Session IV - Geriatrics

External Fixation Revisited: A New Treatment Option for Elderly Patients with Trochanteric Fractures

Antonio Moroni, MD; Cesare Faldini, MD; Francesco Pegreffi, MD; Sandro Giannini, MD; Rizzoli Orthopaedic Institute, Bologna, Italy

Purpose: Although there are many treatments for fixation of osteoporotic trochanteric fractures in the elderly, a consensus regarding the treatment of choice has yet to be reached. The goals of treatment for this patient population include stable fixation and minimal surgical trauma. External fixation was once considered a legitimate treatment option, but postoperative complications such as pin loosening, infection, and loss of reduction have caused surgeons to abandon its use. The development of hydroxyapatite-coated pins prompted us to reconsider external fixation as a possible treatment for this patient population. We compared external fixation with hydroxyapatite-coated pins to dynamic hip screw fixation with AO/ASIF stainless steel screws in osteoporotic trochanteric fractures.

Methods: Forty patients were divided into two groups and randomized for treatment with 135° four-hole dynamic hip screws (group A) or external fixation with four hydroxyapatite-coated pins (group B). Included in the study were female patients 65 or more years of age with an AO fracture type A1 or A2 and bone mineral density measured at the contralateral hip lower than -2.5 T score. Pins were numbered 1 through 4, proximal to distal. Two pins were inserted into the femoral head (positions no. 1 and no. 2) and two into the proximal femoral shaft (positions no. 3 and no. 4). Weight-bearing was permitted as tolerated. Fixators were removed at 3 months; pins were removed in outpatient facilities. Pin track infection was evaluated according to the procedure of Checketts and Otterburn. Femoral neck shaft angle was measured postoperatively and at 6 months.

Results: There were no differences in patient age, fracture type, bone mineral density, ASA score, length of hospital stay, or reduction quality. The average number of blood transfusions was 2 ± 0.1 in group A, and none in group B (P <0.0001). Operative time was 64 ± 6 minutes in group A and 34 ± 5 minutes in group B (P <0.005). Postoperative femoral neck shaft angle was 134 ± 6° in group A, and 132 ± 4° in group B, which was not significantly different. In group A, fracture variation at 6 months was 6 ± 8°, in group B, 2 ± 1° (P = 0.002). The Harris Hip Score was 62 ± 20 in group A and 63 ± 17 in group B. No pin infections occurred in group B. Pin fixation was improved over time, as mean pin extraction torque was greater than mean pin insertion torque. In group A there was one lag screw cutout; in group B one fracture redisplaced after fixator removal.

Discussion: When compared with use of a dynamic hip screw, external fixation with hydroxyapatite-coated fixation was superior. Reduction was maintained over time, as there were no significant differences between the femoral neck shaft angle postoperatively and at 6 months. This is a positive finding, because it is difficult to restore and maintain a normal hip anatomy in elderly patients with a trochanteric fracture. We believe that the osteointegration ability of the hydroxyapatite-coated pins was responsible for the superior fixation. No need for blood transfusions and reduced operative time are some of the significant advantages of external fixation. The results of this study show that external fixation can now be considered a viable treatment alternative for elderly patients with an osteoporotic trochanteric fracture.