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

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.
Pb Journal of Orthopaedics Vol-XII, No.1, 2011
7
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