Proximal femoral nail antirotation versus hemiarthroplasty in the treatment of senile intertrochanteric fractures: Case report

Cemented bipolar hemiarthroplasty for unstable intertrochanteric fracture in elderly patients over 70 years: Boon or bane?

INTRODUCTION

The surgical management of intertrochanter femur fracture in elderly patient is still under debate. Various implants can be utilised but prosthetic replacement is gaining popularity. This study was performed to evaluate the functional and clinical outcomes of cemented bipolar arthroplasty as a primary treatment for unstable intertrochanteric fracture in elderly patients (> 70 years).

MATERIALS AND METHODS

Thirty-seven patients with unstable intertrochanteric fracture in elderly patient (> 70 years) who underwent cemented bipolar hemiarthroplasty. Intra-operative and post-operative complications were noted; functional outcomes were assessed using Harris hip score (HHS). All patients were followed up for a minimum of 12 months.

RESULTS

Overall 90% of patients has some minor or major intra or post-operative complication. One year mortality rate was 16% (6/37). Cardiopulmonary events were the most common life threatening incident. Mean fall in Haemoglobin was 1.6 gm/dL. The average time for full weight bearing mobilisation with the help of walker was 2.8 ± 1.2 days (1-8 days). The average duration of surgery was 58 ± 6 min (44-96 min) with an average blood loss of 126 ± 24 mL (90-380 mL). HHS at the end of 12 months was 77.

CONCLUSIONS

The use of bipolar hemiarthroplasty in senile patient with unstable hemiarthroplasty gives an advantage of early weight bearing. However, it is associated with risk of significant intra or post-operative morbidity due to intra-operative trauma, surgical time and blood loss during the surgery. Although hemiarthroplasty can be a single-time solution to the complexities of intertrochanter fracture in elderly patients but should be performed in selected patients only.

Study of outcomes of cemented hemiarthroplasty for comminuted intertrochanteric fractures in the elderly

Aims & objectives

To assess the functional outcomes of the unstable intertrochanteric fractures in the osteoporotic individuals treated by primary cemented hemiarthroplasty by early mobilization and immediate weight-bearing, restoration of limb length, and gait Assessment.

Materials and methods

It is a prospective study of 17 elderly patients with comminuted intertrochanteric fractures managed with cemented hemiarthroplasty attending to the Department of Orthopaedics, Government General Hospital, Rangaraya medical college, Kakinada.

Results

17 cases of unstable intertrochanteric fractures were treated with cemented bipolar hemiarthroplasty. The average follow-up period was 12 months. The average age was 72.75 years with a standard deviation of 5.56. Most (82.3%) of the patients presented with Boyd and Griffin type 2 fracture. The functional assessment by HHS showed good to excellent outcomes in most of the patients (64.7%). 2 patients had abductor weakness, 1 patient had superficial surgical site infection, one had hypotension, and 1 patient had bedsore.

Conclusions

Primary cemented bipolar prosthetic replacement in comminuted intertrochanteric fractures in the elderly patients provide s painless, stable, and mobile hip joint so that we can institute early postoperative mobilization which can avoid the consequences of prolonged recumbency. Hemiarthroplasty also avoids a second procedure in such elderly patients with multiple comorbidities as there is a high risk of failure of internal fixation in patients with poor bone quality, subjecting them to a second surgery and anaesthesia being a risky proposition.

Intramedullary Nail or Primary Arthroplasty? A System Review and Meta-Analysis on the Prognosis of Intertrochanteric Femoral Fractures Based on Randomized Controlled Trials

Introduction

There is no consensus regarding the superiority between intramedullary nailing and primary arthroplasty in the management of intertrochanteric femoral fractures. This systematic review was performed to investigate and compare the clinical efficacy of intertrochanteric femoral fractures treated with these 2 methods.

Materials and methods

We systematically searched PubMed, Embase, Cochrane, Web of science core collection and ClinicalTrials.gov for randomized controlled trials which compared the clinical outcomes of intertrochanteric fractures treated with either intramedullary nails or primary arthroplasty. Relevant data of the postoperative complications, reoperations, mortality and functional assessment, were pooled and presented graphically.

Results

A total of 6 trials with 427 participants were identified and included in the analyses. The pooled estimates suggested these 2 techniques have comparable risks in terms of overall complications (pooled risk ratio [RR] .80; 95% confidence interval [CI] .43 to 1.43; I2 = 79.94%), the rate of patients with orthopedic complications (RR .71, 95% CI .40 to 1.27; I2 = .00%), reoperations (RR 1.33, 95% CI .48 to 3.71; I2 = .00%), the overall mortality (RR .52; 95%CI .26 to 1.02; I2 = 31.35%) and 1-year mortality (RR .67; 95%CI .38 to 1.19; I2 = .00%). Primary arthroplasty associated with higher HHS at 3 months postoperatively (MD -21.95, 95% CI -28.29 to -15.60; I2 = 70.44%). While the difference was not significant at 6 months (MD 2.32, 95% CI -1.55 to 6.18; I2 = .00%), and even reversed at 12 months postoperatively (MD 13.02, 95% CI 8.14 to 17.90; I2 = 73.42%).

