Role of primary bipolar arthroplasty or total hip arthroplasty - Punjab ...

Original Article
Role of primary bipolar arthroplasty or total hip arthroplasty for
the treatment of intertrochanteric fracture femur in elderly
Jaswinder Pal Singh Walia*, Dheeraj Sansanwal**, Sonam Kaur Walia**,
Sargun Singh***, Avinash Chander Gupta****
*Professor, **Junior Resident, ***Undergraduate, ****Associate Professor
Department of Orthopaedics,
Govt. Medical College and Rajindra Hospital, Patiala, Punjab.
ABSTRACT
Extracapsular fractures of femur in elderly patients are associated with high rate of morbidity and mortality.
Primary cemented hip arthroplasty is a very useful procedure for the unstable comminuted intertrochanteric
fractures with osteoporotic bone in elderly patients. The procedure markedly improved the clinical as well as
functional status of the patients. The present study was conducted on 50 cases of extra capsular fractures of
femur above the age group of 50 years. Out of the 50 cases, 25 were those in whom cemented bipolar
prosthesis was used while in other 25, total hip replacement arthroplasty was done. There was no significant
difference between two forms of arthroplasty (Bipolar hemi-replacement or Total Hip replacement) in terms
of hospital stay, time period required for partial or complete weight bearing, and functional results. Though
total hip arthroplasty appears to provide slightly better results regarding pain and mobility; its instability
in addition to impaired reflexes, cognitive impairment, and weaker musculature in elderly shows higher
dislocation rates. This can lead to increased hospital stay or revision surgery. This complication was not
seen by us in hemiarthroplasty group.So we are of the opinion that although it may appear to be equally
good results in both groups, in elderly patients, however, the choice should fall for bipolar hemi-arthroplasty
than for total hip replacement.It should however be noted that a larger randomized trial, with higher number
of patients, or multi-centric trial can improve the interpretation of the results.
Keywords: Inter-trochanteric femoral fractures, primary bipolar arthroplasty, total hip arthroplasty,
elderly femoral fractures.
INTRODUCTION
Hip fracture is a devastating injury, incidence of which has
increased because of increased life expectancy 1 . Disability
frequently results from persistent pain and limited physical
mobility in hip fractures and is associated with substantial
morbidity and mortality. For the health care system and to
society in general, intertrochanteric fractures and femur neck
fracture represents an epidemic disease 2 .
In elderly, osteoporotic bones, a trivial fall is the cause of
90% of hip fractures 3 .
Corresponding Author :
Dr. JPS Walia
Professor of Orthopaedics
19, Phulkian enclave, Patiala, Punjab.
E-mail : doc_jpswalia@yahoo.co.in
A typical patient with hip fracture is characterized by old
age, severe osteoporosis and significant co-morbid diseases.
Primary aim of treatment should be to perform a surgery that
provides the individual with greatest opportunity for early
ambulation 4 . This requirement is fulfilled to a great extent by
use of a primary prosthetic replacement implant with or without
cement. This technique allows early ambulation, thus avoids
recumbency and its associated complications.
We studied the results of 50 cases of extra capsular fracture
neck femur in elderly patients treated with primary cemented
bipolar arthroplasty or total hip replacement arthroplasty
(25 cases each).
MATERIAL AND METHODS
This study was conducted on 50 cases of extra capsular fractures
of femur above the age group of 50 years.
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Walia et al
Surgery was done under general or spinal anaesthesia
depending upon the choice of anaesthesiologist. All patients
were operated in lateral decubitus via posterolateral
approach. The fascia was incised in line with the skin incision.
After blunt dissection of gluteus maximus the gluteus medius
was retracted to expose the short external rotator muscles of
the hip. The abductor-greater trochanter-vastus lateralis
complex was kept intact. Short external rotators were divided
close to their insertion and an inverted T shaped incision was
made on the joint capsule. The femoral neck was osteotomised
and the femoral head was removed. Patients were subjected to
either hemiarthroplasty, with cemented bipolar prosthesis, or
total hip arthroplasty depending upon condition of the
acetabulum
Hemiarthroplasty - Once the head-neck fragment has been
removed the medullary canal of the femur is readily accessible.
The canal was rasped with an appropriately sized broach and
trial prosthesis was inserted. A helpful guide used for the
appropriate height of calcar reconstruction is the relationship
between the centre of femoral head and tip of the greater
trochanter: It should be essentially coplanar. Although this
may be difficult to assess in presence of trochanteric fracture,
usually, the greater trochanter fragments are still somewhat
attached and can be used as a gross guide for evaluating the
appropriate level for prosthesis. Following an acceptable trail
fit, leg length and hip stability are assessed. The head was redislocated
and a permanent bipolar prosthesis was cemented
into the femur at the proper level. After reduction the movements
of the hip were checked.
