The Journal of Arthroplasty xxx (2015) xxx–xxx
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Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture Xiaojun Shi, MD, Zongke Zhou, MD, PhD, Jing Yang, MD, Bin Shen, MD, Pengde Kang, MD, PhD, Fuxing Pei, MD Orthopedic Department, West China Hospital, Sichuan University, Chengdu, China
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Article history: Received 10 February 2015 Accepted 21 May 2015 Available online xxxx Keywords: total hip arthroplasty intertrochanteric fracture nonunion internal fixation failure non-modular stem
a b s t r a c t Thirty one patients were treated with salvage total hip arthroplasty (THA) for failed internal fixation of intertrochanteric fracture. After a mean follow-up of 47.5 months, all patients reported remarkable pain relief and return to ambulation. Twenty five patients had no pain, and 6 patients complained of residual trochanteric low-grade pain without compromise of activities. The Harris Hip score increased from a preoperative average of 28.4 points to a postoperative average of 85.6 points. All patients demonstrated successful bony union and five had Brooker I or II heterotopic ossification. Seven patients had intraoperative or early complications and were treated successfully. There was no infection, re-fracture, loosening, or revision for any reason. Salvage THA using non-modular cementless long-stem prosthesis represents an effective procedure after failed intertrochanteric fixation. © 2015 Elsevier Inc. All rights reserved.
Intertrochanteric fractures are common in the elderly people, and most can be treated successfully with open or closed reduction and internal fixation [1,2]. However, nonunion or early loss of fracture fixation occurs occasionally, and the reported overall failure rates with internal fixation are in the range of 3%–13% [3,4]. Most patients with internal fixation failure have marked pain and dysfunction, which may result in complications related to prolonged recumbency and may affect the vital prognosis of these fragile patients; therefore, an effective salvage procedure allowing immediate ambulation is particularly important. However, the management of fixation failure before fracture union is a challenge for orthopedic surgeons and the reported incidence rate of complications is up to 47%, including trochanteric nonunion, infection, lateral hip pain, and dislocation [5–7]. Various salvage procedures including revision internal fixation and hip arthroplasty have been reported [8–13]. Revision internal fixation has been reported to lead to high union rates in younger patients with excellent general condition and good bone quality, while total hip arthroplasty (THA) is considered for older patients, patients with severely compromised bone inadequate for fixation, or patients with severe articular cartilage wear [5,14–17]. Recently, several studies have reported the successful treatment of failed intertrochanteric fixation with salvage THA using modular cementless implants, which is allegedly adapted for proximal femoral bone loss, osteoporotic bone quality, altered anatomy, offset,
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.05.041. Reprint requests: Fuxing Pei, M.D., Orthopedic Department, West China Hospital, Sichuan University, Chengdu, China.
anteversion, and limb length discrepancy [6,18–22]. However, the modular femoral stem may consume more operative time, which may increase the incidence rate of postoperative medical complications. Most important of all, the fracture of modular cementless femoral stems at the mid-stem junction is an intractable problem, especially in these patients with inadequate proximal osseous support because of nonunion of intertrochanteric fracture [23–25]. It seems that non-modular cementless revision stems are more suitable for these patients, without the need for complex intraoperative assembly or worry about fracture of the modular stem at the mid-stem junction. However, to our knowledge, there is no published study analyzing the result of non-modular cementless revision stems in the treatment of failed intertrochanteric fracture fixation. The purpose of the current study was to evaluate the results, technical problems, and complications associated with THA using non-modular porous-coated cementless distal fixation stem as a salvage procedure for failed internal fixation of intertrochanteric fracture in our institute. Materials and Methods The institutional review board approval was obtained prior to the study. Between January 2006 and August 2012, 31 patients (12 males and 19 females) were treated at our university hospital with salvage THA following failed fixation of intertrochanteric or subtrochanteric hip fracture. The mean age at the time of salvage surgery was 72.4 years (range, 58.5–84.8 years). The mean interval from initial fracture fixation to conversion arthroplasty was 8.2 months (range, 5– 16 months). Seventeen patients had failed treatment with a dynamic hip screw for intertrochanteric or subtrochanteric fractures, 8 patients
http://dx.doi.org/10.1016/j.arth.2015.05.041 0883-5403/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
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Table 1 Demographic Data of Patients. Age (year) Gender Male Female BMI (kg/m2) Interval between internal fixation and salvage THA (month) Average follow-up (month) Fixation used Intramedullary (γ) nail Dynamic hip screw Anatomic plate Indication(failure of fixation) nonunion with severe hip pain and varus deformity nonunion with secondary acetabular erosion by a penetrated lag screw nonunion with breakage of the side plate and screws AO classification A1.1/A1.2/A1.3 A2.1/A2.2/A2.3 A3.1/A3.2/A3.3
72.4 (range, 58.5–84.8) 12 19 26.7(range, 20.4–34.5) 8.2 (range, 5–16) 47.5 (range, 13–83) 8 17 6 16 8 7 1/0/1 2/9/10 2/3/3
AO indicates Arbeitsgemeinschaft für Osteosynthesefragen.
