Abstract

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Context: Most Inter-trochanteric fractures occur in elderly people (above 65 yrs) with high mortality rates. Problems with osteoporotic bone fractures includes geometry (grossly comminuted), high instability and difficult to treat. Conservative treatment in such patients demanding prolonged immobilization lands up with complications.

Aim: To study the efficacy of PFN Vs Cemented Hemiarthroplasty in proximal femoral fractures in elderly patients with severe osteoporosis.

Methods and Material: We prospectively compared the two modalities viz. PFN & cemented hemi-arthroplasty. Modality used depends upon two criteria: 1) Singh index & 2) reducibility and alignment achieved with skeletal traction. Patients with Singh index >3 and with traction x-ray showing reducible fracture and good alignment were treated with PFN. Patients with singh index <3 & with traction x-ray showing irreducible and unstable fracture and not showing good alignment were treated with cemented hemi-arthroplasty.

Results: Total 50 cases with mean age of 79.5 yrs. Mean Harris hip score 78.28 for PFN and 76.84 for Hemiarthroplasty. Mean intra-operative blood loss 530 ml in hemi-arthroplasty and 180 ml in PFN cases. 4 cases died of medical complications earliest being 3 months and late being 18 months. 2 hemi-arthroplasty cases had superficial infection treated with oral antibiotics and 1 case of screw back-out due to collapse in PFN case treated with revision surgery with cemented hemi-arthroplasty. Mean time for radiological union for PFN cases was 12.04 weeks.

Conclusions: By following the above mentioned criteria we can treat IT fractures with either PFN or cemented Hemiarthroplasty with equally good results.

Introduction

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1. Most Inter-trochanteric fractures occur in elderly people (above 65 yrs) with reported mortality rates ranging from 15% to 30%. (1)
2. Problems with osteoporotic bone fractures includes geometry (grossly comminuted), high instability and difficult to treat.
3. Conservative treatment in such patients demanding prolonged immobilization often lands up with complications. (2)

AIM: To study the efficacy of Proximal Femoral Nailing (PFN) Vs Cemented Hemiarthroplasty in proximal femoral fractures in elderly patients with severe osteoporosis.

STUDY & DESIGN: Prospective comparative study- 50 cases.

STATISTICAL ANALYSIS USED:  Two sample T-test was used to compare the outcomes in the two groups.

Out- come was measured with Harris hip score. (3)

RATIONALE FOR STUDY: We retrospectively observed the results in 10 cases of IT fractures treated with PFN.

All 10 cases were graded for osteoporosis by Singh index (4), with traction x-ray was taken; but irrespective of the two, cases were treated with PFN

(i) Of the 10 cases, at follow-up we observed fixation failure in 2 cases.
(ii) Modes of failure observed were-

1. Screw back-out

2. Screw cut- out.

We analyzed the causes for failure in both cases and observed that:

1. Both cases had Singh index < 3.
2. In both cases, with traction x-ray did not show integrity of postero- medial cortex and adequate alignment.

This study was taken by us as a pilot study. Hence we further studied 50 cases of IT fractures comparing the two modalities of treatment viz. PFN and Hemi-arthroplasty.

Methods

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Modality used depends upon two criteria:

1. Quality of bone stalk (Singh index ) (4)
2. Integrity and alignment of postero-medial cortex of GT and Calcar achieved with heavy skeletal traction.
3. Patients with Singh index >3 and with traction x-ray showing satisfactory alignment in acceptable position were treated with PFN.
4. Patients with Singh index <3 & with traction x-ray showing loss of integrity of postero- medial cortex and inadequate alignment were treated with cemented bipolar hemi-arthroplasty.
5. Greater Trochanter and Lesser Trochanter were reconstructed where indicated with TBW or Encirclage (GT) and Encirclage/ Fashioned bone graft/ Cement collar (LT). (5)
6. We used Harris hip score for evaluating the functional outcome of the two groups.
7. Permission from the ethical committee was obtained prior.
8. The patients with proximal femoral fractures in elderly people with severe osteoporosis were admitted through OPD or Casualty.
9.They were screened clinically and radio-logically preoperatively for knowing the geometry of fracture, any associated disease like hypertension, diabetes, ischemic heart disease, etc.

