Nghiên cứu tình trạng loãng xương và kết quả phẫu thuật thay khớp háng bipolar điều trị gãy liên mấu chuyển xương đùi ở người cao tuổi tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF DEFENSE
MILITARY ACADEMY

LE NGOC HAI

RESEARCH ON OSTEOPOROSIS SITUATION AND
RESULTS OF BIPOLAR HIP REPLACEMENT SURGERY
TO TREATMENT INTERTROCHANTERIC FRACTURE
IN THE ELDERLY
Specialization: Surgery
Code: 9720104

SUMMARY OF THE DISSERTATION OF MEDICINE

HANOI - 2020


WORKS ARE COMPLETED AT MILITARY ACADEMY
Science instructor:
1. Assoc.Prof.Dr. TRAN DINH CHIEN
Reviewer 1: Assoc.Prof.Dr. Ngo Van Toan
Viet Duc Hospital
Reviewer 2: Assoc.Dr. Nguyen Nang Gioi
Central Military Hospital 108
Reviewer 3: Assoc.Prof.Dr. Pham Dang Ninh
Military Medical Academy
The dissertation will be protected before the school-level thesis
dissertation council
at: 14:00 on October 10, 2019

The thesis can be found at:

1. National Library
2. Library of Military Medical Academy


QUESTION
1. The urgency of the topic
Intertrochanteric fractures in the elderly are very common, women
are more male than men, often due to falls. In the USA, it is estimated
that there are about 200,000 intertrochanteric fractured patients each
year, the mortality rate is up to 15% - 30%, mostly in patients over 70
years old, the cost of this type of treatment is about 10 billion USD a
year [1].
Intertrochanteric fractures are a large fracture, treatment is often
difficult in the elderly due to complex fracture properties, poor bone
quality (osteoporosis) and a combination of chronic systemic diseases.
The intertrochanteric fracture treatments have been studied and
applied such as fracture with DHS braces, locking braces, gama nails
or hip replacement, if properly indicated, the results will be good. The
choice of treatment for intertrochanteric fractured patients is based on
many factors such as age, fracture location, fracture properties and
bone quality. The intertrochanteric fractured patients have good bone
quality, firm fractures, age is not too high often indicated to combine
bones to preserve hip joints. However, in the case of elderly patients
with unstable fractures, fractures with fragments or osteoporosis, bone
resorption methods are often difficult, skeletal unstable so the rate of
bone fractures, false joints, or immediately high deviation. Moreover,
according to some studies, the failure rate is up to 50-56% [2], [3], [4],
after surgery the patient must have time to wait for bone to not move,
move early so easily develop more systemic complications such as
pneumonia, spleen ulcers. For these cases, many authors advocated

the replacement of the hip joint for bipolar purpose to help patients
recover early movement or sit up early to avoid systemic
complications due to prolonged immobilization of spleen ulcers.
pneumonia, urinary inflammation or other systemic diseases [2], [5].
To assess the quality of the head bone area on the femur, there are
many different methods such as X-ray, dual energy X-ray (DEXA),
CT.scaner or MRI [6], [7], [8], [9],[10]. In fact, surgical doctors often
rely on Singh's index (number of osteosarcoma in the femoral neck)
[6], or bone thickness [7], [11], however these methods The price of
osteoporosis accuracy is not high, depending on the shooting
technique, film quality, beam density and the level of readers. The
method of common osteoporosis diagnosis currently being widely


used in the world is bone density measurement according to DEXA
method [9], [12], [15]. This is a method of using dual-energy X-rays
that allows a quantitative assessment of bone mineral mass at a
specific location in the body, or measure bone mineral Density
(BMD), thus determining the bone or osteoporosis through T-score
index. This method is considered by the WHO to be the gold standard
for diagnosing osteoporosis [14].
In Vietnam, in recent years, many treatment facilities have
replaced the hip joint joint of bipolar for elderly patients with
intertrochanteric fractures. However, there is no agreement on the
indication and no studies have evaluated and monitored osteoporosis
status in elderly patients with broken intertrochanteric by DEXA
method. From the above fact, we conducted research on the topic
"Research on osteoporosis situation and results of Bipolar hip
replacement surgery for intertrochanteric fracture treatment in the
elderly"

2. Research objectives
- Survey of osteoporosis in the femoral head in patients ≥ 70 years of
age, intertrochanteric fractures were replaced with Bipolar by DEXA
method.
- Evaluate the results of Bipolar hip replacement surgery in elderly
patients with intertrochanteric fractures.
3. New contributions of the thesis
- The study showed that elderly patients with Intertrochanteric
fractures with osteoporosis of 1,2,3 degrees according to Singh's
degree were osteoporosis when measured by DEXA method with Tscore ≤ -2,5. The degree of osteoporosis in the areas of the head above
the femur is: T-score neck: -3.62 ± 0.55 (-4.7 to -2.6); T-score Troch:
-3.03 ± 0.44 (-4.4 to -2.5); Inter T-score: -3.02 ± 0.40 (-3.8 to -2.5); Tscore Wards = -3.91 ± 0.58 (-5.1 to -2.6); T-score total: -3,20 ± 0,53 (5,0 to -2,5). The rate of female osteoporosis is higher than that of men
with P <0.05.
- Contribute more experience in bipolar partial hip replacement
technique in elderly patients with femoral fractures: Cut the neck of
the femur, take the cap then fix and fix the debris. Retaining the end of
the bone in the femoral canal to fix and fix fragments and fractures,
thus correcting the fragments more easily and when using porous


screws or kirschner nails to connect the bones will avoid piercing into
the canal..
4. Layout thesis
The thesis consists of 116 pages, 45 tables, 3 charts, 16 pictures, 5
pictures, 7 sections
- Question: 2 pages
- Chapter I: Overview of 35 pages
- Chapter II: Subjects and research methods 17 pages
- Chapter III: Studying 26 pages
- Chapter IV: Discussion 34 pages

