Short-term effect of lengthened shank semi-hip replacement combined with wire ligation in the treatment of unstable intertrochanteric fracture of femur in elderly patients

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Short-term effect of lengthened shank semi-hip replacement combined with wire ligation in the treatment of unstable intertrochanteric fracture of femur in elderly patients

https://doi.org/10.21203/rs.3.rs-2592989/v1

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[Objective] To investigate the short-term clinical effect of femoral lengthening biological stem half-hip replacement combined with large or small rotor reduction wire loop reconstruction in the treatment of unstable intertrochanteric fracture of the femur in the elderly.

[Methods] Thirty patients with unstable intertrochanteric fractures of the senile femur were treated by WangnerSL double-action head and half hip replacement with biological extension stem in the Second Affiliated Hospital of Bengbu Medical College from June 2018 to July 2021. The operative time, intraoperative blood loss, postoperative complications, and so on were recorded. VAS and hip Harris scores were used before surgery and 3 and 12 months after surgery. Hip radiographs were reviewed 1 week, 3, 6, 12, and 18 months after surgery to observe whether the prostheses were loose or sinking, and hip function was assessed.

[Results] All the operations were completed in this group. The average follow-up time was (12.5±6.5) months. Hip joints were stable after surgery, and no complications such as infection, dislocation, and loosening occurred. The Harris score rate was 83.3%, and the VAS score and Harris score showed a significant statistical difference.

[Conclusion] In the treatment of unstable intertrochanteric fracture of the elderly femur, femoral lengthening biological stem half-hip replacement combined with large or small rotor reduction wire ligation can shorten the bedtime of patients, promote the functional recovery of hip earlier, reduce the occurrence of bed complications, the clinical efficacy is satisfactory, and has good clinical application value.

intertrochanteric fracture of the femur

extended stalk

joint replacement

wire

complications

trochanter

and trochanter

Intertrochanteric fracture of the femur refers to the proximal fracture of the femur involving the large or small trochanteric fracture of the femur [1], also known as intertrochanteric fracture of the femur, which is a common fracture type among elderly orthopedic patients, accounting for 3.6% of total limb fractures [2] and 48% of hip fractures [3], and increasing by 1%-3%. It is more common in the elderly over 65 years old, often accompanied by serious osteoporosis and a variety of serious medical diseases, and the choice of treatment is often difficult [4]. Currently, the main treatment option is internal fixation, represented by intramedullary nailing at the proximal end of the femur. However, for elderly patients with unstable intertrochanteric fractures of the femur, intramedullary nailing is prone to difficult reduction, unstable fixation, longer bedtime, and restricted hip joint activity. In this way, a vicious cycle is formed. Patients will suffer from increased osteoporosis, internal fixation loosening, coxa varus, bone non-union, etc. [5], and even internal fixation fracture, internal fixation cutting out the femoral head and wearing the acetabulum, etc., which requires a secondary operation. The mortality rate of complications in these patients is relatively high, which can reach 20%[6]. With the development of China's economy and medical treatment, the proportion of the elderly is increasing in the whole society. Patients can recover quickly and return to normal social and family life as soon as possible. The ultimate goal of treatment is to enable elderly patients to obtain stable and painless hip joints with good function. The extended shank artificial half hip joint can bear the load-bearing axial load of the human body, increase the mechanical strength of the hip joint, and enable patients to get out of bed as soon as possible after surgery [7], which conforms to the current concept of rapid rehabilitation and is a better choice [8]. From June 2018 to July 2021, we selected WangnerSL double-action head and half hip replacement with a biological extended stem for the treatment of unstable intertrochanteric fracture of the femur in elderly patients. Patients could get out of bed early and reduce bed complications [9], and the clinical effect was satisfactory. The report is as follows:

