Trochanteric locking nail versus arthroplasty in unstable intertrochanteric fracture in patients aged over 75 years

A Novel Interfragmentary Technique vs. A Conventional Posterolateral Approach for Unstable Femoral Intertrochanteric Fractures in the Elderly: A Retrospective Cohort Study

Background and Objectives: Intertrochanteric fractures of the femur are common in the elderly due to the increase in longer life expectancy. However, unstable intertrochanteric fractures in the elderly population were still a significant concern for the postsurgical period after total hip arthroplasty (THA). This study aimed to compare the demographics, operative time, dislocation rate, and length of stay of the novel interfragmentary technique (IFT) and the conventional posterolateral approach (CPA) for unstable intertrochanteric femoral fractures treated with THA in the elderly. Materials and Methods: This retrospective study investigated community-dwelling elderly patients with type III, IV, and V unstable femoral intertrochanteric fractures according to the Evans-Jensen classification, treated with THA by a well-experienced single surgeon. The patients were separated into IFT (n = 74) and CPA (n = 67) groups. Patient demographics (age, gender, and body mass index), total surgical duration, dislocation rates, length of stay and follow-up, and complication rates were recorded. Results: The mean age was 80.37 years in the IFT and 80.14 in the CPA groups (p = 0.838). Body mass index, gender, complication, and revision rates did not differ between groups (p > 0.05). The mean follow-up of the IFT group was 4.15 years, and 10.25 years in the CPA group (p = 0.001). Total surgical duration was comparable, with 69.98 min in the IFT group and 69.55 min in the CPA group (p = 0.697). The dislocation rate was 2.7% (n = 2) in the IFT group and 9% (n = 6) in the CPA group (p = 0.109). The mean length of stay was 66.97 h in the IFT group and 67.83 h in the CPA group (p = 0.729). Conclusions: The interfragmentary surgical technique, a novel technique for unstable intertrochanteric fracture surgery, shows promising clinical outcomes. Preserving the short rotator muscles and posterior capsule utilizing the novel IFT can be advantageous for the risk of dislocation without increasing surgical duration. It can be concluded that performing THA using IFT emerges as a practical and viable procedure for treating unstable intertrochanteric fractures in elderly patients.

Predictive factors of gait recovery after hip fracture: a scoping review

OBJECTIVE

This scoping review aimed to identify predictive factors influencing gait recovery post-hip fracture surgery among adults aged 65 and older.

DESIGN

A systematic search of MEDLINE, Embase and CINAHL databases was conducted, focusing on studies assessing predictive factors of gait recovery within one month to one-year post-surgery. Two independent reviewers carried out study selection, quality assessment and data extraction using the Quality in Prognosis Studies Tool to gauge evidence levels.

RESULTS

About 10,627 articles were initially identified. After duplicates were removed, 7665 were screened based on title and abstract, then 796 based on full text; 138 articles were finally included.The review identified a total of 77 predictive factors. However, just under half (34) of these were supported by studies with a low risk of bias. Higher-level evidence-supported factors were age, pre-fracture independence in daily activities, cognitive impairment, delirium, orthogeriatric multidisciplinary co-management, specific surgical interventions, allowing weight-bearing, comorbidities, nutritional status, rehabilitation treatments and polypharmacy.

CONCLUSION

The identified factors influencing gait recovery include both non-modifiable factors [such as younger age, pre-fracture independence in activities of daily living, absence of cognitive impairment, fewer comorbidities and lower anaesthetic risk] and modifiable factors, including rehabilitation treatments, organisational factors, absence of delirium, orthogeriatric co-management, surgical factors such as implant type and unrestricted weight-bearing, better nutritional status and strength, and reduced polypharmacy. We believe the latter should be prioritised in managing patients with hip fractures to achieve optimal recovery.

Posttraumatic Anterior Hip Dislocation with Ipsilateral Comminuted Intertrochanteric Fracture: A Rare Case Report

Hip joint is a ball and socket type of joint and its anatomic features makes it very stable. However, Incidence of hip dislocation has increased recently due to high energy trauma like road traffic accident, fall from height etc. It is usually associated with fracture of femoral head, neck, shaft and acetabular wall. Association of ipsilateral intertrochantric fracture is exceedingly rare and only a few case reports are available in the literature. We are presenting a rare case report of neglected anterior hip dislocation with ipsilateral comminuted intertrochanteric fracture managed with hemiarthroplasty using long cemented distal press-fit revision stem. A 66-year-old male presented to our outpatient department with history of fall from a tree 22 days back with pain in right hip and inability to bear weight on right lower limb. Radiographs were suggestive of anterior hip dislocation with fracture of ipsilateral comminuted intertrochanteric fracture of right side. Anterior hip dislocation with ipsilateral intertrochanteric fracture is a very rare entity, and only a few case reports are available in the literature. Management includes early open reduction and fixation to achieve optimal outcomes, but doing primary arthroplasty is also a viable option especially in neglected cases as there is high chances of avascular necrosis and secondary osteoarthritis of the hip joint later on.

Should trochanteric fractures in elderly patients be treated by arthroplasty or internal fixation?

Most trochanteric fractures are treated by fixation, most often intramedullary. Nevertheless, the desire to have patients walk as soon as possible and the fear of fixation failure has driven some surgeons to carry out an arthroplasty instead, especially for unstable fractures and/or in patients with severe osteoporosis, in order to avoid the difficult conversion to arthroplasty later on if the fixation fails. The aim of this review was to specify the role, technique and results of performing arthroplasty in this context. In which fractures? Unstable fractures (A2.2, A2.3 and A3), especially in osteoporotic bone, which are the most difficult to reduce and fix, and in cases with associated osteoarthritis. For which patients? Arthroplasty should not be done in patients who have ASA≤3 due to greater blood loss and longer operative time. Since the postoperative Parker score often drops, arthroplasty should not be done in patients having a Parker score<6. What are the technical problems? Arthroplasty must be done by an experienced surgeon because of the lack of anatomical landmarks, although fracture fixation has its own demands (satisfactory reduction, appropriate length and position of cervicocephalic screw). What are the results and complications? Despite several comparative studies (randomized trials, meta-analysis and prospective studies), it is difficult to draw any conclusions. These studies show worse performance of dynamic hip screws relative to intramedullary nails. The complication and revision rates were higher for nails than arthroplasty, but not in every study, while the functional outcomes with nails (with or without immediate weightbearing) were better than those of arthroplasty beyond 6 months. What is the mortality rate? It was lower after nailing in a few studies but was mainly determined by the patient's comorbidities and preoperative Parker score. The best indication for arthroplasty may be self-sufficient patients over 70 years of age who have an unstable fracture with severe osteoporosis. Nevertheless, new studies should be done to compare arthroplasty to nailing with immediate return to weightbearing in patients having the same type of fracture, defined using 3D CT scan. Level of evidence: Expert advice.

Patients with trochanteric hip fractures and pre-existing osteoarthritis can be treated with nailing osteosynthesis without significant decrease in functional status

PURPOSE

Functional outcome in patients after trochanteric fracture fixation with pre-existing radiographic osteoarthritis (OA) is unclear. Analyzing their function and independence, before and after fracture, could optimize their treatment and decrease the socioeconomic burden in this particular group.

METHODS

The influence of pre-existing radiographic hip OA on functional outcome was retrospectively analyzed with a cohort of patients undergoing proximal femoral nailing for trochanteric fracture. OA was graded according to the Tonnis classification. Functional outcome was assessed preoperatively and 12 months after surgery by the Parker Mobility Score (PMS). We consider a meaningful reduction a difference between preoperatively PMS and 12 months after surgery ≥ 2. In order to evaluate if OA is related to PMS reduction ≥ 2, we calculate the SubHazard ratio (SHR) performing a competing risk regression model considering death as a competing risk event, adjusting by confounders. Death, reoperations, readmissions, surgical time, and fracture reduction quality in patients with and without osteoarthritis were recorded.

RESULTS

375 trochanteric hip fractures treated with cephalomedullary nails were included, from which 80 (21% CI95% 17%-21%) were classified as Tonnis 2 or 3. This group of patients with pre-existing OA was significantly older (mean age of 88.6 [SD 5.65] vs 85.5 years [SD 6.95]) than the group without OA. The preoperatively PMS score was 6.28 (2.71) in non-OA patients and 5.69 (2.67) in OA patients. The mean PMS reduction 12 months after surgery was 1.3 (SD 2.05) in OA patients and 1.07 (SD 2.2) in non-OA patients (p = 0.43). Competing risks analysis, adjusted by confounders had an SHR of 1.15 (IC95% 0.77 - 1.69). Death, readmission, reoperations, surgical time, and fracture reduction quality did not differ in both groups.

