Background: Intertrochanteric femoral fractures are one of the most common types of bone fractures that are usually caused by severe direct or indirect force. It has also been estimated that nearly 50% of all the fractures are intertrochanteric fractures and the remaining are unstable fractures. Also, it has been found that the mortality related to hip fractures is as high as 15-20%. With an increase in the life expectancy of people, there has been a substantial increase in the number of patients with postmenopausal or senile osteoporosis. Aim: To compare Proximal femoral nail anti-rotation with cementless bipolar hemiarthroplasty for unstable femoral intertrochanteric fracture Methods: It was a retrospective study carried out at the Government Medical College, Baramati for a period of 1 year. One hundred patients were included for the scope of the study. Out of which 50 patients belonged to the PFNA group, and 50 patients belonged to the CPH group. Results: The number of patients in the PFNA group was 50 and that in the CPH group was 50. Both groups show male preponderance. The mean age among both the groups was almost the same, and there was no statistically significant difference among the two groups regarding the mean age. The mean operation time for PFNA was 54.15±16.1 mins, and that of the CPH group was 76.69±15.89 mins. The mean bleeding time for PFNA was 133.12±33.16 ml, and that of the CPH group was 289.25±44.01 ml. There was no statistically significant difference among the ASAA grade scores of the two groups. There was no statistically significant difference among the Evans-Jensen classification of the two groups. The mean length of hospital stay for PFNA group was 7.89±2.0 days, and the mean hospital stay for CPH group was 6.54±1.9 days. Conclusion: The current study depicted that CPH and PFNA are both safe and effective methods of treating elderly patients suffering from intertrochanteric fractures. However, it was found in the current study that CPH was found to have more mean operative time and increased blood loss. Still, the recovery and hospitalization time was almost similar in both the groups. Both the groups had almost similar ASA and Evans Jensen scores that made both the techniques equally safe.
Primary hemiarthroplasty was recommended by some surgeons as the preferred choice in treating unstable senile intertrochanteric fractures with osteoporosis. However, many studies reported that proximal femoral nail antirotation (PFNA) currently was as an optimal implant for the treatment of different type of intertrochanteric fractures. Which method is better for treating senile intertrochanteric fractures remains controversial due to the insufficient clinical evidences.
We reviewed all consecutive senile intertrochanteric fractures treated with PFNA or cemented hemiarthroplasty at our institution between July 2010 and March 2015. The primary outcome measures were postoperative complications, reoperation rate and hip function. The secondary outcome measures were intraoperative blood loss, transfusion rate, surgical time, postoperative hemoglobin, hospital stay and 1- year mortality.
Seventy-one patients in PFNA group and 52 patients in hemiarthroplasty group were included for analysis. There were no significant differences between the two groups regarding to the orthopaedic complications, reoperation rate, surgical time and Harris Hip Score at 1year follow-up. Significant differences were found between PFNA and hemiarthroplasty group in comparison of intraoperative blood loss (P<0.001), transfusion rate, medical complications (P=0.037) and hospital stay (P=0.001). Patients treated with hemiarthroplasty had a trend of higher postoperative 1- year mortality compared to those underwent PFNA but this was statistically not significant (P=0.134).
These findings indicate that PFNA has obvious advantages over hemiarthroplasty in the treatment of senile intertrochanteric fractures. Hemiarthroplasty in treating these fractures is associated with greater surgical trauma and higher incidence of postoperative medical complications.
p class="abstract"> Background: Ideal management of intertrochanteric fractures in elderly individuals has been debated for several years. Due to difficulty in obtaining anatomical reduction, management of the complex intertrochanteric fractures in elderly patients is challenging and controversial .
Methods: In the present study prospective comparative evaluation has been done between dynamic hip screws ( DHS), proximal femoral nail (PFN) and bipolar hemiarthroplasty for overall clinical outcome of patients with unstable intertrochanteric fractures. The total numbers of patients were 90 with each group consisted of 30 patients.
Results: Complication rate and requirement of revision surgery was more in DHS group but this was not found to be statistically significant. Harris Hip Score & hence the functional outcome was found to be more in PFN group as compared to DHS which was statistically significant. Bipolar hemiarthroplasty provides early full wieght bearing leading to better HHS at 6 weeks evaluation but almost similar score to PFN in long term .