- Conclusion: 02 pages
- Recommendation: 01 page
Chapter 1: OVERVIEW DOCUMENT
1.1. Anatomical features of hip and intertrochanteric joints
The hip joint is a joint located deep under many thick layers of
muscle that surrounds [15], [16], [17]. According to De palma, LMC
is the bone area between the neck and femoral body, limiting from the
boundary of the collar in the base to the small 5cm transfer tab, Lord
thinks that under the small 2.5cm transfer tab, it is still considered the
transfer area [ 1]. Ward (1878) described 5 bones.
1.2. Osteoporosis and related issues
1.2.1. Elderly concept and osteoporosis
The elderly are Vietnamese citizens who are 60 years old or older
[22]. In 2001, WHO: osteoporosis was a pathological condition of the
skeletal system with reduced bone strength, leading to an increased
risk of bone fractures. Bone strength reflects the combination of bone
mineral density and bone quality [14],[26].
1.2.2. The pathogenesis of osteoporosis
The process of bone formation and bone destruction is balanced
until about 40 years of age, the peak of this process is called peak
bone mass, then the destruction of the osteoclast is overactive, the
higher bone destruction leads to bone decreased bone mass over time
[14].
1.2.3. Classification of osteoporosis
Osteoporosis by cause, is primary osteoporosis and secondary
osteoporosis [14], [29].
1.2.4. Criteria for diagnosis of osteoporosis


Diagnosis of osteoporosis based on DEXA is the gold standard for

measuring bone mineral density through T-score [14], [32], [33], [34].
According to WHO in 1994, the results of bone density measurement
were shown by 2 indicators: T-score and Z-score. Index T-score:
Normal: T-score ≥ -1; Bone reduction: -2.5 Osteoporosis: T-score ≤ -2.5; Severe osteoporosis: T-score ≤ -2.5 and
accompanied fractures
1.2.5. Method of measurement
Measure according to DEXA method, compare with Singh index
1.2.6. Some risk factors for osteoporosis Common:
Sunbathing, smoking, drinking alcohol affects bones.
1.2.7. Treatment of osteoporosis in the elderly
Fosamax Plus 70mg weekly 1capsule/1 time, Calcium, Vitamin D
[48],[49].
1.2.8. The situation of osteoporosis research in the world
Although osteoporosis problems often occur in the elderly,
influenced by ethnicity. from 1990-2025, the population over the age
of 59 will increase by 130-150% in Europe and about 200% or more
in all other regions, with the most significant increase in Asia [50].
1.2.9. The situation of osteoporosis research in Vietnam
In 2011, Ho Pham Shu Lan and colleagues "It should be
emphasized that diagnosis of osteoporosis is based on the T index of
the femoral neck, not the lumbar spine or the whole bone."[12].
1.3. Treatment of intertrochanteric fractures in the elderly
1.3.1. intertrochanteric classification methods
There are many ways to classify intertrochanteric, classified by
Boyd and Griffin (1949), Evans (1949), Ramadier (1956) Decoux and
Lavarde (1969); Ender (1970); Tronzo (1973); Jensen (1975);
Deburge (1976); Briot (1980), AO / ASIF (1981-1987).
1.3.2. The treatments intertrochanteric fracture
1.3.2.1. Conservation treatment

1.3.2.2. Combine bones with external fixation frames
1.3.2.3. Combine bone with AO splint and styrofoam
1.3.2.4. Combine bones with corner braces
1.3.2.5. Bone match with Gamma nails
1.3.2.6. Combing bone with lock brace:
1.3.3. The method of replacing the hip joint of Bipolar part
The lines of surgery replace the intertrochanteric fractures


* Modified Harding Road: Road to the outside of the hip joint
* The road to the back side of Gibson's hip joint: It is an incision that
is becoming more popular because of its many advantages.
Accidents and complications in hip replacement surgery:
1.4. Bipolar hip replacement study situation
1.4.1. On the world:
In 2010, Sino K, et al[81] studied 102 patients with
intertrochanteric fractures, divided into 2 groups, group 1 consisting
of 48 patients (14 men, 34 women) replaced Bipolar with cement, 78,6
age (70 - 96 years), hospitalization of 6.3 ± 1.8 days. Group 2 included
54 patients with internal bones, age 78.7 (21 men 33 women). The
research team said that bipolar joint replacement surgery is a good
choice for elderly patients over 70 years, intertrochanteric fractures. In
2018, Sibabalan, et al, Cemented bipolar joint replacement for 60 :
28% excellent. 43% good and 23% fair outcome. 2% ended with poor
[106].
1.4.2. In Viet Nam
In 2014, Tran Manh Hung et al, bipolar joint replacement for 59
patients, 81.8 years, the rate of women / men was 2.3 / 1. The results
were 82% good, 12% fair, 6% average and bad [76]. In Vietnam, until
now, no work has examined bone density according to DEXA in

elderly patients intertrochanteric fractures treated with bipolar joint
replacement and reevaluated after osteoporosis treatment.
Chapter 2: SUBJECTS AND METHODS
2.1. Research subjects
60 patients aged 70 and over intertrochanteric fractures, Bipolar
hip replacement with cement at Hospital 103 from 7/2012-10/2015
2.1.1. Criteria for selecting research patients:
Patients aged 70 and older, intertrochanteric fractures degree A1,
A2 according to AO have osteoporosis 1-2-3 degree according to
Singh. The mortar is not deformed on the X-ray. The whole body is
eligible for surgery according to ASA 1,2,3 [108]
2.1.2. Exclusion criteria of study patients
Distorted femoral body observed on X-ray. The surgical skin is
inflamed. Patients did not agree to participate in the study, patients did
not agree to surgery.
2.2. Place:
In the Department of Orthopedic Trauma-BM1 103 Military Hospital


2.3. Method
2.3.1. Research design:
Prospective study, describing clinical controls without controls
2.3.2. Sampling method and sample size
Convenient sampling, n = 60 patients.
24. Research content
2.4.1. Patient characteristics
Age, gender; Causes of fractures; Classify fractures according to AO;
Osteoporosis according to Singh; combined pathology; The method
was treated before replacement of joints; Time of fracture until
surgery.

