The mortality rate of elderly patients with intertrochanteric femur fractures is high due to the combination of multiple medical diseases, and Horowitz reported a mortality rate of 34.6% with traction and 17.5% with internal fixation [1]. In our department, we have been treating 34 elderly patients with intertrochanteric femoral fractures combined with multiple medical diseases by using anti-rotation intramedullary fixation of the proximal femur combined with herbal ironing since 2008 with satisfactory results. The results are summarized as follows.
1. Clinical data
There were 34 cases in this group, 20 males and 14 females. Age 60-83 years old, average 72 years old. The fractures were classified by BoydAndGriffin: 10 cases of type I, 13 cases of type II, 7 cases of type III, and 4 cases of type IV. There were 21 cases of two or more combined medical diseases and 13 cases of one. Comorbidities included: hypertension, coronary artery disease, old myocardial infarction, sequelae of cerebral embolism, bronchial asthma, emphysema, and diabetes mellitus.
2.Treatment method
2.1 Preoperative preparation
Patients were routinely admitted to the hospital for bone traction and monitoring of the function of the main organs of the heart, lungs and kidneys, perfecting preoperative examination, consulting with relevant internal medicine physicians for concomitant medical diseases, and carrying out formal treatment, with preoperative blood glucose control below 10 mol/L, blood pressure maintained below 150/90 mmHg, hemoglobin ≥ 90 g/L, albumin ≥ 30 g/L, arterial PO2 ≥ 60 mmHg. PCO2≤45mmHg, and intravenous broad-spectrum antibiotics were given once each on the day before and during surgery.
2.2 Surgical methods
All 34 cases in this group were treated with epidural anesthesia, and the patients were placed supine on an orthopedic traction bed with the healthy limb in a flexed hip and knee external booth and the affected limb in a neutral position with 10-15° of internal rotation, and repositioned and maintained in the repositioned position under C-arm fluoroscopy. A longitudinal incision is made above the greater trochanter of the femur, approximately 5 cm in length, to expose the bone at the top of the greater trochanter, and a needle is inserted into the medullary cavity of the femur under fluoroscopy. Place the threaded guide pin under the spiral blade, determine the good position of the guide pin, measure the required length of the spiral blade, select the corresponding spiral blade to tap in, lock the spiral blade, lock the distal fixation screw according to the operation of the sight, remove the sight, fluoroscopy to determine the good position of the PFNA, and suture the incision layer by layer.
2.3 Postoperative treatment
Low molecular heparin calcium 4100U abdominal subcutaneous injection was applied 12 hours after the end of surgery for 10 days, supplemented with lower limb herbal scalding therapy on the second day. The composition of the self-designed herbal scalding formula: 1.5 parts of each of Qiangwu, Doklamia, Thornbush, Fangfeng, Xanthophora, and Turbinicarpus, 1 part of each of Chuanwu, Caowu, Angelica, Radix Paeoniae, Chuanxiong, Safflower, and Gui Zhi, and the above mentioned herbs were mixed and crushed with aged vinegar and soaked for one month. When used, the medicine bag (25X20cm) is packed and heated to a suitable temperature to iron the lower and middle thighs, knee joints and calves for 30 min each time, once a day, and the medicine bag can be repeatedly heated for application. Because of the dull sensation of the elderly, attention was paid to the prevention of burns during the operation; after the operation, the affected limb was placed in an abducted neutral position, and the changes of vital signs were closely monitored, while medical comorbidities were actively treated; functional exercises of the quadriceps muscle and ankle dorsiflexion and plantarflexion activities were started on the second day after the operation, 1 week of standing without weight-bearing with the help of crutches, 3-4 weeks of walking with partial weight-bearing with the help of crutches, 6-8 weeks of X-ray review, and the decision to go to crutches was made according to the healing of the fracture.
3. Treatment results
In this group of 34 patients, the operation time was 60-110min, about 75min, the intraoperative bleeding was about 100ml, the wounds were all grade A healed, and there was no case of deep vein thrombosis in the lower limbs. The follow-up time was 6-14 months, with an average of 8.5 months, and the fractures were all healed, according to the evaluation standard of Zhao Torchai et al [2]: 23 cases were excellent, 10 cases were good, and 1 case was poor.