Conclusions: PFN is better choice of fixation if good bone quality present while extremely osteoporotic patients or extreme comminution at fracture site favours bipolar hemiarthroplasty in elderly patients . </p
Cephalomedullary (CM) nailing is widely used for the treatment of pertrochanteric hip fractures. Fixation failures with CM nailing tend to occur in unstable fracture patterns often necessitating revision surgery. The purpose of this study was to compare the complications and clinical outcomes of primary arthroplasty to CM nailing for the treatment of unstable pertrochanteric hip fractures.
We conducted an age-, sex-, and fracture type-matched case-controlled study and identified 29 patients who underwent hip arthroplasty for an unstable pertrochanteric fracture (AO/OTA classification type 31A2.2/3 and 31.A3) at our institution. Their outcome was compared to a matched control group of 29 patients treated with a CM nail.
There was one major complication in the arthroplasty group (3.4 %), whereas there were six major complications in the nailing group (20.7 %) (P = 0.04). We found no significant difference between the groups with regards to blood loss, operative time, hospitalization time and the number of patients discharged to rehabilitation. Clinical outcome measured with Oxford hip score and SF-12 at the time of final follow-up was not significantly different between the groups.
Arthroplasty is a viable option for treatment of unstable pertrochanteric fractures in an elderly population. Arthroplasty may offer a lower re-operation rate in the treatment of unstable pertrochanteric hip fractures as compared to CM nailing.
Management of intertrochanteric fractures in elderly osteoporotic patients continues to be a challenging problem for orthopedic surgeons. Cutting out of implant from the femoral head and varus malpositioning of fragments is often seen in such cases if early ambulation is allowed. Prolonged bed rest in elderly patients leads to higher risk of complications such as bed sores, pneumonia and deep vein thrombosis not uncommonly leading to fatal pulmonary embolism. The purpose of this case series study was to assess the role of hemiarthroplasty in the treatment of intertrochanteric fractures in elderly patients and study the complications.
Materials and methods
Twenty-five patients were treated at a tertiary care center with hip hemiarthroplasty in intertrochanteric fractures. Mean age of the patients in the study was 77.8 years. Young patients with stable fractures and patients with active infection were excluded from study. Seventy-two percent of patients in the study were osteoporotic and associated comorbidity was present in 18 patients. Preoperative ambulatory status of all patients was noted for comparison. If calcar was deficient, calcar was reconstructed with a cut autograft from the femoral neck.
All Patients were followed for 1 year and evaluated using Modified Harris Hip Score except one patient who expired in postoperative period probably due to embolism. He had poor cardiopulmonary reserve preoperatively and cement was used in this case. Average period of initiation of full weight bearing in the present study was 5.5 days. Excellent/good results were seen in 20 patients (80%). One of the patients, who remained bedridden even after surgery, developed decubitus ulcer on the back and was labeled as failure. This patient expired 9 months after surgery. Dislocation of prosthesis was not seen in any case. One patient had shortening more than 1.5 cm due to sinking of prosthesis.
Although majority of patients with intertrochanteric fractures can be successfully managed with osteosynthesis, older patients with severe osteoporosis and associated comorbidity may benefit from prosthetic replacement. However, large scale studies are required to prove it conclusively.
Bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients is a viable option that can prevent the complications of an open reduction, such as nonunion and metal failure. This study evaluated the clinicoradiological results of cementless bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients.
Forty hips were followed for more than 2 years after cementless bipolar hemiarthroplasty using a Porocoat® AML Hip System. The mean age was 78.8 years and the mean follow-up period was 40.5 months. The Harris hip score and postoperative hip pain were analyzed clinically. The radiological results were assessed using a range of indices.
At the last follow-up, the mean Harris hip score was 80.6 points. There were one case of hip pain and one case of thigh pain. Twenty-four cases (60%) showed no decrease in ambulation capacity postoperatively. Radiologically, there were 23 cases (57.5%) of fixation by bone ingrowth and 17 cases (42.5%) of stable fibrous fixation. There were no cases of osteolysis. Eleven cases (27.5%) of new bone formation were found around the stem. All stems were stable without significant changes in alignment or progressive subsidence.
The short-term results of cementless bipolar hemiarthroplasty in elderly patients with unstable intertrochanteric fractures were satisfactory.
