Treatment of Intertrochanteric Femur Fractures with Hip Arthroplasty in Older Patients: A Narrative Review of Indications and Outcomes

Cemented bipolar hemiarthroplasty for unstable intertrochanteric fracture in elderly patients over 70 years: Boon or bane?

INTRODUCTION

The surgical management of intertrochanter femur fracture in elderly patient is still under debate. Various implants can be utilised but prosthetic replacement is gaining popularity. This study was performed to evaluate the functional and clinical outcomes of cemented bipolar arthroplasty as a primary treatment for unstable intertrochanteric fracture in elderly patients (> 70 years).

MATERIALS AND METHODS

Thirty-seven patients with unstable intertrochanteric fracture in elderly patient (> 70 years) who underwent cemented bipolar hemiarthroplasty. Intra-operative and post-operative complications were noted; functional outcomes were assessed using Harris hip score (HHS). All patients were followed up for a minimum of 12 months.

RESULTS

Overall 90% of patients has some minor or major intra or post-operative complication. One year mortality rate was 16% (6/37). Cardiopulmonary events were the most common life threatening incident. Mean fall in Haemoglobin was 1.6 gm/dL. The average time for full weight bearing mobilisation with the help of walker was 2.8 ± 1.2 days (1-8 days). The average duration of surgery was 58 ± 6 min (44-96 min) with an average blood loss of 126 ± 24 mL (90-380 mL). HHS at the end of 12 months was 77.

CONCLUSIONS

The use of bipolar hemiarthroplasty in senile patient with unstable hemiarthroplasty gives an advantage of early weight bearing. However, it is associated with risk of significant intra or post-operative morbidity due to intra-operative trauma, surgical time and blood loss during the surgery. Although hemiarthroplasty can be a single-time solution to the complexities of intertrochanter fracture in elderly patients but should be performed in selected patients only.

Biomechanical Effects of the Porous Structure of Gyroid and Voronoi Hip Implants: A Finite Element Analysis Using an Experimentally Validated Model

Total hip arthroplasty (THA) is most likely one of the most successful surgical procedures in medicine. It is estimated that three in four patients live beyond the first post-operative year, so appropriate surgery is needed to alleviate an otherwise long-standing suboptimal functional level. However, research has shown that during a complete THA procedure, a solid hip implant inserted in the femur can damage the main arterial supply of the cortex and damage the medullary space, leading to cortical bone resorption. Therefore, this study aimed to design a porous hip implant with a focus on providing more space for better osteointegration, improving the medullary revascularisation and blood circulation of patients. Based on a review of the literature, a lightweight implant design was developed by applying topology optimisation and changing the materials of the implant. Gyroid and Voronoi lattice structures and a solid hip implant (as a control) were designed. In total, three designs of hip implants were constructed by using SolidWorks and nTopology software version 2.31. Point loads were applied at the x, y and z-axis to imitate the stance phase condition. The forces represented were x = 320 N, y = -170 N, and z = -2850 N. The materials that were used in this study were titanium alloys. All of the designs were then simulated by using Marc Mentat software version 2020 (MSC Software Corporation, Munich, Germany) via a finite element method. Analysis of the study on topology optimisation demonstrated that the Voronoi lattice structure yielded the lowest von Mises stress and displacement values, at 313.96 MPa and 1.50 mm, respectively, with titanium alloys as the materials. The results also indicate that porous hip implants have the potential to be implemented for hip implant replacement, whereby the mechanical integrity is still preserved. This result will not only help orthopaedic surgeons to justify the design choices, but could also provide new insights for future studies in biomechanics.

[Femoral neck blade cut-in after internal fixation of a trochanteric femoral fracture with a TFNA©]

Following fixation of a trochanteric femoral fracture with a TFNA© and despite correct fracture reduction and fixation, a 96-year-old patient suffered a complete cut-in, i.e. a medialization of the entire femoral neck blade through the nail into the hip joint. Against the background of implant development and current literature, this increasingly frequent type of complication is described and distinguished from other fixation failures such as the cut-out. Attempts to explain this phenomenon as well as research options are presented and a pragmatic approach to avoid this problem is outlined.

RECONSTRUCTION OF THE TROCHANTERIC ZONE IN PRIMARY ARTHROPLASTY OF UNSTABLE PERTROCHANTERIC FRACTURES

OBJECTIVE

The aim: To justify the concept and features of acetabular reconstruction during primary endoprosthesis for transcatheter fractures from the standpoint of radiological data, biomechanical calculations and intraoperative observations.

PATIENTS AND METHODS

Materials and methods: A retrospective analysis of the use of primary cement arthroplasty for osteoporotic fractures of the trochanteric zone in 52 elderly and senile patients was conducted. Before implantation of the femoral component, fragments of the proximal metaphysis were fixed with cerclage tightening loops which depended on the type of fracture. For fractures 31-A2.1, 31-A2.2, 31-A2.3, reconstruction of the destroyed trochanteric zone and the walls of the bone marrow canal opening was performed using our own methodology. Finite-element modeling with the SolidWorks program was used to investigate the influence of the reconstruction of the trochanteric zone on the distribution of strain on the bone tissue around the implant under osteopenic conditions and load during single-support standing.

RESULTS

Results: Clinical and X-ray results were studied in 39 (74.36%) operated patients within 3 to 33 months. There were no complications associated with recon-struction of the proximal part of the femur and implantation of endoprostheses. Restoration of movements in the hip joint and full loading of the operated limb was allowed the day after surgery, depending on the patients` physical condition. The results of finite-element modeling indicate a significant reduction of the strain on the proximal metaphysis in the zone of predominant destruction of the medial and posterior walls of the bone marrow canal of the trochanteric zone reconstruction and ensuring the stability of the femoral component.

CONCLUSION

Conclusions: Clinical results and biomechanical calculations confirm the possibility and feasibility of using primary arthroplasty in unstable osteoporotic fractures of the trochanteric zone with the aim of early restoration of the support function of the damaged limb in individuals with limited physical capabili¬ties. Reconstruction of the intertrochanteric area with a ring-shaped autograft contributes to the achievement of primary stability of the femoral component, restoration of the total femoral offset and stabilizing function of muscles around the joints.

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery

BACKGROUND

Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.

METHODS

Patients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.

RESULTS

Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar.

CONCLUSION

Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision-making.