Femoral intertrochanteric fracture is one of the common injuries in elderly people. 27 cases of unstable femoral intertrochanteric fracture in elderly people were treated with artificial femoral head replacement between January 2000 and September 2003 in our hospital, and satisfactory results were obtained.
1.General information
There were 27 cases in this group, 10 males and 17 females. The age ranged from 67 to 88 years old, with an average of 74 years old. According to Evans [1] typing, 11 cases were type IIIA, 10 cases were type IIIB, and 6 cases were type IV. There were 25 cases of previous medical diseases, including 9 cases of coronary heart disease, 7 cases of hypertension, 6 cases of diabetes mellitus, 1 case of senile dementia, 6 cases of gastric ulcer, 5 cases of chronic bronchitis, 1 case of renal insufficiency, and 1 case of decubitus ulcer. All of them had fracture laxity, and the bone density decreased by 32%-47% respectively by dual-energy X-ray examination.
2.Treatment method
After admission, skin traction of the affected limb was routinely performed, and medical comorbidities and complications were actively treated. Twenty-two cases were operated within 5-17 days after injury, 4 cases were operated more than 3 weeks later, and 1 case was operated after 11 months of internal fixation failure.
Surgery: The standard double-action cemented artificial femoral head was selected, and the surgical incision was made through the posterior lateral approach to the hip joint, separating the gluteus maximus and gluteus medius gaps, cutting the posterior rotator minimus muscle group at the posterior stop of the ramus, exposing the fracture end and posterior joint capsule, cutting the joint capsule, and making a standard plane osteotomy at the femoral neck 1-1.5 cm above the ramus minimus. The fracture is then retracted to free the bone fragments from the greater and lesser trochanter, and the blood flow of the fracture is preserved as much as possible. The bone marrow cavity of the proximal femur was opened and the marrow was expanded with the standard artificial femoral head replacement technique. If the annulus of the femoral spur (on the lesser trochanter) is intact, it should be removed and the marrow expanded separately to maintain a more complete shape as much as possible.
A suitable trial mold is selected and inserted into the medullary cavity of the femur, the larger bone block is repositioned, temporarily fixed with a thin wire or repositioning forceps, the trial mold is removed, rinsed and injected with a prepared bone cement, and before inserting the artificial femoral head into the medullary cavity of the femur, the annular femoral spur is inserted into the root of the stem of the artificial femoral head (or the fragmented femoral spur is restored) and positioned with the bone cement. The artificial femoral head is inserted into the bone marrow cavity to the appropriate angle and depth, and the bone fragments are replaced and compressed before the bone cement is firm. The partial defect can be filled with bone cement. After checking the position of the prosthesis is satisfactory, the joint is reset. Postoperative treatment of coexisting diseases and systemic support is continued, and the drainage tube is removed at 24 to 48 hours. On the postoperative day, instruction and assistance in isometric contraction of the quadriceps muscle of the affected limb were started to promote blood circulation and prevent deep vein thrombosis. Partial weight-bearing activities in bed were started from the 3rd day to 2 weeks after surgery.
3.Results
There were 27 cases in this group and 26 cases were followed up. The follow-up time ranged from 17 months to 3 years and 3 months, with an average of 23 months. The preoperative hospital stay ranged from 3 to 12 days, and the operative time ranged from 65 to 100 min (mean 75 min). Intraoperative blood loss ranged from 280 to 1100 ml, with a mean blood loss of 650 ml. 9 cases were transfused with 200 to 800 ml. 3 days to 2 weeks after surgery, one patient with dementia fell again to a contralateral intertrochanteric fracture on day 35 after surgery, and the remaining 26 cases regained walking function. According to the Harris [2] score: 13 cases were excellent, 9 cases were good, and 4 cases were acceptable, with an excellent rate of 84.6%. No serious complications occurred intraoperatively or during the perioperative period. The total hospital stay ranged from 12 to 35 days (mean 19 days). In this group, the follow-up time was short, and there was no fracture or prosthesis loosening yet, and all 26 fractures healed within 2.5-3 months after surgery.
