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HIP Table of Contents   
Year : 2004  |  Volume : 38  |  Issue : 3  |  Page : 147-150
Hip arthroplasty following failed dynamic hip screw fixation for per-trochanteric femoral fractures


1 Orthopedics & Joint Replacement Institute, India
2 Max Healthcare, New Delhi, India

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   Abstract 

Background: Unstable trochanteric fractures have a poor outcome in patients in whom fixation fails and revision to a total hip arthroplasty is required. The primary indication for secondary surgery is relief of pain.
Method: A retrospective review was performed on 17 patients with hip arthroplasty following failure of dynamic hip screw fixation done for per-trochanteric femoral fractures. Three patients underwent bipolar hip arthroplasty and total hip replacement in the remaining fourteen.
Results: Clinical and radiological results at final follow up were equally good following bipolar or total hip arthroplasty conversions. Extreme care needs to be taken to avoid fracture and penetration of the femoral shaft. Auto graft, allograft or head and neck replacement components should be made available for reconstruction of difficult cases.
Conclusion: The principles of a successful outcome include preservation of the functional continuity of the abduction apparatus during surgery, and early supervised weight bearing.

Keywords: Failed fixation; Trochanteric fracture; Revision; Hip arthroplasty

How to cite this article:
Marya S, Thukral R, Bawari R, Gupta R. Hip arthroplasty following failed dynamic hip screw fixation for per-trochanteric femoral fractures. Indian J Orthop 2004;38:147-50

How to cite this URL:
Marya S, Thukral R, Bawari R, Gupta R. Hip arthroplasty following failed dynamic hip screw fixation for per-trochanteric femoral fractures. Indian J Orthop [serial online] 2004 [cited 2019 Dec 15];38:147-50. Available from: http://www.ijoonline.com/text.asp?2004/38/3/147/37268

   Introduction Top


Closed reduction and internal fixation is the preferred initial treatment for young active patients who sustain a displaced pertrochanteric hip fracture[1]. The outcome in patients in whom this procedure fails and who subsequently require revision to a total hip arthroplasty has only recently been studied extensively[2]. With the increasing life span of patients with fixed trochanteric fractures, late complications of these surgeries are becoming significant. Within this scenario, it has been argued that the most effective solution to the femoral neck fracture in the majority of patients is open reduction and internal fixation, with elective conversion, when necessary, to total hip arthroplasty in patients who have a complication[3].

Unstable trochanteric fractures demonstrate overall failure rates in the range of 3%-12%, with non-union in 2% to 5%, device penetration in 2% to 12%, and varus collapse in 5%-11% [3],[5],[5],[6]. The primary indication for secondary surgery is relief of pain resulting from the aforementioned complications[5]. Bipolar or total hip arthroplasty may be utilized for the salvage of such failed fracture fixations of the proximal femur.

In the conversion of these cases to hip replacement, various technical difficulties may be encountered[7]. Also, a high incidence of intra- and post-operative complications may occur because of the altered biomechanics and bone stock, including femoral fracture, wound infection, and aseptic loosening[7]. The purpose of this study is to review experience with conversion of fractures of the proximal femur (treated by dynamic hip screw fixation) to hip arthroplasty, assess the technical difficulties encountered, and to report the shortterm outcome in our series of seventeen patients.


   Materials and Methods Top


Six males and 11 females with a mean age of 65 years (range 60-72 years) were reviewed retrospectively for age, gender, type of fracture, complication necessitating hip arthroplasty, status of the acetabulum, time interval to conversion, type of components used, postoperative position of the components, leg length restoration, technical problems encountered at surgery, blood loss, postoperative complications and clinical end result.

Three patients (all females) had healthy acetabuli, and cemented bipolar arthroplasty was performed in them. Fourteen patients had significant arthritic changes in their acetabulae necessitating total hip replacement. The mean follow up was 30 months (range, 9 months to 72 months).

Deficiency of proximal femoral bone was managed using autogenous graft (femoral head), or use of the long-neck / long-stem replacement prosthesis. Long stemmed prostheses were used in all our cases, the distal tip extending about 2-3 cms. distal to the last screw hole (of the removed dynamic hip screw plate). Long neck stems were used in six of the patients. Distal plug of bone was inserted with the help of Hardinge restrictor holder. Screw holes were blocked with cement (manual pressurization). No neurological or vascular complications were encountered. Post-operatively all patients were made to stand and walk within 3-5 days and were put on a vigorous physiotherapy program.

At final follow-up, patients were analyzed for pain, limp, use of support, distance walked, difficulty with stairs, ability to dress, sitting pain, and use of transportation. They were also rated on a 10-point Visual Analog Scale as to their level of satisfaction.


   Results Top


The time interval from the original internal fixation to conversion to hip arthroplasty averaged 20 months for the entire study group. Charnley cemented Ogee acetabular (except the bipolar patients) and femoral components were utilized in all cases. Pre-operative shortening of the femur averaged 16 mm. Restoration of leg length to within 5 mm of equality was accomplished in all patients.

