LETTER TO EDITOR
Year : 2011 | Volume
: 45 | Issue : 4 | Page : 380-
Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly
Raviraj Aadala, Ashish Anand
Department of Orthopaedic Surgery, Fortis Hospitals Ltd., Bannerghatta Road, Bangalore, India
Consultant Orthopaedic Surgeon, 154/9 Fortis Hospitals, Opposite IIMB, Bannerghatta Road, Bangalore - 560 076
|How to cite this article:|
Aadala R, Anand A. Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly.Indian J Orthop 2011;45:380-380
|How to cite this URL:|
Aadala R, Anand A. Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly. Indian J Orthop [serial online] 2011 [cited 2020 Mar 31 ];45:380-380
Available from: http://www.ijoonline.com/text.asp?2011/45/4/380/82347
We read with great interest the article "Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly: A retrospective case series" by Sancheti et al.  We have several concerns regarding this article.
In the introduction, the authors question the utility of intramedullary devices; which is quite out of sync with current literature, wherein intramedullary devices are recommended for osteoporotic and comminuted intertrochanteric fractures. Simmermacher et al., in their study, concluded proximal femoral nail antirotation (PFNA) due to its helical blade possibly limits the effects of early rotation of the head/neck fragment in unstable trochanteric fractures and therefore seems currently to be the optimal implant for the treatment of these fractures, especially in an osteoporotic bone. 
The authors have described a very high neck cut, almost at the subcapital level, for removal of the femoral head, and they describe the neck cut about 2 cm proximal to the lesser trochanter. The authors fail to describe why they are doing a two-staged resection of the femoral neck, instead of doing the primary neck cut 2 cm proximal to the lesser trochanter. In either case, the free lesser trochanter or the calcar fragment can be wired to the main shaft fragment.
Though the authors describe leaving the lesser trochanter loose with soft tissue attachment, when comminuted, they leave the reader unexplained why the lesser trochanter in their representative case [Figure 4]  was left unwired to the shaft fragment even when there was no comminution.
The authors also explain using the cement mantle to reconstruct the medial defect when there was comminution. This would lead to lack of support in the proximal portion, resulting in varus stresses on the cemented stems, in turn, resulting in early failure. Why did the authors not consider a calcar replacing prosthesis in such a situation?
The authors explain suturing of severely comminuted greater trochanteric fracture using ethibond, steel wires and attaching this "loosely" to the main shaft. This leaves the reader perplexed as to the stability of these stitches against the strong abductor forces in the postoperative period. There is lack of clarity as to what postoperative rehabilitation program was followed. Were the intraoperative comminution, stability predictors of postoperative mobilization or weight bearing walking?
The authors also explain reattaching the greater trochanter and lesser trochanter after insertion of the cemented stem. The authors have not explained the technique of getting the right anteversion intraoperatively in such cases, i.e., those with severe comminution. The use of cemented stem leaves unexplained, the biology of healing of these fragments to the shaft fragment, as the cement will creep along the fracture lines while the stem is being implanted.
Authors fail to explain the average shortening of (range, 5-15 mm) in 10 patients, despite their technique of intraoperative leg length correction. Was a subsidence of the prosthesis seen in these cases in the follow-up radiographs? The authors also report no evidence of loosening; however, if one looks at the X-rays done at the 2-year follow-up, [Figure 3]  one can see change in position of the stem tip and fragmented cement mantle. There is no mention of trochanteric nonunion despite mention of abductor lurch.
|1||Sancheti KH, Sancheti P, Shyam A, Patil S, Dhariwal Q, Joshi R. Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly: A retrospective case series. Indian J Orthop 2010;44:428-34.|
|2||Simmermacher RK, Ljungqvist J, Bail H, Hockertz T, Vochteloo AJ, Ochs U, et al. AO - PFNA studygroup. The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury 2008;39:932-9.|