Clinical and Radiologic Outcomes among Bipolar Hemiarthroplasty, Compression Hip Screw and Proximal Femur Nail Antirotation in Treating Comminuted Intertrochanteric Fractures

Extramedullary versus intramedullary fixation of unstable trochanteric femoral fractures (AO type 31-A2): a systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs.

METHODS

Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI).

RESULTS

Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available.

CONCLUSION

Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.

Bipolar Hemiarthroplasty in Unstable Intertrochanteric Fractures with an Effective Wiring Technique

Purpose

Bipolar hemiarthroplasty has recently been acknowledged as an effective option for treatment of unstable intertrochanteric fracture. Trochanteric fragment nonunion can cause postoperative weakness of the abductor muscle and dislocation; therefore, reduction and fixation of the fragment is essential. The purpose of this study was to perform an evaluation and analysis of the outcomes of bipolar hemiarthroplasty using a useful wiring technique for management of unstable intertrochanteric fractures.

Materials and Methods

A total of 217 patients who underwent bipolar hemiarthroplasty using a cementless stem and a wiring technique for management of unstable intertrochanteric femoral fractures (AO/OTA classification 31-A2) at our hospital from January 2017 to December 2020 were included in this study. Evaluation of clinical outcomes was performed using the Harris hip score (HHS) and the ambulatory capacity reported by patients was classified according to Koval stage at six months postoperatively. Evaluation of radiologic outcomes for subsidence, breakage of wiring, and loosening was also performed using plain radiographs at six months postoperatively.

Results

Among 217 patients, five patients died during the follow-up period as a result of problems unrelated to the operation. The mean HHS was 75±12 and the mean Koval category before the injury was 2.5±1.8. A broken wire was detected around the greater trochanter and lesser trochanter in 25 patients (11.5%). The mean distance of stem subsidence was 2.2±1.7 mm.

Conclusion

Our wiring fixation technique can be regarded as an effective additional surgical option for fixation of trochanteric fracture fragments during performance of bipolar hemiarthroplasty.

A comparison of hemiarthroplasty versus dynamic hip screw fixation for intertrochanteric femoral fractures: a systematic review

INTRODUCTION

Intertrochanteric fractures are predominantly treated by dynamic hip screw (DHS) fixation. However, recent evidence has found acceptable clinical results following hemiarthroplasty for these fractures. Thus, a systematic review was conducted to compare hemiarthroplasty with DHS fixation for intertrochanteric fractures.

METHODS

A computerised search was performed, using the databases Medline, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials, with supplementation from Google Scholar and appropriate reference lists. Studies with comparative data comparing clinical outcomes of hemiarthroplasty versus DHS fixation were included. Data were extracted and quality assessment of the papers performed by 2 reviewers.

RESULTS

320 articles were independently reviewed by the investigators. A total of 10 studies met the inclusion criteria, comprising 2 randomised controlled trials and 8 cohort designs. 7 of the studies assessed unstable fracture patterns. There was no difference in operating time (SMD -1.169 min; 95% CI, -0.657 to 0.689) or blood transfusion volume (SMD-0.110 units; 95% CI, -0.520 to 0.891) between modalities. There was also no difference in length of stay (SMD -0.778 days; 95% CI, -0.606 to 0.336), mortality (RR 0.942; 95% CI, 0.749-1.183) or major complications. Hemiarthroplasty conferred significantly better Harris Hip Scores at 12 months (SMD 12.3; 95% CI, 0.0135-2.789) and allowed earlier weight-bearing than DHS fixation.

DISCUSSION

Qualitative and quantitative compilation of the included studies demonstrates hemiarthroplasty to result in better functional scores and a quicker time to weight-bearing than DHS fixation for intertrochanteric fractures. Results are comparable for other major parameters, including operative time, length of stay and mortality. Thus, hemiarthroplasty is a suitable alternative to DHS fixation for unstable intertrochanteric fractures in elderly patients.

A Comparative Study of Hip Arthroplasty and Closed Reduction Proximal Femur Nail in the Treatment of Elderly Patients with Hip Fractures

Objective

To compare the clinical effect of hip arthroplasty and closed reduction intramedullary nailing of proximal femur in the treatment of elderly hip fracture patients.

Methods

There are 90 elderly hip fracture patients being recruited in the present study. Fifty patients in Group A received closed reduction intramedullary nailing of proximal femur, and 40 patients in Group B received hip arthroplasty. All patients were followed up for 12 months after surgery, clinical outcomes included surgical indicators, visual analog scale (VAS) score, Harris score, quality of life, mental status, and complications.

Results

The surgery time, bleeding volume, infusion volume of patients in Group A are all significantly lower than those in Group B (p < 0.05), while the weight-bearing activity time and first workout time of Group A are all significantly higher than those in Group B (p < 0.05). The VAS score in patients of Group A at 1 week postoperative is significantly lower than that in patients of Group B (p < 0.05). The Harris score in patients of Group A at 3, 6, and 12 months postoperative are all significantly higher than those in patients of Group B (p < 0.05), and the excellent and good rate of hip function recovery at 12 months postoperative in patient of Group A is significantly lower than that in patients of Group B (80% vs. 95%, p < 0.05). Furthermore, The score of SF-36 standardized physical component, SF-36 standardized mental component and Barthel in patients of Group A at 6 months postoperative are significantly lower than those in patients of Group B (p < 0.05), and the score of mini-mental state examination is significantly higher (p < 0.05), while there are not significantly different at 12 months postoperative (p > 0.05). The incidence of postoperative complications in Group A was significantly lower than that in Group B (10% vs. 27.5%, p < 0.05).