CONCLUSIONS

Patients with pre-existing radiographic OA treated with femoral nailing have a similar reduction in functional outcomes compared to the non-OA group at one-year follow-up. Further studies will be needed to compare the results of the functional outcome in arthroplasty with those of femoral nailing for the treatment of trochanteric femur fractures in patients with OA.

Trochanteric Bolt Failure in a Modular Femoral Revision System

With the incidence of primary total hip arthroplasty continuing to rise in the United States, the innovation behind improving current total hip arthroplasty systems inevitably grows with it-each new design potentially ushering in new flaws. We report a case of screw failure with the Arcos Modular Femoral Revision System-Trochanteric Bolt and Claw Technique in a 74-year-old male patient. The patient presented to the investigator's clinic for their 20-month follow-up evaluation of their complex right hip revision. Radiographs revealed failure of the screw attaching the claw plate to the stem resulting in dislodgement and relocation of the screw within the intra-articular cavity. The patient elected for nonsurgical management and will continue to be monitored. Consent by the patient involved in this case report was obtained.

Conversion arthroplasty after failed extracapsular hip fracture fixation is associated with high complication rates

Background/Aim: There is no standard treatment of choice that addresses all extracapsular fractures, which account for approximately half of the elderly hip fractures. Arthroplasty is mostly favored secondary to unsuccessful fixation or unstable primary fractures. However, conversion arthroplasty complication rates are high in the literature. This study compares arthroplasty performed after unsuccessful fixation and primary arthroplasty for unstable extracapsular hip fractures. Methods: In this retrospective study, we compared the first-year results of the groups that underwent conversion arthroplasty (cHA) and the primary arthroplasties (pHA) for extracapsular hip fractures. In the cHA group, patients were indicated for operation if there was a failure of fixation after extracapsular hip fractures (n=44). In the pHA group, patients were for unstable extracapsular hip fractures (n=44). In the cHA group, failure of fixation causes were cut-out of lag screws (54.5%), cut-through of lag screws (9.1%), non-union of fractures (27.3%), and osteonecrosis of femoral heads (9.1%). While total hip replacement was applied to all patients in the cHA group, total hip replacement was applied to ten patients in the pHA group and hemiarthroplasty to 34 patients. In comparing groups, duration of operation, amount of bleeding, intraoperative complications, post-operative complications, mobilization capacities, functional status, and mortality rates were used. Results: There were 44 patients in both groups. The surgical time (134.3 [34.5)] vs. 66 [16], [P<0.001]), the amount of bleeding (1000 ml [400] vs. 300ml [200], [P<0.001]), the need for red blood cell transfusion in the operations (80% vs. 32%, [P<0.001]), and the frequency of intraoperative femur fracture (30% vs. 0%, [P<0.001]) were larger or longer in the cHA group compared to pHA group (P<0.001). While 14 complications requiring surgical intervention were observed in 12 of 44 patients in the CHA group in the post-operative 1st year, four complications were observed in four of 44 patients in the pHA group. There was no difference in mortality rates (3 vs. 3, [P =1]), mobilization capacities (5.9 [2.1] vs. 5.7 [2.0], [P=0.597]), and functional status (12.5 [3.3] vs. 13.0 [2.7], [P=0.434]) between the groups. Conclusion: Arthroplasty performed as conversion surgery after unsuccessful fixation has a higher risk of intraoperative and post-operative complications than primary arthroplasty performed after extracapsular hip fractures. We believe the cases prone to implant failure, non-union, or restricted mobilization because of the patient and fracture-type reasons should be treated with primary arthroplasty.

Functional Outcome of Hemiarthroplasty of the Hip for Unstable Intertrochanteric Fractures of the Femur in Elderly Patients: A Prospective Study

Introduction It is frequently challenging to treat an unstable intertrochanteric fracture in elderly people by internal fixation because of difficult anatomical reduction, poor bone quality, the need for prolonged bed rest and restricted ambulation. As an alternative to internal fixation, cemented bipolar hemiarthroplasty has been used as a treatment for unstable intertrochanteric fractures to avoid the postoperative immobilization-related complications. The aim of this study was to evaluate the functional and clinical outcomes of primary cemented bipolar hemiarthroplasty for elderly patients with unstable intertrochanteric fractures. Methodology A prospective study was conducted that included 30 patients who were admitted to the apex trauma center at a tertiary care center from January 2019 to August 2020 with unstable intertrochanteric fractures (Association for Osteosynthesis/Orthopaedic Trauma Association, or AO/OTA, types 31-A2.2 and 31-A2.3); patients treated with cemented bipolar hemiarthroplasty, with at least one year of follow-up were included in the study. Basic descriptive statistics were used and the results were presented in frequencies, percentages for categorical variables and means and standard deviations for continuous variables. Results According to the Harris Hip Score, at the end of 12 months, 9 patients (30%) had excellent results, 14 patients (46.67%) had good results, 5 patients (16.67) had fair results, and 2 cases (6.67) had poor results. With cemented hemiarthroplasty, 87.7% of older patients with unstable intertrochanteric fractures were able to walk sooner, and the results were good. Conclusion Hemiarthroplasty of the hip with a cemented bipolar prosthesis appears to be a reliable treatment method for the management of unstable intertrochanteric fractures in elderly patients with osteoporosis; it allows for early ambulation and leads to a favorable functional outcome in most patients following surgery.

A bone-conserving revision stem for unstable intertrochanteric fractures of the geriatric osteoporotic population

Purpose

Primary hemiarthroplasty is gaining popularity for the treatment of unstable intertrochanteric fractures in geriatric patients with severe osteoporosis. This study evaluated early clinical and radiographic outcomes by using a bone-conserving revision stem for unstable intertrochanteric fractures in the geriatric osteoporotic population.

Methods

A retrospective study involving 31 patients with unstable intertrochanteric fractures was conducted. The patients were aged 82.1 years on average. All patients underwent primary hemiarthroplasty using bone-conserving, fully porous-coated revision stem. The operative time, intraoperative blood loss, length of hospitalization, and need for blood transfusion were noted during the hospital stay. Postoperative complications, including dislocations, deep venous thrombosis, infections, peri-prosthetic fractures, and frontal thigh pain were also recorded. Koval's category was used to quantify activity level, and Harris hip score (HHS) was used for functional assessment. Radiographic outcomes, including osteolysis, bone ingrowth, subsidence of the femoral component, lower limb length discrepancy, and heterotopic ossification, were collected at each follow-up.

Results

The 31 patients were followed for an average time of 23 months postoperatively. The average operative time lasted for 74.2 min, while the mean intraoperative blood loss was 200.1 ml, with an average hemoglobin decrease of 11.1 g/L after the procedure. The mean visual analog scale (VAS) score for pain dropped from 7.4 preoperatively to 2.4 at the 4-week follow-up. At the latest follow-up, the mean Harris hip score was 82.1, and the VAS was 1.7. No intraoperative or postoperative peri-prosthetic fractures were noted. Postoperative complications included one case of thrombosis formation in the posterior tibial vein and one case of congestive heart failure. Both patients were discharged uneventfully after treatment. Radiographically, none of the hips had evidence of stem loosening or osteolysis. Within the follow-up period of 23 months, the mortality rate was 3.2% (1/31), and no revision surgeries were required.

Conclusion

Primary hemiarthroplasty using a bone-conserving, cementless revision stem could serve as a reliable alternative for the treatment of unstable intertrochanteric fractures in the geriatric population with osteoporosis.

Mortality and functional consequences after revision osteosynthesis for peritrochanteric fractures treated by intramedullary nail: A retrospective study of 312 patients

INTRODUCTION

Osteosynthesis of peritrochanteric fractures by intramedullary nail is associated with a 3 to 15% rate of complications requiring revision surgery. The objective of our study was to compare mortality and autonomy between patients who required revision surgery after osteosynthesis, and patients without revision surgery.

HYPOTHESES

Patients who underwent revision surgery after osteosynthesis of a peritrochanteric fracture by intramedullary nail did not exhibit excess mortality or loss of autonomy compared to those who did not undergo revision surgery.

METHODS

Between January 2017 and October 2019, 312 consecutive patients were operated on for a peritrochanteric fracture by intramedullary nail. Among them, 23 patients (7.4%) required revision surgery (change, nail removal, total hip arthroplasty). Mortality at 90 days and at one year was evaluated and compared between the group of "revision" patients and "no revision" patients. The level of autonomy was assessed by the Parker and Palmer score, one year postoperatively and compared between the 2 groups.

RESULTS

The patients requiring revision surgery were younger: 73 years old vs. 86 years old (p<0.011). The overall mortality was 7.25% at 90 days after surgery and 15% at one year. Mortality was zero at 90 days, and at 1 year, postoperatively for patients requiring revision surgery. There was no significant difference for the mortality at 90 days (p=0.39) between the 2 groups, however at 1 year, it was significantly less for the revision patients (0% vs. 17%, p=0.032). There was no significant difference for the Parker score between the "revision" group; 5 (4-9) and the "no revision" group; 4 (3-7), at one year postoperatively (p=0.24).

