The pertrochanteric femur fracture in the elderly - An indication for a hemiarthroplasty?

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The aim of the present study was to answer the question whether or not a hemiarthroplasty has a place in the treatment of pertrochanteric femur fractures for elderly patients. At the Kantonsspital Baden 80 hemiarthroplasties were implanted in 76 patients for pertrochanteric femur fractures from 1988 to 1993. The average age of the patients was 82 years (SD 7.5 years). The operating time, the blood loss and the cement reactions were obtained retrospectively from charts. The long term result was assessed with the clinical score of Merle d'Aubigne and Postel. At the time of follow-up 46 patients (60%) were deceased. The mean survival time of these patients was 58 weeks, ranging from 0 to 326 weeks. The review of the records showed a significantly poorer general health preoperatively (mean ASA score 2.7) compared to the survivors (mean ASA score 2.2). There was, however, no increased complication rate, blood loss or cement reaction found. The remaining 30 patients were available for clinical examination (n = 25) or could be interviewed by telephone (n = 5) after an average follow-up of 165 weeks, ranging from 1 to 6 years. The score of Merle d'Aubigne and Postel showed a nearly painfree hip joint (mean score 5) with a good mobility (mean score 5). The walking ability was reduced due to the advanced age (mean score 3). A painful hip was found in 6 patients (20%). At the time of review no hemiarthroplasty had to be converted into a total hip replacement. It is concluded that the hemiarthroplasty guarantees a primary stability without an increased operative risk and a low complication rate. We regard the hemiarthroplasty as a good alternative to DHS and Gamma-nail for the treatment of pertrochanteric fractures for elderly patients.

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Die dynamische Hüftschraube (DHS) der AO ist ein bewährtes Osteosynthesemittel bei stabilen Frakturen. Die Versorgung instabiler Frakturen bereitet hingegen Probleme, da es aufgrund des Schraubengleitprinzips zu einer erheblichen lateralen Dislokation der Fragmente kommen kann. Steht alternativ kein anderes Operationsverfahren zur Verfügung, kann die Belastungsstabilität der DHS durch eine lateral aufgesetzte T-Platte verbessert werden. In vier Fällen konnte primäre Belastungstabilität erreicht werden. The dynamic hip screw (DHS) is a widely used method of osteosynthesis. Nevertheless, supplying instable pertrochanteric fractures is problematic because the gliding screw may cause a considerable dislocation of fragments in lateral direction. Is there any alternative method disposable, bearing stability of DHS-osteosynthesis can be improved by adding a lateral T-plate. We reached full bearing stability in four cases.
1376 cases of trochanteric fractures, which were treated according to the techniques recommended by the Swiss Study Group are examined for early results and complications. Four hundred twenty-one cases of this series were at our disposal for a long-term follow-up study. In cases in which anatomically correct reconstruction was being attempted, the 130° plate was mainly used for the fixation of simple fractures while the condylar plate was used with increasing frequency for more complex fractures. With a 75 year average age in this series the death rate during the hospital stay was 10.5%. On discharge only 2.5% of the cases were unsatisfactory. In 118 patients (8.6%) 132 reoperations were necessary, mostly due to instability and fatigue fracture of the implant. Nearly always there was inadequate assessment of the fracture or a technical error. The position of the tip of the blade in the trabecular crossing point in all 3 methods, reconstruction of the medial cortex and especially impaction in valgus position were the essential preconditions to avoid failure. In the long-term control 90% of the patients were able to fully bear weight, 63% using a walking aid; 87% of the patients had none or only occasional pain. There were no significant differences in the final results in the patients aged over 80 years and in those aged under 80 years. As might be expected, the results differed according to the type of fracture. Thus following simple fractures, the rate of deformity and that of complications, many of them requiring operation, were respectively one third and one half of those following more complex fractures. The use of cane for walking correlated to a certain degree with the presence of severe deformity but was mainly determined by the age of the patient and by the presence of arthrotic joint changes.
During a ten year period (1978-1988) 565 patients, aged 70 years and over, suffering a fresh pertrochanteric fracture have been treated in the Department of Traumatology at the University Hospitals of Leuven, Belgium. According to the system of Evans and Jensen, 388 fractures were classified as unstable. Special attention was given to the 324 cases of type I C and I D fractures. The method of treating greatly changed during the period of study. All patients were followed up prospectively during one year. Our study showed that for these unstable fractures, fixation with an angled plate or Ender nails should be forsaken. The overall results of the dynamic hip screw treatment were good (reoperation rate 2%, good functional results in 64%), but as this treatment has a risk for serious collapse and pain in about 80% of all type I D fractures, one could suggest to treat these complex multifragment fractures primarily with an endoprosthesis. This treatment needs no longer to be considered as a severe intervention, as the danger of mechanical complications being very minimal (less than 1%).
Altogether we used the Gamma-Nail in 150 cases. We show here a series of 50 instable pertrochanteric femur fractures in very old patients which we treated with a Gamma-Nail. All cases started with full weight bearing at the 4th day after operation. A clinical and radiological control 12 weeks later shows good mobilisation of the hip in 70% of the cases. Shortening of the operated leg is rare in comparison of cases treated with a DHS. Two thirds of the patients returned after dismission of the hospital to the old social situation. The advantages in treating instable pertrochanteric femur fractures with the Gamma-Nail are immediate full weight bearing without risks of shortening of the operated leg and the closed reduction of the fracture.
The authors compare the results obtained in a group of 100 patients submitted to pertrochanteric osteosynthesis during the year 1991 (50 with a gamma nail and 50 with a compression-sliding plate) based on parameters of anesthesiology. The same type of anesthesiology was used in all 100 of the patients, as similar were the general clinical conditions of the patients, ASA classification, and the mean value of preoperative hemoglobin. The gamma nail proved to be preferable in terms of a shorter amount of time required for surgery, a minor loss of blood intra and postoperatively, and minor incidence of complications.