Femoral neck fractures are one of the most common fractures in elderly patients and account for approximately 50% of total hip fractures.⁽¹⁾With life expectancy increasing with each decade, our society is becoming increasingly an active geriatric society.⁽²⁾Due to an aging population, the annual incidence of osteoporosis is on the rise and these are often complicated by concomitant hip fractures.^(3-5) Arthroplasty has become a standard treatment over internal fixation for displaced femoral neck fractures in elderly patients, which can achieve good results such as improved hip function, relief of hip pain, early ambulation, functional recovery after surgery, return to independent living and without the risk of potential complications.^{(2-6) The} advantages of bipolar hemiarthroplasty are less operative time, minimal bleeding and the lesser price to the patient when compared to total arthroplasty of the hip. This is suitable for elderly patients who generally are in poor condition and unable to tolerate major surgery. ⁽⁷⁾ Traditionally, cemented prostheses were mainly for elderly patients with poor bone quality. ^{(8, 9)}

Delay in the presentation of fractured neck of femur in the elderly is not uncommon in India, especially after osteopathic treatment.⁽¹⁰⁾ Though much is discussed about the management of delays in young individuals, very few studies are available on the management of neglected fractured neck of the femur in the elderly.Neglected neck fracture cases are generally associated with complications related to fractures like bed sores, DVT, soft tissue contractures, etc., and is a challenge to manage such fractures.⁽²⁾

This study aims to evaluate the outcome of neglected fracture neck of the femur in elderly patients managed with cemented bipolar hemiarthroplasty.

It is both retrospective and prospective study of 18 cases for 6 years (from Jan 2016 - Dec 2022) at M.V.J. Medical College, Bangalore. This study was conducted on Neglected Fracture neck of femur cases in the elderly with the following inclusion and exclusion criteria

Inclusion criteria: Age >60 yrs, >3 weeks after injury, previously independently ambulatory, Associated comorbidities and complications (DVT, Bed sores, Shortening)

Exclusion criteria: Previous arthritic hip, Pathological fracture other than osteoporosis, Patient requiring uncemented bipolar prosthesis, Old age dementia, and neurological deficit.

Protocol: Comorbidities and complications of fracture like bed sores, DVT, and Medical conditionswere managed appropriately. Patients were put on skin traction until comorbidities were addressed, but no patients were put on skeletal traction. After evaluation, all patients underwent cemented bipolar hemiarthroplasty by posterior approach and the majority of patients required adequate soft tissue release. All patients were mobilized at 1 week post op with walker support. All cases were followed up at 3 weeks, 6 weeks, 3 months, and 6 months and results were evaluated. Their return to pre-injury activity level and complications were assessed for a minimum of 6 months follow up and patient satisfaction was noticed.

It is both retrospective and prospective study of 18 cases for 6 years (from Jan 2016 - Dec 2022) at M.V.J. Medical College, Bangalore. This study was conducted on Neglected Fracture neck of femur cases in the elderly with the following inclusion and exclusion criteria

Inclusion criteria: Age >60 yrs, >3 weeks after injury, previously independently ambulatory, Associated comorbidities and complications (DVT, Bed sores, Shortening)

Exclusion criteria: Previous arthritic hip, Pathological fracture other than osteoporosis, Patient requiring uncemented bipolar prosthesis, Old age dementia, and neurological deficit.

Protocol: Comorbidities and complications of fracture like bed sores, DVT, and Medical conditionswere managed appropriately. Patients were put on skin traction until comorbidities were addressed, but no patients were put on skeletal traction. After evaluation, all patients underwent cemented bipolar hemiarthroplasty by posterior approach and the majority of patients required adequate soft tissue release. All patients were mobilized at 1 week post op with walker support. All cases were followed up at 3 weeks, 6 weeks, 3 months, and 6 months and results were evaluated. Their return to pre-injury activity level and complications were assessed for a minimum of 6 months follow up and patient satisfaction was noticed.

We collected 6 years of data retrospectively and prospectively from patients whose age is above 60 years with femoral neck fractures in our hospital. Eighteen cases were included in the study as per the including and excluding criteria. Information about age, sex, side, time of presentation, type of fracture, union, complications, intraoperative and postoperative complications, implant failure, reduction difficulty, functional status at 6 months noted, and the results analyzed. Observations were tabulated below. (Table 1-5). Avg age 74.33 yrs(min- 64yrs, max- 93yrs). Avg duration of delay 18.66 weeks (min-3week, max – 59 weeks).

