Treatment of intertrochanteric fractures in geriatric patients with a modified external fixator

Injury, Int. J. Care Injured (2005) 36, 635—643

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Treatment of intertrochanteric fractures in geriatric patients with a modified external fixator Yilmaz Tomaka,*, Mehmet Kocaoglub, Ahmet Piskina, Cemil Yildizc, Birol Gulmana, Leman Tomakd a

School of Medicine, Department of Orthopaedics and Trauma Surgery, Ondokuz Mayis University, 55139 Kurupelit-Samsun, Turkey b Istanbul School of Medicine, Istanbul University, 34390 Capa-Istanbul, Turkey c Gulhane Military Hospital, Department of Orthopaedics and Trauma Surgery, 06100 Ankara, Turkey d School of Medicine, Department of Public Health, Ondokuz Mayis University, 55139 Kurupelit-Samsun, Turkey Accepted 11 October 2004

KEYWORDS Intertrochanteric fractures; External fixation; Internal fixation; Closed reduction; Dynamic hip screw; Gamma nail; Osteoporosis; Ilizarov

Summary Forty-two geriatric patients who had an intertrochanteric fracture were treated with a semicircular modification of the Ilizarov frame designed by Cattaneo and Catagni between January 1997 and September 2001. Twenty-five of the patients were female, 17 male. The average age of the patients was 77.5 years (range, 63—99). No intraoperative complication occurred. Deep pin-track infection was found in four patients and varus deformity was observed in two patients and shortening of less than 2 cm in 10 patients. Fixator removal was achieved in a mean time of 12 weeks (range, 10—18). No implant failure, refracture or stiffness of knee and hip joint movements was recorded. We concluded that the treatment of intertrochanteric fractures of the elderly patients with our modification provides significant advantages such as minimal operative and anaesthetic risks, no blood loss, early weight-bearing, short hospitalisation time and rapid union time. # 2004 Elsevier Ltd. All rights reserved.

Introduction Hip fractures, a significant cause of morbidity and mortality in the elderly, are expected to show an exponential increase in frequency over the next * Corresponding author. Tel.: +90 362 4576000/2361; fax: +90 362 4576041. E-mail address: [email protected] (Y. Tomak).

50 years as a result of increased life expectancy and rate of osteoporosis. The overall cost of hip fractures includes not only death and illness, but also the costs of medical and social care, functional limitations, reduced life quality, loss of independence, and inability to work, as well as other factors that are difficult to assess, most notably the indirect effect of the hip fracture on the spouse or family members responsible for care.24 The treatment of choice for intertrochanteric fractures in geriatric patients is surgical because

0020–1383/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.10.013

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non-operative treatment almost always involves high morbidity and mortality compared to surgical treatment.7,20 The aim of treatment in the geriatric patients should be to apply a surgical method that achieves minimal surgical blood loss, short operative and hospitalisation time, minimal anaesthetic risk, the least morbidity and mortality rates and early weight bearing by using a stable fixation.

There are reports of closed reduction and external fixation.3,4,6—9,16,21,22 But we could not find any reports in the English literature of using the semicircular modification of the Ilizarov external fixator for intertrochanteric fractures of elderly patients. We evaluated the efficacy of the modified external fixator in the treatment of elderly patients who had sustained an intertrochanteric fracture.

Table 1 Details of 42 patients who had treated with modified external fixator Case Age Sex Systemic disease

Anaesthesia HsT FRT Complication Follow-up Cause of Fracture OT (min) type (days) (weeks) (years months) fracture typea

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Fallen Fallen Fallen Fallen TA Fallen Fallen Fallen TA Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen TA Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen Fallen

74 86 99 94 63 72 77 75 69 78 81 87 77 71 71 76 79 75 65 82 91 72 77 73 79 80 75 73 84 79 70 78 70 77 73 79 78 74 75 81 78 90

F F F M M F F F M M F F F F F F M M M F F M F F M F M F M F M M F M M M F M F F F F

COPD DM + HT DM + SD CD None CD CD CD None SD + DM + CD DM DM + HT COPD + HT HT HT DM + HT DM + COPD + HT None DM SD + DM SD None SD + DM None CD COPD lung cancer + HT None DM + COPD COPD HT + CD HT + DM HT CD None CD SD + DM None None CD + SD CD + DM COPD + DM

