• Hip & pelvis
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• v.35 no.3
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• pp.193-199
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• 2023

Purpose: Cephalomedullary (CM) nailing is widely performed in treatment of elderly patients with femoral intertrochanteric fractures. However, in cases of fixation failure, re-operation is usually necessary, thus determining factors that may contribute to fixation failure is important. In this study, we examined factors affecting the occurrence of fixation failure, such as age or fracture stability, after CM nailing in elderly patients. Materials and Methods: This study was conducted retrospectively using registered data. From April 2011 to December 2018, CM nailing was performed in 378 cases diagnosed with femoral intertrochanteric fractures, and 201 cases were finally registered. Cases involving patients who were bed-ridden before injury, who died from causes unrelated to surgery, and those with a follow-up period less than six months were excluded. Results: Fixation failure occurred in eight cases. Comparison of the surgical success and fixation failure group showed that the mean age was significantly higher in the fixation failure group compared with the control group (81.3±6.4 vs. 86.4±6.8; P=0.034). A significantly high proportion of unstable fractures was also observed (139/54 vs. 3/5; P=0.040), with a significantly high ratio of intramedullary reduction (176/17 vs. 5/3; P=0.034). A significantly higher ratio of unstable fractures compared with that of stable fractures was observed in the intramedullary reduction group (132/49 vs. 10/10; P=0.033). Conclusion: Fixation failure of CM nailing is likely to occur in patients who are elderly or have unstable fracture patterns. Thus, care should be taken in order to avoid intramedullary reduction.

• Hip & pelvis
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• v.35 no.4
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• pp.246-252
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• 2023

Purpose: The aim of this study was to compare short-term results from use of the direct anterior approach (DAA) and the conventional posterolateral approach (PLA) in performance of bipolar hemiarthroplasty for treatment of femoral intertrochanteric fractures in elderly patients. Materials and Methods: A retrospective review of 100 patients with intertrochanteric fractures who underwent bipolar hemiarthroplasty was conducted. The PLA was used in 50 cases from 2016 to 2019; since that time we have used the DAA in 50 cases from 2019 to 2021. Measurements of mean operative time, blood loss, hospitalization period, and ambulation status, greater trochanter (GT) migration and stem subsidence were performed. And the incidence of complications was examined. Results: Operative time was 73.60±14.56 minutes in the PLA group and 79.80±8.89 minutes in the DAA group (P<0.05). However, after experiencing 20 cases using DAA, there was no statistically difference in operative time between two groups (P=0.331). Blood loss was 380.76±180.67 mL in the PLA group and 318.14± 138.51 mL in the DAA group (P<0.05). The hospitalization was 23.76±11.89 days in the PLA group and 21.45 ±4.18 days in the DAA group (P=0.207). In both groups, there were no progressive GT migration, intraoperative fractures or dislocations, although there was one case of infection in the PLA group. Conclusion: Although use of the DAA in performance of bipolar hemiarthroplasty required slightly more time in the beginning compared with the PLA, the DAA may well be an alternative, safe surgical technique as a muscle preserving procedure in elderly patients with intertrochanteric fractures.

• Hip & pelvis
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• v.30 no.4
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• pp.254-259
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• 2018

Purpose: Internal fixation using compression hip screws (CHS) and traction tables placing patients in the supine position is a gold standard option for treating intertrochanteric fractures; however, at our institution, we approach this treatment with patients in a lateral decubitus position. Here, the results of 100 consecutive elderly (i.e., ${\geq}45$ years of age) patients who underwent internal fixation with CHS in lateral decubitus position are analyzed. Materials and Methods: Between March 2009 and May 2011, 100 consecutive elderly patients who underwent internal fixation with CHS for femoral intertrochanteric fracture were retrospectively reviewed. Clinical outcomes (i.e., Koval score, Harris hip score [HHS]) and radiographic outcomes (i.e., bone union time, amount of sliding of lag screw, tip-apex distance [TAD]) were evaluated. Results: Clinical assessments revealed that the average postoperative Koval score decreased from 1.4 to 2.6 (range, 0-5; P<0.05); HHS was 85 (range, 72-90); and mean bone union time was 5.0 (range, 2.0-8.2) months. Radiographic assessments revealed that anteroposterior average TAD was 6.95 (range, 1.27-14.63) mm; lateral average TAD was 7.26 (range, 1.20-18.43) mm; total average TAD was 14.21 (range, 2.47-28.66) mm; average lag screw sliding was 4.63 (range, 0-44.81) mm; and average angulation was varus $0.72^{\circ}$(range, $-7.6^{\circ}-12.7^{\circ}$). There were no cases of screw tip migration or nonunion, however, there were four cases of excessive screw sliding and six cases of varus angulation at more than $5^{\circ}$. Conclusion: CHS fixation in lateral decubitus position provides favorable clinical and radiological outcomes. This technique is advisable for regular CHS fixation of intertrochanteric fractures.

