MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF DEFENSEMILITARY ACADEMY LE NGOC HAI RESEARCH ON OSTEOPOROSIS SITUATION AND RESULTS OF BIPOLAR HIP REPLACEMENT SURGERY TO TREATMENT INTERT
Trang 1MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF DEFENSE
MILITARY ACADEMY
LE NGOC HAI
RESEARCH ON OSTEOPOROSIS SITUATION AND RESULTS OF BIPOLAR HIP REPLACEMENT SURGERY TO TREATMENT INTERTROCHANTERIC
FRACTURE IN THE ELDERLY
Specialization: Surgery
Code: 9720104
SUMMARY OF THE DISSERTATION OF MEDICINE
HANOI - 2020
Trang 2WORKS ARE COMPLETED AT MILITARY ACADEMY
Science instructor:
1 Assoc.Prof.Dr TRAN DINH CHIEN
Reviewer 1: Assoc.Prof.Dr Ngo Van Toan
Viet Duc Hospital
Reviewer 2: Assoc.Dr Nguyen Nang Gioi
Central Military Hospital 108
Reviewer 3: Assoc.Prof.Dr Pham Dang Ninh
Military Medical Academy
The dissertation will be protected before the school-level thesis dissertation council
Trang 31 The urgency of the topic
Intertrochanteric fractures in the elderly are very common, womenare more male than men, often due to falls In the USA, it is estimatedthat there are about 200,000 intertrochanteric fractured patients eachyear, the mortality rate is up to 15% - 30%, mostly in patients over 70years old, the cost of this type of treatment is about 10 billion USD ayear [1]
Intertrochanteric fractures are a large fracture, treatment is oftendifficult in the elderly due to complex fracture properties, poor bonequality (osteoporosis) and a combination of chronic systemic diseases.The intertrochanteric fracture treatments have been studied andapplied such as fracture with DHS braces, locking braces, gama nails
or hip replacement, if properly indicated, the results will be good Thechoice of treatment for intertrochanteric fractured patients is based onmany factors such as age, fracture location, fracture properties andbone quality The intertrochanteric fractured patients have good bonequality, firm fractures, age is not too high often indicated to combinebones to preserve hip joints However, in the case of elderly patientswith unstable fractures, fractures with fragments or osteoporosis, boneresorption methods are often difficult, skeletal unstable so the rate ofbone fractures, false joints, or immediately high deviation Moreover,according to some studies, the failure rate is up to 50-56% [2], [3], [4],after surgery the patient must have time to wait for bone to not move,move early so easily develop more systemic complications such aspneumonia, spleen ulcers For these cases, many authors advocatedthe replacement of the hip joint for bipolar purpose to help patientsrecover early movement or sit up early to avoid systemiccomplications due to prolonged immobilization of spleen ulcers.pneumonia, urinary inflammation or other systemic diseases [2], [5]
To assess the quality of the head bone area on the femur, there aremany different methods such as X-ray, dual energy X-ray (DEXA),CT.scaner or MRI [6], [7], [8], [9],[10] In fact, surgical doctors oftenrely on Singh's index (number of osteosarcoma in the femoral neck)[6], or bone thickness [7], [11], however these methods The price ofosteoporosis accuracy is not high, depending on the shootingtechnique, film quality, beam density and the level of readers Themethod of common osteoporosis diagnosis currently being widely
Trang 4used in the world is bone density measurement according to DEXAmethod [9], [12], [15] This is a method of using dual-energy X-raysthat allows a quantitative assessment of bone mineral mass at aspecific location in the body, or measure bone mineral Density(BMD), thus determining the bone or osteoporosis through T-scoreindex This method is considered by the WHO to be the gold standardfor diagnosing osteoporosis [14].