The management of unstable osteoporotic intertrochantric fractures in elderly is challenging because of difficult anatomical reduction, poor bone quality, and sometimes a need to protect the fracture from stresses of weight bearing. Internal fixation in these cases usually involves prolonged bed rest or limited ambulation, to prevent implant failure secondary to osteoporosis. This might result in higher chances of complications like pulmonary embolism, deep vein thrombosis, pneumonia, and decubitus ulcer. The purpose of this study is to analyze the role of primary hemiarthroplasty in cases of unstable osteoporotic intertrochanteric femur fractures.
We retrospectively analyzed 37 cases of primary hemiarthroplasty performed for osteoporotic unstable intertrochanteric fractures (AO/OTA type 31-A2.2 and 31-A2.3 and Evans type III or IV fractures). There were 27 females and 10 males with a mean age of 77.1 years (range, 62-89 years).
Two patients died due to unrelated cause (myocardial infarction) within 6 months of surgery and remaining 35 patients were followed up to an average of 24.5 months (range,18-39 months). The average surgery time was 71 min (range, 55-88 min) with an average intraoperative blood loss of 350 ml (range, 175-500 ml). Six patients needed blood transfusion postoperatively. The patients walked on an average 3.2 days after surgery (range, 2-8 days). One patient had superficial skin infection and one had bed sore with no other significant postoperative complications. One patient of Alzheimer's disease refused to walk and had a poor result. A total of 32 out of 35 patients (91%) had excellent to fair functional results and 2 had poor result with respect to the Harris hip score (mean 84.8±9.72, range 58-97). One patient who had neurological comorbidity refused to walk post operatively and was labeled as failed result.
Hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in elderly results in early ambulation and good functional results although further prospective randomized trials are required before reaching to conclusion.
Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Salvage treatment with hip arthroplasty may be considered. The aim of this study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Twenty-one patients were treated in our hospital with hip arthroplasty for failed treatment of intertrochanteric hip fracture. There were sixteen women and five men with a mean age of 75.8 years (range 61-85 years). Fourteen patients had failure of a previous nail fixation procedure, five had failure of a plate fixation, one of hip screws fixation and one of Ender nail fixation. In 19 out of 21 patients we performed a total hip arthroplasty-14 cases used modular implants with long-stems and five cases used a standard straight stem. In 2 of 21 cases we used a bipolar hemiarthroplasty. A statistically significant improvement was found comparing pre and postoperative conditions (p < 0.05). Our experience confirms that total hip arthroplasty is a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture in elderly patients with few serious orthopaedic complications and acceptable clinical outcomes.
The Finnish orthopaedic tradition has preferred hemiarthroplasty to internal fixation in femoral neck fracture treatment, while in Sweden internal fixation has been the method of choice. We decided to study whether internal fixation would prove superior to hemiarthroplasty even in displaced femoral neck fractures in patients over 75 years old.
We randomized 32 displaced femoral neck fractures in patients over 75 years old to receive internal fixation or hemiarthroplasty.
Fifteen (47%) patients died within two years. Seven of 16 (44%) patients in the internal fixation group were reoperated, none in the hemiarthroplasty group (p = 0.007). Seven of the complications in the internal fixation group developed during the first year and it would have been unethical to continue the study.
We conclude that displaced femoral neck fractures in patients over 75 years should be treated by arthroplasty.
The aim of this study was to compare the outcomes of intertrochanteric femur fractures treated with proximal femoral nail (PFN) and bipolar hemiarthroplasty (BPH) in elderly patients.
A total of one hundred and forty-three patients with intertrochanteric femur fractures treated surgically between January 2008 and January 2012 were included into the study. Patient demographics, type of fracture according to Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) classification, and the American Society of Anesthesiologists (ASA) classification system scores; type of surgical procedure (BPH or PFN), operative details, complications and follow-up scores (Harris Hip Score [HHS]; Mean Mobility Score [MMS]) were recorded.
The preoperative characteristics of the patients in both PFN and BPH groups were similar. BPH had higher operation times, blood loss in operation and mortality rates (p<0.005). Reoperation times were higher in PFN group (p<0.005). There were no differences with regard to the HHS and the reduction in MMS at the last follow-up with a 30.4 (10.9) months follow-up (p>0.05).
