A research on bone mineral density in the hip joint and evaluation on intertrochanteric fracture treatment with bipolar joint hip replacement in the elderly from 2012 to 2015 at 103 military hospital – Le Ngoc Hai

Journal of military pharmaco-medicine n 0 9-2018 134 A RESEARCH ON BONE MINERAL DENSITY IN THE HIP JOINT AND EVALUATION ON INTERTROCHANTERIC FRACTURE TREATMENT WITH BIPOLAR JOINT HIP REPLACEMENT IN THE ELDERLY FROM 2012 TO 2015 AT 103 MILITARY HOSPITAL Le Ngoc Hai1; Tran Dinh Chien2 SUMMARY Objectives: To investigate hip osteoporosis among elderly patients with intertrochanteric and to evaluate the outcome of fracture treatment with bipolar joint replacement in the elderly. Subjects and methods: A retrospective and prospective study on 60 patients (15 men and 45 women), mean age 82.62 ± 5.75 (from 70 to 102 years old) were treated for hip fracture with hip replacement partially used cement at 103 Military Hospital from 09 - 2012 to 12 - 2015. Clinical description of age, gender, lesion characteristics, bone mineral density in the hip and immediate and predicted results. Results and conclusions: Age group 80 - 89 accouted for 48.33%, women/men ratio 3.0/1. Classified based on AO, group A2 made up 63.33%. Bone mineral density measured in accordance with DEXA was 60 patients: BMI index 18.5 - 22.9 accounted for 73.33%, Singh highest grade 55.0%, T-score average femur neck -3.62 ± 0.55, T-score = -3.9 for majority, T-score for femoral neck -3.03 ± 0.44; T-score average intertrochanteric fracture -3.02 ± 0.4; mean T-score of Ward area -3.91 ± 0.58; T-score mean head-to-hip ratio -3.20 ± 0.53. Bone mineral density of the neck - trochanteric - intertrochanteric - total head on the male thigh bone was significantly higher than that of females (p < 0.05); However, Ward's triangle bone between two groups of males and females was not different (p = 0.18487). Immediate evaluation: 100%, distance scale results according to Merle D’Aubigné - Postel: very good: 10.0%, good: 53.33%, quite: 23.33%, medium: 8.33%, bad: 5.0%. * Keywords: Intertrochanteric; Bipolar; Elderly; Hip replacemen; DEXA. INTRODUCTION Intertrochanteric hip fracture among the elderly is very common. Women outnumber men, due to the common cause of falls. In the United States, it is expected that 200,000 patients suffer from hip fractures usually with mortality up to 15 - 30%, commonly found in patients older than 70 years, whose treatment is up to $10 bil per year [5]. Intertrochanteric fracture is painful, even more traumatic specifically in the elderly treatment due to the elderly‘s fracture complexity, poor bone quality and chronic systemic combination. Many methods of treatment of intertrochanteric fractures have been studied and applied such as bone grafts with DHS splint, braces, nails Gamma have brought good results. However, in cases of unstable fractures, 1. Thanhhoa Department of Health 2. 103 Military Hospital Corresponding author: Le Ngoc Hai (phhaingoai@gmail.com) Date received: 11/06/2018 Date accepted: 19/11/2018 Journal of military pharmaco-medicine n 0 9-2018 135 broken bones, or thinning of the bones, bone grading methods are ineffective for the patients who are unable to bone slow recovery, ill hip joint, limiting the rapid recovery, making the patients unable to move early. In these cases, many authors advocate partial hip replacement for the purpose of helping patients quickly to restore their movement or even to sit up early. This approach helps avoiding systemic complications due to long-term restlessness including ulceration, pneumonia, or other systemic diseases. In Vietnam in recent years, many hip replacement surgery clinics have applied partial hip replacement on the elderly patients with intertrochanteric fractures. However, no agreement on this issue has been reached and no study has evaluated osteoporosis in the elderly patients with intertrochanteric fractures. Therefore, we have conducted a study on the topic with the goal: - To review