Comparison of external fixation and intramedullary nailing in geriatric patients with intertrochanteric fractures of the femur

Abstract

Aim: The healing time of femoral intertrochanteric fractures in the elderly population is prolonged due to the presence of osteoporosis. However, mortality is high because of major causes such as embolism due to long-term bed rest. It is particularly important that these patients be operated and given the freedom to move in the early postoperative period. In this study, we aimed to compare the clinical outcomes of Proximal Femoral Nail (PFN) and External Fixation (EF) in older patients with intertrochanteric fractures of the femur (ITFF).

Methods: This study included 72 patients aged 65 years or older who were diagnosed with ITFF and underwent PFN (n=38) or EF (n=34) between 2011 and 2017. Patient data including demographic characteristics, preoperative ASA score, surgical technique, postoperative complications, and functional outcomes at final follow-up, Harris Hip Score (HHS) and Mean Mobility Score (MMS) scores were recorded for each patient.

Results: The results indicated that both PFN and EF provided equally satisfactory functional outcomes in the patients. EF was found to have major advantages including significantly lower operative times, lower intraoperative blood loss, and administration of sedation only in high-risk patients. PFN was also found to have remarkable advantages such as lower reoperation risk, reduced mortality, and lower risk of superficial wound infection.

Conclusion: Although both PFN and EF were found to have remarkable advantages, PFN seems to be more advantageous in terms of complications. Meaningfully, PFN could be more reliable and effective in the treatment of extracapsular ITFF in old-age patients.

Keywords

• External fixation,Harris Hip Score,Femur intertrochanteric fracture,Mortality,Proximal femoral nail

Geriatrik femur intertorakanterik kırıklarında, eksternal fiksatör ile intramedüller çivilerin karşılaştırılması

Abstract

Amaç: Yaşlı popülasyonda intertrokanterik femur kırıklarının (ITFK) iyileşme süresi osteoporoz varlığı nedeniyle uzar. Bununla birlikte bu hastalarda uzun süreli yatak istirahati sonucu emboli gibi başlıca nedenlerden dolayı ölüm oranı yüksektir. Bu hastaların erken dönemde ameliyat edilmesi ve hareket verilmesi çok önemlidir. Bu çalışmada, ITFK olan yaşlı hastalarda uygulanan Proksimal femoral çivi (PFÇ) ve Eksternal fiksatör (EF) yöntemlerin klinik sonuçlarını karşılaştırmayı amaçladık.

Yöntemler: Çalışmaya 2011-2017 yılları arasında ITFK nedeniyle ameliyat edilen 72 hasta alındı. Bu hastalardan 38 tanesine proksimal femoral çivi, 34 tanesine eksternal fiksatör uygulandı. Hastaların demografik verileri, ameliyat öncesi ASA skoru, cerrahi teknik, ameliyat sonrası komplikasyonlar, final fonksiyonel sonuçlar, Harris kalça skoru ve ortalama kalça hareket skorları herbir hasta için kaydedildi. 

Bulgular: Her iki grubun fonksiyonel sonuçları tatminkar olup EF uygulanan grupta ameliyat süresinin daha kısa ve kan kaybının daha az olması, sedasyonla müdahele edilmesi başlıca avantajlarıdır. PFÇ yapılan grupta ise tekrar opere edilme ve mortalite riskinin daha az olması, yüzeyel cilt enfeksiyonlarının olmaması başlıca avantajları olarak görüldü.

Sonuç: PFÇ ile EF’nin karşılaştırıldığı bu çalışmada, PFÇ uygulamasında komplikasyonların daha az olduğu ve bu nedenle ekstrakapsüler ITFK’ da Proksimal femoral çivi yönteminin daha güvenli ve daha effektif bir tedavi olduğu kanaatindeyiz.

