Mid-term survivals of cemented calcar-replacement bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients

Cemented Calcar Replacement versus Long Stem Cemented Hemiarthroplasty in Unstable Intertrochanteric Fractures in Octogenarians

Objective  The aim of the present study was to compare functional results after Cemented Calcar replacement vis-a-vis Long stem Cemented hemiarthroplasty in patients aged more than 80 years with unstable intertrochanteric fractures. Methods  The present prospective, randomized trial included 140 patients with AO/OTA type 31-A2, A3 intertrochanteric femur fracture, randomized into 2 treatment groups and followed-up for a minimum of 2 years. Sixty-seven patients in group A were treated with a cemented calcar replacing prosthesis, and 65 patients in group B were treated with a cemented long stem femoral stem prosthesis. The primary end points were hip functions at 2 years. The secondary end points were the complications encountered, mortality, surgical time, reoperation, blood loss, and activities of daily living. Results  There were no major differences between the groups in terms of hip function, quality of life (health related), reoperation, mortality, and blood loss. However, the function in hip joint and activities of daily living deteriorated in both groups in comparison with prefracture levels. Conclusion  In octogenarians with an unstable intertrochanteric fracture, cemented calcar replacing prosthesis has similar clinical results in comparison with long stem cemented hemiarthroplasty. Hemiarthroplasty with either implant is a good option in this subset of patients. Level of evidence: I.

Primary hemiarthroplasty after unstable trochanteric fracture in elderly patients: mortality, readmission and reoperation

Background

Most unstable trochanteric fractures are treated with internal fixation and often with high complication rates. Hemiarthroplasty might be an alternative method in difficult condition, especially in unstable comminuted fracture in fragile bone. However, few have investigated the long-term outcomes after hemiarthroplasty for unstable trochanteric fracture. We conducted a population-based retrospective cohort study of trochanteric fracture after primary hemiarthroplasty using competing risk analysis on their long-term outcomes, including mortality, readmission and reoperation.

Methods

We studied a total of 2798 patients over 60 years old, with a mean age of 79 years, of which 68% are females and 67.23% have at least one comorbidity. They underwent a hemiarthroplasty for unstable trochanteric fracture during the period between January 1, 2000 and December 31, 2010 and were follow-up until the end of 2012, or death. Survival analysis and Cox model were used to characterize mortality. Competing risk analysis and Fine and Gray model were used to estimate the cumulative incidences of the first readmission and the first reoperation.

Results

The follow-up mortality rate for 1-year was 17.94%; 2-year, 29.76%; 5-year, 56.8%; and 10-year, 83.38%. The cumulative incidence of the first readmission was 16.4% for 1-year and 22.44% for 3-year. The cumulative incidence of the first reoperation was 13.87% for 1-year, 18.11% for 2-year, 25.79% for 5-year, and 38.24% for 10-year. Male gender, older age, higher Charlson Comorbidity Index (CCI) and lower insured amount were all risk factors for the overall mortality. Older age and higher CCI were risk factors for the first readmission. Older age was a protective factor for reoperation, which is likely due to the competing death.

Conclusions

The mortality and revision rates after hemiarthroplasty for unstable trochanteric fracture are acceptable as a salvage procedure for this fragile sub-population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04277-7.

Internal Fixation versus Hemiarthroplasty in the Treatment of Unstable Intertrochanteric Fractures in the Elderly: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the clinical efficacy of internal fixation versus hemiarthroplasty in the treatment of unstable intertrochanteric fractures in the elderly.

METHODS

A search was conducted in PubMed, Web of Science, Embase, and Cochrane Library databases up to April 2020. The present study compared internal fixation and hemiarthroplasty in the treatment of unstable intertrochanteric fractures in the elderly. RevMan5.3 software provided by the International Cochrane Group was used for the meta-analysis. To compare the differences in the operation time, intraoperative bleeding, length of hospital stay, superficial infection, Harris hip score, mortality within 1 year, mortality within 2 years, reoperation, incidence of deep venous thrombosis (DVT), partial weight-bearing time, non-union, and implant-related complications between an internal fixation group and an hemiarthroplasty group.

RESULTS

A total of 1300 patients were included in nine studies. The results showed that the operation time (MD = -18.09, 95% CI: -27.85--8.34, P = 0.0003), intraoperative bleeding (MD = -195.31, 95% CI: -244.8--147.74, P < 0.0001), implant-related complications (MD = 3.83, 95% CI: 1.74-8.45, P = 0.0008), and partial weight-bearing time (MD = 17.21, 95% CI: 1.63-32.79, P = 0.03) have statistical significance. However, there is not statistical significance for the Harris hip joint function scale (HHS) (MD = 5.60, 95% CI: -1.13-12.33, P = 0.10), DVT (MD = 1.02, 95% CI: 0.45-2.27, P = 0.97), length of hospital stay (MD = -1.08, 95% CI: -2.82-0.66, P = 0.22), superficial Infection (OR = 0.92, 95% CI: 0.43-1.98, P = 0.89), mortality within 1 year (OR = 0.95, 95% CI: 0.61-1.48, P = 0.81), mortality within 2 years (OR = 0.93, 95% CI: 0.61-1.43, P = 0.75), reoperation (MD = 1.80, 95% CI: 0.64-5.04, P = 0.26), and non-union (OR = 1.20, 95% CI: 0.48-3.03, P = 0.70). The result of the subgroup analysis showed no significant differences between the less than 2 years follow-up and the 2 years or more follow-up group. The only difference was for the Harris hip score: the internal fixation group was superior to the hemiarthroplasty group in the less than 2 years subgroup analysis, while there was no difference between the internal fixation group hemiarthroplasty group in the 2 years or more subgroup analysis.

CONCLUSION

Compared with the internal fixation group, those in the hemiarthroplasty group could carry out weight-bearing training early and implant-related complications were reduced, but it requires longer operation time and there is greater intraoperative blood loss. There is no difference in mortality, the incidence of DVT, non-union, HHS, reoperation, length of hospital stay, and superficial infection. Hemiarthroplasty may be a better choice for unstable intertrochanteric fractures in the elderly.