Conclusion

Elderly hip fracture patients treated with closed reduction intramedullary nailing of proximal femur has less surgical trauma and lower complication rates, but slower postoperative recovery compared with hip arthroplasty.

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.

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

BACKGROUND

The literature has limited evidence regarding the mid-term survivals of cemented calcar-replacement bipolar hemiarthroplasty (HA) in elderly patients with unstable intertrochanteric (IT) fracture. The purpose of the present study was to evaluate clinical and radiological outcomes of cemented calcar-replacement bipolar HA for unstable IT fractures in elderly patients.

METHODS

One hundred and twenty-two patients with the mean age of 80.6 years were enrolled in this retrospective study after they met the selection criteria. Demographics, main clinical characteristics, and operative data were recorded for all patients. Functional outcomes were assessed according to Koval's categories. Clinical and radiological evaluations were performed. Kaplan-Meier survival analysis was used to construct the cumulative survival rate. The mean follow-up time was 25.7 ± 2.9 months (ranges 0-72 months).

RESULTS

Based on Koval's categories, 3 or 4-level decrease was detected in 21 patients (17%). Three patients (2 periprosthetic infections, 1 periprosthetic fracture) underwent reoperation during follow-up. No patient underwent revision of bipolar HA prosthesis. Femoral stem loosening and stem subsidence was the most common complication, observed in 22 patients (18%), followed by acetabular erosion that was seen in 12 patients (9.8%). The mean cumulative survival rate of prosthesis was 56.5% (95% confidence interval: 51.3-61.6).

CONCLUSION

Based on the results of our study, cemented calcar-replacement HA is an appropriate treatment option in elderly patients with unstable IT fractures owing to the advantages of satisfactory functional outcomes and lower reoperation rates. However, orthopedic surgeons should consider the low survival rates of cemented calcar-replacement HA prosthesis because of the increased femoral loosening in osteoporotic elderly patients.

Radiologic outcomes of open reduction and internal fixation for cementless stems in Vancouver B2 periprosthetic fractures

Objective

The aim of this study was to evaluate the radiologic outcomes of open reduction and lateral plating with wiring in the treatment of Vancouver B2 periprosthetic femoral fractures.

Methods

We retrospectively recruited 37 patients treated with ORIF with lateral plating and wiring for Vancouver B2 fractures. The 27 patients (15 men and 12 women; mean age: 70.8 ± 8.3 years) without follow-up loss had achieved complete bony union without notable complications. The average union period was checked after operation with radiologic findings. Radiologic outcomes were evaluated by ipsilateral limb length discrepancy (LLD) and subsidence between immediate postoperative length and length at postoperative 1 year after adjusting for magnification differences. The average distance to which the retained stem sunk down was investigated between immediate postoperative radiographs and final radiographs showing union.

Results

Ten patients could not be evaluated, because of mortality or failure to follow up. The average time to union was 18.3 weeks, and the average distance of stem sinking was 2.5 ± 1.7 mm (range: 0–7.2 mm), which was significantly different between immediate postoperative radiographs and final radiographs. There was no case with loss of reduction or loss of fixation, requiring revision surgery.

Conclusion

Open reduction and lateral plating with wiring as a treatment for Vancouver B2 periprosthetic femoral fractures produced good radiologic outcomes with successful bony union. ORIF can be considered the alternative option for treating patients with Vancouver B2 PPF, instead of stem revision surgery.

Level of evidence

Level IV, Therapeutic study.

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.

Application of 3D printing rapid prototyping-assisted percutaneous fixation in the treatment of intertrochanteric fracture

The aim of the present study was to investigate the application of 3D printing (3DP) rapid prototyping (RP) technique-assisted percutaneous fixation in the treatment of femoral intertrochanteric fracture (ITF) using proximal femoral nail anti-rotation (PFNA). A total of 39 patients with unstable ITF were included in the current study. Patients were divided into two groups: 19 patients were examined using computed tomography scanning and underwent PFNA with SDP-RP whereas the other 20 patients underwent conventional PFNA treatment. Anatomical data were converted from the Digital Imaging and Communications in Medicine format to the stereolithography format using M3D software. The 3DP-RP model was established using the fused deposition modeling technique and the length and diameter of the main screw blade was measured during the simulation. The postoperative femoral neck-shaft angle (NSA), surgery duration, intraoperative and postoperative blood loss, and the duration of hospital stay were recorded and compared with the corresponding values in conventional surgery. No significant differences were observed in mean PFNA size between the implants used and the preoperative planning estimates. It was demonstrated that the 3DP-RP assisted procedure resulted in more effective reduction of the NSA. Furthermore, patients undergoing 3DP-RP experienced a significant reduction in duration of surgery (P<0.01), as well as reductions in intraoperative (P=0.02) and postoperative (P=0.03) blood loss, compared with conventional surgery. At 6 months post-surgery, no cases of hip varus/vague deformities or implant failure were observed in patients that underwent either the 3DP-RP-assisted or conventional procedure. The results of the present study suggest that the 3DP-RP technique is able to create an accurate model of the ITF, which facilitates surgical planning and fracture reduction, thus improving the efficiency of PFNA surgery for ITFs.

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.