Figure 1: Pre and post operative X-ray of bipolar case
Total Hip Replacement - The acetabulam was prepared by
excising the ligamentum teres and removing the articular
cartilage with acetabular reamer till raw cancellous bleeding
bone was exposed. The fitting of the acetabular component
was checked. Acetabular cup was placed in a position of 45-55 0
abduction and 10-15 0 anteversion. Femoral preparation was
done as already mentioned above for bipolar hemiarthroplasty.
Trail reduction was done and soft tissue tension
checked. Following an acceptable trail fit, leg length and hip
stability are assessed. The head was re-dislocated and a
permanent prosthesis was cemented into the femur at the
proper level. After reduction the movements of the hip were
checked.
Figure 2: Pre and post operative X-ray of THR case
Trochanteric reconstruction: Displaced trochanter was
fixed accordingly as per geometry, comminution of fracture with
the help of SS Wire or vicryl numbrt 1 reinforced with bone
cement. Femoral head was used for reconstructing the medial
bone loss wherever required.
After reattachment of capsule and short external rotators,
closure in layers was done over drain.
Physiotherapy was started on the first postoperative day.
On the second postoperative day, patients were allowed
to sit on the side of the bed or upright in a chair. Gait training
was begun and weight-bearing was permitted earliest, as
tolerated. As all the patients were elderly, they required a walker
for balance during gait training.
Patients were discharged 5-12 days after surgery and were
advised to continue physiotherapy until they could return to
independent living.
Patients were evaluated clinically according to the Harris
hip score 5 and Salvati-Wilson hip score 6 in out-patient facilities
at follow-ups.
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Bipolar or total hip arthroplasty for intertrochanteric fracture
RESULTS
A total of 50 elderly patients with intertrochanteric fractures
underwent arthroplasty between 2008 and 2010. Mean followup
duration was 21.8 months (range, 7-34months). No mortality
was noted. Mean age of patients was 69.04 years. Maximum
number of patients was in the age group of 60-79 years
comprising of 80% of total patients. In the bipolar group average
age was 67.44 years, while in THR group average age was 70.64
years. There were 38% female patients and 62% male patients.
Patterns were similar in both the groups.
In our Series 66% of intertrochanteric fractures were caused
by minor trauma in the form of stumbling or fall on uneven
surface and rest 34% cases by severe trauma in the form of
vehicular motor accidents. Patterns were similar in two groups
with minor trauma as cause in 60% in bipolar group and 72% in
THR group.
In present study, 64% cases were operated within 7 days
of admission, 26% cases with in 8 to 15 days of admission and
10% cases were operated after 15 days of admission in the
hospital. The delay was mostly because of associated medical
conditions. Hypertension was most common associated
disease.
The mean operative time in bipolar group was 50 minutes
(range, 45-70 minutes). Average intraoperative blood loss
was 120 ml (range, 90-25 0 ml) while in THR group mean
operative time was 74 minutes (range, 60-100 minutes).
Average intraoperative blood loss was 154 ml (range, 100-300
ml).
In Bipolar group 88% patients were allowed partial weight
bearing within 7-14 days of operation 8% in third week and it
was delayed till fourth week in one patient. In THR group 64%
patients were allowed partial weight bearing within 7-14 days
of operation 24% in third week and it was delayed till fourth
week in 3 patients. Delayed weight bearing was due to
comminution of fracture.
In THR group 22 patients 88(%) were allowed full weight
bearing within 4-6 weeks of operation. While in BIPOLAR group
24 patients 96(%) were allowed full weight bearing within 4-6
weeks of operation.
At last follow-up in bipolar group, 3 cases (12%) had limp
while walking. In THR group, only 2 cases (8%) had limp while
walking.
In THR series 2 cases had dislocations (8%), one happened
after 2 weeks when patient slipped and fell; while in another
case more than one year later in a road accident. Both were
treated by closed reduction. This was followed by a 2-3 weeks
period of immobilization with traction followed by guarded
weight bearing. There were no dislocations in bipolar group.
In our study of 50 cases outcome was excellent to good in
all the cases as per Salvati and Wilson hip score. Functional
scores were slightly better in THR group (mean 34.16/40) when
compared to bipolar group (33.60/40) but difference was not
statistically significant (p value > 0.05).
Mean Harris hip score at final follow up was 82 in bipolar
group and 84.4 in THR group.
