Title: Medium-term surgical results of intertrochanteric fractures in people over 50
Author(s): Mohammad Reza Farahanchi MD, Seyyed Mohammad Jazayery MD, Mohhamad Reza Abbasian MD*
Affiliattion(s): Shahid Beheshti University of Medical Sciences, Tehran, Iran
* Corresponding Author
Vol 1, Num 2, October 2014
Introduction: Hip fractures due to falls are among the most common and costly fractures in the elderly. Regardless of the type of fracture, it is obvious that the rate of mortality and morbidity is very high in these patients.
Materials and Methods: This retrospective descriptive study was performed on patients who were admitted and surgically treated for intertrochanteric fracture in Akhtar hospital between 1994 and 2004.During the evaluation hips were carefully examined and Harris Hip Score was recorded for each hip. In the radiographs, the position of the device, alignment of the fracture and the situation of union were assessed.
Results: A total of 65 patients died during the follow-up period and only 293 (57.22%) people were present at the hospital to be evaluated. From the total number of 293 cases, 194 (66.2%) were male and 99 (33.9%) were female. The mean age of patients was 65 ± 6.67 years (51 – 83 years). The follow-up time for each patient was at least 1 year. Among the patients, in 121 cases (41.3%) HHS was 80-100, in 101 cases (34.5) was 60-80, in 46 cases (15.7%) was 40-60 and in 25 cases (8.5%) was less than 40. From all 293 patients who were evaluated, only 90 cases (30.7%) acquired their preoperative ADL abilities.
Conclusion: Intertrochanteric fractures are associated with great mortality and morbidity following surgical treatment even within 48 hours past the injury. So preventive measures seems to be so important to reduce this morbidity and mortality rate.
Keywords: Intertrochanteric, Fracture, Internal fixation
Hip fractures due to falls are among the most common and costly fractures in the elderly.(1,2) The patients with these fractures occupy about 20 percent of orthopedic beds in the UK.(2)
The total number of these fractures all around the world are assumed to be 1.26 million/year and this number is expected to raise to 2.6 million in 2025 and about 4.5 million in 2050.(3)
Regardless of the type of fracture, it is obvious that the rate of mortality and morbidity is very high in these patients.(4) Mortality in the first year after the fracture is about 20 percent. Near 31% of men and 17% of women with hip fractures die from the complications of these fractures.(5) Fractures of the proximal femur are 2 to 3 times more common in women than men.(6)
In the USA, more than ninety percent of proximal femoral fractures are seen in patients older than 50 years. It is noteworthy that the incidence of these doubles with each 10 years after age 50.(4) There are various factors influencing the incidence of these fractures, like older age, smoking, history of previous fractures of the hip, consumption of too much alcohol or too much caffeine, lack of physical activity, lower weight, dementia and some psychologic problems (4) and most important, osteoporosis.(7)
Intertrochanteric fractures the same as the distal radial and vertebral body fractures are osteoporotic fracture.(8) One of the main problems in treating this type of fracture, is low rate of return of patient to the preoperative level of activity and independence in activity of daily living (ADL).(9) More than half of these patients require a support to perform their activity of daily living and more than 25% of them need life-long support.(10)
In elderly people, the major mechanism of hip fractures is falling down.(1, 7)
There are different classification systems for describing intertrochanteric fractures. One of the most commonly used systems is Boyd and Giriffin classification, which describes all the fractures in the proximal femoral from intracapsular region up to 5 cm inferior to lesser trochanter.(11) But according to the study by Jin et al, the AO classification system was more accurate and reliable than Boyd and Griffin and Evans systems.(12) Since osteoporosis is nowadays very common and the expected risk for intertrochanteric fracture is very high in elderly people and on the other hand, each of these fractures impose a huge amount of expenses to both family and society, we decided to evaluate the surgical result of intertrochanteric fractures in patients treated in Akhtar orthopaedic hospital between 1994-2004. The results of this study would provide an overview of the effectiveness of surgical treatments for intertrochanteric fractures. If these results are not satisfactory, geriatricians can help us how to prevent these fractures in order to reduce the number of these catastrophic fractures.
Materials and Methods
This retrospective descriptive study was performed on patients who were admitted and surgically treated for intertrochanteric fracture in Akhtar hospital between 1994 and 2004.
At first, we assessed the archives of the hospital and found 512 patients with intertrochanteric fractures. The required information including name, address, phone number, age, sex, cause of accident, presence of osteoporosis, fracture classification according to X-rays and the procedure used were recorded in the information sheath. Patients were then contacted and invited to attend the clinic.
Inclusion criteria were the presence of intertrochanteric fracture, age≥50 years and surgical treatment. Patients with intertrochanteric fractures with pathological origin, those who did not have perfect reduction in the postoperative X-rays and those who were not treated surgically were excluded.
Patients who came to follow-up were initially requested to sign a written consent to the agreement and those who signed this consent, underwent clinical evaluation.