Conclusions

Meta-analytic pooling of current evidences demonstrated that primary arthroplasty is related to a better early functional recovery at the early stage postoperatively, but the long-term result tends to favor to intramedullary nailing. The differences in overall complications, the rate of patients with orthopedic complications, reoperations, overall and 1-year mortality did not reach a significant level.

Percutaneous reduction with double screwdrivers versus limited open reduction in the treatment of irreducible extracapsular hip fractures

Background

The reduction in irreducible extracapsular hip fractures has always been controversial. Here, we present a new minimally invasive reduction technique and compare it with limited open reduction (LOR) to treat irreducible extracapsular hip fractures.

Methods

From January 2016 to January 2018, our institution treated 653 patients with extracapsular hip fractures by intramedullary fixation. Among them, 525 cases got a successful closed reduction. The other 128 were irreducible and reduced by percutaneous reduction with double screwdrivers (PRDS) or LOR. There were 66 cases in the PRDS group while 62 in the LOR group. All fractures were classified using the Evans-Jensen classification. In addition, the differences in incision length, blood loss, fluoroscopic number, operation time, inpatient time, weight training time, Harris score, and complications were analyzed.

Results

The incision length was 8.4 ± 1.4 cm in the PRDS group and 15.3 ± 3.0 cm in the LOR group, respectively (p < 0.05); blood loss was equal to 151 ± 26 and 319 ± 33 ml, respectively (p < 0.05); fluoroscopic number was 14 ± 3 and 8 ± 2, respectively (p < 0.05); operation time was 44 ± 9 and 73 ± 11 min, respectively (p < 0.05); inpatient time was 6.2 ± 1.7 and 8.4 ± 2.2 days, respectively (p < 0.05); weight training time after the operation was 4.5 ± 1.5 and 10.7 ± 1.8 days, respectively (p < 0.05); and the excellent rate of Harris score was 92.4% and 88.7%, respectively (p > 0.05). There was no significant difference in complication incidence between the two groups (p > 0.05).

Conclusions

The PRDS group presented better clinical effects for managing irreducible extracapsular hip fractures than the LOR. Therefore, the PRDS technique could be the first reduction choice for patients with irreducible fractures.

Distally-fixed non-modular monoblock fluted long-stem hemiarthroplasty versus proximal femoral nailing for elderly patients with an osteoporotic intertrochanteric fracture: a retrospective comparative study

BACKGROUND

The treatment of Intertrochanteric fractures in the elderly osteoporotic patient is still controversial. The aim of this study was to compare the outcomes of proximal femoral nailing (PFN) and a distally-fixed non-modular monoblock fluted long-stem hemiarthroplasty (HA) in elderly patients with an osteoporotic intertrochanteric fracture.

METHODS

This retrospective study included patients who had undergone surgery for an unstable intertrochanteric fracture. The patients were separated into PFN and HA groups. The demographic features of the 2 groups were compared. All patients were evaluated using the Singh index, ASA score, AO/OTA classification, Harris Hip Score (HHS), and Parker and Palmer mobility score.

RESULTS

The most common complications were nonunion (12.0%) and cut-out of the screw (10.7%) in the PFN group, and dislocation of the prosthesis (6.7%) and wound infection (5.7%) in the HA group. Overall, the 2-year mortality rate was 29.3%. Mortality, particularly within the first 3 months, was 2.4 times higher in the PFN Group than in the HA group (40% vs. 19.75%). Although the HHS was significantly higher in the first year for the HA group, no significant difference was seen between the 2 groups at 24 months.

CONCLUSIONS

Although PFN and HA have similar good outcomes at 2 years, HA allows earlier mobilisation and has fewer complications and a lower mortality rate.

Cemented hemiarthroplasty versus proximal femoral nail antirotation in the management of intertrochanteric femoral fractures in the elderly: a case control study

Background

The treatment for intertrochanteric femoral fractures (IFF) among the elderly has been a controversial topic. Hemiarthroplasty (HA) and proximal femoral nail antirotation (PFNA) have their own advantages in the management of IFF. Hence, this study aims to compare and analyze differences in the effectiveness of both procedures on IFF among the elderly.