In Vietnam, in recent years, many treatment facilities havereplaced the hip joint joint of bipolar for elderly patients withintertrochanteric fractures However, there is no agreement on theindication and no studies have evaluated and monitored osteoporosisstatus in elderly patients with broken intertrochanteric by DEXAmethod From the above fact, we conducted research on the topic
"Research on osteoporosis situation and results of Bipolar hipreplacement surgery for intertrochanteric fracture treatment in theelderly"
2 Research objectives
- Survey of osteoporosis in the femoral head in patients ≥ 70 years ofage, intertrochanteric fractures were replaced with Bipolar by DEXAmethod
- Evaluate the results of Bipolar hip replacement surgery in elderlypatients with intertrochanteric fractures
3 New contributions of the thesis
- The study showed that elderly patients with Intertrochantericfractures with osteoporosis of 1,2,3 degrees according to Singh'sdegree were osteoporosis when measured by DEXA method with T-score ≤ -2,5 The degree of osteoporosis in the areas of the head abovethe femur is: T-score neck: -3.62 ± 0.55 (-4.7 to -2.6); T-score Troch:-3.03 ± 0.44 (-4.4 to -2.5); Inter T-score: -3.02 ± 0.40 (-3.8 to -2.5); T-score Wards = -3.91 ± 0.58 (-5.1 to -2.6); T-score total: -3,20 ± 0,53 (-5,0 to -2,5) The rate of female osteoporosis is higher than that of menwith P <0.05
- Contribute more experience in bipolar partial hip replacementtechnique in elderly patients with femoral fractures: Cut the neck ofthe femur, take the cap then fix and fix the debris Retaining the end ofthe bone in the femoral canal to fix and fix fragments and fractures,thus correcting the fragments more easily and when using porous
Trang 5screws or kirschner nails to connect the bones will avoid piercing intothe canal
4 Layout thesis
The thesis consists of 116 pages, 45 tables, 3 charts, 16 pictures, 5pictures, 7 sections
- Question: 2 pages
- Chapter I: Overview of 35 pages
- Chapter II: Subjects and research methods 17 pages
- Chapter III: Studying 26 pages
- Chapter IV: Discussion 34 pages
- Conclusion: 02 pages
- Recommendation: 01 page
Chapter 1: OVERVIEW DOCUMENT
1.1 Anatomical features of hip and intertrochanteric joints
The hip joint is a joint located deep under many thick layers ofmuscle that surrounds [15], [16], [17] According to De palma, LMC
is the bone area between the neck and femoral body, limiting from theboundary of the collar in the base to the small 5cm transfer tab, Lordthinks that under the small 2.5cm transfer tab, it is still considered thetransfer area [ 1] Ward (1878) described 5 bones
1.2 Osteoporosis and related issues
1.2.1 Elderly concept and osteoporosis
The elderly are Vietnamese citizens who are 60 years old or older[22] In 2001, WHO: osteoporosis was a pathological condition of theskeletal system with reduced bone strength, leading to an increasedrisk of bone fractures Bone strength reflects the combination of bonemineral density and bone quality [14],[26]
1.2.2 The pathogenesis of osteoporosis
The process of bone formation and bone destruction is balanceduntil about 40 years of age, the peak of this process is called peakbone mass, then the destruction of the osteoclast is overactive, thehigher bone destruction leads to bone decreased bone mass over time[14]
Trang 6Diagnosis of osteoporosis based on DEXA is the gold standard formeasuring bone mineral density through T-score [14], [32], [33], [34].According to WHO in 1994, the results of bone density measurementwere shown by 2 indicators: T-score and Z-score Index T-score:Normal: T-score ≥ -1; Bone reduction: -2.5 <T-score <-1;Osteoporosis: T-score ≤ -2.5; Severe osteoporosis: T-score ≤ -2.5 andaccompanied fractures
1.2.5 Method of measurement
Measure according to DEXA method, compare with Singh index
1.2.6 Some risk factors for osteoporosis Common:
Sunbathing, smoking, drinking alcohol affects bones
1.2.7 Treatment of osteoporosis in the elderly
Fosamax Plus 70mg weekly 1capsule/1 time, Calcium, Vitamin D[48],[49]
1.2.8 The situation of osteoporosis research in the world
Although osteoporosis problems often occur in the elderly,influenced by ethnicity from 1990-2025, the population over the age
of 59 will increase by 130-150% in Europe and about 200% or more
in all other regions, with the most significant increase in Asia [50]
1.2.9 The situation of osteoporosis research in Vietnam
In 2011, Ho Pham Shu Lan and colleagues "It should beemphasized that diagnosis of osteoporosis is based on the T index ofthe femoral neck, not the lumbar spine or the whole bone."[12]
1.3 Treatment of intertrochanteric fractures in the elderly
1.3.1 intertrochanteric classification methods
There are many ways to classify intertrochanteric, classified byBoyd and Griffin (1949), Evans (1949), Ramadier (1956) Decoux andLavarde (1969); Ender (1970); Tronzo (1973); Jensen (1975);Deburge (1976); Briot (1980), AO / ASIF (1981-1987)
1.3.2 The treatments intertrochanteric fracture
1.3.2.1 Conservation treatment
1.3.2.2 Combine bones with external fixation frames
1.3.2.3 Combine bone with AO splint and styrofoam
1.3.2.4 Combine bones with corner braces
1.3.2.5 Bone match with Gamma nails
1.3.2.6 Combing bone with lock brace:
1.3.3 The method of replacing the hip joint of Bipolar part
The lines of surgery replace the intertrochanteric fractures