2.4.2. Survey of osteoporosis status according to DEXA
BMI; Risk factors for osteoporosis; Measure the head bone
mineral density on femur bone according to DEXA
2.4.3. Evaluation of surgical results
Anesthesia in surgery; Incision; Joint replacement technique; Type
of hip joint sold bipolar part with cement; Time of surgery, the amount
of blood infused during surgery; Time to mobilize patients' exercise;
Recent results (Evolution at the incision: Pain, edema, surgical
incision after surgery [109], [110] Bipolar hip placement on X-ray
Quality of cement injection according to Barrack standards. Accidents,
complications after surgery. Outcome: Time from 1 year. Point ladder
Merle D’Aubigné - Postel. Barrack hip joints according to Barrack
standards: Liquid looseness, mortar wear, bone resorption. Other
systemic complications. Measure bone density in the head of the
femur after surgery according to DEXA
2.5. Method of conducting and controlling errors:
2.5.1. Criteria and evaluation criteria in research
Calculating BMI for Asians [111]. The risk of osteoporosis. Assess
the level of fracture according to AO classification. Systemic status
according to ASA [108]. Osteoporosis on X-rays is often attributed to
Singh [6]. Measuring osteoporosis in the head on the femur before and
after surgery: according to DEXA method. assess osteoporosis
according to WHO standards [26]. Evaluate x-ray of hip joints when
re-examining according to Barrack et al [113] standards (location,
quality of cement, mortar); Evaluation of postoperative hip joint
function: applying index of Merle D’Aubigné - Postel.
2.5.2. The research proceeds with the following steps


Examination of specific patients and treatment records according

to the research form. Exploiting information about the risk of
osteoporosis. Use prophylactic antibiotics before surgery. Measured
on X-ray film and clinically reviewed to choose the type of joint and
size appropriate for each specific patient case. Measuring osteoporosis
of patients with DEXA method before surgery and on re-examination.
Directly involved in surgery, care and instruction, post-surgical care,
combination of osteoporosis treatment. Preparing long-term follow-up
of Bipolar hip replacement patients. Evaluate surgical results based on
joint function and X-ray;
2.5.3. Methods of measuring osteoporosis
We measured the bone mineral density of patients in this study on
the same osteoporosis device at Hospital 103, using DEXA (Hologic,
QDR 4500C slite), measuring hip area.
2.5.4. Joint replacement technique bipolar for intertrochanteric
fractures
Prepare patient: carry out administrative procedures, measure
DEXA hip. Prepare tools: according to regulations. Bipolar hip
replacement surgery: Patients undergo spinal anesthesia, lie 90 0. Skin
incision along the Gibson line is 10cm to 15cm long, depending on the
patient's size. If the top of the transfer point is used as a landmark, the
lower half of the incision (in the thigh) is 2-5cm longer than the top.
Slit the scales, splitting along the large gluteus muscles, revealing the
muscles that show the area behind the transfer line, lifting the glutes to
the side. 900 folded pillow, inner thigh closed and revealing, revealing
a short rotating muscle group, cutting a short rotating muscle group
close to the posterior edge of the large transfer, then opening the Lshaped or T-shaped joint to the back of the femoral neck of the transfer
area . Stitching and binding of the joints and the short rotation muscles
with Vicryl No. 1, placing 2 bone elevations on the upper and lower
edges of the femur neck widen the surgery. Assessing the specific
condition of the LMC fracture, cutting the femoral neck close to the

neck base, 1cm away from the transfer edge, in the case of the small
transfer area and the broken neck base, locate the fragments again cut according to the neck base, take Remove the cap, then measure the
diameter to prepare the artificial tip. Cut off the round ligament and
stop the bleeding. Lift the head on the femur, the tube will open, small
to large. After the root canal has been assembled, keeping the end of


the root canal as the core to seal the fragments, avoiding nails or loose
screws, the steel thread penetrating the canal will make it difficult to
install. In case of fracture, there are small fragments and fragments
close to the base of the neck, leaving the fragments to position the root
canal. For small transfer fractures, use the steel thread to fix the
fragment with two separate steel threads and then fix the twisted ends
of the steel thread together to avoid displacement along the bone body.
The debris in the large transfer area, correcting the debris to the
anatomical position, can be fixed with foam screws or Kirschner nails
with combination of 8 steel straps. The small fragments are arranged
in anatomically position and will be attached with cement. Put cement
stopper. Cement has been mixed well and put into a cement squeezing
gun, placed the gun barrel deeply close to the stopper, then slowly
pumped the cement to squeeze out evenly and completely filled the
root canal to the level of the femoral neck. Closes the selected joint
into the root canal, removing excess cement. When the cement begins
to heat, physiological salt water pump is used to reduce the
temperature of the cement. Leave some cement outside to check the
level of cement solidification, while waiting for the cement to solidify,
keep the grip steady until the cement cools. Assemble the test cap and
reinstall the joint, check the length of the limb with the healthy limb
by comparing the length of the two pillows and perform a Piston test
to select the appropriate tip. If the joint is firm, the length of the two

limbs are equal, the dislocated movement is the real cap It should be
noted that in this case, when re-placing the joint, the limb must be
slightly pulled and gradually increasing the tension, do not rotate the
joint too hard to avoid fracturing the thigh bone due to osteoporosis.
Wash pump, put 01 Hemovac drainage, close the surgical layer 02
layers. Cover the incision, fixation of the groin - with an anti-rotation
brace, change the dressing for the first time after 24 hours, then once
every 2 days. Antibiotics 7 days, cut only after 2 weeks PT, motor
does not compress the neck - feet, knees, hip joints on the 1st or 2nd
post PT, for patients to sit up according to the recommended time of
anesthesia. Practice standing, compressing on the operating leg with
support from a support frame or supporting two armpits from day 3
after PT. Practice walking from day 4 depending on the patient's
condition. Closely monitor the developments after PT. After a joint
replacement, do not squat, do not sit cross-legged, do not fold


excessively, do not stand on one side of the joints, use the toilet. After
3-4 weeks of removing 01 crutches on the legs without changing
joints, it is best to use U-shaped crutches to practice with the elderly to
be the safest and most effective. After 2 months with crutches, practice
walking up the stairs. Patients do not make excessive stretches or
groin movements in the first 2 months to avoid dislocations, without
carrying or carrying heavy loads.
2.5.5. Treatment and prevention of osteoporosis after surgery
Supplement vitamin D and calcium through eating, sunbathing
and taking Calcium corbiere10ml x 2 tubes / day, 1 ampoule morning,
1 ampoule x 10 days. Drink 1 month ago. Fosamax Plus 70mg x1
tablets / week x 12 months. Oral medicine with many water before
breakfast 30 minutes.

