Cementless bipolar hemiarthroplasty in femoral neck fractures in elderly

Sir,

We read the article “Cementless bipolar hemiarthroplasty in femoral neck fractures in elderly” by Marya et al.¹ with interest. We congratulate the authors for their excellent work. We have the following concerns.

In the selection criteria for their study, the authors have mentioned that patients above the age of 70 years and with multiple co-morbidities were considered for the study. It is quite surprising that all consecutive patients fell into American Society of Anesthesiologists (ASA) grade 3 or 4 and none were in ASA grade 1 or 2. The authors also failed to describe when the co-morbidities were considered “multiple”? For example, a patient in their series did not have hypertension, diabetes mellitus, or coronary artery disease, but was having benign prostatic hyperplasia, anemia and bronchitis. Will such a patient qualify to be labeled as having “multiple co-morbidities”?

The classical teaching was to use uncemented stems in Dorr type A and B femoral canals and cemented stems in Dorr type C (broader proximal femoral medullary canal). It is also our experience that uncemented stems work well in patients with narrow proximal femoral canal and with good bone stock. We are concerned about the usage of uncemented stems in osteoporotic femora with wide proximal femoral canal with regards to the following: (a) inadequate fit in the proximal femoral canal; (b) chances of intraoperative femoral cortical perforation or fracture due to poor bone quality; (c) postoperative subsidence of the femoral stem; (d) delay in full weight bearing, for which the compliance is an issue in elderly patients.

The reader was left uninformed whether all the consecutive patients with fracture neck of femur, above the age of 70 years, were chosen for bipolar prosthesis, irrespective of the activity level of the patients. We are of the opinion that the physiological age is more important and there is literature to support that elderly active patients with fracture neck of femur could be treated with a total hip arthroplasty.²

Further, we do not agree with the authors when they generalize that a bone mineral density test was not performed as the patients were above 70 years of age. Age and co-morbidities are important factors in elderly patients, but do not allow the generalization that all patients above 70 years of age are osteoporotic, multiply co-morbid, and fragile. It is not uncommon in our practice to see elderly active patients above 70 years of age with good bone stock and this subset of the patients should be offered a total hip arthroplasty.