U U U S U S S S S U S S U S S U U S U U S S S S U S S S U S S U S S S S U S S U U U

45 50 70 35 60 40 45 35 30 75 40 40 45 35 35 45 50 30 45 40 35 30 30 40 55 40 35 35 40 30 50 35 40 40 45 40 50 30 45 30 30 35

Epidural Local Local Local General Epidural Local Local Epidural Local Local Local Epidural Epidural General Local Local Local General Local Local Epidural Local Epidural Local Local Local Epidural Local Local Epidural Local Local Local Local Local Local Local Local Local Local Local

9 10 12 8 6 7 9 8 6 14 8 10 8 7 8 11 8 7 9 8 7 5 7 5 10 8 12 6 8 8 5 10 6 8 7 9 8 6 7 4 5 6

14 15 16 12 14 12 12 11 10 18 12 12 12 10 10 13 14 10 12 14 12 10 12 12 14 10 12 10 10 12 10 12 10 10 11 12 14 10 12 11 12 12

PTI None None None None None None Shortening None PTI + VD None Shortening Shortening None None Shortening Shortening None None Shortening Shortening VD None None None PTI Shortening None Shortening None None PTI None None None None Shortening None None None None None

3yr 4mo 1yr 5mo 8mo (died) 1yr 3mo 1yr 6mo 2yr 5mo 9mo (died) 1yr 4mo (died) 2yr 6mo 10mo (died) 1yr 8mo 1yr 1mo 2yr 10mo 3yr 6mo 1yr 11mo 1yr 1mo (died) 2yr 5mo 1yr 7mo 8mo (died) 10mo 1yr 6mo 2yr 4mo 1yr 2mo 1yr 1mo 1yr 6mo 7 mo (died) 3 yr 11 mo 1 yr 1 mo 1 yr 11 mo 1 yr 5 mo 2 yr 2 mo 6 mo (died) 1 yr 2 mo 4 mo (died) 3 mo (died) 2 yr 1 yr 2 mo 1 yr 10 mo 1 yr 8 mo

OT: operation time, HsT: hospitalisation time, FRT: fixator removal time, F: female, M: male, L: left, R: right, COPD: chronic obstructive pulmonary disease, DM: diabetes mellitus, HT: hypertension, SD: senile dementia, CD: cardiac disease, TA: traffic accident, S: stable, U: unstable, PTI: pin track Infection deep, VD: varus deformity with shortening of more than 2 cm and shortening less than 2 cm, mo: months, yr: years. a The fractures were classified according to Jensen’s modification of Evans’ classification.12,13

Treatment of intertrochanteric fractures of the geriatric patients

Materials and methods Between January 1997 and September 2001, 42 elderly patients, 25 women and 17 men, were treated using a modified external fixator (Table 1). Fixation was by the semicircular modification of the Ilizarov designed by Cattaneo and Catagni composed of a 908 angled femoral arch, an adjustable half-pin clamp, half-pin clamp or half-pin gripping cube, 5.0—6.0 mm half-pins, nuts and bolts. The selection of the patients for the procedure was based on their poor general health condition, moderate or high surgical and anaesthetic risks for open operative procedures or prolonged anaesthesia. To assess the role of the severity of a patient’s health problems at the time of admission, the rating system of American Society of Anaesthesiologists was used.23 Seven patients had cardiac disease, three had chronic obstructive pulmonary disease, two had type II diabetes mellitus, three had hypertension, one had senile dementia and 17 had multiple systemic diseases. Only nine patients had no signs of any systemic disease, but they had either malnutrition or a nutritional anaemia. Mental status was assessed using mental test score of Hodkinson.13 The fractures were classified using Jensen’s modification of Evans’ classification.14,15 We excluded fractures which were basicervical or subtrochanteric extension, although the semicircular modification of the Ilizarov external fixator can also be assembled for these kinds of fractures. Three patients were operated under general anaesthesia. Epidural anaesthesia with 20 ml bupivacaine 0.25% was used in nine patients by an anaesthesiologist, local anaesthesia with 10—20 ml prilocaine 1% was used in 30 patients by the surgeon. During closed reduction and application of half-pins, 2 mg/kg fentanyl was administrated intravenously to the patients under local anaesthesia.

