Comparative evaluation of postoperative health status and functional outcome in patients treated with either proximal femoral nail or hemiarthroplasty for unstable intertrochanteric fracture

Abstract

Purpose: This study aimed to compare functional recovery and change in morbidity status from the preoperative levels among patients who underwent two different surgical treatments for unstable intertrochanteric fracture. Methods: This retrospective comparative study enrolled 140 patients (aged >80 years) who were referred to two hospitals. Of these, 64 were treated using proximal femoral nail (PFN) and 76 were treated using hemiarthroplasty (HA). To evaluate functional recovery, primary outcome measures were cumulative illness rating scale (CIRS) score to evaluate changes in morbidity status, activity of daily living (ADL) index, and mobility scores. Results: The proportion of patients who experienced increased CIRS scores in the HA group was higher at the 3-month follow-up (p ¼ 0.02) but similar at the 6-month followup (p ¼ 0.2) in comparison to the PFN group. Treatment with HA, American Society of Anesthesiologists scores of 3-4, and lower, preoperative ADL indexes were the major predictors of increased postoperative CIRS score. Impaired ambulatory ability and the need for walking aids were significantly higher in the PFN group at the 3-month follow-up (p ¼ 0.01 and p ¼ 0.02, respectively) but similar at the 6-month follow-up with respect to the HA group. PFN treatment and high patient body mass index were the major predictors of decreased ambulatory ability at postoperative 3 months. Conclusion: HA has several advantages, including early mobilization and decreased dependency. However, it is associated with greater blood loss, a higher need for blood transfusion, and longer surgical duration than PFN, all of which are predisposing factors for significantly higher risk of reduced CIRS scores.

Bipolar Hemiarthroplasty should not be selected as the primary option for intertrochanteric fractures in elderly patients aged 85 years or more

“…[ 9 , 16 , 17 ] But, due to failures of PFNA have also been reported in elderly ITFs patients, [ 7 ] lots of researchers tried BPH as the primary treatment option for elderly ITFs patients, however, the conclusion of BPH as the primary option for elderly ITFs patients differs in different papers. [ 4 – 7 ] In this study, we as the first study to investigate clinical data of elderly ITFs patients aged 85 or more treated with PFNA or BPH, and found that although BPH and PFNA have similar functional outcome and mortality rates 12 months after operation, BPH has more postoperative complications in elderly patients aged 85 years or more with ITFs, BPH is not a good primary treatment for ITFs in elderly patients aged 85 years or more.…”

“…Although early surgical treatment has been accepted as the optimal strategy for managing ITFs in elderly, [ 2 ] the debate on the superiority of intramedually (nails) and extramedually (screws or plates) fixations, [ 3 ] internal fixation and arthroplasty arises again in recent years. [ 4 ] Whilst proximal femoral nail antirotation (PFNA) has been selected by most of surgeons for elderly ITFs patients, [ 5 , 6 ] failures of PFNA have also been reported in elderly ITFs patients due to osteoporosis, extensive comminution or long bedridden duration. [ 7 ] As a result, bipolar hemiarthroplasty (BPH), which permits early full-weight bearing, avoids the failures of osteosynthesis, was first chosen as the primary treatment for elderly ITFs patients by Green et al in 1987 [ 8 ] and subsequently been advised as an alternative method for elderly ITFs patients by lots of researchers.…”

Cemented hemi-arthroplasty for unstable intertrochanteric fractures in the elderly: a retrospective study

“…3,4 All these serious risk factors can increase the one-year mortality rate up to 20-30% in hip fractures. 3,5,6 Intertrochanteric fractures with posteromedial comminution involving the lesser trochanter, with subtrochanteric extension of fracture and the reverse oblique type fractures are considered unstable varieties. 2 Almost 50-60% of trochanteric fractures belong to the unstable group.…”

“…8 Proximal femoral nails (PFN) and dynamic hip screws (DHS) are widely recommended for internal fixation of intertrochanteric fractures all over the world. 3,5 But these internal fixation methods are often plagued by failures due to screw cut-out, excessive collapse of fractures, loss of fixation, malunion, and nonunion etc. 5,[8][9][10] Because of these complications early full-weight bearing mobilization in the elderly with osteoporosis and unstable fracture morphology can be very risky.…”

“…3,5 But these internal fixation methods are often plagued by failures due to screw cut-out, excessive collapse of fractures, loss of fixation, malunion, and nonunion etc. 5,[8][9][10] Because of these complications early full-weight bearing mobilization in the elderly with osteoporosis and unstable fracture morphology can be very risky. Therefore, some researchers turn to cemented or uncemented hemiarthroplasty as an option to achieve a stable hip joint suitable for early weight-bearing rehabilitation.…”