Methods

Overall, 99 patients (81.09 ± 8.29 years; 68 women) underwent HA or PFNA from January 2016 to May 2020. IFF were classified according to the Arbeitsgemeins für Osteosynthesefragen (AO) classification. The difference in underlying diseases, the American Society of Anesthesiologists (ASA) grade, Singh index, Harris scores, surgical time, intraoperative bleeding, postoperative blood test results, postoperative number of days to partially bearing weight, and survival outcomes were analyzed. Postoperative follow-ups were performed every 3 months.

Results

There was no significant difference in the AO classification, underlying diseases, ASA grade, Singh index, surgical time, and survival outcomes of the HA (45 patients) group and PFNA group (54 patients). The HA group was associated with earlier partial weight-bearing (HA: 4 [2 ~ 4.5] days, PFNA: 10 [8~14] days). It also had a higher total Harris score than the PFNA group at the 6-month follow-up visit (HA: 86.8 [81.90 ~ 90.23], PFNA: 83.48 [75.13 ~ 88.23]). Harris scores decreased more in patients aged ≥90 years in the PFNA group than in the HA group. The postoperative stress recovery rate in the HA group was faster based on postoperative blood test results.

Conclusions

PFNA and HA have good therapeutic effects in the treatment of IFF. The advantages of HA were reflected in short-term weight bearing, faster recovery from stress, and better joint function in the long term. This advantage is more obvious in the patient population aged over 90 years. Therefore, we suggest that surgeons should consider the benefit of HA in the treatment of IFF among the elderly.

Trial registration

Chinese Clinical Trial Registry, ChiCTR2000035814. Registered 17 August 2020, https://www.chictr.org.cn/showproj.aspx?proj=57083

Comparison of clinical outcomes with hip replacement versus PFNA in the treatment of intertrochanteric fractures in the elderly: A systematic review and meta-analysis (PRISMA)

BACKGROUND

The purpose of this meta-analysis was to evaluate the clinical efficacy and safety of HR and PFNA in the treatment of intertrochanteric fractures in the elderly.

METHODS

We carried out this review according to the principle of preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline. The clinical randomized controlled trials (RCTs), prospective cohort studies, retrospective cohort studies (RCSs), and case-control studies involving HR and PFNA in the treatment of intertrochanteric fractures in the elderly from 2000 to 2020 were compared by searching Web of Science, Pubmed, the Cochrane Library, and Embase. The quality of the included cohort study (CS) lines was evaluated using the Newcastle-Ottawa Scale (NOS). The quality of the included RCT lines was evaluated using Jadad. Forest plots were drawn by RevMan5.4 software based on the results and the data were analyzed.

RESULTS

After screening, a total of 9 articles were included, of which one was a clinical RCT and eight were RCSs with 1374 patients. The operative time of the PFNA group was shorter [WMD = 15.20; 95% CI (13.17, 17.23), P < .05] and the intraoperative blood loss was less [WMD = 178.81; 95% CI (97.24, 260.38), P < .05] than the HR group, while the first weight-bearing time of the HR group was shorter [WMD = -7.70; 95% CI (-10.54, -4.86), P  < .05] than the PFNA group. There was no significant difference in the length of hospital stay, HHS, postoperative orthopedic complications, and postoperative medical complications between the 2 groups.

CONCLUSION

With the development of HR technology and minimally invasive technology, the trauma caused by surgery is decreasing. Under the premise of improving perioperative management, such as optimizing the preoperative preparation and postoperative management, shortening the operative time, reducing intraoperative blood loss, and actively managing co-existing diseases, HR has more advantages than PFNA in the treatment of senile intertrochanteric fractures.

Comparison of Cementless Calcar-Replacement Hemiarthroplasty With Proximal Femoral Nail for the Treatment of Unstable Intertrochanteric Fractures at Older Age Group

Background: The aim of this study was to compare the outcomes of unstable intertrochanteric femur fractures treated with cementless calcar-replacement bipolar hemiarthroplasty (CRH) and proximal femoral nail (PFN) in elderly patients.

Methods: All consecutive unstable intertrochanteric fractures treated with cementless CRH or PFN at our institution between January 2015 and January 2019 were reviewed retrospectively. The primary outcome measures were postoperative complications, reoperation rate, and hip function. The secondary outcome measures were intraoperative blood loss, transfusion rate, surgical time, hospital stay, and two- year mortality.

Results: Ninety-four patients in the hemiarthroplasty group and 77 patients in the PFN group were included for analysis. There were no significant differences between the two groups regarding the complications, ASA score, and reoperation rate. Significant differences were found between hemiarthroplasty and PFN group in comparison of the average length of hospital stay (P < 0.05), time from hospitalization to operation (P < 0.05), intraoperative blood loss (P < 0.001), transfusion rate (P < 0.001), operation time (P < 0.001), Harris Hip Score (HHS; P < 0.001), and two-year mortality (P < 0.05).

