A research on bone mineral density in the hip joint and evaluation on intertrochanteric fracture treatment with bipolar joint hip replacement in the elderly from 2012 to 2015 at 103

Objectives: To investigate hip osteoporosis among elderly patients with intertrochanteric and to evaluate the outcome of fracture treatment with bipolar joint replacement in the elderly. Subjects and methods: A retrospective and prospective study on 60 patients (15 men and 45 women), mean age 82.62 ± 5.75 (from 70 to 102 years old) were treated for hip fracture with hip replacement partially used cement at 103 Military Hospital from 09 - 2012 to 12 - 2015.

A RESEARCH ON BONE MINERAL DENSITY IN THE HIP JOINT AND EVALUATION ON INTERTROCHANTERIC FRACTURE TREATMENT WITH BIPOLAR JOINT HIP REPLACEMENT IN THE ELDERLY FROM 2012 TO 2015 AT 103 MILITARY HOSPITAL

Le Ngoc Hai 1 ; Tran Dinh Chien 2

SUMMARY

Objectives: To investigate hip osteoporosis among elderly patients with intertrochanteric and

to evaluate the outcome of fracture treatment with bipolar joint replacement in the elderly Subjects and methods: A retrospective and prospective study on 60 patients (15 men and 45 women), mean age 82.62 ± 5.75 (from 70 to 102 years old) were treated for hip fracture with hip replacement partially used cement at 103 Military Hospital from 09 - 2012 to 12 - 2015 Clinical description of age, gender, lesion characteristics, bone mineral density in the hip and immediate and predicted results Results and conclusions: Age group 80 - 89 accouted for 48.33%, women/men ratio 3.0/1 Classified based on AO, group A2 made up 63.33% Bone mineral density measured in accordance with DEXA was 60 patients: BMI index 18.5 - 22.9 accounted for 73.33%, Singh highest grade 55.0%, T-score average femur neck -3.62 ± 0.55, T-score = -3.9 for majority, T-score for femoral neck -3.03 ± 0.44; T-score average intertrochanteric fracture -3.02 ± 0.4; mean T-score of Ward area -3.91 ± 0.58; T-score mean head-to-hip ratio -3.20 ± 0.53 Bone mineral density of the neck - trochanteric - intertrochanteric - total head on the male thigh bone was significantly higher than that of females (p < 0.05); However, Ward's triangle bone between two groups of males and females was not different (p = 0.18487) Immediate evaluation: 100%, distance scale results according to Merle D’Aubigné - Postel: very good: 10.0%, good: 53.33%, quite: 23.33%, medium: 8.33%, bad: 5.0%

* Keywords: Intertrochanteric; Bipolar; Elderly; Hip replacemen; DEXA

INTRODUCTION

Intertrochanteric hip fracture among

the elderly is very common Women

outnumber men, due to the common

cause of falls In the United States, it is

expected that 200,000 patients suffer

from hip fractures usually with mortality

up to 15 - 30%, commonly found in

patients older than 70 years, whose

treatment is up to $10 bil per year [5]

Intertrochanteric fracture is painful, even more traumatic specifically in the elderly treatment due to the elderly‘s fracture complexity, poor bone quality and chronic systemic combination Many methods

of treatment of intertrochanteric fractures have been studied and applied such as bone grafts with DHS splint, braces, nails Gamma have brought good results However, in cases of unstable fractures,

1 Thanhhoa Department of Health

2 103 Military Hospital

Corresponding author: Le Ngoc Hai (phhaingoai@gmail.com)

Date received: 11/06/2018

Date accepted: 19/11/2018

broken bones, or thinning of the bones,

bone grading methods are ineffective for

the patients who are unable to bone slow

recovery, ill hip joint, limiting the rapid

recovery, making the patients unable to

move early In these cases, many authors

advocate partial hip replacement for the

purpose of helping patients quickly to

restore their movement or even to sit up

early This approach helps avoiding

systemic complications due to long-term

restlessness including ulceration, pneumonia,

or other systemic diseases

In Vietnam in recent years, many hip

replacement surgery clinics have applied

partial hip replacement on the elderly patients

with intertrochanteric fractures However, no

agreement on this issue has been reached

and no study has evaluated osteoporosis

in the elderly patients with intertrochanteric

fractures Therefore, we have conducted

a study on the topic with the goal:

- To review osteoporosis in the hip of

associated with intertrochanteric fracture

- To evaluate bipolar partial hip

replacement in the elderly patients with

intertrochanteric fracture

SUBJECTS AND METHODS

1 Subjects

- 60 patients aged 70 years old and

above, regardless of sex, intertrochanteric

fractured type A1, A2, A3 by AO classification, Singh grade 1 - 2 - 3 osteoporosis according to Singh, bipolar surgery with cement at 103 Military Hospital from 09 - 2012 to 12 - 2015 provided with accompanied documents: Full medical records, with pre-operative, postoperative and scheduled screening Bone mineral density in the hip based DEXA surgery were measured and recorded

- All 60 patients with the first time of hip replacement, with the mortar in good condition, not degraded, not deformed

2 Methods

- Retrospective and prospective study, clinical description

Reseach categories include: Age, sex, traumatic features, bone density survey, indicative draw and studies of treatment results: Evaluation of the close results: Closeness of wound rehabilitation of hip joint and the complications of premature and complete onset Outcome evaluation: According to Merle D'Aubigné - Postel:

17 - 18 points: excellents; 15 - 16 points: good; 13 - 14 points: quite; 10 - 12 points: medium; ≤ 9 points: bad

* Data processing: Processed on

Epi.info 7 software

RESULTS

1 Classification of intertrochanteric fracture based on age, gender in elderly patients

Table 1: Age, gender (n = 60)

Gender

The age group of 80 - 89 accounted for the highest proportion (48.33%); women/men ratio: 3.0/1

Causes of fracture: 2 cases of traffic accident accounted for 3.33%, falls: 58 cases (96.67%); intertrochanteric fracture alone was 58 patients, with two patients with forearm fractures and software lesions

Table 2: Classification of intertrochanteric fractures by AO (n = 60)

AO

Percentage

%

Intertrochanteric fracture was rated by category AO with the highest percentage of 63.33% in A2 fracture, the age group of 80 - 89 had 29 patients (48.33%) in which A2 was present in 18 patients

Table 3: Measurement of bone mineral density of intertrochanteric fracture to Singh

(n = 60)

Osteoporosis

Percentage

%

Among 3 grades of osteoporosis, grade II accounted for the highest percentage (55.0%) Out of the three groups of age, the group aged 80 - 89 made up the highest percentage (48.33%) Compared to male, females aged more vulnerable to osteoporosis

- Systemic combined disease: There was no systemic disease: 20 patients (33.33%), cardiovascular disease, blood pressure: 31 patients (51.67%), diabetes:

5 patients (5.0%), others: 6 patients (10.0%)

Table 4: Osteoporosis level in patients with intertrochanteric fractures with age (n = 60)

Gender Variable

Male (n = 15)

Female

T-score

A research on bone density in the hip

area revealed a decrease in bone density

among 60 patients of hip bone fracture

with DEXA technique, compared to the

mean bone density in the femoral head

However, the comparison between the

genders showed that women's osteoporosis

level was higher than that of men with

difference from p = 0.01069 < 0.05

Comparison of mean hip osteoporosis

on the femur with the corresponding

Singh score: Grade 1/grade 2/grade 3:

mean T-score -3.26 ± 0.47/-3.02 ± 0.38/

-2.78 ± 0.19, respectively, correlated well

with Singh-singularity, the difference

between the level of significance and

p = 0.00710 was statistically significant

2 Treatment results

* Review immediate results:

First dry scalp 60 patients (100%), early X-ray results after surgery 100.0%

of the following artificial joint replacement

in the right place, with no dislocated

or semi-located joint Average postoperative objective exercises were 2.95 ± 0.47 days after surgery, postoperative subjective exercises from 5.32 ± 0.65 days, mean hospital stay after surgery was 8.02 ± 2.55 days

* Outcome evaluation:

During the follow-up from 4 months to

40 months on 60 patients, which mainly falls on the follow-up duration of 36 months, X-ray after surgery shows 100% joint still

in position The patients had tendency

to be able to move at the highest

frequency of fold/stretch/format/fit/ rotate

in/offset were: 100 degrees/5 degrees/

45 degrees/25 degrees/40 degrees/

40 degrees

* Evaluation based on the Merle D'Postel scale:

Very good: 6 patients (10.0%); good:

32 patients (53.33%); quite: 14 patients (23.33%); medium: 5 patients (8.33%); bad: 3 patients (5.0%)

DISCUSSION

1 Characteristics of intertrochanteric fractures of the elderly

Table 5: Comparison of patient characteristics with other authors

In 60 patients, the lowest was 70 years

old, the highest was 102 years old The

mean age was 82.62 ± 5.74 The age

group of 80 - 89 accounted for the highest

percentage (48.33%) Men accounted for

25.0%, women accounted for 75.0%

Women/men ratio 3.0/1 We found that

there was no considerable difference

between our results and other domestic

and foreign authors’ findings in terms of

the age of patients who had the joint

replacement and the proportion of

women/men

The proportion of intertrochanteric

fracture in women is higher compared to

men, as the level of osteoporosis

increased, the bone quality decreased

over time and the rate of high long life

expectancy in females was higher than that of meles [9] Our study found that Singh's grade II osteoporosis had the highest proportion (33/60 patients = 55.0%), which is more common in the age group

of 80 - 89 years old and in females than males Bone mineral density measured by DEXA method were in 60/60: BMI 18.5 - 22.9 accounted for 73.33%, T-score average femur neckline -3.62 ± 0.55, T-score = -3.9 for the majority, T-score for femoral neck -3.03 ± 0.44; T-score average Intertrochanteric fractured -3.02 ± 0.4; Mean T-score of Ward area -3.91 ± 0.58; T-score mean head-to-hip ratio -3.2 ± 0.53 BMD of the neck-capillary-transitional-total head on the male thigh bone was significantly higher than that of females

(p < 0.05); the Ward's difference in bone

density was not significantly different (p =

0.18487) On the DEXA measurement, the

BMD mass was reduced by age group:

0.66 ± 0.14/0.55 ± 0.12/0.43 ± 0.12 g/cm2,

severe osteoporosis according to T-score

of the age group: -3.12 ± 0.46/-3.17 ±

0.56/-3.41 ± 0.50 According to Ho Pham

Thuc Lan, the incidence of femoral neck

BMD in the 70+ and 20-30 age groups is

also higher in women (25%) than men

(13%) [4] This is consistent with the

aging process of the body over time; in

the cases of the older women and men,

the estrogen (women) but age (men)

levels cause the reduction of calcium

biosynthesis, making the elderly-vulnerable

to external forces [4]

This is consistent with the mechanism

of subluxation or sagging in the elderly

mainly due to a fall in the foot slips In our

study on 58 cases of falling, 2 cases

suffered from due to traffic accidents,

which is different from Kumar’s study with

75% of falling at a height and 25% of

traffic accidents [9]

2 Surgery comment

According to Kumar K [9], complexity

of intertrochanteric fractures in elderly

osteoporotic patients poses challenging

problems, with an increasing risk of

morbidity and mortality Although union

rates as high as 100% have been reported

in association with well-reduced, stable

fractures that were treated with ideal

implant placements, failure rates of as

high as 56% have been noted in

association with unstable fractures,

comminutions, suboptimal fracture

fixations, or poor bone qualities in elderly

patients Although the internal fixation of such fractures may reduce the morbidity

of pain, it does not permit an early mobilization with a fear of failure of fixation and thus, indirectly, the morbidity

of fracture remains the same Bipolar hip replacement surgery should be based

on factors as: Bone condition, bone morphology, type fracture classified based on AO, surgeons joint replacement experience, equipment, anesthesia resuscitation, kit and economic condition

of patients

According to our study, the incidence

of intertrochanteric fractures according to the AO classification was high in A2 (63.33%) and the number of patients with A2 fractures in 80 - 89 years old was