Although both PFN and BPH had satisfactory outcomes in surgically treated patients with intertrochanteric femur fractures, we recommend intertrochanteric femur fractures in the elderly tobe treated with PFN; which is an effective and appropriate treatment modality with less surgery related trauma and lower mortality rates.
An accurate diagnosis of osteoporosis and a proper treatment are today recognized to be the most important facts for prevention and for a correct arrangement and treatment of fragility fractures. In the text the Authors describe a case of severe osteoporosis aggravated by 2 femur fractures and 2 periprosthetic fractures occurred in 2 months. In such cases the orthopaedic surgeon needs to formulate first a clinical osteoporotic pattern, than its treatment together with a surgery suitable choice, that has to take into consideration of the bone structural characteristics. In the case described one can note that fractures healing occurred thanks to both an improvement in surgical techniques and antiosteoporotic pharmacological support; in the specific case the Authors used strontium ranelate for its osteoinductive capacity. In our opinion is crucial that the treatment used by orthopaedic surgeons is not related only to the "by-hand" treatment but take into consideration both the underlying disease and the possibility of positively affect bone healing with specific drug therapy.
The best surgical strategy for extra-capsular proximal femoral fractures (PFFs) is controversial in the elderly. Poor bone quality and neck screw instability can adversely affect the results with currently available fixation devices, which predominantly consist in dynamic hip screw-plates and proximal reconstruction nails.
The helical blade of the proximal femoral nail antirotation (PFN-A™) achieves better cancellous bone compaction in the femoral neck, thereby decreasing the risk of secondary displacement.
We retrospectively reviewed consecutive cases of PFN-A™ fixation performed between 2006 and 2008 in 102 patients (75 females and 27 males) with a mean age of 84.9 ± 9.5 years (range, 70-100 years). Functional outcomes were assessed using the Parker Mobility Score.
Mean follow-up in the 102 patients was 21.3 ± 17.5 months (4-51 months). Fracture distribution in the AO classification scheme was A1, n=45; A2, n=41; and A3, n=16. At last follow-up, Parker Mobility Score values in the 65 survivors were 0-3, n=35; 4-6, n=11; and 7-9, n=19. Fracture union was consistently achieved, after a mean of 10.3 ± 3 weeks. Blade back-out allowed by the device design occurred in 16 (15.7%) patients but caused pain due to screw impingement on the fascia lata in only five patients (of whom two underwent reoperation). Cephalic blade cut-out was noted in three (2.9%) patients, of whom one required reoperation because of acetabular penetration. Two hardware-related fractures were recorded.
The new PFN-A™ device ensures reliable fixation with low mechanical complication rates. Although our data do not constitute proof that a helical blade is superior over a neck screw, they suggest a decreased rate of construct failure and may serve as a basis for a comparative study.
The treatment of unstable intertrochanteric fracture in the elderly patient is still controversial. Traditionally, internal fixation using a dynamic hip screw was of choice. Recently, some authors advocated the use of cemented bipolar arthroplasty or hemiarthroplasty which results in better functional outcome.
The aim of this study is to find out which of these treatment options can lead to the best clinical and functional outcomes.
Patients and methods:
One hundred and two patients admitted to Makassed General Hospital between 2002 and 2007 with a diagnosis of unstable intertrochanteric fracture of femur were selected. Preoperative and operative data was retrieved from inpatient hospital files. Postoperative radio clinical data at follow up visits was collected from outpatient department files. Functional outcomes were assessed with use of Harris hip score. The main clinical measures were early postoperative full weight bearing, postoperative complications and functional outcome.
The time to full weight bearing, the rate of postoperative complications, and the functional outcomes was significantly better in the cemented bipolar arthroplasty group.
According to our results, we believe that cemented bipolar hemiarthroplasty is of choice in freely mobile elderly patients above seventy years of age with an intertrochanteric femoral fracture.
The results of primary Bateman-Leinbach bipolar prosthetic replacement for comminuted intertrochanteric fractures of the hip in the elderly are examined. In an effort to avoid the postoperative complications seen in open reduction and internal fixation of severely comminuted fractures with osteoporotic bone, and to avoid postoperative restrictions when fixation is suboptimal, a group of 58 patients were treated with a bipolar Bateman-Leinbach prosthesis. They were followed for an average of 28 months. Surgery was performed using an anterolateral approach, which is recommended. A detailed description of the surgical approach and operative technique are provided. Eighty-eight percent of patients were able to ambulate within the first week, weight bearing as tolerated with no postoperative restrictions, except for a simple abduction pillow for 2 weeks while in bed. Ninety-one percent of patients ambulated prior to discharge. Morbidity and mortality was no greater in this group than in groups treated by open reduction and internal fixation for these types of fractures. Complications were few. Primary Bateman-Leinbach bipolar prosthetic replacement is recommended as the preferred treatment of selected unstable comminuted intertrochanteric fractures in the elderly.