1.1 General treatment

Inclusion criteria:(1) Over 80 years old, can complete the interview;(2)Evans-Jensen: Ⅱ-Ⅲ;(3) Normal acetabulum development, no related hip disease, eligible for semi-hip replacement;(4) Can walk independently before the injury, lower limb muscle strength and muscle tone are normal;(5) Closed fracture, injury time less than 3 weeks;(6) Patients and their families actively request surgery patients.Exclusion criteria:(1)Evans-Jensen༚Ⅰ༛(2) Patients with related hip diseases requiring total hip replacement;(3) Unable to complete the interview;(4) patients with serious internal diseases who cannot tolerate surgery;(5) Brain-related diseases: abnormal muscle strength and tone of lower limbs;(6) Patients with fractures in other parts;(7) Open fracture or injury longer than 3 weeks. This study included 30 patients, including 13 males and 17 females, with an average age of 86.5 years, all of whom were unilateral. According to Evans-Jensen, there were 7 cases of type Ⅱ (4 cases of type Ⅱ A, 3 cases of type Ⅱ B) and 23 cases of type Ⅲ. According to the Singh index, there were 6 cases of type Ⅲ, 11 cases of type Ⅳ, and 13 cases of type Ⅴ. There were 22 cases of hypertension, 18 cases of diabetes, 14 cases of cerebral infarction, 11 cases of coronary heart disease, 14 cases of pulmonary heart disease, 9 cases of liver insufficiency, and 10 cases of renal insufficiency. All cases in this group were high-risk and risky operations, which were reported to the medical department. Patients and their families signed informed consent after fully understanding the situation.

1.2 Surgical Methods

1.2.1 Preoperative preparation

After admission, patients can undergo subcutaneous traction of the affected limb, routine X-ray (FIG. 1), three-dimensional CT of both hip joints (FIG. 2), arteriovenous color ultrasound of both lower limbs, electrocardiogram, chest X-ray examination, cardiopulmonary function examination if necessary, consult relevant departments for patients with cardiopulmonary and brain diseases, and operate after stabilizing the medical disease. Generally, the operation will be completed 3–4 days after admission. Antibiotics and tranexamic acid sodium chloride injection 100ml (100ml containing tranexamic acid 0.5g sodium chloride 0.84g, trade name: Berinine) were administered once every 30 minutes before surgery, and tranexamic acid was reapplied once during the operation.

1.2.2 Surgical method

General use of lumbar epidural anesthesia, healthy lateral position, pay attention to maintaining the standard lateral position.

Conventional disinfection and towel were applied. A conventional posterolateral approach is taken, with the apex of the greater trochanter as the center, with an arc incision of about 45°, about 10–15 CMS in length. The skin, subcutaneously, tensor fascia lata and gluteus maximus are cut layer by layer to protect the superior gluteus nerve and sciatic nerve, and the insertion of the superior and inferior gemellus piriformis muscle at the greater trochanter is cut. Attention should be paid to protecting the continuity of gluteus medius in the trochanter and the bone mass in the greater trochanter as far as possible without displacement. Meanwhile, attention should be paid to protecting the bursae and periosteum around the large and small trochanter, to protect its "cuff" -like effect and avoid exposing large bone mass. After rough reduction, the position of the lesser trochanter can be distinguished. The femoral neck is truncated vertically with the long axis of the femoral neck at 1-1.5 cm on the lesser trochanter. The femoral head and part of the femoral neck are removed, each bone block is preserved as far as possible, and part of the joint capsule and the round ligament are removed. Depending on the condition of the large and small trochanter fracture, the decision should be made whether to use wire loop reconstruction or implant the prosthesis before fixation. After rough reduction, the opening position and the inclination Angle were determined, and the inclination Angle was kept inward at the apex of the greater trochanter, and the marrow was gradually expanded from small to large. An appropriate femoral bioprosthesis stem was selected for implantation, and the fracture was reduced, especially at the femoral moment. 2–4 1.2 steel wires were bound (Fig. 3), and the fracture reduction situation was understood by C-arm X-ray (Figs. 4 and 5). The appropriate double-acting head was selected according to the size of the femoral head, and the appropriate length of the femoral neck was selected according to the height of the greater trochanter vertex and the center of the femoral head, and the length of the lower limbs. The femoral neck and double-acting head were installed, followed by reduction, hip stability evaluation, irrigation, drainage tube placement, and layer-by-layer compliance. The dressing is fastened and the elastic bandage is gradually wound from the toe to the base of the thigh.