Inclusion criteria:

1. Pre-injury status was ambulatory.
2. Co-operative for physiotherapy.
3. Severe osteoporosis.
4. Elderly (age more than 65 yrs.).

Exclusion criteria:

1. Pre-injury status non-ambulatory.
2. Open fractures.
3. Severely moribund patients.
4. Uncontrolled diabetes mellitus.

Pre-Operatively:

1. Skeletal traction with Denham’s pin was given.
2. Patient was graded for osteoporosis by Singh’s index.
3. 4 inj. Decadurabolin fortnightly & calcium with vit.D3 once daily was given.
4. Preoperative anesthetic evaluation for anesthetic fitness was done and patient was posted for surgery.
5. Informed and willful consent was taken prior to the operative procedure.

Cemented hemiathroplasty was performed using the true lateral approach thus directly approaching the fracture site.

Specially designed prosthesis with a broad metaphyseal end and long stem was used.

Prosthesis used was according the groups below (5):

Table I: Type of bipolar prosthesis used.

See Illustration 13

GT/ LT and Calcar were reconstructed as indicated.

For PFN patient was placed on fracture table, closed reduction was achieved with traction, abduction and internal rotation and with a small 5cm incision centring over GT nailing was done. Short PFN with 2 proximal (6.4mm, 8 mm) and 2 distal (4.9mm) screws was used.

Day 1: non weight-bearing (NWB) exercise of hip and knee.

Day 3: bed side sitting and knee bending exercises.

Day 5: standing with support by the side of bed.

Day 7: patient was made to walk with walker.

Day 12: sutures were removed

Patient was discharged with a printed instruction sheet of DO`s and DON`T`s

DO`s:

1. Walk with walker.
2. Sit in chair.
3. Use western toilet.
4. Report to a doctor in any suspicion of infection like UTI / URTI/ local discharge.

DONT`s:

1. Do not sit cross legged.
2. Do not squat.
3. Avoid uneven ground and busy roads.

Subsequently they were followed up in OPD at monthly, 3 monthly and 6 monthly and   yearly intervals.

After 1 month, walking with cane in opposite hand was advised for 4 weeks for PFN cases and 2 weeks for Hemiarthroplasty cases.

Results

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From 2008 we did 50 cases- 25 cemented bipolar Hemiarthroplasty and 25 PFN. The mean age of the patient was 79.5 years, with the youngest being 68 and the oldest 104 years.

The maximum follow up was 4 years and minimum was of 1 year with mean follow up of 29 months.

Data collected:

Male: Female ratio was 2: 3.

22 patients had associated medical problems like HTN (14), IHD (4), DM (10) and others (4).

Of the 50 cases in 25 cases the Singh index was Grade II and in remaining 25 it was Grade III.

GT reconstruction was required in 16 cases while LT/ Calcar reconstruction was required in 4 cases.

Mean blood loss in Hemiarthroplasty cases was 530 ml and in PFN cases was 180 ml.

Mean Harris hip score (5) being 78.2 for PFN and 76.8 for Hemi-arthroplasty cases.

Mean stay in the hospital was 12 days for PFN & 13 days for hemi-arthroplasty patients.

Mean follow up was 29 months.

2 cases of superficial infection in hemi-arthroplasty cases were treated with oral antibiotics.

1 case of screw Back-out due to collapse in PFN case. The failure was due to the collapse of the fragments due to poor bone stock (singh index <3) and reduction of fragments could not be achieved with heavy skeletal traction. Patient was an ideal case for cemented hemi-arthroplasty, but PFN was done as the patient was a known case of old myocardial infarction and had poor cardiac function with ejection fraction of 20%. Hence open reduction and PFN (a short time procedure with less blood loss) was done. Revision surgery with cemented hemi-arthroplasty was performed later when her cardio-pulmonary function improved with rehabilitation and medical treatment after 3 months.

Mean time at which Patients treated with Hemi-arthroplasty started full weight bearing ambulation without support was 6 weeks, while for PFN treated cases it was 8 weeks.

Mean time of radiological union in cases treated with PFN was 12 weeks.