Table 1 : Age distribution

Table 2: Sex distribution

Based on the duration between injury to femur neck and surgical fixation, cases were divided into four groups for convenience and further studies 1) 3 weeks to 3 months, 2) 3 months to 6 months, 3) 6 months to one year, and 4) above one year. (Fig. 1 – 6)

Table 3: Duration since injury to surgery

Fig 1: 72 years old female presenting after 5 months

Fig 2: Post operative Bipolar Hemiarthroplasty

Fig 3: 74 years old female patient presenting after 6 month

Fig 4: Post operative Bipolar Hemiarthroplasty

Fig 5: 70 years old female presenting after 3 week

Fig 6: Post operative Bipolar Hemiarthroplasty

Complications pre-op: Two patients had DVT before surgery, One patient was put on an IVC filter and another patient was put on anticoagulants for 3 weeks after that cardiologist's opinion was taken was operated on low molecular Heparin. Three patients had bed sores appropriately treated, and 10 patients had co-morbidities.

Complications post-op: There were no cases of sciatic nerve palsy, infection, dislocation and no case of post-operative DVT. Two patients had limb length discrepancy, one patient had chronic hip pain and altered gait

Table 4: Pre-op and post-operative complications

OUTCOME: 83% had excellent results and 15 of them returned to almost pre-injury level activities, 1 patient had chronic hip pain and altered gait, and 2 patients had limb length discrepancy.

Table 5: Functional outcome

Due to increased life expectancy and the resultant large elderly population, the incidence of femoral neck fractures (FNFs) is on the rise ⁽¹⁾ as elderly patients are prone to FNFs after fallingsuch fractures heal slowly due to unique anatomy ⁽⁴⁾ .The goal of treatment in neglected fracture NOF is to achieve a painless, mobile and stable hip.⁽¹¹⁾Bipolar hemiarthroplasty remains the main current surgical method for the treatment of FNFs in the elderly.Traditionally, cemented prostheses were mainly for elderly patients with poor bone quality.⁽¹²⁾In elderly patients with FNFs who underwent bipolar hemiarthroplasty achieved a good clinical outcome, with a high rate of return to the pre-injury state.⁽¹³⁾In India patients consulting osteopathic treatment is one of the reason to get delayed presentation to the hospital which leads to morbidity or complications. Whether we have to operate to reduce the further morbidity or mortality.

In our study, we included 18 patients as per the criteria, among which nine patients presented before three months, five patients between 3 months to 6 months, two patients between 6 months to one year, and two patients presented after one year of injury.

Preoperatively two cases were DVT diagnosed by using a Doppler study and treated accordingly by a cardiologist, three cases developed bed sores before presenting to my institute which was managed adequately.

All our elderly patients tolerated the procedure well without any major intra-op or post-op complications, or cerebrovascular or cardiovascular accidents. These were the main concerns for patients undergoing cemented hemiarthroplasty. Insertion of the prosthesis stem into the medullary cavity using the cemented technique, raised the intramedullary pressure, which accentuated fat embolization.^{(14, 15)} Movrin I⁽¹⁶⁾ showed that patients undergoing cemented than uncemented hemiarthroplasty were more likely to have a sudden drop in systolic blood pressureduring the prosthesis stem insertion. Another study reported one patient died of myocardial infarction within 24 hrs of severe hypotension during the cementing procedure.⁽¹⁷⁾ Meta-analysis study showed good postoperative results after cemented hemiarthroplasty procedure and did not increase the risk of mortality, or complications.⁽¹⁸⁾

Postoperatively our patients don’t have any dislocation in contrast to the literature shows that the rate of dislocation in unipolar hemiarthroplasty can be up to 10%⁽¹⁹⁾. The risk of postoperative hip dislocation is lower in the case of bipolar hemiarthroplasty, theoretically under its self-centering mechanism.⁽¹⁹⁾

Thigh pain often occurs earlyon after hip arthroplasty ⁽²⁰⁾, which may be related to the fretting of the prosthesis in the early stage and the proportion of the prosthesis in the medullary cavity after implantation ⁽²¹⁾. In our patients, we didn’t get any thigh pain postoperatively, limb length discrepancy had no problem as we used monoblock bipolar which has fixed neck length, modular bipolar will decrease this problem.

In our study the detailed study was not done considering the length of the neck with respect to the complications and outcome where as A K Jain et al studied the outcome of neglected femoral neck fracture depends on the duration of neglect, as the changes occurring in the fracture area and fracture fragments decides the quality of biological materials required for fracture union.⁽¹⁰⁾

In our study the excellent results in 83%, Compared to Sakib et al., study where cemented Bipolar hemiarthroplasty was found to be safe and gave satisfactory results in 80%.⁽²²⁾

Limitation: A subjective assessment was done to know the return of activities to a pre-injury level no objective assessment was done like the Harris hip score.

Cemented bipolar hemiarthroplasty in neglected fracture neck of the femur gives good results with early mobilization and returns to pre-injury activity level but it is a challenge to a surgeon because of surgical procedure. Even if it is delayed or neglected neck of femur fracture, still it is better to operate and get to near normal pre-injury activity level.

Financial support and sponsorship: Nil

Conflicts of interest: There are no conflicts of interest

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