Unstable, Comminuted inter-trochanteric fracture is a common fracture in old age patients and has a significant impact on the health care system of the society; it is associated with poor quality of the bone, the excessive collapse of the head, loss of fixation, Cut-out, Plate breakage, plate pullout, Z-effect, reverse Z effects are few of the implant-related complications especially with unstable type of fractures [1, 2]. A prosthetic replacement has given good results and has proven good long-term survivorship and early rehabilitation of patients [3-5]. The main reason to perform Cemented Bipolar Hemiarthroplasty for Comminuted Inter-trochanteric Femur Fracture in elderly osteoporotic patients is early mobilization and avoiding complications associated with Open reduction and internal fixation in osteoporotic patients [6].

The incidence of fixation failure is as high as 20% in unstable intertrochanteric fractures due to non-union, femoral perforation, and metal pullout. Also, postoperative ambulation may be delayed in this population due to the difficulty of achieving firm fixation [7,8].

Repeating open surgery may be impossible when Intramedullary nailing fixation or DHS failure happens due to the patient’s general condition and medical complications [9, 10]. The present study describes the functional outcome of 42 elderly osteoporotic patients with Comminuted Inter-trochanteric femur fracture treated with Cemented Bipolar hemiarthroplasty and Tension band wiring for Greater trochanter at our institute and we followed up the patients for 12 months.

Of the 214 proximal femoral fractures in ambulatory patients treated surgically between 2018 and 2022 in our institute, 44 unstable intertrochanteric fractures were treated by cemented hemiarthroplasty but we lost 2 patients to follow up.

Study done on 42 patients with follow up for 1 year.

We had kept certain inclusion criteria for our study.

Inclusion Criteria

• Age- More than 55 years.
• All Patients were osteoporotic, as confirmed on Bone mineral Density as per WHO guidelines. [7]
• All sustained Evans type III and IV, AO/OTA type 31- A2.2 and 2.3 of Inter-trochanteric Fractures. Unstable, Comminated Fractures only.
• No other fracture sustained only isolated Inter-trochanteric fracture present
• No head injury to the patient
• Fracture less than 4 weeks old

Exclusion Criteria

1) Age less than 55 years

2) Any Transcervical, subcapital fractures.

3) Non comminated IT fractures/stable fractures.

 Anaesthesia – Almost all the patients in our study were given Hypotensive epidural anaesthesia, spinal anaesthesia, few were given general anaesthesia.

Operative Technique

Under aseptic precaution, under appropriate anaesthesia, patients were in a lateral decubitus position using the posterolateral approach, scrub paint drape was done with patient in lateral position, incision was taken on lateral aspect of hip, proximally incision was curved posteriorly towards Posterior superior iliac spine. Tensor Fascia Lata was cut in the direction of skin incision.

Proximal Fibres of gluteus maximus were visualised and cut, bursa incised, gluteus medius and pyriformis tagged and rotators cut to expose fracture site. Fracture site dissected and retracted fracture fragments of greater trochanter, reach base of femur neck. Femur head and the attached neck extracted. After extraction of femoral neck and head, acetabulum was visualised and cleared. The femoral canal was serially prepared using a reamer, to conduct stem trials to determine the stem size with appropriate stability and leg length. Minimal reaming was done in all cases to prevent fat embolism and proper placement of the femoral stem in the proximal femoral shaft.

A temporary reduction was performed using the stem trial and cup trial, and intraoperative true leg-length discrepancy was checked. Two holes were made by using drill on lateral aspect of proximal femur and a stainless steel wire was passed from outside through one hole in the medullary canal and then taken out from another hole.

Now the two free ends of the wire are lying on lateral aspect of femur. Implant fixation started now with special care on - Ante version, Length of the implant to be inserted in the femur, cement gun and finger packing was used and no excess cement spread on fracture which may interfere with union of the fracture.

Final implant of adequate size is inserted and the hip is reduced. The fracture pieces of GT are now approximated to each other. A wire passer is passed above tip of the trochanter deep inside the abductors. Previously passed wire is now crossed over and passed through the wire passer, so as to complete figure of 8 tension wire technique which is now tightened.

Compression across the fracture site achieved and restores the abductor mechanism of hip.

Blood loss was measured, Wash given with NS and Betadine solution, Rotators sutured by Ranawat Technique and Closure done in layers, DPA checked, sterile dressing was done along with negative suction drain applied. Patient were shifted for post operative ward.

Post-operative and Rehabilitation Protocol:

All patients were kept under analgesic effect with help of epidural catheter till two days post-operative. To prevent deep vein thrombosis, compressive stockings were applied to both legs and low molecular weight heparin or Aspirin 75mg was administered.