Trang 7* Modified Harding Road: Road to the outside of the hip joint
* The road to the back side of Gibson's hip joint: It is an incision that
is becoming more popular because of its many advantages
Accidents and complications in hip replacement surgery:
1.4 Bipolar hip replacement study situation
is a good choice for elderly patients over 70 years, intertrochantericfractures In 2018, Sibabalan, et al, Cemented bipolar jointreplacement for 60 : 28% excellent 43% good and 23% fair outcome.2% ended with poor [106]
1.4.2 In Viet Nam
In 2014, Tran Manh Hung et al, bipolar joint replacement for 59patients, 81.8 years, the rate of women / men was 2.3 / 1 The resultswere 82% good, 12% fair, 6% average and bad [76] In Vietnam, untilnow, no work has examined bone density according to DEXA inelderly patients intertrochanteric fractures treated with bipolar jointreplacement and reevaluated after osteoporosis treatment
Chapter 2: SUBJECTS AND METHODS
2.1 Research subjects
60 patients aged 70 and over intertrochanteric fractures, Bipolarhip replacement with cement at Hospital 103 from 7/2012-10/2015
2.1.1 Criteria for selecting research patients:
Patients aged 70 and older, intertrochanteric fractures degree A1,A2 according to AO have osteoporosis 1-2-3 degree according toSingh The mortar is not deformed on the X-ray The whole body iseligible for surgery according to ASA 1,2,3 [108]
2.1.2 Exclusion criteria of study patients
Distorted femoral body observed on X-ray The surgical skin isinflamed Patients did not agree to participate in the study, patients didnot agree to surgery
2.2 Place:
In the Department of Orthopedic Trauma-BM1 103 Military Hospital
Trang 82.3 Method
2.3.1 Research design:
Prospective study, describing clinical controls without controls
2.3.2 Sampling method and sample size
Convenient sampling, n = 60 patients
24 Research content
2.4.1 Patient characteristics
Age, gender; Causes of fractures; Classify fractures according to AO;Osteoporosis according to Singh; combined pathology; The methodwas treated before replacement of joints; Time of fracture untilsurgery
2.4.2 Survey of osteoporosis status according to DEXA
BMI; Risk factors for osteoporosis; Measure the head bonemineral density on femur bone according to DEXA
2.4.3 Evaluation of surgical results
Anesthesia in surgery; Incision; Joint replacement technique;Type of hip joint sold bipolar part with cement; Time of surgery, theamount of blood infused during surgery; Time to mobilize patients'exercise;
Recent results (Evolution at the incision: Pain, edema, surgicalincision after surgery [109], [110] Bipolar hip placement on X-rayQuality of cement injection according to Barrack standards.Accidents, complications after surgery Outcome: Time from 1 year.Point ladder Merle D’Aubigné - Postel Barrack hip joints according
to Barrack standards: Liquid looseness, mortar wear, bone resorption.Other systemic complications Measure bone density in the head ofthe femur after surgery according to DEXA
2.5 Method of conducting and controlling errors:
2.5.1 Criteria and evaluation criteria in research
Calculating BMI for Asians [111] The risk of osteoporosis.Assess the level of fracture according to AO classification Systemicstatus according to ASA [108] Osteoporosis on X-rays is oftenattributed to Singh [6] Measuring osteoporosis in the head on thefemur before and after surgery: according to DEXA method assessosteoporosis according to WHO standards [26] Evaluate x-ray of hipjoints when re-examining according to Barrack et al [113] standards(location, quality of cement, mortar); Evaluation of postoperative hipjoint function: applying index of Merle D’Aubigné - Postel
Trang 92.5.2 The research proceeds with the following steps
Examination of specific patients and treatment records according
to the research form Exploiting information about the risk ofosteoporosis Use prophylactic antibiotics before surgery Measured
on X-ray film and clinically reviewed to choose the type of joint andsize appropriate for each specific patient case Measuring osteoporosis
of patients with DEXA method before surgery and on re-examination.Directly involved in surgery, care and instruction, post-surgical care,combination of osteoporosis treatment Preparing long-term follow-up
of Bipolar hip replacement patients Evaluate surgical results based onjoint function and X-ray;
2.5.3 Methods of measuring osteoporosis
We measured the bone mineral density of patients in this study onthe same osteoporosis device at Hospital 103, using DEXA (Hologic,QDR 4500C slite), measuring hip area
2.5.4 Joint replacement technique bipolar for intertrochanteric fractures
Prepare patient: carry out administrative procedures, measureDEXA hip Prepare tools: according to regulations Bipolar hipreplacement surgery: Patients undergo spinal anesthesia, lie 900 Skinincision along the Gibson line is 10cm to 15cm long, depending on thepatient's size If the top of the transfer point is used as a landmark, thelower half of the incision (in the thigh) is 2-5cm longer than the top.Slit the scales, splitting along the large gluteus muscles, revealing themuscles that show the area behind the transfer line, lifting the glutes tothe side 900 folded pillow, inner thigh closed and revealing, revealing