2.6. Data processing methods
Data collected were processed on Epi Info 7 software.
2.7. Ethics in research:
Hip replacement surgery in intertrochanteric fractures has been
applied in the world and Vietnam. DEXA is a cheap, modern
diagnostic method and is considered by the WHO to be the gold
standard for diagnosing osteoporosis. Fully explain the benefits and
risks of complications. Patients agree to participate. All patient
information and privacy is kept confidential.
Chapter 3: RESEARCH RESULTS
3.1. Characteristics of statistics
3.1.1. Age and gender: Age 82.47±6.33(70-102). Female/male: 3.0 /
1
3.1.2. The cause of intertrochanteric fractures
Traffic accidents 02 patients accounted for 3.33%, due to falls
(accidents of living) 58 patients (96.67%).
3.1.3. Combined diseases: Cardiovascular disease - blood pressure
accounted for 55.0%
3.1.4. The time of surgery to replace the hip joint of Bipolar part
Intertrochanteric fractures up to the time of surgery was 2.3 ± 2.3
days (1-15), patients with joint replacement in the first 3 days
accounted for: 78.33% (47 patients).
3.1.5. Pre-surgery treatments
Most have not been treated after injury 58.33%; pain relief and
immobilization of 28.33%.


3.1.5. Characteristics of intertrochanteric fractures: A1 (36.67%),
A2 (63.33%)
3.1.6. Classification of osteoporosis according to Singh: degree 3

(21.67%); degree 2 (55.0%); degree 1 (23.33%)
3.2. Results of bone mineral density survey and related factors
3.2.1. Body morphology: Gơ (5 patients); obese (2 patients) normal
(44 patients)
3.2.2. Risk factors for osteoporosis
Table 3. 10. Risk factors
Yes
No
Variable
Number(n) Ratio % Number(n) Ratio %
History of
2
3,8
58
96,67
fractures
Alcoholism
7
11,67
53
88,33
Smoking
5
8,33
55
91,67
45
100,0
0
0,0

Menopause after
45 years (female)
Average menopause age 50,3 ±2,7
Comment: Menopause age average 50.3 ± 2.7. There are 7 patients
who drink alcohol every day but not more than 15ml / 1 day. Smoking
among men 5/15 males (33.3%) is also accounted for 8.33% of the
total number of studied patients.
3.2.3. Results of bone mineral density measurement
Table 3.18. The degree of sex osteoporosis (n = 60)
Male (n=15)
Female (n=45)
SEX
p
VARIABLE
(
)
(
)
(Neck)
(Troch)
BMD
(Inter)
(g/cm2)
Ward’s
(Total)
(Neck)
(Troch)
T- score (Inter)
Ward’s
(Total)

0,54 ± 0,05
0,50 ± 0,05
0,75 ± 0,19
0,29 ± 0,09
0,65±0,14
-3,45± 0,50
-2,87 ± 0,29
-2,78 ± 0,22
-3,77 ± 0,51
-2,92±0,28

0,48±0,07
0,45±0,07
0,60±0,16
0,28±0,08
0,54±0,14
-3,67±0,56
-3,08±0,47
-3,1 ±0,41
-3,96±0,60
-3,29 ±0,56

0,004
0,010
0,004
0,853
0,006
0,173
0,113

0,006
0,285
0,018


Comment:Osteoporosis of the entire head of the femur, osteoporosis
of women is higher than that of men with P = 0.018 with statistical
significance.
Table 3. 23. Head bone density on femur bone according to Singh
(n = 60)
T-score Total
Singh
Number(n)
About
Mode
(
)
Grade I
Grade II
Grade III

14
33
13

-3,39 ± 0,50
-4,2 đến -2,8
-3,3
-3,23 ± 0,54
-5,0 đến -2,5

-2,9
-2,9 ± 0,44
-3,8 đến -2,5
-2,8
P=0,044
Comment: The average level of osteoporosis of the head area on the
femur according to T-score with the difference of Singh with p =
0.04357 <0.05.
Table 3. 26. Head bone density on AO femoral bone (n = 60)
A2(38 patients)
AO A1 (22patients)
p
VARIABLE
(
)
(
)
Neck
-3,55 ± 0,43
-3,66 ± 0,61
0,461
Troch
-2,98 ± 0,45
-3,06 ± 0,44
0,486
Inter
-2,96 ± 0,40
-3,05 ± 0,40
0,383
Ward’s

-3,81 ± 0,53
-3,97 ± 0,61
0,316
Total
-3,15 ± 0,43
-3,23 ± 0,59
0,595
Comment: the femoral head in severe osteoporosis, comparing bone
mineral density between the groups A1 and A2 with p = 0.595
Table 3. 28. Comparison of T-score on the femoral head before
and after surgery (n = 43)
Time Before surgery After surgery (
Tscore
theo
DEXA

(

VARIABLE

T- score
theo
DEXA

Neck
Troch
Inter
Ward’s
Total

)

-3,60 ± 0,57
-3,03 ± 0,43
-3,03 ± 0,41
-3,86 ± 0,60
-3,24 ± 0,55

)
-2,97 ± 0,32
-2,62 ± 0,31
-2,57 ± 0,31
-2,94 ± 0,33
-2,79 ± 0,41

p

0.000
0.000
0.000
0.000
0.000


Comment: Compare T-score index preoperative and postoperative 1
year and older have osteoporosis treatment combined noticed no
difference with statistical significance at p <0.05

