European Journal of Cardiovascular Medicine

Femoral neck fractures represent one of the most debilitating orthopaedic injuries in the elderly population, with significant implications for mobility, independence, and survival. These fractures predominantly occur due to low-energy trauma in osteoporotic individuals, and their management remains a subject of ongoing debate among orthopaedic surgeons [1]. While internal fixation may be considered for non-displaced or valgus-impacted fractures, arthroplasty, either hemiarthroplasty or total hip replacement (THR), is the preferred treatment for displaced fractures in elderly patients, offering immediate stability and faster functional recovery. Among these options, THR has gained increasing acceptance for active elderly patients due to its superior long-term outcomes, lower revision rates, and better preservation of acetabular cartilage [2]. However, the choice between cemented, uncemented, and hybrid THR techniques remains controversial, particularly concerning intraoperative blood loss, a critical yet understudied factor influencing postoperative recovery and complications. Intraoperative blood loss in THR is a major determinant of patient outcomes, affecting hemodynamic stability, transfusion requirements, and the risk of postoperative anaemia, which can delay rehabilitation and increase morbidity. The extent of blood loss varies significantly depending on the fixation method employed. Cemented THR, which utilizes polymethylmethacrylate (PMMA) for prosthetic fixation, provides excellent implant stability, particularly in osteoporotic bone, by distributing load more evenly and reducing micromotion [3]. However, this technique is associated with greater intraoperative blood loss due to the pressurized cementation process, which can disrupt intramedullary vessels and increase bleeding. Additionally, cemented THR carries the risk of bone cement implantation syndrome (BCIS), a potentially fatal complication characterized by hypoxia, hypotension, and cardiovascular collapse, further complicating perioperative management. In contrast, uncemented THR relies on press-fit fixation, promoting biological osseointegration over time. This approach avoids cement-related complications and may reduce operative time and blood loss, as it eliminates the need for cement pressurization. However, uncemented stems require precise bone preparation and carry a higher risk of intraoperative fractures, particularly in patients with poor bone quality [4]. Additionally, the absence of cement may lead to increased early micromotion, contributing to postoperative thigh pain and a higher likelihood of subsidence in osteoporotic patients. Hybrid THR, combining a cemented femoral stem with an uncemented acetabular component, offers a potential compromise, theoretically balancing the stability of cemented fixation with the biological advantages of uncemented components. While this approach has been studied in terms of implant survivorship and functional outcomes, its impact on intraoperative blood loss remains poorly understood. Some studies suggest that hybrid fixation may reduce blood loss compared to fully cemented THR, but comparative data are limited, particularly in the context of femoral neck fractures [5]. Current guidelines, including those from the National Institute for Health and Care Excellence (NICE), recommend cemented THR for most elderly patients due to its proven durability and lower revision rates [6]. However, surgeons often face dilemmas in high-risk patients with cardiovascular comorbidities, where minimizing blood loss and avoiding BCIS take precedence. Given these uncertainties, a comprehensive comparison of intraoperative blood loss among cemented, uncemented, and hybrid THR techniques is essential to guide evidence-based decision-making. This study aims to provide a detailed comparative analysis of intraoperative blood loss in cemented, uncemented, and hybrid THR for femoral neck fractures.

This study was carried out on patients who had undergone surgery for total hip replacement for neck of femur fractures at the Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India. This study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Institutional Ethics Committee.

Inclusion Criteria:

• Patients aged between 60-85 years
• American Society of Anaesthesiologists (ASA) physical status I or II
• Body weight between 40-70 kg
• Height between 150-185 cm
• Hemoglobin level >10 g/dL preoperatively
• Normal prothrombin time (PT) and activated partial thromboplastin time (aPTT)
• Diagnosed with femoral neck fracture requiring primary total hip replacement
• Scheduled for elective hip surgery under subarachnoid block
• Willing and able to provide informed consent

Exclusion Criteria:

• ASA status III or higher
• Age <60 years or >85 years
• Body weight <40 kg or >70 kg
• Height <150 cm or >185 cm
• Preoperative hemoglobin <10 g/dL
• Abnormal coagulation profile (PT or aPTT)
• History of thromboembolic disorders
• Pre-existing hepatic or renal dysfunction
• Significant cardiac or respiratory disease
• Current use of thrombolytic agents or anticoagulants
• Emergency surgery cases
• Patients requiring general anesthesia
• Known allergy to local anaesthetics
• Active infection at the surgical site
• Previous ipsilateral hip surgery
• Cognitive impairment affecting consent or compliance

Sample Size Calculation:

The sample size for the present study was determined using a power analysis conducted through G*Power software, version 3.0.1 (Franz Faul, Universität Kiel, Germany). The calculation was performed with a significance level (alpha) of 5% (α = 0.05) and a study power of 80% (1 – β = 0.80). An effect size of 0.60 was selected based on findings from a previous study by Annapareddy A. et al., which investigated intraoperative blood loss across different types of hip arthroplasty techniques [7]. The analysis revealed that a minimum of 66 participants would be required to detect a statistically significant difference among three independent groups using one-way ANOVA.

To account for possible data loss or dropouts and to ensure adequate power, the total sample size was increased to 90 patients. These participants were evenly distributed into three groups:

• Group A (Cemented THR): 30 patients received both cemented acetabular and femoral components.
• Group B (Hybrid THR): 30 patients received an uncemented acetabular component and a cemented femoral component.
• Group C (Uncemented THR): 30 patients received both uncemented acetabular and femoral components.

This prospective comparative study evaluated intraoperative blood loss in patients undergoing cemented, uncemented, and hybrid total hip replacement for femoral neck fractures. All surgical procedures were performed under standardized conditions using subarachnoid block anesthesia.

Preoperative Preparation:

All participants underwent a comprehensive pre-anesthetic evaluation, including detailed medical history and physical examination. Standard preoperative laboratory tests assessed hemoglobin, hematocrit, and coagulation parameters (prothrombin time and activated partial thromboplastin time). Patients received premedication with 0.25 mg alprazolam and 20 mg omeprazole orally and maintained an 8-hour fasting period preoperatively.

Anaesthetic Protocol:

Upon arrival in the operating theater, patients received intravenous access with a large-bore cannula and Ringer's lactate infusion at 10 ml/kg. Standard monitoring included non-invasive blood pressure, pulse oximetry, and electrocardiography. Baseline hemodynamic parameters (heart rate, systolic/diastolic blood pressure, respiratory rate, and oxygen saturation) were recorded. Spinal anesthesia was administered using 3 ml of 0.5% hyperbaric bupivacaine. Hemodynamic parameters were monitored every 5 minutes for the first 30 minutes, then every 10 minutes until surgery completion.

Surgical Technique and Blood Loss Measurement: Three surgical approaches were compared: cemented, uncemented, and hybrid total hip arthroplasty. Intraoperative blood loss was quantified using two methods:

1. Gravimetric method: Pre-sterilization dry weights of all surgical gauzes and mops were recorded. Blood loss was calculated by subtracting dry weights from post-use wet weights (1g weight increase = 1 mL blood loss).
2. Suction method: Total suction output minus irrigation fluid volume provides an additional blood loss measurement.

Intraoperative Management:

For blood loss exceeding 40% of the estimated circulating volume, intraoperative transfusion was initiated. Crystalloid replacement followed a 3:1 ratio (lactated Ringer's solution to blood loss).

Postoperative Monitoring:

All patients received surgical site vacuum drainage for 24 hours. Drain output was measured hourly for the first 6 hours, then every 4 hours until 24 hours postoperatively. Total blood loss combined from intraoperative and 24-hour postoperative measurements. Hemoglobin and hematocrit were rechecked at 24 hours postoperatively, with transfusion triggered by >25% decrease from baseline.

Pain Management:

Postoperative analgesia consisted of intravenous tramadol 100mg on patient request, administered as a slow infusion to minimize hemodynamic fluctuations that could affect blood loss measurements. This was done to prevent any increase in heart rate and blood pressure caused by discomfort, since such increases could have negatively affected postoperative blood loss.