Thirty-seven consecutive patients who were more than seventy-five years old and had an unstable intertrochanteric or subtrochanteric fracture were treated by primary bipolar arthroplasty from 1983 through 1986. The functional results, according to the rating scale of Merle d'Aubigné, were rated as good or excellent in 75 per cent of the patients and remained almost unchanged with time. Roentgenographic follow-up showed early bone formation around the extramedullary part of the femoral component. The results in this prospective group of patients were compared with those in a similar but retrospective control group of forty-two patients who were treated by internal fixation from 1979 through 1982 and in whom early full weight-bearing was not possible. In the bipolar arthroplasty group, rehabilitation was easier and faster, and the incidences of pressure sores, pulmonary infection, and atelectasis were significantly lower (p less than 0.05). The early walking with full weight-bearing that the bipolar arthroplasty made possible is considered to be a major contributing factor to these results.
To promote early full weight-bearing and rapid rehabilitation, 20 elderly patients (average age, 82.2 years) with unstable intertrochanteric hip fractures were treated with a bipolar head-neck replacement. Seventeen patients had the prosthesis inserted as primary fracture management, and three, for salvage of failed internal fixation. The patients were ambulating with unrestricted weight-bearing at an average of 5.5 days after the operation. The bipolar design may permit conversion to a total hip arthroplasty without removal of the femoral component, and may reduce the risk of acetabular cartilage damage. By using the greater trochanter as a landmark for precise placement of the femoral head, correct limb length was restored.
208 patients aged over 70 years with a displaced cervical hip fracture were admitted to a prospective randomised trial of internal fixation using 3 parallel cannulated screws or an uncemented Austin Moore hemiarthroplasty. All surviving patients were followed for a minimum of 3 years. Functional assessment of survivors at 1, 2 and 3 years from injury showed no significant difference between groups. Patients treated by the fixation had a marginally lower mortality rate. Other outcomes which favoured internal fixation were a lower risk of wound infection, reduced length of surgery (22 minutes versus 47 minutes), lower operative blood loss (23 mL versus 172 mL), and lower transfusion requirements (4/102 patients versus 18/106). However, internal fixation had a significantly greater re-admission rate (24/102 versus 7/106) and re-operation rate. Following internal fixation, 44 re-operations were required in 36 patients, while re-operation was required in only 4 patients treated with arthroplasty. The results of this randomised trial indicate that both procedures produce comparable final functional outcomes for the survivors.
A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.
The treatment of unstable trochanteric femoral fractures is still challenging. The ideal implant should be easy to handle, allow for immediate full weight-bearing postoperatively and should have sufficient purchase in the femoral head/neck-fragment to limit cut-outs due to varus-deviation and rotation. The proximal femoral nail antirotation (PFNA ®), designed by AO, is an intramedullary device with a helical blade rather than a screw for better purchase in the femoral head and was tested in a clinical study.
Consecutive patients with unstable trochanteric fractures (AO-classification 31.A.2 and A.3 only) were included and followed for 1 year. Primary objectives were assessment of operative and postoperative complications, whereas secondary objectives included surgical details, general complications and final outcome measurements.
In 11 European clinics, 315 patients were included and treated with a PFNA ®. Almost all fractures healed within 6 months. Fifty-six percent of the patients regained the pre-trauma mobility and 18% died within the follow-up period. Forty-six implant-related complications – leading to 28 unplanned re-operations – were recorded, with four acetabular penetrations (three of which were after a new fall on that hip) and seven ipsilateral femoral shaft fractures as the most serious ones.
As the joint-penetrations did not resemble the cut-out seen with other implants it is concluded that the PFNA ® – due to its helical blade – possibly limits the effects of early rotation of the head/neck-fragment in unstable trochanteric fractures and therefore seems currently to be the optimal implant for the treatment of these fractures especially in osteoporotic bone.
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