4. Discussion
With the development of aging society, we are facing more and more patients with high-risk femoral intertrochanteric fractures of advanced age. Due to the good local blood flow, high fracture healing rate, and the development of internal fixation technology, surgical treatment of geriatric femoral intertrochanteric fractures has made great achievements in improving the quality of life and reducing the morbidity and mortality rate of elderly patients. Therefore, internal fixation should be preferred for the treatment of intertrochanteric fractures in the elderly. In the past, multiple Stiletto pins, McDonald’s goose head nail and Gamma nail were mostly used in China, but each has its own advantages and disadvantages. Due to the inter-plate connection structure, the mechanical strength of the fixation site is greatly reduced, and the stress often causes damage to the first screw, which is not conducive to early weight-bearing and functional exercise; if the Gamma nail is improperly positioned in the medullary cavity, it often causes stress concentration in the local bone cortex, resulting in serious complications of femoral stem fracture; although the multi-strike pin has achieved good clinical efficacy, it is not suitable for the treatment of femoral stem fracture. However, due to the more obvious osteoporosis in elderly patients, a smaller external force can cause comminuted fractures and small fracture fragments, so it has certain clinical limitations, and the phenomenon of dislodgement of the pin occurs from time to time. Although the power hip screw (DHS) has been widely used in recent years, it has the disadvantage of weak shear resistance and insufficient rotation resistance because only one main nail is placed into the femoral neck.
Our PFNA nail is a new type of intramedullary fixation device developed by AO, which consists of PFNA main nail, spiral blade, distal locking and locking nut, and has the following characteristics
(1) The main nail is specially designed with a 5° external deflection angle to allow smooth insertion from the top of the greater trochanter and through the proximal medullary cavity of the femur during surgery;
(2) The PFNA spiral blade has a wide contact surface between the spiral blade and the bone, which compresses the cancellous bone when the spiral blade is inserted and improves the anchoring force of the spiral blade in the femoral head, significantly improving stability and preventing rotation and collapse, thus avoiding the cut-out phenomenon;
(3) The relatively flexible tip design makes insertion easier and avoids local stress concentration in the bone;
(4) The proximal single helical blade design makes the procedure simpler while reducing the risk of disrupting the blood flow to the femoral head. In order to shorten the operation time and reduce complications, we adopted preoperative routine bone traction, which effectively reduced muscle tension and facilitated intraoperative repositioning, while creating conditions for the treatment of formal internal diseases. Since most of the intertrochanteric fractures in the elderly are comminuted fractures, intraoperative incisional repositioning was avoided as much as possible. Since the PFNA nail is an intramedullary fixation system, there is no need to forcefully reset the small rotor, and no hip inversion deformity occurred in this group of cases. At the same time, attention should be paid to the process of repositioning without over-distraction, otherwise the stable fracture will become unstable and the main nail will be easily dislocated when inserted. Because of the wide contact surface between the PFNA spiral blade and the bone, the spiral blade should not be inserted with excessive force, especially for those with good bone quality, as the resistance is greater when inserting the spiral blade, which may lead to loss of repositioning.
Because of the poor blood circulation in elderly patients with femoral intertrochanteric fracture, coupled with bed rest, the poor flow of Qi and blood is more likely to lead to deep vein thrombosis, which is even life-threatening and has attracted increasing attention in clinical practice. We routinely adopt the measures recommended in the Draft Guidelines for the Prevention of Deep Vein Thrombosis in Major Orthopedic Surgery [3], namely the application of subcutaneous intramuscular injection of low-molecular heparin calcium, and at the same time take advantage of Chinese medicine to effectively prevent deep vein thrombosis by using traditional Chinese medicine ironing therapy. In the formula, angelica, safflower, red peony and Chuanxiong have the function of activating blood circulation and relieving pain, while Chuan Wu, Cao Wu, Qiang Wu, Dou Wu, Jing Zhi Zhi, Fang Feng, Xie Shu Cao, and Turbinate Cao have the function of dispelling wind and dispersing cold, unblocking and activating channels. Because of the low molecular heparin calcium needle, which is more expensive, reviewing the previous fracture patients, we alone take Chinese medicine ironing, also achieved satisfactory results, worthy of clinical promotion and application.
In conclusion, preoperative and postoperative correct management of comorbidities, effective measures to prevent complications, coupled with PFNA nailing its unique characteristics, making the operation simple, less traumatic, less bleeding, shorten the operation time, become a better treatment for elderly patients with intertrochanteric fracture of the femur, especially combined with osteoporosis.