Mohammed Ashraf M1, Jayachandran N2, Jinumon Mathew3, Rajeev K. S4

Intertrochanteric fractures in osteoporotic bones which are grossly comminuted are highly unstable and difficult to treat. Conservative treatment with traction and prolonged immobilisation lands up with many complications and often fatality. Rate of failure with internal fixation has been found to be high, especially in osteoporotic bones. Revision osteosynthesis is technically demanding and it leads to complications, a second surgical procedure for revision synthesis, arthroplasty or removal of a symptomatic implant is again a risky procedure in elderly patients with lot of comorbidities. The aim of this study was to assess the efficacy of a cemented bipolar hemiarthroplasty with calcar preserving intracapsular osteotomy in the management of unstable trochanteric fractures in elderly patients with osteoporosis.
Hemiarthroplasty in unstable trochanteric fractures have been described in the past with varying outcome. The reasons for poor outcome were shortening, varus positioning and abductor insufficiency. This was mainly due to the deficient medial support due to the removal of lesser trochanter and calcar.
Recently, free calcar grafting excised from the removed neck for medial support was reported, but in our technique we are preserving the calcar and lesser trochanter with all its soft tissue and muscle attachments.
52 patients with mean age 71.4 (range from 65 to 89) who underwent cemented bipolar hemiarthroplasty with calcar preserving osteotomy for unstable intertrochanteric fractures were prospectively evaluated. Posterior approach was used in all patients. Harris hip score was used for the clinical evaluation. The mean followup period was 5 years.
In our study, which was done on 52 cases which had a mean age 71.4 years. The average Harris hip score was 81. Excellent to fair results were obtained at followup in 50 (96%) cases, and in 2(4%) cases the results were poor. Average hospital stay was 14 days. There were 2 cases of a superficial operative site infection and aseptic sinus formation, 2 cases with abductor deficiency, Trendelenburg gait and anterior thigh pain. There was no case with loosening of the prosthesis, dislocation, break in the cement or sinking of the prosthesis.
The gold standard of treatment of intertrochanteric fractures in young patients is osteosynthesis. But the treatment of unstable intertrochanteric fractures in elderly patients with severe osteoporosis differs from the treatment of patients with other proximal femoral fractures. These fractures are better treated with cemented hemiarthroplasty than with internal fixation. Besides an early ambulation and less hospital stay, cemented bipolar hemiarthroplasty provides stable and mobile hips. Weight bearing can be started earlier than in other methods of treatment, which prevents any recumbency related complications