• Hip & pelvis
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• v.30 no.4
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• pp.241-253
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• 2018

Purpose: This study was conducted to compare cemented and cementless bipolar hemiarthroplasty in elderly patients with unstable intertrochanteric fractures via meta-analysis and systematic review of relevant studies. Materials and Methods: Systematic review and meta-analysis were performed on 31 available clinical studies; 19 of these studies used cemented stems, 12 used cementless stems, one used both types of stems, and two studies involved a comparative analysis of both stem types. Results: There were statistically significant differences in rates of leg length discrepancy (LLD) greater than 1 cm between the cemented (event rate, 0.089) and cementless groups (event rate, 0.015 and 0.047; P=0.03). Conclusion: Cemented bipolar hemiarthroplasty and cementless bipolar hemiarthroplasty performed on elderly patients with unstable intertrochanteric fracture revealed similar mortality and complication rates; however, the rate of LLD greater than 1 cm was significantly higher in the cemented group compared with the cementless group.

• Hip & pelvis
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• v.30 no.4
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• pp.269-275
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• 2018

Purpose: The purpose of this study is to describe a method of inserting cement in the femoral head before fixation with dynamic hip screw to prevent screw cut out due to osteoporosis and to evaluate its clinical outcome in these patients. Materials and Methods: In this prospective study, 30 patients aged 60 years and older with intertrochanteric fracture were included. Bone mineral density was measured. After reaming of the femoral head and neck with a triple reamer and polymethyl methacrylate, bone cement was introduced into the femoral head using a customized nozzle and a barrel fitted on a cement gun. A Richard screw was inserted and the plate was fixed over the femoral shaft. Patients were mobilized and clinical outcomes were rated using the Salvati and Wilson's scoring system. Results: More patients included in this study were between 66 and 70 years old than any other age group. The most common fracture according to the Orthopaedic Trauma Association classification was type 31A2.2 (46.7%). The T-score was found to be $-2.506{\pm}0.22$ (mean${\pm}$standard deviation); all patients were within the range of -2.0 to -2.8. The duration of radiological union was $13.67{\pm}1.77$ weeks. Salvati and Wilson's scoring at 12 months of follow up was $30.96{\pm}4.97$. The majority of patients were able to perform their normal routine activities; none experienced implant failure or screw cut out. Conclusion: Bone cement augmentation may effectively prevent osteoporosis-related hardware complications like screw cut out in elderly patients experiencing intertrochanteric fractures.

• Journal of the Korean Orthopaedic Association
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• v.55 no.3
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• pp.193-199
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• 2020

A gamma nail has been used to treat intertrochanteric fractures since 1988. Although such cephalomedullary nails have mechanical advantages over extramedullary fixation devices, such as sliding hip screw, their beneficial effects on treating the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31-A1 and 31-A2 fractures are still controversial. During their 30-year history, many problems have been overcome, and new types of cephalomedullary nails have been introduced in clinical practice. New cephalomedullary nail systems facilitate nailing procedures and enhance the purchase capability of the femoral head by a lag screw. On the other hand, the failure rate still depends on the hands of the orthopedic surgeons. This review article focused on the basic principle of medial support and restoration of a medial buttress during the treatment of trochanteric fractures using a cephalomedullary nail.

• Journal of the Korean Orthopaedic Association
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• v.55 no.3
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• pp.237-243
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• 2020

Purpose: This study examined the effects of the postoperative administration of parathyroid hormone (PTH) on fracture healing in intertrochanteric fractures accompanied by osteoporosis in elderly females. Materials and Methods: Female patients aged 65 years and more who underwent surgery after a diagnosis of intertrochanteric fractures and osteoporosis during the period from July 2013 to December 2017 were included as subjects. The subjects were divided into two groups: PTH-treated group and non-PTH-treated group. The formation time of the first callus, timing of the bridging callus, and time of bony union for both groups were evaluated. Results: In the PTH-treated group, the mean time of the first callus formation, average time of bridging callus, and the average time of bony union were 32, 58, 83 days, respectively, which were significantly shorter than that of the untreated group. Conclusion: PTH, a treatment for osteoporosis, promotes callus formation and the healing process. Therefore it will be helpful in intertrochanteric fractures accompanied by osteoporosis in elderly females.