CONCLUSION

This study did not show any excess mortality, nor loss of autonomy at 1 year postoperatively, for patients who required osteosynthesis for a trochanteric fracture, and who presented with a complication requiring revision surgery.

LEVEL OF EVIDENCE

III, comparative retrospective study.

The role of internal fixation in the treatment of femoral head necrosis with ipsilateral hip fracture

Whether internal fixation or hip arthroplasty is the most appropriate initial treatment for patients with ipsilateral hip fracture and osteonecrosis of the femoral head remains unknown. In this study, the prognoses of patients who underwent internal fixation or hip arthroplasty were analyzed and compared to explore the role of internal fixation in treating such patients. We retrospectively reviewed 69 patients diagnosed with osteonecrosis of the femoral head and ipsilateral hip fracture from 1999 to 2018. They were divided into the hip arthroplasty or internal fixation group. The visual analog scale and Harris score were used. The incidence of complications and the conversion to arthroplasty were also investigated to further explore the role of internal fixation. Male patients (male/female: 25/31 vs 20/38, P = .015), younger patients (average age: 46.80 ± 13.14 vs 61.07 ± 15.61, P < .001), and patients with femoral neck fractures (fracture type, femoral neck/trochanter: 21/31 vs 12/38, P = .003) were more likely to receive 1-stage hip arthroplasty. Of 38 patients undergoing internal fixation, fracture nonunion was identified in 9, and progression of osteonecrosis was identified in 16. Meanwhile, conversion to secondary hip arthroplasty occurred in 13 patients. Four independent risk factors for conversion to secondary hip arthroplasty were identified: age of ≤60 years (odds ratio [OR] = 9.786, 95% confidence interval [CI] = 2.735-35.015), male sex (OR = 6.790, 95% CI = 1.718-26.831), collapse of the femoral head before injury (OR = 7.170, 95% CI = 2.004-25.651), and femoral neck fracture (OR = 8.072, 95% CI = 2.153-30.261). A new scoring system was constructed for predicting conversion to hip arthroplasty in patients undergoing internal fixation treatment. A cutoff of ≤2 points indicated low risk for conversion, 3 to 4 points indicated moderate risk, and ≥5 points indicated high risk. Patients who underwent internal fixation had worse prognoses than those who underwent 1-stage hip arthroplasty. However, in this study, hip arthroplasty conversion did not occur in most patients who received internal fixation. Using the new scoring system to identify patients who may require conversion to replacement may help make appropriate patient management and clinical decisions.

Reoperation rates after proximal femur fracture fixation with single and dual screw femoral nails: a systematic review and meta-analysis

Purpose

Methods

Results

Conclusion

Primary Arthroplasty or Internal Fixation in Intertrochanteric Femur Fractures: A Survey of Surgical Attitudes of Orthopedic Surgeons in Turkey

This study aimed to examine the primary arthroplasty attitudes of Turkish orthopedics and traumatology specialists and residents to patients with intertrochanteric fractures, of various ages, comorbidity situations and fracture types, using an internet-based questionnaire. Between March and April 2021, a cross-sectional survey was conducted with a total of 159 orthopedics and traumatology specialists and residents in Turkey, using an online questionnaire that consisted of 16 different patient scenarios of varying intertrochanteric fracture types, ages, and comorbidity conditions. Respondents’ preference ratio for primary arthroplasty was 24.1% in the scenarios with patients over the age of 71, while it was 8.4% in the scenarios with patients aged between 50 and 70. The ratios of primary arthroplasty preference were 12.4%, 21% and 27.3% in 2-part, 3-part and 4-part fracture scenarios, respectively. The primary arthroplasty preferences of respondents with 10 years or more of professional experience were observed to be statistically significantly different to those of the respondents with 1 to 10 years of experience in the 4-part fracture scenario where the patient was aged 71 years and above with an ASA (American Society of Anesthesiologists) score of 3–4 (p < 0.05). Despite varying opinions in the literature in recent years, primary arthroplasty can be considered a valuable alternative approach for Turkish surgeons, and in older adult patients with unstable intertrochanteric fractures, particularly those who need early mobilization and have high ASA scores.

Fracture fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: A systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION

There are three common types of operative options for unstable intertrochanteric fracture (ITF), i.e. dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA). Results of these operations are still inconclusive. This systematic review and network meta-analysis was therefore conducted to compare the efficacy among those operative strategies.

HYPOTHESIS

These three operative techniques (i.e., DHS, PFN, and BHA) were not different in operative failure, reoperation, and Harris Hip Score (HHS) for unstable ITF.

MATERIAL AND METHODS

Randomized controlled trials (RCTs) comparing outcomes among DHS, PFN, and BHA in patients with unstable ITFs were searched from Medline and Scopus databases. Primary outcomes included operative failure, reoperation, and HHS. Direct meta-analysis (DMA) and network meta-analysis (NMA) were performed to compare among three operative techniques. Qualitative and quantitative evidences of all included studies were tested for heterogeneity, transitivity, and consistency in NMA. The surface under the cumulative ranking curve (SUCRA) was used to estimate the probability of being the best in lowering poor clinical outcomes, but high HHS.

RESULTS

Seven RCTs (n=528) were eligible. DMA showed that DHS and PFN were significantly higher risk of operative failure compared with BHA with risk ratio (RR) and 95% confidence interval of 7.98 (1.35, 47.06) and 3.08 (1.00, 9.51), respectively. Compared with BHA, PFN was 4.47 (1.04, 21.60) times significantly higher risk of reoperation, and lower HHS at 3-6months [mean difference (MD)=-5.41 (-15.91, 5.10)], but higher HHS at>6-12months [MD 11.67 (2.98, 20.36)], although these HHSs were not significant. NMA and SUCRA demonstrated the highest ranks for operative failure and reoperation were DHS and PFN, whereas the highest HHS was BHA.

DISCUSSION

In specific group of unstable ITF, BHA might be the best operative technique in term of lower operative failure and reoperation, and highest HHS during short to intermediate period comparing with PFN and DHS. However, PFN had higher long-term HHS than BHA.

LEVEL OF EVIDENCE

I, meta-analysis of RCTs.

Proximal Femoral Plate, Intramedullary Nail Fixation Versus Hip Arthroplasty for Unstable Intertrochanteric Femoral Fracture in the Elderly: A Meta-analysis

INTRODUCTION

Multiple operative modalities are available for management of unstable intertrochanteric femoral fractures. This meta-analysis was conducted to find out if there is superiority of surgical fixation by proximal femoral plate or surgical fixation by intramedullary nail over hip arthroplasty for management of unstable intertrochanteric femoral fractures in the elderly.

METHODS

A search for relevant studies that published from January 2000 to November 2018 through the electronic literature database of Cochrane library, Medline, Trip Database and Wiley online library.

RESULTS

A total of 19 studies including 14 prospective RCTs, and five retrospective studies. This meta-analysis showed that nail group had shorter operative time than plate group (P < 0.0001), and less blood loss than the plate and arthroplasty groups (P < 0.0001), cut-out was higher in nail group than the plate group (P < 0.0001), mortality rate was higher in hip arthroplasty compared to other groups (P < 0.0001), Harris hip score within 6 months of the operation was higher in the arthroplasty group compared with the nail and plate groups, while within 1 year of the operation, nail group had higher Harris hip score than arthroplasty group (P < 0.0001).

CONCLUSIONS

This meta-analysis suggested that the intramedullary nail fixation method is a preferred method for management of unstable intertrochanteric femoral fractures in the elderly over hip arthroplasty and proximal femoral plate fixation.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00426-1.

Treatment of Intertrochanteric Femur Fractures with Hip Arthroplasty in Older Patients: A Narrative Review of Indications and Outcomes

Intertrochanteric femur fractures are common in older patients and often have a significant impact on disability. The treatment aims to achieve a rapid return to the prior functional level with a low rate of complications and mortality. Surgical management by internal fixation is the mainstay of treatment for most of these fractures. Even when treated with intramedullary nails, the overall complication rates are high, especially for unstable or highly comminuted fractures or in the presence of poor bone quality. Hip arthroplasty is an alternative in older patients with intertrochanteric femur fractures at high risk of fixation failure or with concomitant intraarticular pathologies. Especially patients whose condition precludes prolonged bedrest and who are at risk of significant deterioration if their locomotor function cannot be restored rapidly are likely to benefit from hip arthroplasty. The choice of the surgical technique mainly depends on the surgeon’s preferences and the fracture characteristics. Bipolar hemiarthroplasty is the most common type of prosthesis used with primary or revision femoral stems. Compared with intramedullary nails, hip arthroplasty has a better early functional outcome and lower rates of surgical complications as well as reoperations. However, the functional outcome and the mortality rate in the longer term tend to favor intramedullary nails, even though the results are inconsistent, and a statistically significant difference cannot always be obtained. Currently, there are no guidelines that define the role of hip arthroplasty in the treatment of intertrochanteric femur fractures in older patients. The literature only offers an overview of the possibilities of the usage of hip arthroplasty, but methodological limitations are common, and evidence levels are low. Further studies are needed to identify the intertrochanteric fractures that are at high risk of internal fixation failure, the characteristics that determine which patients may benefit most from hip arthroplasty, and the optimal surgical technique.

