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The aim of this prospective study was to assess the outcome of trochanteric fractures of the femur after external fixation in a group of elderly patients with high surgical risk. The study population consisted of 50 patients with trochanteric fractures of the femur and a mean age of 87 years who were classified by an anaesthetist as ASA 3 or 4 and considered not suitable for conventional fractures fixation. The fracture was fixed with an external fixator under spinal anaesthesia. The final follow-up was at 12 months. All fractures healed within 12 weeks. Superficial pin tract infection occurred in 30 patients, and fracture united with a shortening of 14 mm (5–20) in 12 patients. No implant failures or limitation of knee movements were recorded. Five patients died within 1 year. External fixation is a valuable treatment alternative for trochanteric fracture of the femur in elderly patients.
Le but de cette étude prospective est d’évaluer le devenir de patients traités par fixation externe sur un groupe de patients âgés avec risque opératoire. Matériel et méthode: 50 patients présentant une fracture trochantérienne du fémur et âgés en moyenne de 87 ans ont été classés par les anesthésistes en ASA 3 et 4 et considérés comme difficiles à traiter par les techniques conventionnelles. La fracture a été fixée par un fixateur externe sous rachi-anesthésie. Le suivi a été réalisé sur une période de 12 mois. Résultat: toutes les fractures ont guéri dans un délai de 12 semaines. Des infections sur broches sont survenues chez 30 patients et la fracture a consolidé avec un raccourcissement moyen de 14 mm (5 à 20) chez 12 patients. Il n’y a pas eu d’échec dû au matériel ou de limitation de la mobilité du genou. 5 patients sont morts durant cette première année. En conclusion, la fixation externe est un traitement alternatif valable pour les fractures trochantériennes du fémur chez les patients très âgés.
Fracture of the hip is a leading cause of death and disability in the elderly [4, 14]. Treatment goals for these patients include early rehabilitation, restoration of anatomical alignment, and maintenance of the fracture reduction . There are a variety of fixation methods, the most commonly used being the dynamic hip screw. However, a significant number of elderly patients are quite frail and present a high surgical risk . For such patients, prolonged anaesthesia and intraoperative blood loss are not well tolerated, posing contraindications for the commonly used surgical procedures. Conservative treatment is an unacceptable alternative, since it has been associated with mortality of up to 60% [10, 12]. The aim of this prospective study was to test an external fixator in a group of high surgical risk elderly patients.
Between 2003 and 2005, 50 patients with trochanteric fractures admitted to our department were classified by the anesthetist as ASA grades 3 or 4 and considered not suitable for conventional fracture fixation. The medical conditions causing the patients to be considered as high risk are shown in Table 1, and the demographic details are given in Table 2. We treated those 50 patients with an external fixator. There were 22 male and 28 female patients with mean age of 87 years (70–100 years). The right hip was involved in 20 cases and the left in 30. The fractures were classified according to the modified Evans classification as 38 stable and 12 unstable, reducible under image intensifier. The operations were performed under spinal anaesthesia. All the patients received intravenous antibiotic before surgery and orally thereafter until 2 days after discharge from the hospital. A guide wire was inserted percutaneously at an angle of approximately 130° through the middle of the femoral neck into the head. Self-tapping pins of 4.5 mm or 6.5 mm in diameter were inserted manually through a drill sleeve on either side of the guide wire and within the confines of the femoral neck. The pins were advanced to a point 5 mm short of the subchondral bone of the head. These pins guided the insertion of two 4.5 mm Schanz pins into the proximal femur. A drill sleeve and low speed drill were used in all cases to minimise trauma to the soft tissue. The intra-operative time was measured from the time of incision for the implantation of the first pin to when the fixator was completely mounted. The mean operative time was 18 min, ranging from 10 to 30 min. The blood loss was measured as the difference in weight between the dry swabs and those soaked in blood.
Postoperatively all patients had a progressive programme of weight bearing using a walking frame from the first day of surgery. Appropriate physiotherapy was advised for hip and knee movement. Pin sites were cleaned daily with saline, and the family member or carer of the patients were given instructions on continuing care after discharge. All fixators were removed at 3 months, without anaesthesia, in the outpatient clinic. All patients were reviewed at 6, 12, 18, and 24 weeks. Observations regarding shortening, malunion in external rotation, varus angulation, pain at the hip and knee, range of movement of the hip and knee, evidence of union, and infection were recorded. The final follow-up was at 12 months when function was assessed using a modified Harris Hip Score  and function of the knee was assessed using a modified Western Ontario and McMaster University Osteoarthritis (WOMAC) index . This study had ethical approval from the ethical committee of B. P. Koirala Institute of Health Sciences.
