Intertrochanteric fractures have been recognized as the most common fractures in geriatric patients. intertrochanteric fracture account for 45 % of hip fracture out of which 30 to 40 % are unstable (1).This fracture is associated with high mortality, 15%-30% at one year (2) Degree of osteoporosis in fracture influences fracture type, standard treatment for trochanteric fractures are treated by internal fixation without considering significance of fracture type, age of the patient or associated co-morbidities. Standard internal fixation devices used in comminuted intertrochanteric fracture in elderly patients with osteoporosis has high failure rates. The weak porotic bone tolerates screws poorly so cut out is the major problem in internal fixation (3). Many times a patient spends a long time in bed, following standard internal fixation, which complicates the recovery. Complications like deep vein thrombosis (20%) & hypostatic pneumonia (19.4%) are high (1) .Bipolar hemiarthroplasty offers a durable and versatile solution for comminuted intertrochanteric fractures in the elderly. For intracapsular fracture standard southern

Moore’s(posterior approach) or lateral hardinge approach is used both this approach have some disadvantage when it comes to comminuted intertrochanteric fracture where in greater trochanteric is split (type 3 and 4 part intertrochanteric fracture )

Primary arthroplasty offers a solution to both prevent and treat these problems (1,4). However Dislocation and sepsis are the dreaded complications of this procedure, especially in elderly patients (1,5,6)

In 2008 Bombaci described a transtrochanteric approach in intertrochanteric femur fractures to perform hemiarthroplasty which seem to have addressed the disadvantages of the standard approach for hemiarthroplasty [7] we are performing transtrochanteric cemented bipolar hemiarthroplasty approach for comminuted intertrochanteric fracture.

25 patients underwent cemented bipolar hemiarthroplasty between June 2022 to July 2023 who had sustained comminuted intertrochanteric fractures in osteoporotic bones. All patients who were operated by the primary author by trans trochanteric approach. We selected this approach as in all our cases greater trochanter and lateral wall was fractured so in all cases femoral head was approached through the fracture site.

INCLUSION CRITERIA:

Age- More than 60 years

Unstable inter-trochanteric fractures AO/ OTA type 31 A2.2 and 2.3

EXCLUSION CRITERIA:

Age – less than 60 years

Stable inter-trochanteric fractures and intra capsular fractures Associated vascular injuries

Patients with pathological fractures

Twenty-five patients who met the inclusion criteria underwent Cemented Bipolar hemiarthroplasty between 2022 and 2023 were included in the study. Among patients included in our study with 15 female and 10 male patients, 23 patients had suffered the injury due to trivial trauma like fall from bed, slip in bathroom or in house on floor. Two patient sustained the fracture following a RTA

Surgical procedure:

All surgeries were performed using standard aseptic precautions. Surgeries were performed under epidural plus spinal anaesthesia. Intravenous antibiotics were given 30 minutes prior to surgery. Patient is positioned in straight lateral position with the patient lying on the unaffected side. Posterior Skin incision: With hip in 20-30 degree flexion, curved incision was taken at the junction of anterior one third and posterior two third over greater trochanter extending 3 cm to 4 cm proximally and 5cm to 6 cm distally towards femoral shaft. Fascia lata is incised in line with the skin incision and a Charnleys’ retractor is placed to expose the lateral aspect of the proximal femur. Gluteus maximus tendon is identified and divided at its insertion to facilitate internal rotation of the shaft. Fracture line is palpated. Usually the major portion of the abductor will be attached to a postero superior fragment of the greater trochanter. And the minor portion will be attached to the antero inferior fragment which may be a separate fragment in a 4 part or a comminuted fracture or in continuous with the shaft in a 3 part fracture. Femoral head with neck approached through fractured greater trochanter preserving attachments of short external rotators to the greater trochanter, capsule is incised and femoral head with neck extracted by flexion & external rotation at hip joint with the help of corkscrew. Head size measured. We prepared femoral medullary canal by sequential broaches in flexed & externally rotated hip. Trial implants were placed & hip was reduced to decide the final implants sizes. The length of the implant to be sunk is determined by judging the length of the postero superior fragment of greater trochanter and the center of the prosthetic head. The gap is filled with bone cement. After removing the trial implants thorough wash given with pulse lavage. Cement restrictor was placed in the medullary canal 2 centimeters below the tip of femoral stem. Canal was dried using hydrogen peroxide soaked roller gauze .Before cementing with the help of drill bit femur is drilled from lateral to medial cortex just 1 cm below the vastus ridge 18 mm wire is passed through the drilled hole Cementing was done with cement gun. Placement of the femoral stem was done. Hip joint was reduced all movements with stability is checked ,finally fractured greater trochanter is reduced and TENSION BAND WIRING is done in figure of 8 manner through wash given drain placed in negative suction skin closed in layers and dressing done.