Fixation options for reconstruction of the greater trochanter in unstable intertrochanteric fracture with arthroplasty

INTRODUCTION

With the aggravation of population aging, the incidence of intertrochanteric fracture also increases dramatically. Patients are often elderly accompany with severe osteoporosis and various complications. Therefore, we should select an individualized treatment based on the each patient's state. Arthroplasty is recommended for unstable fractures with obvious osteoporosis, ipsilateral femoral head necrosis or arthritis. Rigid fixation of the greater trochanter with arthroplasty is challenging because of the powerful pulling forces created by multiple muscles being transmitted to the greater trochanter. Currently, there are few contemporary literatures on the evaluation of unstable intertrochanteric fracture with efficient fixation of the greater trochanter. Moreover, there is no consensus to choose which implant to immobilize the greater trochanter. The purpose of this study was to review previous literatures and provide a valuable guidance.

CONCLUSIONS

The locking plate, which not only provides rigid fixation but also results in lower rate of postoperative complications. However, further prospective randomized and cohort studies are needed.

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.

Application of the reversed LISS-DF technique in an elderly patient to salvage infection-related failure of trochanteric fracture fixation

Failure of cephalomedullary fixation in geriatric trochanteric fractures is a potential complication. Attempts have been made to optimize the implant fixation (e. g. cement augmentation) and several factors (e. g. malreduction, tip apex distance) have been identified as risk factors for failure. Nevertheless, if intramedullary fixation fails, it is often associated with bone defects in mostly preexisting poor bone-stock. Accordingly, conversion to total hip arthroplasty (THA) is recommended by some authors as the only valid treatment option. However, in specific situations (e. g. implant associated infection) conversion to THA might be less reasonable than an attempt to re-osteosynthesis. This article reports on the successful use of a reversed contralateral LISS-DF (LISS for the distal femur, DePuy Synthes, Zuchwil, Switzerland) application after failed cephalomedullary fixation and failed re-osteosynthesis using a blade plate in a trochanteric fracture in an elderly patient with additional implant associated infection.

Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip combined with intertrochanteric fracture: a case report and literature review

BACKGROUND

Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip (DDH) is a complex procedure. Crowe type IV DDH combined with intertrochanteric frature is very rare.

CASE PRESENTATION

A 75-year-old patient suffering from left hip pain after a fall was sent to our hospital. Plain radiographs and computed tomography scans were used to diagnose this patient with DDH combined with an intertrochanteric fracture. We conducted a total hip arthroplasty using an S-rom prosthesis following subtrochanteric shortening osteotomy in this patient, after which steel wires were used to fix the intertrochanteric fracture. The patient did not suffer any significant intraoperative or postoperative complications, and treatment was sufficient to overcome lower leg abnormalities. The patient was encouraged to resume walking with support at 3 days post-surgery, and at 6-month postoperatively he had regained the majority of his original range of motion. At 10-month postoperatively, the intertrochanteric fracture and subtrochanteric osteotomy of left femur had healed effectively,and the patient's VAS and mHSS scores had improved significantly.

CONCLUSIONS

Total hip arthroplasty is an effective approach to treat patients suffering from Crowe type IV DDH combined with an intertrochanteric fracture, and can achieve satisfactory clinical outcomes.

Reoperation rate, mortality and ambulatory ability after internal fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: a study on Korean Hip Fracture Registry

INTRODUCTION

The treatment of unstable intertrochanteric fracture in elderly patients is challenging and how to treat these patients remains controversial. The purposes of this study were to compare (1) reoperation rate, (2) mortality and (3) the postoperative change of walking ability between patients undergoing internal fixation (IF) and those undergoing bipolar hemiarthroplasty (HA) due to this type of fracture based on the data from the Korean Hip Fracture Registry.

MATERIALS AND METHODS

Between July 2014 and June 2016, we extracted 623 unstable intertrochanteric fractures (616 patients aged ≥ 65 years) according to the classification of the Association for the Study of Internal Fixation-American Orthopaedic Trauma Association. Among the 564 patients, 396 were treated with IF (IF group) and 168 with bipolar HA (HA group). We compared the reoperation rate and mortality between IF group and HA group. In patients, who were followed up more than 2 years after the surgery, we compared the postoperative change of walking activity from ambulatory outdoors (Koval's grade 1, 2, 3) to housebound (Koval's grade 4, 5, 6).

RESULTS

The rate of reoperation was higher in the IF group (24/396, 6.1%) than in the HA (4/168, 2.4%) (p = 0.046). At the final follow-up, 79 (35.7%) of the 221 IF patients became housebound, whereas 21 (23.3%) of the 90 HA patients became housebound (p = 0.022).

CONCLUSION

This study showed HA was associated with lower rate of reoperation and lower decrement rate of walking ability compared to IF in elderly patients with unstable intertrochanteric fractures.

Comparative evaluation of postoperative health status and functional outcome in patients treated with either proximal femoral nail or hemiarthroplasty for unstable intertrochanteric fracture

PURPOSE

This study aimed to compare functional recovery and change in morbidity status from the preoperative levels among patients who underwent two different surgical treatments for unstable intertrochanteric fracture.

METHODS

This retrospective comparative study enrolled 140 patients (aged >80 years) who were referred to two hospitals. Of these, 64 were treated using proximal femoral nail (PFN) and 76 were treated using hemiarthroplasty (HA). To evaluate functional recovery, primary outcome measures were cumulative illness rating scale (CIRS) score to evaluate changes in morbidity status, activity of daily living (ADL) index, and mobility scores.

RESULTS

The proportion of patients who experienced increased CIRS scores in the HA group was higher at the 3-month follow-up (p = 0.02) but similar at the 6-month follow-up (p = 0.2) in comparison to the PFN group. Treatment with HA, American Society of Anesthesiologists scores of 3-4, and lower, preoperative ADL indexes were the major predictors of increased postoperative CIRS score. Impaired ambulatory ability and the need for walking aids were significantly higher in the PFN group at the 3-month follow-up (p = 0.01 and p = 0.02, respectively) but similar at the 6-month follow-up with respect to the HA group. PFN treatment and high patient body mass index were the major predictors of decreased ambulatory ability at postoperative 3 months.

CONCLUSION

HA has several advantages, including early mobilization and decreased dependency. However, it is associated with greater blood loss, a higher need for blood transfusion, and longer surgical duration than PFN, all of which are predisposing factors for significantly higher risk of reduced CIRS scores.

[Treatment of AO/OTA type 31-A3 intertrochanteric fracture with proximal femoral nail antirotation combined with mini plate reconstruction of lateral femoral wall]

OBJECTIVE

To explore the effectiveness of proximal femoral nail antirotation (PFNA) combined with mini plate for reconstruction of lateral femoral wall in the treatment of type AO/Orthopaedic Trauma Association (AO/OTA) type 31-A3 intertrochanteric fracture.

METHODS

The clinical data of 70 elderly patients with AO/OTA type 31-A3 intertrochanteric fracture treated between January 2013 and January 2018 were retrospectively analyzed. They were divided into group A (PFNA alone, 35 cases) and group B (PFNA combined with mini plate reconstruction of lateral femoral wall, 35 cases). There was no significant difference in the general data of gender, age, side, cause of injury, time from injury to operation between the two groups ( P>0.05). The operation time, intraoperative blood loss, fracture healing time, postoperative complications, and the tip apex distance (TAD) at 2 months after operation were recorded and compared between the two groups. Harris hip score was used to evaluate the function at 12 months after operation.

RESULTS

Both groups were followed up 9-21 months, with an average of 16.6 months. The operation time and intraoperative blood loss in group A were significantly less than those in group B ( P<0.05); there was no significant difference in TAD between the two groups at 2 months after operation ( t=0.096, P=0.462). There were 5 complications (14.3%) occurred in group A, including 2 cases of blade perforating from the hip joint, 2 cases of screw back out, and 1 case of bone nonunion; only 1 case (2.9%) in group B had screw back out after operation; there was no significant difference in the incidence of complications between the two groups ( χ 2=2.917, P=0.088). All the fracture healed in group B, and 1 patient in group A suffered bone nonunion and eventually main nail fracture. The healing time of fracture in group A [(15.6±2.7) weeks] was significantly longer than that in group B [(12.5±2.5) weeks], showing significant difference ( t=2.064, P=0.023). At 12 months after operation, according to Harris score, the results were excellent in 5 cases, good in 9 cases, fair in 13 cases, and poor in 8 cases in group A, the qualified rate (Harris score>70) was 77.14%; and the results were excellent in 7 cases, good in 11 cases, fair in 16 cases, and poor in 1 case in group B, the qualified rate was 97.14%; there was significant difference in the qualified rate between the two groups ( χ 2=6.248, P=0.012).