No patient required blood transfusion postoperatively. The fixator did not interfere with sitting or lying. There was restriction of knee movement but it was regained after removal of the fixator and physiotherapy. The average time to fracture union was 12 weeks (range, 10–14 weeks). No fracture failed to unite and we encountered no implant failure. There were no cases of pin loosening, breakage, or penetration of femoral head. Twelve patients had an average limb shortening of 14 mm. This ranged from 5 mm to 20 mm and was the result of some impaction and or collapse in varus that occurred in some unstable fractures. Ten patients had an average varus angulation of 5° (range 4°–8°). The average time for surgery was 18 minutes (range, 10–30 minutes), and average blood loss was 33.33 ml (range, 20–50 ml). Grade I pin-track infection was observed in 30 patients (60%), but all resolved on removal of the pins. The infections were successfully treated with oral antibiotics and daily cleansing with antiseptic solutions, which healed by 2 weeks. Average duration of hospital stay was 2 days (range, 2–4 days). The mean Harris Hip Score at 1 year was 90 and the WOMAC index was 3. During the 1 year follow-up period five patients died from causes unrelated to the operation. Forty-three of the 45 surviving patients at 1 year returned to their prefracture ambulatory status.
Improvement in health services has resulted in a significant increase in life expectancy. This has been accompanied by an increase in the incidence of pertrochanteric fracture, which mainly occur in the elderly. Elderly patients with a host of medical conditions who sustain a pertrochanteric fracture usually require prolonged hospital stay following conventional fixation of their fracture. The need to reduce risks of fracture fixation, permit early mobilisation, and reduce hospital stay has prompted several authors to propose external fixation as an alternative treatment option for these elderly high-risk patients. In recent studies pertrochanteric fractures treated with newly-developed external fixators show better results than those reported previously . Our study has confirmed the advantages of external fixation for treating pertrochanteric fracture in elderly high-risk patients. The operative time of 18 min is significantly reduced compared to internal fixation (mean 40 minutes in our department). Blood loss is negligible and the surgical stress for the patient minimal. Postoperative pain is minimal and easily controllable, making the nursing and mobilisation of these patients easier. Studies using new fixators (Orthofix Pertrochanteric Fixator) have also shown that external fixation can provide results that are similar to, or even better than, those obtained with conventional internal fixation techniques [13, 14].
Despite these evident advantages, the external fixator has failed to become popular with most surgeons because of the significant reported complications in previous studies, infection being the most common. Cases of deep infection that required pin removal or repositioning have been reported . Vossinakis and Badras  reported that pin-track infection developed in 15 of their 50 patients (30%) treated with the Orthofix external fixator using standard pins. In a similar study, 18 of 41 patients (45%) had pin-track complications . In our study grade I pin-track infection was observed in 30 cases (60%) and all healed after removal of pins. Urine incontinence has been implicated as a cause of infection, and is considered a contraindication to the use of external fixation. However, this was successfully managed with long term catheterisation in our patients as previously suggested. Devgan and Sangwan  reported pin-track infection and knee stiffness as major complications of external fixation. This was not seen in our study, possibly due to the low speed drill and more proximal placement of the femoral shaft Schanz pins.
Shortening due to collapse and varisation of the femoral neck is a well-recognised complication of both internal and external fixation in unstable fractures or in the presence of severe osteoporosis [7, 12]. In our study,12 of 50 patients had an average shortening of 14 mm (range, 5–20) and varus angulation of 5° (range, 4°–8°) in ten patients. The device used in this study offers enough stability to allow full weight bearing without compromising fracture healing. In a previous report the proximal pins penetrated into the hip joint in three cases . This complication was not encountered in our series.
Finally, the presence of osteolysis around the pins without infection has been reported . This has been attributed to incorrect surgical technique without any further clarification. It is possible that it was the result of thermal necrosis following high speed drilling. We did not observe any signs of osteolysis and we attribute this to our atraumatic technique.
We believe that the use of appropriate external fixation for the management of pertrochanteric fracture in elderly patients of poor health is a valuable alternative. External fixation is minimally invasive and causes no additional tissue trauma. In elderly patients of poor health (ASA 3 or 4), who are often malnourished, stable fixation without surgical trauma could be vital for a faster recovery and mobilisation, with reduced morbidity and mortality.
However in our previous randomised controlled trial we observed the external fixation is a less traumatic and cost effective option than the sliding hip screw in all cases of trochanteric fractures . This study proves the external fixator is even more cost effective when indicated in elderly and high-risk patients with trochanteric fractures.
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