Hemiarthroplasty for the Management of unstable femoral intertrochanteric fractures in elderly patients over 75 years old: a retrospective matched comparative study

Background Methods 45 patients with intertrochanteric fractures (17 males and 28 females) admitted to our hospital from January 2016 to January 2018 were collected. The mean age was 84.82 ± 0.73 years. All injuries were caused by falls during daily activities. Patients were divided into two groups according to the surgical method: the first group was the hemiarthroplasty group, referred to as the hemiarthroplasty group, with a total of 22 patients, and the average length of hospital stay was 13.09 ± 5.03 days. According to the improved Evans-Jensen classification [5], there were 1 cases of III, 9 cases of IV, and 12 cases of V12.The second group was the Proximal Femoral Nail Antirotation group, and the average length of hospital stay was 13.09 ± 6.97 days. According to the Evans-Jensen classification, 1 patient was III, 16 patients were IV, and 6 patients were V.


Abstract Background
To compare and analyze the therapeutic effect of Proximal Femoral Nail Antirotation and hemiarthroplasty on intertrochanteric fracture. Methods 45 patients with intertrochanteric fractures (17 males and 28 females) admitted to our hospital from January 2016 to January 2018 were collected. The mean age was 84.82 ± 0.73 years. All injuries were caused by falls during daily activities. Patients were divided into two groups according to the surgical method: the first group was the hemiarthroplasty group, referred to as the hemiarthroplasty group, with a total of 22 patients, and the average length of hospital stay was 13.09 ± 5.03 days. According to the improved Evans-Jensen classification [5], there were 1 cases of III, 9 cases of IV, and 12 cases of V12.The second group was the Proximal Femoral Nail Antirotation group, and the average length of hospital stay was 13.09 ± 6.97 days. According to the Evans-Jensen classification, 1 patient was III, 16 patients were IV, and 6 patients were V.

Results
Intraoperative blood loss was higher in the The Proximal Femoral Nail Antirotation group than in the hemiarthroplasty group(P=0.034).In the postoperative recovery of the two groups, the time from operation to partial weight-bearing of the hemiarthroplasty group was shorter than that of the PFNA group p 0.000 , and the postoperative HHS of the hemiarthroplasty group was also better than the latter (p 0.0005). In terms of total cost during hospitalization, the Hemiarthroplasty group was less than the PFN group(p 0.017). One year after surgery, the mortality rate increased to 34% in the PNFA group and 9% in the hemiarthroplasty group( P = 0.038), which was statistically significant.

Conclusion
Hemiarthroplasty for intertrochanteric fractures in the elderly can reduce intraoperative blood loss, achieve early recovery, improve survival rates, and reduce the economic burden on patients Background Intertrochanteric fracture is a common type of hip fracture (1). The patients are mostly elderly, and the risk and severity of fracture may increase with age.In recent years, with the aging population becoming more and more serious, the fracture rate caused by osteoporosis has also increased (2).After osteoporosis, bone trabecular thinning, sparse arrangement and partial fracture, bone cortex thinning and bone strength decreasing, the violent action of low energy can cause fracture (3), and once the intertrochanteric fracture occurs, comminuted fracture is easy to occur, resulting in instability at the fracture end.
The classification of intertrochanteric fracture is based on the morphology of the fracture, gradually formed the understanding of the fracture "stability". Evans's study (4), first published in 1949, divided trochanteric fractures into two main types based on fracture line orientation and whether fracture stability could be achieved and maintained through closed reduction and bone traction. In 1975, Jensen improved the Evans typing(5), namely, Evans-Jensen typing (Fig. 1), which was adopted by most scholars who studied intertrochanteric fractures in the future. This classification system believed that the fracture stability decreased with the increase of the number of comminuted fractures between the lesser trochanter and the greater trochanter. The classification of type I and type Ⅱ, for stable fractures Ⅲ ~ Ⅳ for unstable fracture. Because these patients are mostly elderly patients, most of them are associated with chronic diseases. After fracture, long-term lying in bed can cause pressure sores, falling pneumonia, urinary tract infection, pulmonary embolism and other complications, and even death in severe cases. Moreover, long-term lying in bed will further aggravate the loss of bone mass, making patients with osteoporosis worse and forming a vicious cycle. Therefore, most researchers believe that patients with unstable intertrochanteric fractures and osteoporosis who can endure surgery should be treated with surgery as soon as possible, so that patients can go to the ground at an early stage, recover their activities and self-care ability earlier, and reduce various complications caused by long-term bed rest (6,7).
At present, the surgical treatment methods for unstable intertrochanteric fractures include internal fixation and femoral head replacement, among which internal fixation includes dynamic hip screw, proximal femoral nail and proximal femoral locking plate. At present, there is still no unified conclusion on which surgical method can achieve the best curative effect. Studies have reported the application of proximal femoral intramedullary nails in the treatment of intertrochanteric fractures in patients with osteoporosis (8).As a classic treatment method, artificial femoral head replacement is also used in the treatment of unstable intertrochanteric fractures in patients with osteoporosis (9). In the treatment, bone cement type artificial femoral head replacement is often used, and the prosthesis is firmly fixed in the medullary cavity with the immediate mechanical fixation of bone cement, which also achieves good clinical results. Therefore, for complicated unstable fractures, it is of great significance to select appropriate surgical methods to promote early recovery, shorten bed time, reduce disability rate and mortality, and reduce postoperative complications.