1.3 Postoperative Management

Antibiotics should be used for 1–3 days after surgery to prevent infection. Changes in vital signs should be paid attention to. The amount of fluid replenishment should generally be controlled at 1000-1500ml, and the speed of fluid replenishment should be controlled. Immediately after surgery, the patient was taught isometric lower extremity contraction exercises and ankle pump exercises, multi-mode analgesia. If the patient does not vomit, starts to drink water and eat easily digestible food 2 hours after the operation, and generally does not have a blood transfusion after the operation, and recheck blood cell analysis 6 hours after the operation. If the patient with severe anemia has an appropriate blood transfusion according to the specific situation, low molecular weight heparin anticoagulation should be used starting 12 hours after the operation. The drainage tube was removed within 24–48 hours, and plain radiographs of both hips (Fig. 6) and anteroposterior and lateral radiographs of the unilateral hip joint (Fig. 7, 8) were reexamined after the drainage tube was removed. The patients walked with partial weight on the bed crutches 3–4 days after surgery, abandoned crutches and walked 3–4 weeks after surgery, and were followed up in the clinic for 2 weeks and 3 months.

1.4 Evaluation indicators and statistical methods

The operative time, intraoperative blood loss, and postoperative complications were recorded. VAS and hip Harris scores were used before and 3 months after surgery. Hip radiographs were reviewed 1 week, 3, 6, 12, and 18 months after surgery to observe whether the prostheses were loose or sinking, and hip function was assessed. Femoral stem stability was assessed using Ength criteria [10]. Any progressive subsidence > 3mm, change in stem position, continuous penetrating line > 2mm, or the widening of the femoral bone marrow cavity are considered unstable. The SPSS22.0 statistical software was used to analyze the data, which was consistent with the normally distributed dose data. Mean ± standard deviation (X-±S) and paired T-test was used. P < 0.05 was considered statistically significant. width > 2mm, or widening of femoral bone marrow space was considered unstable.

All the operations were completed in this group. The operation time was 90-185min, with an average of (120.5 ± 20.1)min. Intraoperative blood loss was 600-1100ml, with an average of (800.5 ± 128.4)ml; Postoperative pulmonary infection occurred in 3 cases, heart failure in 3 cases, new cerebral infarction in 1 case, deep vein thrombosis in the lower limb in 1 case, all of which were significantly improved after consultation and treatment by relevant departments. The mean follow-up time was (12.5 ± 6.5) months, and the hip joints were stable without complications such as infection, dislocation, and loss of joints. The Harris score was excellent in 8 cases, good in 17 cases, fair in 4 cases, and poor in 1 case, with an excellent and good rate of 83. 3%.Preoperative VAS score (7.5 ± 0.4), postoperative VAS score (2.5 ± 0.3), postoperative VAS score (1.3 ± 0.2), postoperative VAS score (1.3 ± 0.2), and postoperative VAS score (t = 20.94, P = 0. 00;t = 26.24, P = 0. 00) 12 months after surgery. Harris score before surgery (34.8 ± 2.3), 3 months after surgery (61.4 ± 6.5), and 12 months after surgery (84.3 ± 2.2), the difference between postoperative and preoperative Harris score was statistically significant (t = 15.86, P = 0.12 months after surgery t = 35.64P = 0. 00)( Table 1, Table 2)

Table 1

Comparison of VAS and Harris scores 3 months before and after surgery
	VAS	Harris
preoperative	7.5 ± 0.4	34.8 ± 2.3
Postoperative (3 months)	2.5 ± 0.3	61.4 ± 6.5
t	20.94	15.86
P	0.00	0.00

Table 2

Comparison of VAS and Harris scores 12 months before and after surgery
	VAS	Harris
preoperative	7.5 ± 0.4	34.8 ± 2.3
Postoperative (12 months)	1.3 ± 0༎2	84.3 ± 2.2
t	26.24	35.64
P	0.00	0.00

