Role of bipolar hemiarthroplasty and total hip arthroplasty in unstable intertrochanteric fracture femur

Introduction

Intertrochanteric fracture is common fracture in elderly people. Their incidence has increased due to the increased life expectancy and osteoporosis.^[1] Earlier, these fractures were managed conservatively by traction or external splinting which resulted in higher morbidity and complication.^[2] Hence, trends for operative intervention increased with time.^[3,4,5] Stable intertrochanteric fractures can be easily treated by osteosynthesis with predictable good result^[6,7] whereas the management of unstable intertrochanteric fracture are challenging because of poor bone quality, osteoporosis, and other underlying diseases.^[8,9] In past, fixed nail plate devices used for the fixation of these fracture, had high rates of cut-out and fracture displacement,^[10,11] subsequently, a sliding hip screw was used with much success and became the predominant method of fixation of these fractures.^[12,13,14] Intramedullary interlocking devices have shown reduced tendency for cut-outs in osteoporotic bone^[15] and also have better results in cases of unstable intertrochanteric fractures.^[15,16] Complications such as head perforations, excessive sliding leading to shortening, plate pull-out, and plate breakage continued to be a problem, especially with the unstable type of fractures.^[17,18] Osteoporosis and instability are most important factors leading to unsatisfactory results.^[19,20] In internal fixation, a period of restricted mobilization is suggested,^[21] which may lead complications such as atelectasis, bed sores, pneumonia, and deep vein thrombosis. Despite advances in internal fixation techniques, the failure rate of the dynamic hip screw is 6.8% to 9.8% while failure rate of the proximal femoral nail is between 7.1% and 12.5% in unstable fractures. There have been various reports of successful outcomes after the use of hemiarthroplasty and total hip arthroplasty (THA).^[22] Endoprosthetic replacements have also been shown to achieve early rehabilitation of the patient and good long-term result. Many author reported that primary cemented endoprosthesis brought better results than compression hip screw in unstable intertrochanteric fractures in elderly osteoporotic patients who were eligible for early mobilization.^[23] In failed intertrochanteric treatment cases, two main treatment options are available, either revision of internal fixation or salvage treatment with hip arthroplasty.^{[24,25,26,27]} Revisions of internal fixation for nonunited fractures have been reported to have good results in younger patients with good bone stock while in older patients with poor bone quality and degenerative acetabular changes; hip arthroplasty has been advocated as a salvage procedure. However, an ideal treatment method is still rather controversial. Hence, the purpose of our study is to study the role of prosthesis replacement in this kind of intertrochanteric femur fracture.

Materials and Methods

In our study, at S.N. Medical College, Agra, 18 cases of intertrochanteric fractures were treated with bipolar hemiarthroplasty or THA between April 2013 and November 2014 were studied prospectively, and subjected to study the role of these surgeries in the intertrochanteric fracture femur.

The inclusion criteria were as follows:

• Unstable intertrochanteric fractures in elderly patient (three or more part intertrochanteric fractures with a loss of posteromedial cortical buttress and reverse obliquity fractures)

• Nonunion of intertrochanteric fracture in old patient

• Malunion of intertrochanteric fracture with arthritis of hip joint

• Elderly patient of intertrochanteric fracture with coexisting hip arthritis.

Exclusion criteria were as follows:

• Preinjury status nonambulatory

• Open fractures

• Severely moribund patients

• Senile dementia

• Any evidence of previous infection.

Among these 18 patients, 12 patients were treated by bipolar hemiarthroplasty whereas 6 patients were treated by THA. In bipolar hemiarthroplasty, Group 5 patients were treated by uncemented and rest seven by cemented hemiarthroplasty, whereas in total arthroplasty, Group 4 patients treated by uncemented while two were by cemented THA. Out of 18 patients, 8 were failed cases of internal fixation. The decision to perform a hemiarthroplasty or a THA was made based on functional demands of the patient and the condition of the acetabular articular cartilage at the time of surgery. Meticulous preoperative templating and careful surgical planning was done. Anteroposterior and lateral radiographs of the femur including the pelvis were taken for all patients. The fractures were classified according to Evans classification. Templates were used to predict the necessary length and diameter of the implant, optimal site of cortical fixation, and proximal femur stem options best suited to reestablish the desired offset and neck length. Assessment of limb length was done using the inter teardrop line and the distance to lesser trochanter.

