International Journal of Research in Orthopaedics

Erkmen D et al. Int J Res Orthop. 2023 Sep;9(5):863-869

http://www.ijoro.org

DOI: https://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20232462
Original Research Article

Comparison of calcareous replacement hemiarthroplasty and proximal

femoral nail in elderly ıntertrochanteric femur fractures
Deniz Erkmen1, Ozdamar F. Oken2, Yunus Demirtas3*

1
Department of Orthopedics and Traumatology, Niğde Ömer Halisdemir University, Turkey
2
Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Bilkent City Hospital, Ankara,
Turkey
3
Department of Orthopedics and Traumatology, Faculty of Medicine, Yüksek İhtisas University, Private Liv Hospital,
Ankara, Turkey

Received: 18 July 2023

Revised: 24 July 2023
Accepted: 27 July 2023

*Correspondence:
Dr. Yunus Demirtas,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: In this study, a retrospective evaluation was made of patients aged 70 years and over who were applied
with proximal-femoral nail (PFN) or calcareous replacement cemented hemiarthroplasty in respect of early and late-
stage morbidity and mortality and functional personal independence.
Methods: The study included a total of 77 patients aged over 70 years with an AO type 31-A1 or 31-A2 fracture. The
patients were separated into two groups as those applied with proximal femoral nailing and those applied with calcar
replacement hemiarthroplasty. Statistical comparison was made of the groups in respect of preoperative age,
comorbidities, type of anaesthesia, ASA score, and fracture type, and postoperative amount of blood loss, albumin
decrease, wound complications, other complications, Harris hip functional scores, Barthel daily living activity index,
mortality rates.
Results: The two groups were found to be similar in respect of age, gender, comorbidities, AO fracture type and type
of anaesthesia. The operating time was shorter in the proximal femoral nailing group. The Harris hip scores and the
Barthel daily living activity ındex values were similar in both groups. Rates of wound infection were higher in the
hemiarthroplasty group. Mortality rates at one month, six months and one year were similar in both groups.
Conclusions: Proximal femoral nailing can be one of the primary treatment options for intertrochanteric hip fractures
in the elderly. Furthermore, although functional results and mortality rates are similar, as cemented calcar replacement
hemiarthroplasty has serious life-threatening complications, it should not be the first choice of treatment method.

Keywords: Intertrochanteric fracture, Cemented hemiartroplasty, PFN

INTRODUCTION establish these fractures.4 It has been reported by some

studies that intramedullary nail devices, proximal-femoral
Rate of hospitalization due to hip fracture has significantly nail (PFN) are suitable devices for intertrochanteric
increased in the last 20 years and intertrochanteric fractures, as shown by biomechanical studies.5-7 However,
fractures and its surgery and the troubles afterwards are implant insufficiency and screw stripping in severe
still major public health issues.1-3 The implant to be used osteoporotic fractures bring out partial hip prosthesis as an
in the treatment of intertrochanteric fractures is still a alternative method of treatment and it has satisfying results
matter of debate due to low bone mass, co-existing in literatures.8,9
diseases and the reason that there are many implants to

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 Erkmen D et al. Int J Res Orthop. 2023 Sep;9(5):863-869

In this study, we have retrospectively evaluated patients patients. A single lag screw could be placed to the femoral
older than 70 years old that have fixed with PFN and head over the nail at an angle of 128 degrees and solid
partial prosthesis with cemented calcar replacement in our sliding lag screw was used in all our patients. There was
clinic and researched whether prosthesis with cemented an option of locking with single screw in distal. Prosthesis
calcar replacement could be an alternative to PFN for these with cemented calcar replacement (BiometInc. Warsaw,
patients by comparing their early and late mortality and IN, USA) that is designed for proximal femur was
morbidities, degrees of achieving functional personal performed with lateral approach to all our patients who
independence. underwent hemiarthroplasty.