18 patients Osteoporosis II and III were 76.67% With such patients we chose bipolar with cement, as this technique provides a more stable fixation, especially

in case of AO breakdown A2, avoid secondary misalignment In the cases of complicated fracture, we use Kirchner screws through the large wires, using a tightening of the 8-wire strings Postoperative pain relief is better, allowing early movement, without the complications of superinfection lung, uremia, ulceration of the knee due to long lying This conclusion is consistent with other authors’ findings [1, 7, 9]

Elderly people commonly suffer from cardiovascular disease, hypertension and other systemic diseases, so they need to

be examined carefully before surgery, according to the study of bipolar operation, it can be seen the propotion among groups as follows: No systemic

disease: 20 patients, cardiovascular

disease, blood pressure: 31 patients

(51.67%), diabetes: 3 patients (5.0%),

other diseases: 6 patients (10.0%) All

cases have been treated before surgery

3 Evaluation of treatment results

* The short-term results:

Dry scalp, right in the first treatment

were found 60/60 patients (100%)

Immediate X-ray results after surgery

showed that 100% of artificial joints were

in the right position, cases of dislocated or

half-dislocated joint No complications in

surgery occured Only one case of

cerebral stroke after 4 days of surgery

was detected promptly and treatment is

stable before the patient’s discharge

Patients were instructed to exercise

passively from day 2 after surgery (2.95 ±

0.47 days), active training from day 4,

medium from 5.32 ± 0.65 days, slight

incision Other authors’ findings [2, 6, 10]

suggested that rapid rehabilitation after

treatment due to joint activity and

exercise, reduces overall complications

intertrochanteric fracture caused

* Follow-up results:

The follow-up of 60 patients after

surgery ranged from 4 months to 40 months,

average 22.82 ± 10.15 months, the

number of 36 month follow-up patients

accounted for the highest rate,

prostoperative X-ray surgery shows 100%

in the right position without any cases of

dislocation

Merle D'Postel: very good: 10.0%,

good: 53.33%, quite: 23.33%, medium:

8.33%, bad: 5.0%

Our follow-up period was longer than

that of Hoang The Hung [2], where

average follow-up time was 16.17 ± 10.86 months with excellent results 37.1%, good 42.9%, fair 17.1%, bad 2.9%

According to Joong-Myung Lee et al,

32 out of 41 patients (78%) recovered walking ability

CONCLUSION

According to a study of 60 high-risk fractured hip fracture patients with bipolar with cement at 103 Military Hospital from September 2012 to December 2015, we conclude that:

- Bone mineral density survey: 60/60 bone mineral density survey DEXA technique showed that all patients had

osteoporosis levels in women were higher than in men with a difference of p = 0.04130 < 0.05

Comparison of mean hip osteoporosis

on DEXA females with Singh score: Grade 1/grade 2/grade 3: average T-score -3.39 ± 0.50/-3.24 ± 0.53/-2.83 ± 0.36, respectively, correlated well with Singh-singularity, the difference between the level of significance and p = 0.01425 was statistically significant

- Evaluation of partial hip replacement

in patients with intertrochanteric fracture:

+ Personal and traumatic features:

Age from 70 to 102 years (mean 82.62

± 5.75) Age from 80 to 89 was the highest (48.33%) Women/men ratio 3.0/1 Class A2 was the high rate (63.33%), A2 fracture in the age of 80 - 89 was 18 patients Osteoporosis II, III was 76.67%

+ Specification review:

Bipolar has cement for fixation of

firmer joints with intertrochanteric

fractures of the elderly, osteoporosis This

helped the patients to move early, in

which the average postoperative active

exercise was 5.32 ± 0.65 days after

surgery The treatment provided better

pain relief, reducing hospital stay to 8.02

± 2.55 days, which enabled the patients

rapidly rehabilitate, thus improving the

quality of life

- Surgical results:

+ 100% incision in the first period

Patients are instructed to exercise after

surgery soon

+ Excellent: 10.0%, good: 53.33%, fair:

23.33%, medium: 8.33%, bad: 5.0%

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Evaluation of partial hip replacement surgery

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2013

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