CONCLUSION

Compared with PFNA alone, the treatment of AO/OTA type 31-A3 intertrochanteric fracture with PFNA combined with mini plate reconstruction of lateral femoral wall can significantly reduce postoperative complications, promote fracture healing, and improve functional recovery of patients after operation.

The effect of surgery type on mortality in elderly patients with pertrochanteric femoral fracture: A Korean nationwide cohort study

BACKGROUND/OBJECTIVE

The purpose of this study is to analyze the effect of surgical methods on mortality and the relative risk of patients who underwent internal fixation (IF) or hemiarthroplasty (HA) after being diagnosed as a pertrochanteric fracture over 65 years old in a Korean nationwide cohort with a single insurance medical system.

METHODS

The Korean National Health Insurance Service-Senior cohort (NHIS-Senior, NHIS-2018-2-111) was used in this study. The eligibility criteria for incident hip fracture patients were the following: (1) first-time admission to acute care hospitals (index admission) with pertrochanteric fracture (ICD-10 S721), (2) three years of hip fracture-free period, (3) recipients of typical surgeries including IF, HA, (4) age between 65 and 99.

RESULTS

a total of 7223 patients were enrolled in the cohort. There were 1662 patients (23%) in the HA group and 5561 patients (77%) in the IF group. Mortality rates of the IF group and HA group were 13.46 and 17.94 cases per 100 person-years, respectively. In the multivariable-adjusted Cox proportional hazard model, the HA group had 1.22 times more hazard of all-cause mortality than IF group (aHR 1.22, 95% CI 1.13-1.32). In subgroup analysis, aged 65-79 and female patients showed a prominent association between surgery type and mortality (aHR 1.52, 95% CI 1.29-1.79).

CONCLUSIONS

In patients with pertrochanter fracture over 65 years, 1.22-fold mortality rate was observed when HA was performed compared to that of IF, and the difference in mortality was particularly prominent within 1-year after surgery.

Is rigid fixation of the greater trochanter necessary for arthroplasty of intertrochanteric fractures?

INTRODUCTION

Stable fixation of the greater trochanter fracture fragments is necessary in arthroplasty of intertrochanteric hip fractures, as nonunion of the greater trochanter fracture comminution may result in impaired function or dysfunction of the abductor lever arm.

HYPOTHESIS

The ethibond suture technique is an efficient method for fixation of the greater trochanter fracture fragments.

MATERIALS AND METHODS

A total of 47 cases were studied. The mean age of the patients was 80.6 years, and the minimum follow-up was 6 months. Radiologic evaluation was done by examination of greater trochanter healing and measurement of migration of the greater trochanter fragment. Functional evaluation was done by comparison of pre-injury and postoperative ambulation status.

RESULTS

The mean migration of the greater trochanter fragment with ethibond sutures was 5.98mm. Union was achieved in 76.6%, and the nonunion rate was 23.4%. 86.9% of patients had no difference in ambulation or had a difference of only 1 level by the Koval score after treatment compared to their pre-injury status.

DISCUSSION

The ethibond suture technique provides good fixation of the greater trochanter fragments in arthroplasty of intertrochanteric hip fractures.

LEVEL OF EVIDENCE

IV, Case series.

Cementless distal fixation modular stem without reconstruction of femoral calcar for unstable intertrochanteric fracture in patients aged 75 years or more

INTRODUCTION

Hemiarthroplasty (HA) using standard-length femoral stem with reconstruction of femoral calcar or using calcar replacing prosthesis for unstable intertrochanteric fractures in elderly patients is a viable option. However, both of the techniques increase the complexity of procedure, operative trauma and complication. This study evaluated the clinico-radiological results of the MP-Link cementless distal fixation modular prosthesis without reconstruction of femoral calcar for unstable intertrochanteric fracture in patients aged 75 years or more.

HYPOTHESIS

Bipolar HA using the MP-Link cementless distal fixation modular prosthesis for unstable intertrochanteric fractures in patients aged 75 years or more, do not need to reconstruct the femoral calcar.

MATERIALS AND METHODS

Forty-two patients (42 hips) underwent bipolar HA using the MP-Link cementless distal fixation modular prosthesis for unstable intertrochanteric fractures from January 2008 to January 2012. Five (11.9%) patients were lost to follow-up. The 37 remaining patients (37 hips) were available for evaluation. The mean age was 83.9±5.2 years. Their clinico-radiological data were prospectively gathered.

RESULTS

All of 37 patients, 4 patients (10.8%) died within 1 year postoperatively. At the final follow-up, 31 (83.8%) out of 37 patients were regained preoperative ambulatory status; the mean Harris hip score (HHS) of the 15 patients who died during the follow-up period of 7-59 months, was 84.5±2.4 points; the 22 healthy patients were followed for 68.6±14.7 months, with mean HHS of 84.6±2.8 points. Radiologically, none of stems had evidence of loosening; 16 stems had subsidence of 2-3mm without clinical significance; the bone in-growth fixation was achieved in 24 patients and stable fibrous fixation in 13 patients.

DISCUSSION

Bipolar HA using the MP-Link cementless distal fixation modular prosthesis for unstable intertrochanteric fractures in patients aged 75 years or more, without reconstruction of the femoral calcar, may achieve a satisfactory clinico-radiological outcome, and could regain preoperative ambulatory status in most patients (83.3%).

LEVEL OF EVIDENCE

IV, Retrospective study.

Comparison of complications and functional results of unstable intertrochanteric fractures of femur treated with proximal femur nails and cemented hemiarthroplasty

A prospective, comparative study was done over a period of 3 years to compare the complications and functional results of two treatment modalities of unstable intertrochanteric fractures of the femur in the elderly; i.e closed reduction and internal fixation (CRIF) with proximal femur nail (PFN) and primary cemented hemireplacement arthroplasty (HRA) with bipolar prosthesis. 100 elderly patients with unstable intertrochanteric fractures of femur were studied over a period of 3 years. 50 patients underwent CRIF with PFN and 50 patients were treated with primary cemented hemireplacement arthroplasty with bipolar prosthesis. Harris Hip score analysis revealed that the difference between the patients treated with cemented hemiarthroplasty and proximal femoral nailing was statistically significant in favour of the hemiarthroplasty group within the first 3 months. However, this difference diminished at the 6th month time point and reversed at the 12 month time point indicating a better functional outcome of Proximal Femur Nail in the long term. Although cemented hemireplacement arthhroplasty allows early pain free mobilization and has a good short term outcome, over time it is associated with a variety of complications which significantly affects quality of life of patients. On the other hand, although patients treated with PFN had delayed post op mobilization, they had better results when followed up at 1 year post surgery.

Mid-Term Survivals After Cementless Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fractures in Elderly Patients

BACKGROUND

Treatment of unstable intertrochanteric fracture in elderly patients remains challenging. The purpose of this prospective study is to determine clinical and radiological results of cementless bipolar hemiarthroplasty using a fully porous-coated stem in osteoporotic elderly patients with unstable intertrochanteric fractures with follow-up over 5 years.

METHODS

From January 2010 to December 2011, we performed 123 cementless bipolar hemiarthroplasties using fully porous-coated stem to treat unstable intertrochanteric fractures in elderly patients with osteoporosis. Clinical and radiographic evaluations were performed.

RESULTS

Fifty-three patients died and 14 patients were lost during the follow-up period. Mean follow-up period was 61.8 months postoperatively. Their mean Harris hip score was 77 points (range 36-100). None of these hips had loosening of the stem or osteolysis. Postoperative complications included nonunion of greater trochanter in 2 hips and dislocation in 2 hips. Two patients were reoperated due to periprosthetic fracture. One patient underwent implant revision due to periprosthetic infection. Thirty-one patients maintained walking activities similar to those before fracture. With follow-up period of 83 months, cumulative survival rates were 97.3% and 99.1% with reoperation for any reason and femoral stem revision as endpoint, respectively.

CONCLUSION

Cementless bipolar hemiarthroplasty using a fully porous-coated stem is a useful surgical treatment option for unstable intertrochanteric fracture in elderly patients with osteoporosis.

IS FUNCTIONAL OUTCOME BETTER AFTER ARTHROPLASTY FOR TROCHANTERIC FRACTURES IN OLDER ADULTS?

Objectives:

This article evaluated functional recovery and mortality after surgery to repair trochanteric fracture with regard to treatment technique through one year of follow-up.

