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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 19-22

Study of effectiveness of coxofemoral bypass in comparison to proximal femoral nail in the treatment of unstable intertrochanteric fractures in the elderly


Department of Orthopaedics, Kasturba Medical College, Mangalore, Karnataka, India

Date of Web Publication17-Aug-2018

Correspondence Address:
Dr. Narendra Reddy Medagam
Flat No: East Wood 3A, Fairmont Gardens, Manapakkam, Chennai - 600 089, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_67_17

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  Abstract 

Background: Osteosynthesis of unstable intertrochanteric (IT) fractures in geriatric population needs prolonged bed rest to prevent implant failure, which in turn results in complications such as pressure sore and pulmonary infection. In literature, a newer approach, such as prosthetic replacement for unstable intertrochanteric fractures, has been described to allow earlier restoration of postoperative weight bearing. Our study aimed to evaluate the effectiveness of coxofemoral bypass in comparison to proximal femoral nail in the treatment of unstable intertrochanteric fractures in the elderly. Materials and Methods: Forty-two elderly patients with unstable IT femur fractures were included in this study, of which 21 patients underwent coxofemoral bypass with remaining 21 patients treated with proximal femoral nail. Both the groups were comparable with regard to demographic data and injury variables. The clinicoradiological evaluation was done at regular follow-up visits at 6 weeks, 3 months, and 6 months postoperatively. The functional outcome between the two techniques was evaluated using Harris hip score. Results: The complications such as pressure sore and pulmonary infection were higher in proximal femoral nail group compared to coxofemoral bypass group. There was statistically significant difference in functional outcome between two groups at the end of 6 weeks (P = 0.048) but not significant at the end of 6 months (P = 0.357, better in coxofemoral bypass group). Conclusion: Coxofemoral bypass is a better option than proximal femoral nail in the treatment of unstable IT fractures in the elderly as it provides stable, pain-free, mobile joint with earlier restoration of walking ability, less complications, and good functional outcome.

Keywords: Coxofemoral bypass, proximal femoral nail, unstable intertrochanteric fracture


How to cite this article:
Medagam NR, Reddy B. Study of effectiveness of coxofemoral bypass in comparison to proximal femoral nail in the treatment of unstable intertrochanteric fractures in the elderly. J Orthop Traumatol Rehabil 2018;10:19-22

How to cite this URL:
Medagam NR, Reddy B. Study of effectiveness of coxofemoral bypass in comparison to proximal femoral nail in the treatment of unstable intertrochanteric fractures in the elderly. J Orthop Traumatol Rehabil [serial online] 2018 [cited 2018 Sep 18];10:19-22. Available from: http://www.jotr.in/text.asp?2018/10/1/19/239266


  Introduction Top


Intertrochanteric (IT) femur fractures are the most common fractures around the hip in geriatric population with osteoporotic bones that occur mainly due to low-energy trauma.[1] The incidence of these fractures was 10%–34% of all hip fractures.[2] These fractures are more common in females compared to males due to osteoporosis.[3] Approximately 10%–30% of elder patients with an IT fracture will die within 1 year.[4] The treatment of unstable IT fractures in elderly patients is challenging because of osteoporosis and difficult anatomical reduction. Elderly patients with unstable IT fractures with osteoporotic bones treated with sliding hip screw may develop unacceptable shortening and external rotation deformity.[5],[6],[7],[8] Internal fixation in unstable IT fractures involves prolonged bed rest, to prevent implant failure secondary to osteoporosis, which in turn results in increased chances of complications such as pressure ulcer, pulmonary infection, deep vein thrombosis, and pulmonary embolism.[9] Some surgeons used prosthetic replacement for unstable IT fractures to allow earlier restoration of postoperative weight bearing.[10],[11],[12],[13],[14],[15] The purpose of this study was to evaluate the effectiveness of coxofemoral bypass in comparison to proximal femoral nail in the treatment of unstable IT fractures in the elderly.