METHODS Infection prophylaxis and thromboembolism prophylaxis

were performed all the patients. Those patients whose
85 patients older than 70 years old, which received general condition were sufficient after the operation were
treatment November 2008 and December 2009 due to put on full load on day one in the hospital of a doctor to
Arbeitsgemeinscaft fur Osteosyntesefragen (AO) type 31- the extent they could bear the pain. In the follow-up of our
A1 and 31-A2 intertrochanteric hip fracture in Ankara PFN patients, based on their physical examinations and the
Numune Education and Research Hospital, were examined radiographies, after ensuring full union in an average of
retrospectively. Eigth patients, those who had pathological three months, they were put on full load. The patients were
fractures, ipsilateral or contralateral amputation were called to their post-operative follow-ups as; sixth week,
excluded from the study. Sixteen of theremaining 77 third month, sixth month, 12th month. Quality of reduction
patients have lost their lives. Case details of those patient according to radiographic evaluation during the follow-up
who lost their lives were used in our study for statistical of the patients was classified as anatomic (varus-valgus,
purposes. anteversion- retroversion less than 5 degrees), reasonable
(5°-10°), orbad (>10°). The position of the lag screw was
Ourpatients were divided into two groups, PFN group and qualified good in center/inferior-center position according
hemiarthroplasty group. Fracture sides, intraoperative and to anterior-posterior radiography and in center position in
postoperative amounts of bleeding, anesthesia types and lateral radiography; and qualified bad in other positions.
ASA scores, fracture types according to AO, average
hemoglobin decline amounts, blood transfusion amounts, Analysis of the data was carried out on statistical package
average albumin decline amounts, operation durations, for the social sciences (SPSS) for Windows 15 package
time from injury to surgery, hospitalization duration and program. Descriptive statistics were shown as
total follow-up time of two different surgical techniques average±standard deviation or median (minimum-
were evaluated and a comparison was made between the maximum) for continuous and intermittent numeric
groups. variables, while categorical variables were shown as
number of cases and (%). Results were considered
Modified Harris hip score criteria were observed by taking statistically significant for p<0.05.
into consideration the pain, walking capacity and physical
examination symptoms of the patients clinically and Ethics committee approval was obtained for our study
criteria of modified Barthel activities of daily living ındex from the ethics committee of Ankara Numune Education
(MBI) that assesses the degree of dependency of the and Research Hospital with protocol number 536-2013.
patients on ful filling their daily life activities, personal
care and needs were applied and their condition in the first RESULTS
year was evaluated.
PFN group consisted of 36 patients while prosthesis group
The patients were radiologically evaluated for consisted of 41. Minimum age in the PFN group was 70
complications that could be observed in postoperative years old, maximum 98 years old, average 79 years old;
follow-up such as implant failure, screws cut-out, minimum age in the prosthesis group was 74 years old,
mechanical failure and secondary varus malalignment, maximum 97 years old and average 83 years old.
shortness, acetabular penetration, acetabular protrusion, Considering the intra group gender distribution; while
dislocation, fracture around the implant and prosthesis there were 19 (52.8%) women and 17 (47.2%) men in the
loosening. The two different techniques were evaluated in PFN group, there were 27 (65.9%) women and 14 (34.1%)
terms of wound infection, fat necrosis, decubitus ulcer, men in the prosthesis group. There was no significant
severe local pain, symptomatic deep vein thrombosis, difference in terms of median age and gender distribution
pulmonary thromboembolism complications and between the prosthesis and PFN groups (p=0.077 versus
compared. First month, sixth month, first year and total p=0.350). There was no difference between the groups in
mortalities of the two groups were compared. terms of frequency and distribution of co-existing diseases
and average number of co-existing diseases, fracture
PTN (Pertrochanteric nail; BiometInc. Warsaw, IN, USA) distribution according to AO-OTA classification and type
system was performed to the patients in the PFN group. In of anesthesia. The fracture etiology in all our patients was
this system which has length options of extra short, short due to low-energy trauma caused by a simple fall. As
and tall; we performed the short length option for our additional trauma, 7 of our patients had radius distal end

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 Erkmen D et al. Int J Res Orthop. 2023 Sep;9(5):863-869

fracture (4 percutaneous pinning, 3 closed reduction and re-operation. Those 4 patients who had screw cut-out were
plaster treatment), 2 of our patients had humerus surgical in the group of patients with bad lag screw positions. There
neck fracture (one patient open reduction + internal was no difference between the groups once the Harris hip
fixation, other one percutaneous pinning), 1 of our patients score of the patients in PFN and prothesis groups were
had shoulder dislocation (closed reduction) (Table 1). compared (Table 2).

