ORIGINAL ARTICLE
Year : 2023 | Volume
: 19 | Issue : 1 | Page : 14--18
Geriatric intertrochanteric fractures – A challenge to manage
P Madhuchandra, KM Pawankumar, K Manish, KP Raju
Department of Orthopaedics, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India
Correspondence Address:
K Manish
Department of Orthopaedics, BGS Global Institute of Medical Sciences, No. 60, Uttarahalli Main Road, Kengeri, Bengaluru - 560 060, Karnataka
India
Abstract
Background: Intertrochanteric fractures are among the frequently seen fractures in the elderly population. Treating these fractures is very challenging considering the fact that the quality of bone is poor and highly osteoporotic. The high failure rates with dynamic hip screw (DHS) especially in unstable fractures lead to the development of intramedullary devices such as proximal femoral nail (PFN) which has got multiple advantages over DHS. Materials and Methods: This prospective study included 30 patients above the age group of 60 years with unstable intertrochanteric fractures conducted in a tertiary institute between February 2021 and June 2022. Results were analyzed clinically and radiologically using the Modified Harris hip score. Results: Patients' age group was 61–85 years with a mean age of 69 years, comprising 63% female and 37% male. The average Harris hip score was 83.76 at 24 weeks' follow-up with 33.33% excellent, 56.66% good, 3.33% fair, and 6.67% poor. Postoperative complications included revision surgery in two patients, superficial infection in one patient, Z effect in one patient, peri-implant fracture in one patient. Conclusion: Treatment with PFN for unstable intertrochanteric fracture has the advantages of closed reduction, less tissue damage, early rehabilitation, and return to work. Osteosynthesis with short PFN resulted in good-to-excellent functional and radiological outcomes.
How to cite this article:
Madhuchandra P, Pawankumar K M, Manish K, Raju K P. Geriatric intertrochanteric fractures – A challenge to manage.J Indian Acad Geriatr 2023;19:14-18
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How to cite this URL:
Madhuchandra P, Pawankumar K M, Manish K, Raju K P. Geriatric intertrochanteric fractures – A challenge to manage. J Indian Acad Geriatr [serial online] 2023 [cited 2023 Mar 22 ];19:14-18
Available from: http://www.jiag.com/text.asp?2023/19/1/14/371895 |
Full Text
Introduction
Intertrochanteric fractures are among the most frequently seen fractures in the elderly population. The International Osteoporosis Foundation estimates that approximately 1.6 million such fractures occur per year worldwide, a figure which may rise to 6 million by 2050.[1] The increasing incidence of these fractures is due to a high increase in the osteoporosis and reduced reflexes of the patients.
More than 50% of these fractures are unstable. Poor bone quality with complex fracture patterns makes these fractures challenging to treat. The greatest challenges for the treatment of these fractures are instability and osteoporosis, and the complications of fixation that may arise from them.[2]
The bone-implant interface experiences more stress in unstable fractures if the ability to recover this is constrained by comminution or the orientation of the fracture. Thus, implants used to treat unstable fractures must be able to support more weight to prevent loss of reduction due to collapse. Studies on implant loading show that an intramedullary device serves better in cases of both varus malreduction and unstable fracture patterns since these factors increase the load borne by an implant.[3],[4]
We hypothesized that Proximal Femoral Nail (PFN) will give adequate stability for unstable fractures and excellent biomechanical advantages over side plates with lesser complications. We evaluated the effectiveness, advantages, and complications of the proximal femoral nailing in intertrochanteric fractures of femur in our setup.
Materials and Methods
A prospective, time-bound, and hospital-based clinical study was conducted in a tertiary care center between February 2021 and June 2022. Around 30 patients with unstable intertrochanteric fractures who underwent conventional short proximal femoral nail were included in the study and were evaluated on a regular basis for functional and radiological outcomes. Patients with unstable intertrochanteric fractures who were above the age of 60 years and closed fractures were included in the study. Patients with stable intertrochanteric fractures, age <60 years, open fractures, and medically unfit patients were excluded from the study. Informed consent was taken from all the patients included in the study. Institutional ethics committee approval was taken before the initiation of the study. The study was conducted by the principles laid down by the Declaration of Helsinki.