Graph 3. 2. Bone density in the femoral head before surgery and
follow-up (n=43)

Comment: Comparison of bone density in the femur before surgery
and postoperative for 1 year or more with combination treatment of
osteoporosis showed that the bone density at follow-up increased
significantly with p <0.05


3.3. Results of Bipolar hip replacement surgery
3.3.1. Recent results after Bipolar hip replacement surgery
3.3.1.1. Rate of interventional hip joints (n = 60)
Percentage of patients with intertrochanteric fractures left accounted
for 63.33%
3.3.1.2. Surgery time: surgery 75,68 ± 21,28 (45-120) minutes, blood
transfusion 470,83 ± 80,93ml (250-500ml).
3.3.1.3. Head size: 42mm is the majority (25.0%).
3.3.1.4. Postoperative X-ray results: 100.0% right position
3.3.1.5. Surgical situation and hospital stay: the incision is 100.0%
head; hospitalization 8.03 ± 2.54 days (3-20)
3.3.2. Long-term results after surgery
3.3.2.1. Long-term follow-up time after surgery: Monitor 22.82 ±
10.15 months.
3.3.2.2. The movement amplitude of the hip joint is replaced
Fold/Stretch/Shape/Close/Rotate in/Rotate out are: 100 degrees/5
degrees/40 degrees/25 degrees/40 degrees/40 degrees respectively
3.3.2.3. Functional hip replacements
Table 3. 40. Merle D’aubigne’-Postel point (n = 53)
Merle D’-Postel
AO

Very
good

(n)

Good
(n)

Quite
(n)

Medium
(n)

Total

Bad
(n)

n

%

A1
A2

2
15
2
1
0
20
37,74

3
16
9
3
2
33
62,26
5
31
11
4
2
Total
53
100,0
9.43
58.49 20.75
7.55
3.77
Comment: The proportion of patients with bad results accounted
for 3.77% of the group A2
Table 3. 41. Head bone density on femoral bone according to
Mesle D'-Postel (n = 43)
BMD Total
Total
Merle D’-Postel
(
)
n
%

Very good : 17-18 points

Good: 15-16 points
Quite: 13-14 points
Medium: 10-12 points

0,818 ± 0,087
0,736 ± 0,094
0,652 ± 0,095
0,696 ± 0,071

3
24
10
4

6,98
55,81
23,26
9,30


Bad: ≤ 9 points
0,634 ± 0,096
2
4,65
Total
0,714 ± 0,100
43
100,0

P-value = 0.037
Comment: bone density tested far after surgery for 1 year or more
compared to the group of points with significant differences with p
<0.05.
3.3.3. Surgery complications: 100.0% of patients are safely operated
3.3.4. Complications after surgery:
There is 01 patient with 1.5cm short; 01 patient is 01cm short.
3.3.5. Remote complications
After 1 year or more, there are 4 patients wearing coronary layer 1
(7.55%), most normal (92.45%). No patients loosen their grip.
Chapter 4: DISCUSSION
4.1. Clinical characteristics of intertrochanteric fractures.
We conducted the evaluation of hip replacement results for elderly
patients intertrochanteric fractures in 103 Hospital from 2012 to 2015,
with 60 patients who met the research criteria obtained results (Table
3.1), Age 82, 47 ± 6,33 (70-102 years). The age of meeting the most is
85 years, the group of 80-89 years old accounts for the highest rate in
the research group (48.33%); males accounted for 25.0%, females
accounted for 75.0%. male / female: 1 / 3.0. patients with
intertrochanteric fractures with many associated diseases are
cardiovascular diseases - blood pressure accounts for 55.0%, 30.0% of
patients who have never had other diseases must be hospitalized to be
treated until intertrochanteric fractures.

Table 4. 1. Comparison of sex and age of surgery
Female /
Age
male ratio
Laffosse JM et al (2007)[120]
3,8/1

81,1(70-91)
Sino K et al (2010)[81]
1,6/1
78,6(70-96)
Nguyen Manh Khanh (2012)[55]
3,3/1
78,9 (70-97)
Tran Manh Hung và cs (2014)[76]
2,3/1
81,8 (70-94)
Puttakemparaju KV, et al (2014)[87]
0,8/1
78.1(70-92)
We (2015)
3,0/1
82,47 (70-102)
Through comparison in Table 4.1, we find that the percentage of
Women / Men in the study group is similar to the authors in the
country and the world. Intertrochanteric fractures in females are
Author


higher than males associated with decreased bone quality over time
and bone loss during pregnancy, reproduction as well as menopause in
women.
The study of Lee K.J. et al. [121] on the differences in bone
density of T-score among patients with atypical fractures, with 63
patients with an average age of 73.0 years, the author found almost All
patients with atypical femoral fractures suffer from osteoporosis
In the study, we had 58 cases of falls, 02 cases due to traffic

accidents, different from the results of Kumar G.N.K. with 75%
falling from above, 25% of traffic accidents [2]. Besides, the elderly
have cardiovascular disease, hypertension and many other systemic
diseases, so need to examine carefully before surgery. Survey of 60 bn
with intertrochanteric fractures we found: There was no systemic
disease 30.0%, cardiovascular disease, 55.0% blood pressure, other
pathologies 15.0%, 01 patient with sequelae of vascular accident brain
blood was stable (1.67%). Among patients with comorbidities, the
number of patients with 2 comorbidities accounted for 10.0%, with 1
disease accompanied by 60.0%. The age group of 80-89 accounts for
48.33% of patients with intertrochanteric fractures with osteoporosis,
and the group of 80-89 years of age results for men accounting for
20.69%; women 79.31%; If calculating the number of female patients
aged 80 and older, accounting for 68.89%. For elderly patients with
osteoporosis, the risk of fractures during falls is very high [25]. This is
consistent with the mechanism of injury when falling in the elderly
mainly due to slipping and falling.
The time of injury is up to the admission time of 2.3 ± 2.3 days.
The number of patients with joint replacement in the first 3 days of
intertrochanteric fractures accounted for the highest rate of 78.33%
(47 patients), 58.33% of patients were not given any first aid
measures; The male tobacco bundle accounted for 8.33% of patients,
yet 22/60 patients were treated to bracing before coming to the
hospital. patients hospitalized for 1-3 days account for the highest
percentage. This also shows that the right sense of responsibility for
care and treatment of intertrochanteric fractures in elderly people is
focused, the lower level has transferred patients to the provincial level
promptly and quickly. Elderly people also have the right to care [22],
while many families, even patients who have broken intertrochanteric
fractures have the wrong view that it is a warning sign of a near death,

