|Year : 2012 | Volume
| Issue : 1 | Page : 36-42
Cemented hemi-arthroplasty in proximal femoral fractures in elderly with severe osteoporosis: A case series
Rahul M Salunkhe, Shrirang Limaye, Samar K Biswas, Rahul P Mehta
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||20-Jun-2012|
Samar K Biswas
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune-411018, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Inter-trochanteric fractures in osteoporotic bones which are grossly comminuted are highly unstable and difficult to treat. Conservative treatment with traction and prolonged immobilization lands up with many complications and often fatality. Rate of failure with internal fixation with dynamic hip screw has been found to be high, especially in osteoporotic bones. Revision osteo-synthesis is technically demanding and leads to complications. Aim: To assess the efficacy of cemented hemiarthroplasty in the management of proximal femoral fractures in elderly patients with severe osteoporosis. Settings and Design: A Case series of 50 cases. Materials and Methods: We divided these fractures into three groups and accordingly the prosthesis was used. Group 1- intact calcar and lesser trochanter non-communited-AMP type of bipolar prosthesis, Group 2- fracture of calcar - Thompson's type of bipolar prosthesis with calcar reconstruction, Group 3- group 2 + instability of postero-medial wall-modular type bipolar prosthesis with lesser trochanter and calcar reconstruction. Greater trochanter, calcar, and lesser trochanter were reconstructed with encirclage, tension band wiring, fashioned bone graft, or bone cement collar accordingly. Results: In our study of 50 cases with mean age 79.57 years, 20 cases were type 1, 19 type 2, and 11 type 3 fractures. The average Harris hip score was 79. Excellent to fair results were obtained at follow-up in 46 (92%) and in 4 (8%) results were poor. The mean Harris hip score was 83 (good) in Group- I, 79 (Fair) in Group- II, and 72 (Fair) in Group- III patients. Average hospital stay was 12.5 days. There were four cases of superficial operative site infection which were treated with short course of oral antibiotics. Four cases died of medical complications, earliest being 3 months, and latest being 18 months. No case of loosening of the prosthesis, break in the cement or sinking of prosthesis was seen.
Keywords: Cemented hemiarthroplasty, direct approach to fracture site, osteoporosis, proximal femoral fractures
|How to cite this article:|
Salunkhe RM, Limaye S, Biswas SK, Mehta RP. Cemented hemi-arthroplasty in proximal femoral fractures in elderly with severe osteoporosis: A case series. Med J DY Patil Univ 2012;5:36-42
| Introduction|| |
Most inter-trochanteric fractures occur in elderly people (above 65 years) with reported mortality rates ranging from 15 to 30%.  Problems with osteoporotic bone fractures are geometry (grossly communited), high instability and difficult to treat. The primary treatment goal is stable fixation and immediate full-weight-bearing mobilization. 
Inter-trochanteric fractures occur in the transitional bone between the femoral neck and the femoral shaft.  Transitional bone is composed of cortical and trabecular bone. These bone types form the calcar femorale posteromedially, which provides the strength to distribute the stresses of weight bearing. Consequently, the stability of inter-trochanteric fractures depends on the preservation of the postero-medial cortical buttress. 
The physiological factors like age, osteoporosis, medical diseases, and instability of fractures as components of these fractures are always overlooked. 
Conservative treatment in such patients demands prolonged immobilization and lands up with complications of hypostatic pneumonia, pulmonary embolism, bed sores, senile psychosis, and lastly fatality. 
These fractures should be classified as stable and unstable. 
Various classifications for inter-trochanteric fractures are mentioned in literature, but none of them dictates the implant to be used in a specific fracture type.
The most commonly used classification is the Jensen classification, which is a modification of the Evans classification, divides the fractures into Stable and Unstable, but it does not guides the surgeon to which implant to be used.
Hence we propose to divide the patients with inter-trochanteric fractures into three groups as stated below and use the prosthesis accordingly.
