Treatment of intertrochanteric femur fracture with closed external fixation in high-risk geriatric patients: can it be the most reliable method that reduces mortality to minimum compared to proximal femoral nail and hemiarthroplasty?

Abstract

The optimal surgical treatment of intertrochanteric femur fractures (ITF) to minimize the increased mortality in geriatric patients with high anesthetic risk was investigated by comparing closed external fixation (EF), a minimal invasive and biological osteosynthesis technique, proximal femoral nail (PFN) and hemiarthroplasty (HA) methods. Three different surgical methods were performed to 167 patients who were admitted to our clinic for ITF between 2014 and 2020 and considered at high risk (American Society of Anesthesiologists III - American Society of Anesthesiologists IV) by the Anesthesiology and Reanimation Department. Patients with multi-trauma, osteoarthritis, those with malignancies and developmental hip dysplasia were excluded from the study. Group I included patients who underwent closed reduction - external fixation (n = 46), Group II included patients who underwent partial arthroplasty (n = 77), and Group III included those who received PFN (n = 44). All fractures were classified according to the Modified Evans (Kyle) method and divided into 2 categories as type 1-2 (stable) and type 3-4 (unstable). The mean operation duration was 23 minutes and follow-up time was 14 months in Group 1, in which there was no in-hospital mortality. Five patients died due to non-operative reasons within 1 year. The mean operation duration and follow-up time in Group 2 were 40 minutes and 12 months, respectively. Six patients (7.8%) died during the operation or hospitalization, while 17 patients died due to comorbidities within 1 year. In Group 3, the mean operation duration and follow-up time were 40 minutes and 13 months, respectively. One patient died during the operation and 1 patient (n = 2, 4.5%), within 24 hours in the postoperative intensive care unit. Seven patients died due to comorbidities within 1 year. Statistical analysis revealed that the mean duration of operation, postoperative hospital stay, overall mortality and blood product transfusion amount were significantly lower in the EF group compared to other treatment methods. Closed EF is the most reliable surgical method that can minimize mortality in geriatric patients compared to other surgical options, due to the short duration of the operation, no evacuation of the fracture hematoma, early mobilization, lack of blood transfusion requirement, and early union.