4. Discussion
Intertrochanteric fractures of the femur occur mostly in the elderly and have a rather high mortality rate under non-operative treatment. In the 1960s, Horowitz reported a mortality rate of 34.6% for intertrochanteric fractures treated with traction. In contrast, medical complications after internal fixation are fewer and less severe than with nonoperative treatment. Early Jewett nail, Ender nail, Richard nail, fixation angle plate, power hip screw (DHS), Gamma nail, the choice of which should be determined on a case-by-case basis, such as DHS for stable intertrochanteric fractures has the advantage of early mobility and weight bearing, and its efficacy is significantly better than that of fixed angle internal fixation. However, with the widespread clinical use, its shortcomings are also emerging day by day. In patients with severe comminuted fractures and osteoporosis, the action of compressive stress can lead to screw cutting the femoral head, nail head penetrating the femoral head, fracture at the nail plate junction or screw slipping out at the plate, etc.
Gamma nail has obvious mechanical advantages, less surgical trauma, and preserves fracture blood flow, and the success rate of surgery can reach 98% [3], which is suitable for type I and II fractures. We used artificial femoral head replacement to treat the unstable fracture between the coarse bulge in the elderly with obvious osteoporosis, and achieved an excellent rate of 84.6% by allowing early activity, shortening the time of bed rest, and restoring limb function earlier. Complications such as decubitus ulcer, pulmonary infection and cardiovascular disease were reduced. Compared with other internal fixation procedures, it does not increase surgical trauma and blood loss. Although it cannot replace conventional internal fixation surgery, artificial femoral head replacement can be used for unstable intertrochanteric fractures in the elderly with severe osteoporosis
Indications for surgery.
(1) Unstable intertrochanteric fractures with significant osteoporosis in the elderly.
(2) No life-threatening concomitant diseases or those who are ready to tolerate anesthesia and surgical trauma after adjustment and preparation.
(3) Those with good pre-injury ambulatory function in pursuit of quality of life.
(4) Those who have failed internal fixation.
Advantages of surgery.
(1)It does not increase the difficulty and technical standard of surgery, and can be done by doctors who have artificial joint operation skills.
(2) Immediate stabilization, early weight-bearing and functional movement of the joint, and early recovery of walking function.
(3) Reduce many complications and systemic osteoporosis caused by long-term bed rest.
(4) Avoid deformity and bone discontinuity caused by internal fixation failure.
(5) The artificial joint achieves immediate stability, preserves the pre-operative blood supply, and facilitates fracture healing.
Key points of surgical operation: apply the standard artificial joint operation technique combined with trauma and repositioning internal fixation technique. The fracture block in the rudimentary area should be treated accordingly. In patients with a more complete fracture at the base of the neck, after making an osteotomy in the neck, the bone is kept as complete as possible and the bone is expanded with bare hands in order to admit the stalk of the artificial femoral head. The small bone fragments between the thick ridge may be removed temporarily. The large bone fragments are kept intact as much as possible without interfering with the blood supply of the repositioning premise. Before the completion of femoral reaming and injection of bone cement, a trial mold of the same type is inserted to simulate the repositioning process and to clarify the exact location of the fracture block, the depth and angle of the prosthesis.
Under the backing of the trial mold, the large fracture block was repositioned and temporarily fixed with wire ties or with repositioning forceps to bring the fracture fragments as close together as possible to reduce the bone cement embedded between the fracture lines. After cement modulation, the femoral talar ring or a more complete bone block can be pre-glued to the root of the artificial femoral head stalk, which can be used as a reference for the depth and angle of the prosthesis when it is placed. Reply to all bone fragments before the bone cement is solid, with appropriate pressure to make contact with the prosthesis and surrounding bone, and small defect areas can be filled with bone cement. The postoperative management is the same as that of artificial femoral head replacement.
The treatment of unstable intertrochanteric fractures in the elderly with severe osteoporosis is still one of the clinical challenges in orthopedics. Although the use of cemented artificial femoral head replacement for this type of fracture is controversial. As long as the number of cases and long-term follow-up results are accumulated, it is undoubtedly the best choice for the treatment of unstable intertrochanteric fractures (type III and IV), severe osteoporosis and failure of internal fixation of intertrochanteric fractures in the elderly, provided that the indications and operation methods are correctly mastered.