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Cementless Calcar-Replacement Hemiarthroplasty Compared with Intramedullary Fixation of Unstable Intertrochanteric FracturesA Prospective, Randomized Study
Shin-Yoon Kim, MD1; Yong-Goo Kim, MD1; Jun-Kyung Hwang, MD1
1 Department of Orthopedic Surgery, Kyungpook National University School of Medicine, Jung Gu Sam Duck 2 Ga 50, Daegu 700-721, South Korea. E-mail address for S.-Y. Kim: syukim@knu.ac.kr
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopedic Surgery, Kyungpook National University School of Medicine, Daegu, South Korea

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Oct 01;87(10):2186-2192. doi: 10.2106/JBJS.D.02768
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Abstract

Background: Unstable intertrochanteric fractures in elderly patients are associated with a high rate of complications. The purpose of this investigation was to compare the results of long-stem cementless calcar-replacement hemiarthroplasty with those of treatment with a proximal femoral nail for unstable intertrochanteric fractures in elderly patients.

Methods: Fifty-eight elderly patients with an AO/OTA type 31-A2 intertrochanteric fracture of the femur were randomized into two treatment groups and were followed for a minimum of two years. The twenty-nine patients in Group I were treated with a long-stem cementless calcar-replacement prosthesis, and the twenty-nine patients in Group II were treated with a proximal femoral nail. The two treatment groups were comparable with regard to demographic and injury variables.

Results: There were no significant differences between the groups in terms of functional outcomes, hospital stay, time to weight-bearing, or general complications. Patients treated with a proximal femoral nail had a shorter operative time, less blood loss, fewer units of blood transfused, a lower mortality rate, and lower hospital costs compared with those treated with the long-stem cementless calcar-replacement prosthesis.

Conclusions: In elderly patients with an unstable intertrochanteric femoral fracture, a proximal femoral nail provides superior clinical outcomes but no advantage with regard to functional outcome when compared with a long-stem cementless calcar-replacement arthroplasty.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Shin-Yoon Kim
    Posted on December 24, 2005
    Dr. Kim, et al, reply to Dr. Cebesoy, et al
    Kyungpook National University Hospital, Dept. of Orthopedic Surgery, KOREA

    We thank Dr.Cebesoy and associates for the interest shown in our paper and the queries raised. Several previous reports showed external fixation was associated with minimal blood loss, shorter operative time, and preservation of the fracture callus. The disadvantages of external fixation were pin site infection, inflammation, pin loosening, and post-operative loss of reduction because the bone is usually osteoporotic (1,2). These problems seemed to be improved using the modified design external fixator and hydroxyapatite-coated pins (1,3). In a prospective, randomized study comparing use of a dynamic hip screw with external fixation for the treatment of osteoporotic peritrochanteric fractures, the external fixation with hydroxyapatite-coated pins group showed brief operation time, minimal blood loss, minimal pin site infection and pin loosening, adequate fixation, and maintenance of reduction over time. (3)

    Our study compared cementless calcar-replacement hemiarthroplasty with intramedullary fixation of unstable intertrochanteric fractures in a prospective, randomized manner in a single center and by a single surgeon. Our conclusion was that proximal femoral nailing was associated with less operative time, less bleeding, and less morbidity compared with cementless calcar-replacement hemiarthroplasty. We did not compare proximal femoral nailing with external fixation. Nevertheless, we agree that external fixation can be a good option for the treatment of trochanteric fracture, especially unstable fractures in elderly patients.

    Dr. Cebesoy states that an advantage of external fixation is that it avoids the need for deep implant removal. However, an advantage of the proximal femoral nail, especially in elderly patients, is that it be retained, because femoral neck fractures can occur after nail removal(4). The other question is whether weight bearing should be delayed after removal of external fixation pins because fracture through the empty pin holes is possible (just as fracture is possible through empty screw holes after removal of plate and screw in long bone fracture). We think it is necessary to perform a prospective, randomized study comparing proximal femoral nailing with external fixation using hydroxyapatite-coated pins for the treatment of osteoporotic peritrochanteric fractures in a single center or multi-centers by experienced trauma or hip surgeons.

    1. Tomak Y, Kocaoglu M, Piskin A, Yildiz C, Gulman B, Tomak L. Treatment of intertrochanteric fractures in geriatric patients with a Modified external fixator.Injury. 2005;36:635-43.