The average blood loss for bipolar arthroplasty was 400 ml, while that for total hip replacement was 600ml. Total operative time for conversion to bipolar arthroplasty averaged 60 minutes compared to 80 minutes for total hip replacement.

A unique complication occurred in one of our earlier patients. The stem of the prosthesis followed the path created by dynamic hip screw and was projecting out on the lateral aspect of the shaft of the femur. This was recognized during the surgical procedure, exit holes were cemented and the prosthesis was inserted in proper position.

One patient with failure of operated intertrochanteric fracture had dislocation of his converted THR two days after surgery [Figure - 1]a,b. This was recognized immediately and closed reduction was successful. Abduction brace was applied for 6 weeks. He has had no recurrence of the dislocation since then [Figure - 1]c

No patient had persistence of pain, sitting or otherwise. Reasonably good function was achieved in the majority, and the patients were themselves quite satisfied with the end results [Figure - 2]a,b.


   Discussion Top


Reduction and internal fixation remains the primary treatment of displaced pertrochanteric fractures in most patients because of the benefits of preservation of the normal hip joint. However, if this method of treatment fails, revision to a hip arthroplasty is a universally accepted option[7],[8],[9]. In general, the results of secondary replacement are comparable to those obtained following primary arthroplasty or failed internal fixation for femoral neck fractures[7],[8],[9]. The risk of early complications is however higher and hip function may be poorer than if the arthroplasty had been performed as a primary procedure[2]. Contemporary techniques of fracture fixation with compression screw-plate devices demonstrate failure rates of 5% to 10%[4],[5]. Many patients will therefore require hip arthroplasty to salvage failed internal fixation of proximal femur fractures. This series demonstrates that satisfactory results may be achieved in the majority of cases.

The treatment algorithms for displaced fractures of the femoral neck in the elderly need to be improved if we are to reduce the need for secondary surgery. Primary hip replacement provides a better outcome than internal fixation for the elderly, relatively healthy, lucid patients with a displaced fracture of the femoral neck[10]. In comparison with osteosynthesis, endoprosthetic replacement is less extensive, the mortality no higher and the complication rate lower. It is therefore the procedure of choice in arthritic hip fractures[11].Internal fixation may be only appropriate for those who are very frail[12].

A review of literature on the comparative results of internal fixation and arthroplasty for unstable extracapsular trochanteric femoral fractures show no significant differences between the two methods of treatment for operating time, local wound complications, mortality rate or mobility of previously independent patents. Primary replacement arthroplasty has not been demonstrated to have any significant advantage over the sliding hip screw for extracapsular hip fractures[6]. In a study by Berry[13], final hip scores at 2 years or more after total hip arthroplasty were not statistically different between patient groups undergoing primary or conversion hip arthroplasties. The authors concluded that total hip replacement is a satisfactory salvage procedure for failed fracture treatment despite the increased incidence of operative difficulty and increased incidence of complications[9],[13].

Salvage of failed intertrochanteric fractures proves to be considerably more challenging. Unstable intertrochanteric fracture patterns tend to heal with distortion of the neckshaft relationship. Sizable medial displacement of the distal portion of the canal made conventional reaming and broaching difficult, which has to be done carefully[7]. The commonly encountered fracture patterns leave the proximal femur shortened, in varus, and with medial displacement of the neck on the shaft. If the surgeon does not recognize the deformity of the upper femur, penetration of the shaft or fracture of the upper end of the femur may occur[7],[13]. In our series there was no perforation of the canal.

Endoprostheses are now considered invaluable in the salvage of failed internal fixation of a subtrochanteric or intertrochanteric fracture[7],[11],[13],[14],[15]. Preservation of the functional continuity of the abduction apparatus during surgery, and early weight bearing made possible by the arthroplasty are considered to be the major factors contributing to the published good results[16].

Reconstruction of the proximal femur is almost always required, and may be achieved by various means. One may simply use a standard component with a long neck (suitable for simple fracture patterns). Unstable fractures have special requirements. The medial displacement of the shaft may not accommodate the curvature of the conventional femoral stem. In such cases, the surgeon may choose to rebuild the proximal femur either by using the bone from the femoral head and neck as an intercalary graft or, if this is not of sufficient quality, a femoral allograft7. Autograft, allograft or head and neck replacement components should be available for reconstruction of difficult cases[7],[15]. Calcar-replacement implants may also be occasionally required[15]. We prefer the use of the long neck prosthesis as a simpler solution, especially in older individuals. This technique has proved successful in the short follow-up period in our series.

Another technical difficulty we encountered is containment of the acrylic cement when it is pressurized. The cement tends to extrude through previous screw holes, but this can be contained by soft tissue and the pressure afforded by the assistant surgeon's fingers.

