Trochanteric fractures are frequent in the elderly, and the number is increasing with time because of an increasing life span and a more sedentary lifestyle. A typical trochanteric femoral fracture is characterized by old age, poor bone stock, and significant comorbid conditions. Most patients suffer from these injuries because of minor trauma. Unstable intertrochanteric fractures in elderly patients are associated with a high mortality rate of up to 20% during the first postoperative year [1].  Excessive collapse at the fracture site, loss of fixation, and migration of the lag screw result in poor functional problems associated with internal fixation of unstable intertrochanteric fractures in elderly patients with osteoporotic bones. Approximately 35–40% of these fractures are unstable (Association Osteosynthesis (AO)/Orthopaedic Trauma Association (OTA) type 31-A2.2 and 31-A 2.3), with displacement and comminution of the posteromedial cortex [2]. Stable fractures can be managed successfully with osteosynthesis by internal fixation with satisfactory results; however, unstable intertrochanteric fractures are difficult to manage by internal fixation because anatomical reduction is difficult to achieve. The failure rate of unstable intertrochanteric fractures managed with internal fixation devices has been reported to be approximately 6–32% [3,4].

Poor bone quality and unstable fracture configuration are the most important factors contributing to failure. Delayed mobilization in elderly patients with unstable intertrochanteric fractures leads to complications such as bedsores, respiratory problems such as Lower Respiratory Tract Infections (LRTI), and deep vein thrombosis. Therefore, stable fracture fixation, bone quality, and early mobilization collectively contribute to the final functional outcome in these patients. Intramedullary devices have decreased the incidence of screw cut-outs in osteoporotic bones, but their role in osteoporotic unstable and comminuted intertrochanteric fractures remains unclear. The literature shows encouraging results for these types of fractures with endoprosthetic replacement. Therefore, we conducted a prospective study to evaluate the functional and clinical outcomes of hemiarthroplasty with a cemented bipolar prosthesis as a primary treatment for unstable intertrochanteric fractures in elderly patients.

This prospective study was done in the Department of Orthopedics, Govt Medical College and Hospital Solapur. Institutional Ethical approval was obtained for the study based on the Helsinki protocol for human research. Written consent was obtained from all the participants included in the study after explaining the nature of the study in the vernacular language.

Inclusion Criteria:

1. Elderly patients (aged ≥55 years) diagnosed with unstable intertrochanteric fractures (AO/OTA type 31-A2.2 and 31-A2.3 fractures)
2. Patients are medically fit for surgery as determined by preoperative evaluation.
3. Ability to provide informed consent or availability of a legal guardian to do so.
4. Ambulatory status before the fracture (independent or with assistive devices).
5. No prior surgery or implant in the affected hip.

Exclusion Criteria:

1. Pathological fractures resulting from metastatic disease or infection.
2. Severe cognitive impairment or dementia precluding informed consent or postoperative rehabilitation.
3. Active infection at the surgical site or systemic infections.
4. Contraindications to anesthesia or surgery due to comorbidities.
5. Prior hip arthroplasty or fixation on the same side.

The study included 24 patients who presented to the Orthopedic Outpatient Department and Emergency of our institution from January 2021 to Sept 2024 with trochanteric femoral fractures which are unstable, comminuted, and osteoporotic based on the inclusion and exclusion criteria. Males were 18 cases and females were 6 cases, the male-to-female ratio was 3: 1 (18 male and 6 female). Trochanteric femoral fractures were classified according to AO. Only AO/OTA type 31-A2.2 and 31-A2.3 fractures were included in this study. Previously, non-ambulatory patients, patients with mental disorders, neuromuscular weakness, compound fractures, and pathological fractures were excluded from this study. Out of 24 patients, 14(58.3%) patients were walking without support and 10(41.7%) patients were walking with support before injury. Replacement and stabilization were done with cemented bipolar prosthesis along with trochanteric reconstruction.

Operative technique: Patient positioning: Position the patient with the affected hip upward in a lateral position. Prepare the skin over the hip and square off the lateral aspect of the hip from the iliac crest to the proximal thigh with towels and drapes. We used the lateral approach in the lateral position. Subcutaneous tissue is divided along with a skin incision in a single plane down to fascia lata and fascia covering gluteus medius superiorly. Fracture fragments were exposed. The femoral head is dislocated anteriorly and removed. When the lesser trochanter is found as a separate fragment it is tied to the shaft using stainless steel (SS) wires. In cases of greater trochanter fracture en masse, it is attached to the main shaft using SS wires. In cases in which the greater trochanter is coronally split, a tension band wiring is used. In cases in which the greater trochanter is severely comminuted, Ethibond sutures are used to suture together the trochanteric pieces and the soft tissues to make a stable construct. After a proper neck cut, the femoral canal is prepared with adequate anteversion. After trial reduction, we inserted a cemented bipolar prosthesis by using a cementing technique.