Method:

Eighty consecutive patients with trochanteric fractures were divided into two groups according to treatment technique (osteosynthesis and arthroplasty). We evaluated patient data including age, sex, time to surgery, total hospital stay, transfusion volume, and functional status according to FIM (Functional Independence Measure) scores. Scores for FIM were assessed three times: prior to fracture, six months after surgery, and one year after surgery.

Results:

Patients who received osteosynthesis had shorter hospital stays than arthroplasty patients. The arthroplasty group had significantly higher functional independence six months after surgery, while no difference was detected one year after surgery. Patient age, transfusion volume, and FIM scores were detected as significant predictors of mortality.

Conclusion:

Trochanteric fractures lead to unavoidable functional loss, although this can be reduced in the short term by treating with arthroplasty instead of osteosynthesis. Age, transfusion and functional situation predict one-year mortality for patients with trochanteric fractures. The patient’s functional situation must be considered when choosing treatment for trochanteric fractures in order to reduce patient morbidity. Level of Evidence II; Therapeutic prospective study.

Comparison of intramedullary fixation and arthroplasty for the treatment of intertrochanteric hip fractures in the elderly: A meta-analysis

BACKGROUND

More and more studies conduct to compare intramedullary fixation (IMF) with arthroplasty in treating intertrochanteric hip fractures, but it remains controversy. The aim of this meta-analysis was to find out whether IMF or arthroplasty was more appropriate for treating intertrochanteric hip fractures in elderly patients.

METHODS

Relevant studies were searched in the electronic databases of PubMed, Embase, and The Cochrane Central Register of Controlled Trials from January 1980 to September 2016 with English language restriction. Surgical information and postoperative outcomes were analyzed using RevMan 5.3 version.

RESULTS

A total of 1239 patients from 11 studies which satisfied the eligibility criteria were included. Compared with IMF, the use of arthroplasty reduced implant-related complications (odds ratio [OR]: 2.05, P = .02) and reoperation rate (OR: 7.06, P < .001), and had similar length of hospital stay (weighted mean difference [WMD]: -0.41, P = .63). However, IMF reduced blood loss (WMD: -375.01, P = .001) and transfusion requirement (OR: 0.07, P < .001), shorter operation time (WMD: -18.92, P = .010), higher Harris hip score (WMD: 4.19, P < .001), and lower rate of 1-year mortality (OR: 0.67, P = .02) compared with arthroplasty.

CONCLUSION

The main treatment of intertrochanteric hip fractures is internal fixation using IMF. In the absence of concrete evidence, arthroplasty should be undertaken with caution in carefully selected patient and surgeon should be aware of the increased complexity of doing the arthroplasty in these elderly patients. Further high-quality randomized controlled trials (RCTs) are needed to provide robust evidence and evaluate the treatment options.

Early Rehabilitation in Elderly after Arthroplasty versus Internal Fixation for Unstable Intertrochanteric Fractures of Femur: Systematic Review and Meta-Analysis

The purpose of this study was to compare the outcomes focusing on the functional outcome and clinical results of replacement arthroplasty (AP) vs. internal fixation (IF) for the treatment of unstable intertrochanteric femoral fracture in elderly. Systematic review and meta-analysis were performed on 10 available clinical studies (2 randomized controlled trials and 8 comparative studies). Subgroup analysis was performed by type of methodological quality. Partial weight bearing time in AP group was earlier than that in IF group (SMD = -0.86; 95% CI = -0.42, 1.29; P = 0.050). The overall outcomes such as mortality, reoperation rate, and complication showed no significant diffrence between the 2 groups (AP vs. IF). Therefore, this systematic review demonstrates that AP provides superior functional outcomes especially earlier mobilization, as compared to IF in elderly patients with an unstable intertrochanteric femoral fracture.

Comparison of Post-Operative Muscular Strength Between Gamma Nailing and Hemiarthroplasty System in Femoral Intertrochanteric Fractures

Background:

The current study focuses on the comparison of postoperative muscular strength around the hip joint of patients with femoral intertrochanteric fractures treated either by cephalo-medullary (CM) nailing or a new bipolar hip prosthesis (BHP), an especially attached device to secure displaced greater trochanteric fragment.

Methods:

Twenty patients treated with CM nailing were age- and sex- matched with a control group of 20 patients treated with BHP. Maximum isometric forces at the bilateral hip joint were measured during the follow up period. Means of 3 measurements were represented.

Results:

The mean and standard deviation values (kg) of muscle strength at the non-operative/ operative side in the CM nailing group were as follows: flexion strength 9.5±4.7/8.5±4.9 (P=0.06), extension strength 6.2±3.5/5.5±3.7 (P=0.08), abduction strength at 0 degrees 7.7±3.5/6.2±2.8 (p=0.002), abduction strength at 10 degrees 5.5±2.0/4.2±2.0 (p=0.001). In the BHP group, mean and standard deviation values of muscle strength at the non-operative/ operative side were as follows: flexion strength 6.5±2.8/6.0±3.4 (P=0.08), extension strength 4.4±0.9/4.4±0.6 (P=0.83), abduction strength at 0 degrees 5.1±1.9/5.0±1.6 (p=0.12), and that at 10 degrees 4.7±1.4/4.6±1.3 (p=0.10).

Conclusion:

Our results demonstrate that CM nailing may cause a 25-30% decrease in postoperative muscle strength around the hip joint, particularly during hip abduction. With the new BHP, greater trochanter reduction is achieved allowing early weight bearing and maintaining strength in abduction. Surgeons should consider postoperative muscular strength as one of the necessary factors for selection of the appropriate surgical procedure.

Level of Evidence:

Therapeutic Level III.

Is arthroplasty preferable to internal fixation for the treatment of extracapsular fracture of the upper femur in the elderly?

INTRODUCTION

Although internal fixation is the reference treatment for extracapsular fracture of the upper femur, indications for arthroplasty are broadening, especially in unstable comminutive fracture in fragile bone. The present study hypothesis was that arthroplasty reduces early mortality and morbidity and provides better recovery of autonomy in over-80 year-old patients than does internal fixation.

MATERIAL AND METHODS

A prospective multicenter study was conducted on 8 sites. Internal fixation was systematically used in 5 centers; arthroplasty was used systematically in 1 center, and reserved for unstable fracture in 2 centers. A total of 697 patients aged over 80 years (mean age, 85±5 years), presenting with extracapsular fracture, were included; 521 were treated by internal fixation and 176 by arthroplasty. Results were studied on multivariate analysis of ASA score, blood loss, transfusion, and also of treatment modality as an independent factor for early (first 6 months) mortality and morbidity (mechanical, general and nutritional complications) and functional outcome (autonomy and dependence).

RESULTS

Overall mortality was 19.2%. Autonomy deteriorated in 56% of patients alive at 6 months and dependence worsened in 44%. Two percent of those managed by internal fixation underwent revision for disassembly (n=8) or infection (n=1). Eight percent of those managed by arthroplasty underwent revision for dislocation (n=4), implant loosening (n=3) or infection (n=7). On univariate analysis, mortality was higher in the arthroplasty group (25%) than with internal fixation (17%; P=0.002), as were blood loss (425±286mL versus 333±223mL; P<0.0001), transfusion rate (61% versus 32%; P<0.0001) and infection (4% versus 0.2%; P<0.001). On multivariate analysis, however, treatment modality no longer showed impact on mortality or on morbidity and autonomy at 6 months. Nutritional status was better conserved at 6 months following arthroplasty, but dependence worsened. Poor preoperative autonomy, ASA score, and nutritional status and time to treatment were independent factors for mortality. Transfusion, associated with onset of mechanical complications, significantly increased dependence.

CONCLUSION

Type of treatment had little impact on mortality, morbidity or functional outcome. Differences seemed more related to preoperative functional and nutritional status.

LEVEL OF EVIDENCE

III, prospective case-control study.

Unstable intertrochanteric versus displaced femoral neck fractures treated with cementless bipolar hemiarthroplasty in elderly patients; a comparison of 80 matched patients

BACKGROUND

While hemiarthroplasty (HA) is considered the treatment of choice for displaced femoral neck (FN) fractures in elderly patients, HA has been partly performed as an alternative treatment option for unstable intertrochanteric (IT) fractures. However, there is a paucity of data regarding the risk and availability of HA for unstable IT fractures compared to HA for displaced FN fractures in elderly patients. Therefore, we performed this case-control study to determine whether HA for unstable IT fractures provides clinical results and survival comparable to HA for displaced FN fractures in elderly patients.

HYPOTHESIS

HA for unstable IT fractures in elderly patients provides clinical results and 1-year survival comparable to HA for displaced FN fractures in the same aging group.