IV Antibiotic was administered for 3 days. Static Quadriceps femoris muscle strengthening exercises and ankle pump were started on the day of surgery. Dynamic Quadriceps exercises and standing with full weight bearing begun on post op day one.

Full weight bearing and mobilization with the help of walker was started from post op day2 and continued for 6 weeks. Patient was advised to use only Western style commode for Toilet activity to avoid dislocation of bipolar hemiarthroplasty. Patient was instructed to avoid cross legged sitting and squatting. Patients were followed up regularly at 2 weeks, 6 weeks, 3 months and 1 year

The 42 patients comprised 17 men (27%) and 25 women (73%), and were aged from 55–82 years. Mode of Injury: 77.9 % patients -trivial trauma like fall from chair/bed, slip in bathroom or in house on floor. 22.1%: major trauma like fall from significant height, road traffic accident or fall from stairs. None of the patients developed intraoperative complications. In all 42 cases, bipolar hemiarthroplasty was performed by using cement stem and the wiring technique.

Table 1: Variables in the study population

Complications:

We had complications in 4 out of 42 patients with no mortality

 Complications Treatment:

1. Dislocation (Immediate)- Closed reduction under GA
2. Shortening – If needed, shoe raise was given.
3. Anterior thigh pain- Relieved on analgesic medication.
4. Superficial surgical site infection- IV Antibiotic given according to pus culture report; it subsided in 2 weeks. No patients with complications like Bed sore, aspiration pneumonitis, atelectasis and deep vein thrombosis due to early mobilization.

Failure rates have been reported between 6% - 32% for internal fixation of both stable and unstable intertrochanteric hip [11, 12]

Stable intertrochanteric fractures can easily be treated by osteosynthesis and have good results [13-15]. Management of unstable intertrochanteric fractures remains controversial, especially in patients with osteoporosis [16]. The incidence of all hip fractures is approximately 80 per 100,000 population around the world and according to reports it is expected to get double over the next fifty years as the population ages [17]. Internal fixation achieves good results in stable fractures with good bone stock. But in unstable comminuted unstable and osteoporotic IT fracture all types of fixation devices have failed to achieve the good result

Knowing the importance of early postoperative ambulation and early rehabilitation, bipolar hemiarthroplasty is considered one of the most effective primary treatment methods for unstable intertrochanteric fracture.

Cemented fixation is more advantageous than uncemented fixation for achieving initial implant stability and early rehab in unstable intertrochanteric fractures with poor bone quality in elderly patient

The complications like PE, DVT, and pneumonia ranges from 22%–50% when mobilization is delayed after internal fixation [17-18]. A lower re-surgery and lower decrement rate of walking ability has been reported by patient with use of bipolar hemiarthroplasty compared to internal fixation after surgery for treatment of unstable IT fracture in elderly patients [19].

Displacement of the greater trochanter can cause gait disturbance after surgery due to weakness of the abductor muscle, psoas, and flexor muscle and could also result in postoperative dislocation [20]. Therefore, for early ambulation strong fixation with strong wiring is important.

Grip plate can also be used to attain rigid fixation but use of this technique has been associated with complications of non-union and symptoms of irritation, therefore wiring is preferable and effective for maintenance of the reduction of trochanteric fragment.

Unsatisfactory surgical outcome is common in elderly patients with intertrochanteric fractures treated with internal fixation due to medical illness, osteoporosis, fracture instability, complication due to late mobilization are contributing factors.

Therefore we did cemented hemi arthroplasty for the treatment of unstable trochanteric fractures in the elderly in order to decrease internal fixation complications like screw cut-out, Plate breakage, Z-effect, Reverse Z-effect and early mobilization to avoid pulmonary embolism, Bed sores, Deep vein thrombosis, atelectasis etc which gets further complicated with already existing co-morbidities of the patient.

The primary cemented bipolar hemiarthroplasty along with TBW for unstable inter-trochanteric fractures of femur in old age patient provide early ambulation to avoid late mobilization complications like deep vein thrombosis, pulmonary embolism, bed sores. Good functional outcome, pain free movement of hip, less failure and less Intramedullary technique complications without the need for revision surgery are other benefits of cemented bipolar hemiarthroplasty in osteoporotic elderly patient.

Trochanteric reconstruction helps in avoiding abduction lurch and very good functional outcome. Hence primary cemented bipolar hemiarthroplasty can be considered as a better surgical option compared to traditional dynamic hip screw fixation or other intramedullary fixation technique in elderly osteoporotic patients.

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