Unstable Intertrochanteric Fractures: Hemiarthroplasty V/S Fixation

• Author Details:   
• Zulfikar M. Patel
• Shaival S. Dalal
• Kalpesh A. Mehta
• Akash J. Shah

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Background and Objectives: For many decades, attempts have been made to overcome the difficulties which surgeons encounter in the treatment of proximal femoral fractures. Extra medullary and intramedullary implants have improved in recent years, although consensus is lacking concerning the definition and classification of unstable intertrochanteric fractures, with uncertainties regarding treatment. In this era of technologically sound and tested fixation methods we shall compare functional outcomes and complications of various methods available for unstable it fracture fixation.
The purpose of this study is to analyze the role of primary hemi arthroplasty in cases of unstable osteoporotic intertrochanteric femur fractures and compare the outcomes with conventional fixation techniques to find out a better management plan for the patient.
Materials and Methods: This is a prospective study of fifty cases of unstable intertrochanteric fractures, either treated with primary replacement (hemi or total) or fixation. Between February 2012 and December 2012, fifty patients with an unstable comminuted intertrochanteric femoral fracture (AO/OTA type 31A2.2, A2.3, A3.2, A3.3) were enrolled in the study, which was approved by our institutional review board.

Inclusion Criteria: 

1.        More than 60 years of age. 

2.        All patients with unstable IT femur fracture type

a.        31- A2.2 and 31- A2.3 (AO/OTA classification)

b.        Posteromedial fragmentation

c.        Basicervical

d.        Reverse oblique

e.        Displaced greater trochanter (lateral wall fractures)

f.         Patient must be ambulatory before sustaining injury 

Exclusion Criteria:

a.        Chronically debilitated and bed ridden patients.

b.        Compound fracture 

c.        Medically compromised patients- ASA grade iv &v 

d.        Local infection ¾ Stable fracture

Results: Maximum patients (88%) belonged to 60-80 years of age. Since most of the patient belong to elderly age group, medical comorbidities are very common.
Average requirement of blood transfusion needed was significantly higher in hemi replacement group than in fixation group. (Z= 3.56, p<0.05). This indicated the surgical complexity of hemi replacement.
There was significant shortening of limb in fixation group as compared to hemi replacement. (Z=6.98,p value <0.05)
Thus hemi replacement provided faster rehabilitation to the patient. This implies that those patients who had hemi replacement had a significantly better activity of daily living. 

Harris hip scores were significantly better in hemi replacement group. (Z=4.31, p value<0.05) suggesting better functional outcomes. There was no significant difference between immediate postoperative complications though skin incision, operating time, and blood loss were significantly higher in hemi replacement group.(Z=0.7, p>0.05) but the rate of delayed complications and revision surgeries were significantly higher in fixation group. (p<0.05)
There was no significant difference in mortality rates of both groups despite more blood loss and duration of surgeries in hemi replacement group.
Interpretation and Conclusion: In conclusion we state that hemi replacement arthroplasty, is a valid treatment option for mobile and mentally healthy patients, as compared to fixation for faster rehabilitation and better activity of daily living.
Aims & Objectives:

·         To study the results of primary replacement (hemi or total) in unstable intertrochanteric fractures and compare it with conventional methods of fixation. 

·         To assess functional outcome in patients having unstable intertrochanteric fractures in both groups as per Harris hip score. 

·         To study the effect of pre-existing illness on final outcome of the patients in both groups. 

·         To study the stability of fixation in osteoporotic bones. 

·         To note any complication developed. 

To compare final outcome of this study with that of the other studies