Conclusion: Both hemiarthroplasty and PFN produce satisfactory results in surgically treated unstable intertrochanteric femur fractures in the elderly. Both groups are associated with their own complications, but in the PFN group, better functional results, less surgery-related trauma, and lower mortality rates are the main advantages.

A multicenter intertrochanteric fracture study in the elderly: Hemiarthroplasty versus proximal femoral nailing

Objectives

This study aims to compare the clinical and functional results of intertrochanteric femoral fractures treated with bipolar hemiarthroplasty (BHA) or proximal femoral nailing (PFN) in elderly patients.

Patients and methods

This multicenter, prospectively followed-up, retrospectively compared cohort-type study included 308 patients (81 males, 227 females; mean age 78.4±7.2 years; range, 65 to 95 years) who were treated with BHA or PFN for intertrochanteric fractures by five orthopedic surgeons in four provinces and seven clinics between January 2014 and May 2018. Clinical follow-up was performed at third week, third and sixth months, and at the end of the first and second years. The American Society of Anesthesiologists for preoperative status, Singh index for bone quality, and Harris Hip Score (HHS) for functional outcomes were evaluated.

Results

While 156 patients (38 males, 118 females; mean age 77.7±5.9) were treated with BHA, 152 patients (43 males, 109 females; mean age 79±6.1) were treated with PFN. While there was no significant difference between the two groups in terms of total HHS, a significant difference was found in the sub-parameters (p<0.001). Good and excellent results were found in 78.2% of BHA and 86.2% of PFN patients. Mortality rates were similar at the end of two years (14% and 13.6%, respectively).

Conclusion

In general, clinical and functional outcomes of BHA and PFN are similar. The rates of pulmonary embolism and deep vein thrombosis are significantly higher in BHA. However, BHA is advantageous in terms of operation time and early weight bearing compared to PFN.

Femoral trochanteric fracture: PFNA spiral blade placement with the aid of an angler

Objective

To investigate the effect of angler-assisted proximal femoral nail antirotation (PFNA) spiral blade fixation in treating femoral trochanteric fractures.

Methods

Patients who underwent angler-assisted PFNA screw blade fixation (angler-assisted group), or conventional internal fixation-intramedullary nailing (traditional surgery group) were included. Intraoperative indicators and treatment effects data were retrospectively analysed.

Results

Statistically significant differences were observed between the angler-assisted group (n = 27) and traditional surgery group (n = 28) regarding surgery duration (71.24 ± 8.01 min versus 81.50 ± 11.56 min), number of intraoperative fluoroscopy images (7.28 ± 0.91 versus 12.83 ± 1.55), and surgical bleeding volume (88.80 ± 7.98 ml versus 121.11 ± 27.21 ml). Rates of one-time intramedullary pin puncture for internal fixation in the angler-assisted and traditional surgery groups were 92.59% (25/27) and 32.14% (9/28), respectively. At 1 year following surgery, fractures in both groups had healed without internal fixation failure or fracture displacement failure. Harris hip function scores were 90.68 ± 4.23 (angler-assisted group) versus 81.69 ± 5.85 (traditional surgery group).

Conclusions

Angler-assisted intramedullary nailing with PFNA spiral blade provides good spiral blade positioning, low internal fixation failure rate, low fluoroscopy, short surgery time, and low bleeding volume. Hip function was well restored.

Comparison between Cementless and Cemented Bipolar Hemiarthroplasty for Treatment of Unstable Intertrochanteric Fractures: Systematic Review and Meta-analysis

Purpose

This study was conducted to compare cemented and cementless bipolar hemiarthroplasty in elderly patients with unstable intertrochanteric fractures via meta-analysis and systematic review of relevant studies.

Materials and Methods

Systematic review and meta-analysis were performed on 31 available clinical studies; 19 of these studies used cemented stems, 12 used cementless stems, one used both types of stems, and two studies involved a comparative analysis of both stem types.

Results

There were statistically significant differences in rates of leg length discrepancy (LLD) greater than 1 cm between the cemented (event rate, 0.089) and cementless groups (event rate, 0.015 and 0.047; P=0.03).

Conclusion

Cemented bipolar hemiarthroplasty and cementless bipolar hemiarthroplasty performed on elderly patients with unstable intertrochanteric fracture revealed similar mortality and complication rates; however, the rate of LLD greater than 1 cm was significantly higher in the cemented group compared with the cementless group.