so prepared to wait for that death at home, so did not take patients to
timely treatment, the consequences of pain, superinfection and
depletion due to not eating or taking proper care lead to death risk
high death. However, the first aid by fixed measures of fracture has
not been properly concerned or neglected (58.33% has not been
handled before admission).
Satomi E. et al [46] surveyed 123 patients with intertrochanteric
fractures 60 years of age and older, analyzed in relation to
osteoporosis treatment, pre-and post-fracture treatment. Research
results show that even before hospitalization, the rate of diagnosis and
treatment of osteoporosis is low. Investigation and treatment to
prevent fractures were not done before and during a hospitalized
fracture. Only 43% of patients were diagnosed with osteoporosis
before intertrochanteric fractures treatment. The author found a lack of
definite intervention on osteoporosis in elderly patients
intertrochanteric fractures.
4.2. Bone mineral density and risk factors for osteoporosis.
4.2.1. Bone mineral density of intertrochanteric fractures patients.
For elderly intertrochanteric fractures with osteoporosis will
greatly affect bone healing, the bone healing process is much longer
than others, not only causing disability but also increasing the risk of
death for patients. According to IOF statistics, up to one third of
women and one in five men over age 50 are at risk for osteoporosis
[40]. IOF assesses osteoporosis as one of the major threats to global
health of the elderly. To examine the level of osteoporosis in the
human body, there are 6 positions to measure: Head area on the femur,
lumbar spine, wrist (head under the bone), heel bone. However, the
results of bone density measurement at the top of the femur are used

to diagnose osteoporosis, results of other bone density measurements
are used for reference and assessment of treatment process[12],[122],
[123]. Therefore, for elderly intertrochanteric fractures, the
investigation of bone density is necessary to contribute to the decision
of surgical methods and the selection of treatment materials. DEXA
measurement method, is the best technique of bone density
measurement applied in clinical practice. Since 2003, WHO considers
DEXA a gold standard to diagnose osteoporosis [26].
From the standard and reliable values of the method of measuring
osteoporosis density according to DEXA and in accordance with the


conditions of 103 Military Medical Hospital, we selected the
evaluation method according to DEXA. In fact, currently in most
treatment facilities, assessing osteoporosis status in pre-operative
fractures, surgeons often rely on Singh or bone thickness according to
Dorr above. X-ray results are often [7], however, this method depends
on shooting techniques, film quality, film readers. In this study, we
compared the results of osteoporosis assessment according to Singh
index with the results of osteoporosis assessment according to DEXA
method. The result of this comparison is a reference for the health line
that does not yet have a osteoporosis meter according to DEXA.
For patients with intertrochanteric fractures, before the authors
and writers used a combination of bone, whether using a screw brace,
a DHS brace, a gamma nail or an external fixation frame, it is still
necessary to drill and fix the brace - screw in the head. on the femur the cervical neck, the shift and part under the femoral transfer. Failure
of the method of combining the main bone is to loose the nail, the
screw leads to loose splint, the angle of the neck, the neck and neck the femoral head, not bone and rotate the neck shaft, even punctured
the femoral neck. Derived from the force-bearing area of the head on
the femur, the fundamental mechanical position of the screws, the

fixation of the splint as well as the complication status of the methods
of combining bone in intertrochanteric fractures in the elderly. We
found that the factor contributing to the failure of the above methods
is due to osteoporosis in the head of the femur, so that there is
evidence of specific bone density of each area in the head on the
femur. We conducted a bone density survey on femur bone according
to DEXA.
Comparing Singh's index to 60 patients on X-ray films studied
immediately before surgery obtained results with 23.33% (14/60)
degrees I; 55.0% level II (33/60); level III is 21.67% (13/60);
corresponding to the head area on the femur, measured by DEXA
technique for 60bn, the results of 100.0% of osteoporosis patients
according to Singh classification have a measure according to DEXA
showing the degree of severe osteoporosis in the femoral neck area.
100.0% of patients with intertrochanteric fractures had T-score ≤ -2.5,
femoral neck T-score = -3.62 ± 0.55 (-4.7 to -2.6); The number of
patients with T-score = -3.9 accounts for the majority, T-score of


femoral neck and females -3.67 ± 0.56 and in men is -3.45 ± 0.50 with
no difference between two sexes with p = 0.173.
Results in the intertrochanteric region with severe osteoporosis
accounted for 100.0% (60/60 patients). Wards region 100.0% of
severe osteoporosis, Head area on femur with osteoporosis accounts
for 100.0% of patients studied by patients with intertrochanteric
fractures with T-score ≤ -2.5, the rate of severe osteoporosis T-Score
level with standard T-score ≤ -2.5 with fracture (intertrochanteric
fractures in all researched patients).
Comparing the average level of osteoporosis by gender, we found
that the area of the male femoral neck (T-score = -3.42 ± 0.50) /