Rehabilitation

All the patients were started with physiotherapy. All patients were trained for quadriceps strengthening exercises immediately. Full weight bearing walking was started from post-op day1 with the help of a walker for the first 6 weeks postoperative. Thereafter patients started full weight bearing with support of a stick. Patients were instructed to avoid activities involving squatting and cross legged sitting for the rest of their life as a precautionary measure to avoid dislocation of the bipolar hemiarthroplasty. Patients were followed up regularly at 6 weeks, 12 weeks, 3 months and one year post-operatively

Results:

Prospectively collected clinical and radiological data of 25 patients operated for unstable osteoporotic inter trochanteric fracture (AO/OTA TYPE 32 A2.3) with primary bipolar hemiarthroplasty use transtrochanteric approach with tension band wiring of greater trochanter were assessed. The collective included 10 male and 15 female with the mean age of (67.2 years). 23 patients were injured after fall from a standing height (trivial injury) 2 patient were injured with road traffic accident

Statistical Analysis was done by the MiniTab version

Patients were evaluated at 6 weeks, 3 months, 6 months and 1 year postoperatively using Harris Hip score .We had 25 patients included in our study with 15 female and 10 male patients. Most of the patients had suffered the injury due to trivial trauma like fall from chair/bed, slip in bathroom or in house on floor.

Table1: shows that we had a total of 25 patients with a mean age of 67.2 years. Our mean operative time was 90.04 minutes with mean blood loss of 85.12 ml. We had operated all the patients within first two weeks of trauma with mean time between injury and operation being 4 days. All the patients were mobilized immediately on the next day of surgery so the recovery and rehabilitation was quick with mean postoperative stay in hospital being 16.64 days. Mean Harris hip score at 3 months follow up was 75.77 and 1 Year follow up was 81.24 respectively. Of 25 patients we had 20 % patients with excellent Harris hip score, 50% patients with good Harris hip score, 20% patients had fair and 10%patients had poor scores.

Table2: Show that postoperatively 3 patients had shortening of the operated limb so they were given a heel raise. They walked with the help of a cane. 1 patient had a shortening more than 2cm: he had a slight limp and used quadruple walker support while walking. Two patient had infection immediate foe which wound debridement was done. One patient had a periprosthetic fracture for which open reduction and plating was done.

Table 1: Demography variables- 25 cases

Table 2 : complications

Case 1: 65 year old female patient with history of slip and fall at home

Figure 1: pre-operative

 Figure 2: post-operative x ray

Figure 3: intraoperative picture

Placement of cemented stem to precise length after measurement of length by trail with help of scale, fixation of greater trochanter by tension band wire

Case: 2 60 year old male patient with history of slip and fall at home

Figure 4: preoperative x ray

Figure 5: post op x ray

Figure 6 : distribution of age

b

Figure 7: distribution of sex

Figure 8: distribution of operative time

Figure 9: distribution of blood loss

Figure 10: distribution of Harris hip score

Figure 11: distribution of functional outcome

Intertrochanteric fractures in elderly osteoporotic patients pose challenging problems, with risk of increased morbidity and mortality. Failure rates as high as 56% have been noted in association with unstable, comminuted fracture, suboptimal fracture fixations, or poor bone quality in elderly patients (8, 9). Internal fixation of such unstable and comminuted fractures may reduce the morbidity of pain, it does not permit an early mobilization with a fear of failure of fixation and thus, indirectly, the morbidity of fracture remains same .early ambulation following surgeries are important especially in elderly patients, for preventing complications that can be caused by long term immobilization in case of osteosynthesis specially in patients with poor general conditions.