• Journal of the Korean Orthopaedic Association
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• v.55 no.6
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• pp.503-510
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• 2020

Purpose: Bipolar hemiarthroplasty is used as an alternative to open reduction and internal fixation for unstable intertrochanteric fractures in elderly patients. Recent advances in medical systems and technologies have resulted in increased survival rates after intertrochanteric fractures of the femur, requiring selection of the appropriate femoral stems considering the mid- to long-term duration of survival. Hemiarthroplasty was performed for unstable intertrochanteric fractures using a double tapered quadrilateral femoral stem (C2 stem), and the clinical and radiological results were evaluated as a five-year follow-up post-surgery. Materials and Methods: From January 2004 to December 2013, 43 patients (43 hips) who underwent hemiarthroplasty with a C2 stem were enrolled in this study. Their mean age was 78.6 years (range, 70-84 years), and the mean follow-up period was 85.4 months (range, 60-96 months). During the follow-up period, clinical parameters, such as the changes in pain, walking ability, and functional status, were examined. Radiologically, changes in the proximal femur, such as osteoporosis and bone resorption of cortical bone, were noted. Complications that occurred during the follow-up period, such as dislocation and prosthetic features, were also reviewed. Results: Initially, the pain was relieved postoperatively, but it increased four years after surgery. The walking ability was reduced by two steps in nine patients after 60 months, and the Harris hip score was reduced significantly postoperatively after two to three years. Radiologically, cortical osteoporosis occurred in 14 patients. Five patients developed cortical bone resorption. Four of them showed nonunion of the trochanteric fracture fragments, and three of them suffered reverse oblique fractures. Conclusion: Careful selection considering the general health condition and remaining lifespan of the patient would be necessary for primary hip hemiarthroplasty using a 3C type cementless femoral stem for unstable intertrochanteric fractures in elderly patients with osteoporosis.

• Journal of Korean Academy of Nursing Administration
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• v.13 no.2
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• pp.199-207
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• 2007

Purpose: Clinical characteristics and medical cost were analyzed according to the surgical procedures for intertrochanteric fracture in aged patients to assess the appropriateness of treatment expense and to find possibility of reducing the medical cost. Method: Variable for the statistical analysis were; the clinical characteristics, medical cost according to the surgical procedures, the treatment success rate, the total medical expense, and the average expense per case. SAS Package Version 8.02. was used to analyze the relevant data. Results: Operative procedures differ significantly according to the gender and by the location of institution. Only significant clinical variables according to the operative procedure were duration of general anesthesia and amount of blood transfusion. Average cost per treatment was the highest in the bipolar hemiarthroplasty followed by the gamma nail and hip compressing screw. Average cost for bipolar hemiarthroplasty was significantly higher than other surgical procedures. Conclusions: The difference in hospital costs for treatment of intertrochanteric fracture originates from the utilized surgical procedures, mostly by the materials used. The method of surgical treatment should be carefully determined by the purpose of the surgery, in order to improve the quality of medical care and also to reduce the hospital cost.

• Hip & pelvis
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• v.35 no.3
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• pp.183-192
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• 2023

Purpose: This study aims to determine which intertrochanteric (IT) hip fracture and patient characteristics predict the necessity for adjunct reduction aides prior to prep and drape aiming for a more efficient surgery. Materials and Methods: Institutional fracture registries from two academic medical centers from 2017-2022 were analyzed. Data on patient demographics, comorbidities, fracture patterns identified on radiographs including displacement of the lesser trochanter (LT), thin lateral wall (LW), reverse obliquity (RO), subtrochanteric extension (STE), and number of fracture parts were collected, and the need for additional aides following traction on fracture table were collected. Fractures were classified using the AO/OTA classification. Regression analyses identified significant risk factors for needing extra reduction aides. Results: Of the 166 patients included, the average age was 80.84±12.7 years and BMI was 24.37±5.3 kg/m². Univariate regression revealed increased irreducibility risk associated with RO (odds ratio [OR] 27.917, P≤0.001), LW (OR 24.882, P<0.001), and STE (OR 5.255, P=0.005). Multivariate analysis significantly correlated RO (OR 120.74, P<0.001) and thin LW (OR 131.14, P<0.001) with increased risk. However, STE (P=0.36) and LT displacement (P=0.77) weren't significant. Fracture types 2.2, 3.2, and 3.3 displayed elevated risk (P<0.001), while no other factors increased risk. Conclusion: Elderly patients with IT fractures with RO and/or thin LW are at higher risk of irreducibility, necessitating adjunct reduction aides. Other parameters showed no significant association, suggesting most fracture patterns can be achieved with traction manipulation alone.