osteoporosis in the hip of associated with intertrochanteric fracture. - To evaluate bipolar partial hip replacement in the elderly patients with intertrochanteric fracture. SUBJECTS AND METHODS 1. Subjects. - 60 patients aged 70 years old and above, regardless of sex, intertrochanteric fractured type A1, A2, A3 by AO classification, Singh grade 1 - 2 - 3 osteoporosis according to Singh, bipolar surgery with cement at 103 Military Hospital from 09 - 2012 to 12 - 2015 provided with accompanied documents: Full medical records, with pre- operative, postoperative and scheduled screening. Bone mineral density in the hip based DEXA surgery were measured and recorded. - All 60 patients with the first time of hip replacement, with the mortar in good condition, not degraded, not deformed. 2. Methods. - Retrospective and prospective study, clinical description. Reseach categories include: Age, sex, traumatic features, bone density survey, indicative draw and studies of treatment results: Evaluation of the close results: Closeness of wound rehabilitation of hip joint and the complications of premature and complete onset. Outcome evaluation: According to Merle D'Aubigné - Postel: 17 - 18 points: excellents; 15 - 16 points: good; 13 - 14 points: quite; 10 - 12 points: medium; ≤ 9 points: bad. * Data processing: Processed on Epi.info 7 software. Journal of military pharmaco-medicine n 0 9-2018 136 RESULTS 1. Classification of intertrochanteric fracture based on age, gender in elderly patients. Table 1: Age, gender (n = 60). Gender Age Men Women Total Percentage % 70 - 79 years old 7 14 21 35.0 80 - 89 years old 6 23 29 48.33 > 90 years old 2 8 10 16.67 Total 15 45 60 Percentage % 25.0 75.0 100 The age group of 80 - 89 accounted for the highest proportion (48.33%); women/men ratio: 3.0/1. Causes of fracture: 2 cases of traffic accident accounted for 3.33%, falls: 58 cases (96.67%); intertrochanteric fracture alone was 58 patients, with two patients with forearm fractures and software lesions. Table 2: Classification of intertrochanteric fractures by AO (n = 60). AO Age A1 A2 Total Percentage % 70 - 79 years old 9 12 21 35.0% 80 - 89 years old 11 18 29 48.33% ≥ 90 years old 2 8 10 16.67% Total 22 38 60 100.0% Percentage % 36.67% 63.33% Intertrochanteric fracture was rated by category AO with the highest percentage of 63.33% in A2 fracture, the age group of 80 - 89 had 29 patients (48.33%) in which A2 was present in 18 patients. Table 3: Measurement of bone mineral density of intertrochanteric fracture to Singh (n = 60). Osteoporosis Age Grade I Grade II Grade III Total Percentage % 70 - 79 years old 0 13 8 21 35.0% 80 - 89 years old 5 19 5 29 48.33% ≥ 90 years old 9 1 0 10 16.67% Total 14 33 13 60 100.0% Percentage % 23.33 55.0 21.67 Journal of military pharmaco-medicine n 0 9-2018 137 Among 3 grades of osteoporosis, grade II accounted for the highest percentage (55.0%). Out of the three groups of age, the group aged 80 - 89 made up the highest percentage (48.33%). Compared to male, females aged more vulnerable to osteoporosis. - Systemic combined disease: There was no systemic disease: 20 patients (33.33%), cardiovascular disease, blood pressure: 31 patients (51.67%), diabetes: 5 patients (5.0%), others: 6 patients (10.0%). Table 4: Osteoporosis level in patients with intertrochanteric fractures with age (n = 60). Gender Variable Male (n = 15) Female (n = 45) Note Neck 0.54 ± 0.05 0.48 ± 0.07 p = 0.00346 Troch 0.50 ± 0.05 0.45 ± 0.07 p = 0.00950 Inter 0.74 ± 0.21 0.61 ± 0.16 p = 0.01498 Ward’s 0.29 ± 0.09 0.28 ± 0.08 p = 0.83085 BMD (g/cm2) Total 0.64 ± 0.16 0.54 ± 0.14 p = 0.01505 Neck -3.42± 0.50 -3.68±0.56 p = 0.11739 Troch -2.88 ± 0.30 -3.08±0.47 p = 0.12216 Inter -2.8 ± 0.25 -3.1 ±0.42 p = 0.01069 Ward’s -3.75 ± 0.47 -3.98±0.61 p = 0.18487 T-score Total -2.95±0.30 -3.27 ±0.56 p = 0.04130 A research on bone density in the hip area revealed a decrease in bone density among 60 patients of hip bone fracture with DEXA technique, compared to the mean bone density in the femoral head. However, the comparison between the genders showed that women's osteoporosis level was higher than that of men with difference from p = 0.01069 < 0.05. Comparison of mean hip osteoporosis on the femur with the corresponding Singh score: Grade 1/grade 2/grade 3: mean T-score -3.26 ± 0.47/-3.02 ± 0.38/ -2.78 ± 0.19, respectively, correlated well with Singh-singularity, the difference between the level of significance and p = 0.00710 was statistically significant. 