    2. Subasi M, Kesemenli C, Kapukaya A, Necmioglu S. Treatment of intertrochanteric fractures by external fixation.Acta Orthop Belg. 2001;67:468-74.

    3. Moroni A, Faldini C, Pegreffi F, Hoang-Kim A, Vannini F, Giannini S. Dynamic hip screw compared with external fixation for treatment of Osteoporotic pertrochanteric fractures. A prospective, randomized study. JBone Joint Surg.2005;87-A:753-59.

    4. Hesse B,Gacherter A. Complications following the treatment of trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg. 2004;124:692-98.

    Oguz Cebesoy
    Posted on December 07, 2005
    Treatment of Unstable Intertrochanteric Fractures
    Gaziantep University, Faculty of Medicine, Dept. of Orthopedics & Traumatology, Gaziantep, TURKEY

    To The Editor:

    We read with great pleasure the study by Kim et al(1). They have made an excellent contribution to the relevant literature. We certainly agree that operative treatment is mandatory as most of these fractures occur in elderly patients who require rapid mobilization following treatment.(2,3). The calcar replacement prosthesis is a proven and valuable option but has certain disadvantages like blood loss, fat embolism (during reaming and cement pressurizing) and the length of anesthesia. Proximal femoral nails seem to be a less morbid operation, and also have the advantage of preserving the patient’s own bone as reflected by this study.

    We also believe that external fixators offer advantages for treatment of both stable and unstable intertrochanteric fractures (4). These include minimal blood loss, less operating time, preservation of the fracture haematoma and allowance of full weightbearing(2,3,5-7). The procedure can be done under local anesthesia with laryngeal mask support. Also the hospitalization time is short and the union time is rapid(2,3,7,10). One more advantage of this system is that the implant removal is not a problem as opposed to proximal femoral nails and can even be done in the policlinics(3).

    In addition, the time to union is short, the reduction is maintained overtime and even slight malunions can be compatible with excellent functional outcome (5,8-10). Especially in patients infected by various disease or having serious comorbidities, external fixation may be the method of choice.

    REFERENCES:

    1: Kim SY, Kim YG, Hwang JK.Cementless calcar-replacement hemiarthroplasty compared with intramedullary fixation of unstable intertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg Am. 2005 Oct;87(10):2186-92

    2: Tomak Y, Kocaoglu M, Piskin A, Yildiz C, Gulman B, Tomak L. Treatment of intertrochanteric fractures in geriatric patients with a Modified external fixator. Injury. 2005 May;36(5):635-43.

    3: Devgan A, Sangwan SS.External fixator in the management of trochanteric fractures in high risk geriatric patients--a friend to the elderly.Indian J Med Sci. 2002 Aug;56(8):385-90.

    4: Eksioglu F, Gudemez E, Cavusoglu T, Sepici B. Treatment of intertrochanteric fractures by

    5: Moroni A, Faldini C, Pegreffi F, Hoang-Kim A, Vannini F, Giannini S. Dynamic hip screw compared with external fixation for treatment of Osteoporotic pertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg Am. 2005 Apr;87(4):753-9.

    6: Milenkovic S, Mitkovic M, Radenkovic M, Mladenovic D, Soldatovic G, Micic I,Stanojlovic M. [Surgical treatment of pertrochanteric fractures using dynamic methods of internal and external fixation] Vojnosanit Pregl. 2003 Nov-Dec;60(6):663-7.

    7: Ozdemir H, Dabak TK, Urguden M, Gur S. A different treatment modality for trochanteric fractures of the femur in surgical high-risk patients: a clinical study of 44 patients with 21-month follow-up. Arch Orthop Trauma Surg. 2003 Dec;123(10):538-43. Epub 2003 Aug 26.

    8: Kourtzis N, Pafilas D, Kasimatis G. Management of pertrochanteric fractures in the elderly patients with an external fixation. Injury. 2001 Dec;32 Suppl 4:SD115-28.

    9: Ozdemir H, Urguden M, Dabak TK, Soyuncu Y.[Treatment of intertrochanteric femoral fractures with the use of a modular axial fixator device] Acta Orthop Traumatol Turc. 2002;36(5):375-83.

    10: Subasi M, Kesemenli C, Kapukaya A, Necmioglu S. Treatment of intertrochanteric fractures by external fixation.Acta Orthop Belg. 2001 Dec;67(5):468-74.

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