Table II: comparison of outcomes

See Illustration 14

Discussion

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In proximal femoral fractures with severe osteoporosis and poor bone stock there is a high risk of failure of fixation of any type.

The treatment of proximal femoral fractures in elderly patients with severe osteoporosis defers with the treatment of proximal femoral fractures in young individuals.

These should be grouped according to fracture geometry as stable and unstable (5) (6) so that correct choice of prosthesis/ implant can be used.

Peculiarities of these fractures include:

1. Instability.
2. Osteoporosis.
3. Associated medical co-morbidities.
4. Post-operative complications with delayed ambulation.

Requirements for the treatment are:

1. Maintenance of neck- shaft angle.
2. Good bone stock.
3. Near anatomical alignment.
4. Right choice of prosthesis/ implant.
5. Early Ambulation.

Failure to fulfil these requirements leads to high chances of failure of implant (Excessive collapse, loss of fixation and cut-out of the screws) resulting in poor function.

In 1997 PFN was introduced for the treatment of per-trochanteric fractures of femur and was designed to reduce implant related complications. Prospective clinical studies of PFN shows cut-out rates ranging from 0.6 – 1.4 % and a low tendency for varus displacement as compared to other implants. (7) (8) (9)

Studies also show that intra- medullary devices are several times stronger than the DHS, with less or no deformity at maximum loads. (10) PFN has an advantage of shorter operative time, less blood loss, lower hospital stay and low hospital cost with no difference in functional outcome, time to weight bearing and general complications as compared to hemi-arthroplasty.

Also in contrast to hemi-arthroplasty, patients treated with PFN, after fracture union can squat and sit cross legged.

Conclusion(s)

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By following the above mentioned criteria we can treat IT fractures with either PFN or cemented Hemiarthroplasty with equally good results.

Abbrebriation

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IT: Intertrochanteric
PFN: Proximal Femoral Nail
PWB: partial weight bearing
FWB: full weight bearing
GT: greater trochanter
LT: lesser trochanter

Refrences

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1. Canale. S, Beaty. J. Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier; 2007.
2. Zhang B, Chui K Y, Wang M. Hip Arthroplasty For Failed Internal Fixation Of Intertrochanteric Fractures. The Journal Of Arthroplasty. 2004 April; 19(3): p. 329- 33.
3. H H. Harris Hip Score. J.B.J.S Am..1969; 51 A: p. 737- 55.
4. Singh M, Nagrath A R, Maini P S. Changes In Trabecular Pattern Of The Upper End Of The Femur As An Index Of Osteoporosis. J.B.J.S. Am. 1970, April; 52(3): p. 457- 67.
5. Rahul M. Salunkhe, Shrirang Limaye, Samar K Biswas, Rahul P Mehta. Cemented hemi-artgroplasty in proximal femoral fractures with severe osteoporosis- a case series. Medical Journal of Dr.D.Y.Patil University. 2012 January- June; 5(1): p. 36-42.
6. Evans. The Treatment Of Trochanteric Fractures Of Femur. J.B.J.S. 1949 May; 31- B: p. 190- 203.
7. Dimon. J, Hughston. Unstable intertrochanteric fractures of hip. J.B.J.S. 1967; 49- A: p. 440.
8. Boldin C, Seibert J, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R. the proximal femoral nail (PFN)- a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patientswith a follow-up of 15 months. Acta Orthop Scand. 2003; 74: p. 53- 58.
9. Domingo LJ, Cecilia D, Herrera A, Resines C. Trochanteric fractures treated with proximal femoral nail. Int Orthop. 2001; 25: p. 298- 301.
10. Schwab E, Hontzsch K, Weise K. Die versorgung instabiler per-und subtrochanter femur fracturen mit dem Proximalen Femurnagel (PFN). Akt Traumatol. 1999; 28: p. 56- 60.
11. Gotze B, Bonnaire F, Weise K, Friedl HP. Belastbahrkeit von osteosynthesenbei instabilen per- und subtrochanteren femurfracturen. Akt Traumatol. 1998; 28: p. 197- 204.

Source(s) of Funding

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Nil

Competing Interests

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No

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