Results

In our study, 18 patients were included. Among these, 12 patients were treated by bipolar hemiarthroplasty (8 cemented and 4 uncemented) whereas 6 patients were treated by total hip replacement (4 cemented and 2 uncemented). In this study, patients were 40-80 years of age, average period of follow-up was 12 months. After 12 months follow-up, the mean HHP for hips having bipolar prosthesis was 82.52 points and for the hips having total hip prosthesis, it was 82.95 points. Mean WOMAC score for preoperative patients in bipolar and THA series was 84.02 and 86.66, respectively, which improved to 42.58 and 47.46, respectively, at 1-year of follow-up [Table 1]. In our study, two patients have superficial wound infection which was cured with dressing and antibiotic treatment. In bipolar hemiarthroplasty group, average surgery duration was 95 min, blood loss of 315 ml, and mean hospital stay 14.2 days. While in THA group, average surgery duration of 152 min, mean hospital stay 16.5 days, and blood loss of 565 ml [Table 2]. After 12 months, 100% of cemented THA group has good outcome, 75% of uncemented THA group have excellent to good result, 71.5% of cemented bipolar group have good to excellent outcome whereas 80% of uncemented bipolar group have good to excellent outcome [Table 3]. No intraoperative fractures occurred, and there were no cases of nerve palsy seen. Deep vein thrombosis found in one uncemented bipolar hemiarthroplasty group cases, which managed successfully. At last follow-up, 12 patients were walking without any aid, three patients had a limp and used a stick for walking, and one patient used a walker. Seven patients had shortening of the operated limb with an average shortening of 1.5 cm (range, 5-20 mm) which was well compensated by giving a shoe raise. Three patients have lengthening of operative limb of 1.0 cm. All patients' demonstrated clinically significant pain relief and return to ambulation after the surgery, there were no dislocation, loosening, or late infection seen.

Table 1 Functional outcome

Table 2 Demographic and perioperative data

Table 3 Functional results after arthroplasty (on the basis of Harris hip score)

Discussion

Hip fractures are associated with notable morbidity and mortality in elderly patients. About 35-40% of all intertrochanteric hip fractures are unstable three- and/or four-part configurations with displacement of the posterior medial cortex.^[4] The dynamic hip screw and proximal femoral nail have been commonly used for internal fixation of intertrochanteric fractures with good or excellent results.^[28] The failure rate of unstable intertrochanteric fractures with osteoporosis has been reported to be between 4% and 16.5%.^[4,5,29] The failure rate of the dynamic hip screw is 6.8-9.8%^[30] while failure rate of the proximal femoral nail is between 7.1% and 12.5%.^[31,32] The incidence of general complications as pulmonary embolism, deep venous thrombosis, and pneumonia ranges from 22% to 50%^[33] Comminution, osteoporosis, and instability often preclude the early resumption of full weight-bearing and worsen the prognosis. Use of primary THA and hemiarthroplasty is documented to treat unstable intertrochanteric fractures in an effort to mobilize the patients more rapidly and avoid complications of hip screw migration and general complication.^{[34,35,36,37]} Tronzo claimed to be the first to use long, straight-stemmed prosthesis for the primary treatment of intertrochanteric fractures.^[38] Rosenfeld and Schwartz reported good results with the use of the Leinbach prosthesis. Rodop et al.,^[39] in a study of primary bipolar hemiprosthesis for unstable intertrochanteric fractures in 37 elderly patients, obtained 17 excellent (45%) and 14 good (37%) results after 12 months according to the HHP-scoring system. Faldini et al. reported the use of hemiarthroplasty and THA in 54 patients^[40] and the finding that hip replacement permits a more rapid recovery with immediate weight-bearing and facilitates nursing care better than other fixation techniques. Haentjens et al.^[37] reported on a series of 100 patients, 75 years of age or older, who were treated with either a cemented bipolar arthroplasty (91 patient) or THA (9 patients) for an unstable intertrochanteric or subtrochanteric fracture. Good to excellent results were noted in 78% of patients; however, 45% of THA patients sustained a hip dislocation, compared with 3% in the bipolar group. Other complications included loss of greater trochanteric fixation in four cases, one fracture distal to femoral component, and one femoral nonunion. In our study, 12 patients of unstable intertrochanteric fracture [Figure 1] were operated by bipolar hemiarthroplasty [Figure 2]. According to HHP, 75% of bipolar hemiarthroplasty group had excellent to good outcome (mean HHP 82.52). No any chest infection, fat embolism, dislocation, and no any fracture around the stem noted whereas one case of bed sore and two cases of superficial surgical wound infection occurred which were managed successfully with dressing and antibiotic treatment.

