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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 249-254

Management of intertrochanteric fracture in elderly high-risk patients using simple external fixation


Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission24-Mar-2013
Date of Acceptance18-Aug-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
Mohamed Elreweny
MBChB, 2nd Floor, House No. 34, Elsalam Street, Tanta-Elstad
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141667

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  Abstract 

Objectives
The goal of this study was to report and evaluate the role of external fixation in the treatment of trochanteric fractures in patients with a high unacceptable operative risk to withstand conventional osteosynthesis and to obviate the many disadvantages of traction and prolonged rest in bed.
Background
External fixation has been used for the management of fractures for a long period of time. Good fixation, mild blood loss, and early ambulation are always the main advantages of this technique. Its other advantages are that it is simple, quick, inexpensive, and causes minimal surgical trauma.
Materials and methods
Between March 2011 and September 2012, 20 patients, six men and 14 women, mean age 65.9 years, with trochanteric fractures and considered preoperatively as 'poor medical status', were treated in the Orthopedic Department, El-Menufiya University Hospital, by external fixation and early mobilization. The technique was prescribed.
Results
All fractures were united at ~22.2 weeks (range 16-26 weeks). A superficial pin-tract infection was found in 14 patients. Two cases showed penetration of the femoral head; shortening of more than 2 cm was observed in four patients.
Conclusion
The use of the external fixator in these patients reduced their time in the hospital and facilitated their postoperative rehabilitation by allowing uncomplicated healing of a complicated fracture.

Keywords: Elderly, external fixation, intertrochanteric fractures


How to cite this article:
Elmowafy H, Elsattar TA, Darwish A, Elreweny M. Management of intertrochanteric fracture in elderly high-risk patients using simple external fixation. Menoufia Med J 2014;27:249-54

How to cite this URL:
Elmowafy H, Elsattar TA, Darwish A, Elreweny M. Management of intertrochanteric fracture in elderly high-risk patients using simple external fixation. Menoufia Med J [serial online] 2014 [cited 2019 Nov 12];27:249-54. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/249/141667


  Introduction Top


Intertrochanteric fracture of the femur usually occur because of low-energy trauma such as simple falls; increased longevity together with osteoporosis and senile muscular insufficiency may explain the increasing number of patients with intertrochanteric fractures [1]. An overwhelming majority of these patients (>90%) are older than 50 years of age.

The incidence of these fractures is two to three times more in women compared with men [2]. Older patients with hip fractures are at risk of significant morbidity and mortality, both of which can be reduced by prompt surgical fixation of the fracture and early, effective rehabilitation [3].

The goal of treatment remains restoration of the patient to his or her preoperative status in the earliest possible time, with low morbidity and mortality, and with the least cost and to ensure union in the appropriate position. Operative management of intertrochanteric fractures can be two-fold: either by open reduction and internal fixation with nails or plates or by an external fixator [4].

Elderly patients often have medical problems such as diabetes mellitus, hypertension, stroke, and cardiopulmonary problems, and are unable to tolerate major surgical procedures requiring a long operative time and risk of excessive bleeding. They are also not suitable candidates for conservative treatment as it carries the risk of prolonged recumbency and its complications, and also complications such as shortening and varus collapse [3]. An external fixator offers significant advantages in the form of minimal surgical trauma, negligible blood loss, preservation of fracture hematoma, short operative time, and minimal anesthetic complications, allowing early ambulation of the patient, easy day care, shorter hospital stay, and removal of the implant as a simple outpatient procedure [5].


