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Postoperative Stroke After Hemiarthroplasty for Femoral Neck Fracture: A Report of 2 Cases and Review of Literature

Ding, David Yi MD*; Christoforou, Dimitrios MD*; Turner, Garth MD; Tejwani, Nirmal C. MD*

doi: 10.1097/PTS.0000000000000063
Case Report

Introduction: Femoral neck fractures in the elderly comprise a significant number of orthopedic surgical cases at a major trauma center. These patients are immediately incapacitated, and surgical fixation can help increase mobility, restore independence, and reduce morbidity and mortality. However, operative treatment carries its own inherent risks including infections, deep vein thromboses, and intraoperative cardiovascular collapse. Cerebrovascular stroke is a relatively uncommon occurrence after hip fractures.

Methods: We present 2 cases with unusual postoperative medical complication after cemented hip hemiarthroplasty for femoral neck fracture that will serve to illustrate an infrequent but very serious complication.

Results: Case 1 was a 73-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, he developed neurological deficits, and a postoperative noncontrast head computed tomography showed a right medial thalamic infarct. Case 2 was an 82-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, the patient became hemodynamically unstable. A postoperative noncontrast head computed tomography showed a large evolving left middle cerebral artery stroke.

Conclusions: General anesthesia in the setting of decreased cardiac function (decreased ejection fraction and output) carries the risk for ischemic injury to the brain from decreased cerebral perfusion. Risk factors including advanced age, history of coronary artery disease, atherosclerotic disease, and atrial fibrillation increase the risk for perioperative stroke. Furthermore, it is known that during the cementing of implants, microemboli can be released, which must be considered in patients with preoperative heart disease. As a result, consideration of using a noncemented implant or cementing without pressurizing in this clinical scenario should be an important aspect of the preoperative plan in an at-risk patient. Further studies are needed that can elucidate a causal relationship.

From the *Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York; and †Department of Neurology, NYU School of Medicine, New York, New York.

Correspondence: Nirmal C Tejwani, MD, Department of Orthopaedics, NYU Hospital for Joint DiseasesDepartment of Orthopaedic Surgery301 East 17th Street, New York, NY 10003 (e-mail: Nirmal.Tejwani@nyumc.org).

The authors disclose no conflict of interest.

Investigation conducted at Bellevue Hospital Center, New York University Hospital for Joint Diseases, New York, NY.

© 2014 by Lippincott Williams & Wilkins