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Unstable Intertrochanteric Fracture In Elderly Patients – Bipolar Arthroplasty Or Internal Fixation?—A Matched Pair Analysis Of High Risk Cohort To Compare Mortality And Morbidity In Two Group

 Patil Suresh S*,   Panghate Atul**

*Senior Registrar
**Lecturer, Dept. of Orthopaedics
Department Of Orthopaedics, 6th Floor M.S.B., K.E.M. Hospital, Parel, Mumbai-400012

Address for Correspondence:  

Patil Suresh S.
Department Of Orthopaedics,
6th Floor M.S.B., K.E.M. Hospital,
Parel,  Mumbai-400012


Aim:  To compare the mortality and morbidity and post op complication in high risk Intertrochanteric fractures treated by cemented bipolar and internal fixation.
Material and methods: Thirty five selected patients matched for age, sex, weight, fracture type and preop ASA grade-III were treated by primary bipolar arthroplasty (Group A) from January 2002 to June 2005. All patients were operated by the same surgeon. Bipolar implants were cemented (tapered design, 2nd generation cemented technique, standard length) and trochanteric comminution was circlage to restore abductor mechanism The results of this group of patients were compared with thirty nine patients treated with Internal Fixation (Group B) by Dynamic Hip Screw and side plate with appropriate reduction and fixation.The comparison was done with emphasis on perioperative mortality and morbidity in terms of day of full weight bearing, pressure sore, pulmonary complication.
Discussion and result: The Bipolar Arthroplasty (Group A) was able to full weight bear significantly earlier than the Internal Fixation (Group B) patients. Rehabilitation was easier and faster and post op morbidity like pressure sore pulmonary complication was significantly low (P<0.05). The mortality in cemented bipolar group (5/35) was significantly lower than internal fixation group (12/39) (P<0.05).
Conclusion: Statistically Mortality and morbidity in bipolar Arthroplasty (Group A) was significantly lower compared to internal fixation (Group B). Bipolar Arthroplasty may be a better alternative treatment for osteoporotic unstable Intertrochanteric fractures in elderly morbid patients.

J.Orthopaedics 2008;5(3)e7

fracture fixation, internal; hip fractures; hip prosthesis;


Intertrochanteric fractures are major cause of disability and death in elderly. The incidence of all hip fractures is approximately 80 per 100,000 persons and is expected to double over the next 50 years as the population ages (1).Intertrochanteric fracture make up 45% of all hip fractures.

        Unstable intertrochanteric fractures in elderly patients are associated with high rates of morbidity and mortality (2) although the results have improved with the use of internal fixation. In these patients however, comminution, osteoporosis, and instability often preclude the early resumption of full weight bearing (3).Treatment with primary bipolar arthroplasty rather than internal fixation could perhaps return these patients to their preinjury level of activity more quickly, thus obviating the postoperative complications caused by immobilization or failure of the implant (4). 

       Recent publications indicate concern with excessive sliding of these fixation devices when used in unstable intertrochanteric fractures (5).The excessive sliding can result in unacceptable shortening and external rotation deformity of the limb. Bendo et all

reported that most of the patients with moderate or severe collapse had poor functional results. Elderly patients often are unable to cooperate with partial weight bearing, or if allowed full weight bearing, voluntarily limit loading of the injured limb (6). To allow immediate postoperative full weight bearing and to avoid excessive collapse at the fracture site, some surgeon (7) recommended prosthetic replacements for unstable intertrochanteric fracture

       The purpose of this study was to determine whether cemented hemiarthroplasty using a standard femoral stem is a reasonable alternative to reduction and fixation with sliding hip screws for elderly patients in unstable intertrochanteric fracture to reduce mortality and morbidity in term of day of full weight bearing, pressure sore, pulmonary complication and deep vein thrombosis associate with long rehabilitation

Material and Methods :

        Between Jan 2002 and Nov 2005   Seventy four patients who were older than sixty five years,  associated with preexisting systemic disease, who are high risk for anaesthesia  (ASA Grade III &IV),osteoporosis as asses by Singh’s index and who had been independently mobile before sustaining an unstable intertrochanteric fracture were treated by the same surgical team

         Patients who were unable to walk before the fracture, who were younger than sixty five years old, not associated with any medical disease or who had stable fracture with intact lesser trochanter been not included in the study

Table.1     Properative   Clinical Data Of Seventy Four Patients Who Had An Unstable Intertr0chanteric Fracture Treated By Primary Bipolar   Arthroplasty Or Internal Fixation With Dhs And Side Plate



