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International Journal of Pharmaceutical and Clinical Research 2023; 15(5); 2125-2134
Original Research Article

A Prospective Study to Evaluate Functional Outcome of Cemented

Bipolar Hemiarthroplasty for the Treatment of Osteoporotic
Unstable Intertrochanteric Fractures in Elderly People
Ravishankar J1, Sanjeev MN2, Somesh C3, Anuj Dixit4, Veeranna HD5
1
Associate professor, Department of Orthopaedics, Sri Siddhartha Medical College and
Hospital, Tumkur.
2
Assistant professor, Department of Orthopaedics, Sri Siddhartha Medical College and
Hospital, Tumkur.
3
Senior Resident, Department of Orthopaedics, Sri Siddhartha Medical College and
Hospital, Tumkur.
4
Senior Resident, Department of Orthopaedics, Sri Siddhartha Medical College and
Hospital, Tumkur.
5
Professor, Department of Orthopaedics, Sri Siddhartha Medical College and Hospital,
Tumkur.
Received: 16-03-2023 / Revised: 30-03-2023 / Accepted: 30-04-2023
Corresponding author: Dr. Somesh C
Conflict of interest: Nil
Abstract
Background and Objectives: One of the most significant health issues affecting the older age
group, particularly those with osteoporotic bones and unstable intertrochanteric fractures. Due to
longer life expectancies and a sedentary lifestyle. When compared to younger populations,
unstable intertrochanteric fractures in elderly populations are more frequently caused by low-
velocity trauma. The preferred therapy for older patients who are ambulatory and have an unstable
intertrochanteric fracture is cemented bipolar hemiarthroplasty, which provides a robust and
adaptable option for the elderly population.
Methods: The participants in this prospective study, who have been admitted to the SSMC
Tumkur, between November 2020 and August 2022 with an unstable intertrochanteric fracture and
osteoporosis, were taken into consideration based on inclusion and exclusion criteria. Follow-up
is done at 8, 12, and 24 weeks.
Results: In present study, the Mean Harris Hip Score in post-operative period 79.06±5.24 at 8
weeks, which improved to 89.12± 4.71 at 24 weeks. Out of 33 participants, 19 participants (60%)
showed excellent, 12 participants (37%) showed good, 2 participants (3%) showed fair score.
Mean score was 89.12. In our study 29 (88%) participants not having any complications. 2
participants (6%) had knee stiffness and 2 participants (6%) superficial infection.
Conclusion: In a 24-week short-term follow-up, cemented bipolar hemiarthroplasty in older
patients results in a better functional outcome for unstable intertrochanteric fractures. Because it
allows for early full weight-bearing after surgery, a shorter hospital stay, excellent functional
stability, and the absence of postoperative complications related to non-weight bearing after
internal fixation in hemiarthroplasty with cemented bipolar prosthesis, this method of treating
unstable intertrochanteric fractures in elderly patients is effective and promising.
Keywords: Unstable Intertrochanteric Fracture, Cemented Bipolar Hemiarthroplasty, Mean
Harris Hip Score, Osteoporosis.

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This is an Open Access article that uses a funding model which does not charge readers or their institutions for access and distributed under the
terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0) and the Budapest Open Access Initiative
(http://www.budapestopenaccessinitiative.org/read), which permit unrestricted use, distribution, and reproduction in any medium, provided original
work is properly credited.