  Materials and methods Top


Twenty patients, six men and 14 women, with intertrochanteric fractures of the femur were treated by external fixation between March 2011 and September 2012. Eight patients had right and 12 patients had left intertrochanteric fractures. The mean age of the patients was 68.1 years (range 50-85 years). Two fractures were the result of traffic accidents and 18 were because of simple falls. The patients had high surgical and anesthetic risk factors for an open surgical procedure or for extended anesthesia because they had more than one accompanying disease. Patients included in this study were graded according to the American Society of Anaesthesiologists (ASA) scale [Table 1],[Table 2],[Table 3],[Table 4] and [Table 5]. There were 12 ASA grade III patients and eight ASA grade IV patients.
Table 1: SD of time of injury, union, follow-up, and OR time

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Table 2: SD of varus deformity and shortening

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Table 3: Medical problems

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Table 4: ASA classification

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Table 5: Satisfactory and unsatisfactory results

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We used the Evan classification in this study to evaluate the type of fractures. Four patients had type II fracture, four patients had type IV fracture, and 12 patients had type V fracture.

The patients were operated on at an average of 8.6 days (range 2-17 days) following admission. Anesthesia was chosen according to the patient's condition and ASA grade, which was used for estimation of the overall condition of the patient. During the operation, 10 patients underwent spinal, two general, and eight local infiltration anesthesia, together with narcotic analgesic support. The average time of the operation was 27.5 min (range 20-35 min).

A specially designed unilateral uniplanar external fixator construct (ALEX-FIX), made by Professor Dr AdelRefaat (Professor of Orthopedic Surgery, Alexandria University), utilizing femoral neck and femoral shaft Schanz screws, was used in this study [Figure 1]. The C-arm was used for the closed reduction of the fracture and insertion of the Schanz screws into their proper position. The first Schanz screw with a diameter of 6 mm was introduced gradually under bidirectional fluoroscopic guidance into the femoral neck from the base of the greater trochanter across the fracture site at an angle of 125-130° with the femoral shaft and approximately in the center of the femoral head and neck in both the anteroposterior and the lateral views. The tip of the Schanz was stopped 0.5-1 cm from the articular surface of the head. The external fixator clamp was applied to the inserted Schanz screw; then, using the same implantation technique of the first screw, a second proximal Schanz was inserted into the femoral neck through the clamp of the external fixator. Then, two 6-mm-diameter Schanz screws were inserted, through the clamp of the external fixator, into the proximal part of the femoral diaphysis at a right angle to the femoral shaft. The final position of the Schanz screws as well as reduction were checked by an image intensifier in both anteroposterior and lateral views. Finally, the external fixator clamp was tightened by an Allen wrench and thus rigid fixation was obtained at the fracture site [Figure 2],[Figure 3] and [Figure 4].
Figure 1:

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Figure 2:

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Figure 3:

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Figure 4:

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Postoperative protocol

Postoperative regimen

Intravenous prophylactic antibiotics such as ceftriaxone and ampicillin sulbactam were administered immediately before surgery and continued for 3 days postoperatively together with analgesics to alleviate pain.

Ambulation

Patients were allowed to sit in bed on the first postoperative day with active lower limb muscle exercises in the form of quadriceps drill, knee flexion, and ankle motion to prevent deep vein thrombosis. They were encouraged to move their fractured limbs in bed actively and to dangle their feet at the bedside on the second postoperative day.

Patients were encouraged to get out of bed and perform partial weight bearing using a walker, depending on the general condition and co-operation of the patient, bone quality, type of fracture, and stability of reduction, medical status, and prefracture ability to walk. Level of pain was assessed with the start of ambulation on a four-grade verbal scale (none, mild, moderate, or severe).

Immediate postoperative radiographs were compared with those 2 weeks after partial weight bearing to estimate the stability of the fixed fracture.

Care of the fixator

Before discharge, the patients' relatives were instructed on care of the pin tract by daily dressing (by alcohol and betadine) and care of the fixator by weekly brushing.

Statistical analysis

Statistical presentation and analysis of the present study were carried out using the c2 -test.

In c2 -test the hypothesis was that the row and column variables are independent, without indicating the strength or the direction of the relationship. Pearson's c2 -test and likelihood-ratio c2 -test, Fisher's exact test, and Yates' corrected c2 -test were used for 2 × 2 tables.


  Results Top


The results were evaluated according to Kyle and Wright (1980) as excellent, good, fair, and poor in terms of the following points.