a short rotating muscle group, cutting a short rotating muscle groupclose to the posterior edge of the large transfer, then opening the L-shaped or T-shaped joint to the back of the femoral neck of thetransfer area Stitching and binding of the joints and the short rotationmuscles with Vicryl No 1, placing 2 bone elevations on the upper andlower edges of the femur neck widen the surgery Assessing thespecific condition of the LMC fracture, cutting the femoral neck close
to the neck base, 1cm away from the transfer edge, in the case of thesmall transfer area and the broken neck base, locate the fragmentsagain - cut according to the neck base, take Remove the cap, thenmeasure the diameter to prepare the artificial tip Cut off the roundligament and stop the bleeding Lift the head on the femur, the tube
Trang 10will open, small to large After the root canal has been assembled,keeping the end of the root canal as the core to seal the fragments,avoiding nails or loose screws, the steel thread penetrating the canalwill make it difficult to install In case of fracture, there are smallfragments and fragments close to the base of the neck, leaving thefragments to position the root canal For small transfer fractures, usethe steel thread to fix the fragment with two separate steel threads andthen fix the twisted ends of the steel thread together to avoiddisplacement along the bone body The debris in the large transferarea, correcting the debris to the anatomical position, can be fixedwith foam screws or Kirschner nails with combination of 8 steelstraps The small fragments are arranged in anatomically position andwill be attached with cement Put cement stopper Cement has beenmixed well and put into a cement squeezing gun, placed the gun barreldeeply close to the stopper, then slowly pumped the cement to squeezeout evenly and completely filled the root canal to the level of thefemoral neck Closes the selected joint into the root canal, removingexcess cement When the cement begins to heat, physiological saltwater pump is used to reduce the temperature of the cement Leavesome cement outside to check the level of cement solidification, whilewaiting for the cement to solidify, keep the grip steady until thecement cools Assemble the test cap and reinstall the joint, check thelength of the limb with the healthy limb by comparing the length ofthe two pillows and perform a Piston test to select the appropriate tip.
If the joint is firm, the length of the two limbs are equal, the dislocatedmovement is the real cap It should be noted that in this case, when re-placing the joint, the limb must be slightly pulled and graduallyincreasing the tension, do not rotate the joint too hard to avoidfracturing the thigh bone due to osteoporosis Wash pump, put 01Hemovac drainage, close the surgical layer 02 layers Cover theincision, fixation of the groin - with an anti-rotation brace, change thedressing for the first time after 24 hours, then once every 2 days.Antibiotics 7 days, cut only after 2 weeks PT, motor does notcompress the neck - feet, knees, hip joints on the 1st or 2nd post PT,for patients to sit up according to the recommended time of anesthesia.Practice standing, compressing on the operating leg with support from
a support frame or supporting two armpits from day 3 after PT.Practice walking from day 4 depending on the patient's condition
Trang 11Closely monitor the developments after PT After a joint replacement,
do not squat, do not sit cross-legged, do not fold excessively, do notstand on one side of the joints, use the toilet After 3-4 weeks ofremoving 01 crutches on the legs without changing joints, it is best touse U-shaped crutches to practice with the elderly to be the safest andmost effective After 2 months with crutches, practice walking up thestairs Patients do not make excessive stretches or groin movements inthe first 2 months to avoid dislocations, without carrying or carryingheavy loads
2.5.5 Treatment and prevention of osteoporosis after surgery
Supplement vitamin D and calcium through eating, sunbathingand taking Calcium corbiere10ml x 2 tubes / day, 1 ampoule morning,
1 ampoule x 10 days Drink 1 month ago Fosamax Plus 70mg x1tablets / week x 12 months Oral medicine with many water beforebreakfast 30 minutes
2.6 Data processing methods
Data collected were processed on Epi Info 7 software
2.7 Ethics in research:
Hip replacement surgery in intertrochanteric fractures has beenapplied in the world and Vietnam DEXA is a cheap, moderndiagnostic method and is considered by the WHO to be the goldstandard for diagnosing osteoporosis Fully explain the benefits andrisks of complications Patients agree to participate All patientinformation and privacy is kept confidential
Chapter 3: RESEARCH RESULTS 3.1 Characteristics of statistics
3.1.1 Age and gender: Age 82.47±6.33(70-102) Female/male: 3.0 /
1
3.1.2 The cause of intertrochanteric fractures
Traffic accidents 02 patients accounted for 3.33%, due to falls(accidents of living) 58 patients (96.67%)
3.1.3 Combined diseases: Cardiovascular disease - blood pressure accounted for 55.0%
3.1.4 The time of surgery to replace the hip joint of Bipolar part
Intertrochanteric fractures up to the time of surgery was 2.3 ± 2.3days (1-15), patients with joint replacement in the first 3 daysaccounted for: 78.33% (47 patients)
3.1.5 Pre-surgery treatments
Trang 12Most have not been treated after injury 58.33%; pain relief andimmobilization of 28.33%.