Introduction
One of the most significant health issues Since it offers quick and early rehabilitation
affecting the older age group, particularly and superior functional outcomes, prosthetic
those with osteoporotic bones and unstable replacement, including hemiarthroplasty and
intertrochanteric fractures. complete hip arthroplasty, looks to offer
Due to longer life expectancies and a excellent results in unstable intertrochanteric
sedentary lifestyle. When compared to fractures. The preferred therapy for older
younger populations, unstable patients who are ambulatory and have an
intertrochanteric fractures in elderly unstable intertrochanteric fracture is
populations are more frequently caused by cemented bipolar hemiarthroplasty, which
provides a robust and adaptable option for the
low-velocity trauma.
elderly population.
In India, the prevalence of osteoporosis is
42.5% in women over 50 and as high as Materials and Methods
24.6% in men. As a result, unstable A prospective study conducted between
intertrochanteric fractures are more common November 2020 and August 2022 in SSMC
in female than in male. Tumkur orthopedics department. According
Most proximal femoral fractures are to the specified inclusion criteria, 33 patients
intertrochanteric and neck of femur fractures. were included in the study. Patients who
About 35 to 40 percent of all proximal voluntarily agreed in the study were chosen
femoral fractures are unstable and cannot be after being counselled in relation to fractures
internally fixed due to the high likelihood of and the inclusion criteria. Informed and
written consent given by patients and form
implant failure.
was approved by the institutional ethical
The three most often employed techniques committee.
for treating unstable intertrochanteric
fractures are proximal femoral nailing (PFN), Inclusion criteria
cannulated cancellous screws, dynamic hip 1. Age above 60 yrs.
screws (DHS) and CC screws. 2. Boyd & Griffin type II, III and IV
According to a failure rate of approximately intertrochanteric fractures of femur.
6-32% and complications like implant 3. Closed fractures.
loosening, head perforation, plate pull out, 4. Unilateral fractures.
plate breakage, avascular necrosis of the 5. Independently ambulatory before
femoral head, nonunion, leg shortening, sustaining the fracture.
rotational deformities, delayed weight Exclusion criteria
bearing, and problems from prolonged bed 1. Related head, spine, and neurovascular
rest following internal fixation are not always injuries.
appropriate for osteoporotic bones and 2. Patient who are unfit for surgery.
unstable intertrochanteric fractures. 3. Patients suffering psychological
Early ambulation is necessary for these disorders.
fractures in order to reduce the risks of deep 4. Type I Boyd & Griffin Intertrochanteric
vein thrombosis, bed sores, pneumonia, etc. fracture.

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Surgical procedure with a broach (rasp). Close to the fracture, the

A longitudinal incision starts 5 cm from the whole femoral head and neck part was
greater trochanter's tip and runs down the removed.
length of the femur for roughly 8 cm. Sharp They assessed the anteversion and
dissection is used to separate gluteus medius retroversion. Depending on the degree of
fibers that are attached to the fascia lata by comminution, either bone cement or a bone
splitting the fascia lata superficially and graft obtained from the medial cortex of the
retracting anteriorly to expose the gluteus neck was used to rebuild the medial cortex.
medius tendon. To avoid damaging the To determine the prosthesis' size and ensure
superior gluteal nerve, deep dissection splits its suction fit in the acetabulum, a trial
the gluteus medius fibers longitudinally and prosthesis was used.
extends incision inferiorly into the vastus The prosthesis was fitted into the femur with
lateralis fibers. bone cement using conventional cementing
By using a bone hook to tug on the greater techniques including washing, cleaning,
trochanter, the posterior portion of the drying, and canal plugging. The prosthesis
capsule can be seen. A T-shaped aperture was was positioned 15-20 degrees in anteversion.
created by cutting the capsule from distal to The stability of the hip joint was then
proximal along the length of the femur's neck evaluated before the prosthesis was reduced
and at an angle to it. A femoral head gauge using mild thigh traction. Absolute
was used to measure the head's size after it hemostasis was obtained. The fascia lata and
had been pulled out of the acetabulum. In capsule were stitched together. Suction drain
order to prepare the femoral shaft for the
kept and wound closed in layers.
installation of the prosthesis, it was rasped

SKIN MARKING FASCIA LATA DISSECTION

HEAD EXTRACTION RASPING

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CEMENT PREPARATION CEMENT INSERTION

PROSTHESIS FIXATION WOUND CLOSURE & DRAIN

Figure 1: Surgical Steps Of Cemented Bipolar Hemiarthroplasty

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Results
33 participants who had an unstable intertrochanteric femoral fracture underwent cemented bipolar
hemiarthroplasty treatment.
Table 1: Age Distribution
Age (years) Frequency Percentage
61-70 14 42.4
71-80 11 33.3
81-90 8 24.2
Total 33 100.0
Mean±SD 73±9.92

In our study,
42.4% participants, 14 were between 61- 70yrs of age group
33.3% participants, 11 were between 71-80yrs of age group
24.2% participants, 8 were between 81-90yrs of age group
The Mean age of participants involved in our study were of 73yrs

