Prospective study of management of unstable intertrochantric femur fractures in elderly: hemiarthroplasty vs. osteosynthesis by proximal femoral nail

INTRODUCTION

Intertrochanteric fractures account for roughly 34% of all hip fractures.¹ With the aging population, the incidence rate of osteoporosis is rapidly increasing.² These fractures are predicted to reach 2.6 million in 2025 and 4.5 million in 2050 worldwide.³ The incidence of these fractures, which frequently occur due to falls, is two-three times higher in females than in males.⁴ Intertrochanteric fractures, which are unstable, usually can only be treated surgically.⁵

Intertrochanteric fracture in the elderly is still a grievous issue with multiple options of managing them with often suboptimal outcomes especially in unstable osteoporotic and severely comminuted intertrochanteric fractures. There is no consensus for the treatment of unstable intertrochanteric fractures and the most appropriate line of management according to the patient's age, osteoporosis and fracture pattern. It has been concluded that bipolar prosthesis is a viable alternative to internal fixation in the management of unstable trochanteric fractures in the elderly patients.⁶

Objectives

The present study was undertaken to compare the functional outcome in patients of unstable intertrochanteric femur fractures in elderly treated with hemiarthroplasty against those treated with proximal femoral nail and complications and to determine which implant would be ideal for which fracture type so as to provide the best results with the least complications.

METHODS

Study design, duration and location

This was an interventional prospective randomized control trial study. The study was carried out over 3 years from 2019 to 2022. The present study had been carried out in the hospital settings of department of orthopaedics, PCMC’s postgraduate institute Yashwantrao Chavan Memorial Hospital, Pimpri, Pune, Maharashtra, India

Sample size

Total 50 patients were randomly divided into two groups; Group A (unstable intertrochanteric femur fracture patients treated by bipolar hemi-arthroplasty) and Group B (unstable intertrochanteric femur fracture patients treated by proximal femoral nailing) with 25 patients in each group. Outcomes were evaluated on follow ups at 1/3/6 months based on functional outcomes, mean surgical time, mean blood loss during surgery, post-operative length of stay, post-operative complications. Harris hip Score was used to assess clinical functional outcomes. SPSS (Stastical package for social sciences) was used for statistical analysis.

Inclusion and exclusion criteria

Inclusion criteria in current study were; patient age >60 years, traumatic unstable intertrochanteric fractures of proximal femur and ability to walk before trauma. Exclusion criteria in current study were; patients age <60 years, pathological fracture, compound fractures, concomitant neuromuscular pathologies, unwillingness to participate and pre injury status non-ambulatory.

Group A-Hemiarthroplasty group

Planning was done on preoperative roentgenograms to find out the horizontal and vertical offset, the size of head of femur and length of extra-medullary portion of the femoral prosthesis. position: patients were placed in true lateral position, with the affected limb uppermost. Because most patients requiring surgery are elderly and have delicate skin, it is important to protect the bony prominences of the legs and pelvis and so cotton pads were placed under the lateral malleolus and knee of the bottom leg and a pillow between the knees. Prosthesis: the prosthesis used was the standard modular bipolar hip prosthesis. Coxafemoral bypass technique: all patients in coxafemoral bypass group were operated using a standard lateral approach. After assessing fracture anatomy, incision was made over greater trochanter, which extended proximally and distally about 3 inches.⁷ Tensor fascia lata incised in the plane of incision and coronal fracture plane was identified. Plane between the fragments was developed by reflecting anterior and posterior fractured trochanteric fragments. Head along with neck was circumferentially dissected from the capsular attachments. After delivering the head out, it was measured. Limb was placed in flexion and internal rotation. Shaft was then reamed with sequential broaching. Trial reduction was done to know the limb length and version stability. Two drill holes were placed in the proximal end of the shaft of femur for passing stainless steel wires. Then bone cement was put into the medullary canal manually. After cementing Modular bipolar prosthesis was placed with proper anteversion. The wound was closed in layers with suction drain, sterile dressing was done.

Group B: Proximal femoral nail (PFN) group

All patients were given supine position following anaesthesia, on a fracture table, closed reduction and manipulation was done after the patients were anaesthetized. 3-5 cm skin incision was made few cm proximal to the tip of greater trochanter. Soft tissue dissected to identify the tip of trochanter and awl entry was made under c-arm guidance. Guide wire was passed maintaining fracture reduction, successive reaming was performed maintaining reduction. Proximal femoral nail was inserted to the appropriate depth to allow screw placement in femoral head. Two guide pins were passed under c-arm guidance for placement of Femoral neck screw and Derotation screw respectively and were overdrillled with 6.5 mm drill bit for 8.0 mm femoral neck screw and 5.0 mm drill bit for 6.4 mm derotation screw. Appropriately sized femoral neck screw and derotation screws were placed to adequate depth in femoral head for subchondral purchase. Distal locking done with 4.9 mm interlocking bolts of appropriate sizes after drilling with 4.0 mm drill bit.

Post operative protocol

IV antibiotics given till fifth post-op day. Analgesics 5 days/epidural top up for 2 days on an average, drain removal on second post-op day. Static quadriceps exercises from day 2 were begun. Early hip and knee assisted ROM were started. Suture removal after 14 days. Rehabilitation: partial weight bearing was started around 3-4 days for bipolar hemiarthroplasty group and around 2 weeks post operatively for PFN group patents. Full weight bearing was allowed after radiological and clinical signs of union Subsequently they were followed up in OPD at monthly, 3 monthly and 6 monthly intervals. After 1 month.

