| Objective:To compare the operation time, blood loss, postoperative rehabilitation time, the incidence of postoperative complications and postoperative hip Harris score between prosthetic replacement and internal fixation for senior citizens unstable intertrochanteric fracture. The clinical treatemnt results of these two methods would be analyzed and the indications for hip arthroplasty in the treatment of senile osteoporosis unstable intertrochanteric fracture would be also defined.Methods:51 old patients (26 men and 25 women) suffered from the unstable osteoporotic intertrochanteric fractures were selected from January 2003 to March 2007 in the First Hospital of Jinlin Universicity. The ages were between 62 to 93 and the average age was 74.8. there were 17 examples with age above 75 year old and average age was 88.7 years old..31 patients with other medical diseases, there were five cases with one single disease, 14 cases with two enternal diseases , 12 cases with more than three enternal diseases. According to Evans-Jensen classification: 16 cases belonged to Evansâ…¢A, 12 cases of typeâ…¢B, Evansâ…£of 20 cases, Evansâ…¤of 3 cases. The osteoporosis Singht index of the contralateral neck of femur were in the three following.1.35 patients were in the internal fixation group. Within this group, 27 patients were fixed by DHS, hollow screw fixed 2 cases, anatomical plate fixed 2 cases, proximal femur intramedullary nail (PFN) fixed 4 cases. the fllow-up time for this group was between 4 months to 38 months, and the average flow-up time was 22.7 months. 2. The hip arthroplasty group included 16 patients. The ages were between 63 to 93 and the average age was 76.5. 5 patients with the age less than 75 and 11patients above 75 year old. 13 patients were with other chronic enteral disease. 2 cases with one kind of disease , five cases with two kinds of disease, six cases with more than 3 kinds of disease. Total hip arthroplasty were carried out in 5 cases, and hemiarthroplasty was for 11cases (five cases of unipolar and bipolar six cases). bone cement was applied in all thses 16 patients. The flow-up was between 2 months to 40 months, and the average time was 25.9 months. Surger time and blood-transfusion during operation were recorded in both groups, and the postoperative ambulatory time, the occurrence of complications were considered. The data was processed by statistical software SPSS(Statistic Package for Social Science)11.5. P>0.05 was considered to have statisitc differences.Results:There was no difference in operation time between the hip arthroplasty group and the internal fixation group (P=0.115>0.05) by the t-test. There was difference of bleeding volume between the two groups by the t-test(P = 0.029 < 0.05).The bleeding of hip arthroplasty group was more than the internal fixed group. There was no statistical difference between the two groups in the incidence of postoperative complications by the X2 -test( P = 0.065> 0.05). The interna fixation group had more comlications and bed confied time). Replacement group decreased the time Lying in bed, and had no postoperative complications with the braking.There was significant difference between the two groups in Harris score the t-test(P=0.032<0.05).The clinical effects of the hip arthroplasty was better than that of the internal fixation group. The complications in arthroplasty group after the technique showed that there was no statistics difference between the age below and abvoe 75 years through chi-square test P=1.000>0.05. The Harris score decreasesed after the joint replaces. And the technique was proved non-statistics difference after T-test P=0.056>0.05. In internal fixation group: the complications after sugery had statistics difference in the age below and above 75 years old chi-square test P=0.005<0.05. The Harris score decreased after the joint replaces the technique was proved having statistics difference by T-test P=0.0313<0.05. Discussion:Intertrochanteric fractures in elderly people with different levels of osteoporosis were more unstable. Literatures reported that unstable intertro- chanteric fracture was up to 60.5%. The key of treating this kind of fratures is to restore the integrity of calear femorale, to retain the stability of intertrochanteric fracture. to recover the anatomical structure of greater trochanter and to reinforce the sagittal stability of intertrochanteric to prevent the dumping of femoral head.Currently, there are a good many of devices of fixation for intertro- chanteric fracture . The more effective are the nail-plate system , bue they are difficult to avoid the fracture line, resulting implant instability in penetration of the femoral neck and will easily lead displacement after postop.On the other hand, to expose the side of the lesser trochanter is difficult. It is not easy reset and fixed difficultily, can not guarantee the integrity of the calear femorale., easy produce cinching the implant and translocation and coxa vara. According to the statistics the fixation failure rate is as high as 16 percent ,they are not an ideal internal fixation material.The reasons for the failure of fixed are as follows: 1.Osteoporosis and bone mineral density decreased strength between implant to ossature. 