Cemented Bipolar Hemiarthroplasty for Fracture Neck of Femur and Unstable Intertrochanteric Fractures-Prospective and Retrospective Study

Hip fractures in elderly patients are becoming a major social problem from various perspectives, including the progressive aging of global societies. The elderly have a high risk of hip fracture, even with minor injuries because of osteoporosis, while early surgical treatment may be difficult due to comorbidities and medication. In this study, significant risk factors were identified. Patients over age 70 had three times the mortality of younger patients. Greater than three pre­existing medical conditions is associated with a 25 percent mortality rate, more than twice that of healthier patients. Surgery performed on the first day of admission and beyond the fifth day was associated with a 34 percent mortality rate. Those patients operated in during days 2 through 5 had a 5.8 percent mortality rate. There was no failures related to inadequate stem or mechanical loosening. The tendency to dislocation can be clinically identifiable by major discrepancy in length, there was no failures related to inadequate stem or mechanical loosening. The tendency to dislocation can be clinically identifiable by major discrepancy in length and only 1 patient had shortening of about 2 cms post operatively which was slightly better than that of James et al (11%).


INTRODUCTION
Comminuted intertrochanteric fractures with severe displacement are common in elderly patients. These patients have poor bone quality and conventional osteosynthetic procedures frequently lead to nonunion and metal failure. The intertrochanteric fractures and femoral neck fractures occur in the more elderly age group. Most inter trochanteric hip fractures can be treated successfully with internal fixation. The failure after internal fixation had been due to initial fracture pattern, comminution, sub optimal fracture fixation and poor bone quality [15].
Stable intertrochanteric fractures can be easily managed with osteosynthetic methods with satisfactory results but the same cannot be expected in comminuted and unstable intertrochanteric fractures. Excessive collapse, loss of fixation and cut through of the screw are commonly encountered when conventional osteosynthesis is attempted.
In these patients treatment with primary cemented hemiarthroplasty could perhaps return the patients to their pre injury level of activity more quickly thus obviating the post operative complications caused by immobilization or failure of the implant.The purpose of the present study was to evaluate the results, technical problems with cemented hemi arthroplasty for comminuted, osteoporotic fracture neck of femur and comminuted unstable intertrochanteric fractures of the elderly.

METHODOLOGY
This prospective study included 20 cases of elderly patients with mean age of 73.5 years who sustained multifragmentary/communited inter trochanteric femur fracture treated with Primary cemented bipolar hemiarthroplasty with trochanteric and calcar reconstruction to emphasize the importance of restoration soft tissue tension to reduce the risk of unstable Hemiarthroplasty.
The 30 elderly osteoporotic patients with neck of femur and unstable intertrochanteric fractures were taken for the study. After the preliminary approaches have performed the fracture site is exposed. With the fracture fragments temporarily reduced, the neck of the femur is cut approximately 1 cm above the lesser trochanter. If the fracture in the calcar fragment had extension beyond the lesser trochanter the fragment was stabilized partially using a cerclage wire or a bone reduction clamp when the femoral canal is reamed. The femoral stem was cemented in place using standard modem cementing techniques that include, lavage, cleaning, drying and plugging of the canal. The fractured greater trochanter with the abductor mechanism was stabilized with the main fragment by using 18 gauge cerclage wire, in a figure of 8 fashion. The wound was closed in layers with a suction drain. The drain was removed at 48 hrs and the patient was made to walk with full weight bearing as tolerated, under the supervision of a physical therapy team.

RESULTS AND DISCUSSION
Osteosynthesis of such fractures may reduce the morbidity of pain; it does not permit an early mobilization with a fear of failure of fixation. In old osteoporotic patients surgeon is often confronted with a challenge and dilemma between achieving bony union in a weakened bone stock with poor implants hold, against need for early mobilization. The special problems associated with unstable fractures in the geriatric age group are possibly due to one or more of the following factors: Osteoporosis. Comminution. Age related medical illnesses, and need for rapid mobilization.
Hemiarthroplasty has been used for unstable intertrochanteric fractures since 1971, however less frequently as compared to femoral neck fracture. The outcome of fixation depends mainly on quality of bone, age of patient, general health, trauma surgery interval, adequacy of treatment, comorbidities, and stability of fixation.
In our study the minimum follow up was 5 months and the maximum follow up was 20 months with a mean follow up of 11.4 months. Maximum number of patients were followed between 7 to 12 months. Except 2 patients all the other patients had follow up more than 6 months.
The following observations are made in this study: There was a slight female preponderance (56.66%).The incidence of fracture was common in the age group of 71 to 80 years . This shows those elderly age groups were more susceptibleIn most of our patients left side (63.33%) was commonly affected. In the distribution of fracture types based on this study 50% were based on neck of femur fractures and other 50% were on intertrochanteric fracturesIn majority of our patients the common pre existing co morbid conditions are Diabetes mellitus (63.33%), Systemic hypertension (43.33%), Coronary artery disease (20%), Chronic renal failure (3.33%)In most of the patients the Singh's Index was Grade 3 (56.66%).
Kenzora et al found on overall mortality rate of 15 percent in fractures about the hip compared to an expected mortality rate of 9 percent for the normal population. In his study, significant risk factors were identified. Patients over age 70 had three times the mortality of younger patients. Greater than three preexisting medical conditions was associated with a 25 percent mortality rate, more than twice that of

CONCLUSION
We hereby conclude that primary cemented bipolar hemiarthroplasty is an excellent option in selective unstable fractures like neck of femur and that of trochanter. It is both cost effective and permits early rehabilitation in the elderly with co morbid conditions.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the authors.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the authors.