Correlation between fracture type and alignment of bipolar long stem cemented in the elderly intertrochanteric fracture

JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 CORRELATION BETWEEN FRACTURE TYPE AND ALIGNMENT OF BIPOLAR LONG STEM CEMENTED IN THE ELDERLY INTERTROCHANTERIC FRACTURE Vu Anh Dung¹, Vu Nhat Dinh¹ Summary Objectives: To observe the characteristic fracture and evaluate the relationship between fracture type and alignment of bipolar long stem cemented in the elderly intertrochanteric fracture Subjects and methods: A total of 79 senile patients (> 60 years) with inter-trochanteric femur fractures due to low energy injuries treated with long stem cemented bipolar hip arthroplasty (BHA) between 2016 and 2021 were evaluated All patients were evaluated by radiologic findings in the pre and post-operation Patient age and gender were compared between fracture with stable (AO/OTA) The age was classified follows WHO Alignment was divided into three groups: valgus alignment, neutral, and varus Results: Patients with stable fractures included men and 26 women, while patients with unstable fractures included 16 men and 32 women (p > 0.05) There was no statistical difference in patient age between the two groups (stable and unstable) A male to female ratio was statistically higher in patients with unstable fractures (16/32 vs 5/26, p < 0.05) There were 49 cases with varus tilt and valgus tilt Among these, the average stem varus tilt in the sagittal plane was 1.8° (1 - 4°) There was a significant difference between the two groups (stable and unstable) regarding the alignment of the stem Conclusion: Stability of intertrochanteric fractures maybe not be associated with age and alignment of bipolar long stem cemented when elderly patients fall There was a significant difference between the two groups (stable and unstable) regarding the alignment of the stem Gender may be a possible contributing factor but requires further proof * Keywords: Intertrochanteric fracture; Bipolar long stem cemented; Elderly ¹Trauma and Orthopedic Center, Military Hospital 103 Corresponding author: Vu Anh Dung (surgeonvuanhdung@gmail.com) Date reveiced: 5/4/2022 Date accepted: 11/4/2022 193 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 INTRODUCTION For many years, intertrochanteric fractures have been the most common in the elderly, usually due to a simple fall in the house Conceptually, the intertrochanteric fracture should be treated more carefully to lower the treatment failure rate The treatment options include internal fixation by intramedullary and extramedullary However, complications including malrotation, instability, varus deformity, delayed union, and nonunion can be observed, and there are some challenges in the outcomes after the operation Recently, hip arthroplasty by bipolar long stem cemented has been a surgical method that helps patients relieve pain, limit long-term complications, relieve pain and improve the quality of life for patients However, the correlation of alignment stem with fracture type is unknown Therefore, this study aimed: To observe the characteristic fracture and determine the correlation alignment of stem and fracture type in elderly intertrochanteric fracture SUBJECTS AND METHODS Subjects 79 elderly patients with intertrochanteric femoral fractures underwent operations 194 with bipolar long stem cemented through a direct lateral approach in Trauma and Orthopedic Center, Military Hospital 103 between 2016 and 2021 All patients were evaluated preoperatively with the use of standard plain radiography, an anterior-posterior radiograph * Inclusion criteria: were age ≥ 60 years and intertrochanteric fracture * Exclusion criteria: Included open fracture, pathological fractures, infection, inherited bone disorders or a bone cyst, previous femoral fracture, and failure of ORIF Methods * Surgical procedures: All patients were operated on by the same senior surgeons Surgery was performed with the patient's lateral decubitus on an operating table A lateral direct approach incision was made During the arthroplasty, the greater trochanteric and medial fracture fragments were attached to the stem and fixed with wires The wires were tightened and tied with Kirschner wire bows We used Evolve stem (Signature Orthopedics) with a stem length of 200 mm JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 * Data collection: The following data were collected: Patient’s demographic information The age was classified follows WHO [9]: Young - old (60 - 74 years), middle - old (75 - 90 years and old-old (> 90 years) The fracture type was classified according to AO/OTA system: Stable fracture (type A1): Intact lesser trochanter [8] Unstable fracture (types A2, A3): Displaced lesser trochanter or reverse obliquity fractures All patients had postoperative anteroposterior (AP) radiographs for assessment and evaluation of the alignment of the stem The alignment was determined by the angle formed between the line parallel with the prosthesis stem until it angled with the anatomical axis of the femur (fig 1) Alignment was divided into three groups: Valgus, neutral, and varus alignment All patients were divided into three groups depending on the alignment of the stem Figure 1: Evaluation of the alignment of the stem * Statistical analysis: Data in our study were analyzed and calculated by the medical statistics software SPSS 26.0 with p < 0.05 was accepted as statistically significant 195 