Female (T-score = -3.67 ± 0.56) - Large area of male transition: Tscore = -2.88 ± 0.30 (-3.5 to -2.5); Female: T-score = -3.08 ± 0.47 (4.4 to -2.5); Intertrochanteric region of South: T-score = -2,8 ± 0,25 (3,2 to -2,5) and Female: T-score = -3,1 ± 0,42 (-3,8 to -2 , 5). Head
area on male femur: T-score = -2.95 ± 0.30 (-3.5 to -2.5); Female: Tscore = -3.27 ± 0.56 (-5,0 to -2,8). Comparing the average level of
osteoporosis in the femoral head (t-score Total), the results showed
that the average score of low-score <-2.5 accounted for the entire
number of patients, and there were differences. The level of
osteoporosis in women was higher than that of men with statistical
significance with p <0.05.
We found that all patients in the study had T-score in the femoral
neck area below (-2.5), equivalent to the level of severe osteoporosis.
So in the case of patients with no hip replacement with Bipolar with
cement, but using bone resorption or conservative measures, the
results of bone healing will be slow, poor and the risk of loose bone
material is high due to regional bone quality. poor femoral neck osteoporosis. Thus, if the bones are combined with these patients, the
risk of bone fracture is slow, liquid nails are permanent, the patient
will have a longer immobilization, the risk of pain, complications with
multiple urinary infections, ulcers of the pressure areas due to
prolonged lying. This is consistent with the judgment of other authors
[2], [5], [60].
On the other hand, the results of bone density in the head of the
femoral head in patients with intertrochanteric fractures in the study
group had T-score--2.5, compared with WHO osteoporosis standards,
these patients belong to group of severe osteoporosis (T-score ≤ -2.5;


accompanied by fractures). Results of bone density measurement in
femoral neck with T-score = -3.62 ± 0.55 (-4.7 to -2.6) - T-score = -3.9
accounted for the majority; T-score of large transfer tab -3.03 ± 0.44 (4.4 to -2.5) - T-score = -2.8 accounted for the majority. T-score
intertrochanteric -3.02 ± 0.40 (-3.8 to -2.5) - T-score = -2.9 accounted
for the majority. With such a high level of osteoporosis in 3 essential
areas for bone healing, the chances of bone healing are very poor,

although the brace is fixed to 3 positions on a bone screw, or DHS
brace, Gamma nail, the bone screws are still Cling to bone wall, bone
marrow to immobilize bone. But when these fixed bone screws cling
to the substrate with severe osteoporosis (table 3.13 –3.17) will be
very weak, the force is weak, the failure of liquid screw - splint, nonbone fracture, bending of the body's neck or rotating axis is the thing.
prognosis before. For the combination of bone on osteoporosis, the
opportunity for early movement is impossible, thereby increasing the
risk of opportunistic infections due to long immobilization, stiffness
and the risk of failure is permanent with patients. Elderly
intertrochanteric fractures have osteoporosis.
4.2.2. Risk factors for osteoporosis of elderly patients
intertrochanteric fractures: There are 45 female patients,
menopause age 50.30 ± 2.7, accounting for 100.0%. Smoking in men
5/15 males (33.3%); patients with BMI below 18.5 (8.33%), normal
BMI had 44 patients accounting for 73.33% of the surveyed patients.
From the results of table 3.24, comparing the effects of different
risk factors between bone mineral density of groups, complementary
patients, calcium supplementation, sunbathing, exercise, bone density
is better. group without calcium supplementation and poor exercise sun exposure is statistically significant with risk factors: exercise,
sunbathing, calcium supplementation, milk intake with p: 0.000; P =
0.001; P = 0.000, P = 0.002. patients with calcium supplementation
had a bone loss of T-score of -2.8 ± 0.21; while patients without
calcium supplementation had a low calcium density of -3.65 ± 0.42
with P = 0.000 <0.05 with statistical significance.
4.3. Treatment of intertrochanteric fractures with Bipolar hip
replacement
4.3.1. Indications for joint replacement for patients with
intertrochanteric fractures

We indicated the replacement of bipolar intertrochanteric fractures
treatment in elderly people aged 70 years and older, A1-A2 degree
according to AO, osteoporosis from 1 to 2 degrees - 3 degrees,
according to Singh [6] density survey. Bone according to DEXA found
that the T-score index on the femoral head decreased below -2.5.
When you want to combine the bones, position the fixed screws to fix
the splint to the bone shells into the bone marrow, but if these areas
are osteoporosis, the solid fixation of the screws will be very poor,
these are patients with dilution Bone according to Singh and DEXA.
For fractured femoral LMC has many classifications, the clinician
choose the classification also depends on surgical habits. In the
classification of fractures according to AO very clear, simple, easy to
apply because the fracture morphology is consistent with the AO
classification, thereby helping the officer to assess the level of damage
in the LMC region, orienting the PT method as well as selection of
suitable alternative materials, which is the basis for prognosis and
evaluation of treatment outcome. On the other hand, at Military
Hospital 103, during the study period, there was no indication of the
type of fracture of LMC level A3 for joint replacement, so we did not
include the group A3 in the study.
Fractures of the femur have many different treatments, and the
indication of the method is controversial. In the case of young patients
with good bone quality, the policy of combining inner bone for
fracturing femoral LMC [60], [68]. But in the case of elderly patients
with osteoporosis, the policy of bipolar joint replacement helps
patients to exercise early after surgery [58], [59], [66].
We found that, in DHS bone fixation, the neck cap screw driver
needed to drill large-size directional holes through the neck to the cap,
while patients with osteoporosis in the neck of the head, the wide hole
drilling, devastating cervical bone marrow will slow bone healing,

even without bone due to the loss of the bone bridge in the lobe of the
neck bone, the ability to recover itself is very poor, leading to
instability in the cervical neck, loosing the cervical neck, bending the
neck angle Dear. On the other hand, if using a brace, even the locking
brace has a multi-point and multi-directional bone fixation position
because the screw in addition to catching the bone also has a thread to
attach to the brace. Screw attachment position to immobilize the brace
must still catch on the bone, bone and bone marrow of the LMC


