With the development of China’s economy, the speed of China’s development towards an aging society is also developing rapidly, while the number of patients with osteoporosis and serious complications of high-grade femoral intertrochanteric fractures is also increasing significantly in the clinic.
Although the clinical use of internal fixation materials such as hip power screws and gamma nails for intertrochanteric fractures has achieved significant efficacy, it is not ideal for the elderly patients with intertrochanteric fractures, and they cannot move early after internal fixation, and some patients still die from complications after surgery.
Therefore, the authors have been using artificial hip arthroplasty for more elderly patients over 70 years of age since October 2006, and are now following up 179 elderly patients over 70 years of age after 2000 who underwent both procedures, and are reported and summarized as follows.
1. Clinical data
1.1 General data of this group, male, 43 cases, female, 136 cases; age 70~95 years old. 89 cases were internally fixed before 2000~October 2006, while after 2006, 90 cases except 9 patients had no obvious complications, and patients refused to perform artificial hip replacement and performed internal fixation, all of them performed hip replacement, among which 15 cases were total hip replacement, while 66 patients underwent artificial femoral head replacement.
The time between injury and surgery ranged from 1 to 18 days. The types of fractures were classified according to Evans’ classification: 8 cases of type I, 10 cases of type II, 79 cases of type III, and 82 cases of type IV. All of these 179 cases had varying degrees of osteoporosis, with 156 severe cases.
The comorbidities accompanying the disease were: 98 cases of hypertension, 35 cases of respiratory diseases, 15 cases of renal insufficiency, 68 cases of cerebrovascular accident sequelae, 58 cases of coronary atherosclerotic heart disease, 5 cases of senile dementia, 32 cases of diabetes mellitus, and 55 cases of more than 2 diseases combined at the same time. Before the fracture, 15 cases were unable to walk normally due to the sequelae of cerebrovascular disease and had to be supported by others. All patients had fresh fractures.
1.2 Surgical methods Preoperative preparation was routinely performed after admission, but it was more comprehensive than the general preoperative preparation, and ultrasound examination of both lower extremities was performed after May 08; preoperative consultation was routinely requested from relevant departments to treat their comorbidities, and preoperative evaluation was performed, and surgical treatment was performed as soon as possible without absolute contraindications. All patients underwent lumbar anesthesia, epidural anesthesia and combined lumbar and rigid anesthesia.
In the artificial total hip treatment group, 62 of the 81 patients were treated with a posterior-lateral surgical approach, in which the lateral tuberosity was cut off, the joint capsule was incised at the femoral neck, a normal osteotomy was made at the femoral neck to preserve the femoral spur, and the femoral head was removed, then the lower extremity was fully internally rotated and the plantar aspect of the affected foot was placed against the ceiling, and the large and small trochanter with the femoral spur was placed and then the medullary cavity was expanded with a medullary file, and the wires were crossed into the corresponding part of each fracture. After full rinsing, dry with gauze and place the appropriate prosthesis.
Then the wires were tied firmly. In the anterolateral group, 19 cases were operated in the same way, but only the surgical approach was different. 15 cases of total hip replacement were considered to be in better health and had a longer survival time, and their acetabulum was repaired and the corresponding artificial acetabulum was placed. Bone cement type was applied in 75 cases and biological type in 6 cases. In the internal fixation group, 72 cases were treated with DHS nails and 26 cases with GAMMA nails. All cases were treated in the operating room under fluoroscopic traction of C-arm X-ray machine.
2. Results
2.1 General comparison of general conditions: The operative time of the joint replacement group was 58~135 minutes, with an average of 75 minutes. Intraoperative blood loss was 350ML~680ML averaging 480ML. blood transfusion was 0ML~600ML, averaging 250ML. 81 cases had comorbidities. In contrast, the operative time of the fixed group was 63-130 minutes, with an average of 80 minutes.