  Materials and Methods Top


This study is done in a tertiary care hospital from June 2012 to June 2015 over a period of 3 years. After obtaining ethical clearance, 42 patients aged above 70 years with unstable IT fractures were included in the study. Stable IT fractures and fractures in younger patients were excluded from the study. Thorough clinical and radiological evaluation was done. The patients were operated after obtaining medical fitness. Among them, 21 patients underwent closed reduction and internal fixation with proximal femoral nail [Figure 1], with remaining 21 patients being treated with coxofemoral bypass surgery through standard lateral approach. Cemented modular bipolar prosthesis was used in all the cases [Figure 2]. Both the groups were comparable with regard to demographic data and injury variable.
Figure 1: Pre- and postoperative X-ray of proximal femoral nail

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Figure 2: Pre- and postoperative X-ray of coxofemoral bypass

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Coxofemoral bypass technique

All patients in coxofemoral bypass group were operated using a standard lateral approach. After assessing fracture anatomy, incision was made over greater trochanter which extended proximally and distally about 3 inches. Tensor fascia lata incised in the plane of incision and coronal fracture plane is identified. Plane between the fragments was developed by reflecting anterior and posterior fractured trochanteric fragments. Head along with neck is circumferentially dissected from the capsular attachments. After delivering the head out, it was measured. Limb was placed in flexion and internal rotation. Shaft is then reamed with sequential broaching. Trial reduction was done to know the limb length and version stability. Canal was plugged with bony plug removed from the head of the femur. Two drill holes were placed in the proximal end of the shaft of femur for passing stainless steel wires. Then, 40 g bone cement was put into the medullary canal manually. Modular bipolar prosthesis was placed with proper anteversion. Reduction is achieved and stability was checked. One stainless steel wire was passed through the anterior fractured trochanteric fragment and second stainless steel wire was passed through the posterior fractured fragment and tightened to restore the abduction mechanism. The wound was closed in layers with suction drain. Patients were made to sit in the 1st postoperative day and made to walk with full weight bearing on the 2nd postoperative day.

All the patients in both the groups were followed up at regular intervals with clinicoradiological examination including radiological union in proximal femoral nail group, and functional status was evaluated using the Harris hip score (HHS)[16] and was graded as <70 = poor, 70–79 = fair, 80–89 = good, and 90–100 = excellent.


  Results Top


This study included 42 geriatric patients, aged >70 years with unstable IT femur fracture, of which 21 underwent proximal femoral nail surgery with remaining 21 patients undergone coxofemoral bypass surgery. In this prospective study, the patients were well matched according to age, sex, and fracture type. The preinjury walking ability was comparable in both the groups of patients treated with coxofemoral bypass and proximal femoral nailing. The study population included 30 (71.4%) females and 12 (28.6%) males. Most of the fractures (88.1%) were the result of trivial fall. Eighty-five percent of patients in proximal femoral nail group and 81% in coxofemoral bypass group were walking without support before the injury. The mean length of incision in proximal femoral nail group was 4.524 cm and in coxofemoral bypass group was 12.667 cm. The mean duration of surgery in proximal femoral nail group was 49.5 min whereas in coxofemoral bypass group was 71 min. The mean intraoperative blood loss in proximal femoral nail group was 147 ml and in coxofemoral bypass group was 508 ml. The difference between the two groups regarding length of incision, duration of procedure, and blood loss was statistically significant.

The complications encountered in proximal femoral nail group were bedsore, malunion, pulmonary infection, wound dehiscence, implant failure, and shortening of operated limb in 3, 2, 1, 1, 1, and 1 patient, respectively. Whereas, complications noted in coxofemoral bypass group were wound dehiscence, bedsore, shortening of operated limb, retroverted placement of prosthesis in 2, 1, 1, and 1 patient, respectively [Table 1]. One patient in coxofemoral bypass group died during surgery after inserting bone cement secondary to reactive hypotension.
Table 1: Complication rates of both the procedures

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The mean HHS at the end of 6 weeks in proximal femoral nails (PFN) group was 73.09 and in coxofemoral bypass group was 77.8 [Table 2]. At the end of 6 months, the mean HHS in PFN was 77.38 and in coxofemoral bypass group was 79.85. The study shows statistically significant difference in HHS at the end of 6 weeks (P = 0.048) between two groups, but the difference between two groups at the end of 6 months was not significant statistically (P = 0.357) [Table 3].
Table 2: Harris hip score at the end of 6 weeks postoperatively