Group A


Group B


Number of patient




Sex – male








Disease preoperatively


     Chronic Lung disease

     Renal disease

     Liver dysfunction




















Bipolar Arthroplasty (Group-A)

This group consist of 35 consecutive patient (23 women’s) underwent primary cemented bipolar arthroplasty. Preoperatively fourteen patient(  40%) had cardiovascular disease; five (14% ),a chronic lung disease; two( 6% ), a renal disease; three( 8.5% ), a liver dysfunction; four(11.5% ), a hypertension; seven(20% ) ,a diabetic(Table-1)

A standard length stem (small-133mm, standard-138mm, large-143mm), tapered design femoral component with modern technique of cementing used; greater trochanter fixed to the proximal part of femur and to lateral part of prosthesis by two TBW wires, lesser trochanter fixed to medial part with circlage wire passed through hole, self centering cup is available with 7 different sizes with external diameter ranges from 39 to 51 millimeter.

The appropriate templates are placed over the preoperative roentgenograms of the fractured femur and the contralateral, uninvolved femur in order to determine the outer diameter of the acetabular component, and the length of the extramedullary part of the femoral component that is needed to achieve equal limb lengths. The final size of the prosthetic components is chosen intraoperatively, on the basis of the desired tension in the abductor muscles of the hip as determined during the last trial reduction 

 Surgical Technique:

The patient is placed in lateral decubitis position on a standard operating table, with the trunk supported by chest-rests. The surgical approach is through a standard posterior incision, the subcutaneous layer is dissected and the fascia lata is split longitudinally, exposing the fracture hematoma and the greater trochanter. superior part of greater trochanter attached to abductors are reflected superiorly and head approached through the fracture site without cutting external rotators, The outer diameter of the self-centering cup that is to be used is determined by measuring the diameter of the resected .



Fig. 1-A: A seventy year-old patient who had a comminuted trochanteric fracture.

Fig. 1-B: Immidiate postop Radiograph, shows cemented bipolar arthroplasty with Wiring of the lesser and the greater trochanter  

femoral head, after exposing the proximal femoral diaphysis, canal prepared the femoral shaft is then prepared first by a straight intramedullary reamer is used, and next the proximal part of the shaft is prepared further with a reamer that has a conical enlargement, so that a correct fit is obtained between it and the larger proximal shaft of the prosthesis. The appropriate length of the extramedullary portion of the femoral component can be chosen by using the adjustable trial stem. The trial stem is assembled with a trial cup, and test reductions are performed to determine the exact length that will provide the desired tension of the abductor muscles. The hip is dislocated again, and all trial components are removed. Before cementing two wires passed in proximal diaphysis so that we can use for subsequent reattachment of greater trochanter and a circlage wire is passed through the lesser trochanter to permit its subsequent fixation to the medial side of the femoral component. The femoral stem was cemented in place using standard modern cementing techniques that include lavage, cleaning, drying, and plugging of the canal. After all components have been removed, a cement restrictor is inserted and the medullary canal is rinsed with saline solution. One or two units of polymethylmethacrylate cement (CMW-3) are injected under pressure, and the femoral component after the polymethylmethacrylate has set, the self-centering cup is locked onto the prosthetic head and the prosthesis is into the acetabulum. The two wires that we passed previously in proximal diaphysis are passed through greater trochanter and gradual tightening done so as to approximate fracture site and third wire encirclaging the proximal diaphysis that we previously positioned through lesser trochanter .The fascia lata is closed and sutured, and the skin is closed. Suction drainage is used in all patients for forty-eight hours. An antibiotic is given just before operation and is continued for five days postoperatively.

Postoperatively, the patients receive thromboembolic prophylaxis (LMW). Unless contraindicated, anti-inflammatory medication is administered postoperatively for one week Active and passive mobilization of both limbs is started as soon as possible, taking care to avoid forced adduction or rotation of the hip that was operated on. Moderate flexion of both the hip and knee joints, with a large pillow between the ankles during bed rest, is recommended. In our series, walking with full weight-bearing was allowed on 2nd day postoperatively. The average time to walking with full weight-bearing was fifth days.


That were made at three, six, and twelve months, two year postoperatively were analyzed. The duration of follow-up ranged from six months to three years, with an average of eighteen months; it was determined largely by how long the patients lived, as most of them were quite elderly.







Roentgenograms mad at two years (Fig.2-A, anteroposterior & Fig.2-B, lateral  View) showing good bone formation around lesser and greater trochanter .