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Figure 1

A 68-year-old female of unstable intertrochanteric fracture femur right sides

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Figure 2

A case of 68-year-old female of unstable intertrochanteric fracture femur treated by cemented bipolar hemiarthroplasty

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In failed treatment cases, there are two treatment options available, one is reification and the other is arthroplasty such as THA and bipolar hemiarthroplasty.^[4,5,41] The treatment for failed internal fixation of intertrochanteric fractures is challenging. Most surgeons prefer refixation for young patients and even for active elderly patients with adequate bone quality. However, many elderly patients have poor bone quality, osteoporosis, limb shortening, and damaged cartilage of the femoral head and acetabulum due to penetrating and scratching cartilage by the previous implant.^[37,42] where salvage hip arthroplasty preferred. Some authors report excellent results with bipolar hemiarthroplasty for salvage treatment^[41] while others report better outcome with THA

Hip arthroplasty for salvage has many technical challenges to be overcome.^[4,5] Failed internal fixation implants with or without broken screws must be removed. Nonunion fragments must be mobilized before removal. Careful dissection of scar tissue and calcar-replacement implants or long stems are usually needed,^[4,5] and complications such as intraoperative fractures and postoperative dislocations are still common. However, many authors have reported favorable results with arthroplasty. Haidukewych and Berry^[4,5,41] studied the results of hip arthroplasty in sixty patients of failed internal fixation treated between 1985 and 1997. About 32 total hip arthroplasties and 27 bipolar hemiarthroplasty were performed. The 7-year survivorship of the arthroplasties free of revision for any reason was 100%; 10-year survivorship was 88%. Serious complications were uncommon, and most patients' ambulatory status and pain were markedly improved. In our study, results were comparable to above study as eight patients of failed intertrochanteric cases [Figure 3] out of which two patients were treated by cemented bipolar hemiarthroplasty and six patients were treated by cemented/uncemented THA [Figure 4]. After 12 months follow-up, all patients were ambulatory, there were no hip dislocation, loosening of implant occur, no any serious complication occurred.

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Figure 3

A 56-year-old male patient of failed case of intertrochanteric fracture femur treated by dynamic hip screw 1 year back

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Figure 4

A 56-year-old male patient of failed case of intertrochanteric fracture femur treated by dynamic hip screw 1 year back treated by uncemented total hip arthroplasty

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In a study conducted by Thakur et al.,^[43] patients with failed internal fixation were subsequently treated by cementless modular hip arthroplasty. They evaluated 15 elderly patients treated with a tapered, fluted, modular, distally fixing cementless stem. At an average follow-up of 2.86 years, mean HHP improved from 35.90 preoperatively to 83.01. In our study, results were comparable to above study as six patients of failed intertrochanteric fracture were operated by THA, average age of THA group was 58.16 years. Average operation time in this group was 152 min whereas average blood loss was 565 ml. All patients provided postoperative blood transfusion, mean haris hip score improved from preoperative 36.12 to 82.95 12 months postoperative follow-up. In the present study, operating time and blood loss in the THA group were slightly higher than those in the bipolar hemiarthroplasty group. Many authors report that operating time and blood loss in conversion to THA were only slightly higher than those in primary THA.^[44] However, the increased blood loss and longer operating time associated with THA did not increase the mortality rate and complications.^[45] On the basis of the results of our study, hip arthroplasty with either bipolar or total endoprosthesis seems to be a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture or as a primary intervention in unstable intertrochanteric femur fracture.

Conclusion

Arthroplasty does provide a stable, pain-free, and mobile joint with acceptable complication rate in unstable intertrochanteric fracture femur and in failed intertrochanteric fracture femur cases as seen in our study. Limitations of our study are small number of cases and short follow-up periods, so a larger prospective randomized study with large number of cases and larger follow-up periods are needed further.