All the patients underwent surgery “closed reduction and internal fixation with short PFN” once the medical fitness was obtained. Weight-bearing was started depending upon the pain tolerance of the patient and range of motion exercises were started from day 1 following surgery. The patients were followed up at 2 weeks, 6 weeks, 12 weeks, 18 weeks, and 24 weeks postoperatively. Patients were assessed for functional outcome and radiological union during each follow-up and data were compiled. Results were analyzed clinically and radiologically and outcomes were assessed using Modified Harris hip score.[5]
Statistical analysis
Based on the previous literature for an outcome variable on intertrochanteric fractures in adults treated by short proximal femoral nail with 70% in type 3, in a prospective study domain, 95% confidence interval, with 20% margin of error, the sample size of 30 is adequate.
Descriptive and inferential statistical analysis has been carried out in the present study. Results on continuous measurements are presented on mean ± standard deviation (minimum–maximum) and results on categorical measurements are presented in number (%). Significance is assessed at 5% level of significance. The following assumptions on data are made, assumptions: (1) dependent variables should be normally distributed, (2) samples drawn from the population should be random, cases of the samples should be independent The one-way analysis of variance (ANOVA) is employed to determine whether there are any statistically significant differences between the means of three or more independent (unrelated) groups. The one-way ANOVA compares the means between the groups you are interested in and determines whether any of those means are statistically significantly different from each other. Specifically, it tests the null hypothesis. Chi-square/Fisher's exact test has been used to find the significance of study parameters on a categorical scale between two or more groups, nonparametric setting for qualitative data analysis. Fisher's exact test is used when cell samples are very small.
P value obtained by Fisher's test is considered,
Mildly significant when P value is 0.05 to 0.10
Moderately Significant when P value is 0.01 to 0.05 and
Strongly significant when P value is < 0.01.
Statistical software
The Statistical software namely SPSS 22.0 (IBM, Chicago, IL, USA), and R environment version. 3.2.2 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs and tables.
Results
All the patients in the study were above the age of 60 years. The mean age of the patients is 69 years (range 61–85 years). Majority of the patients were in the age group of 71–80 years (66.6%). Of 30 patients, 19 (63.3%) were female and 11 (36.7%) were male, showing a female preponderance with the ratio being female: male > 3:2. The left side was involved in 16 (53.3%) patients and the right side was involved in 14 (46.7%) patients. The distribution of the patients as per Boyd and Griffin classification is as per [Table 1]. All the fractures had unstable fractures. In our study, out of 30 patients, 16 patients, comprising 53.3% of all patients had one or the other types of comorbidities, increasing the morbidity in the patients, while 14 (46.7%) of the patients had no comorbidities [Figure 1].{Figure 1}{Table 1}
Out of 30 patients, 13 (43.3%) patients were operated on within 2 days' time from injury to surgery, 14 (46.7%) patients between 3 and 6 days and 3 (10%) patients between 7 and 10 days based on associated clinical conditions and comorbidities. In this study, majority of the subjects were operated on within a week time from injury to surgery. In majority of the patients, closed reduction and internal fixation with short PFN were done, except 1 (3.3%) patient where the open reduction was done owing to fracture comminution and displaced lesser trochanter. Additional cerclage wiring was done for the same. All the patients were followed for a minimum period of 6 months.
