|Year : 2014 | Volume
| Issue : 2 | Page : 81-86
Unstable intertrochanteric fracture in elderly treated with bipolar hemiarthroplasty: A prospective case series
KV Puttakemparaju1, N Raghavendra Beshaj2
1 Department of Orthopaedics, Victoria Hospital, B.M.C.R.I, Bengaluru, Karnataka, India
2 Department of Orthopaedics, Aarupadai Veedu Medical College and Hospital, Puducherry, India
|Date of Web Publication||10-Apr-2015|
Dr. N Raghavendra Beshaj
Department of Orthopaedics, Aarupadai Veedu Medical College and Hospital, Puducherry - 607 402
Source of Support: Funding by institution under Government of
Karnataka, Conflict of Interest: None
Purpose: To evaluate functional results of bipolar hemiarthroplasty for unstable intertrochanteric fracture in elderly patient.
Materials and Methods: Between 2005 and 2012 20 elderly patients more than 65 years with intertrochanteric fractures <3 weeks old, having associated medical comorbidities like diabetes mellitus, hypertension, chronic bronchitis and emphysema were included. And patients with open intertrochanteric fractures, poly-trauma, pathological fractures, and aged <65 years were excluded from study.
Results: There were 11 male and 9 female patients with mean age of 78.1 years treated by cemented bipolar hemiarthroplasty. The average surgery time was 123 min with an average intraoperative blood loss of 431.5 ml. Eleven patients were transfused a pint of blood. Grade 1 bedsores in two patients healed with regular dressing, regular change of position and antibiotics. One patient developed deep wound infection for whom implant removal and excision arthroplasty was done. Limb length discrepancy was <1 cm in six patients. No case of dislocation, rotational deformities or subsidence of the prosthesis was seen during the follow-up. Functional results were graded as per Harris Hip Scoring System, mean Harris Hip Scorewas 78.2 at 6 months and 83.25 at 24 months.
Conclusion: Careful restoration of neck length, offset and version maximizes the stability of the hip joint and increases the durability of the prosthesis which is very essential in achieving a good outcome. The procedure offered faster mobilization, rapid return to pre injury level and gave a lasting solution in elderly patients with intertrochanteric fractures of the femur.
Level of Study: Level 4 case series.
Keywords: Bipolar, elderly, hemiarthroplasty, length, trochanteric fractures, version
|How to cite this article:|
Puttakemparaju K V, Beshaj N R. Unstable intertrochanteric fracture in elderly treated with bipolar hemiarthroplasty: A prospective case series. Afr J Trauma 2014;3:81-6
|How to cite this URL:|
Puttakemparaju K V, Beshaj N R. Unstable intertrochanteric fracture in elderly treated with bipolar hemiarthroplasty: A prospective case series. Afr J Trauma [serial online] 2014 [cited 2020 Feb 27];3:81-6. Available from: http://www.afrjtrauma.com/text.asp?2014/3/2/81/154930
| Introduction|| |
Hip fractures are an increasingly important public health problem. Their incidence has increased due to the increased life expectancy and osteoporosis.  Stable intertrochanteric fractures can be easily treated by osteosynthesis with predictable good results, , whereas the management of unstable intertrochanteric fractures is challenging because of poor bone quality, osteoporosis and other underlying diseases. , Failure rate of unstable intertrochanteric fractures with osteoporosis treated with osteosynthesis has been reported to be between 4% and 16.5%.  Incidence of general complications such as pulmonary embolism, deep venous thrombosis (DVT) and pneumonia ranges from 22% to 50% when internal fixation was adopted. , Due to high failure rate and complications associated with internal fixation, prosthetic replacement has been recommended by some authors as primary treatment for unstable intertrochanteric fractures. ,,
The purpose of this study is to evaluate the functional and clinical outcomes of cemented bipolar arthroplasty as a primary treatment for unstable intertrochanteric fracture in the elderly patient.
| Materials and Methods|| |
From 2005 to 2012 20 elderly patients presenting with unstable intertrochanteric fractures to Victoria Hospital attached to Bangalore Medical College and Research Centre were studied. Elderly patients more than 65 years with intertrochanteric fractures <3 weeks old, having associated medical comorbidities like diabetes mellitus, hypertension, chronic bronchitis and emphysema were included in the study. Patients with open intertrochanteric fractures, poly-trauma, pathological fractures, and patients <65 years of age were excluded from study.