Rehabilitation protocol: The patients were allowed to sit up on the bed hanging legs by the side on the second day. Quadriceps strengthening exercises, knee flexion, and extension exercises were started on the second day and patients were allowed a full weight-bearing walk with a walking aid after the third day and/or as the pain and discomfort were tolerated. Adduction and abduction exercises of the hip started after seven days. Squatting and sitting cross-legged were restricted and patients were encouraged to leave their walking aids as soon as possible. The postoperative hip function was evaluated using the Harris Hip-Scoring system. The mean follow-up period was 2 years (2–4 years).

Statistical analysis: All the available data was refined and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 22 in Windows format. The continuous variables were represented as mean, standard deviation, and percentages. Categorical variables were determined by the Chi-square test and the values of p (<0.05) were considered as significant.

Table 1 depicts the age and sex distribution of cases included in the study. The majority of patients were in the age groups of 61-70 years (41.67%) and >80 years (25%). The mean age of the patients was 69 ± 8.5 years (range: 55–83 years). Out of 24 patients, 18 (75%) were female and six (25%), were male with a male: female ratio of 3: 1.

Table 1: Age and sex-wise distribution of cases included in the study

Figure 1: Showing the AO Classification of fractures included in the study

The left hip was involved in 13(66.7%) patients and the right hip was involved in 11(33.3%) patients. There were 20 patients of type 31-A2.2 and 8 were of type 31-A2.3 according to AO classification (Figure 1). In all, 37.5% are hypertensive, 25% are diabetic, 12.5% have cardiac problems, and 25% cases are without any medical comorbidities (Figure 2).

Figure 2: Showing the existence of comorbidities in the cases of the study

Most of the surgeries were performed within 10 (50%) days of admission; the mean delay was 5 days because of a pre-anesthetic check-up. In all patients, hemiarthroplasty was done with a cemented bipolar prosthesis. Before injury, three of the patients were ambulatory indoors and 21 were successfully participating in community activities. Most cases required 1 unit of postoperative blood transfusion, and four cases required 2 units. The mean duration of surgery was 90 min, ranging from 55 to 125 min. The mean blood loss was 250 ml and ranged between 200 and 300 ml.

The majority of patients are allowed full weight-bearing on the third to fifth postoperative day. The mean hospital stay was 7 days (1–2 weeks). A total of 12 (50%) patients were discharged from the hospital within a week of the operation and nine (37.5%) patients were discharged after stitch removal on the 15th day; three (12.5%) patients were discharged after 15 days because of superficial wound infection, which was managed by daily dressing. None of the patients required debridement. The dislocation rate in our study was zero. Although the surgical technique might decrease the risk of dislocation if proper soft tissue balancing around the hip joint, proper restoration of equal leg length, and proper selection of the neck length, offset, and version were performed.

Table 2: Harris Hip Scores at various intervals in the study

The mean Harris hip score improved progressively with time of follow-up (Table 2). The mean score was 50.30 on the third day, which increased to 60.61 at 2 weeks, whereas at 3 and 6 months the scores were 77.1 and 88.87, respectively. The final average Harris hip score at the last follow-up was 82.90. At the last follow-up, 15 patients were walking without any aid and nine patients were walking with support. After 2 weeks of surgery, the score was poor. By 6 weeks, the majority had a fair score. At 3 months, Harris's hip score was good in all the patients. At the last follow-up, the score was good in 19 patients and excellent in five patients. Thus, it was observed that the score increased progressively and the difference in score between two consecutive follow-ups was highly significant, especially between 2 and 6 weeks. One patient died after 9 months of operation because of some other medical problem not related to surgery. This patient was included in Harris hip score for 6 months. Limb length discrepancy was observed in seven patients and average shortening was 1.2 cm (range: 0.4–1.6 cm). At the final follow-up, four patients had abductor muscle weakness on Trendelenberg’s test.

