Treatment of Unstable Intertrochanteric fracture of the femur in Elderly Patients

Hwang, Deuk Soo; Ahn, Cheol Se; Lee, Sang Yong

Abstract

Intertrochanteric fractrures in elderly are a frequent problem and are becoming more common as the population of elderly people in the population increase. The treatment of unstable intertrochanteric fracture present a challenging problem. Severe comminution in elderly osteoporotic patients renders internal fixation difficult and precipitate varus malpositioning after internal fixation. We analysed 48 unstable intertrochanteric fractures in 48 elderly patient (58 to 91 yeared, mean age : 78 years) with advanced osteoporosis (grade III or more by Singh et al., and by BMD) between May, 1990 to March, 1995 ; Nineteen had been treated with an anatomical reduction with dynamic hip screw(DHS). In addition to DHS fixation, additional circumferential wiring was done in 1 cases, adjunctive methylmethacrylate bone cement fixation in head and neck was done 2 cases. We classified lag screw fixation alone group as DHS , lag screw fixation and additional oircurnferential wire reinforcement group as DHS II. Twenty had been treated with an anatomical reduction with gamma nail. Another nine that had severe comminuted fracture had been treated with bipolar hemiarthroplasty. In DHS II and gamma nailing group, operation time was longer and amount of transfusion after postoperative period was much than DHS I group. In DHS fixation group, lag screw fixation and additional tircurnferential wire reinforcement of posteromedial fracture fragment group was more favor result than lag screw fixation alone. Nonunion developed in two cases of adjunctive methylmethacrylate fixation with DHS, and malunion(external rotation) developed in two cases of DHS fixation group. We concluded that better result are obtained when posteromedial fracture fragment reduced with circumferential wiring with DHS. In addition to anatomical reduction of fragment, encouraging early postoperative ambulation also contribute to good prognosis. A number of the patients who had fear for weight bearing after 3 month postoperatively compromise ambulation on further follow up. In severely commented fracture that was not able to get stable reduction or in patient necessary for early weight bearing, hemiarthroplasty permit to early ambulation, but it also have many disadvantage.