Keywords

• External fiksatör,Femur intertorakanterik kırık,Harris Kalça skoru,Mortalite,Proksimal femoral çivi

References

1. 1. Demirel ME, Ali, I.H. Evaluation of trauma patients admitted to the emergency department of in Mogadishu Training and Research Hospital, Somalia: Cross-sectional study of 1106 patients. J Surg Med. 2019;3:722-4.
2. 2. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res. 1998:87-94.
3. 3. Atay İM, Aslan, A., Atay, T., Burç,H. Genel ve spinal anestezi uygulanan yaşlı kalça kırığı olgularında deliryum yaygınlığı, risk faktörleri ve bilişsel fonksiyonlar. Turkish Journal of Geriatrics. 2012;5:273-8.
4. 4. Cooper C, Cole ZA, Holroyd CR, Earl SC, Harvey NC, Dennison EM, et al. Secular trends in the incidence of hip and other osteoporotic fractures. Osteoporos Int. 2011;22:1277-88.
5. 5. Hornby R, Evans JG, Vardon V. Operative or conservative treatment for trochanteric fractures of the femur. A randomised epidemiological trial in elderly patients. J Bone Joint Surg Br. 1989;71:619-23.
6. 6. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005;87:1123-6.
7. 7. Seyfettinoglu F, Ersan O, Kovalak E, Duygun F, Ozsar B, Ates Y. Fixation of femoral neck fractures with three screws: results and complications. Acta Orthop Traumatol Turc. 2011;45:6-13.
8. 8. Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P, 3rd, Obremskey W, Koval KJ, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am. 2003;85:1673-81.

9. 9. Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J Bone Joint Surg Br. 1993;75:797-8.
10. 10. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737-55.
11. 11. Moroni A, Faldini C, Pegreffi F, Hoang-Kim A, Vannini F, Giannini S. Dynamic hip screw compared with external fixation for treatment of osteoporotic pertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg Am. 2005;87:753-9.
12. 12. Ozdemir H, Dabak TK, Urguden M, Gur S. A different treatment modality for trochanteric fractures of the femur in surgical high-risk patients: a clinical study of 44 patients with 21-month follow-up. Arch Orthop Trauma Surg. 2003;123:538-43.
13. 13. Atıcı T, Şahin, N., Öztürk, A., Yaray, O. İleri yaşlı (≥65 yaş) yüksek riskli olgularda gelişen intertrokanterik femur kırıklarının eksternal fiksatörle tedavisi. Ulusal Travma Acil Cerrahi Dergisi. 2010;16:413-20.
14. 14. Duramaz A, Sarı, C., Bilgili, G.M., Erçin, E., Kural,C., Avkan, M.C. Outcomes of Four Different Surgical Techniques in the Treatment of Geriatric Intertrochanteric Femur Fractures. Haseki Tıp Bülteni. 2014;52:256-61.
15. 15. Parker MJ, Das A. Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2013:CD000339.
16. 16. He SH, Peng JY, Zhao X. The comparison of three operation methods for treatment of femoral intertrochanteric fracture. Zhongguo Gu Shang. 2009;22:6-9.
17. 17. Wang DW, Su EL, Wang WJ, Wang S, Wang BF. Case control study of different fixing methods for intertrochanteric fractures. Zhongguo Gu Shang. 2010;23:769-71.
18. 18. Moroni A, Faldini C, Pegreffi F, Hoang-Kim A, Giannini S. Osteoporotic pertrochanteric fractures can be successfully treated with external fixation. Journal of Bone and Joint Surgery-American. 2005;87a:42-51.
19. 19. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br. 2005;87:76-81.
20. 20. Ekstrom W, Karlsson-Thur C, Larsson S, Ragnarsson B, Alberts KA. Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the Medoff sliding plate. J Orthop Trauma. 2007;21:18-25.
21. 21. Özdemir H, Urguden, M., Dabak, T.K., Soyuncu, Y. Treatment of intertrochanteric femoral fractures with the use of a modular axial fixator device. Acta Orthopaedica et Traumatologica Turcica. 2002;36:375-83.
22. 22. Uzun M, Erturer E, Ozturk I, Akman S, Seckin F, Ozcelik IB. Long-term radiographic complications following treatment of unstable intertrochanteric femoral fractures with the proximal femoral nail and effects on functional results. Acta Orthop Traumatol Turc. 2009;43:457-63