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 RESULTS 79 patients were included in the study (the left hip with 48 patients and the right hip with 31 patients) The mean age was 82 years over the range of 69 to 97 years There were 58 males and 21 females in the study Table 1: Distribution of gender in classification AO/OTA Classification Fracture type Stable Gender Unstable A1.1 A1.2 A1.3 A2.1 A2.2 A2.3 A3.1 A3.2 A3.3 Males 5 1 Females 17 16 11 0 19 21 15 Total Table 2: Distribution of gender for the stability of the fracture Stable Stability Unstable Gender n % n % Males 16.1 16 33.3 Females 26 83.9 32 66.7 31 100 48 100 Total p > 0.05 Patients with stable fractures included men and 26 women, while patients with unstable fractures included 16 men and 32 women (p > 0.05) Among the 79 patients, 21 patients were men, and 58 patients were women (a male to female ratio of 1:3) Among 21 male patients, fractures were a stable type, and 16 fractures were unstable type There was no statistical difference in patient age between the two groups Among 58 female patients, 26 fractures were a stable type, and 32 fractures were unstable type There was no statistical difference in patient age between the two groups 196 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 Table 3: Comparison of elderly patients with intertrochanteric fractures for stable and unstable fractures Stability Gender Age Stable fractures (n = 31) 81.9 (6.6) Unstable fractures (n = 48) 82.6 (7.2) > 0.05 5/26 16/32 < 0.05 Male/female p SD: Standard deviation Statistical significance Average (SD) Patients with stable fractures were aged from 71 to 93 years (average, 81.9 years), while patients with unstable fractures were aged from 69 to 96 years (average, 82.6 years, p > 0.05) Especially, a male to female ratio was statistically higher in patients with unstable fractures (16/32 vs 5/26, p < 0.05) Table 4: Distribution of age in classification AO/OTA Classification Fracture type Stable Age groups Unstable A1.1 A1.2 A1.3 A2.1 A2.2 A2.3 A3.1 A3.2 A3.3 60 - 74 (A) 2 0 75 - 90 (B) 15 15 12 1 > 90 (C) 2 0 Total 19 21 15 According to table 4, the most popular fracture type was A2.1, with 21 cases Moreover, there was no case classified into A3.2 Table 5: Distribution of age group for stability Stable Stability Gender Unstable n % n % 60 - 74 (A) 12.9 16.7 75 - 90 (B) 24 77.4 33 68.8 > 90 (C) 9.7 14.6 Total 31 100 48 100 p > 0.05 There are 12 patients in group A, patients with stable fractures and patients with unstable fractures Notably, there are 57 patients in group B have 24 stable 197 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 fractures and 33 unstable fractures In group C, the number of patients with stable and unstable fractures is and 7, respectively (p > 0.05) Table 6: Distribution of age in males in classification AO/OTA Classification Fracture type in male Stable Age groups Unstable A1.1 A1.2 A1.3 A2.1 A2.2 A2.3 A3.1 A3.2 A3.3 60 - 74 (A) 0 0 75 - 90 (B) 2 1 0 > 90 (C) 0 1 0 Total 4 1 According to table the most popular fracture type among males was A2.1 with cases On the other hand, there was no case classified into A1.1 and A3.2 Table 7: Distribution of age group for stability in males Stability Stable Unstable n % n % 60 - 74 (A) 0 25 75 - 90 (B) 80 56.2 > 90 (C) 20 18.8 Total 100 16 100 Gender p > 0.05 Among males in the group A were patients with unstable fractures There are 13 male patients in group B; among these, males were stable fractures, and males were unstable fractures In group C, the number of patients with stable and unstable fractures is and 3, respectively (p > 0.05) 198 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 Table 8: Distribution of age in females in classification AO/OTA Classification Fracture type in female Stable Age groups Unstable A1.1 A1.2 A1.3 A2.1 A2.2 A2.3 A3.1 A3.2 A3.3 60 - 74 (A) 2 0 0 75 - 90 (B) 13 12 0 > 90 (C) 2 0 Total 17 16 11 0 According to table 8, among 58 female patients, the most popular fracture type was A1.2 with 17 cases Furthermore, there was no case classified into A3.1 and A3.2 Table 9: Distribution of age group for stability in females Stable Stability Gender Unstable n % n % 60 - 74 (A) 15.4 12.5 75 - 90 (B) 20 76.9 24 75 > 90 (C) 7.7 12.5 Total 26 100 32 100 p > 0.05 Among patients in group A, patients with stable fractures and patients with unstable fractures Of the 44 female patients in group B, 20 females had stable fractures and 24 females had unstable fractures In group C, the number of female patients with unstable fractures was twice as many as those with stable fractures, accounting for cases Table 10: Tilt of femoral stem Range Mean Number of cases Varus tilt - 4° 1.8° 49 Valgus tilt - 4° 3.5° Table 10 shows 49 cases with varus tilt and valgus tilts Among these, the average stem varus tilt in the sagittal plane was 1.8° (1 - 4°) 199 ... correlation of alignment stem with fracture type is unknown Therefore, this study aimed: To observe the characteristic fracture and determine the correlation alignment of stem and fracture type in elderly. .. assessment and evaluation of the alignment of the stem The alignment was determined by the angle formed between the line parallel with the prosthesis stem until it angled with the anatomical axis of the. .. 1) Alignment was divided into three groups: Valgus, neutral, and varus alignment All patients were divided into three groups depending on the alignment of the stem Figure 1: Evaluation of the alignment