During the evaluation hips were carefully examined and Harris Hip Score was recorded for each hip. Then, we obtained a new X-ray of the affected hip and compare with the previous X-rays. In these radiographs, the position of the device, alignment of the fracture and the situation of union were assessed. To avoid bias, all the clinical evaluations and X-ray interpretations were performed by the same surgeon.
All the data were analyzed by SSPS software and the results extracted.
A total of 512 cases of intertrochanteric fractures were found in archival records. Of these, 154 patients were excluded due to displacement from the recorded address and lack of access to them. A total of 65 patients died during the follow-up period and only 293 (57.22%) people were present at the hospital to be evaluated. From the total number of 293 cases, 194 (66.2%) were male and 99 (33.9%) were female. The mean age of patients was 65 ± 6.67 years (51 – 83 years). The follow-up time for each patient was at least 1 year.
In assessing the X-rays, 252 (86%) out of 293 patients had complete fracture union and 41(14%) had nonunion. (P <0.01) In assessing the alignment at the fracture site, 158 patients (54%) had inappropriate alignment and the rest had proper alignment. (p <0.2) Any malalignment in the medial cortex or asymmetry in the proximal femur with respect to the contralateral hip from the fracture site and any device failure were considered as inappropriate alignment. All the cases had perfect alignment postoperatively and those with malalignment in the postoperative X-rays were excluded.Among the patients, in 121 cases (41.3%) HHS was 80-100, in 101 cases (34.5) was 60-80, in 46 cases (15.7%) was 40-60 and in 25 cases (8.5%) was less than 40.
From all 293 patients who were evaluated, only 90 cases (30.7%) acquired their preoperative ADL abilities. But, the remaining 203 cases (69.3%) lost their preoperative ADL abilities. (p≥0.05) The assessment of this ability was evaluated by asking the patient himself.
The association between returning to the preoperative abilities and factors such as age, sex and the time interval between the accident and the surgery were evaluated. Of 90 patients who could return to their preoperative abilities, 63 cases (70%) were male and 27 (30%) were female. 39 cases out of these 90 patients(43.3%) were younger than 65 years and 51 cases (56.7%) were older than 65 years. Among the patients who could return to their preoperative abilities, 65 cases (72.2%) and among those who could not return to their preoperative abilities, 168 cases (82.7%) were operated on with at least 48 delay. (p=0.3) (Table 1)
Proximal femoral fractures are one of the most common reasons for hospital admission in the elderly. There seems to be a significant increase in the incidence of these fractures due to the increase in the percentage of elder people in the society in the future decades.(13) According to orthopaedic literature, the annual incidence of intertrochanteric fracturesis 63 cases among every 100,000 women and 34 cases among every 100,000 men.(6)
Intertrochanteric fractures occur in the region between two trochanters which is a transitional area between the femoral neck and shaft.(8) The intertrochanteric fracture is an independent risk factor for mortality.(5)
The incidence of these fractures increases with advancing age.(9) The main mechanism of intertrochanteric fractures in the elderly is falling and the major underlying factor is osteoporosis.(8) So, the intertrochanteric fractures, like distal radial and vertebral body fractures, are among the osteoporotic fractures.(6)
In a study with 10 years follow-up, the mortality rate following an intertrochanteric fracture was 2 times more than the general population. The walking ability during the first year after the fracture was reduced significantly but during the following years, it remained at a steady-state.(3)
In another study, the morbidity and mortality rate was least following the displaced femoral neck fractures and was the most following unstable intertrochanteric fractures.(10)
In our study 83% of our patients sustained fractures following simple falls and the rest are due to fall from height and car accidents. 66.1% of the patients were male and 33.9% were female. This finding is opposite to the literature.(6,14) This difference could be due to a difference in our living cultures with that of western people. In our country, the social activities of female people are very much limited in their 60s and over with respect to men. So, our old men should be the main target of prevention programs.
Risk of nonunion in fractures of the trochanteric region is very low, occurring in one or two percent of intertrochanteric fractures.(15) It would be due to good blood supply and presence of spongy bone in the area.
In the study by Verattas (17) and colleagues a case of nonunion was reported, however, we found 14% of nonunion which shows a significant difference.
In other studies by Johnell et al (2) and Evans (4) this incidence of nonunion was close to that in our study. The literature shows a rate of 6 to 26% of malalignment following surgical treatment of intertrochanteric fractures.(18)
Verattas et al reported 14 cases (22%) of malalignment and our study shows a rate of 46%, which is significantly more than the literature.
Although the major goal of surgical treatment of these fractures is returning the patient to his/her preoperative level of activity, our study shows this happens in only 30.7% of patients, which is consistent with the literature. This shows that internal fixation of intertrochanteric fractures is not the best treatment option. In a study comparing one year results of the intertrochanteric fractures treated by THA with hemiarthroplasty and internal fixation, the results of THA was better than two other methods.(9) But this treatment modality is expensive.
Our results show that the age older than 65 years is a risk factor for returning to preoperative level of activities, which may be due to increased incidence of comorbidities and increased incidence of osteoporosis. Literature shows the same results.(10)
In the present study, sex was not a negative factor for returning to the preoperative activities.
