Management of Simultaneous Bilateral Neck of Femur Fractures in an Elderly Patient

Abstract

Simultaneous bilateral neck of femur fracture is rare. There have been few reports of such a condition in the literature. This uncommon pattern of injury has been associated with high-energy trauma, underlying bone disease, and seizure disorders. We describe our experience of such a condition involving an elderly patient with significant cardiovascular comorbidity. The operative approach involved single-stage repair of both the involved joints. Bilateral uncemented hemi-arthroplasty was performed using a single tray of sterile surgical instruments and 2 sterile drapes. We report a satisfactory outcome. Uncemented arthroplasty should be considered in such a case so as to minimize the risk of a possible bone cement implantation syndrome.

Introduction

Simultaneous bilateral neck of femur fracture is a rarely reported injury. There exists a relative paucity of reports in the literature describing this pattern of injury. We describe our experience of a case that was recently encountered at our institution.

Case Report

An 87-year-old gentleman was admitted through the emergency department, having presented with simultaneous bilateral neck of femur fractures. His past medical history was notable for ischemic heart disease, recent non-ST elevation myocardial infarction (NSTEMI) 10 months previously, hypertension, glaucoma, and benign prostatic hypertrophy. He had no known prior history of seizure activity.

On presentation, the patient was disorientated to place and time. A collateral history revealed the patient had experienced a 5-minute episode of making incomprehensible noise and nonverbal response. The patient subsequently reported bilateral hip pain and was unable to bear weight or mobilize on either hip. His baseline premorbid mobility was independent with the assistance of 1 walking stick. Clinical examination revealed bilateral externally rotated legs. A plain film pelvis confirmed the diagnosis of bilateral intracapsular neck of femur fractures (see Figure 1). It was thought that the mechanism of injury was a first presentation of a tonic–clonic seizure in this gentleman resulting in bony injury.

Figure 1.

Plain film radiograph anteroposterior pelvis demonstrating bilateral intracapsular femoral neck fractures.

Following appropriate resuscitation, the patient was brought to the operating theater for surgical management. Given the patient’s significant cardiovascular comorbidity, a single-stage repair under general anesthesia was undertaken. Bilateral uncemented hemi-arthroplasty (Accolade System, Stryker) was performed through bilateral anterolateral approaches. A single tray of sterile surgical instruments and 2 sets of sterile drapes were used, with the patient positioned in the lateral decubitus position for each hip, respectively. The right hip was repaired initially, before the patient was repositioned for repair of the contralateral side. Postoperatively, he recovered in a higher dependency unit with one-to-one nursing care, before transfering back to the orthopedic ward. On the first postoperative day, he was able to mobilize bearing full weight. Postoperative plain film imaging demonstrated a satisfactory result (see Figure 2).

Figure 2.

Plain film radiograph anteroposterior pelvis taken postoperatively following bilateral uncemented hemiarthroplasty.

Following investigation by the local neurology team, a diagnosis of tonic–clonic seizure was made. Given the severity of injury associated with this first presentation of seizure, the patient was commenced on levetiracetam prior to discharge. He made a good recovery, and having completed appropriate physiotherapy and rehabilitation, he was discharged home.

Discussion

Simultaneous, bilateral neck of femur fractures may be considered rare, and there have been few cases reported in the literature. Before the 1960s, such injuries were seen in association with powerful muscular contractions induced by electroconvulsive therapies.¹ Since then, this pattern of injury has been reported to be the result of high-energy trauma,² high-voltage electrical injury,³ abnormal anatomy,⁴ chronic renal failure,⁵ and associated with primary and secondary bone disease such as osteomalacia.⁶ In the elderly population, simple trip and fall can lead to bilateral hip injury.⁷

Simultaneous bilateral hip fracture secondary to seizure activity has been described.^8-10 It is thought that uncontrolled strong muscular contractions in the proximal thigh, which generate forces toward the groin, may result in hip injury.¹¹ Our case is somewhat unusual in that the injury sustained actually preceded the diagnosis of a seizure disorder, unlike previously reported cases. Moreover, unlike in our case, earlier reported cases describe injury to younger individuals. Grisoni and colleagues report a mean age of 63 years (range, 34-88).¹² In their series of 8 patients, 2 patients sustained injuries following a motorcycle accident, while 4 more were involved in motor vehicle accidents. One further patient fell down a flight of stairs, while another had a fall from standing height.

A number of operative techniques for the management of bilateral neck of femur fractures have been described in the literature. These include closed reduction and percutaneous pinning¹³ and total hip arthroplasty.¹⁰ Sood and colleagues describe single-stage repair of bilateral hip fractures with the patient in the supine position.⁷ In their report, the injury was repaired using cemented hemi-arthroplasty via an anterolateral approach to hip. We also opted for a single-stage repair. However, given the patient’s preexisting significant cardiovascular comorbidity, we preferred an uncemented hemi-arthroplasty. It was felt the patient had sufficient bone stock to achieve adequate fixation. The avoidance of bone cement would also minimize the potential for the so-called “cement-reaction” or bone cement implantation syndrome (BCIS). This poorly understood reaction, which is typically seen in pressurized cemented arthroplasty, can lead to hypoxia, hypotension, cardiac arrhythmia, and cardiac arrest.¹⁴ Given this elderly patient’s history of recent non-ST-segment elevation myocardial infarction, minimizing the risk of potential bone cement implantation syndrome was deemed prudent. “Cement-reaction” can probably be avoided by unpressurized cement injection and optimizing patient physiology at time of cementation. Nevertheless, we felt that bilaterally cementing the femoral canals, whether pressurized or not, would probably increase the risk in this patient. As such, alternative surgical strategies should be considered.

Patients presenting with joint pain, and in particular hip pain, with a known history of seizure activity, or postconvulsive episode, should undergo a careful and methodical musculoskeletal evaluation to rule out possible fracture. Pain in any joint should prompt routine radiological investigation.

Simultaneous bilateral neck of femur fracture is uncommonly encountered in clinical practice. Single-stage, uncemented hemi-arthroplasty using one tray of sterile surgical instruments and 2 sterile drapes is an acceptable approach in this situation. Where possible, uncemented instrumentation should be considered to minimize the possible risk of “cement reaction” in the patient with significant cardiovascular comorbidity.