Intraoperative blood loss ranged from 380 ML to 820 ML, with an average of 500 ML. transfusion volume ranged from 0 ML to 600 ML, with an average of 240 ML. 79 of 98 cases had different degrees of comorbidity, while no comorbidity was detected in 19 cases. One case died intraoperatively due to pulmonary embolism formation caused by venous thrombosis of the lower extremity.
2.2 Post-operative complications and efficacy comparison of the joint replacement group began functional exercise 1 day after surgery. 5 days for downward activities, the hospital stay ranged from 15 days to 28 days, with an average of 18 days, and 15 cases of venous thrombosis of the lower extremities. After early detection and timely treatment and recovery, no reoccurrence was seen in bed; there were 5 cases of combined postoperative mental abnormalities, 4 cases recovered by treatment, and 1 case died after two dislocations occurred and the patient’s family gave up treatment.
In one case, the patient’s family gave up treatment and died after two dislocations. The time of getting out of bed for weight-bearing activities was from 2, 5 months to 24 months after surgery. The duration of hospitalization ranged from 18 days to 35 days, with a mean of 25 days. There were 32 cases of venous thrombosis of lower limbs, 12 cases of sudden pulmonary embolism, 7 cases of death, and 6 cases of death within 2 years due to long-term postoperative bed rest. There were 6 cases of postoperative pulmonary infection and 8 cases of cerebrovascular accident with mental abnormality.
In one case, the hip joint could not move after surgery, and the X-ray found that the main nail fixing the femoral head was too long and entered into the hip joint, and the hip joint was replaced after one month of conservative treatment. After three months, the X-ray showed that the stem angle of the femoral neck became larger and the fracture healed abnormally in 15 cases, and the fracture did not heal and the stem angle of the femoral neck became larger, resulting in cutting of the femoral head.
The second artificial hip joint replacement was performed in 6 cases, and the remaining 8 cases died within 2 years of long-term bed rest. According to Huang Gongyi et al.’s method, the excellent rate of the joint replacement group was 97.5%, and the poor rate was 2.5%; 35 cases with more than three years of follow-up did not see any obvious loosening and discomfort. In contrast, the excellent rate of the group with internal fixation was only 65,3%, with a difference of 34,7%, and there was a significant difference between the two.
3. Discussion
3.1 The anatomical characteristics of the femoral trochanter and the requirements of fixation materials Under normal conditions, the human proximal femur is a mechanical material with an optimal structure adapted to a specific functional state. The proximal femur is shaped like a pendant beam due to the presence of the cervical stem angle. However, because of the special structure of the femoral spine, an oblique support rod is attached to the underside of the beam, thus forming a truss-like upper and lower chord; the femoral spine and the main pressure beam parallel to it are equivalent to the oblique rods of the truss.
This structure is undoubtedly more reasonable than the suspension beam, and the bending and shear stresses on the proximal femur will be greatly reduced by the support of the “diagonal rod” during weight bearing.
The clinically designed internal fixation cannot completely achieve the normal mechanical shape of the intertrochanteric femur, and cannot completely eliminate the shear stress on the upper end of the femur, which will produce the phenomenon of femoral head cutting after the fracture is fixed, and the screw of internal fixation cannot get out of bed normally after contact with the acetabulum, or there is a deformed healing with a larger neck stem angle although the phenomenon of femoral head cutting is not produced.
3.2 The difficulty in the treatment of artificial hip replacement for intertrochanteric fractures is mainly due to the destruction of the femoral spur and the greater trochanter, the loss of normal anatomical markings, and the lack of an effective support structure for the proximal femur, so there is a lengthened stem type artificial femoral stem in the design of the hip joint. To enhance the stability of the implanted prosthesis. Moreover, the broken bone of the large trochanter attached to the gluteus muscle and the small trochanter attached to the iliopsoas muscle can be tied with steel wire to maintain the normal muscle strength of each muscle and the stability of the hip joint.