Operative technique All operations were carried out by the four experienced surgeons (YT, MK, AP, BG) on a traction table with the patient supine. Under anaesthesia, a closed reduction of the fracture was performed using image intensification. After achieving the appropriate position of the fracture, the insertion point of the half-pin and the anteroposterior angle were determined by using a guide wire. All incision areas were infiltrated with prilocaine before insertion of the half-pins. The first 5.0—6.0 mm half-pin was inserted thorough a stab incision, from the level of the lesser trochanter, across the fracture site and the tip was no closer than 1 cm from the chondral surface. Following appropriate incisions, the second

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and/or third half-pins were inserted parallel into the neck and head of the femur. The lengths of these half-pins should be as long as 200—250 mm. They were then clamped to an adjustable half-pin clamp. This component was then fixed to a 908 angled femoral arch by using a nut and bolt. A gripping cube was fixed on the inferior surface of the femoral arch (Fig. 1). If short segment fixation is needed, it can be fixed to the superior surface of the femoral arch (Fig. 2). It is possible to obtain interfragmentary compression of the fracture with a special halfpin. It has a double-thread: on one end the thread is 6.0 mm, while the other end is the same as a rod. It allows for a powerful grip in the femoral neck and head, allowing interfragmentary compression. Two 5.0 mm half-pins were then inserted at right angles into the shaft of the femur, through holes in the pin clamp or cube. According to the configuration of the fracture, one or two 5.0 mm half-pins were applied to the subtrochanteric area of the femur, through mono pin clamps or cubes fixed on the femoral arch. All the clamps and nuts were re-tightened and the final position checked with image intensification. Low-molecular-weight heparin was administered for thromboembolic prophylaxis, until partialweight-bearing was achieved. Non-weight-bearing walking with a frame was started 48 h after the operation. The patients were encouraged to exercise the hip and knee actively until removal of the apparatus. Full-weight-bearing was allowed at the end of the first-month (Fig. 3). Pin site care was applied meticulously; the pin sites were cleaned with antiseptics until the day that serous drainage of stab incisions stopped. Thereafter, hydrogen peroxide was used to clean away any scab or clot present around the pins. For preventing skin mobility, the pin sites were wrapped continuously. This is especially important for proximal pins. The patients were evaluated clinically and radiologically first at postoperative first-month and then bi-weekly. The radiological evaluation of all patients were made with anteroposterior (AP) and lateral radiographs of the proximal femur by current authors. The reduction was admitted to be anatomical if the neck-shaft angle was between 1208 and 1408 and the distraction at the fracture site was less than 2 mm. Minor valgus angulation (<108) and a distraction of less than 5 mm were admitted to be acceptable if an anatomical reduction was not obtained. No unacceptable reduction was observed in the patients. Angles less than 1208 were considered a varus deformity. Clinical examination included range of motion of the hip, knee and limb-length discrepancy. Range of motion of the knee and hip joint was measured with a goniometer by the authors. Limb length was measured by comparing the distance between the umbi-

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Figure 1 Modified external fixator and its assembly in the proximal part of femur. A double thread special half-pin was inserted to the middle hole of the adjustable half-pin clamp and fixed with nuts from front and back of the adjustable half-pin clamp to provide interfragmentary compression.

licus and the medial malleolus of both tibias. A difference greater than 5 mm was considered a leg length discrepancy. The patients’ living status (lives independently, needs partial help, needs full help) and walking capacity (without an aid, aids, non-walker, bedridden) were assessed both preoperatively and postoperatively (Table 2). The patients’ preoperative evaluations of living and functional status were assessed according to the history obtained from patients or their families.

Results The average age of the patients was 77.5 (63—99). Males averaged 75.5 years (63—94) and females 78.9 years (70—99). Ninety-three percentage of patients had fallen at home. Only 7% had fractures resulting from traffic accident. Of the 42 fractures, 25 were stable and 17 were unstable. Only 7 of 42 patients had senile dementia (score  7) according to mental test score of Hodkinson. The mean oper-

Figure 2 Alternate assembly of modified external fixator in the proximal part of femur. Fixing the half-pin gripping cube on the superior surface of the femoral arch, allows shorter segment fixation than the assembly in Fig. 1.