Figures 1 and 2 show the radiographs and functional Operation duration, average amount of bleeding,
results of patients in PFN group and arthroplasty group. transfusion need, decrease in hemogram and albumin
amounts of the patients were indicated in Tables 3 and 4.
Considering the quality of fracture reduction of the Results of modified Barthel index were indicated in Table
patients in the PFN group, reduction qualities achieved in 5.
16 (44.4%) patients was anatomic, in 17 (47.2%) patients
was reasonable and in 3 (8.3%) patients was bad. Frequency of other complication sex, wound infection was
Considering the implant position, initial position of the lag found to be similar between the PFN and prosthesis
screw was evaluated as good in 30 (83.3%) patients and groups. Wound infection was found to be significantly
bad in 6 (16.7%) patients. Cut-out occurred in the lag high in the prosthesis group compared to the PFN group
screws of our 4 patients during their follow-up. Upon bone (p=0.032) (Table 6).
union formation in 2 of our patients who had screw cut-out
in the postoperative 2nd month, they underwent screw While the mortality rates at 1st month, 6th month and 1st
removing operation. Screw cut-out happened on the 3rd years of the prosthesis group were higher to the PFN
week for our 2 other patients. These patients were confined group, there was no significant difference between the
to bed. The patients and their relatives did not perfomed groups (p>0.05) (Table 7).

Table 1: Demographic and clinical characteristics of the cases according to prosthesis and PFN groups.

Characteristics Prosthesis (n=41) (%) PFN (n=36) (%) P value

Age, (year) 83 (74-97) 79 (70-98) 0.077†
Gender 0.350‡
Male 14 (34.1) 17 (47.2)
Female 27 (65.9) 19 (52.8)
Alzheimer's 9 (22.0) 4 (11.1) 0.336‡
DM 9 (22.0) 14 (38.9) 0.170‡
HT 34 (82.9) 33 (91.7) 0.321¶
COPD 12 (29.3) 9 (25.0) 0.870‡
CAD 9 (22.0) 8 (22.2) 1.000‡
Parkinson's 4 (9.8) 3 (8.3) 1.000¶
Heart failure 5 (12.2) 2 (5.6) 0.438¶
Chronic kidney failure 1 (2.4) 0 (0.0) 1.000¶
Asthma 1 (2.4) 0 (0.0) 1.000¶
Number of co-morbid diseases 2 (1-4) 2 (1-4) 0.985†
Type of anesthesia 0.974‡
General 17 (41.5) 16 (44.4)
Spinal 24 (58.5) 20 (55.6)
ASA 0.151†
2 2 (4.9) 4 (11.1)
3 22 (53.7) 22 (61.1)
4 15 (36.6) 9 (25.0)
5 2 (4.9) 1 (2.8)
†Mann Whitney U test, ‡continuity corrected Chi-square test, ¶Fisher's exact test, $student's t test

Table 2: Findings regarding fracture characteristics of the cases according to prosthesis and PFN groups.

Characteristics Prosthesis (n=41) (%) PFN (n=36) (%) P value

Fracture classification
31 - A1.1 4 (9.8) 2 (5.6) 0.679†
31 - A1.2 4 (9.8) 2 (5.6) 0.679†
31 - A1.3 1 (2.4) 2 (5.6) 0.596†
31 - A2.1 8 (19.5) 13 (36.1) 0.169‡
Continued.

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 Erkmen D et al. Int J Res Orthop. 2023 Sep;9(5):863-869

Characteristics Prosthesis (n=41) (%) PFN (n=36) (%) P value

31 - A2.2 15 (36.6) 8 (22.2) 0.261‡
31 - A2.3 9 (22.0) 9 (25.0) 0.964‡
Harris score 77.8±10.2 77.0±11.0 0.786¶
Harris score 0.728$
Bad 6 (20.6) 6 (18.8)
Moderate 10 (34.4) 14 (43.8)
Good 8 (27.5) 7 (21.9)
Excellent 5 (17.2) 5 (15.6)
Quality of reduction -
Bad - 3 (8.3)
Reasonable - 17 (47.2)
Anatomic - 16 (44.4)
Position of implant -
Bad - 6 (16.7)
Good - 30 (83.3)
†Fisher's exact test, ‡continuity corrected Chi-square test, ¶student's t test, $Mann Whitney U test (Harris score calculated survive patients)

Table 3: Other clinical symptoms of the cases according to prosthesis and PFN groups.

