Research on osteoporosis situation and results of bipolar hip replacement surgery to treatment intertrochanteric fracture in the elderly

teel 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 Variable Yes No Number(n) Ratio % Number(n) Ratio % History of fractures 2 3,8 58 96,67 Alcoholism 7 11,67 53 88,33 Smoking 5 8,33 55 91,67 Menopause after 45 years (female) 45 100,0 0 0,0 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) SEX VARIABLE Male (n=15) () Female (n=45) () p BMD (g/cm2) (Neck) 0,54 ± 0,05 0,48±0,07 0,004 (Troch) 0,50 ± 0,05 0,45±0,07 0,010 (Inter) 0,75 ± 0,19 0,60±0,16 0,004 Ward’s 0,29 ± 0,09 0,28±0,08 0,853 (Total) 0,65±0,14 0,54±0,14 0,006 T- score (Neck) -3,45± 0,50 -3,67±0,56 0,173 (Troch) -2,87 ± 0,29 -3,08±0,47 0,113 (Inter) -2,78 ± 0,22 -3,1 ±0,41 0,006 Ward’s -3,77 ± 0,51 -3,96±0,60 0,285 (Total) -2,92±0,28 -3,29 ±0,56 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) Singh Number(n) T-score Total () About Mode Grade I 14 -3,39 ± 0,50 -4,2 đến -2,8 -3,3 Grade II 33 -3,23 ± 0,54 -5,0 đến -2,5 -2,9 Grade III 13 -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) AO VARIABLE A1 (22patients) () A2(38 patients) () p T- score theo DEXA 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 VARIABLE Before surgery () After surgery () p T- score theo DEXA Neck -3,60 ± 0,57 -2,97 ± 0,32 0.000 Troch -3,03 ± 0,43 -2,62 ± 0,31 0.000 Inter -3,03 ± 0,41 -2,57 ± 0,31 0.000 Ward’s -3,86 ± 0,60 -2,94 ± 0,33 0.000 Total -3,24 ± 0,55 -2,79 ± 0,41 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) AO Merle D’-Postel Total Very good (n) Good (n) Quite (n) Medium (n) Bad (n) n % A1 2 15 2 1 0 20 37,74 A2 3 16 9 3 2 33 62,26 Total 5 31 11 4 2 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) Merle D’-Postel BMD Total () Total n % Very good : 17-18 points 0,818 ± 0,087 3 6,98 Good: 15-16 points 0,736 ± 0,094 24 55,81 Quite: 13-14 points 0,652 ± 0,095 10 23,26 Medium: 10-12 points 0,696 ± 0,071 4 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 Author Female / male ratio Age 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 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: T-score = -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: T-score = -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, non-bone 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 o