region, the neck of the femoral head. This is a factor that helps to lock
the brace better than the DHS splint which is a multidirectional
fixation, screw fastening to the neck of small femur, reducing the
damage to the bone bridges in the medulla and cusp. In the case of
patients with osteoporosis, screwing in the weak, loose bone area will
lead to immobilized immobilization, bone loss, from which it is
impossible to move early, causing a lack of bone around the bone
screw bone, to loosen. splint, causing complications after surgery, the
risk of surgery is very high.
Research by Kumar G.N.K. shows that the treatment of
osteoporotic fractures of the femoral femur with osteoporosis is very
difficult in the elderly. Although 100% of cases have been reported to
incorporate stable bones, fracture arrangements in the correct
anatomical shape, a failure rate of 56% has been reported in a complex
fracture fracture, or poor bone quality in elderly patients [2]. Such
internal bone-combination therapies may reduce pain, but do not allow
early movement due to fear of failure. Designation of Bipolar hip
replacement surgery should be based on: Patient condition, bone
properties of patients, type of fracture according to AO, joint
replacement experience of surgeons, equipment, good resuscitation

anesthesia and neurological conditions of patients. The author
replaced Bipolar joints with cement for 20 elderly patients with
osteoporosis grade 1 (2 patients), 2 (14BN), 3 (3BN) according to
Singh; PT time 116 ± 14 minutes.
Emami M. et al. [83], a comparison between two groups of
femoral fracture fractures treated with Bipolar and DHS joint
replacement found that patients in the Bipolar joint replacement group
could stand firm after 3 days of PT, while DHS group only to practice
standing 4-6 weeks after PT.
In our study, the AO type A2 fracture accounted for high
percentage of 63.33%, the A2 fracture at age of 80-89 was 18 patients
(62.07%). In the age group 80 - 89 there are 29 patients, type A2
fracture is 38 patients. According to Singh, the level II is 55.0% grade I accounts for 23.33%; and with the above level of osteoporosis,
Bipolar hip joint should be replaced with cement, because this
technique helps to stabilize more firmly, especially in cases of fracture
A2 according to AO. No systemic illness 18 patients (30.0%),
hypertension 33 patients (55.0%), diabetes 03 patients (5.0%), other


diseases 6 patients (10.0 %). The number of patients with 2 diseases is
10.0%, there is 1 disease with 60.0%. The patients were treated stably
before surgery.
The authors [75], [88], [93], [104], found that elderly patients with
osteoporosis and fractured LMC, poor bone quality, fixation of
internal bones will lead to poor function results. Bipolar joint
replacement helps patients carry weight early, allowing for early
walking and improving the quality of life. Early mobilization prevents
complications of pneumonia caused by stasis, pressure ulcers, deep
vein thrombosis, reduces hospitalization time, and reduces the rate of
complications after PT. Thus, the majority of authors found that the

option of hip replacement for treatment of femoral fracture fracture in
elderly patients with osteoporosis is necessary to help patients to
exercise early, reduce complications due to lying long after PT. in,
helping patients better pain relief, shorter surgery time, reducing the
risk of death and superinfection.
We found that the appointment of Bipolar joint replacement for
elderly patients with femoral fractures with osteoporosis is consistent
with the trend in the world and in the country [4], [92], [97].
4.3.2. Joint replacement technique for patients with
intertrochanteric fractures
In Bipolar hip replacement for elderly patients with osteoporosis
of the femoral fracture, We have proactively used the femoral neck
cutting technique before fixing the debris, because if fixed before
cutting the femoral neck, secondary displacement of debris. Use the
femoral head to measure the diameter of the crown to select the
appropriate artificial cap. Root canal, assemble root canal from small
to large size. After the root canal is finished, keeping the last one in
the root of the canal as a core to help strengthen the bone, avoiding
nails or porous screws, only steel penetrating the canal will make it
difficult to install cement blocks or install gripe. In case of fracture,
there are small fragments and fragments close to the base of the neck,
leaving the fragments to position the root canal. In the case of small
fracturing fractures, use the steel thread to fix the fragment with two
separate steel threads and then fix the twisted ends of the steel thread
together to avoid displacement along the bone body. The debris in the
large transfer area, correcting the debris back to anatomical position,
can be fixed by porous screws or Kirschner nails combined with


pressure pin 8 with steel thread. The small fragments are arranged in

anatomically position and will be attached with cement. For the case
of baby transfer fracture, we use a steel guide to hook through the
front in the baby transfer tab, forcing two separate rings including 1
upper, one below the baby transfer debris, forcing outwards , then tie
the two twisted steel threads of those two separate threads together to
help the loop to keep each other from being moved, sliding due to
uneven structure of the head area on the thigh bone, especially the
small transfer area. Thanks to the technique of fixing steel only so that
the calcar area is strong without bone grafting in this area.
Thus, for a firm fracture, we do not have difficulty in joint
replacement, however, in cases of unstable fractures, shaping the
femoral neck to cut the neck is a difficult one, placing the hilt is
difficult because the lower fracture does. Anatomical mold no longer
requires surgeons to have experience. Some authors have advocated
strengthening the calca region by cutting off part of the femoral neck
to insert it into [13], [94]. The steady fixation of joints in the lumen of
the canal as well as ensuring the stability of the calca neck neck is
decisive to the postoperative outcome. Some authors advocate the use
of long-lasting bipolar joints in cases of unstable LMC fractures with
osteoporosis for greater rigidity [60].
Abdelkhalek M. et al [84] replaced Bipolar hip groin for 20
patients, average age of 69, using steel thread to bind fragments of
bone, followed by an average of 30.5 months, X-ray results without
bone defects, Mortar bearing, all bone body stable. The average score
is 83.3 points. The authors conclude that a partial calcium replacement
joint is a good option for unstable LMC fractures in elderly patients
with severe osteoporosis. Sivabalan T. et al. [106] conducted Bipolar
joint replacement with cement and bone grafting combination for 60
patients aged over 70 years, followed for 2 years, the results were 28%
excellent, 43% good, the authors concluded Bipolar hip replacement

with cement with intermediate calcar enhancement can be considered
as a major option for elderly patients with unstable fractures but
osteoporosis. Thakkar C.J. et al [94] retrospectively replaced Bipolar
cemented joints for 34 patients with an average age of 79.2 years old,
fractured femoral LMC, the author combined to take bone at the neck
of the femur was cut off to transplant and recover. calcar region.
Follow-up after surgery 54.5 months found 94% of the graft was good,