Unstable intertrochanteric fractures in elderly patients are characterized by osteoporosis, severe comminution, and displacement. The maintenance of reduction can be a major problem in patients with osteoporotic and/or comminuted fractures during the healing period. To reduce healing time, dynamic devices are replaced with static devices. Biomechanical studies have shown that dynamic implants have greater weight-bearing capacity than static implants [5–7]. It has been recommended that the position of the screw in the femoral head should be in the center [8], which yields a cut-out rate of approximately 13%. Accurate anatomic reduction of these fractures is difficult to achieve and rather more difficult to maintain, which usually leads to malunion or failure of reduction. Therefore, postoperative early full weight-bearing is not easy, and postoperative complications and mortality rates are high. Intertrochanteric fractures account for 45% of all hip fractures [2]. Stable two-part fractures can be fixed using sliding hip screws or intramedullary implants. However, 35–40% of fractures are unstable (AO/OTA type 31-A2.2 and 31-A2.3) and are associated with high rates of morbidity and mortality [2]. The overall failure rate of internal fixation of intertrochanteric fractures ranges from 3 to 16.5%, which is higher in elderly patients with unstable fractures [9]. Because of the high failure rates, and complications associated with internal fixation, the use of hemiarthroplasty, and total hip arthroplasty as primary treatment for these fractures have emerged. Tronzo [10] pioneered the use of prostheses for the primary treatment of comminuted intertrochanteric fractures. Stern and Goldstein [11] used the Leinbach prosthesis for the primary management of 22 intertrochanteric fractures and concluded that early mobilization and recovery to preinjury status are definite advantages. Rodop et al. [12] in a study of primary bipolar arthroplasty for unstable intertrochanteric fractures in 37 elderly patients obtained 17 (45%) excellent and 14 (37%) good results after 12 months according to the Harris hip-scoring system. Haentjens et al. [13] compared the outcomes of internal fixation and hemiarthroplasty and reported a significantly reduced incidence of pneumonia and pressure sores in the hemiarthroplasty group. Sancheti et al. [14] concluded that primary hemiarthroplasty provides a stable, pain-free, and mobile joint with an acceptable complication rate. Elderly patients who are often unable to cooperate with partial weight-bearing, which is required after internal fixation, respond to full weight-bearing with arthroplasty. This reduces the period of recumbency and related complications. We conclude that arthroplasty allows early and rapid recovery of preinjury status with immediate weight-bearing and maintenance of a good level of function with minimal risk of mechanical failure. The tendency for dislocation was limited to negligible by the use of a bipolar prosthesis with a large-diameter head and a self-centered cup [15]. We performed cemented bipolar surgery in all elderly patients with osteoporotic/unstable/comminuted intertrochanteric fractures. They can ambulate early, thereby avoiding the potential complications of prolonged immobilization. Therefore, there was no uncertainty in the union of the fracture. This provided substantial stability to the hip and allowed full weight-bearing in the immediate postoperative period. The limitations of our study are the small number of patients and the relatively short follow-up period. In the future, a comprehensive prospective study with a longer follow-up period is necessary.

Trochanteric reconstruction with Ethibond or steel wires and the formation of calcar with cement plays an important role in the stable and correct placement of bipolar prostheses. Early postoperative full weight-bearing, shorter hospital stays, excellent functional stability, and absence of postoperative complications related to non-weight-bearing after internal fixation in arthroplasty with cemented bipolar prosthesis make this a valid and promising modality for the management of unstable intertrochanteric fractures in the elderly.

1. Esser MP, Kassab JY, Jones DH. Trochanteric fractures of the femur. A randomized prospective trial comparing the Jewett nail plate with the dynamic hip screw. J Bone Joint Surg Br 1986; 68:557–60.
2. Grimsrud C, Monzon RJ, Richman J, Ries MD. Cemented hip arthroplasty with a novel circlage technique for unstable intertrochanteric hip fractures. J Arthroplasty 2005; 20:337–43.
3. Thomas AP. Dynamic hip screw that fails. Injury 1991; 22:45–46.
4. Kouvidis G, Sakellariou VI, Mavrogenis AF, Stavrakakis J, Galanakis J, Kampas D, et al. Dual lag screw ceplalo-medullary nail versus the classic sliding hip screw for stabilization of intertrochanteric fractures. A prospective randomized study. Strategies Trauma Limb Reconstr 2012; 7:155–62.
5. Chang WS, Zuckerman JD, Kummer FJ, Frankel VH. Biomechanical evaluation of anatomic reduction versus medial displacement osteotomy in unstable intertrochanteric fractures. Clin Orthop Relat Res 1987; 225:141–46.
6. Desjardins AL, Roy A, Paiement G, Newman N, Pedlow F, Desloges D, et al. Unstable intertrochanteric fracture of the femur. A prospective randomized study comparing anatomical reduction and medial displacement osteotomy. J Bone Joint Surg Br 1993; 75:445–47.
7. Davis TR, Sher JL, Horsman A, Simpson M, Porter BB, Checketts RG. Intertrochanteric femoral fractures. Mechanical failure after internal fixation. J Bone Joint Surg Br 1990; 72:26–31.
8. Haentjens P, Casteleyn PP, Opedecam P. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient. Arch Orthop Trauma Surg 1994; 113:222–27.
9. Davis TR, Sher JL, Horsman A, Simpson M, Porter BB, Checketts RG. Intertrochanteric femoral fractures. Mechanical failure after internal fixation. J Bone Joint Surg Br 1990; 72:26–31.
10. Tronzo RG. The use of an endoprosthesis for severely comminuted trochanteric fractures. Orthop Clin North Am 1974; 5:679–81.
11. Stern MB, Goldstein TB. The use of the Leinbach prosthesis in intertrochantric fractures of the hip. Clin Orthop Relat Res 1977; 128:325–31.
12. Rodop O, Kiral A, Kaplan H, Akmaz I. Primary bipolar hemiprosthesis for unstable intertrochanteric fractures. Int Orthop 2002; 26:233–37.
13. Haentjens P, Casteleyn PP, de Boeck H, Handelberg F, Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. Primary bipolar arthroplasty compared with internal fixation. J Bone Joint Surg Am 1989; 71:1214–25.
14. Sancheti KH, Sancheti PK, Shyam AK, Patil S, Dhariwal Q, Joshi R. Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly: a retrospective case series. Indian J Orthop 2010; 44:428–34.
15. Charnley J. Low friction principle, and clean air operating − theory. In: Low friction arthroplasty of the hip. Theory and practice. First edition. New York, NY: Springer. 1979; 3–15: p. 152–168.