Excellent: Normal range of motion, minimum limp, pain, and rare use of a cane.

Good: Normal range of motion, limp, mild pain, and use of a cane.

Fair: Limited range of motion, limp, moderate pain, and use of two canes or a walker.

Poor: Pain on any motion or on a wheel chair or nonambulatory.

In this study, excellent and good results were considered as satisfactory and fair and the poor results were considered unsatisfactory. Overall results were excellent in 10 patients, good in six, fair in two, and poor in two patients. Union occurred in all patients. The time of union (according to radiographic data) and removal of the fixator ranged from 16 to 26 weeks, with an average of 22.2 weeks. No patient required blood transfusion intraoperatively or postoperatively. The external fixator was small and did not interfere with sitting, lying, or walking in conventional clothes. Patients who had performed early weight bearing with crutches on the fractured limb showed better results than patients with delayed weight bearing.

Complications

Pin-tract infection was observed in 14 cases; they all were superficial infections. Shortening less than 1 cm occurred in 10 patients and shortening of more than 1 cm was observed in 10 patients; the result of patients with less than 2 cm shortening was not affected. However, it was unsatisfactory in those with more than 2 cm shortening [Table 6],[Table 7],[Table 8] and [Table 9]. Varus alignment less than 10° was observed in 14 patients, whereas that of more than 10° was present in six patients. There were two cases of penetration of the femoral head (which did not affect the result) 8 weeks postoperatively in one patient and 6 weeks postoperatively in the other. Four patients died a few months after the removal of the fixator because of medical problems (which did not affect the result).
Table 6: Time of union and fixator removal

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Table 7: Pin-tract infection and the end results

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Table 8: Varus deformity and the end results

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Table 9: Shortening and the end results

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The results were not affected by age, sex, side affected, time lag before surgery, medical diseases, and pin-tract infection, but they were affected by the type of the fracture, prefracture walking ability, shortening, and varus deformity.


  Discussion Top


Fractures of the proximal femur have been identified as one of the biggest problems today. Patients with this type of fracture occupy at least 30% of beds in orthopedic institutions [6]. Trochanteric fractures are a usual occurrence in older patients, older than 65 years of age, when there is far greater loss of the skeletal mass (osteoporosis) [7],[8]. In patients with a high surgical risk, conservative treatment by traction in bed is good, provided the patient can survive the hazards of prolonged recumbency. In a developing country such as ours, this type of treatment for intertrochanteric fractures is not suitable because it involves a prolonged bed occupancy rate in the hospital. Keeping patients on traction for at least 8-12 weeks would be difficult; external fixation may therefore be a suitable treatment for those patients with a high operative risk [9].

In high-risk elderly patients, the duration of surgery and amount of blood loss are important controllable variables that affect patient morbidity [9].

The mean operative time was 27.5 min. This is in agreement with the results of many authors [4],[10],[11]. Aly et al. [12] and Kazakos et al. [13], who reported a longer mean operative time of 35.37 min in their group. No patients in this study required intraoperative or postoperative blood transfusion; also, blood loss was negligible, as reported by other authors [1],[4],[10],[11],[12],[13].

Initial knee stiffness was recorded in the majority of patients treated with other fixator types [4],[14]. Knee stiffness was not a problem in this study because our frame was too short to transfix the vastus lateralis for a long distance; in addition, the distal Schanz screws were, whenever possible, inserted posterior to the iliotibial tract.

Union was achieved on an average of 22.2 weeks, ranging from 16 to 26 weeks. The rate of union at this period is within the average rate of union at this area because of its rich blood supply and the fixation adopted.

Infection was the most commonly encountered complication in this study. Most patients had a superficial pin-tract infection during the course of treatment. This high incidence may be because the patients involved in this study were immunocompromised, and because of the social situation of some patients. A high incidence of superficial infection was also reported in previous studies [4],[15].

