Published: 2020-09-24

Comparison of mortality rate between bipolar hemiarthroplasty and proximal femoral nail anti-rotation for intertrochanteric fractures in Sanglah hospital, Bali

I. Wayan Suryanto Dusak, I. Gusti Ngurah Wien Aryana, Cokorda Gde Oka Dharmayuda, I. Wayan Subawa, Hans Kristian Nugraha, I. Made Arya Susila


Introduction: Intertrochanteric fractures occur in about 50% of all hip fracture events, with a mortality rate within 1 year after fracture reaching 15 to 20%. The most common treatment nowadays is either the bipolar hemiarthroplasty procedure or proximal femoral nail anti-rotation (PFNA), although there is still no consensus regarding which is better from the two, especially on patient mortality.

Method: This study was an observational study using a retrospective cohort design. A total of 102 study subjects who met the inclusion requirements were grouped into 2 groups, one with bipolar hemiarthroplasty fixation treatment and another with PFNA fixation treatment. Mortality rate was recorded by survey 2 years after surgery.

Result: Chi-square test showed that 2-year mortality rate after intertrochanteric fracture treated with bipolar hemiarthroplasty (21.4%) was significantly higher than the PFNA group (10.3%)
(p=0.028). Bipolar hemiarthroplasty group also had longer length of stay (LoS) (50%) than the PFNA group (32.4%), albeit statistically insignificant (p=0.13). There was no significant difference between the 2-year mortality rate and LoS (p=0.976).

Conclusion: Patients with intertrochanteric fractures who underwent bipolar hemiarthroplasty have significantly higher 2-year mortality rate than similar patients underwent fixation with PFNA, while they did not experience higher LoS than the PFNA group. Future prospective, multi-center study with larger sample size will be likely to validate similar fixation choice needed to decrease the mortality rate in intertrochanteric fractures.


Hip fracture, Intertrochanteric fracture, Bipolar hemiarthroplasty, PFNA, Mortality

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Zhou S, Liu J, Zhen P, Shen W, Chang Y, Zhang H et al. Proximal femoral nail anti-rotation versus cementless bipolar hemiarthroplasty for unstable femoral intertrochanteric fracture in the elderly: a retrospective study. BMC Musculoskelet Disord. 2019;20(1):500.

Chang SM, Hou ZY, Hu SJ, Du SC. Intertrochanteric Femur Fracture Treatment in Asia: What We Know and What the World Can Learn. Orthop Clin North Am. 2020;51(2):189-205.

Ülkü TK, Tok O, Seyhan M, Gereli A, Kaya A. Comparison of Third Generation Proximal Femoral Nails in Treatment of Reverse Oblique Intertrochanteric Fractures. Bezmialem Sci. 2019;7(4):271-5.

Liu JJ, Shan LC, Deng BY, Wang JG, Zhu W, Cai ZD. Reason and treatment of failure of proximal femoral nail antirotation internal fixation for femoral intertrochanteric fractures of senile patients. Genetics and Molecular Research. 2014;13(3):5949-56.

Xie Y, Dong Q, Xie Z. Proximal femoral nail anti-rotation (PFNA) and hemi-arthroplasty in the treatment of elderly intertrochanteric fractures. Acta Orthop Belg. 2019;85(2):199-204.

Luo X, He S, Zeng D, Lin L, Li Q. Proximal femoral nail antirotation versus hemiarthroplasty in the treatment of senile intertrochanteric fractures: Case report. Int J Surg Case Rep. 2017;38:37-42.

Dusak WS, Simanjuntak HA, Putra IGNPW. Comparison between the results of proximal femur nail anti-rotation and cemented bipolar hemiarthroplasty in treatment of intertrochanteric fractures in Sanglah Hospital in 2016. Int J Res Med Sci. 2019;7(9):3475-9.

Doyle DJ, Goyal A, Bansal P, Garmon H. American Society of Anesthesiologists Classification (ASA Class). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.

Lim YW, Kwon SY, Han SK, Sun DH, Choi SP, Kim YS. Postoperative mortality and factors related to mortality after bipolar hemiarthroplasty in patients with femoral neck fractures. J Arthroplasty. 2009;24(8):1277-80.

Şahin EK, İmerci A, Kınık H, Karapınar L, Canbek U, Savran A. Comparison of proximal femoral nail antirotation (PFNA) with AO dynamic condylar screws (DCS) for the treatment for unstable peritrochanteric femoral fractures. Eur J Orthop Surg Traumatol. 2014;24(3):347-52.

Huang J, Shi Y, Pan W, Wang Z. Bipolar Hemiarthroplasty should not be selected as the primary option for intertrochanteric fractures in elderly patients. Sci Rep. 2020;10(1):4840.

Esen E, Dur H, Ataoğlu MB, Ayanoğlu T, Turanlı S. Evaluation of proximal femoral nail-antirotation and cemented, bipolar hemiarthroplasty with calcar replacement in treatment of intertrochanteric femoral fractures in terms of mortality and morbidity ratios. Eklem Hastalik Cerrahisi. 2017;28(1):35-40.

Lingsma HF, Bottle A, Middleton S, Kievit J, Steyerberg EW, Marang-van de Mheen PJ. Evaluation of hospital outcomes: the relation between length-of-stay, readmission, and mortality in a large international administrative database. BMC Health Serv Res. 2018;18(1):116.

Nordström P, Gustafson Y, Michaëlsson K, Nordström A. Length of hospital stay after hip fracture and short term risk of death after discharge: a total cohort study in Sweden. BMJ. 2015;350:696.

Nikkel LE, Kates SL, Schreck M, Maceroli M, Mahmood B, Elfar JC. Length of hospital stay after hip fracture and risk of early mortality after discharge in New York state: Retrospective cohort study. BMJ Clin Resea Ed. 2015;351:6246.