MATERIALS AND METHODS

We identified 80 patients aged 75years or older, who underwent cementless bipolar HA for unstable IT fracture (AO/OTA type 31-A2.2/3 and A3.3). Their clinical results and 1-year survival were compared to the matched control group of 80 patients with displaced FN fractures (Garden type 3 and 4) treated with the same procedure. Perioperative results, postoperative complications, and 1-year survival were investigated between the two groups. Functional outcome was assessed by walking status and Harris hip score (HHS) 6months after surgery.

RESULTS

Operating time was significantly longer in the IT group than the FN group (97.3min [50 to 255] vs. 79.3min [40 to 175], P=0.016). However, the two groups did not significantly differ regarding perioperative results, such as total blood loss, transfusion, intraoperative fracture, length of hospital stay, and postoperative complication. No statistically significant differences in walking status and HHS were observed between the groups. No significant difference in cumulative survival was observed between the two groups (P=0.836), with a 1-year survival rate of 80% (95% confidence interval [CI], 71.8 to 87.5) in the IT group and 82% (95% CI, 73.1 to 89.4) in the FN group.

CONCLUSION

HA for unstable IT fractures in elderly patients showed clinical results and 1-year survival comparable to HA as the treatment of choice for displaced FN fractures in the same aging group.

LEVEL OF EVIDENCE

Level III, case-control study.

Proximal femoral nail shows better concordance of gait analysis between operated and uninjured limbs compared to hemiarthroplasty in intertrochanteric femoral fractures

PURPOSE

The purpose of this study was to compare the results of pedobarographic gait analysis between the patients treated by proximal femoral nail or bipolar partial hemiarthroplasty due to intertrochanteric fractures.

METHODS

Thirty-seven patients with a minimum 1-year follow-up who had been operated for intertrochanteric fractures were evaluated clinically, radiologically and with pedobarographic gait analysis. Proximal femoral nail had been performed to 21 patients (group A), whilst 16 patients had been operated by partial bipolar hemiarthroplasty (group B). Pedobarographic analysis was performed by measuring plantar pressure, force and contact area values in both static and dynamic manner. Pedobarographic results of operated limb were compared among groups. Same data's also were compared between operated and uninjured limbs in each group to determine any asymmetry on weight-bearing.

RESULTS

Average follow-up period in group A and group B was 36 (12-56) and 30 (12-48) months, respectively. There were no statistically significant differences among groups in terms of age, gender, body mass index, type and side of fracture, follow-up period, leg length discrepancy and postoperative hip scores. When the pedobarographic results of operated limb were compared, group B showed much more plantar force and pressure values than group A, on both static and dynamic evaluations. If the evaluation was taken into consideration to comparison of pedobarographic results between operated and uninjured limbs in each group, we found asymmetry in static load bearing, caused by higher load on uninjured limb in both groups. However, there was no statistically significant asymmetry between operated and uninjured limbs in respect to dynamic pedobarographic parameters for patients in group A. On the contrary, operated limbs in group B exposed much more plantar force and pressure values than uninjured limbs, which indicated asymmetric weight-bearing on dynamic evaluation.

CONCLUSIONS

Assessment of pedobarographic parameters can be another way of measuring the results of treatment in intertrochanteric fractures. Uninjured limbs of patients expose much more loading than operated limbs in postoperative static evaluation for both treatment options. However in dynamic evaluation, there is a better concordance of gait analysis between both limbs in patients operated by proximal femoral nail.

Arthroplasty for Pertrochanteric Hip Fractures

The mainstay of treatment of pertrochanteric fractures is internal fixation using a sliding hip screw or a cephalomedullary device. However, in patients with ipsilateral hip osteoarthritis or avascular necrosis of the femoral head, or inflammatory arthritis, arthroplasty should be considered as the primary treatment modality to reduce the likelihood of a secondary procedure. Unstable fracture patterns with concomitant poor bone quality represent a challenge for internal fixation, with high rates of lag screw cut-out and hardware failure. Prosthetic replacement for unstable pertrochanteric fractures has therefore been considered as an alternative primary treatment option. Further prospective randomized trials are required.

Prospective study of the reproducibility of X-rays and CT scans for assessing trochanteric fracture comminution in the elderly: a series of 110 cases

BACKGROUND

Trochanteric fractures are common but difficult to analyse in the elderly on plain X-rays. Fixation failures are related to the severity of the comminution, but comminution and the degree of instability are not easy to determine on standard X-rays. Use of computed tomography (CT) improves assessment of complex fractures, but this finding has not been confirmed versus intraoperative data. The primary objective of this prospective study was to determine the error rate when evaluating comminution on X-rays and CT scans. The secondary objectives were to determine whether CT data on comminution and stability were consistent with intraoperative findings and to define the fracture characteristics.

HYPOTHESIS

Standard X-ray assessment underestimates the complexity of trochanteric fractures and is not very reproducible.

METHODS

Between January and December 2013, all proximal femur fractures in the trochanter area of patients aged 75 years or older (mean age 85) were analysed prospectively with standard X-rays and computed tomography (CT). One hundred and ten patients (88 women and 22 men) with trochanteric fractures were included in the study. Fracture stability was evaluated using the Müller AO classification; the other fracture characteristics were evaluated independently. A senior surgeon evaluated the anonymised X-rays. A radiologist specialised in musculoskeletal imaging interpreted the CT scan images. All patients underwent total hip arthroplasty (110 patients) and 104 fixations of the greater trochanter. The X-ray and CT findings were compared to the intraoperative findings (gold standard) to evaluate their reproducibility.

RESULTS

The reproducibility of the X-ray evaluation was poor for comminution, with a kappa of 0.4, sensitivity of 44 % and a negative predictive value of 29 % but a positive predictive value and specificity of 100 %. The CT evaluation had a kappa of 0.94, sensitivity of 95 % and negative predictive value of 79 %. According to the AO classification, unstable fractures were found in 65 patients based on X-rays, 80 patients based on CT scan and 83 patients based on intraoperative findings. Comminution was mainly identified during surgery; it was medial in 34 % of cases, posterior in 22 % and posteromedial in 21.8 %.

DISCUSSION AND CONCLUSION

In the current study, 75.4 % of fractures were complex and unstable, with medial and/or posterior comminution present in three-quarters of these fractures. X-ray assessment underestimates posterior comminution and the complexity of the fracture line and was not very reproducible. The current results of this study suggest that comminution contributes to instability and that this finding is not taken into account in the AO classification, which is not well suited for this type of fracture and raises the question of how to best evaluate and treat these fractures.

LEVEL OF EVIDENCE

Prospective diagnostic study, Level III.

Unstable intertrochanteric femur fractures in geriatric patients treated with the DLT trochanteric nail

OBJECTIVE

To evaluate clinical-functional and radiological results of geriatric patients with unstable intertrochanteric femur fracture treated with intramedullary nail.

MATERIALS AND METHODS

Thirty-two patients treated with intramedullary nail (DLT trochanteric nail) due to unstable intertrochanteric femur fractures were reviewed retrospectively. Fractures 31-A2 and 31-A3 (AO classification) were evaluated. Operation time, blood loss, and blood transfusion requirements, hospitalization period, time to fracture union were evaluated and perioperative and postoperative complications were recorded. According to the modified Baumgaertner criteria fracture reduction was analyzed radiologically, and nail tip-apex distance was measured. Femoral neck-shaft angle was also evaluated. Harris Hip Score for clinical evaluation and Kyo criteria for walking capacity were used.

RESULTS

The mean age was 72 years (65-81), mean follow up time was 18.3 months (12-26). Nineteen patients had type 31-A2 and 13 had type 31-A3 fractures. Mean operation time was 36.3min (25-45), blood loss 185.9ml (100-250). Blood transfusion was required in 7 patients. The average hospitalization duration was 6 days (4-14) while the time to surgery from admission was 2.9 days (2-6). Radiologically, in 21 of the cases fracture reduction was well (65.6%), acceptable in 9 (28.1%), and poor in 2 (6.3%). In early postoperative period, the mean collo-diaphyseal angle was 129.1° (120-140°), mean tip-apex distance was 15.5mm (10-27). The mean Harris Hip Score was 63.4 (38-90). Two patients (6.3%) had excellent, 21 patients (65.6%) had good, 7 patients (21.8%) had moderate, and 2 patients (6.3%) had poor results. Walking capacity in the last follow-up in 20 of the cases (62.5%) was pre-fracture level. While complications were observed in seventeen patients (53.1%) (5 superficial wound infections, 5 fractures of the greater trochanter, 3 cases of secondary varus angulation and 4 cases of heterotopic ossification) none of them required additional surgery, no implant failures or cut-outs were observed.

CONCLUSION

Functional and radiological results are satisfactory in using intramedullary nailing in the treatment of geriatric patients with unstable intertrochanteric fractures. Optimum surgical technique can minimize the risk of implant-related complications.

