There was no significant difference in the age, medical illness and injury cause between the two groups, general information of the involved patients were comparable   (P > 0.05; Table 1).

 

All involved patients completed the surgery successfully. There was no significant difference in the intraoperative blood loss, time of weight loading postoperatively and Harris scores at the last follow-up (P > 0.05). The operation time in intertrochanteric fracture group was significantly longer than that in femoral neck fracture group (P < 0.01; Table 2).

 

Seven cases (20%) in intertrochanteric fracture group had complications, including two cases of pulmonary infection, one case of urinary tract infection, one case of deep vein thrombosis, and three cases of cardiovascular disease (heart failure, cerebral infarction). Ten cases (18%) in femoral neck fracture group had complications, including two cases of pulmonary infection, three cases of urinary tract infection, two cases of deep vein thrombosis, and three cases of cardiovascular disease (heart failure, infarction). No cases in the two groups appeared pressure sores and incisional infection, there was no significant difference in the complication rate between the two groups (P > 0.05).

 

In the intertrochanteric fracture group, two cases appeared hip joint space changes and pain, two cases appeared prosthesis loosening, and one case received prosthesis revision. In the femoral neck fracture group, four cases appeared hip joint space changes and pain, one case appeared prosthesis loosening, and one case received prosthesis revision. The host response and prosthesis revision rate showed no significant difference between the two groups (P > 0.05).

Hip fractures are frequently seen in the elderly, conservative treatment needs long-term bed rest and causes many complications, high morbidity and high mortality^[1]. Therefore, surgery has become the preferred treatment for hip fractures when patients can tolerate surgery^[2]. It’s well known that, femoral head replacement has been widely applied in treatment of displaced femoral neck fractures in the elderly patients. Whether femoral head replacement or arthroplasty can serve as the initial treatment of intertrochanteric fractures remains controversial. In this study, elderly patients with intertrochanteric fractures achieved good effects by cemented bipolar hemiarthroplasty in the Center of Orthopedics, Haikou Municipal People's Hospital Affiliated to Xiangya School of Medicine, Central South University, from March 2006 to October 2011. The therapeutic effect was compared with elderly patients with femoral neck fractures after cemented bipolar hemiarthroplasty.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程
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A retrospective case analysis.

 

Experiments were performed in the Center of Orthopedics, Haikou Municipal People's Hospital Affiliated to Xiangya School of Medicine, Central South University, from March 2006 to October 2011.

 

 

The fractures were diagnosed by imaging examinations (X-ray or CT).

 

(1) Patients aged ≥ 80 years. (2) Ipsilateral hip function was normal before injury. (3) Patients were in good general condition and could tolerate surgery. (4) Patients and their families were informed of the treatment and agreed.

 

(1) Patients had a history of ipsilateral hip fracture or surgery. (2) Patients had surgical contraindications.

 

All involved patients were treated using bipolar cemented handled prosthesis, 9 cases in intertrochanteric fracture group were treated using lengthened handled prosthesis.

 

Patients were inquired of previous history after admission and received physical examination. Laboratory and conventional examinations were performed at Emergency Room. X-ray films at pelvic anteroposterior, hip anteroposterior, proximal femoral anteroposterior, and chest position were photographed. Blood vessels at the affected side were detected with ultrasound examination if necessary. Intertrochanteric fracture was detected with CT + three-dimensional examination. Preoperative risk assessment was performed and a consultation was suggested for patients with severe medical illness. Patients were treated with antibiotics 1 hour before surgery, to maximize blood drug concentration and prevent infection. Blood preparation was also carried out before surgery. Without any contraindications, preoperative preparations were performed, the affected limbs were immobilized to relax muscles, the fracture was fixed to correct hip varus deformity and achieve fracture alignment. Surgery is performed as early as possible after admission.

