Intertrochanteric fractures often occur in the combination of osteoporosis in the elderly, as older patients often merge many medical conditions such as cardiovascular system, respiratory system, urinary system disease, if for intertrochanteric fractures without effective treatment as early as possible, often leads to various complications, these complications are likely to quality of life in elderly patients, and even a threat to life. Conservative treatment is mainly bed traction. Although conservative treatment avoids the impact of surgery on patients, long-term bed rest of elderly patients will lead to a series of complications, such as lung and urinary tract infection, lower limb deep vein thrombosis, pulmonary embolism, etc., and long-term braking will aggravate osteoporosis, muscle atrophy, joint stiffness, etc. If not effective braking traction, fracture healing may result in hip varus, malunion, lower limb shortening, etc. In a word, conservative treatment for elderly patients with intertrochanteric fracture of the femur, its advantages are not greater than its long-term disadvantages. At present, surgical treatment has become a priority treatment method for elderly intertrochanteric fractures. The incidence of complications and length of hospital stay of surgical treatment for intertrochanteric fractures are far lower than that of conservative treatment. Currently, the main surgical methods for intertrochanteric fractures are internal fixation and hemiarthroplasty.
PFNA is the most commonly used internal fixation technique. PFNA is developed on the basis of Proximal Femoral Nail (PFN) for patients with osteoporosis, which makes up for the deficiency of PFN and reduces the rate of screw resection in patients with osteoporosis(11). Compared with other internal fixation methods, PFNA has advantages of short operative time, small trauma, low blood loss and fast postoperative recovery(12–14).Some scholars believe that PFNA is suitable for most senile osteoporotic intertrochanteric fractures(15). PFNA fixation of intertrochanteric fractures has significant advantages in mechanical principle and anti-rotation function (16), which is currently the most widely used fixation method. However, with the increase in the number of cases of PFNA surgery, the number of cases of fixation failure is also gradually increasing. Some studies have shown that PFNA treatment for intertrochanteric fractures has a failure rate of 5%~30%(17, 18). The reasons for failure may be related to the patient's bone density, fracture type, surgical skills, internal fixation selection, postoperative functional exercise, etc. When internal fixation fails, most orthopedic surgeons resort to arthroplasty. However, this kind of secondary surgery is not a small burden for patients, either physically or financially. With the development of artificial joint replacement technology, more and more reports have been reported on the direct treatment of intertrochanteric fractures. Artificial joint replacement mainly includes total hip replacement and hemiarthroplasty. In view of the elderly's activity level and surgical trauma, arthroplasty for elderly patients with intertrochanteric fractures is mostly hemiarthroplasty, and bipolar femoral head replacement is more commonly used. Compared with total hip replacement, hemiarthroplasty has the advantages of short operation time, less bleeding and less cost. However, patients with pure femoral head replacement may suffer from discomfort caused by acetabular wear. Some scholars prefer total hip replacement as a revision operation after failure of internal fixation(19).Some scholars believe that there is no significant difference between the two in postoperative complications, length of hospital stay, degree of hip pain and mortality (20).Cement-type hemiarthroplasty and reconstruction of proximal femoral structure can obtain immediate bone tissue and joint stability, which is conducive to the rapid recovery of patients and the reduction of disability rate and mortality, especially for unstable fractures. Some scholars also believe that joint replacement surgery is long, the amount of blood loss, postoperative infection and dislocation and other complications are high. A randomized prospective study of Stappaerts(21) compared the efficacy of internal fixation with artificial joint replacement: 90 patients aged ≥ 70 with fresh unstable intertrochanteric fractures, 47 with internal fixation, and 43 with artificial joint replacement. After 3 months of follow-up, there was no significant difference in operative time, mortality, and complications between the two groups, but the hemiarthroplasty group had more blood transfusion, while the internal fixation group had 11 cases of severe fracture displacement and collapse, requiring a second operation, while the hemiarthroplasty group only had 1 case requiring a second operation. Leonardsson(22) reported that 450 patients over 70 years of age with intertrochanteric fractures from 1995 to 1997 were randomly divided into the internal fixation group and the hemiarthroplasty group. After 10 years of follow-up, the failure rate of the internal fixation group was 45.6%, while that of the hemiarthroplasty group was 8.8%. They believed that the primary replacement could provide long-term reliable fixation effect for displaced intertrochanteric fractures.
