Management of Intertrochanteric Fractures in the Geriatric Population with Concurrent Proximal Femoral Locking Plate and Simple Femoral Head Replacement

Abstract

Intertrochanteric and periprosthetic fractures are common osteoporotic injuries recognized for their therapeutic complexity and heightened risk of complications. These fractures typically manifest along the continuum from the base of the femoral neck to the level of the lesser trochanter [1]. Intertrochanteric fractures are classified into two primary types: adducted and abducted, with the abducted variant being more frequently observed. Pertrochanteric fractures include a spectrum of injuries within the peritrochanteric region of the femur [2], comprising fractures at the greater and lesser trochanters as well as along the intertrochanteric line.

Keywords: Intertrochanteric fractures with subtrochanteric fractures; Isolated femoral head replacement; Proximal femoral locking plate; Osteoporosis; Elderly patients

Introduction

Traditional therapeutic modalities often prove insufficient for the effective restoration of hip function and are associated with various complications, including nonunion of fractures and impaired hip function. The integration of straightforward femoral head replacement with a proximal femoral locking plate in the management of intertrochanteric fractures involving periprosthetic structures presents several distinct advantages. This approach is minimally invasive, entails a shorter surgical duration, and facilitates the rapid and efficient restoration of hip functionality, thereby reducing the incidence of hip-related complications. Moreover, it is particularly well-suited for the elderly patient demographic. The use of a proximal femoral locking plate offers strong biomechanical stability, effectively stabilizing the fracture site and promoting the healing process [3].

Case Report

The patient, a 74-year-old female, was hospitalized for a duration of 26 days due to right hip pain, swelling, and impaired mobility. She reported an incident occurring two hours prior to her admission, where she was struck by a bicycle, leading to trauma of the right hip for which she had received oral analgesics. Upon physical examination, notable findings included swelling of the right hip, significant tenderness, and deformities of the right lower limb characterized by flexion, shortening, and external rotation. Palpation of the right lower limb revealed a pronounced presence of a strong dorsalis pedis pulse. Diagnostic imaging, which included X-ray, Computed Tomography (CT) scans, and three-dimensional reconstructions, indicated the presence of a right intertrochanteric fracture with associated periprosthetic involvement and displaced fractures (Figure 1a-d). Upon admission, the patient underwent a comprehensive assessment of the right hip, followed by surgical intervention involving right femoral head replacement and fixation of the right femoral greater trochanter, performed under general anesthesia. Intraoperative findings confirmed an intertrochanteric fracture of the right femur, along with fractures of both the greater and lesser trochanters. Careful removal of blood clots surrounding the fractured femoral head was conducted, with the surgical site being thoroughly irrigated using normal saline and iodophor solution to minimize the potential risk of infection. An appropriately sized femoral stem was selected based on the dimensions of the femoral canal, and a corresponding femoral head was chosen based on the size of the acetabulum. The femoral stem was implanted first, followed by the insertion of the femoral head, which led to the successful reduction of the prosthetic femoral head (refer to Figure 1e-g). To prevent dislocation of the stem, the fractured greater trochanter (Figure 1h-i) was subsequently stabilized using a proximal femoral locking plate. The patient commenced gradual ambulation three days postoperatively. Follow-up X-rays confirmed that the surgical hardware was appropriately positioned (Figure j-l). The patient's recovery was closely monitored during subsequent follow-up appointments.

    

    

    Figure 1: a-d) X-ray, CT scan and three-dimensional reconstruction show intertrochanteric fracture of the right femur with periprochanteric fracture and fracture displacement. e-g) The selection of the appropriate femoral stem is determined based on the dimensions of the femoral canal. Subsequently, the femoral head is chosen in accordance with the size of the acetabulum. The surgical procedure commences with the implantation of the femoral stem, followed by the installation of the femoral head. Finally, the artificial femoral head is reduced into its proper position. h-i) To prevent dislocation of the stem, the already fractured greater trochanter is then fixed with a proximal femoral locking plate. j-l) Post-op x-rays show hardware in good position.