2.Decreased bone strength, not firmly fixed in the fracture site, or small bone fracture site defected, or bone-free without firmly fixing. 3.After the cost of demineralized bone of bedridden, the internal fixation control is weaker. 4. Implant compression fracture and the blood circulation stress shielding and other reasons, lead to the failure or secondary fracture fixation. 5.Contrary to the principle of biomechanics operation and the way using the implant.During Artificial hip prosthesis replacement, exposed fully in the operation is to ensure the integrality of the the anatomical structure of the calear femorale and the fastness of fixing. Bone cement fix faultlessly prothesis through filling the volume and fixing-lock . That transmits uniformly the stress and avoid prothesis jogging at the interface and prevent to sink. That avoids fracture healing imperfectly or delay and shortens hospitalization time, reduces death and the occurrence of fracture malunion. So that patients restored to pre-injury level of functional activit quickly to reduce the time on the bed and complications caused by long-term bed and the recurrence of the original disease.Therefore hip replacement in the treatment of senile osteoporosis and unstable intertrochanteric fracture is a better way.The indications of thr hip replacement surgery is: (1)Age (age>75 years) and unstable intertrochanteric fracture and Evans III level or above .(2) With osteoporosis (especially Singh classification 3 below) and other internal fixation difficult to forecast effectively; (3) Not coexist with other long-term bedridden braking; (4) No significant limitation of the knee before the hip injury and can walk independently or can walk with crutches. (5) The body can tolerance the surgery and the internal medicine diseases can be adjusted to be able to nearly normal levels; (6) Old intertrochanteric fracture or fracture healing faultily.The surgery choice for artificial hip are: fresh intertrochanteric fracture and no pain preoperative hip and inspection found no avascular necrosis or acetabular dysplasia and being in the view of the acetabular cartilage as well. That can be feasibiitied artificial bipolar hemiarthroplasty. If the acetabular cartilage has been senescent, the acetabular cartilage will soon be wear and the femoral head will be displacement of center after the artificial bipolar hemiarthroplasty . The operation is less effective and propose to deploy total hip replacement.However, hip replacement is not able to substitute opening-reduction and internal fixation for the treatment of such fractures. It is a useful supplement for internal fixation. We advocate opening reduction and internal fixation for patients above 75 without complications. For patients older than 75 with severe osteoporosis and unstable fractures, hip arthroplasty could be a better way to take.Conclusion:1. Compared with open reduction internal fixation for the senior citizens osteoporosis unstable intertrochanteric fracture, hip replacement prosthesis had short operation time, less blood loss and short time on bed. the incidence of complicatios had no significant differences (fewer complications related to bed) and postoperative functional recoveries was fast and be betttter in short-term.In the patients of the fixed group technique, complication rate after technique was high and the Harri Score decreased seriously between the patients with the age below and above 75 years old. After the joint replace- ment, the complications and the Harris Score did not decrease obviously. The replacement cannot substitute for the internal fixation to treat this kind of bone fracture , it is only a kind of beneficial supplement.To the pateinets below 75 years old with no serious osteoporosis, we advocate internal fixations .To the patients above 75 years old with unstable bone fracture , we advocate hip replacement technique.2. Hip arthroplasty for treatment of senior citizens unstable intertro- chanteric bone is one of the treatment options. For fresh intertrochanteric fracture, no hip pain preoperative, no avascular necrosis or acetabular dysplasia, in the view of the acetabular cartilage as well, adopts artificial bipolar arthroplasty. If the acetabular cartilage has been degeneration ,the results artificial bipolar hemiarthroplasty is poor and proposed use artificial hip replacement.3. The number of cases in this group study are relatively little. There were some limitations to reflect the accuracy and comprehensiveness of the results and they suit small samples of the recent complications in the comparison. During follow-up time, Joint function resumed gradually and the ocurrence of the long-term complications happened in internal fixation group. The long-term complications and joint function of the two methods have yet to need relatively large samples for further study. |
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