Internal Fixation (Group B)

This group consist of 39 consecutive patient (25 women’s) underwent Internal fixation with DHS with side plate. Preoperatively  sixteen patient(41%) had cardiovascular disease; five (13%),a chronic lung disease; three(7.6% ), a renal disease; four(10.2%), a liver dysfunction; four( 10.2%), a hypertension; seven(18%) ,a diabetic (Table-1) 

Surgical Technique:

The operation is performed on an orthopaedic fracture table, with the patient lying supine. Fluoroscopy is routinely used. The aim of the closed reduction is to obtain

An optimum position, with a correct angle between the femoral neck and shaft19’38’39.  The proximal part of the femur is exposed through a lateral approach38’39’48, and DHS with side plate is inserted. Postoperatively, the patients receive thromboembolic prophylaxis (LMW) unless contraindicated and analgesic, Sitting up in a chair and walking without weight bearing on the fractured limb are permitted as soon as possible.

The operating surgeon determines when the patient should start walking, on the basis of the stability of fixation at operation and the findings on the postoperative roentgenograms. Non-weight-bearing is continued until consolidation is confirmed roentgenographically. Full weight-bearing is allowed only when complete osseous healing has occurred. The average time from operation to walking with full

Weight-bearing without support was 3.5 months. Prophylactic antibiotics were given for five days routinely. And roentgenograms of the fractured hip were made, both at regular intervals, until the fracture had united or technical failure had occurred. Technical failure

Was defined as the absence of fracture-healing, with breakage of the implant that necessitated reoperation.

Results :

Analysis of result by using chi-square test, unpaired “t” test, Fisher exact test

There were no significant differences between the two groups in terms of demographic data (age, sex), fracture type, preoperative Singh’s index, ASA Grade for anaesthesia and preoperative systemic disease (Table 1)

Also there were no significant difference (p >0.05) between operative time, blood loss, and hospital stay (Table2)





Group A



B Group



‘p’ value

Operative time

110 min


102 min





Blood loss


420 ml



450 ml






Hospital stay


15 days

18 days



The time to full weight bearing was significantly earlier in patients who underwent hemiarthroplasty; the mean follow-up period for the hemiarthroplasty group was 24 months (range, 6–36 months). Five (14%) of the 35 patients died in the first half year. Among them, one developed deep infection on day15 and did not respond to postoperative antibiotics. One had a pulmonary infection and one sustained a cerebral hemorrhage (associated with hypertension) both within one month. The remaining 2 patients died from causes unrelated to the primary injury. Among the 30 patients still surviving, early complications included 2 with bed sores,1 had pulmonary infection  and 1 had intraop fracture of proximal femoral diaphysis at time of preparation of canal due narrow canal. Two patients were unable to walk because of unrelated conditions.  There was no dislocation, apparent acetabular protrusion or aseptic loosening of the stem. Require long term follow up to asses these complication

The internal fixation group fitted with a DHS was followed up for a mean of 23 months (range, 6–38 months). Twelve (31%) of the 39 patients died in the first half year; one sustained a cerebral infarct from thromboembolism after 2 months. The remaining 11 deaths were attributed to pre-existing systemic disease. Six months after surgery, 27 (69%) of the 39 patients in this group were surviving Among them, 18 developed early complications ;bed sores in 9,pulmonary infection in 5,mechanical failure in 4  who underwent revision surgery by arthroplasty or implant removal.

Discussion :

Unsatisfactory surgical outcome is common in elderly patients with intertrochanteric fractures; medical illness, osteoporosis, and fracture instability are contributing factors. Early mobilisation may decrease the risk of mortality and morbidity, although older patients are unable to walk well and only capable of partial weight bearing in the postoperative period. (8)

In patients with osteoporotic fractures, maintenance of reduction can be a major problem during the healing period. To reduce the healing time, dynamic devices are replaced with the static ones. Biomechanical studies show that dynamic implants have more weight-bearing capacity than static implants.(9)Furthermore, partial weight bearing creates a micromovement in the dynamic systems which increases union rate. However, cut-out is the main complication of internal fixation. Central positioning of the screw in the femoral neck has been recommended, (10) which yields cut-out rate of about 13%. The strength of fixation depends on screw positioning and bone quality. The cut-out rate in the present study was 10% and the respective patients underwent revision surgery (arthroplasty or implant removal).