Trans trochanteric approach with coronal osteotomy of the great trochanter: A new technique for extra-capsular trochanteric fracture patients treated by total hip arthroplasty (THA) in elderly

Several surgical approaches could be used in hip arthroplasty or trauma surgery: anterior, anterolateral, lateral, posterior (with or without trochanterotomy), using or not an orthopedic reduction table. Subtrochanteric and extra-capsular trochanteric fractures (ECTF) are usually treated by internal fixation with mandatory restrictions on weight bearing. Specific complications have been widely described. Mechanical failures are particularly high in unstable fractures. Hip fractures are a major public health issue with a mortality rate of 12%–23% at 1 year. An alternative option is to treat ECTF by total hip arthroplasty (THA) to prevent decubitus complications, to help rapid recovery, and to permit immediate weight bearing as well as quick rehabilitation. However, specific risks of THA have to be considered such as dislocation or cardiovascular failure. The classical approach (anterior or posterior) requires the opening of the joint and capsule, weakening hip stability and the repair of the great trochanter is sometimes hazardous. For 15 years, we have been treating unstable ECTF by THA with cementless stem, dual mobility cup (DMC), greater trochanter (GT) reattachment, and a new surgical approach preserving capsule, going through the fracture and avoiding joint dislocation. Bombaci first described a similar approach in 2008; our trans fractural digastric approach (medial gluteus and lateral vastus) is different. A coronal GT osteotomy is performed when there is no coronal fracture line. It allows easy access to the femoral neck and acetabulum. The THA is implanted without femoral internal rotation to avoid extra bone fragment displacement. With pre-operative planning, cup implantation is easy and stem positioning is adjusted referring to the top of the GT after trial reduction and preoperative planning. The longitudinal osteotomy and trochanteric fracture are repaired with wires and the digastric incision is closed. This variant of Bombaci approach could be use routinely for hemiarthroplasty or THA in the cases of unstable ECTF. It reduces complications usually linked to this procedure. Blood loss, operating time, and pain are limited, allowing fast recovery in order to decrease morbidity and mortality.

Hemi replacement arthroplasty for unstable inter-trochanteric fractures of femur

INTRODUCTION

Unstable inter-trochanteric fracture in the geriatric population is a common injury and is associated with poor bone quality, excessive collapse, loss of fixation, and cut-out of the lag screw, are the common problems of attempts to fix these fractures. Present study is an attempt to evaluate the functional outcome of primary cemented bipolar hemiarthroplasty in unstable inter-trochanteric fractures in elderly patients.

MATERIALS AND METHODS

This prospective study included 25 cases with unstable inter-trochanteric fracture of femur between 60 -75 y of age in whom primary Cemented Bipolar hemi - arthroplasty was performed. The patients were followed up at six week, three month, six month and one year postoperatively and assessed using Harris Hip Score (HHS), Lower Extremity Functional Scale (LEFS), Visual analogue scale (VAS) for evaluation of outcome.

RESULTS

The mean HHS score was 78.86+8.13 by the end of one year. Similarly mean LEFS score was 34.36+7.01 by the end of one year, whereas the mean pain score on VAS Scale by the year end was 1.04+1.02.

DISCUSSION

The changes in HHS, LEFS and VAS up to six months periods are much greater which starts showing a stable trend thereafter. Fair to good scores were observed in all the patients. We compared our results with those reported by other authors and our study gave quite comparable results. We also used lower extremity function status score (LEFS) for assessment of functional ability. The purpose of its use was that while Harris Hip Score (HHS) provides information on a multitude of factors, LEFS is more patient oriented and provides the correct information about the level of activities a patient can resume post-operatively and can be offered as a self assessment tool. No significant complication except for grade I pressure sores in four patients were seen in postoperative period but they all resolved with proper nursing care by six week follow up. No patient required revision surgery.

CONCLUSION

The authors believe that primary cemented bipolar hemiarthroplasty for unstable inter-trochanteric fractures of femur in elderly does provide early ambulation, good functional outcome, pain free joint with minimal complications without the need for revision surgery.

Primary Cementless Hip Arthroplasty in Unstable Intertrochanteric Femur Fracture in Elderlys: Short-term Results

Purpose

This study was aimed to explore and report the short term results of primary cementless hip arthroplasty in treatment of unstable intertrochanteric femur fracture in elderlys.

Materials and Methods

Between March 2009 and Feburary 2012, 35 arthroplasty cases performed by single surgeon and followed up for more than one year were evaluated. They were 21 females and 14 males with mean age of 78 years (range, 71-92 years). Preoperative evaluation was performed by American Society of Anesthesia score. Retrospective evaluation was performed by operative time, transfusion amount, time to operation days, hospital stay and time to full weight bearing. Clinically, ambulatory ability was checked by Parker and Palmer (P&P) score and function of hip was appraised by Harris hip score (HSS). Radiologically, bone healing of fractured trochanteric fragment and presence of subsidence, stress shielding or osteolysis were checked.

Results

Fracture type was 11 cases of A2.2, 18 cases of A2.3 and 6 cases of A3.3. Femoral stems used were 8 cases of rectangular tapered wedge type and 27 cases of fluted modular distal fixation type. P&P score improved from mean preinjury score of 7.1 to mean postoperative last follow-up score of 6.5. Median HHS at last follow-up was 75. Mean time to full weight bearing was 47 days (24-79 days). Postoperative complications were one case of linear periprosthetic femoral fracture and one case of postoperative dislocation.

Conclusion

Cementless hip replacement arthroplasty could be a good option for unstable intertrochanteric femoral fracture in elderlys.

Treatment of recent trochanteric fracture in adults

Recent trochanteric fracture is frequent in adults, and mainly affects elderly patients who risk loss of independence. Treatment is surgical, of various sorts. Open reduction internal fixation (ORIF) with intra- or extra-medullary implants is the most frequent attitude in these fractures, which usually heal easily. In elderly patients, arthroplasty is an alternative of choice for some authors. These different treatment modalities are presented, focusing on technical details. Possible technical difficulties and the means of dealing with them are considered. Published results help in choosing the treatment most suitable for a particular type of fracture in a particular patient.

Unstable intertrochanteric femur fractures: is there a consensus on definition and treatment in Germany?

BACKGROUND

Extramedullary and intramedullary implants have improved in recent years, although consensus is lacking concerning the definition and classification of unstable intertrochanteric fractures, with uncertainties regarding treatment.

QUESTIONS/PURPOSES

We conducted a national survey of practicing chairpersons of German institutions to determine current perspectives and perceptions of practice in the diagnosis, management, and surgical treatment of unstable intertrochanteric fractures.

METHODS

Between January and February 2010, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 26-question web-based survey regarding three broad domains: fracture classification and instability criteria, implants and surgical treatment algorithms, and timing of operations. Response rate was 42%.

RESULTS

There was a clear preference for use of the AO/OTA fracture classification with geographic variations. Absence of medial support was considered the main criterion for fracture instability (84%), whereas a broken lateral wall and detached greater trochanter were considered by 4% and 5% of the respondents, respectively, to determine instability. Two percent routinely fixed unstable intertrochanteric fractures with extramedullary devices. Ninety-eight percent of German hospitals reportedly perform surgery within 24 hours after admission. Time to surgery was dependent on hospital level, with more direct surgeries in Level I hospitals.

CONCLUSIONS

Despite varying opinions in the literature in recent years, we found some instability criteria (lateral wall breach, a detached greater trochanter) played a minor role in defining an unstable intertrochanteric fracture pattern. Despite recent meta-analyses suggesting clinical equivalence of intra- and extramedullary implants, few respondents routinely treat unstable intertrochanteric fractures with extramedullary plates. Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures.

Hip arthroplasty after failed fixation of trochanteric and subtrochanteric fractures

BACKGROUND AND PURPOSE

Hip arthroplasty is an option for elderly patients with osteoporosis for the treatment of failure after fixation of trochanteric and subtrochanteric fractures, either as a total hip arthroplasty (THA) or as a hemiarthroplasty (HA). We analyzed the reoperation rate and risk factors for reoperation in a consecutive series of patients.

METHODS

All patients (n = 88) operated from 1999 to 2006 with a THA (n = 63) or an HA (n = 25) due to failure of fixation of a trochanteric fracture (n = 63) or subtrochanteric fracture (n = 25) were included. Background data were collected from the patient records. A search was performed in the national registry of the Swedish National Board of Health and Welfare in order to find information on all reoperations. The follow-up time was 5-11 years.

RESULTS

The reoperation rate was 16% (14/88 hips). A periprosthetic fracture occurred in 6 patients, a deep prosthetic infection in 5 patients, and a dislocation of the prosthesis in 3 patients. Standard-length femoral stems had an increased risk of reoperation (11/47) compared to long stems (3/41) (HR = 4, 95% CI: 1.0-13; p = 0.06).

INTERPRETATION

The high reoperation rate reflects the complexity of the surgery. Using long femoral stems that bridge previous holes and defects may be one way to reduce the risk for reoperation.