Symptoms Prosthesis (n=41) PFN (n=36) P value †

Duration of operation (mins.) 40 (35-55) 25 (20-35) <0.001
Intra-op bleeding (cc) 400 (200-500) 150 (100-250) <0.001
Blood transfusion (unit) 2 (0-5) 1 (0-2) <0.001
Post-op drainage (cc) 400 (200-600) 100 (50-150) <0.001
Follow-up period (month) 19 (15-26) 19 (14-25) 0.571
†Mann Whitney U test

Table 4: Preoperative and postoperative laboratory measurements of the cases according to prosthesis and PFN
groups.

Parameters Pre-op Post-op P value † Change P value ‡

Hemoglobin <0.001¶¶
Prosthesis 11.5±1.2 8.7±0.9 <0.001¶ -2.8±1.1
PFN 11.0±1.2 9.6±1.2 <0.001¶ -1.4±0.6
Albumin <0.001$$
Prosthesis 32 (21-41) 20 (13-28) <0.001$ -13 (-20-4)
PFN 35 (20-46) 28.5 (15-42) <0.001$ -6 (-15-1)
†Comparisons made between preoperative and postoperative with in the groups, ‡comparison made for the amount of change in the
postoperative period compared to preoperative period with in the groups, ¶paired samples t-test, $Wilcoxon sign ranked test, ¶¶student's
t test, $$Mann Whitney U test

Table 5: MBI distribution of the cases according to prosthesis and PFN groups.

Parameters Prosthesis (n=41) (%) PFN (n=36) (%) P value

MBI 0.077†
Slightly dependent 6 (20.6) 10 (31.3)
Reasonably dependent 11 (37.9) 15 (46.9)
Significantly dependent 12 (41.3) 7 (21.9)
†Mann Whitney U test (MBI score calculated survive patients)

Table 6: Complication distribution of the cases according to prosthesis and PFN groups.

Parameters Prosthesis (n=41) (%) PFN (n=36) (%) P value

Complication 20 (48.8) 15 (41.7) 0.692†
PTE 8 (19.5) 2 (5.6) 0.094‡
Wound infection 8 (19.5) 1 (2.8) 0.032‡
Continued.

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 Erkmen D et al. Int J Res Orthop. 2023 Sep;9(5):863-869

Parameters Prosthesis (n=41) (%) PFN (n=36) (%) P value

Development of shortness 2 (4.9) 5 (13.9) 0.242‡
Fat necrosis 4 (9.8) 2 (5.6) 0.679‡
Residual pain 1 (2.4) 4 (11.1) 0.179‡
Decubitus 3 (7.3) 1 (2.8) 0.618‡
UTI 1 (2.4) 1 (2.8) 1.000‡
DVT 2 (4.9) 0 (0.0) 0.496‡
Pneumonia 1 (2.4) 0 (0.0) 1.000‡
†Continuity corrected Chi-square test, ‡Fisher's exact test, DVT: deep vein trombosis, PTE: pulmonary tromboembolism, UTI: urinary
tract infection

Table 7: Mortality rates according to the follow-up time of the cases according to the prosthesis and PFN groups.

Time Prosthesis (n=41) (%) PFN (n=36) (%) P value

1 month 6 (14.6) 2 (5.6) 0.271†
6 months 9 (22.0) 4 (11.1) 0.336‡
12 months 12 (29.3) 4 (11.1) 0.093‡
†Fisher's exact test, ‡continuity corrected Chi-square test