In elderly osteoporotic patients the metaphysis is broad with thin cortex and hence for greater stability prosthesis with broad metaphyseal end and long stem was used in all cases.
- Calcar and lesser trochanter intact, no communition- Bipolar prosthesis AMP type.
- Calcar is fractured or less- Bipolar-thompson's type.
- Instability of postero-medial wall with lesser trochanter, calcar, and greater trochanter fractured-modular type of bipolar prosthesis with reconstruction of greater trochanter and calcar reconstruction.
Also as mentioned earlier, integrity of the postero-medial buttress mainly decides the stability, hence we suggest the different methods of reconstructing greater trochanter, lesser trochanter, and calcar.
Follow-up studies of internal fixation of such fractures with DHS done shows high percentage of failure like bending/break/cutout of implants. 
Studies comparing bipolar hemiarthroplasty vs internal fixation have also concluded that arthroplasty group had easier and faster rehabilitation. 
After implant failure if revision osteo-synthesis is planned then it becomes technically extremely difficult and further immobilization adds up to the complications.
| Materials and Methods|| |
The patients with proximal femoral fractures in elderly people with severe osteoporosis were admitted through OPD or Casualty.
They were screened clinically and radiologically preoperatively for knowing the anatomy of fracture, any associated disease like hypertension, diabetes, ischemic heart disease, etc.
We included only the extra-capsular fractures in the group of proximal femoral fractures.
- Pre-injury status was ambulatory.
- Co-operative for physiotherapy.
- Severe osteoporosis.
- Elderly (age more than 65 years).
We divided these fractures into three groups, and the type of prosthesis was used accordingly.
- Pre-injury status non-ambulatory.
- Open fractures.
- Severely moribund patients.
- Uncontrolled diabetes mellitus.
- Calcar and lesser trochanter intact, no communition- bipolar prosthesis AMP type.
- Calcar is fractured or less-bipolar-Thompson's type.
- Instability of postero-medial wall with lesser trochanter and calcar shattered-modular type of bipolar prosthesis with reconstruction of greater trochanter and calcar reconstruction.
Informed, valid, and willful consent was taken from all patients prior to operation.
The patients were put on skeletal traction with Denham's pin, while the patients were treated for associated problems, if any.
All the patients were graded for osteoporosis according to Singh index.  All were either grade 2 or grade 3. All the patients were given 4 injections decadurabolin fortnightly and calcium with vit.D 3 once daily preoperatively and postoperatively.
Preoperative anesthetic evaluation for anesthetic fitness was carried out. After fitness, patient was taken for surgery and cemented hemi-arthroplasty was done using appropriate type of prosthesis- Modular, Thompson's type or Austin Moore type [Figure 1] was used according to the fracture pattern as mentioned before.
All prosthesis were specially designed with broad metaphyseal end and long stem.
We exposed the neck of femur through the fracture site by lateral approach [Figure 2] approximately 5 cm incision and removed only the head and the neck [Figure 3] leaving the greater trochanter intact with rotators.
Reconstruction of greater trochanter was done with tension band technique/purse-string sutures with 5-0 ethibond. [Figure 4], [Figure 5] and [Figure 6].
Lesser trochanter and calcar were reconstructed with encirclage /bone graft (fashioned from removed head and neck)/collar of cement at the site of calcar during insertion of prosthesis. [Figure 7]a, b, [Figure 8], [Figure 9] and [Figure 10].
Post-operatively patient was put on non weight-bearing (NWB) exercise of hip and knee from day 1, bed side sitting and knee bending exercises from day 3, standing with support by the side of bed from day 5 and from day 7 onwards patient was made to walk with walker. The sutures were removed on day 12 and the patient was discharged with a printed instruction sheet of DO's and DON'T's. Patient was advised to walk with walker, sit in chair, use western toilet, report to doctor in any suspicion of infection like UTI/URTI/Local, not to squat or sit cross legged, and to avoid uneven ground and busy roads.
Subsequently they were followed up in OPD at monthly, 3 month and 6 month and yearly intervals.