Although union rates are report good in association with well reduced, stable fracture that were treated with ideal implant placements, but the poor mechanical properties of the weak and osteoporotic bones in elderly patient do not provide good purchase for the screws, which subsequently lead to an early biomechanical failure. This leads to collapse, with migration of the femoral head in varus and retroversion. Another complication of internal fixation is that implant (cephalomedullary screw) can be cut through from femoral head in case of osteosynthesis by PFN, which can lead to profound functional disabilities. (10, 11)

The comparison of internal fixation and hemiarthroplasty was done by Haentjens et al. showing a significant reduction in the incidence of pneumonia and pressure sores in those undergoing prosthetic replacement (12) Hemiarthroplasty patients were allowed full weight bearing significantly earlier than internal fixation patients. The Indian perspective regarding the use of primary arthroplasty as a modality of treatment for severe comminuted unstable intertrochanteric fractures is been commented on by few authors ;( 13, 14)

Hemiarthroplasty has been used for unstable intertrochanteric fractures .There are multiple studies showing good results using these techniques. Tronzo was the first to use long, straight stemmed prosthesis for primary treatment of intertrochanteric fracture (15). Liang et tal ., in their study which was done on unstable intertrochanteric fracture , concluded that hemiarthroplasty was effective and safe method for treating unstable intertrochanteric fracture in elderly, it leads to decrease in complication and mortality(16) Stern and Goldstein used the Leinbach prosthesis for the primary treatment of 22 AO/OTA Type 31A2.3 per trochanteric fractures and found early ambulation and early return to the pre fracture state as a definite advantage(17).primary arthroplasty provides adequate fixation and allows early mobilization and weight bearing thus reducing post operative complication Grimsrud et al. showed that AO/OTA Type 31A2.3 fractures can be safely treated with a standard femoral stem and cerclage wiring of both trochanter, the technique allows safe and early weight bearing on injures hip and has a lower rate of complication.(18,19)

Primary hemiarthroplasty in elderly with severe osteoporosis, fracture comminution , multiple comorbidities and reduced activities is reasonable option to gain early ambulation and prevent complication,(16,20) .Ozkayin et al and jolly et al found increased mobility and better outcome in hemiarthroplasty group in first 3 months , but better functional outcome at 1 year in fixation group,(21,22). Destelli studied in a lower age group and found better quality of life on fixation group at 2 years (23) other studies like park et al, Tang et al and kim et al found equal functional results at 1 year (2, 24, 25).A meta- analysis concludes that bipolar hemiarthroplasty has the advantage of immediate useful in frail patients with lower life expectancies. These patients have poor physical strength and could be less compliant to specific instructions and non-weight bearing (10)

Approaches to hip are usually posterolateral and lateral hardinge with lesser rate of dislocation associated with hardinge approach(26).Bombaci approach to hip is through the coronal fracture site allowing maintenance of posterior short external rotators and capsule, this reduces chances of dislocation and sciatic nerve injury(7). In this study we used transtrochanteric approach femoral neck entered through the coronally split greater trochanter without disturbing short external rotators followed by implantation with the cemented bipolar prosthesis and finally reconstruction of greater trochanter is an important step of surgery , for maintaining the stability of hip joint and in this study TBW was done in all the patients .

The infection rate post hemiarthroplasty varies from 2 to 17 %( 27) .In our study we had one postoperative infection, the patient was managed through debridement and IV antibiotics.

In our study all patients were advised for bed side sitting and quadriceps on day one and full weight bearing walking with the help of a walker on day 2. Dressing was done on post op day 2 and 5, patients were discharged post op day 7 and called up for sutures removal on day 14.

Ideally, surgeries are to be done within 48 hours in hip fractures to reduce mortality .In your study we had a delay of 72 hrs. to 96 hrs. On average mostly in view of patients co-morbidities and antiplatelet drugs. Delaying surgery to optimize the patient resulted in decreased mortality in 1 study.

Primary hemiarthroplasty offers a modality of treatment that provides adequate fixation and early mobilization in these patients, thus preventing postoperative complication. The cornerstone of management of such fracture is early surgery followed by mobilization.

Limitations:

Due to the small sample size and short follow up it was not possible to do an analysis on mortality in current study. This study also had too few patients for doing analyses on rare adverse effects such as dislocations, periprosthetic fracture and loosening of prosthesis.

Osteosynthesis with Dynamic hip screw fixations or intramedullary fixation are the most-commonly performed operations for intertrochanteric fracture of hip. These fractures are better treated with Cemented bipolar hemiarthroplasty through a trans-trochanteric approach that gives good results in a majority of elderly patients with unstable intertrochanteric fracture. Cemented hemiarthroplasty provides stable and mobile hip, it has advantage of an early ambulation as compared to the internal fixation. Also, the patient's rehabilitation is easy and fast.

DECLARATIONS:

Funding: No funding

Conflict of interest: No conflict of interest

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