2. Treatment results. * Review immediate results: First dry scalp 60 patients (100%), early X-ray results after surgery 100.0% of the following artificial joint replacement in the right place, with no dislocated or semi-located joint. Average postoperative objective exercises were 2.95 ± 0.47 days after surgery, postoperative subjective exercises from 5.32 ± 0.65 days, mean hospital stay after surgery was 8.02 ± 2.55 days. * Outcome evaluation: During the follow-up from 4 months to 40 months on 60 patients, which mainly falls on the follow-up duration of 36 months, X-ray after surgery shows 100% joint still Journal of military pharmaco-medicine n 0 9-2018 138 in position. The patients had tendency to be able to move at the highest frequency of fold/stretch/format/fit/ rotate in/offset were: 100 degrees/5 degrees/ 45 degrees/25 degrees/40 degrees/ 40 degrees. * Evaluation based on the Merle D'Postel scale: Very good: 6 patients (10.0%); good: 32 patients (53.33%); quite: 14 patients (23.33%); medium: 5 patients (8.33%); bad: 3 patients (5.0%). DISCUSSION 1. Characteristics of intertrochanteric fractures of the elderly. Table 5: Comparison of patient characteristics with other authors. Author Proportion of women/men The average age Tran Manh Hung et al (2014) [1] 2.3/1 81.8 (70 - 94) Hoang The Hung (2013) [2] 2.8/1 82.19 ± 4.8 (72 - 95) Nguyen Manh Khanh (2012) [3] 3.3/1 78.9 (70 - 97) Joong-Myung Lee (2011) [6] 2.6/1 78.3 (64 - 95) Zhang Q et al (2005) [7] 1.25/1 72 - 91 Laffosse JM et al (2007) [8] 3.8/1 81.1 (70 - 91) We (2015) 3.0/1 82.62 ± 5.75 (70 - 102) In 60 patients, the lowest was 70 years old, the highest was 102 years old. The mean age was 82.62 ± 5.74. The age group of 80 - 89 accounted for the highest percentage (48.33%). Men accounted for 25.0%, women accounted for 75.0%. Women/men ratio 3.0/1. We found that there was no considerable difference between our results and other domestic and foreign authors’ findings in terms of the age of patients who had the joint replacement and the proportion of women/men. The proportion of intertrochanteric fracture in women is higher compared to men, as the level of osteoporosis increased, the bone quality decreased over time and the rate of high long life expectancy in females was higher than that of meles [9]. Our study found that Singh's grade II osteoporosis had the highest proportion (33/60 patients = 55.0%), which is more common in the age group of 80 - 89 years old and in females than males. Bone mineral density measured by DEXA method were in 60/60: BMI 18.5 - 22.9 accounted for 73.33%, T-score average femur neckline -3.62 ± 0.55, T-score = -3.9 for the majority, T-score for femoral neck -3.03 ± 0.44; T-score average Intertrochanteric fractured -3.02 ± 0.4; Mean T-score of Ward area -3.91 ± 0.58; T-score mean head-to-hip ratio -3.2 ± 0.53. BMD of the neck-capillary-transitional-total head on the male thigh bone was significantly higher than that of females Journal of military pharmaco-medicine n 0 9-2018 139 (p < 0.05); the Ward's difference in bone density was not significantly different (p = 0.18487). On the DEXA measurement, the BMD mass was reduced by age group: 0.66 ± 0.14/0.55 ± 0.12/0.43 ± 0.12 g/cm2, severe osteoporosis according to T-score of the age group: -3.12 ± 0.46/-3.17 ± 0.56/-3.41 ± 0.50. According to Ho Pham Thuc Lan, the incidence of femoral neck BMD in the 70+ and 20-30 age groups is also higher in women (25%) than men (13%) [4]. This is consistent with the aging process of the body over time; in the cases of the older women and men, the estrogen (women) but age (men) levels cause the reduction of calcium biosynthesis, making the elderly-vulnerable to external forces [4]. This is consistent with the mechanism of subluxation or sagging in the elderly mainly due to a fall in the foot slips. In our study on 58 cases of falling, 2 cases suffered from due to traffic accidents, which is different from Kumar’s study with 75% of falling at a height and 25% of traffic accidents [9]. 