Intertrochanteric fracture of the femur occurs mostly in the elderly and is an extraarticular fracture. Patients are often elderly patients with medical diseases and osteoporosis [11], and bone density is mostly lower than − 2.5. Fractures in this part are mostly comminuted and accompanied by destruction of the lateral wall of the femur and femoral moment, and unstable fractures account for 50%-60%[12]. Due to the high mortality rate of patients treated with conservative treatment, surgical treatment is currently regarded as the preferred treatment method [13] to reach a consensus, but it is difficult to obtain an ideal therapeutic effect [14]. The main objective of treatment is to get patients out of bed as soon as possible without pain if conditions permit. Currently, there are two main types of internal fixation: (1) intramedullary fixation, represented by PFNA, and (2) extramedullary fixation, represented by DHS and PFLCP. Intramedullary fixation is more reliable than extramedullary fixation, but it is difficult to reconstruct the lateral wall of the proximal femur. Due to the existence of osteoporosis, internal fixation control is not enough, and rigid fixation of internal fixation is prone to cutting and loosening, loss of reduction, coxa varus, bone nonunion and other complications [15]. It has been reported that the postoperative failure rate of unstable intertrochanteric fracture of the femur is 6–32%[16], and the repair rate is high due to internal fixation cutting or bone nonunion [17]. Patients with unstable internal fixation need to stay in bed for 4–6 weeks or even longer, resulting in an increased chance of bed complications, osteoporosis, a significant increase in the probability of partial loss of hip function, and a significant increase in the probability of reoperation after internal fixation failure. For unstable intertrochanteric fracture of the femur in osteoporosis patients, the focus is not on reduction and fixation, but on how to enable patients to obtain a well-functioning, stable, and painless hip joint as soon as possible [18], to enable patients to get out of bed as soon as possible, reduce various complications, improve quality of life and prolong lifetime. Although hip replacement is not the gold standard for the treatment of intertrochanteric fracture of the femur, it has a higher rate of excellent hip function after hip replacement [19], which is a better choice and an effective remedy for the failure of PFNA and other internal fixation in the treatment of an intertrochanteric fracture. Some studies suggest that hip replacement with an extended shank is an important treatment method for intertrochanteric fracture of the femur, especially for patients with osteoporosis[20].

In this group of patients, all of them were elderly patients with osteoporosis, large and small trochanteric fractures were displaced, and common femoral head replacement was proximal stable, with difficulty in fixation and easy instability. Femoral stalk extension was an ideal choice, which not only increased the length of the stalk but also increased the contact area in the medullary cavity. The fixation principle of the extended stem of the femur is mainly based on the stability of the distal femur, which has little relation with the defects of the internal and external walls of the proximal femur. The extended stem is shaped like a vertebral column and located in the femoral bone marrow, acting as an "intramedullary nail" in the proximal femur, which spans the femoral stenosis and reaches the anterior wall of the anterior arch of the femur at the farthest end. As the patient gets out of bedtime, the effect of axial gravity of the body, Mechanical stability will become more and more stable, as bone growth can achieve long-term stability. It has been reported that the efficacy of joint replacement in the treatment of unstable intertrochanteric fractures of the elderly femur is comparable to PFNA [21], but after joint replacement, it is more conducive for patients to get out of bed early and walk with weight, and the bedtime is short, which can reduce the possibility of bed complications. The hemihip of the femur with an extended stem can withstand the axial load of the human body when it is loaded, increase the mechanical stability of the hip joint, meet the biomechanical requirements, and enable patients to bear weight earlier after surgery. In this group of cases, we generally removed the drainage tube on the second day after surgery and asked the patient to walk with the crutches after rechecking the X-ray film on the third day after surgery.