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Table 3: Harris hip score at the end of 6 months postoperatively

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  Discussion Top


IT fractures were associated with increased morbidity and mortality in elderly patients. Internal fixation of these fractures reduced the mortality rate. The intramedullary devices were biomechanically superior to extramedullary devices for unstable IT femur fractures.[17] However, earlier mobilization is still not recommended in these cases to prevent implant failure. Prosthetic replacement offers a modality of treatment option for IT fractures that provides stable hip and early mobilization, thus reducing postoperative complications. Stern and Goldstein used the Leinbach prosthesis for the primary treatment of 22 IT fractures and found early ambulation and early return to the prefracture status.[18]

Hemiarthroplasty is commonly used for neck of femur fracture and rarely in IT fractures. Tronzo was the first used long and straight stemmed prosthesis as the primary treatment of IT fractures.[19] In this study, fractures were more common in females than in males. Most of the fractures occurred because of trivial fall. In comparison with the proximal femoral nail group, the coxofemoral bypass group took longer operating time and was associated with longer incision. The amount of blood loss in coxofemoral bypass was more in comparison to proximal femoral nail group, which is statistically significant. Earlier study done by Broos et al. concluded that the blood loss, operative time, and mortality rates were comparable between the two groups, with a slightly higher percentage (73% vs. 63%) of those receiving a prosthesis considered to be pain free.[12] Liang et al., in their study, concluded that hemiarthroplasty is an effective method for the unstable IT fractures in elderly patients as it can decrease the complications, reduce the mortality, and improve the patient's living quality.[20]

We have observed that complications such as malunion, bedsore, pulmonary infection, and implant failure were high in proximal femoral nail group compared to coxofemoral bypass group. The implant screw cutout rate in proximal femoral nail group was 4.8%. Previous prospective clinical studies of the proximal femoral nail showed implant cut out rates ranging from 0.6% to 1.4%.[21],[22] Earlier similar study done by Haentjens et al. also had similar results, which showed a significant reduction in the incidence of pneumonia and pressure sores in those undergoing prosthetic replacement.[13] In another comparative study by Kayali et al., patients treated with prosthetic replacement were allowed full weight bearing significantly earlier than the internal fixation patients.[14] Grimsrud et al. treated 39 patients of unstable IT fractures with a standard femoral stem and cerclage wiring of the trochanter and observed early weight bearing on the injured hip and had a relatively less complications.[23]

We found significant differences in the functional outcome between two groups at the end of 6 weeks following surgery with P = 0.048. However, the difference between the two groups in terms of functional outcome at the end of 6 months was statistically not significant with P = 0.357. However, there are limited comparative studies between intramedullary devices and prosthetic replacement in literature and our results were in agreement with Kim et al. who concluded that in elderly patients with an unstable IT femoral fracture, a proximal femoral nail had no advantage with regard to functional outcome when compared with a prosthetic replacement arthroplasty.[9] Rodop et al. observed good-to-excellent results in 80% of patients with unstable IT femur fractures, using HHS, who had been treated with a bipolar Leinbach hemiprosthesis.[24]


  Conclusion Top


Coxofemoral bypass is a better option than proximal femoral nail in the treatment of unstable IT fractures in the elderly as it provides stable, pain-free, mobile joint with earlier restoration of walking ability, less complications, and good functional outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Buchotz RW, Fleckrnan JD, Court-Brown CB. Rockwood and Green ' s Fractures in Adults. 6th ed., Vol. 2. Lippincott Williams & Wilkins; 2006. p. 1827-44.  Back to cited text no. 1
    
2.
Lavelle DG. Fractures and Dislocations of Hip; Campbell ' s Operative Orthopaedics. 11th ed., Vol. 3, Ch. 52. Mosby, An Imprint of Elsevier; 2007. p. 3237-308.  Back to cited text no. 2
    
3.
Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res 1980;146:53-61.  Back to cited text no. 3
    
4.
Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am 1979;61:216-21.  Back to cited text no. 4
    
