annual incidence of approximately 30 cases of fracture neck of femur. For the 18-month study period, approximately 45 cases were expected. After accounting for an anticipated 15% reduction/error corresponding to approximately five cases, the final sample size was determined as: 45 − 5 = 40 patients Thus, the final sample size was n = 40. Sampling Method Eligible patients presenting during the defined study period who fulfilled the study criteria and underwent bipolar hemiarthroplasty were included in the study. Inclusion Criteria 1. Were aged more than 60 years. 2. Had an intracapsular fracture neck of femur. 3. Underwent hemiarthroplasty using a bipolar endoprosthesis. 4. Had been ambulatory prior to sustaining the fracture. 5. Were available for postoperative follow-up. Exclusion Criteria 1. Had been non-ambulatory prior to the fracture. 2. Had dementia. 3. Had fracture neck of femur associated with other fractures. 4. Had a pathological fracture. Preoperative Assessment Following admission, a detailed history was obtained with particular emphasis on the mode of injury and associated medical illnesses. A thorough clinical examination was performed. Anteroposterior radiographs of the affected hip and pelvis with both hips were obtained. Routine preoperative investigations included blood investigations, blood grouping and typing, urine examination, random blood sugar, serum urea and creatinine, HBsAg, HIV testing, chest radiography and electrocardiography. Associated medical conditions such as anaemia, diabetes mellitus, hypertension, ischemic heart disease, chronic obstructive pulmonary disease and asthma were evaluated and treated appropriately before surgery. Surgical Procedure All patients underwent bipolar hemiarthroplasty under spinal or epidural anaesthesia using standard aseptic precautions. Patients were positioned laterally on the unaffected side, and the posterior/Moore's (Southern) approach was used in all cases. Postoperative Assessment Patients were monitored during their hospital stay for the occurrence of postoperative complications. Clinical findings and complications were documented in the study proforma. The complications subsequently periprosthetic fracture, postoperative sciatic nerve neuropraxia, posterior dislocation of the prosthesis, bone cement implantation syndrome and superficial infection. No deep-seated infection was observed. Follow-up Patients were followed at 6 weeks, 3 months and 6 months following surgery. At each follow-up, clinical examination was performed systematically and a radiograph of the operated hip was obtained for radiological assessment. All 40 patients were included in the six-month analysis. Radiological Assessment Postoperative radiographs of the operated hip were evaluated during follow-up. At six months, the position of the femoral component in the frontal plane was assessed on anteroposterior radiographs. The femoral component position was classified as: • Central • Valgus • Varus Outcome Measures The primary outcome was the occurrence and pattern of early postoperative complications following bipolar hemiarthroplasty. The secondary outcome was the radiological position of the femoral component—central, valgus or varus—at the end of the six-month follow-up. Ethical Considerations Ethical clearance was obtained from the institutional ethics committee before commencement of the study. Written informed consent for surgery was obtained from the patients after explaining the procedure and associated risks. Statistical Analysis Data were summarized using descriptive statistics. Continuous variables were expressed as mean and standard deviation where appropriate, while categorical variables such as postoperative complications and radiological outcomes were expressed as frequencies and percentages. For the research article, categorical associations could be evaluated using the Chi-square test or Fisher's exact test, where the patient-level data supported such comparisons. A p-value <0.05 would be considered statistically significant.

The odds ratios ranged from 3.3 for myalgia to 4.7 for stiffness, indicating a strong association between LP and musculoskeletal involvement.

A total of 40 elderly patients with intracapsular fracture neck of femur who underwent bipolar hemiarthroplasty were evaluated for postoperative complications and radiological outcomes. The results below are restricted to the second article's objectives.

Table 1. Associated Medical Comorbidities Among the Study Participants (n=40)

Interpretation: Fourteen patients (35%) had at least one associated medical disorder, while 65% had no documented comorbidity. Diabetes mellitus was the most frequently recorded condition (30%), followed by hypertension (15%) and ischemic heart disease (2.5%).

Table 2. Duration of Hospital Stay Following Bipolar Hemiarthroplasty (n=40)

Mean ± SD: 9.00 ± 3.79 days
Observed range: 6–22 days

Interpretation: Three-fourths (75%) of patients were discharged within 10 days. Only 10% required hospitalization for more than 15 days. The overall mean hospital stay was 9.00 ± 3.79 days, indicating that most patients had a relatively short postoperative hospital course.

Table 3. Incidence and Pattern of Postoperative Complications (n=40)

Interpretation: Postoperative complications occurred in 7 of 40 patients (17.5%), whereas 82.5% remained free of the recorded complications. Periprosthetic fracture and superficial infection were the most frequent complications, each occurring in 5%. Posterior dislocation, sciatic nerve neuropraxia/foot drop, and BCIS each occurred in one patient (2.5%).