Materials And Methods
Study population. 45 patients with intertrochanteric fractures (17 males and 28 females) admitted to our hospital from January 2016 to January 2018 were collected. The mean age was 84.82 ± 0.73 years. All injuries were caused by falls during daily activities. Patients were divided into two groups according to the surgical method: the first group was the hemiarthroplasty group, referred to as the hemiarthroplasty group, with a total of 22 patients, and the average length of hospital stay was 13.09 ± 5.03 days. According to the improved Evans-Jensen classification, there were 1 cases of III, 9 cases of IV, and 12 cases of V12.The second group was the PFNA group, and the average length of hospital stay was 13.09 ± 6.97 days. According to the Evans-Jensen classification, 1 patient was III, 16 patients were IV, and 6 patients were V. The data of patients in the two groups, such as gender, age, assessment score of admission daily living ability, length of stay, fracture to operation time and fracture type composition, are shown in the following table: Inclusion and exclusion criteria. After admission, all patients received traction fixation of lower limbs before surgery, and the relevant preoperative examination was improved. Through the assessment of the patients' physical condition, related complications were treated by consultation of internal medicine or related departments. After adequate preoperative preparation, the surgery was performed by the same group of experienced orthopedic surgeons under general anesthesia or combined lumbar and epidural anesthesia. hemiarthroplasty groups.
After the patient was in the lateral position, a posterolateral incision was made on the affected side of the hip joint, layer by layer incision was made to expose the joint capsule and the fracture, and the joint capsule was cut open to avoid damage to the joint capsule as much as possible. Femoral neck osteotomy was performed at the back of the femoral neck to expose the femoral head, then the femoral head was removed, the size of the trochanteric was retained, the broken bone mass of the trochanteric fracture was reduced, and the attachment point of the gluteus medius muscle was preserved. With the pulp cavity file, the pulp cavity reaming was performed, then the appropriate lengthened femoral stem prosthesis was selected, and finally the bone cement and lengthened stem prosthesis were inserted. After the bone cement solidified, the femoral head prosthesis test model was used to select the appropriate femoral head prosthesis, then the shaft and the femoral head prosthesis were fixed, and the trochanteric fracture block was fixed with Kirschner wire tension belt or steel wire, and then the joint was reset.Finally, the range of motion and stability of the joint were tested. If the surgical results were satisfactory, the wound was rinsed and the incision closed layer by layer. (Fig. 2) PFNA group.
After the patient is supine, fix the traction frame. The uninjured side outreaches, the affected limb flexes after traction, the pronation, the adduction, under the fluoroscopy adjustment to the satisfactory position. The proximal greater trochanter of the affected limb was incised through a straight incision about 4-6cm long, the skin, subcutaneous and deep fascia were incised, the gluteus medius muscle was obtuse separated, the tip of the greater trochanter was palpable, After lifting the greater trochanter by Steinmann Pin, the fracture was repositioned under fluoroscopy until satisfactory. The guide wire was inserted at the apex of the greater trochanter with the reduction maintained, the proximal medullary cavity was enlarged, and the proximal intramedullary nail was inserted. The positions were adjusted below the X-ray line, followed by the upper proximal antirotation blade and the distal locking nail. After the fracture reduction and internal fixation position were checked to be satisfactory, the incision was cleaned and sutured layer by layer.
Perioperative management. SPSS 25.0 statistical software was used. Measurement data were represented by `x ± s, and two independent samples t-test was used for inter-group comparison. The χ2 test was used to compare the enumeration data sets. P < 0.05 was considered statistically significant.

Comparison of intraoperative conditions
There was no significant difference in the operation time between the two groups, while the intraoperative blood loss in the hemiarthroplasty group was less than that in the PFNA group (P=0.034), and the intraoperative blood transfusion rate (the percentage of intraoperative blood transfusion patients in the group) in the hemiarthroplasty group was less than that in the PFNA group. By comparing the hemoglobin concentrations of the two groups at the time of admission and on the third day after surgery, no statistical difference was found in the changes in hemoglobin concentrations between the two groups. The results are shown in Table 2.

Postoperative recovery and discharge status
In the postoperative recovery of the two groups, the time from operation to partial weight-bearing of the hemiarthroplasty group was shorter than that of the PFNA group(p=0.000), and the postoperative HHS of the hemiarthroplasty group was also better than the latter (p 0.0005). In terms of total cost during hospitalization, the Hemiarthroplasty group was less than the PFN group(p 0.017). However, there was no significant difference in daily living ability score at discharge. The results are shown in Table 3.  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)(13)(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, 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. 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).

Conclusion
Hemiarthroplasty for intertrochanteric fractures in the elderly can reduce intraoperative blood loss, achieve early recovery, improve survival rates, and reduce the economic burden on patients.

Availability of data and materials
The datasets used/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate
This study was approved by the medical ethics committee of China-Japan Friendship Hospital. All procedures conducted in the study comply with the ethical standards of our institutional ethics committee. All participants in the study received informed consent. The above three pictures are all from an 83-year-old female patient with intertrochanteric fracture. A: the patient fell and caused the right intertrochanteric fracture. B shows good joint stability after hemiarthroplasty. C.:The patient was reexamined one year after surgery and the prosthesis had good function.