DISCUSSION

Despite technological advances, the treatment of hip

fractures continues to be a controversial problem all over
the world.10-12 While there was an average of 1.7 million
proximal femur fractures in the world during 1990, it is
estimated that this number will reach 6.3 million in the
year 2050. Independently of the surgery performed,
mortality rate changes between 18% and 33% in the year
after the trauma.13 The most effective method of treatment
for instable intertrochanteric femur fractures at the present
time is fixation of the fracture and internal devices.14,15
While it is expected that the implant to be used in order to
perform this fixation is applicable via minimal invasive
technique, enable full load after the operation and have low
complication rates; a number of complications are
observed in all of the implants that are used in the
treatment of intertrochanteric fractures.16,17 The implant
that will provide all these conditions is appropriately not
available today. Therefore, choice of the implant fort the
Figure 1: 68-year-old male patient with 31 A2-2 left treatment of the intertorachanteric hip fracture is still
interthoracanteric fracture after falling, radiographs controversial. Nowadays, perthoracanteric nail, dynamic
and functional images in the first year follow up. hip screw (DHS), plate screw osteosynthesis,
hemiarthroplasty and total hip arthroplasty are among the
methods used in the treatment of intertorchanteric femur
fractures.18

Rodop et al in which they published results of a 54 patients

that treated bipolar Leinbach hemiarthroplasty; it was
stated that 80% of the patients received perfect and good
results according to Harris hip score system and there was
no compilication.19 In another study by Huang et al, they
treated total of 131 patients with interthoracanteric
fracuters three different methods (PFNA, DHS,
arthroplasty). They found out Harris scores at 12 weeks
after operation in hemiarthroplasty was higher than that of
DHS and PFNA, but there was no statistical difference
Figure 2: Postoperative radiographs and functional between DHS and PFN They concluded that
status of an 81-year-old male patient with AO 31-A2-2 hemiarthorplasty is the best method for the who has a
fracture during the first year follow-up. severe unstable osteoporotic multifragment fracture in

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 Erkmen D et al. Int J Res Orthop. 2023 Sep;9(5):863-869

elderly patients.20 In another study by Jolly et al, they that the more invasive approach in the prosthesis patients
evulated the Harris scores of a total of 100 patients treated make these patients more prone to wound complications.
with PFN (50 patients) and cemented hemiarthroplasty (50 Although the difference between the groups is statistically
patients). They found it higher in the arthroplasty group in not significant, were of the opinion that cemented
the first 3 months, but higher in the PFN group in the 6th hemiarthroplasty poses a risk in terms of vascular
and 12th months. And mean mobility score was better in complications.
the pfn group at 6 months, but they did not detect any
difference between the two groups at 12 months.15 We Limitations
used modified Harris hip score system (MHHS) in this
study too.21 When we evaluated the functional results of Limitations of our study include: difficulty of
alive PFN and hemiarthroplasty patients with MHHS and standardization due to the number of patients in the groups
made a comparison between the groups, we could not being low compared to their studies in the literature, every
detect a significant difference at one year results. We patient's co-morbidities affecting each patient differently
evaluated independency of our patients regarding personal according to their biological condition, were other
care duties according to modified Barthel index (MBI) in limitations of our study.
our study.22 We have detected external dependence levels
of PFN and prosthesis during postoperative term to be CONCLUSION
similar, however; a more accurate comparison can be done
by evaluating the patients condition before the fracture in According to our knowledge hemiarthroplasty may be an
the assessment of independency in personal care duties. alternative treatment method in these patients, but serious
cardiac and vascular complications, high mortality rate,
Hemiartroplasty has a serious complications such as longer operation time, greater amount of bleeding and
requiring a broad incision during the operation, amount of need for transfusion, and long-term loosening, prosthesis
bleeding being high, hypotension and embolism dislocation, acetabular protrusion and periprosthetic
developing due to the use of bone cement, dislocation of fracture may be encountered in these patients. Such serious
prosthesis after the operation, higher rates of deep and complications limit theuse of hemiarthroplasty. According
superficial infection.23 On the other hand, superficial and to our knowledge more objective results can be obtained
deep infection, pulmonary complications and cut-out are by conducting prospective studies comparing PFN and
important complications in patients who underwent PFN.24 uncemented hemiarthropasty.
Complications of the patients who received prosthesis via
PFN or other internal fixation methods have been Funding: No funding sources
compared in many studies. While some articles have found Conflict of interest: None declared
internal fixation methods to be better, some found Ethical approval: The study was approved by the
functional results of hemiarthroplasty better. Generally, Institutional Ethics Committee
the mortality rates of the patients who done internal
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International Journal of Research in Orthopaedics | September-October 2023 | Vol 9 | Issue 5 Page 869