Treatment of intertrochanteric fractures of the geriatric patients

ating time was 40 min (range, 30—75). The preparation time, including placing on an orthopaedic table and closed reduction of the fracture, was excluded from this time. During the intraoperative period, no complications or technical difficulties were encountered. Intraoperative blood loss was negligible. The mean hospitalisation time was 7.8 days (range, 5— 14). The mean duration of fixator was 12 weeks (range, 10—18), it was kept until union was secured and then removed. The mean period of follow-up after removal of the apparatus was 1 year and 5.5 months (range, 3 months (because of death of the patient) to 3 years and 6 months). No local or systemic complications occurred during the early postoperative period. At the first postoperative month, varus deformity was detected in the radiographs of two patients. The adjustable pin clamp was loosened, the deformity corrected and then it was re-tightened in the acceptable position. Superficial pin site infections were seen in 22 patients but were successfully treated with daily dressings and oral antibiotics. In four patients, pin site infections were deep and could not be controlled with daily dressing and oral antibiotics. These required removal of the infected half-pins and parenteral first generation cephalosporin. The fractures healed without developing osteomyelitis. Other complications included postoperative varus deformity with shortening of more than 2 cm in two patients and shortening of less than 2 cm in 10 patients. No half-pin breakage or mechanical failure was observed No refracture was seen after the removal of the apparatus. The range of motion of the hip and knee joint were 908 or more in all patients at the final followup, with no muscle atrophy. Ten patients died due to systemic disorders during the follow-up. Three patients who used no assistance before injury required a care for walking after surgery and the others returned to the same functional status as before injury (Table 2).

Discussion Nonunion is not common in intertrochanteric fractures. This is probably related to copious cancellous bone and a good blood supply. In elderly patients providing a perfect reduction of the intertrochanteric fracture is not of primary importance, and it is more important is to operate with the least blood loss in the shortest time and using anaesthetic procedures that are low risk. Another important point is early mobilisation in the postoperative period. An operation producing significant blood loss, requiring a long time with extensive anaesthesia

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causes high morbidity and mortality risks for these patients. The widely preferred treatment method of choice for most intertrochanteric fractures is internal fixation with the dynamic hip screw (DHS) and Gamma nails.1,2,10,12,18 The average fixation failure rate with the DHS is about 10% in unstable intertrochanteric fractures.18 Several modes of failure of the DHS led to the development of intramedullary devices, which it was suggested, have the advantage of closed fixation resulting in shorter operating and union time and decreased anaesthetic problems, and a mechanical advantage because of a shorter lever arm.12 The Gamma nail, is associated with fracture of the femoral diaphysis and cutting-out of the implant from the femoral head requiring reoperation.11,17,19 There was no implant failure in our cases and no re-operation was needed in any patient; similarly the fixators were removed easily in the outpatient clinic. In addition, at the latest follow-up period, the living status of the patients has not changed; only three patients who did not need an aid at prefracture period needed a cane after the operation. Harrington et al. treated 52 patients with a DHS, 50 patients with an intramedullary hip screw (IMHS).12 They detected two technical complication in the DHS group and three in the IMHS group. They reported that most fractures had united at 3 months without significant difference between the two groups in radiological or functional outcome at 12 months. Ahrengart et al. also compared the DHS with the Gamma nail in the treatment of 426 intertrochanteric fractures.2 They reported that 88% of the fractures were healed at 6 months and the most frequent surgical problem for patients in the Gamma group was problems with distal locking. When the literature is reviewed for external fixation in the treatment of intertrochanteric fractures,3,4,6—9,16,21,22 some special features attract attention: (1) The fixators used in the treatment were of several designs, but, all have a stable construct, a simple, safe and quick application time, no blood loss, easy nursing care, early weight-bearing and rapid union time. The most important step of our method is insertion of the first halfpin. It must be parallel to the superior and inferior cortex of the femoral neck on the anteroposterior view and central on the lateral view. The position can be adjusted using the image intensification during insertion. The second or third half pin is inserted in the femoral neck in the same direction. Fixation is then completed easily using the femoral arch, half-pins, half-pin

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Treatment of intertrochanteric fractures of the geriatric patients

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Table 2 Living and functional status of the patients Number (n = 42)