The cemented bipolar hemiarthroplasty was performed via the hip posterior-lateral approach among the involved patients under the lumbar anesthesia-epidural block anesthesia. An incision, 8-10 cm long, was made. The gluteus medius muscle attached in the femoral trochanter should be preserved. The joint capsule was cut via a T-shaped incision at 1.0-1.5 cm adjacent to the lesser trochanter. Intertrochanteric fractures were treated with two osteotomy surgeries: the first osteotomy was performed in the femoral neck to remove the femoral head and provide enough space for the following surgeries, then calcar femorale was subjected to anatomical reduction and the secondary osteotomy was performed on the bone template. The great and lesser trochanter fractures, as well as the attaching fascia were retained, after the great trochanter was anatomically repositioned, the reconstructed calcar femorale and proximal segment were fixed using steel wire or bone cement. As for femoral neck fractures, femoral neck was truncated with oscillating saw above the lesser trochanter, 1.5 cm lateral to the calcar femorale. During the surgery, medullary cavity was expanded and trimmed according to the osteoporotic conditions and the cavity size. The cemented prosthesis is placed at the anteversion angle of 15°, the contracting adductor should be released. After surgery, the affected limbs were fixed in the 15°-30° abduction position.

 

Patients were treated with antibiotics for 2-3 days postoperatively to prevent infection. The drainage tubes were removed within 24 hours to reduce the risk of retrograde infection. Deep vein thrombosis can be prevented through the following interventions: (1) intermittent compression system at the affected limbs, twice per day; (2) subcutaneous injection of low-molecular-weight heparin calcium 6 000 U, once per day, for 2-3 weeks or 10 mg rivaroxaban, once per day, for 2-3 weeks (rivaroxaban prevention therapy after September 2008). On day 1 postoperatively, patients were instructed to do quadriceps functional exercise and were informed of the range of motion, functional exercise followed the order of active + auxiliary → active → anti-resistance. At 1-2 weeks postoperatively, patients were allowed to get off the bend and resume weight-bearing activities by the support of nursing personnel. Hip flexion should be restricted (< 90°) within 6 months, hip adduction and rotation were forbidden.

 

The involved patients were followed up for 1-5 years postoperatively through regularly check (outpatient data, Harris score, X-ray plain film), phone visit and on-site visit.

 

(1) Biocompatibility to the host. (2) Operative time, intraoperative blood loss, time of weight loading postoperatively, Harris scores at last follow-up. (3) Complications.

Data were statistically analyzed using SPSS 13.0 software (SPSS, Chicago, IL, USA). Measurement data were expressed as the mean ± SD. The difference between the two samples was compared using normal distribution test and homogeneity of variance test, then t test was performed if data met normal distribution and non-parametric rank rum test was performed if data did not meet normal distribution. Count data were compared using chi-square test. A P < 0.05 level was considered statistically significant and P < 0.01 was extremely significant difference.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

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Femoral hemiarthroplasty has been widely concerned in treatment of displaced femoral neck fractures in the elderly, previously it is often applied in the revision when the internal fixation failure occurs, but whether it serve as the initial treatment of intertrochanteric fractures remains unclear^[3]. Some scholars argue that, intertrochanteric fracture heals rapidly and blood supply is abundant at the bottom, few cases appear nonunion and nonhealing after of internal fixation. Growing evidence of clinical trials indicates that, internal fixation caused many complications in treatment of severe osteoporotic intertrochanteric fracture, even the newly emerging LCP and PFN-A implants also appear serious complications such as plate rupture, screw-caused damage on femoral head, hip varus deformity, nonunion and femoral head necrosis^[4-5]. Therefore, primary hemiarthroplasty has been widely concerned in treatment of intertrochanteric fractures^[6-7]. Guan et al ^[8] compared hemiprosthesis arthoplasty and internal fixation for treatment of senile patients with unstable femoral intertrochanteric fracture, and the results revealed that the complication rate during hospitalization, time of out-of-bed loading, and excellent rate of joint function in the hemiprosthesis arthoplasty were significantly better than that in the internal fixation group. Shen et al ^[9] found that, after 43 elderly patients with intertrochanteric fractures were successfully treated with cemented total hip replacement, the surgical time was 60-90 minutes and the average bedridden time was 9.4 days. No cases appeared infection, deep vein thrombosis, early dislocation and other serious complications; no prosthesis loosening, subsidence, dislocation was found at the follow-up of 6 months to 4 years. At postoperative 9-12 months, excellent rate of Charnley score reached 92.8%, which suggest that artificial joint replacement is effective for treatment of unstable intertrochanteric fractures.