Bipolar hip prosthesis was used which has a large contact surface area and the two planes of rotation reduce the wear at acetabular surface and preserve the native acetabular cartilage. Self-centring action - The positive eccentricity of the centres of rotation corrects alignment. Informed written consent was obtained from the patients. All surgeries were performed in the elective theatre using standard aseptic precautions. Surgery was performed under spinal, epidural or general anaesthesia according to the patient's general condition and the anesthetist preference. Two approaches to hip were used anterolateral, posterolateral which was random in selection and positioning of the patient was supine for anterolateral and lateral for posterolateral approach. Draping was done in such a way that only the operative site was exposed.
Once the capsule of the joint was in view, it was incised longitudinally to expose the hip joint and proximal part of femur. Preparation of the proximal femur was done with respect to bipolar prosthesis.
Few essential steps in performing hemiarthroplasty in unstable trochanteric fractures that we followed are:
- Maintaining the version (anteversion-retroversion) of the prosthesis: Was determined using the imaginary transcondylar axis of the lower end of the femur as a guide. This was crosschecked by temporarily reducing the lesser trochanter into its anatomical position and referencing the endoprosthesis from it.
- Maintaining the offset: In severely comminuted fractures, it was difficult to determine the prosthesis height properly. We use the anatomical landmarks of trochanters. Then femoral medullary canal was then reamed to appropriate stem size and diameter. Trial reductions were performed to determine the exact length that will bring the knee of the operating limb at level with the opposite limb as shown in [Figure 1]. This can also be crosschecked by the desired tension and tissue balancing of the abductor muscles after temporarily reducing the greater trochanter in anatomical position. The exact amount of the prosthesis length to be driven into the femoral canal is noted.
|Figure 1: Measuring the level of the knee to check the vertical offset after placement of trial prosthesis|
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The definitive femoral stem was cemented into the femoral canal to the exact length which restores the vertical offset as determined. Second-generation cementing techniques (medullary lavage, use of an intramedullary cement plug, hand-mixing of cement, use of a cement gun to deliver the cement in a doughy state in a retrograde fashion in all patients) were used. Any protrusion of cement between reduced bone fragments was cleaned out.
- Reconstruction of greater and lesser trochanter: Greater trochanter was reconstructed with tension band technique and the lesser trochanter including the calcar was reconstructed with en-cerclage wiring or collar of cement at the site of calcar during insertion.
The joint was reduced and range of motion, stability was checked; in [Figure 2] we can see the prosthesis is reduced in to the joint. After reduction of the prosthesis, distracting force was applied to the joint by pulling the limb, this assesses the amount of opening (distraction) of joint. We took <0.5 mm distraction as stable joint. Wound was closed in layers with sterile suction drain in-situ. Postoperative pain was managed by epidural top-up, opioids in the 1 st postoperative day. We switched to NSAIDS on 2 nd postoperative day onwards or tramadol in case of patients with reduced renal function for 5 days. Drain removal was done after 48 h. Check radiograph was taken after 48 h; [Figure 3] and [Figure 4] shows preoperative and postoperative radiograph of a case of intertrochanteric fracture managed by hemiarthroplasty. Patients were made to sit up on the 2 nd day, stand-up with support (walker) on the 3 rd day and were allowed to full weight bear and walk with the help of a walker on the 4 th postoperative day. When the patients did well they were encouraged to walk unaided thereafter. Sitting cross-legged and squatting were not allowed. Suture removal was done on the 12 th postoperative day. The patients were assessed for any shortening or deformities. Any complications like infections and bed sores are treated before discharging the patients.
|Figure 2: Trochanteric hemireplacement after reducing the prosthesis into the joint|
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|Figure 4: Post-operative X-ray image of trochanteric fracture treated with hemiarthroplasty|
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Patients were followed-up at an interval of 6 weeks, 6 months and 12 months and 24 months. The minimum follow-up was 24 months and maximum follow-up was 6 years. Clinical follow-up based on Harris Hip Score (HHS). Radiological follow-up for signs of loosening, subsidence, protrusion, dislocation or dissociation. [Table 1] is showing master chart of our study.