2. Surgery comment. According to Kumar. K [9], complexity of intertrochanteric fractures in elderly osteoporotic patients poses challenging problems, with an increasing risk of morbidity and mortality. Although union rates as high as 100% have been reported in association with well-reduced, stable fractures that were treated with ideal implant placements, failure rates of as high as 56% have been noted in association with unstable fractures, comminutions, suboptimal fracture fixations, or poor bone qualities in elderly patients. Although the internal fixation of such fractures may reduce the morbidity of pain, it does not permit an early mobilization with a fear of failure of fixation and thus, indirectly, the morbidity of fracture remains the same. Bipolar hip replacement surgery should be based on factors as: Bone condition, bone morphology, type fracture classified based on AO, surgeons joint replacement experience, equipment, anesthesia resuscitation, kit and economic condition of patients. According to our study, the incidence of intertrochanteric fractures according to the AO classification was high in A2 (63.33%) and the number of patients with A2 fractures in 80 - 89 years old was 18 patients. Osteoporosis II and III were 76.67%. With such patients we chose bipolar with cement, as this technique provides a more stable fixation, especially in case of AO breakdown A2, avoid secondary misalignment. In the cases of complicated fracture, we use Kirchner screws through the large wires, using a tightening of the 8-wire strings. Postoperative pain relief is better, allowing early movement, without the complications of superinfection lung, uremia, ulceration of the knee due to long lying. This conclusion is consistent with other authors’ findings [1, 7, 9]. Elderly people commonly suffer from cardiovascular disease, hypertension and other systemic diseases, so they need to be examined carefully before surgery, according to the study of bipolar operation, it can be seen the propotion among groups as follows: No systemic Journal of military pharmaco-medicine n 0 9-2018 140 disease: 20 patients, cardiovascular disease, blood pressure: 31 patients (51.67%), diabetes: 3 patients (5.0%), other diseases: 6 patients (10.0%). All cases have been treated before surgery. 3. Evaluation of treatment results. * The short-term results: Dry scalp, right in the first treatment were found 60/60 patients (100%). Immediate X-ray results after surgery showed that 100% of artificial joints were in the right position, cases of dislocated or half-dislocated joint. No complications in surgery occured. Only one case of cerebral stroke after 4 days of surgery was detected promptly and treatment is stable before the patient’s discharge. Patients were instructed to exercise passively from day 2 after surgery (2.95 ± 0.47 days), active training from day 4, medium from 5.32 ± 0.65 days, slight incision. Other authors’ findings [2, 6, 10] suggested that rapid rehabilitation after treatment due to joint activity and exercise, reduces overall complications intertrochanteric fracture caused. * Follow-up results: The follow-up of 60 patients after surgery ranged from 4 months to 40 months, average 22.82 ± 10.15 months, the number of 36 month follow-up patients accounted for the highest rate, prostoperative X-ray surgery shows 100% in the right position without any cases of dislocation. Merle D'Postel: very good: 10.0%, good: 53.33%, quite: 