1.Clinical data
There were 3 male cases and 7 female cases in this group of 8 cases. The age ranged from 65 to 94 years old, with an average of 85 years old. The shortest duration of the disease was 2 months, the longest was 5 months, and the average was 3 months. There were 6 cases of fresh fractures and 4 cases of old fractures, including 3 cases of postoperative internal fixation failure, all of which were caused by falls, 2 cases of combined femoral head necrosis and 3 cases of hip osteoarthritis.
2.Treatment method
Most of the patients with intertrochanteric fracture are of advanced age, so it is necessary to actively improve the patient’s general condition, treat the comorbidities and enhance the patient’s resistance before surgery. At the same time, we should actively improve the preoperative auxiliary examinations and treat the comorbidities in time. After the condition is stabilized, elective surgery is performed. The surgery is performed under combined lumbar and rigid anesthesia or general anesthesia, and the surgical approach is the conventional lateral or posterior lateral surgical approach for artificial hip replacement. The fracture end of the femoral trochanter is first exposed, and after the fracture is repositioned, temporary fixation is given with a Clinique pin, and then the conventional operation of artificial hip replacement is performed.
For patients with failed internal fixation, the failed internal fixation can be removed first, and the surgical area should be adequately cleaned and disinfected with iodine soak if necessary, and then the conventional operation of artificial hip replacement should be performed.
After surgery, patients should be kept in supine position with the affected limb in abducted neutral position and wear anti-rotation shoes. After surgery, patients should be instructed to perform functional exercises for the quadriceps and ankle joints of the affected limb to prevent the occurrence of venous thrombosis in the lower limb.
After 3 days, flexion and extension exercises of the affected limb were feasible, and after 1 month, depending on the healing of the fracture, weight-bearing exercises of the affected limb with double crutches, no cross-legged, no side-lying and no squatting were carried out as appropriate. 3 months later, after the fracture healing was confirmed by X-ray, weight-bearing exercises of the affected limb were gradually carried out.
3. Treatment results
The postoperative radiographs of the 10 cases showed that the hip prosthesis was properly placed and the joint correspondence was good. 9 cases had stage I healing of the surgical incision and 1 case had stage II healing of the surgical incision. All 10 patients in this group were followed up for 6 months after surgery, the shortest follow-up period was 3 months, the longest was 12 months, and the average was 7 months. x-rays taken showed that all fresh fractures had reached bony healing, and the average healing time was 3 months (2 months to 4 months).
There was no 1 case of death. After 6-month follow-up, the hip function of 12 patients in this group was evaluated according to the Harris scale, and the hip joint of the affected limb was flexed from 90° to 140°, and none of them had deformed healing. 1 patient basically recovered the function of the hip joint before the injury, 6 patients recovered the function of the hip joint to the pre-injury state, and 2 patients had significantly improved the function of the hip joint compared with the pre-injury state. There were 7 cases of excellent, 2 cases of good, and 1 case of loosening of the prosthesis, with an excellent rate of 90%. There were no fracture non-healing, hip inversion deformity, shortening of the affected limb and other sequelae.
4. Discussion
Femoral intertrochanteric fracture is a common disorder in the elderly. Due to long-term bed rest or surgery, it brings great pain to the patients and even recurs the cost of life. For the treatment of femoral intertrochanteric fracture, the choice between non-operative treatment and surgical internal fixation, most scholars prefer the latter, and the mortality rate of surgical treatment is significantly lower than that of non-operative treatment.
There are many internal fixation devices in this area, and there are two mainstream internal fixation devices: lateral femoral nail plate fixation and proximal femoral intramedullary fixation, the former mainly includes sliding compression screw plate system, and the latter is gamma nail, PFN, etc.
In recent years, with the progress of treatment and research on this disease, how to shorten the patient’s bed time, reduce trauma and maximize the restoration of limb function has become an important principle in the treatment of this disease. In accordance with this principle, there are many reports in the domestic and international literature on the treatment of this disease.
Although these methods have some application value, most of them are based on stronger internal fixation, cumbersome fixation and greater trauma, leading to further destruction of soft tissues at the fracture end and prolongation of the disease course. In recent years, the failure of internal fixation has been reported more and more, and it has been shown that in unstable intertrochanteric fractures, the failure rate of internal fixation is as high as 16%, which brings greater pain to the patient and makes the later treatment impossible, thus the efficacy is not very satisfactory. In recent years, some scholars have been actively using artificial joints to treat intertrochanteric fractures of the femur in special populations.
In recent years, our department has adopted the method of artificial hip joint replacement to treat elderly patients with other hip pathologies, which not only satisfies the firm fixation of the fracture, but also improves the function of the hip joint, treats the comorbidity of the hip joint, shortens the healing time of the fracture, reduces the time of bed rest, and creates conditions for the functional reconstruction of the affected limb.
The selection of this procedure should also follow strict surgical indications, fresh senior intertrochanteric fracture, fresh comminuted intertrochanteric fracture, old intertrochanteric fracture after surgery, patients who can no longer have internal fixation, and patients with intertrochanteric fracture combined with hip joint disorders (femoral head necrosis, hip osteoarthritis, rheumatoid or ankylosing spondylitis that have seriously affected hip joint dysfunction).
Artificial hip joint replacement is used to treat fresh and old intertrochanteric fractures, especially for patients with intertrochanteric fractures combined with hip joint disorders, which is clinically feasible because it is less invasive, faster, shortens the time of fracture healing, reduces the time of bed rest and facilitates the early functional exercise of the affected limb.
Intraoperative experience.
①If cement-based prosthesis is installed during surgery, care should be taken to avoid squeezing the bone cement into the fracture end or outside the femoral marrow cavity, at this time, gelatin sponge can be used to fill in the bone defect area; if a biologic prosthesis is installed, avoid using violence when expanding the marrow and punching in the prosthesis stem to avoid disintegration and separation and displacement of the fracture end, and use the artificial prosthesis stem to press and fix the fracture end between the ramus firmly.
The author recommends choosing cemented prosthesis as much as possible, as osteoporosis is common in elderly patients with intertrochanteric fractures, and cement can provide immediate mechanical stability, so that the artificial joint prosthesis and the femur can be completely adapted and integrated, and the stress can be transmitted from the proximal end of the prosthesis to the distal end of the femur. The initial stability of the femoral prosthesis stem-cement-femoral structure after hip reconstruction for intertrochanteric instability fractures depends mainly on the bone cement, which reduces the stress on the reconstructed hip bone through the protective effect of the bone cement, thus facilitating the healing of the fracture site.
For patients with failed internal fixation, after removing the original internal fixation, the fracture is old and the fracture end is worn and resorbed, so more attention should be paid to the placement angle of the prosthesis. For patients with poor fracture healing, after removing the scar tissue at the fracture end, the resected bone in the femoral head can be implanted with granular bone at the fracture end.
If the fracture is combined with a displaced large and small ramus, the integrity of the large and small ramus should be preserved during surgery to facilitate the stability of the hip joint after the installation of the prosthesis.
The choice of hemi- or total hip replacement depends on the patient’s general condition, tolerance and damage to the cartilage surface of the hip joint.