| Results|| |
The following observations were made from the data collected during the study of 20 cases of intertrochanteric fractures over 7 years as shown in [Table 2], 11 male and 9 female with mean age of 78.1 years (range 70-92 years) treated by cemented bipolar hemiarthroplasty in the Department of Orthopaedics in Victoria Hospital, attached to Bangalore Medical College. The average surgery time was 123 min (range 110-140 min) with an average intraoperative blood loss of 431.5 ml (range 370-490 ml). Of the eleven patients who were transfused a pint of blood eight of them had blood transfusion postoperatively. There was a low rate of infections, namely deep infection in one case, and Grade 1 bedsores in second cases. Bedsore healed with regular dressing, regular change of position and antibiotics. A patient with chronic renal failure, diabetes and anaemia developed deep infection for who implant removal and excision arthroplasty was done. Limb length discrepancy was seen in six patients which was <1 cm. There was no case of dislocation or rotational deformities noted. There were no cases of subsidence of the prosthesis during the follow-up. Subsidence of the femoral stem was defined as a change in the distance from the superolateral edge at the shoulder of the prosthesis to the tip of the greater trochanter on the anteroposterior radiograph of the hip, and subsidence of >5 mm was classified as a subsided stem. The mean day for full weight bearing was on the 5.4 th day. Patients were discharged from the hospital at a mean on the 13 th day. The functional results were graded according to Harris Hip Scoring System, where in, a score of more than 90 indicates excellent result, a score between 80 and 90 indicates good results, a score between 70 and 80 indicates fair results and a score below 70 is rated as poor. In our study the mean HHS at 6 months and at 24 months was 78.2 and 83.25 respectively.
| Discussion|| |
Management of unstable intertrochanteric fracture in elderly is a challenge. Rigid internal fixation and early mobilization are the key points of the treatment. , Kaufer et al. have listed the variables that determine the strength of fracture fragment-implant assembly.
The variables are:
- Bone quality
- Fracture geometry
- Implant design
- Implant placement.
Bone quality and fracture geometry are beyond the control of the surgeon.  Quality of bone (hardness, elasticity and strength) varies considerably depending upon age, sex, race, general state of health, muscle mass, level of activity. Singh et al., have developed a roetgenographic method for determining the bone strength that is based on the trabecular pattern of the proximal femur. The method is simple, readily available, requires no special equipment's, correlates well with histological control, is sufficiently sensitive and prognostically useful.  Loss of continuity of primary tension trabeculae (i.e., Grade III) marks the transition between bone capable of holding an internal fixation device and bone so weak that these devices become ineffective. Clinical studies confirm that regardless of other variables internal fixation failed in 80% of fracture of the bone Grade III or less.
Often because of poor bone quality that is age related osteoporosis there is a high failure rate of internal fixation methods  and early mobilisation is difficult. Incidence of general complications such as pulmonary embolism, DVT and pneumonia ranges from 22% to 50% when internal fixation was adopted because of delayed mobilisation. , Although there are some fixation methods such as fixed nail plate, sliding hip screw and intramedullary interlocking devices, no one guarantees absolute fracture stability and complete bone union in elderly patients. ,, Geiger et al. studied Clinical records including X-ray of all patients with trochanteric femoral fractures, except pathologic fractures and a minimum age of 60 years, which were treated between 1992 and 2005. Of these 283 patients, 132 were treated by primary arthroplasty, 109 with a dynamic hip screw and 42 with a proximal femoral nail. Survival after 1-year and complications, which had to be treated within this period were main outcome measurement. Influencing cofactors such as age, gender and comorbidities were reduced by multivariate logistic regression analysis. Primary hip arthroplasty did not bear a higher 1-year mortality risk than osteosynthesis. 
Hip arthroplasty is an effective salvage procedure after failed treatment of an intertrochanteric fracture in an older patient. Most patients had good pain relief and functional improvement.  Use of Leinbach bipolar prosthesis a calcar replacing prosthesis in elderly debilitating patients in an attempt to get the patient up and walk rapidly is an effective way of treating comminuted and unstable intertrochanteric fractures in the elderly.  In elderly patients with intertrochanteric fractures and related complications, treatment with endoprosthesis is thought to be helpful in decreasing these complications and allows early mobilization of the patient. 
