Due to the aging of the population, the number of elderly patients with ITFs is increasing gradually. Elderly ITFs patients have difficulties to return to prefracture function levels and display poor treatment results because of low bone quality, additional morbidities, and mobilization problems. An ideal surgical technique for elderly ITFs patients should be less trauma and postoperative complications. However, it is still unclear whether BPH or PFNA is the better choice for elderly ITFs patients. Thus, our study was initiated to compare the PFNA and BHA groups and to help orthopedic surgeons to choose a suitable implant to fix ITFs in elderly patients.
As a minimally invasive procedure, PFNA offers the advantages of micro-trauma, minimal bleeding, and short operation times. PFNA nails not only reduces movement, sliding compression but also increases the anti-rotation screw, which significantly enhances the anti-rotation, anti-compression, and anti-tension abilities of the fracture end, increases the stability of the fracture end. Thus, PFNA is particularly suitable for elderly patients with the poor bone condition, which minimizes the risk of medical complications.
In our results, the PFNA group has less blood loss, but longer operating time than BHA, which is different from the previous literature. The patients in our study have severely comminuted fractures, so intraoperative closed traction reductions take longer time. Besides, a lot of intraoperative fluoroscopies are used, to avoid intraoperative complications, such as the internal fixation point explosion, needle’s cut-off from the medial wall of femur, the separation of the end of fracture, etc. Although PFNA has been selected by most surgeons for elderly ITFs patients[15–17], failures of PFNA have also been reported due to extensive comminution, osteoporosis, or long bedridden duration. PFNA complications include cutout of the femoral screw, breakage of the nail, Split of the lateral cortex of the proximal femur, and fracture of the femoral shaft. In our results, two patients cutout the femoral head, eight patients split of the lateral cortex of the proximal femur, and fracture of the femoral shaft, these may be related to comminution fracture and osteoporosis.
BHA, which is advantageous in terms of operation time and allowing early weight-bearing, was first used in 1978 and subsequently used by other surgeons for ITFs treatment with satisfying results, has been suggested as an alternative method for elderly ITFs patients[7, 20]. BHA is recommended as a prior treatment for ITFs with poor stability in the elderly with severe osteoporosis, poor prognosis after internal fixation, and a short life expectancy. Long-stem cementless prosthesis is conducive to biological fixation and can prevent cardiovascular toxicity caused by bone cement. Our study indicates that the use of long-stem cementless prosthesis can relieve pain, restore ambulatory function, provide long-term stability of the implant, and is associated with fewer complications in ITFs of elderly patients.
PFNA offers the advantages of micro-trauma and minimal bleeding, while patients who were treated with BPH can begin functional exercise earlier. However, long-term follow-up results reflect that both procedures can reduce postoperative bedrest-related complications, obtain reliable fixation, relieve patients’ pain, and significantly improve patients’ quality of life. The amount of intra- and postoperative early bleeding was significantly higher in patients undergoing BHA. However, problems such as postoperative early weight-bearing loss and more radiation are encountered with the applications of PFNA[22, 23].
This study reveals that the volume of blood loss in the PFNA group was significantly lower than those of the BHA group (P < 0.05), and the operating time in the BHA group was significantly shorter than that of the PFNA group (P < 0.05). The average hospital stay, Harris score, and postoperative complications had no significant differences between the two groups (P > 0.05).
The benefit of early weight-bearing doesn't advantage elderly patients to recover from our BHA group. Effects of early weight-bearing on postoperative recovery for fractures in BHA are generally publicized. But after the physical injury by fracture, the elder patients have the psychological barriers to do exercises. Avoiding falling again, the elderly patients just stand around the bed, extend the knee and hip joints mildly. Correspondingly, the early weight-bearing shows limited effect in the BHA group.
There were several limitations in our study. Firstly, it was a retrospective controlled study. Although the patient groups appeared similar, patients were not randomly assigned to the groups. Secondly, some patients were excluded due to a lack of follow-up. This exclusion also procures the mortality and morbidity rates of the study decreased. Lastly, study groups could not be selected according to each fracture type in the Evans-Jensen classification.