3.1.5 Characteristics of intertrochanteric fractures: A1 (36.67%),
3.2.2 Risk factors for osteoporosis
Table 3 10 Risk factors
3.2.3 Results of bone mineral density measurement
Table 3.18 The degree of sex osteoporosis (n = 60)
Trang 13Comment:Osteoporosis of the entire head of the femur, osteoporosis
of women is higher than that of men with P = 0.018 with statistical significance
Table 3 23 Head bone density on femur bone according to Singh (n = 60)
Singh Number(n) T-score Total ( ) About ModeGrade I 14 -3,39 ± 0,50 -4,2 đến -2,8 -3,3Grade II 33 -3,23 ± 0,54 -5,0 đến -2,5 -2,9Grade III 13 -2,9 ± 0,44 -3,8 đến -2,5 -2,8
P=0,044Comment: The average level of osteoporosis of the head area on the femur according to T-score with the difference of Singh with p = 0.04357 <0.05
Table 3 26 Head bone density on AO femoral bone (n = 60)
Table 3 28 Comparison of T-score on the femoral head before and after surgery (n = 43)
TimeVARIABLE
Trang 14Comment: Compare T-score index preoperative and postoperative 1
year and older have osteoporosis treatment combined noticed nodifference with statistical significance at p <0.05
Graph 3 2 Bone density in the femoral head before surgery and follow-up (n=43)
Comment: Comparison of bone density in the femur before surgery
and postoperative for 1 year or more with combination treatment ofosteoporosis showed that the bone density at follow-up increasedsignificantly with p <0.05
Trang 153.3 Results of Bipolar hip replacement surgery
3.3.1 Recent results after Bipolar hip replacement surgery
3.3.1.1 Rate of interventional hip joints (n = 60)
Percentage of patients with intertrochanteric fractures left accountedfor 63.33%
3.3.1.2 Surgery time: surgery 75,68 ± 21,28 (45-120) minutes, blood
transfusion 470,83 ± 80,93ml (250-500ml)
3.3.1.3 Head size: 42mm is the majority (25.0%).
3.3.1.4 Postoperative X-ray results: 100.0% right position
3.3.1.5 Surgical situation and hospital stay: the incision is 100.0%
head; hospitalization 8.03 ± 2.54 days (3-20)
3.3.2 Long-term results after surgery
3.3.2.1 Long-term follow-up time after surgery: Monitor 22.82 ±
10.15 months
3.3.2.2 The movement amplitude of the hip joint is replaced
Fold/Stretch/Shape/Close/Rotate in/Rotate out are: 100 degrees/5degrees/40 degrees/25 degrees/40 degrees/40 degrees respectively
3.3.2.3 Functional hip replacements
Table 3 40 Merle D’aubigne’-Postel point (n = 53)
Quite(n)
Medium(n)
Comment: The proportion of patients with bad results accountedfor 3.77% of the group A2
Table 3 41 Head bone density on femoral bone according to Mesle D'-Postel (n = 43)
Merle D’-Postel BMD Total( ) Total
Very good : 17-18 points 0,818 ± 0,087 3 6,98
Quite: 13-14 points 0,652 ± 0,095 10 23,26Medium: 10-12 points 0,696 ± 0,071 4 9,30