After 3 months, walking with cane in opposite hand is advised till end of 1 year.
From 23/03/07 we have done 50 cases of cemented hemi-arthroplasty for proximal femoral fractures in elderly people with severe osteoporosis.
Mean follow-up was of 29 months.
Case-1 [Figure 11]a, b, Case-2 [Figure 12]a, b, Case-3 [Figure 13]a, b.
|Figure 13: (a) Group III fracture (b) Modular bipolar prosthesis with LT encirclage|
Click here to view
| Results|| |
45 (90%) patients were ambulatory prior to discharge.
- Age: The average age of the patient was 79.57 years, with the youngest being 68 and the oldest 104 years of age.
- Gender: Of the 50 patients 22 were male and 28 were female.
- The male/female ratio was 11:14.
- The mode of injury:
- Forty-five patients had an accidental fall at home, while 05 patients met with vehicular accident.
- Singh's index (grades of osteoporosis) :
In 37 patients, Singh index was grade III and in 13 it was grade II.
- Type of fracture: (groups as mentioned above):
Group I- 20, Group II- 19, and Group III- 11.
- Type of prosthesis
In 20 patients Austin Moore type, 19 Thompson type, and in 11 patients Modular type of bipolar prosthesis was used.
- Greater trochanter was reconstructed in 20 cases while lesser trochanter and calcar in 17 cases.
- Harris hip score  : The Harris hip scores are given in [Table 1] and [Table 2].
Excellent to fair results were obtained at follow-up in 46 (92 %) and in 4 (8%) results were poor.
The mean Harris hip score was 83 (good) in Group- I, 79 (Fair) in Group- II, and 72 (Fair) in Group- III patients.
All three groups thus show good to fair functional outcome with the proposed treatment.
All patients were eventually ambulated.
The average stay in hospital was 12.5 days, with shortest being 12 days and longest of (21) days.
37 patients had associated co-morbidities.
There were four cases who died due to medical complications earliest being 3 months post operative period and late being 18 months.
There were four cases of superficial operative site infection which were treated with short course of oral antibiotics.
There was no case of loosening of the prosthesis, break in the cement, or sinking of prosthesis.
At follow-up progress and complications, if any, were noted and treated accordingly.
| Discussion|| |
Complexity of inter-trochanteric fractures in elderly osteoporotic patients poses challenging problems with added risk of increased morbidity and mortality. Internal fixation of such fractures although may reduce the morbidity of pain but does not permits early mobilization with fear of failure of fixation and thus indirectly the morbidity of fracture disease remains same.
There are limitations of use of internal fixation and their obvious complications in special cases where the patient is elderly, bones are severely osteoporotic, fracture is unstable. The incidence of the fixation failure is reported to be as high as 20% in unstable fracture patterns. 
Both, stability and early ambulation are only possible with cemented hemiarthroplasty. 
In proximal femoral fractures with severe osteoporosis and poor bone stock there is 100% risk of failure of fixation of any type. 
Rate of failed fixation of compression hip screw is around 9.7%. There is a significant difference in osteoporosis grade between the failed and successful compression hip screw. 
Kim and co-workers  reviewed 178 inter-trochanteric fractures treated by DHS fixation. They used Singh's index for degree of osteoporosis and Evans classification for stability of fracture. They found failure of fixation in the form of varus angulation >100°, perforation of femoral head, more than 20 mm of extrusion of a lag screw or metal failure, in 49 (27%) cases. In these 2 fractures were stable, and 47 were unstable. Thus the conclusion was unstable fractures with osteoporosis had a failure rate of >50% and in such cases dynamic hip screw should not be the first choice of treatment. 
Primary hemiarthroplasty offers a modality of treatment that provides adequate fixation and early mobilization in these patients thus preventing postoperative complications such as pressure sores, pneumonia, atelectasis, and pseudo arthrosis. 
As observed by the senior author and colleagues, cemented hemi-arthroplasty with posterior approach, cutting the rotators, increases the degree of postero-medial instability, with shattered greater trochanter, increases the risk of dislocation of hip joint.