Many surgeons prefer arthroplasty for the treatment of unstable trochanteric fractures in the elderly in order to decrease complications: Rosenfeld et al.(11) used arthroplasty and reported 86% satisfactory results in the early period. Stern and Angerman9 reported 94% good and excellent results after a mean follow-up period of 8 months. Haentjens et al. (12) compared the clinical results of internal fixation and bipolar arthroplasty for unstable trochanteric fractures and reported 75% satisfactory results and less postoperative complications in the latter group. They insisted that early weight bearing was the major factor responsible for decreasing postoperative complications. K.casey Chan and Gurdevs.Gill (13) found that Use of standard cemented hemiarthroplasty is a reasonable alternative to a sliding screw device for the treatment of intertrochanteric fractures to achieve less postoperative complication. Prof. Chris Grimsud,Raul J. Monzon(14) treated all unstable three and four part hip fractures with standard femoral stem and circlage cabling of trochanters and they conclude that bipolar arthroplasty allows  safe early weight bearing on the injured hip and had a relatively low rate of complication

 P. Florian Geiger; P.Monique Zimmermann-Stenzel found that Mortality was significantly influenced by Age, Gender, Amount of Co-morbidities but not by fracture classification. (15)

Mortality rate of bipolar arthroplasty and internal fixation of different study compare with current study are shown in Table 4       


Journal of arthroplasty-April2005

 Chris Grimsud, Raul J. Monzon

Bipolar Arthroplasty



Stern et al

Green et al

Chris Grismud

Harwin et al

Haentgens et al

Chan et al

Current study








Internal Fixation



Haentgens et a

Kyle et al

Hardy et al


Current study






Bipolar arthroplasty group had a lower postoperative complication rate and resulted in earlier weight bearing, which was also reported by others. There was a significant difference in full weight bearing time between the 2 groups. Though more costly, bipolar arthroplasty is a treatment option for patients with unstable Intertrochanteric fractures, which can achieve earlier mobilisation.

Reference :

  1. JD Zuckerman: Hip fracture. N Engl J Med 1996; 334:1519-1523. 

  2. Jensen, J. S.: Trochanteric Fractures. An Epidemiological, Clinical and Biomechanical Study. Acta Orthop. Scandinavica, Supplementum 188, 1981. 

  3. Bergman, G. D.; Winquist, R. A.; Mayo, K. A.; and Hansen, S. 1. , JR. : Subtrochanteric Fracture of the Femur. Fixation Using the Zickel Nail. J. Bone and Joint Surg., 69-A: 1032-1040, Sept. 1987. 

  4. Asencio, G.: La grande prothse epiphyso-metaphyso-diaphysaire de l’extremitymit suprieure du femur de Vidal-Goalard. Etude clinique a propos de 265 CAS, pp. 23-29, 77-83. Montpellier, Dehan, 1978. 

  5. Bendo JA, Weiner LS, Strauss E, and Yang E: Collapse of intertrochanteric hip fractures fixed with sliding screws. Orthop Rev Suppl: 30-37, 1994. 

  6. Koval KJ, Sala DA, Knmmer FJ, Zuckerman JD: Postoperative weight-bearing after a fracture of the Femoral neckor an intertrochanteric fracture. J Bone Joint Surg 80A:352-356, 1998 

  7. Broos PL, Rommens PM, Deleyn PR, Geens VR, Stappaerts KH: Pertrochanteric fractures in the elderly: Are there indications for primary prosthetic replacement? J Orthop Trauma 5:446-451, 1991 

  8. Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomized prospective study in elderly patients. J Bone Joint Surg Br 1992; 74:345–51. 

  9. 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 

  10. 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. 

  11. Rosenfeld RT, Schwartz DR, Alter AH. Prosthetic replacement for trochanteric fractures of the femur. J Bone Joint Surg Am 1973; 55:420. 

  12. 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. 

  13. K.Casey Chan, Gurudev s. Gill. Cemented Hemiarthroplasty for Elderly Patients with Intertrochanteric Fractures Clinical Orthopaedic and Related Research Number 371, pp. 206-215 

  14. C. Grimsrud, R. Monzon, J. Richman, M. Ries.  Cemented Hip Arthroplasty With a Novel Circlage Cable Technique for Unstable Intertrochanteric Hip Fractures The Journal of Arthroplasty, Volume 20, Issue 3, and Pages 337 - 343.  

  15. P. Florian Geiger; P.Monique Zimmermann-Stenzel.  Mortality was significantly influenced by Age, Gender, and Amount of Co-morbidities but not by fracture classification. Arch Orthop trauma Surg.2007-SEPT


This is a peer reviewed paper 

Please cite as : Patil Suresh S: Unstable Intertrochanteric Fracture In Elderly Patients – Bipolar Arthroplasty Or Internal Fixation?—A Matched Pair Analysis Of High Risk Cohort To Compare Mortality And Morbidity In Two Group

J.Orthopaedics 2008;5(3)e7





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