Our study shows that the return to preoperative level of activities was significantly less among the patients who were operated on after 48 hours past the trauma. Khan et al, in a systematic review on 52 articles, showed that performing the surgery within the first 48 after fracture is associated with a reduced risk of morbidity and mortality.(19)
Our study has some limitations, the most important of which is that it is a retrospective descriptive study.
Intertrochanteric fractures are associated with great mortality and morbidity following surgical treatment even within 48 hours past the injury. So preventive measures seems to be so important to reduce this morbidity and mortality rate.
Mohammad Reza Farahanchi MD Professor emeritus, Orhtopaedic surgeon, Shahid Beheshti Medical University, Tehran, Iran
Seyyed Mohammad Jazayery MD Orthopaedic surgeon, Associate professor, Shahid Beheshti Medical University, Tehran, Iran email@example.com
Mohhamad Reza Abbasian MD Assistant professor, Orhtopaedic surgeon, Shahid Beheshti Medical University, Tehran, Iran Corresponding author firstname.lastname@example.org
Acknowledgements: None declared.
Financial disclosure: None declared.
1. Navali A. M, Moradi A. Survivorship and Outcomes of Patients with Intertrochanteric Fracture of Femur: A Prospective Study with Six Months Follow up. Med J TUS 2008;19(4).
2. Johnell O, Gullberg B, Allander E, Kanis J. A. The apparent incidence of hip fracture in Europe: a study of national register sources. MEDOS Study Group. Osteoporos Int 92;2(6): 298-302.
3. Tsuboi M, Hasegawa Y, Wingstrand H, Thorngren K-G. Mortality and mobility after hip fracture in Japan: A ten-year follow-up. JBJS[Br] 2007;89(4):461-466.
4. Evans P. J, McGrory B. J. Fractures of the Proximal Femur. Hospital Physician 2002;30-38.
5. Karagiannis A, Papakitsou E, Dretakis K, Galanos A, Megan P, Lambiris E, Lyritis GP. Mortality rates of patients with a hip fracture in a southwestern district of Greece: ten-year follow-up with reference to the type of fracture. Calcif Tissue Int.2006;78(2):72-7.
6. Melton L. J, Ilstrup D. M, Riggs B. L, Beckenbaugh R. D. Fifty- year trend in hip fracture in cadence. Clin Orthop Relat Res 1982;162:144-9.
7. Zuckerman J. D. Hip fracture. N Engl J Med 1996;334:1519-25.
8. Cummings S, Black D, Nevitt M. Bone Density at various sites for prediction of hip fracture. Lancet 1994;341:72-75.
9. Haentjens P, Autier Ph, Barette M, Boonen S. Predictors of functional outcome following intracapsular hip fracture in elderly women: A one-year prospective cohort study. Injury, Int J Care Injured 2005;36:842-850.
10. Cornwall R, Gilbert M. S, Koval K. J, Strauss E, Siu A. L. Functional outcomes and mortality vary among different types of hip fractures: a function of patient characteristics. Clin Orthop Relat Res 2004;425:64-71.
11. LaVelle DG. Fractures and dislocations of the hip. Canale S. T, Beaty J. H. Campbell's operative orthopaedics. Pennsylvania: Mosby Elsevier; 2008.
12. Jin W-J, Dai L-Y, Cui Y-M, Zhou Q, Jiang L-S, Lu H. Reliability of classification systems for intertrochanteric fractures of the proximal femur in experienced orthopaedic surgeons. Injury, Int J Care Injured 2005;36:858-861.
13. Giannoudis P. V, Tsiridis E. Proximal femoral fractures: Factors affecting mortality and outcomes. Injury, Int J Care Injured 2006;37:677-678.
14. Koval K. J, Aharonoff G. B, Rokito A. S, et alPatients with femoral neck and intertrochanteric fractures. Are they same? Clin Orthop 1996;330:166-172.
15. Mulholland R. C, Gunn D. R. Sliding screw plate fixation of intertrochanteric femoral fracture. J trauma 1972;12:581-91.
16. Ruff M. E, Lobbers L. M. Treatment of subtrochanteric fractures with a sliding screw plate device. J trauma 1986;26:75-80.
17. Verattas D. A. J, Galanis B, Kazakos K, Hatziyiannakis A, Kotsios E. Fractures of the proximal part of the femur in patients under 50 years of age. Injury 2002;33:41-45.
18. Wiss D. A, Brien W. W. Subtrochanteric fracture of the femur. Results of treatment with an interlocking nail. Clin Orthop 1992;283:231-6.
19. Khan S. K, Kalra S, Khanna A, Thiruvengada M. M, Parker M. J. Timing of surgery for hip fractures: A systematic review of 52 published studies involving 291,413 patients. Injury, Int J Care Injured 2009;40:692-697.
20. Davis T. R. C, Sher J. L, Porter B. B, Checketts R. G. The timing of surgery for intertrochanteric femoral fractures. Injury 1998;19:244-246.