 

The present study showed that the intraoperative blood loss and time of bearing load after surgery had no significant difference in the two groups (P > 0.05), the operative time in intertrochanteric fracture group was slightly longer than that in femoral neck fracture group (P < 0.01). As artificial joint replacement technique develops, the operation time gradually shortens, intraoperative blood loss reduces, surgery risk decreases, postoperative weight bearing is promoted, which contribute to early rehabilitation of patients. In this study, the complication rate was 20% in the intertrochanteric fracture group and 18% in femoral head fracture group, without any difference (P > 0.05); Harris hip score at the last follow-up had no significant difference between the two groups (P > 0.05). This evidence indicates that hemiarthroplasty has equal effect in treatment of unstable intertrochanteric fracture and femoral head fracture among the elderly patients, who can get off the bed early, restore hip function, reduce the bedridden time, and prevent hypostatic pneumonia, atelectasis, deep vein thrombosis and other complications. According to the Evans-Jensen classification, intertrochanteric fracture is unstable and osteoporotic, hip pain is the main mediators of hip functions and requires crutches or walking aids. In this study, two cases appeared hip pain within 3 years, mainly the elderly patients who frequently do exercise. Prosthesis loosening  was found in two cases and prosthesis revision was found in one case, because cemented prosthesis cannot effective fix comminuted fractures. We speculate that, prosthesis loosening is closely related to the patient’s age, bone mass and fracture type, as well as femoral calcar reconstruction and cemented prosthesis satisfaction. The cemented prosthesis cannot achieve effective fixation in osteoporotic comminuted intertrochanteric fractures when femoral calcar fragment is severely damaged and fracture reduction is not satisfactory, long-term heavy load conditions lead to loosening of the prosthesis. Operative experiences are as follows: intertrochanteric fracture patients in this study received secondary osteotomy methods. The first osteotomy surgery was performed at the femoral neck, to remove the femoral head and reserved the space for the operation, then femoral calcar was primarily reset, so intertrochanteric fracture was transformed into the femoral neck fracture^[13]. Subsequently second osteotomy surgery was performed, retaining the great and lesser trochanter, as well as the attached fascia, the femoral calcar  and proximal segment were tied up with wire. As for the severe comminuted segment in femoral calcar cannot be reduced anatomically, the reconstruction of femoral calcar can be performed with bone cement after expanding the medullary cavity, then bone block is placed around the femoral calcar, and the femoral prosthesis is implanted at the anteversion angle of 10°-15°. It is difficult to position the implant in the elderly patients with intertrochanteric comminuted fractures, so we take the femoral bone as the horizontal plane to define a 90° knee flexion angle, then the prosthesis is implanted at the anteversion angle of 10°-15°. As for the greater trochanter comminuted fracture, the length of femoral neck was determined depending on the distance from the greater trochanter apex to the femoral prosthesis center; at the same time, patients were forced to touch bilateral heel in a straight position, thus achieve equal length of lower limbs. Relative to the previously used osteotomy (2-3 hours), the secondary osteotomy surgery has a significantly shorter operation time, and achieved satisfactory reduction of the moferal calcar, great and lesser trochanter, patients can early bear weight, which is conducive to postoperative care and rehabilitation. In summary, hemiarthroplasty has equal effect in treatment of unstable intertrochanteric comminuted fractures and femoral neck fractures among the elderly patients: (1) high success rate (75%-95%); (2) low complications; (3) allowing early joint activities and early weight bearing, with no pain; (4) avoiding malunion and nonunion caused by poor internal fixation; (5) allowing early out-of-bed walking, which is conductive to postoperative rehabilitation; (6) reducing complications caused by long-term bedridden rest and significantly improving the quality of life.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程
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中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

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中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

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