Table 2: Sex Distribution

Sex Frequency Percentage
Male 15 45.5
Female 18 54.5
Total 33 100.0
Out of 33 participants, who sustained fracture
54.5% participants, that is 18 were females
45.5% participants, that is 15 were male
Female:Male = 6:5
Table 3: Singh’s Index (Osteoporosis)
Singh’s Index Frequency Percentage
Grade 3 10 30.3
Grade 2 23 69.7
Total 33 100.0
Out of 33 participants,
70% participants that is 23 shows Grade 2 Singh’s Index
30% participants that is 10 shows Grade 3 Singh’s Index

Table 4: Hip Harris Score Comparison

Week Week Mean Std. Deviation Mean Difference t-value P-value*
Hip Harris Score 8week 79.06 5.24 -5.758 -20.910 <0.001
12week 84.82 4.87
Hip Harris Score 12week 84.82 4.87 -4.303 -13.916 <0.001
24week 89.12 4.71
Mean Harris Hip Score (HHS) in the post-operative period was 79.06±5.24 at 8 weeks, which
improved to 89.12± 4.71 at 24 weeks.

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Table 5: Functional Outcome

Outcome Week 8 Week 12 Week 24 Chi-Square,
Frequency % Frequency % Frequency % P-value*
Fair (70-79) 14 42.4 6 18.2 1 3.0 47.895,
Good (80-89) 19 57.6 21 63.6 12 36.4 <0.001
Excellent (90-100) 0 0.0 6 18.2 20 60.6
Total 33 100.0 33 100.0 33 100.0
Out of 33 participants, 19 participants (60%) showed excellent, 12 participants (37%) showed
good, 2 participants (3%) showed fair score. Mean score was 89.12.

Figure 2: Median Hip Harris Score Comparison

70.0% 63.6%
60.6%
57.6%
60.0%
50.0% 42.4%
40.0% 36.4%

30.0%
18.2% 18.2%
20.0%
10.0% 3.0%
0.0%
0.0%
Week 8 Week 12 Week 24

Fair (70-79) Good (80-89) Excellent (90-100)

Figure 3: Functional Outcome

Table 6: Complications
Complications Frequency Percentage
Yes 4 12.1
No 29 87.9
Total 33 100.0

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Out of 33 participants,
4 participants in this study had complications including
2 participants – knee stiffness
2 participants – superficial infection
Discussion
To assess the functional outcome of participants were female and 45% were male.
cemented bipolar hemiarthroplasty for the In their study, Hunter and Krajbich et al.29
treatment of osteoporotic unstable found that 38% of men and 62% of women
intertrochanteric fractures in older patients, a who suffered intertrochanteric fractures.
prospective study was conducted. 33 senior
Mode of injury
participants with intertrochanteric fractures
of Boyd & Griffin types II, III, and IV 60% of the cases in this study's injury mode
participated in the study. were due to insignificant injuries, such as
falls at home, slips in the bathroom, etc.
Numerous studies were conducted to Another 40% of cases involved injuries from
demonstrate the superiority of cemented traffic accidents as one of the contributing
bipolar hemiarthroplasty over alternative factors. According to research by Ganz et
techniques. In this study who underwent al31 and Hornby et al30, respectively, the
cemented bipolar hemiarthroplasty treatment
incidence of trauma was 80% and 70%.
experienced successful outcomes.
Type of fracture
Surgery in elderly participants
According to Boyd and Griffin's
The average age of the participants in the classification, intertrochanteric fractures
current study was 60 years (42%). On
were classified in the present study. There
average, they were 74 years old. In 2006, 47 were 21 participants (type II), and 9
in China reported 89 cases of comminuted participants (type III), 3 participants (type
intertrochanteric fractures treated with IV). Most common fracture in the study were
bipolar prosthesis, with an average age group type II fractures. The degree of comminution
of 82.6 years, according to a study by Yin Q, depends on bone condition and it occurs more
Jiang Y, et al. (2008). With an average age of frequently in elderly people whose bones are
82.2 years and 20 elderly individuals who
osteoporotic.
had an unstable intertrochanteric fracture,
Green, Stuard M.D. et al. (1984) 48 reported Associated co morbid diseases
excellent surgical outcomes. Due to the fact that most of the research
Sex incidence focused on elderly participants, comorbid
conditions were more prevalent in several of
Females are more likely to experience them. In the present study, 88% of the older
intertrochanteric fractures due to hormonal individuals have non-communicable
changes after menopause. Similar to many disorders such diabetes, hypertension, HT
other studies, our study included a combined with diabetes etc. This factor
preponderance of female participants. Only affected how long patients stayed in the
15 (45.5%) of the 33 participants in the
hospital before surgery and after surgery.
current study were men, whereas 18 (54.5%)
were women. In a similar, G.S. Kulkarni et
al.42 found that 55% of their study