Data Collection:

Parameters recorded included:

• Intraoperative blood loss (gravimetric and suction methods)
• Postoperative drain output
• Transfusion requirements (units and number of patients)
• Hemodynamic parameters
• Laboratory values (pre- and post-operative hemoglobin/hematocrit)

Statistical Analysis: The collected data were organized in Microsoft Excel 2019 and analyzed using GraphPad version 8.4.3. Descriptive statistics were used to calculate frequencies and percentages. The Chi-square test was applied for comparison of categorical variables, while one-way ANOVA was used to compare continuous variables among the three groups. A p-value of less than 0.05 was considered statistically significant.

The baseline demographic and clinical characteristics of the study population are summarized in Table 1. The study included 90 patients, [Group A: 30, Group B: 30 and Group C: 30] with a mean age of participants in Group A was 73.35 years, Group B had a mean age of 71.49 years, and Group C had a mean age of 72.05 years with no statistically significant difference between the groups (p = 0.554). Gender distribution was also comparable among the three groups (p = 0.558). Regarding the side of involvement, 13 participants in Group A had right-sided conditions compared to 11 in Group B and 14 in Group C, whereas left-sided involvement was seen in 17, 19, and 16 participants, respectively, with no significant difference (p = 0.727). Additionally, the mean BMIs were similar among the three groups, with 26.21 kg/m² in Group A, 25.91 kg/m² in Group B, and 26.23 kg/m² in Group C, showing no significant difference (p = 0.904). Overall, these findings indicate that the three groups were well matched in terms of demographic and clinical baseline characteristics.

Table 1: Showing the comparison of baseline demographic and clinical characteristics of the study population

Table 2 and Figure 1 present the comparison of perioperative blood loss among the three groups, cemented (Group A), hybrid (Group B), and uncemented (Group C) total hip replacements, revealing no statistically significant difference. Group A (cemented) demonstrated a mean blood loss of 1106.16 ± 113.82 mL, with values ranging from 871.32 to 1298.67 mL. Group B (hybrid) exhibited a slightly higher mean blood loss of 1116.69 ± 173.65 mL, with a wider range from 815.46 to 1792 mL. Group C (uncemented) showed a mean blood loss of 1087.34 ± 264.56 mL, with a minimum and maximum value of 726.33 and 1987 mL, respectively. Despite the observed differences in means and variability, statistical analysis using one-way ANOVA yielded a P value of 0.839, indicating that the variation in blood loss among the three groups was not statistically significant.

Table 2: Showing the comparison of perioperative blood loss in the three groups of the study population

[* Statistically Not Significant]

Figure 1: Illustration of the comparison of perioperative blood loss in the three groups of the study population by the Box and Whisker plot

The global burden of hip fractures is expected to rise dramatically, with projections estimating an incidence of approximately 2.5 million cases by the year 2050 [8]. In response to this growing trend, and in line with the recommendations of the National Institute for Health and Care Excellence (NICE), there has been an increased preference for total hip replacement (THR) in appropriately selected patients presenting with fractures of the neck of the femur (NOF). According to the most recent data from the UK National Joint Registry, hybrid fixation has emerged as the most commonly utilized method in THR for NOF fractures, closely followed by cemented fixation. In contrast, uncemented fixation is the least frequently used, representing only about one in every seven THR procedures for these fractures [9].

Hemorrhage remains one of the primary causes of intraoperative mortality worldwide [10]. The volume of blood lost during surgery is a major determinant of patient outcomes, as it can significantly affect intraoperative stability, postoperative recovery, surgical duration, hospital stay, the likelihood of reoperation, and, crucially, the need for blood transfusions. In this context, the present study aimed to evaluate and compare perioperative blood loss across different fixation methods in THR.

Substantial intraoperative blood loss, especially when not adequately anticipated or managed, can result in hypotension and reduced oxygen delivery, potentially leading to myocardial infarction or permanent neurological damage. This is particularly critical in elderly patients with pre-existing comorbidities, who are more vulnerable to complications arising from major blood loss during THR [11]. Therefore, evaluating and understanding the implications of different fixation techniques on blood loss is of paramount importance.

