Predicting Factors for Return to Prefracture Ambulatory Level in High Surgical Risk Elderly Patients Sustained Intertrochanteric Fracture and Treated With Proximal Femoral Nail Antirotation (PFNA) With and Without Cement Augmentation

Abstract

Introduction: Postoperative outcomes in the elderly patients with intertrochanteric fracture were generally poor with a low rate of return to prefracture ambulatory level (RPAL). Recent studies showed that proximal femoral nail antirotation (PFNA) with cement augmentation might be useful for postoperative functional recovery. This study aimed to compare the outcomes in elderly patients with high surgical risk, American Society of Anesthesiologist (ASA) grade 3 or 4, who sustained intertrochanteric fractures and were treated with PFNA with and without cement augmentation, and to correlate perioperative surgical factors with the RPAL. Methods: A retrospective consecutive series was conducted based on 135 patients with prefracture ambulation classified as independent in community with or without a single cane (68 in augmented group and 67 in control group). Perioperative data and data on the complications within 1-year postsurgery were collected and compared. Predictive factors for RPAL were analyzed via logistic regression analysis. Results: The overall 1-year postoperative mortality rate was 10% (n = 14) with no significant difference between groups ( P = .273). The proportion of elderly patients with RPAL in the augmented group was significantly higher than for those in the control group (48% vs 29%, P = .043). Via univariate analysis, ASA grade 4 ( P = .077), history of stroke ( P = .035), and use of cement augmentation ( P = .041) were correlated with RPAL. However, multivariate regression analysis showed that ASA grade 4 (odds ratio [OR] = 0.40, 95% confidence interval [CI]: 0.18-0.90, P = .026) and use of cement augmentation (OR = 2.72, 95% CI: 1.22-6.05, P = .014) were the significant predictors for RPAL. Discussion and Conclusions: The results of the present study showed that PFNA with cement augmentation is safe and effectiveness in the intertrochanteric fracture treatment of elderly. Postoperative functional recovery, like RPAL, in elderly patients who sustained intertrochanteric fractures is relatively low, especially in those with ASA grade 4. However, cement augmentation with PFNA might be helpful for increasing the RPAL in high-surgical-risk geriatric patients.

Cement augmentation for trochanteric femur fractures: A meta-analysis of randomized clinical trials and observational studies

“…A detailed description of the search and screening is shown in Fig 1 . Finally three observational studies [ 13 , 14 , 26 ] and four randomized controlled trials [ 12 , 15 , 27 , 28 ] fulfilled the criteria.…”

“…Thromboembolic complications included all venous thrombembolisms in the follow-up period and are listed as a part of systemic complication as well as separately [ 12 , 14 ].…”

“…Primary outcome defined as overall complications were reported in five studies; two randomized clinical trials and three observational studies [ 12 – 14 , 26 , 27 ]. The overall complication rate was significantly lower in the augmented group (28.3% versus 47.2%) with a weighted OR of 0.3 (95%CI 0.1–0.7, I2: 75%) ( Fig 2 ).…”

“…To date there is no clear evidence suggesting a clinical benefit of cement augmentation. Individual studies have either failed to show a significant difference or found small differences [12][13][14][15]. A formal meta-analysis on this topic has not been previously published.…”

Comparison of clinical outcomes with hip replacement versus PFNA in the treatment of intertrochanteric fractures in the elderly

“…The characteristics of PFNA include the following: avoid the instability of the proximal femur after internal fixation; conducive to fracture healing; and reduce the incidence of hip varus deformity. [ 32 ] Zhou et al [ 26 ] reported that hip joint function of patients is effectively improved after surgical treatment, which significantly reduces the incidence of post-operative complications. Based on the above advantages, PFNA is suitable for elderly patients with partial intertrochanteric fractures because this treatment requires low surgical tolerance.…”