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Duration of surgery key factor. Hip discomfort after surgery may

Duration of surgery depends on the type of be brought on by mechanical issues or an
fracture, condition of the participant and infection. Nearly 80% of individuals reported
experiencing pain after surgery. Physical
surgical skill of the surgeon. According to the
present study, 25% of participants had therapy and analgesics were used to treat
surgeries that lasted between 60 and 90 them, and over time, they gradually became
minutes, 60% had surgeries that lasted better.
between 90 and 120 minutes, and 15% had At the end of the study, (58%) 19 participants
surgeries that lasted longer than 120 minutes. reported having no pain at all, whereas (15%)
After operating on 19 participants for their 5 reported having slight pain and (15%) 5
study, SKS Marya et al. (2008) 25 found that reported having mild pain. 4 participants
the average surgical time for bipolar (12%) continued to experience moderate pain
hemiarthroplasty was 60 minutes. Yin Q, after the study was over. When compared to
Jiang Y, and others (2008), 89 patients alternative approaches, Zhang Q et al34,
underwent surgery, with a mean surgery time (2005) found 10% and Gjerstsen JE et al,
of 62 minutes (50 min-70min) Sanchetti et (2008)24 found 14% in their studies,
al.41 found that the typical procedure lasted respectively. On a total of 30 elderly
71 minutes. participants who underwent surgery by
Gallinaro et al., mild pain was noted in 19
Total duration of hospital stay
participants (63%) and severe pain in 2
According to the present study, 75% of the individuals (6%).
individuals spent less than 30 days in the
hospital. 5% of individuals stayed longer than Ambulation and range of movements
40 days, while 20% stayed for 30 to 40 days. After surgery, the pain and inflammation
The typical stay in the hospital was 26.65 subsided all participants in the present study
days. (16-43 days). If there were no post- encouraged to do active hip and knee
operative complications, the patients were movements. In the first post-operative week,
released two weeks after the operation. In a the majority of the individuals were able to
few cases, the length of the hospital stay walk. In one subject, full weight bearing was
exceeded 4 weeks because of complications delayed until the fourth week. In their study,
like HT/DM/IHD/COPD that prevented Harwin SF et al, (1990) 56 found that 88% of
participants from receiving anaesthesia in a participants could ambulate within the first
timely manner. post-op week and 91% were able to do so
The average hospital stay, according to before being discharged. Out of 29
numerous studies, was approximately 16 intertrochanteric fractures stabilised with a
days for a total of 18 participants in Zhang Q proximal femoral replacement, Stern and
et al.'s study from 2005, and 19 days for a Godstein found that 86% of participants were
total of 89 participants in Yin Q et al.'s study mobile within one week following surgery.
from 2008 . An average hospital stay of 11 10 of the 33 participants (30%) demonstrated
days was found by Sanchetti et al, in their an excellent range of movement (211º-300º),
series of 35 intertrochanteric fractures treated 15 participants (45%) demonstrated a good
with bipolar hemiarthroplasty range of movement (161º-210º), 5
participants (15%) demonstrated a fair range
Pain
of movement (101º -160º), 3 participants
The evaluation of the treatment for (10%) had a poor range of movement (61sº -
intertrochanteric fractures includes pain as a