The mean shortening in this study was 1.4 cm and this was almost the same as that reported by Mitkoviæ and colleagues and Kazakos and colleagues. This was probably because of the type and pattern of fracture and its subsequent stability, which led to collapse of the neck shaft angle on weight bearing. Kourtzis et al. [16] suggested that the low demands of the elderly allow this degree of shortening to entail no significant functional compromise.

Patient compliance with the external fixator is an important point for the success of the treatment. In this study, all patients were compliant with the fixator as it is simple and allows sitting, lying on the side, and standing at ease. It was our impression that early weight bearing with crutches on the fractured limb gave the patients confidence and encouraged them to stay out of bed, and to undertake daily activity. This encouragement gave the patients more confidence in returning to an unaided life.

On the basis of our observations, we conclude that external fixation of intertrochanteric fractures can provide an alternative method of fixation in elderly high-risk patients. It can be done under local anesthesia and reduces the complications associated with major surgical procedures. It has good outcome in high-risk geriatric patients, provided due consideration is given to pin-site care in these older patients.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Subasi M, Kesemenli C, Kapukaya A, Necmioglu S. Treatment of intertrochanteric fractures by external fixation. Acta Orthop Belg 2001; 67 :468-474.  Back to cited text no. 1
    
2. Mittal R, Banerjee S. Proximal femoral fractures: principles of management and review of literature. J Clin Orthop Trauma 2012; 3 :15-23.  Back to cited text no. 2
    
3. Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, et al. Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2012; 67 :85-98.  Back to cited text no. 3
    
4. Barros JW, Ferreira CD, Freitas AA, Farah S. External fixation of intertrochanteric fractures of the femur. Int Orthop 1995; 19 :217-219.  Back to cited text no. 4
    
5. UlGani N, Kangoo KA, Bashir A, Muzaffer R, Wani MM. External fixation of ′intertrochanteric′ fractures. Orthop Rev 2009; 1 :31-35.  Back to cited text no. 5
    
6. Zetterberg C, Andersson GB. Fractures of the proximal end of the femur in Göteborg, Sweden, 1940-1979. Acta Orthop Scand 1982; 53 :419-426.  Back to cited text no. 6
    
7. Hordon LD, Peacock M. Osteomalacia and osteoporosis in femoral neck fracture. Bone Miner 1990; 11 :247-259.  Back to cited text no. 7
    
8. Johnell O. Prevention of fractures in the elderly. Acta Orthop Scand 1995; 66 :90-98.  Back to cited text no. 8
    
9. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop Relat Res 1984; 186 :45-56.  Back to cited text no. 9
    
10.Mitkoviæ M, Milenkoviæ S, Bumbašireviæ M, Lesiæ A, Goluboviæ Z, Mladenoviæ D, et al. Surgical treatment of pertrochanteric fractures using personal external fixation system and technique. Med Biol 2002; 9 : 188-191.  Back to cited text no. 10
    
11.Vossinakis IC, Badras LS. The external fixator compared with the sliding hip screw for pertrochanteric fractures of the femur. J Bone Joint Surg Br 2002; 84 :23-29.  Back to cited text no. 11
    
12.Aly TA, Hafez K, Abo El-nor K, Amin O. Treatment of trochanteric fractures by external fixator in patients with high unacceptable operative risk. Pan Arab J Ortho Trauma 2004; 8 .  Back to cited text no. 12
    
13.Kazakos K, Lyras DN, Verettas D, Galanis V, Psillakis I, Xarchas K. External fixation of intertrochanteric fractures in elderly high-risk patients. Acta Orthop Belg 2007; 73 :48.  Back to cited text no. 13
    
14.Kamble KT, Murthy BS, Pal V, Ráo KS. External fixation in unstable intertrochanteric fractures of femur. Injury 1996; 27 :139-142.  Back to cited text no. 14
    
15.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; 56 :385-390.  Back to cited text no. 15
    
16.Kourtzis N, Pafilas D, Kasimatis G. Management of pertrochanteric fractures in the elderly patients with an external fixation. Injury 2001; 32 :SD115-SD128.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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