Main difficulties and matters needing attention in this group of operations:(1) Fixation of large and small trochanters, reconstruction of the femoral moment, selection of femoral neck length, and control of gluteal medius tension. Joints with good motion mainly depend on mechanical stability in the early stage and biological stability of bone insertion in the middle and late stages. Although the extended shank is the primary stabilizing structure located distal to the prosthesis, proximal reconstruction is also important for the primary reason of increasing prosthesis stability after proximal fracture healing. Proximal reconstruction affects muscle tone around the hip joint, especially in the gluteus medius. The order of reduction and fixation of the large and small trochanter and femoral moment and the insertion of the extended shank may vary from person to person. Although large and small trochanteric comminuted fractures are evident, residual fracture reduction is often indicated and simple reduction is given, especially for greater trochanteric reduction. After reduction, the shaft was reamed and implanted. Before the implantation of the true shaft, the penetration depth of the test mold and the length of the femoral neck were determined according to the height relationship between the apex of the greater trochanter and the center of the femoral head, the length of the lower limb and the joint tightness. If necessary, a C-arm machine can be used to understand the implant situation. The real shank was implanted according to the implantation condition of the trial mold, and the length of the lower limb and joint tightness were judged again. Generally, the joint is tight after implantation, indicating that the implantation depth of the prosthesis is not enough. The proper depth of the true stem can be driven according to the judgment situation, and then the fluoroscopy of the C-arm machine can be determined. The soft tissue around the bone block was protected. After the dislocation of the hip joint, 2–4 1.2 wires were strapped and fixed according to the situation of the fracture block. (2) Control of front Angle and neck trunk Angle. The control of the cervical stem Angle is relatively easy. The cervical stem Angle of the half-hip joint is set. During the operation, the main control is to prevent internal and external hip joint inversion. Our experience was to control the placement of the stem in the center of the medullary space at the time of implantation. Attention should be paid to the control of the anterior inclination during the whole process from medullary reaming to true stalk implantation. Before medullary reaming, the position of the residual femoral moment and the lesser trochanter should be identified and roughly reduced to facilitate the control of the direction of the anterior inclination. During the operation, the lesser trochanter and the femoral moment can be first bound if necessary according to the specific circumstances. (3) Control of lower limb length. It is mainly to control the implant depth of the prosthesis stem and the length of the femoral neck. It is mainly based on the relationship between the apex of the greater trochanter and the center of the femoral head, the relationship between the apex of the medial malleolus and the tubercle of the tibia in the standard lateral position, and the judgment of joint tightness. (4) Routinely prepare bone cement stalks to prevent accidents during the implantation of biologically elongated stalks.

Disadvantages of this type of surgery include:(1) The operation is difficult, the technical requirements are high, and the operation time should be shortened as far as possible. (2) The surgical procedure has high requirements for anesthesiologists. (3) Intraoperative blood loss should be controlled, and the possibility of implicit bleeding after PFNA is less. (4) It is difficult to repair. (5) prosthesis sinking may occur in late fracture nonunion.

To sum up, In the treatment of unstable intertrochanteric fracture of the elderly femur, the treatment can shorten the bedtime of patients, promote the functional recovery of hip joints earlier, and reduce the occurrence of bed complications. The clinical effect is satisfactory and has good clinical application value.

Acknowledgments

Funding: This work was supported by the Anhui Provincial University natural science research project (key) subject, number: KJ2021A0756.

Authors’ contributions

LY conceived and designed the study and wrote the manuscript.HT revised the manuscript and submitted it.YL, XZ, JB, and ZZ performed the research. HT, WZ, and YL collected clinical data and performed the statistical analysis. All authors provided feedback and contributed to shaping the research, analysis, and manuscript.

Funding

This study was supported by the Anhui Provincial University natural science research project (key) subject, number: KJ2021A0756.

Availability of data and materials

The datasets used and/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 ethics committee of the Second Affiliated Hospital of Bengbu Medical College (Ethics approval number: No. [2022] 159). All methods were performed in accordance with the relevant guidelines and regulations. Written informed consent was obtained from all individual patients included in the study.

Consent for publication

Not Applicable.

Competing interests

The authors declare that there are no conflicts of interest regarding the publication of this paper.

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No competing interests reported.

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Short-term effect of lengthened shank semi-hip replacement combined with wire ligation in the treatment of unstable intertrochanteric fracture of femur in elderly patients

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