RESUMEN
INTRODUCTION: Although internal fixation is the reference treatment for extracapsular fracture of the upper femur, indications for arthroplasty are broadening, especially in unstable comminutive fracture in fragile bone. The present study hypothesis was that arthroplasty reduces early mortality and morbidity and provides better recovery of autonomy in over-80 year-old patients than does internal fixation. MATERIAL AND METHODS: A prospective multicenter study was conducted on 8 sites. Internal fixation was systematically used in 5 centers; arthroplasty was used systematically in 1 center, and reserved for unstable fracture in 2 centers. A total of 697 patients aged over 80 years (mean age, 85±5 years), presenting with extracapsular fracture, were included; 521 were treated by internal fixation and 176 by arthroplasty. Results were studied on multivariate analysis of ASA score, blood loss, transfusion, and also of treatment modality as an independent factor for early (first 6 months) mortality and morbidity (mechanical, general and nutritional complications) and functional outcome (autonomy and dependence). RESULTS: Overall mortality was 19.2%. Autonomy deteriorated in 56% of patients alive at 6 months and dependence worsened in 44%. Two percent of those managed by internal fixation underwent revision for disassembly (n=8) or infection (n=1). Eight percent of those managed by arthroplasty underwent revision for dislocation (n=4), implant loosening (n=3) or infection (n=7). On univariate analysis, mortality was higher in the arthroplasty group (25%) than with internal fixation (17%; P=0.002), as were blood loss (425±286mL versus 333±223mL; P<0.0001), transfusion rate (61% versus 32%; P<0.0001) and infection (4% versus 0.2%; P<0.001). On multivariate analysis, however, treatment modality no longer showed impact on mortality or on morbidity and autonomy at 6 months. Nutritional status was better conserved at 6 months following arthroplasty, but dependence worsened. Poor preoperative autonomy, ASA score, and nutritional status and time to treatment were independent factors for mortality. Transfusion, associated with onset of mechanical complications, significantly increased dependence. CONCLUSION: Type of treatment had little impact on mortality, morbidity or functional outcome. Differences seemed more related to preoperative functional and nutritional status. LEVEL OF EVIDENCE: III, prospective case-control study.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Fracturas del Cuello Femoral/cirugía , Fijación Interna de Fracturas , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/mortalidad , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea , Estudios de Casos y Controles , Femenino , Fracturas del Cuello Femoral/mortalidad , Estudios de Seguimiento , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/mortalidad , Estado de Salud , Humanos , Vida Independiente , Infecciones/etiología , Masculino , Estado Nutricional , Estudios Prospectivos , ReoperaciónRESUMEN
The spontaneous correction of hip dysplasia occurs at every level of growth of the lower limb and it may be inadequate at any of these levels. Every abnormality of correction may induce different troubles at any level of the lower limb. A complete clinical evaluation, X-ray with different special views and CT examination is mandatory. Every deformation in any of the three spatial planes must be detected for a good understanding of the defect. The authors describe the X-ray techniques necessary for a complete evaluation of the patient and propose a CT protocol to precisely calculate the different angles of torsion of the lower limb. The possibilities of surgical treatment at different levels of the lower limb (acetabular, femoral, tibial and ankle or foot level) in DDH are pointed out to address directly the proper procedure at the correct level of the pathology.