The ongoing debate surrounding the optimal fixation method, cemented vs. uncemented vs. hybrid, for THR in NOF fractures continues, largely due to conflicting evidence. Some studies, including a comprehensive analysis of annual data from five major international arthroplasty registries with long-term follow-ups, have reported no significant clinical difference in outcomes between cemented and uncemented approaches [12]. Similarly, economic evaluations have shown no marked cost advantage between the two techniques in patients aged 70 years and older undergoing THR for NOF fractures [13].

Moreover, blood transfusions themselves are not without risk. They may lead to serious complications such as transfusion-related acute lung injury (TRALI), immunosuppression, and transmission of infections. Notably, transfusions have been linked to increased short- and long-term morbidity and mortality [10]. Additionally, patients who require allogeneic blood transfusions during primary THR tend to experience prolonged hospital stays, which consequently elevate the overall cost of care [14].

This study contributes to the existing literature by specifically comparing the volume of intraoperative blood loss in patients with NOF fractures undergoing THR with cemented, uncemented, and hybrid fixation. While previous studies focusing on patients with osteoarthritis have found no significant differences in blood loss between cemented and uncemented THRs, our findings extend this observation to patients with NOF. The results demonstrate no statistically significant variation in blood loss among the three fixation methods, suggesting that the type of implant fixation may not be a decisive factor in intraoperative bleeding risk for this patient population. These findings carry important clinical implications. Surgeons can base their choice of fixation technique on individualized patient factors such as bone quality, age, comorbidities, and anticipated prosthesis longevity, rather than concerns over intraoperative blood loss. We hope that these results will encourage further randomized controlled trials to better define the role of fixation type in blood loss and its broader implications on outcomes in THR for neck of femur fractures.

The findings of our study are in alignment with those of Haque et al. [15], who also reported no statistically significant difference in intraoperative blood loss between cemented, uncemented, and hybrid total hip replacement (THR) techniques for neck of femur (NOF) fractures. In their retrospective analysis of 62 patients, the mean perioperative blood loss was 1.1086 L in the cemented group, 1.0711 L in the hybrid group, and 0.9012 L in the uncemented group. Despite numerical variations, the differences did not reach statistical significance (p > 0.05), leading the authors to conclude that the mode of fixation should not be influenced solely by concerns over blood loss. Our study supports this conclusion, showing mean intraoperative blood losses of 1106.16 ± 113.82 mL (cemented), 1116.69 ± 173.65 mL (hybrid), and 1087.34 ± 264.56 mL (uncemented), with no statistically significant difference (p = 0.839).

In contrast, the study by Chaudhari et al. (2021) presented a different scenario, where mean intraoperative blood loss during various hip surgeries was reported as 489.75 ± 123.63 mL, with additional mean postoperative blood loss of 205.43 ± 63.31 mL, totalling approximately 695.2 ± 162.44 mL. This lower intraoperative blood loss may be attributed to differences in surgical types (which included dynamic hip screw fixation and bipolar hemiarthroplasty, in addition to THR), patient selection, or perioperative management practices. While Chaudhari et al. emphasize that intraoperative blood loss alone may not be an adequate predictor of total perioperative bleeding, our study adds that, within the specific context of THR for NOF, the choice of fixation method does not substantially affect intraoperative blood loss. This consistency across multiple studies strengthens the case for individualized implant selection based on factors such as bone quality, surgeon preference, and long-term implant performance, rather than concerns over bleeding alone.

Limitations of the study: This study is limited by its small sample size and single-center design, which may affect the generalizability of the results. Additionally, factors like hidden blood loss, surgeon variability, and perioperative management were not controlled, potentially influencing the outcomes.

This study found no significant difference in blood loss between cemented, uncemented, and hybrid total hip replacements for neck of femur fractures. Therefore, blood loss should not be a primary factor in choosing the fixation method. The choice should be based on individual patient factors such as bone quality, age, implant longevity, and risk of cement-related or periprosthetic complications.

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