Percentage

ASA group Group II Group III Group IV Others

9 30 3 0

21.4 71.5 7.1 0

Living status, prefracture Independently Needs partial help (less than 24 h/day) Needs full help (24 h/day)

26 13 3

62.0 30.9 7.1

Living status, postoperative Independently Needs partial help (less than 24 h/day) Needs full help (24 h/day)

26 13 3

62.0 30.9 7.1

Walking ability, prefracture Without an aid Aids Non-walker Bedridden

22 17 1 2

52.3 40.5 2.4 4.8

Walking ability, postoperative Without an aid Aids Non-walker Bedridden

19 20 1 2

45.2 47.6 2.4 4.8

a

a

American Society of Anaesthesiologists rating of operative risk.19

clamps or cubes. Internal fixation with the DHS and Gamma nails necessitates experience for a successful result, we feel our method is simpler for less experienced surgeons. (2) Implant failures and mechanical problems are very rare. Only, Dahl et al. have reported one pin breakage in 154 cases.8 Any serious mechanical failure has not been reported until now. There is always almost several implant failures with internal fixation methods even if high success rates.2,7,10,12,18 (3) The main trouble in external fixation is the care of pin site. Although superficial pin-track infection is commonly seen, it is easily controlled by daily dressing and antibiotics. Rarely, does it necessitate removal of a half-pin. Stiffness of the knee, which is seen with some types of external fixators, is temporary in the most of patients and recovers to normal after removal of the fixator.

(4) Nonunion of the intertrochanteric fracture is not a common situation. Vossinakis and Badras22 have thought that the element of elasticity of external fixation produces rapid and abundant callus formation. (5) Anaesthesia in patients treated by external fixators is not a problem. The operation can be performed under local anaesthesia together with paranteral analgesic support. (6) Because of a short hospitalisation period, removal as an outpatient procedure and the re-usable feature of the fixator, external fixation is an inexpensive method. Our modified external fixator, compared to other external fixators, offered to us further advantages. Because of the modularity of the Ilizarov apparatus, it could be assembled according to the configuration of the fracture. Fixation of an unstable fracture could be strengthened by applying one or several half-pins

Figure 3 74-year-old female patient with an unstable intertrochanteric fracture of the left hip. Preoperative anteroposterior radiograph. Anteroposterior radiograph showing anatomical reduction and beginning of the consolidation postoperatively 6-week. The patient is seen before removal of the fixator. She has been fully weight-bearing since first-month postoperatively. A proximal half-pin was removed due to deep pin track infection at the postoperatively 9week. Anteroposterior radiograph showing a perfect result at the postoperatively 1-year.

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to the subtrocanteric area of the femur. Three-dimensional fixation was accomplished with the help of the femoral arch of Ilizarov external fixator. When needed, we accomplished interfragmentary compression of the fracture thanks to the double threaded special half-pins. Significant stiffness of the knee did not occur because of short segment fixation. The fact that the our modified external fixator provides semi-rigid and stable fixation both together at the same time increased the formation of callus and permits early weight-bearing. Furthermore, varus deformities could be corrected in the early postoperative period owing to the fact that the adjustable pin clamp could be loosened and then retightened in a better position. All the components except half-pins of Ilizarov external fixator were reused time and again; this is especially important for developing countries where resources are limited. In addition, the Ilizarov external fixator is less costly than special trochanteric fixators and is obtainable worldwide. The main disadvantages of Ilizarov apparatus are pin site infections and the clumsy frame construction, which causes some discomfort. However, if the semicircular modification of the Ilizarov is applied properly without any skin tension, tissue necrosis or thermal injury, a painless, well-tolerated construct can be obtained. Our modified external fixator was well tolerated by patients and did not disturb daily activity. Complications were not common in the patients in this study. Likewise, Bendo et al. reported that 93% of patients with intertrochanteric fracture stabilized with DHS had moderate (average 17 mm) or severe (average 26 mm) fracture collapse with poor functional outcomes.5 They stated that patients with minimal collapse (average 5 mm, range 3—9 mm) were asymptomatic and did not have gait disturbances. Our experience suggests that the Ilizarov external fixator offers advantages in the treatment of elderly and moderate or high-risk patients with intertrochanteric fractures.

Acknowledgement We thank Robert Rouzburch, MD, The Hospital for Special Surgery, New York for critically reviewing the manuscript.

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