In this study, functional outcome based on modified Harris hip score showed 20 patients (66.7%) had good to excellent functional outcome in terms of the Harris hip score [Figure 2] and [Figure 3]. While in another 8 patients (26.7%) had good to fair outcomes, while 2 had poor outcomes [Table 2] and [Table 3]. The radiological union was achieved in 25 patients (83%) within 20 weeks while in 3 patients it was seen at around 24 weeks. 2 patients had implant failure and hence revision surgery was done. Functional Outcome – Frequency distribution of patients studied is shown in [Table 4]. A comparison of clinical variables according to the functional outcome of patients studied is given in [Table 5]. In majority of the patients, 24 patients comprising 80% of the study group, osteosynthesis was achieved uneventfully. In another 6 patients (20%) had one or the other complication. There was one case of peri-implant fracture, varus collapse, screw cutout, refracture with implant failure, Z effect, and superficial infection. Patients with refracture and implant failure and Z effect were revised to bipolar hemiarthroplasty [Figure 4] and [Figure 5]. In patient with peri-implant fracture, intertrochanteric fracture had united. However, the shaft fracture was addressed with long PFN. Superficial infection was dealt with regular dressings and oral antibiotics and healed by the end of 2 weeks.{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Table 2}{Table 3}{Table 4}{Table 5}
Discussion
The success of treatment in intertrochanteric fractures is multi-factorial. It depends on factors such as the age of the patient, general condition and comorbidities, time from fracture to treatment fracture patterns, and stability of the fixation. In the present study, 30 patients of either sex with unstable intertrochanteric fractures were studied.
In our study, the intertrochanteric fracture was more common between 6th and 8th decades with an average of 69.06 years. Most of them were comminuted, and unstable fractures required operative management. Since these fractures are associated with high morbidities, early fracture fixation, and rehabilitation is indispensable. The average age of the patients in this study was 69 years which was comparable to most of the Indian authors with similar studies [Table 6]. Our study had a female preponderance with 19 female patients and 11 male patients. Increased incidence in females is attributed to postmenopausal osteoporosis. The prevalence of osteoporotic fractures rises from 4% in women at the age group 50%–59%–52% of women aged >80 years according to a study by Gallagher.[10]{Table 6}
Out of 30 patients, maximum number of patients were seen in Group II, which is comparable to similar series of studies [Table 7]. In this study, all the patients were belong to unstable fracture pattern.{Table 7}
Functional outcome in the patients were assessed using the modified Harris hip score. In our series, we had 33.3% of the patients with excellent, 56.7% good, 3.33% patient fair, and 6.67% poor outcomes in terms of gain of functional ability, similar or comparable to pre-injury ability. Patients, who obtained excellent results, had no residual deformities or pain. The range of motion was within the normal functional range and had no complications. Patients with good results had minimal limitation of activities and occasional pain. Rest of their findings were within acceptable parameters. Patients with fair results had pain and limitation of activities. The patient needed walker support for mobilization. 6.67% of patients had poor outcome, due to implant failure and needed revision surgery [Table 8].{Table 8}
In our study, total 6 patients had complications postoperatively. 1 patient had peri-implant fracture, 1 patient had screw cut out, 1 patient had Varus Collapse, 1 patient had varus collapse with refracture and lag screw back out and broken derotational screw, 1 patient had Z Effect, and superficial infection in 1 patient. The rate of complications was comparable to other similar studies [Table 9].[11],[12] These complications in the patient could be attributed to an unstable fracture pattern, severe osteoporosis, lack of anteromedial buttress, and early weight bearing in selected cases.{Table 9}
Conclusion
The incidence of unstable intertrochanteric fractures is on the rise and is also compounded by various fracture-dependent and independent factors. The results from our study suggest that the proximal femoral nail can be opted as the most well-judged method of treating unstable intertrochanteric fractures. PFN can be used in all configurations of fractures, is less time-consuming, preserves the fracture hematoma, early mobilization, and weight bearing can be allowed. Proximal femoral nail after proper training and technique is a safe and easy implant option for the treatment of complex and unstable intertrochanteric fractures.
Limitations
The study is a time-bound study. Intertrochanteric fractures are very common, hence a study with a bigger sample size would be better.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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