Table 4. Clinical Course and Management of Major Postoperative Complications

Interpretation: Although 17.5% of patients experienced a recorded complication, most individual adverse events were uncommon. The sciatic neuropraxia improved within three months, the dislocation was successfully reduced, and the patient with BCIS recovered following appropriate management. Of the two periprosthetic fractures, one required surgical fixation, while the other was managed conservatively because the patient was medically unfit for surgery.

Table 5. Radiological Position of the Femoral Component at 6 Months (n=40)

p≈0.015.

Interpretation: Valgus positioning was the most frequent radiological finding, observed in 52.5% of patients, followed by central positioning in 32.5% and varus positioning in 15%. The distribution differed significantly from an equal distribution across the three radiological categories (p≈0.015).

Overall interpretation

The study demonstrated an overall recorded complication rate of 17.5%, with 82.5% of patients having none of the reported complications. Periprosthetic fracture and superficial infection were the most frequent individual adverse events, while deep infection was absent. Most patients had a hospital stay of less than 10 days. At six months, valgus stem positioning predominated radiologically (52.5%), followed by central (32.5%) and varus (15%) positioning.

The present prospective observational study evaluated early postoperative complications and six-month radiological outcomes following bipolar hemiarthroplasty in 40 elderly patients with intracapsular fracture neck of femur. Overall, 17.5% of patients developed at least one recorded postoperative complication, whereas 82.5% had an uncomplicated course. The observed complications included periprosthetic fracture in 5%, superficial infection in 5%, posterior dislocation in 2.5%, sciatic nerve neuropraxia/foot drop in 2.5%, and bone cement implantation syndrome in 2.5%, with no cases of deep infection. The overall complication profile was broadly comparable with published literature, although rates vary considerably according to age, comorbidity burden, surgical approach, fixation method, and duration of follow-up. Gerber et al., in a large series of 1,001 elderly patients, reported revision in 3.9% following hemiarthroplasty; indications included dislocation in 1.5%, suspected prosthetic joint infection in 1.7%, periprosthetic fracture in 0.5%, and acetabular erosion in 0.3%.⁸ The somewhat higher overall complication rate in the present study may partly reflect the small sample size and inclusion of complications that did not necessarily require revision surgery. Medical comorbidities were present in 35% of our patients, with diabetes mellitus in 30%, hypertension in 15%, and ischemic heart disease in 2.5%. Jameson et al., analysing more than 77,000 hemiarthroplasties, demonstrated that elderly patients were particularly vulnerable to early medical complications, and patients aged ≥85 years had significantly increased risks of lower respiratory tract infection (OR 1.58), myocardial infarction (OR 1.67), and acute renal failure (OR 1.54) compared with those aged 65–84 years.⁹ This emphasizes the importance of preoperative optimization of comorbid illnesses in elderly hip-fracture patients. The mean duration of hospitalization in our study was 9.00 ± 3.79 days, with 75% of patients staying for less than 10 days and only 10% requiring hospitalization beyond 15 days. Shah et al., in an analysis of 173,508 elderly patients undergoing hemiarthroplasty, showed that prolonged hospital stay and postoperative morbidity were influenced not only by patient characteristics but also by surgeon and hospital case volume.¹⁰ Their findings emphasize that hospital stay after hip-fracture surgery represents a composite indicator influenced by perioperative complications, medical optimization, mobilization, and institutional care pathways. Periprosthetic fracture occurred in 2 patients (5%) in the present study. One patient required reoperation with a long proximal femoral plate, whereas another with lateral cortical breach was treated conservatively because of medical unfitness for further surgery. Yoon et al., in a large series of 1,563 elderly patients undergoing cementless bipolar hemiarthroplasty, reported 37 periprosthetic femoral fractures (2.4%), with 67% occurring during the first postoperative year. Their estimated cumulative incidence was 1.7% at 12 months and 2.2% at 36 months.¹¹ The 5% rate in our study is higher, but interpretation should account for the substantially smaller denominator of only 40 patients. Posterior prosthetic dislocation was observed in one patient (2.5%) and was successfully reduced under general anaesthesia. Kim et al. evaluated 498 bipolar hemiarthroplasties performed through a posterolateral approach and found a dislocation rate of 3.8%, with a mean time to dislocation of 2.2 months. They additionally demonstrated that a smaller acetabular center-edge angle and the method of short external rotator repair significantly influenced dislocation risk.¹² Thus, the 2.5% dislocation rate observed in the present study lies within the range reported in comparable elderly populations. Similarly, Sierra et al., in a series of 1,812 primary bipolar hemiarthroplasties, reported cumulative dislocation probabilities of 1.1% at one year and 1.5% at five years, with more than half of dislocations occurring within the first six postoperative months.