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100º). None of the subjects showed signs of the source of a superficial infection in 2 of the
severe limitation of movement. participants. Antibiotics were administered
In the present study, 10 (or 30%) of the 33 intravenously to the participant. In our series,
we didn't encounter any further
patients walked normally. Twenty of them
(or 60%) displayed a slight limp during the complications such dislocations or
follow-up. At the conclusion of the study, 3 periprosthetic fractures. In research
conducted by SKS, no complications or pain
(10%) participants moderate limping present.
were seen in 19 subjects who had
10 (about 30%) of them were able to walk hemiarthroplasty. In their series, Haentjens et
without support. 15 of them (45%) took long al.38 showed 3% dislocation in groups
walks with a cane. 3 of the participants (10%) receiving bipolar hemiarthroplasty as
walked mostly with a cane. 5 (15%) compared to 45% in total hip replacement
participants used a crutch when walking. groups.
80% of the 33 participants were able to use Harris hip score
public transportation without any difficulties.
20% of the participants reported difficulty In our study, out of 33 subjects, 19 (60%) had
during the last follow-up. Out of 35 subjects excellent Harris hip scores, 12 (37%) good
in a research by Sanchetti et al, 23 were able scores and 2 (3%) fair scores. The average
to walk without support. One member was Harris hip score was 89.12. It demonstrates
wheelchair-bound, and 10 others walked with the beneficial functional outcomes of
a limp. At the three-month follow-up, 22 cemented bipolar arthroplasty in the elderly
subjects in our study who had
subjects had experienced abductor lurch.
intertrochanteric fractures.
Limb length discrepancy
In the study of primary bipolar prosthesis for
33 participants total. 21 participants (64%) unstable intertrochanteric fractures in 37,
shown no difference in limb length. 8 elderly people, Rodop et al. reported 17
participants (24%) had shortening of limb excellent (45%) and 14 good (37%) results
length of between 0.5 and 1 cm. 2 participants according to the Harris Hip Scoring System.
(6%) had limbs that had shortening of limb In a study by Sancheti et al (n = 41), 25 of 35
more than 1 cm. 2 (6%) of the individuals had participants results that were good to
lengthening of between 0.5 and 1 cm. excellent (71%).
19 patients who underwent surgery had their In the study conducted by Yin Q et al, More
leg length restored to within 5 mm after or less similar findings have been observed.
follow-up in a different study by SKS Marya (2008) Harris hip scores for 27 out of the 85
et al. (2008)25 patients. According to participants overall were 84% (excellent in
Sancheti et al.'s study, 10 out of 35 patients 16%, good in 56%, fair in 12%, and poor in
who had cemented bipolar hemiarthroplasty 16%).
for unstable intertrochanteric fractures noted
In a study by Haentjen et al, 100 patients who
an average shortening of 1.1 cm.
were 75 years of age or older underwent
Complications either a cemented bipolar hemiarthroplasty
29 (88%) of the 33 participants in the current (91 participants) or a total hip arthroplasty (9
study did not experience any problems. 2 participants) to fix unstable intertrochanteric
participants (6%) with knee stiffness and 2 or subtrochanteric fractures. Results ranged
participants (6%) with infection. from good to excellent for 78% of
Staphylococcus epidermidis was detected as individuals.

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Conclusion bipolar hemiarthroplasty for treatment of

osteoporotic proximal femoral fracture in
Cemented bipolar hemiarthroplasty elderly people. Indian Journal of
significantly reduces the morbidity Orthopaedics Surgery. 2016;2(3):276-79
associated with prolonged bed rest including 4. Kumar A, Amar. Prospective study of
pressure sores, lung infections, and functional outcome of unstable
atelectasis in elderly patients with unstable intertrochanteric fractures with
intertrochanteric fractures. Early hemiarthroplasty using bipolar prosthesis.
mobilization, consistent pain management Indian journal of orthopaedic surgery. 2020;
and a return to ordinary everyday activities. 6(3):204-208.
In our study, the majority of older patients 5. Thakur A, Lal M. Cemented
hemiarthroplasty in elderly osteoporotic
with unstable intertrochanteric fractures who
unstable trochanteric fractures using fracture
underwent cemented bipolar window. Malaysian Orthopaedic Journal
hemiarthroplasty reported excellent March. 2016; 10(1):5-10.
outcomes. 6. Allam AS. Primary cemented
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