Hence approach was modified through the fracture site (lateral approach) removing the head and neck only, leaving the greater trochanter (shattered/intact) with rotators in situ, after reconstruction of greater trochanter (if shattered), maintains the postero-medial stability, and hence obviates the risk of dislocation.
Reconstruction of greater trochanter and calcar is an important step of surgery to maintain the stability of hip joint and to promote early ambulation with hip movements on D1 and walking with walker D7.
Early mobilization is very essential particularly in patients with other medical co-morbidities and to prevent post-operative complications.
| Conclusion|| |
The proximal femoral fractures should be classified as stable and unstable, the fracture should be graded according to the degree of osteoporosis.
The proximal femoral fractures should be grouped according to fracture geometry so that correct choice of prosthesis can be used.
The treatment of proximal femoral fractures in elderly patients with severe osteoporosis differs from the treatment of other proximal femoral fractures. These fractures are better treated with cemented hemi-arthroplasty.
The treatment of these fractures with cemented hemi-arthroplasty has the advantage of early ambulation and less hospital stay.
The cemented hemi-arthroplasty also provides stable and mobile hip and revision surgery is hardly needed in these elderly patients.
Implant should preferably have broad metaphyseal end and long stem to enhance the stability.
Cement (methyl-methacrylate) is a better fixing agent and it improves the stability of hip.
The Thompson's prosthesis is a better choice when there is fractured calcar or in case when calcar reconstruction is not possible by any way.
The modular type of bipolar prosthesis is a better choice when there is communition of postero-medial wall with lesser trochanter and calcar fracture.
The post-operative physiotherapy is very essential for earlier functional recovery.
The weight bearing can be started earlier than in other methods of treatment.
| References|| |
|1.||Canale S, Beaty J. Campbell's operative orthopaedics, 11th ed. Fractures and Dislocations of the Hip. Philadelphia: Mosby Elsevier; 2007. |
|2.||McKibbin B. The biology of fracture healing in long bones. J Bone Joint Surg Br 1978;60:150-62. |
|3.||Koval KJ, Zuckerman JD. Hip fractures: II. Evaluation and treatment of intertrochanteric fractures. J Am Acad Orthop Surg 1994;2:150-6. |
|4.||In: Kasser JR, editor. Orthopaedic knowledge update 5-home study syllabus. Rosemont (IL): American Academy of Orthopaedic Surgeons; 1996. |
|5.||Dimon J, Hughston. Unstable intertrochanteric fractures of hip. J Bone Joint Surg Am 1967;49:440-50. |
|6.||Zhang B, Chui KY, Wang M. Hip arthroplasty for failed internal fixation of intertrochanteric fractures. J Arthroplasty 2004;19:329-33. |
|7.||Evans EM. The treatment of trochanteric fractures of femur. J Bone Joint Surg Am 1949;31:190-203. |
|8.||Kim WY, Han CH, Kim JY. Failure ofw intertrochanteric fracture fixation with dynamic hip screw in relation to pre-operative fracture stability and osteoporosis. Int Orthop 2001;25:360-2. |
|9.||Haentjens P, Casteleyn P, De Boeck H, Handelberg F, Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients: Primary bipolar arthroplasty compared with internal fixation. J Bone Joint Surg Am 1989;71:1214-55. |
|10.||Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am 1970;52:457-67. |
|11.||Harris H. Harris hip score. J Bone Joint Surg Am 1969;51:737-55. |
|12.||Baumgaertner MR, Levy RN. Intertrochanteric hip fracture. In: Browner BD, Levine AM, Jupiter JB, editors. Skeletal Trauma. Vol 2. Philadelphia: W B Saunders; 1992. p. 1833-81. |
|13.||Haentjens P, Casteleyn PP, Opdecam P. The Vidal-Goalard megaprosthesis: An alternative to conventional techniques in selected cases? Acta Orthop Belg 1985;51:221-34. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
[Table 1], [Table 2]