In our study twenty elderly patients with unstable intertrochanteric fracture were treated with primary cemented bipolar hemiarthroplasty were followed up to an average of 4 years. The mean age of the patients was 78.1 years (70-92 years) which is comparable to the age distribution in similar studies in the literature like by Haentjens et al.,  was 80 years, by Chan et al.,  was 84.2 years, by Haidukewych et al.,  was 78 years. The mean day of full weight bearing was on the 5.4 th day which is comparable to similar study by Green et al.,  in a series of 20 cases, performed bipolar hemiarthroplasty for elderly patients with unstable intertrochanteric fractures with a mean time to ambulation of 5.5 days. The most common associated medical problem was hypertension in 11 cases (55%), followed by anaemia and diabetes in 8 cases (40%), they were all treated accordingly. A total of eleven patients were transfused with a pint of blood, which were uneventful. There were no complications like pneumonia, DVT, pulmonary embolism in the post-operative period.
Grimsrud et al., in a series of 39 patients with unstable three and four part intertrochanteric hip fractures, treated with cemented bipolar hip arthroplasty with a novel technique of cerclage fixation of the trochanteric bone fragments allowing retention of the femoral calcar. At 1-year minimum follow up, there was no loosening or subsidence of the femoral components. All trochanters healed. One dislocation and one deep infection occurred. They concluded that, this technique allows safe early weight bearing on the injured hip and had a relatively low rate of complications. 
We graded the functional results according to Harris Hip Scoring System, where in, a score of more than 90 indicates excellent result, a score in between 80 and 90 indicates good results, a score in between 70 and 80 indicates fair results and a score below 70 is rated as poor. In our study the mean HHS at 6 months was 78.2 and at 24 months were 83.25 respectively as shown in [Table 3]. Functional results of our study are comparable to similar studies in literature as mentioned in the [Table 4].
|Table 4: Comparison of our study results with other similar studies in literature |
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Chan et al., in his series of 55 patients with intertrochanteric fractures, with a mean age of 84.2 years, were treated using cemented bipolar hemiarthroplasty. They reported excellent results in 19 cases good results in 8 cases, and death of 12 cases in the series. They concluded that, cemented bipolar hemiarthroplasties for intertrochanteric fractures have the advantage because the patients can bear full weight immediately after the surgery and there was no risk of excessive collapse, compromising walking function and so is a reasonable alternative to a sliding screw device for the treatment of unstable intertrochanteric fractures. 
Haentjens et al., in a series of 37 cases, with a mean age of 82 years who sustained unstable intertrochanteric fractures were treated with immediate bipolar hemiarthroplasty. Amongst the 37 cases, who were rated according to criteria of Merle d'Aubigne, 7 patients had excellent results, 11 patients had good results, 7 patients had fair results, 5 patients had poor results and reported death of 3 cases. They concluded that immediate bipolar hemiarthroplasty for independently mobile patients older than 70 years having a unstable intertrochanteric fractures, allowed early walking with full weight bearing and helped the patients to return to prefracture level of activity rapidly, preventing complications such as pressure sores, pneumonia, atelectasis and pseudoarthrosis. 
At 24 months follow-up of the 20 patients in our study group, we had excellent results in three patients, good results in twelve patients, fair results in four patients and poor result in one patient according to the Harris Hip Scoring System. The poor result was secondary to medical co-morbidities in a patient with chronic renal failure, diabetes and anaemia who developed deep infection for whom implant removal and excision arthroplasty was done. Overall the procedure offered excellent pain free mobile and stable hip with early rehabilitation and rapid return to functional level. We agree that the study with an average follow-up of 4 years and sample size of 20 is small to comment anything on the results in an arthroplasty series. But with the kind of results we are seeing in this interim follow-up, we advise careful restoration of neck length offset and version making use of the intraoperative techniques mentioned to achieve good results.
| Conclusion|| |
Cemented bipolar hemi-arthroplasty is a technically challenging procedure which requires a reasonable learning curve. But a properly performed procedure is a viable option for unstable trochanteric fractures in very elderly osteoporotic patients.
Careful restoration of neck length, offset and version maximize stability of the hip joint and increases the durability of the prosthesis.
The procedure offered, faster mobilization, rapid return to preinjury level, improved the quality of life and gave a long term solution in elderly patients with intertrochanteric fractures of the femur. Bipolar hemiarthroplasty reduced the complications of prolonged immobilisation, prolonged rehabilitation, marked residual deformities and need for revision surgeries.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]