Total Hip Replacement for Osteoporotic Patients: A Stepwise Approach?

Hip joint replacement in patients with osteoporosis?

Father (70 y/o, severe osteoporosis): After a femoral neck fracture, he has undergone two surgeries: the first was an open reduction, but the fixation implant protruded, causing a defect in the lateral acetabulum; the second was a hemiarthroplasty with lateral acetabular bone screws for augmentation, but three months later (now), the augmented bone has failed, leading to dislocation, necessitating a third surgery for total hip arthroplasty.
I would like to inquire whether, for patients with osteoporosis, total hip arthroplasty is typically not considered immediately after the first fracture? Is it necessary to go through multiple surgeries in a staged approach—reduction → hemiarthroplasty → total hip arthroplasty? Is the so-called "leaving a backup option" truly better for the patient compared to performing a total hip arthroplasty in one go? For patients with osteoporosis, would the use of bone cement in the acetabular component provide greater stability?

Jen, 30~39 year old female. Ask Date: 2019/05/23

Dr. Li Yongheng reply Orthopedics

Hello, generally speaking, for a femoral neck fracture without displacement, the National Health Insurance regulations in Taiwan only cover open reduction and internal fixation with bone screws.
As long as the position of the screws is appropriate, the patient uses a walker, and the affected limb is non-weight bearing, the success rate can reach 90%.
If the femoral neck fracture is accompanied by displacement, the National Health Insurance regulations only allow for hemiarthroplasty with bone screws.
If the first surgery (with bone screws) fails and there is no acetabular defect, then hemiarthroplasty is more appropriate.
If the first surgery (with bone screws) fails and there is an acetabular defect, then total hip arthroplasty is more appropriate.
For patients with osteoporosis, total hip arthroplasty is currently not recommended to use bone cement for the acetabular component, as the success rate does not improve.

Reply Date: 2019/05/23

More Info

Total hip replacement (THR) for osteoporotic patients is a complex decision-making process that often requires a stepwise approach, especially in cases like your father's, who has experienced multiple surgeries due to complications from a femoral neck fracture. Osteoporosis significantly affects bone quality and density, which can complicate surgical interventions and outcomes.

In general, when a patient with osteoporosis suffers a femoral neck fracture, the initial treatment often depends on the fracture's characteristics. If the fracture is non-displaced, conservative management with internal fixation (such as screws) is typically the first line of treatment. However, if the fracture is displaced or if there are concerns about the stability of the fixation due to poor bone quality, a partial hip replacement (hemiarthroplasty) may be considered.
In your father's case, the decision to proceed with a hemiarthroplasty after the initial fixation failure was likely made to provide immediate stability and pain relief. However, the subsequent complications, including the dislodgment of the bone graft and dislocation, indicate that the underlying osteoporosis may have compromised the surgical outcomes.
The question of whether to proceed directly to a total hip replacement (THR) after the first fracture rather than taking a stepwise approach is nuanced. In many cases, surgeons prefer to adopt a staged approach to allow for healing and to assess the patient's overall condition and bone quality before committing to a more extensive procedure like THR. This strategy can also provide the opportunity to manage complications as they arise, rather than risking a more complex surgery without adequate preparation.

Regarding the use of bone cement in osteoporotic patients, it is a common practice to enhance the stability of the implant. Bone cement can provide immediate fixation and can help distribute the load across the bone-implant interface, which is particularly beneficial in patients with poor bone quality. However, the use of cement is not without its risks, including potential complications such as cement leakage or the development of a cement-related syndrome. The decision to use cement should be made on a case-by-case basis, considering the patient's overall health, the quality of the bone, and the specific surgical technique being employed.

In conclusion, while a stepwise approach may seem less aggressive, it often allows for better management of complications and assessment of the patient's condition. In cases of severe osteoporosis, the use of bone cement can enhance the stability of the implant, making it a valuable option in total hip replacement surgeries. It is crucial for the surgical team to evaluate the individual circumstances of each patient, including their bone quality, overall health, and the specifics of their fracture, to determine the most appropriate surgical strategy. Regular follow-up and rehabilitation are also essential to optimize recovery and functional outcomes post-surgery.

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