DISCUSSION
Hip fracture injuries are one of the most serious health care
problems affecting elderly patients. There were an estimated
1.66 million hip fractures world-wide in 1990, this worldwide
annual number will rise to 6.26 million by the year 2050 7,8 .
In elderly the coexistence of unstable comminuted fracture
with osteoporosis worsen the prognosis 9,10 , which is attributed
to presence of various co-morbid conditions, which are
exacerbated by immobility, bed rest and delayed weight
bearing. In osteoporotic fractures, maintenance of reduction
can be a major problem. Unsatisfactory surgical outcome is
common in elderly patients with intertrochanteric fractures;
medical illness, osteoporosis, and fracture instability are
contributing factors.
The orthopaedic literature concerning the treatment
and results of comminuted intertrochanteric fractures of the
hip by Massie (1962) 11 , Holt (1963) 12 and Dimon (1973) 13 have
shown outstanding work in an attempt to change an unstable
fracture to a stable one and fix it with a specific device until it
heals.
Davis et al (1990) 9 studied the causes of mechanical
failure in a series of 230 intertrochanteric fractures which had
been internally fixed with either sliding hip screw or Kuntscher
y-nail. The overall rate of mechanical failure was 16.5%.
Kyle et al (1979) 14 reporting on a series of 74 unstable
intertrochanteric fractures, had a post nailing complication rate
of 6% to 8% and they could not ambulate their patients as late
as four to six weeks due to the unstable nature of the implant
bone construct. Hayward et al (1983) 15 reported a failure rate of
35% using a nail plate combination and a failure rate of 37.5%
using Enders nails.
Kim et al (2001) 16 reviewed 178 intertrochanteric fractures
treated by dynamic hip screw (DHS) fixation followed for a
minimum of one year. Unstable fractures with osteoporosis
had a failure rate of more than 50%. They concluded in such
cases, DHS should not be the first choice for treatment.
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Walia et al
Reoperation rates have been reported as high as 8-16%
with internal fixation in intertrochanteric fractures 17,18 .
Furthermore, repeat surgery in these patients carries with it a
high incidence of medical complications and post operative
dislocation of the prosthesis has also been shown to be
somewhat more common 19 .
From the above review of literature, it is evident that
although the use of internal fixation has decreased the mortality
rate, the rate of complication still ranges from 4-50% 16 and
walking with full weight bearing before the fracture has healed
is often impossible.
There is no doubt that the general consensus would be to
use internal fixation devices in stable intertrochanteric fractures
in younger patients as they can tolerate immobilization and if
needed, reoperation, quite well. However this is not so in elderly,
debilitated patients who sustain an unstable intertrochanteric
fracture.
Primary arthroplasty has been advocated in elderly patients
with a view to make the rehabilitation early and to lessen the
incidence of complications of prolonged immobilization which
are frequently encountered in the treatment with various forms
of internal fixation devices e.g. venous thrombosis, pulmonary
embolism, atelactasis and allied complications. The major
advantage of treatment with cemented endoprosthesis is the
early weight bearing and the rehabilitation of these elderly
patients to their pre-fractures level more quickly than is achieved
with various fixation devices.
Multiple studies 20,21,22 showed that unstable three or four
part hip fractures can be treated with a standard femoral stem
prosthesis and circlage wiring of the trochanters. This technique
allows safe early weight bearing on the injured hip and had a
relatively low rate of complications.
A major complication associated with arthroplasty is high
rate of dislocation 23 . Associated with the dislocations was a
much higher incidence of pressure sores and pulmonary
complications 24 . But use of bipolar arthroplasty instead of
total hip replacements can reduce this complication to an
acceptable rate 25 . Haentjens et al 26 and Geiger et al 27 separately
reported results of arthroplasty in intertrochanteric fractures.
In their studies dislocation rate in the patient group who
underwent total hip arthroplasty was significantly higher
(12% to 44.5%) than those who had bipolar arthroplasty
(0 to 3.3%).
In our study, there was no significant difference between
two forms of arthroplasty (bipolar hemi-replacement or total
hip replacement) in terms of hospital stay, time period required
for partial or complete weight bearing, and functional
results.
Though total hip arthroplasty appears to provide slightly
better results regarding pain and mobility;however, its
instability in addition to impaired reflexes, cognitive impairment,
and weaker musculature in elderly patients shows higher
dislocation rates (8%). This leads to increased hospital stay or
revision surgery. This complication was not seen with bipolar
hemi-arthroplasty.
So we are of opinion that although at the outset, it may
appear that the results are equally good in both the groups, in
elderly patients choice should fall for bipolar hemi-arthroplasty
than for Total hip replacement.
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