5.
Rao JP, Banzon MT, Weiss AB, Rayhack J. Treatment of unstable intertrochanteric fractures with anatomic reduction and compression hip screw fixation. Clin Orthop Relat Res 1983;175:65-71.  Back to cited text no. 5
    
6.
Bendo JA, Weiner LS, Strauss E, Yang E. Collapse of intertrochanteric hip fractures fixed with sliding screws. Orthop Rev 1994;Suppl:30-7.  Back to cited text no. 6
    
7.
Rha JD, Kim YH, Yoon SI, Park TS, Lee MH. Factors affecting sliding of the lag screw in intertrochanteric fractures. Int Orthop 1993;17:320-4.  Back to cited text no. 7
    
8.
Steinberg GG, Desai SS, Kornwitz NA, Sullivan TJ. The intertrochanteric hip fracture. A retrospective analysis. Orthopedics 1988;11:265-73.  Back to cited text no. 8
    
9.
Kim SY, Kim YG, Hwang JK. Cementless calcar-replacement hemiarthroplasty compared with intramedullary fixation of unstable intertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg Am 2005;87:2186-92.  Back to cited text no. 9
    
10.
Shinge AR, Anasane SS, Aitavade EN, Mahadik SS, Mulik PV. Finite element analysis of modified hip prosthesis. Int J Adv Biotechnol Res 2011;2:278-85.  Back to cited text no. 10
    
11.
Sadic S, Custovic S, Jasarevic M, Fazlic M, Smajic N, Hrustic A, et al. Proximal femoral nail antirotation in treatment of fractures of proximal femur. Med Arch 2014;68:173-7.  Back to cited text no. 11
    
12.
Broos PL, Rommens PM, Deleyn PR, Geens VR, Stappaerts KH. Pertrochanteric fractures in the elderly: Are there indications for primary prosthetic replacement? J Orthop Trauma 1991;5:446-51.  Back to cited text no. 12
    
13.
Haentjens P, Casteleyn PP, 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;71:1214-25.  Back to cited text no. 13
    
14.
Kayali C, Agus H, Ozluk S, Sanli C. Treatment for unstable intertrochanteric fractures in elderly patients: Internal fixation versus cone hemiarthroplasty. J Orthop Surg (Hong Kong) 2006;14:240-4.  Back to cited text no. 14
    
15.
Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R, et al. The proximal femoral nail (PFN) – A minimal invasive treatment of unstable proximal femoral fractures: A prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand 2003;74:53-8.  Back to cited text no. 15
    
16.
Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: Treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737-55.  Back to cited text no. 16
    
17.
Schipper IB, Marti RK, van der Werken C. Unstable trochanteric femoral fractures: Extramedullary or intramedullary fixation. Review of literature. Injury 2004;35:142-51.  Back to cited text no. 17
    
18.
Stern MB, Goldstein TB. The use of the leinbach prosthesis in intertrochanteric fractures of the hip. Clin Orthop Relat Res 1977;128:325-31.  Back to cited text no. 18
    
19.
Tronzo RG. The use of an endoprosthesis for severely comminuted trochanteric fractures. Orthop Clin North Am 1974;5:679-81.  Back to cited text no. 19
    
20.
Liang YT, Tang PF, Guo YZ, Tao S, Zhang Q, Liang XD, et al. Clinical research of hemiprosthesis arthroplasty for the treatment of unstable intertrochanteric fractures in elderly patients. Zhonghua Yi Xue Za Zhi 2005;85:3260-2.  Back to cited text no. 20
    
21.
Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): A new device for the treatment of unstable proximal femoral fractures. Injury 1999;30:327-32.  Back to cited text no. 21
    
22.
Domingo LJ, Cecilia D, Herrera A, Resines C. Trochanteric fractures treated with a proximal femoral nail. Int Orthop 2001;25:298-301.  Back to cited text no. 22
    
23.
Grimsrud C, Monzon RJ, Richman J, Ries MD. Cemented hip arthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures. J Arthroplasty 2005;20:337-43.  Back to cited text no. 23
    
24.
Rodop O, Kiral A, Kaplan H, Akmaz I. Primary bipolar hemiprosthesis for unstable intertrochanteric fractures. Int Orthop 2002;26:233-7.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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