If it is difficult to reposition and fix the large trochanter and femoral spur fracture, the center of the medullary cavity of the femur can be determined first, and after expanding the medullary cavity, a wire can be used to pass through it first, and after the bone cement is poured into the medullary cavity and the femoral stalk is punched in, so that each bone block can be stabilized with the bone cement and the fracture block can be fixed temporarily at the same time, and the wire can be tied tightly, and the fracture can be healed after three months.
3.3 Analysis of the characteristics of intertrochanteric fracture of the femur in the elderly is mostly accompanied by a variety of chronic diseases, such as hypertension, diabetes, cerebrovascular disease, lower limb venous embolism, pulmonary heart disease and so on. And the activity of the affected limb and the whole body after the fracture is obviously reduced or even inactive. Life lies in movement, and the complications of fracture are more likely to occur in the elderly if they do not exercise and are bedridden for more than three months. The most obvious one is the formation of deep vein thrombosis in the lower extremities, and it can form lower extremity venous thrombosis off pulmonary embolism death.
Bed sores, pulmonary infections, and urinary tract infections occur with improper care; all can be serious enough to cause death. Long-term bed rest with reduced activity can lead to slow blood flow and cerebral thrombosis. Therefore, in the past, most patients with these fractures had a high mortality rate with conservative treatment. The current internal fixation also has a relatively high complication rate;
The current hip joint replacement technology and the lengthened special materials of artificial femoral stems by various manufacturers are more mature. For elderly people over 70 years old, especially those with multiple morbidities and those who are not expected to survive for a long time, in order to prevent the occurrence of complications after fracture, early bed activity and various functional exercises can be performed. All of them can undergo artificial joint replacement to treat fractures in this area.
3.4 Precautions for artificial hip replacement in elderly patients Elderly patients are extremely risky, often combined with a variety of comorbidities included in contraindications to surgery, so they are very prone to medical disputes; however, for elderly patients whose surgical risks are the same for both surgical internal fixation and joint replacement, the main risk for this patient is anesthesia during surgery.
The patient’s surgical risk estimation and the risk factors that can cause death during the perioperative period should be fully understood. Adequate preoperative examinations should be performed before surgery so that the patient can be treated in a timely manner to prevent accidents from occurring.
The main measures include
1. Adequate preoperative examination should be performed before surgery. In addition to the conventional internal function tests, ultrasound of bilateral lower limbs should be added to check whether there is thrombosis and dislodgement of veins in bilateral lower limbs and to deal with them accordingly.
2. Intraoperative anesthesia should pay attention to strengthen the prevention and control of pulmonary infection, general anesthesia should be used as far as possible, it is appropriate to use lumbar epidural anesthesia or combined lumbar and rigid anesthesia as the main general anesthesia has a significant impact on the respiratory tract and there are elderly patients should not wake up after surgery, natural death phenomenon occurs.
3. Elderly patients have poor compensatory capacity, and most of them have low hemoglobin before surgery, and hemoglobin not only has the role of transporting oxygen and eliminating carbon dioxide, but also can produce nitrogen oxide, which helps to transport oxygen to human tissues and play the role of vasodilation and blood pressure maintenance. Therefore, it is important to raise the hemoglobin to above 90 g/L before surgery. The intraoperative procedure should be performed according to the principle that the amount of blood replenishment is the same as the amount of bleeding.
4. Intraoperative application of lengthened stem prosthesis as far as possible, and biotype should be column type lengthened model.
5. The application of steel wire for temporary stabilization of the large and small bulges during surgery can play a role in maintaining muscle tone, and the patient’s pain is significantly reduced by early bed activity, and functional exercise can be performed early.
6. Awareness of postoperative mental disorder of hip fracture should be raised and timely treatment should be given. Early postoperative complications are more frequent and have a high incidence in senior femoral intertrochanteric fractures, which can be life-threatening in serious cases and must be treated seriously.
Summary: For elderly patients with intertrochanteric femoral fractures in the hip area, in order to get the patient out of bed early and reduce the occurrence of complications, the mortality rate is reduced. Artificial joint replacement should be performed in patients who are in poor health, who are not expected to survive for a long time, and who clearly have osteoporosis.