We thank Dr. Sarda for his interest in our paper. We believe that assessing the degree of osteoporosis in this patient population is extremely important. In our practice we measure bone mineral density in the contralateral hip prior to surgery in all patients older than 65 who present with a hip fracture. Knowing bone density is important for the surgeon in order to select the most appropriate surgical intervention.

Although external fixation can also be used with some unstable fractures, we believe that the best indication is a stable hip fracture in the mentally competent osteoporotic patient. However, we have no data to show any differences in outcomes between stable and unstable fractures treated with external fixation. In general, we believe that unstable hip fractures are better treated with intramedullary nailing.

The magnitude of osteoporosis does not affect our treatment regimen--we use external fixation with HA- coated pins regardless of its severity. The excellent osteointegration ability of these pins leads to good fixation even when bone quality is badly compromised.

In our study we carefully selected patients who were able to walk unassisted prior to the fracture and showed no evidence of dementia. We are glad to hear that Dr. Sarda fully agrees with us about the appropriateness of this minimally invasive technique in this kind of patient.

To The Editor:

Over the decades, different forms of external fixation devices have been used to treat pertrochanteric fractures (1,2). Importantly, these fractures often occur in very elderly patients who require help in activities of daily living (3). Though the HA coated pins have indeed lowered cutout rates and improved results, I believe any external fixation device, especailly when required for periods of three months, may pose difficulties in nursing for patients who are not only incactive, but may suffer from dementia as well.

These patients are often osteopenic and I am interested in knowing if the authors used any indices/scans to quantify the degree of osteoporosis (4). If not, it becomes a very subjective assessment of bone mineral content that can be even more inaccurate because of lack of standardized x-ray technique.

Did the authors use the device in both stable and unstable fractures and were there diffences in outcomes between these two groups? Do they recommend the technique in all patients regardless of the degree of osteoporosis?

In my view, this is a very good technique, if used in a carefully selected group of patients who were reasonably mobile and mentally competent before the fall.

References:

1. Scott IH. Treatment of intertrochanteric fractures by skeletal pinning and external fixation. Clin Orthop 1957; 10:326-34.

2. Gotfried I, Frish E, Mendes DG. Intertrochanteric fractures in high risk geriatrics patients treated by external fixation. Orthopaedics 1985; 8:769-74.

3. Eastwood HD. The social consequences of surgical complications for patients with proximal femoral fractures. Age Ageing 1993; 22:360-4.

4. John D. Kaufmann, MD. Tests for measuring Osteoporosis. AAOS newsletter; March 2000.