Dislocation can occur following conversion of intertrochanteric fractures to joint replacement[9],[13]. This may be prevented by careful component positioning, restoration of leg length, and careful abductor mechanism reconstruction[9],[13].

In older patients with limited functional demands and normal acetabulum, a bipolar acetabular component may afford better stability[17],[18]. Also, rehabilitation is easier and faster, and the incidence of pressure sores, pulmonary infection, and atelectasis are significantly lower with the bipolar prostheses[17],[18].

To sum up, the method of treatment chosen for a failed trochanteric fracture depends on the specific problem: nonunion, aseptic necrosis, infection, degenerative arthritis, or a failed primary prosthesis. Factors influencing treatment include the patient's chronological and physiological age, his general health, his life pattern, familiarity of the surgeon with the technique, and, the advantages and disadvantages of the salvage procedure[19].

The surgeon should be cognizant of the technical difficulties that may be encountered in conversion of failed per-trochanteric fractures, as well as the complications and pitfalls. Recognition of distortion of the proximal femur and the availability of standard implants and head and neck replacement components allows satisfactory outcome in these challenging cases.

 
   References Top

1.Ecker M, Joyce JJ, Kohl EJ. The treatment of trochanteric hip fractures using a compression screw. J Bone Joint Surg (Am). 1975; 57:23.  Back to cited text no. 1    
2.McKinley JC, Robinson CM. Treatment of displaced intracapsular hip fractures with total hip arthroplasty: comparison of primary arthroplasty with early salvage arthroplasty after failed internal fixation. J Bone Joint Surg (Am). 2002; 84:2010-5.  Back to cited text no. 2    
3.Estrada LS, Volgas DA, Stannard JP, Alonso JE. Fixation failure in femoral neck fractures. Clin Orthop. 2002; 399:110-8.  Back to cited text no. 3    
4.Johnsson R. Comparison between hemiarthoplasty and total hip replacement following failure of nailed femoral neck fractures focused on dislocations. Arch Orthop Trauma Surg. 1984; 102:107.  Back to cited text no. 4    
5.Laros GS, Moore JF. Complications of fixation in intertrochanteric fractures. Clin Orthop. 1974; 101: 110.  Back to cited text no. 5    
6.Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures. Cochrane Database Syst Rev. 2000;(2):CD000086.  Back to cited text no. 6    
7.Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures. Clin Orthop. 1991; 269:32-7.  Back to cited text no. 7    
8.Franzen H, Nilsson LT, Stromqvist B, Johnsson R, Herrlin K. Secondary total hip replacement after fractures of the femoral neck. J Bone Joint Surg (Br). 1990;72:784-7.  Back to cited text no. 8    
9.Berry DJ. Salvage of failed hip fractures with total hip replacement. Orthopedics. 2002; 25:949-50.  Back to cited text no. 9    
10.Tidermark J, Ponzer S, Svensson O, Soderqvist A, Tornkvist H. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomized, controlled trial. J Bone Joint Surg (Br). 2003; 85(3):380-8.  Back to cited text no. 10    
11.Broos P, Willemsen PJ, Rommens PM, Stappaerts KH, Gruwez JA. Pertrochanteric fractures in elderly patients. Treatment with a longstem/long-neck endoprosthesis. Unfallchirurg. 1989; 92(5):234-9.  Back to cited text no. 11    
12.Parker MJ, Khan RJ, Crawford J, Pryor GA. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomized trial of 455 patients. J Bone Joint Surg (Br). 2002; 84(8):1150-5.  Back to cited text no. 12    
13.Tabsh I, Waddell JP, Morton J. Total hip arthroplasty for complications of proximal femoral fractures. J Orthop Trauma. 1997;11(3):166-9.  Back to cited text no. 13    
14.Stoffelen D, Haentjens P, Reynders P, Casteleyn PP, Broos P, Opdecam P. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient. Acta Orthop Belg. 1994; 60 Suppl 1:135-9.  Back to cited text no. 14    
15.Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg (Am). 2003; 85:899-904.  Back to cited text no. 15    
16.Haentjens P, Casteleyn PP, Opdecam P. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient. Arch Orthop Trauma Surg. 1994; 113(4):222-7.  Back to cited text no. 16    
17.Green S, Moore T, Proano F. Bipolar prosthetic replacement for the management of unstable intertrochanteric hip fractures in the elderly. Clin Orthop. 1987; 224:169-77.  Back to cited text no. 17    
18.Haentjens P, Casteleyn PP, De Boeck H, Handelberg F, Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric fractures in the elderly patient. Primary bipolar arthroplasty compared with internal fixation. J Bone Joint Surg (Am). 1989; 71(8):1214-25.  Back to cited text no. 18    
19.Albright JP, Weinstein SL. Treatment for fixation complications: Femoral neck fractures. Arch Surg. 1975;110(1):30-6.  Back to cited text no. 19    

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Correspondence Address:
SKS Marya
1193A, Sector B-1, Vasant Kunj, New Delhi - 110070
India
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