Primary arthroplasty as an option for surgical treatment of unstable intertrochanteric fracture femur in elderly patients: a retrospective study
Keywords:Hemiarthroplasty, Unstable intertrochanteric fractures, Osteoporotic fractures
Background: An unstable intertrochanteric fracture in osteoporotic elderly patients presents a very challenging problem to the surgeons. This category of patients if kept in bed for long tends to have many complications like deep vein thrombosis, pneumonia, bed sores, etc. Surgeon’s worldwide face difficulty in getting a good anatomical reduction and do not allow early mobility to these patients because of risk of loss of reduction and implant cut out. The purpose of our study is to study the usefulness of arthroplasty in these patients in terms of better functional outcomes and no increase in complication rates.
Methods: It was a retrospective study involving 25 patients (17 females, 8 males) with mean age of 76±2.3 years having intertrochanteric femur fractures (AO type A 2.2 and above) with osteoporosis operated upon with bipolar hemiarthroplasty at IQ City Medical College and NM Hospital between January 2015 and January 2017.
Results: All the patients were followed up for a period of 1 year. We had a mean operative time of 75 min (range 55-125 min) with an average blood loss of 450 ml. 4 of our patients required postoperative blood transfusion. All patients walked on 2nd postoperative day. We had a mean Harris hip score of 82 and mean VAS of 1 at the end of 1 year.
Conclusions: Hemiarthroplasty done in cases of unstable intertrochanteric femur fractures in elderly patients with osteoporotic bones allows early weight bearing thus improves the final functional outcomes. Further randomized trials are required before deriving any conclusions.
Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis Int. 2006;17(12):1726–33.
Dhanwal DK, Dennison EM, Cooper C. Epidemiology of hip fracture: Worldwide geographic variations. Indian J Orthop. 2011;45(1):15-22.
Rockwood PR, Horne JG, Cryer C. Hip fractures: A future epidemic? J Orthop Trauma. 1990;4:388–93.
Hedlund R, Lindgren U. Trauma type, age, and gender as determinants of hip fracture. J Orthop Res. 1987;5:242–6.
Bergström U, Björnstig U, Stenlund H, Jonsson H, Svensson O. Fracture mechanisms and fracture pattern in men and women aged 50 years and older: A study of a 12-year population-based injury register. Osteoporosis Int. 2008;19:1267–73.
Sernbo I, Fredin H. Changing methods of hip fracture osteosynthesis in Sweden: An epidemiological enquiry covering 46,900 cases. Acta Orthop Scand. 1993;64:173–4.
Larsson S, Friberg S, Hansson LI. Trochanteric fractures: Mobility, complications, and mortality in 607 cases treated with the sliding-screw plate. Clin Orthop Relat Res. 1990;260:232–41.
Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma. 1996;10(1):31–5.
Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Am. 1949;31:190–203.
Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21:S1–133.
Dhiraj V Sonawane. Classifications of Intertrochanteric fractures and their Clinical Importance. Trauma Int. 2015;1(1):7-11.
Wolfgang GL, Bryant MH, O’neill JP. Treatment of Intertrochanteric Fracture of the Femur Using Sliding Screw Plate Fixation. Clin Orthop. 1982;163:148–58.
Ganz R, Thomas RJ, Hammerle CP. Trochanteric Fractures of the Femur. Treatment and Results. Clin Orthop. 1979;138:30–40.
Harper MC, Thomas W. Ender Nailing for Peritrochanteric Fractures of the Femur-An Analysis of Indications, Factors Related to Mechanical Failure, and Postoperative Results. J Bone Joint Surg. 1985;67:79–88.
Jensen JS. Trochanteric Fractures:An Epidemiological, Clinical and Biomechanical Study. Acta Orthop Scand. 1981;(188):11–9.
Kulkarni GS, Limaye R, Kulkarni M, Kulkarni S. Intertrochanteric fractures. Indian J Orthop. 2006;40(1):16-23
Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am. 1979;61:216–21.
Sexson SB, Lehner JT. Fractures Affecting Hip Fracture Mortality. J Orthop Trauma. 1987;1:298–305.
Dahl E. Mortality and life expectancy after hip fractures. Acta Orthop Scand. 1980;51(1):163–70.
Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: Is delay before surgery important? J Bone Joint Surg Am. 2005;87:483–9.
Tronzo RG. The use of an endoprosthesis for severely comminuted trochanteric fractures. Orthop Clin North Am. 1974;5:679–81.
Pho RW, Nather A, Tong GO, Korku CT. Endoprosthetic replacement of unstable, comminuted intertrochanteric fracture of the femur in the elderly, osteoporotic patient. J Trauma. 1981;21:792–7.
Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am. 1970;52:457-67.
Claes H, Broos P, Stappaerts K. Pertrochanteric Fractures in Elderly Patients: Treatment with Ender's Nails, Blade-Plate, or Endoprosthesis? Injury. 1985;16:261–4.
Bonamo JJ, Accettola AB. Treatment of Intertrochanteric Fractures with a Sliding Nail-Plate. J Trauma. 1982;22:205–15.
White BL, Fisher WD, Laurin CA. Rate of mortality for elderly patients after fracture of the hip in the 1980’s. J Bone Joint Surg Am. 1987;69:1335–40.
Harwin SF, Stern RE, Kulick RG. Primary Bateman-Leinbach bipolar prosthetic replacement of the hip in the treatment of unstable intertrochanteric fractures in the elderly. Orthopedics. 1990;13:1131–6.
Chan KC, Gill GS. Cemented hemiarthroplasties for elderly patients with intertrochanteric fractures. Clin Orthop Relat Res. 2000;371:206–15.
Rosenfeld RT, Schwartz DR, Alter AH. Prosthetic replacements for trochantric fractures of the femur. J Bone Joint Surg Am. 1973;55:420.
Stern MB, Goldstein TB. The use of the Leinbach prosthesis in intertrochantric fractures of the hip. Clin Orthop Relat Res. 1977;128:325–31.
Liang YT, Tang PF, Guo YZ, Tao S, Zhang Q, Liang XD, et al. Clinical research of hemiprosthesis arthroplasty for the treatment of unstable intertrochanteric fractures in elderly patients. Zhonghua Yi Xue Za Zhi. 2005;85:3260–2.
Grimsrud C, Monzon RJ, Richman J, Ries MD. Cemented hip arthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures. J Arthroplast. 2005;20:337–43.
Rodop O, Kiral A, Kaplan H, Akmaz I. Primary bipolar hemiprosthesis for unstable intertrochanteric fractures. Int Orthop. 2002;26:233–7.
Haentjens P, Casteleyn PP, De Boeck H, Handelberg F, Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. Primary bipolar arthroplasty compared with internal fixation. J Bone Joint Surg Am. 1989;71:1214–25.
Kayali C, Agus H, Ozluk S, Sanli C. Treatment for unstable intertrochanteric fractures in elderly patients: Internal fixation versus cone hemiarthroplasty. J Orthop Surg (Hong Kong). 2006;14:240–4.
Broos PL, Rommens PM, Deleyn PR, Geens VR, Stappaerts KH. Pertrochanteric fractures in the elderly: Are there indications for primary prosthetic replacement? J Orthop Trauma. 1991;5:446–51.
Kesmezacar H1, Ayhan E, Unlu MC, Seker A, Karaca S. Predictors of mortality in elderly patients with an intertrochanteric or a femoral neck fracture. J Trauma. 2010 Jan;68(1):153-8.
Hardy DC, Descamps PY, Krallis P, Fabeck L, Smets P, Bertens CL, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures: A prospective, randomized study of one hundred patients. J Bone Joint Surg Am. 1998;80:618–30.
Kim SY, Kim YG, Hwang JK. Cementless calcar-replacement hemiarthroplasty compared with intramedullary fixation of unstable intertrochanteric fractures: A prospective, randomized study. J Bone Joint Surg Am. 2005;87:2186–92.
Yoo JI, Ha YC, Lim JY, Kang H, Yoon BH, Kim H. Early Rehabilitation in Elderly after Arthroplasty versus Internal Fixation for Unstable Intertrochanteric Fractures of Femur: Systematic Review and Meta-Analysis. J Korean Med Sci. 2017;32(5):858-67.