In this study, hemiarthroplasty group of patients with intraoperative blood loss and rate of intraoperative blood transfusions are lower than PFNA group, the author thinks that with the continuous development of joint replacement technology, orthopedic surgeons to improve surgical skills in order to shorten the operation time, as well as sufficient preoperative preparation and intraoperative reduce bleeding, traditional ideas think hemiarthroplasty blood loss than PFNA may change. In terms of operation time, no significant statistical difference was found between the two in this study. Previous studies suggested that hemiarthroplasty would take longer than PFNA operation time. Considering that most patients with intertrochanteric fractures are old, the extension of operation time may increase the risk brought by the operation. However, with the development of artificial joint replacement, the time of hemiarthroplasty performed by experienced orthopedic surgeons is even shorter than that of PFNA. Therefore, the idea that longer duration of joint replacement surgery brings higher surgical risk to patients deserves further investigation.
In terms of functional recovery after operation, the advantages of artificial femoral head in the treatment of intertrochanteric fractures are more obvious. The time from the end of the operation to the movement of the patients under partial load was significantly shorter in the displacement group than in the PFNA group (P < 0.01).Artificial femoral head prosthesis, especially bone cement prosthesis, can penetrate into bone trabeculae, strengthen cancellous bone and obtain better endurance performance. After the bone cement solidifies, the two form micro-locking fixation, so as to strengthen the bone strength and achieve stable bone support. In addition, in patients with osteoporosis, the fixation strength can be increased to obtain immediate mechanical stability, reduce local stress and load early. The tolerance of doctors' technical deviation and bone quality is improved, and PFNA defects such as poor stability, fracture of prosthesis and difficult bone growth are avoided. Getting out of bed early after surgery can prevent various complications caused by long-term bed-rest in the elderly, so that the quality of life of the elderly can be significantly improved. In addition, complications after femoral head replacement are relatively few, thus avoiding the harm of the second operation on the patients. PFNA, on the other hand, has a higher rate of surgical failure, complications and surgical failure often require secondary surgery or salvage joint replacement, but it can not bring or bring greater benefits. Elderly patients may die of surgical complications such as pulmonary embolism caused by deep vein thrombosis and pneumonia caused by long-term bed rest. Harris scores in both groups at discharge,hemiarthroplasty group was higher than PFNA group, indicating that the hemiarthroplasty group was superior to the PFNA group in terms of the degree of hip pain relief and the degree of hip movement improvement. However, considering the problems of acetabular wear and other aspects in hemiarthroplasty, long-term postoperative follow-up is still needed to compare the improvement degree of objective feelings of patients in the hip caused by these two surgical methods, which is a deficiency of this study.
In conclusion, our study indicates that the hemiarthroplasty performed by doctors with mature joint replacement technology for such patients has relatively less intraoperative blood loss than PFNA for intertrochanteric fractures. In terms of operation time, although there was no significant statistical difference, the average operation time of the hemiarthroplasty group in this study was relatively short, which may be more obvious with the expansion of sample size. In terms of postoperative recovery, for elderly patients, early underground activities are crucial to reduce complications and improve the quality of life of patients. The movement time of partial weight-bearing patients in the hemiarthroplasty group was earlier than that in the PFNA group, and the Harris score of hip joints in the hemiarthroplasty group before discharge was also higher than that in the PFNA group. Therefore, for elderly patients with three or more intertrochanteric fractures, hemiarthroplasty can shorten the length of hospitalization and recovery time, and reduce the economic burden of such patients(23, 24).