23.33%, medium: 8.33%, bad: 5.0%. Our follow-up period was longer than that of Hoang The Hung [2], where average follow-up time was 16.17 ± 10.86 months with excellent results 37.1%, good 42.9%, fair 17.1%, bad 2.9%. According to Joong-Myung Lee et al, 32 out of 41 patients (78%) recovered walking ability. CONCLUSION According to a study of 60 high-risk fractured hip fracture patients with bipolar with cement at 103 Military Hospital from September 2012 to December 2015, we conclude that: - Bone mineral density survey: 60/60 bone mineral density survey. DEXA technique showed that all patients had osteoporosis in femoral neck, osteoporosis levels in women were higher than in men with a difference of p = 0.04130 < 0.05. Comparison of mean hip osteoporosis on DEXA females with Singh score: Grade 1/grade 2/grade 3: average T-score -3.39 ± 0.50/-3.24 ± 0.53/-2.83 ± 0.36, respectively, correlated well with Singh-singularity, the difference between the level of significance and p = 0.01425 was statistically significant. - Evaluation of partial hip replacement in patients with intertrochanteric fracture: + Personal and traumatic features: Age from 70 to 102 years (mean 82.62 ± 5.75). Age from 80 to 89 was the highest (48.33%). Women/men ratio 3.0/1. Class A2 was the high rate (63.33%), A2 fracture in the age of 80 - 89 was 18 patients. Osteoporosis II, III was 76.67%. Journal of military pharmaco-medicine n 0 9-2018 141 + Specification review: Bipolar has cement for fixation of firmer joints with intertrochanteric fractures of the elderly, osteoporosis. This helped the patients to move early, in which the average postoperative active exercise was 5.32 ± 0.65 days after surgery. The treatment provided better pain relief, reducing hospital stay to 8.02 ± 2.55 days, which enabled the patients rapidly rehabilitate, thus improving the quality of life. - Surgical results: + 100% incision in the first period. Patients are instructed to exercise after surgery soon. + Excellent: 10.0%, good: 53.33%, fair: 23.33%, medium: 8.33%, bad: 5.0%. REFERENCES 1. Tran Manh Hung, Tran Trung Dung. Evaluation of partial hip replacement surgery for hip fracture in elderly patients. Journal of Military Medicine. 2014, 295 (1 - 2). 2. Hoang The Hung. Evaluation of treatment intertrochanteric fracture in the elderly by joint hip replacement bipolar at 103 Military Hospital. 2013. 3. Nguyen Manh Khanh. Partial replacement in patients with broken fractures is unstable. Journal of Orthopedics. 2012, pp.35-38. 4. Ho Pham Thuc Lan et al. Diagnosing osteoporosis: The impact of reference value. Medical Journal. 2011, Vol. 01 & 02, No. 57, pp.3-11. 5. David G, LaVelle. Fractures and dislocations of the hip in Cammpbell's Operative Orthopaedics. 2007, 11th ed, Eleventh, Ed., USA, MOSBY ELSEVIER, pp.3237-3296. 6. Joong-Myung Lee, Hee-Tae Nam, Sang-Hun Lee. Bipolar hemiarthroplasty with cementless femoral stem for unstable intertrochanteric fractures. Original Article J Korean Orthop Assoc. 2012, Vol. 47, No. 2, pp.79-85. 7. Zhang Q, Pang Q, Huang T, Ge Z, Tang T, Chen L. The clinical effect of bipolar long- stem prosthetic replacement on the treatment of comminuted intertrochanteric fracture of hip in the elderly osteoporotic patients. Chinese Journal of Reparative and Reconstrutive Surgery. 2005, Vol. 19, No. 3, pp.198-200. 8. Laffosse J.M, Molinier F, Tricoire J.L, Bonnevialle N, Chiron P, Puget J. Cementless modular hip arthroplasty as a salvage operation for failed internal fixation of trochanteric fractures in elderly patients. Acta Orthop Belg. 2007, 73 (6), pp.729-36. 9. Kiran Kumar G.N et al. Bipolar hemiarthroplasty in unstable intertrochanteric fractures in elderly: A prospective study. Journal of Clinical and Diagnostic Research. 2013, Vol. 7, No. 8, pp.1669-1671. 10. Sancheti K.H, Sancheti P.K, Shyam A.K, Patil S, Dhariwal Q, Joshi R. Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly: A retrospective case series. Indian J Orthop. 2010, Vol. 44, No. 4, pp.428-434.