¹³ Their observations reinforce the importance of close surveillance during the early postoperative period, particularly in patients treated through posterior approaches. Superficial surgical-site infection occurred in 2 patients (5%), while no deep-seated infection occurred in the present study. Zajonz et al. studied 312 hemiarthroplasties and reported an early periprosthetic joint infection rate of 5.1%. Patients developing infection had a median hospital stay of 20 days compared with 10 days among those without infection, and infection was associated with substantially higher in-hospital mortality.¹⁴ The superficial infection rate in our study was therefore numerically similar to their overall early infection rate, although our patients did not develop deep PJI. More recently, Sumi et al. analysed 1,438 elderly patients following hemiarthroplasty and documented periprosthetic joint infection in only 1.4%. Diabetes mellitus and peripheral vascular disease were more prevalent among infected patients, and postoperative hematoma and blood transfusion were also more frequent in the PJI group.¹⁵ These findings are pertinent to our cohort because diabetes mellitus was the most common documented comorbidity, affecting 30% of participants. One patient (2.5%) in our study developed bone cement implantation syndrome and manifested tachycardia, tachypnoea, disorientation, hypoxaemia and hypotension; the patient received medical/ICU management and recovered. Olsen et al. evaluated 1,016 patients undergoing cemented hemiarthroplasty and reported BCIS grade 1, 2 and 3 in 21%, 5.1% and 1.7%, respectively. Severe BCIS was associated with markedly increased mortality, and ASA grade III–IV, COPD, diuretic therapy and warfarin use were identified as independent predictors.¹⁶ This highlights the importance of vigilant anaesthetic monitoring around cementation, particularly in medically fragile elderly patients. Radiological assessment at six months demonstrated valgus positioning in 52.5%, central positioning in 32.5%, and varus positioning in 15% of the operated hips. Radiographic stem position is clinically important because malalignment and inadequate canal fill may alter load transfer and contribute to migration or subsidence. Lo et al. demonstrated that initial femoral stem positioning in cementless bipolar hemiarthroplasty was significantly related to subsequent early implant subsidence, with older age, reduced canal fill, and reduced medial stem overhang identified as important radiographic factors.¹⁷ These findings support routine postoperative radiographic evaluation rather than relying exclusively on clinical recovery. The predominance of valgus positioning in the present study should therefore be interpreted as a technical radiographic finding rather than automatically as a favourable or adverse outcome. Nevertheless, postoperative radiographic surveillance remains essential for detecting changes in stem alignment, migration, fracture, or other implant-related abnormalities during follow-up. Bűcs et al. further demonstrated the impact of surgical technique on early postoperative recovery after bipolar hemiarthroplasty. Patients treated through a direct anterior approach met discharge criteria 1.68 days earlier than those undergoing an anterolateral approach, while accurate restoration of leg length was achieved in 54.9% versus 21%, respectively.¹⁸ These observations illustrate that surgical approach and technical precision can influence both immediate recovery and postoperative anatomical outcomes. Overall, the present study demonstrated an acceptable early safety profile following bipolar hemiarthroplasty, with 82.5% of patients remaining free from recorded complications and no deep infection. Periprosthetic fracture and superficial infection were the most frequent complications, each occurring in 5%, whereas dislocation, sciatic neuropraxia and BCIS were uncommon. Radiologically, valgus stem positioning predominated at six months. Although the relatively small sample size limits definitive assessment of risk factors, the findings are broadly consistent with national and international literature and emphasize meticulous surgical technique, optimization of comorbid illnesses, infection prevention, early recognition of complications, and systematic radiographic follow-up in elderly patients undergoing bipolar hemiarthroplasty.

Bipolar hemiarthroplasty demonstrated an acceptable early postoperative safety profile and satisfactory radiological outcomes in elderly patients with intracapsular fracture neck of femur. In the present study, 82.5% of patients had no recorded postoperative complication, while the overall complication rate was 17.5%. Periprosthetic fracture and superficial infection were the most frequent complications, each occurring in 5% of patients, whereas posterior dislocation, sciatic nerve neuropraxia/foot drop, and bone cement implantation syndrome each occurred in 2.5%. Importantly, no deep-seated infection was observed.  Most complications were successfully managed, although one periprosthetic fracture required reoperation. The mean hospital stay was 9.00 ± 3.79 days, and 75% of patients stayed for less than 10 days. At six months, radiological evaluation demonstrated valgus positioning of the femoral component in 52.5%, central positioning in 32.5%, and varus positioning in 15% of patients.  These findings suggest that bipolar hemiarthroplasty provided satisfactory early structural outcomes with a manageable spectrum of postoperative complications in this elderly population. Careful preoperative optimization, meticulous surgical technique, infection-prevention measures, early recognition of complications, and regular clinical and radiological follow-up remain essential for achieving favourable outcomes.

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