RESULTS

Demographic data

Most common age group was 60-65 years i.e., 09 (36%) and 11 (44%) in-group A & B followed by 65-70 years group i.e., 07 (28%) and 09 (36%) %) in-group A & B respectively. Mean age with standard deviation in years for Group A was 67.24±9.47 years, for Group B was 64.71±10.19 years, and after independent t test result was not statistically significant with p value 0.368 respectively. Most number of patients were male i.e., 18 (72%) and 20 (80%) in Group A & B respectively in comparison to females 07 (28%) and 05 (20%).

Based on functional outcome assessment by Harris hip score at different follow-ups after surgery for Group A it was found that HHS was 62.25±08.26, 65.82±07.65 & 73.71±08.21 at 1 month, 3 months and 6 months respectively. Based on functional outcome assessment by Harris Hip Score at different follow-ups after surgery for Group B it was found that HHS was 70.18±09.05, 73.82±07.61 and 79.12±08.06 at 1 month, 3 months and 6 months respectively.

Mean surgical time (minutes) were 124.15±37.92 and 101.04±42.32 minutes in Group A & B respectively. Mean blood loss during surgery (ml) were 500.13±40.23 and 200.54±12.19 ml in Group A & B respectively. Mean post-operative length of stay (days) were 14.22±03.59 and 07.21±03.59 days in Group A & B respectively. Mean time for partial standing (days) with range were 4 (2~4.5) and 10 (8~14) days in Group A & B respectively. Based on functional outcome most patients given good outcome i.e., 12 (48%) for Group A and 18 (72%) for Group B followed by excellent results i.e., 09 (36%) for Group A and 06 (24%) for Group B respectively.

DISCUSSION

Most common age group was 60-65 years i.e., 09 (36%) and 11 (44%) in-group A & B followed by 65-70 years group i.e., 07 (28%) and 09 (36%) %) in-group A & B respectively. Yogi et al study conducted on 30 elderly patients with intertrochanteric fractures. In the PFN group average mean age was 69.6 (range 60-77 years).⁸ In the Bipolar prosthesis group of 15 patients 7 were males and 8 were females. The average mean age was 70.6 (range 62-79 years).

Gormeli et al study shown average age in PFN group was 76.20 years and for Bipolar hemiarthroplasty group was 77.40 years respectively.^9-11 Sonar et al study shown average age of patients in PFN group was 75.73±6.57 years and in hemiarthroplasty group was 78.07±6.16 years.^12-14 Prasad et al study also shown average age of patients in PFN group was 57 years and in hemiarthroplasty group was 67 years.¹² Most common mode of injury was trivial fall i.e. 16 (64%) and 17 (68%) in Group A & B respectively. Result was statistically not significant with p value >0.05. Based on laterality of injury most common were right sided i.e., 13 (52%) and 14 (56%) in Group A and B respectively. Prasad et al study shown in Bipolar hemiarthroplasty group right sided injury was 62.96% and for the PFN right sided injury was 51.85% respectively.¹² Sonar et al study showing in PFN group in seventeen i.e., 56.67% and in hemiarthroplasty group in twelve fractures i.e., 40% involved right side. Rest fractures were left sided.¹⁴ Most common comorbidities were type 2DM and hypertension i.e., 13 (52%) and 14 (56%) and 14 (56%) and 12 (48%) for Group A and B respectively. Mean time from injury to admission (hours) were 17.25±05.54 and 20.14±06.12 hours in Group A and B respectively. Mean surgical time (minutes) were 124.15±37.92 and 101.04±42.32 minutes in Group A & B respectively. Mean blood loss during surgery (ml) was 500.13±40.23 and 200.54±12.19 ml in Group A & B respectively. Mean post-operative length of stay (days) were 14.22±03.59 and 07.21±03.59 days in Group A & B respectively. Based on functional outcome most patients given good outcome i.e., 12 (48%) for Group A and 18 (72%) for Group B followed by excellent results i.e. 09 (36%) for Group A and 06 (24%) for Group B respectively. Based on functional outcome assessment by Harris hip score at different follow-ups after surgery for Group A it was found that HHS was 62.25±08.26, 65.82±07.65 & 73.71±08.21 at 1 month, 3 months and 6 months respectively. Based on functional outcome assessment by Harris Hip Score at different follow-ups after surgery for Group B it was found that HHS was 70.18±09.05, 73.82±07.61 & 79.12±08.06 at 1 month, 3 months and 6 months respectively. In present study in-group A, complications i.e., 07 (28%) and that of group B only 05 (20%) respectively. Most common complication for group A was infection & limb shortening and that for group B was limb shortening & implant failure respectively.

Limitations

There were few limitations in current study. Firstly, it is not randomized and not double blinded. Secondly, Power of the study is inadequate. Thirdly, Selection bias patients in both groups are not matched. Fourthly, short-term follow-up. Fifth, implants used were the same in all patients.

CONCLUSION

In conclusion, both PFN and bipolar-hemiarthroplasty appear to produce satisfactory outcomes in surgically treated unstable IT (intertrochanteric) fractures. Both groups are associated with their own complications, but although internal fixation with PFN had higher reoperation rates, it’s less surgery related trauma and lower mortality rates are main advantages. Therefore, the surgeon should choose the ideal method for each individual patient, but we think internal fixation may be the effective and appropriate treatment modality for elderly patients with unstable IT (intertrochanteric) fractures.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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