had failed treatment with γ nailing, and 6 patients had failed treatment with anatomic plate. All fractures were evaluated using the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification for intertro-chanteric fractures [26]. The fracture fixation failure modes in the study sample were as follows: nonunion with severe hip pain and varus deformity in 16 patients, nonunion with secondary acetabular erosion by a penetrated lag screw in 8 patients, nonunion with breakage of the side plate and screws in 7 patients. All patients underwent detailed preoperative clinical examination and evaluation for medical comorbidities, including complete blood count with white cell count, Creactive protein (CRP), and erythrocyte sedimentation rate (ESR) to rule out occult infection as a cause of failure. All the patients had femoral reconstruction using a non-modular Solution stem (DePuy, Indiana, USA). Patient demographic data are summarized in Table 1. Operative Technique Radiographs with 100% amplification were taken for all patients in order to facilitate meticulous preoperative templating and planning, including the determination of necessary length and diameter of the implant, optimal site of cortical fixation, and assessment of limb length. All patients were operated on in the lateral decubitus position by the same team of surgeons using the posterolateral approach. Once the joint was opened, synovial fluid was harvested immediately for bacterial culture into a blood culture bottle as a routine procedure. Frozen sections were prepared only if active infection was suspected during surgery, which did not add to operative time because we firstly performed thorough debridement, then the wounds were immersed in hydrogen peroxide and undiluted povidone-iodine for 15 min and rinsed using pulsed irrigation for all patients. The femoral head was dislocated out before hardware removal in order to prevent further fracture. Care was taken to maintain the muscular and perisosteal attachments to the bone, thereby preserving vascularity and preventing disruption of small fragments. Fragments of the greater trochanter were fixed by cerclage wire. Thereafter, the hardware and femoral head were removed, then the femoral canal was prepared by graduated reaming using rasps until an optimal endosteal contact in the distal diaphyseal part of the femur was achieved. Finally, the femoral component was inserted into the canal until rigid fixation was accomplished. Reconstruction of the trochanteric bony fragments along with soft tissue attachment was reinforced with an elastic system of cerclage wires passed transosseously into the metaphyseal region so as to also distalize
the greater trochanter; this careful reconstruction provided good tension for the abductor musculature (Fig. 1). The wound was irrigated and short external rotators were reinserted transosseously. All patients received the same postoperative anticoagulation therapy with low molecular weight heparin (LMWH). The breathing exercises and static exercises for calves, quadriceps and gluteal muscles were executed after anesthesia recovery. Patients were encouraged to start walking with a walker on the second day, with full weight bearing as tolerated, and to avoid excessive flexion and adduction. Postoperative Follow-Up All patients were followed up clinically and radiographically after the arthroplasty at regular intervals of 1, 2, 3, 6, 12 months, and annually thereafter. The clinical status was evaluated by a single joint surgeon (Shi) using the Harris Hip score (HHS) combined with examination of the Trendelendurg sign [27]. Visual Analogue Scale (VAS) was used to evaluate hip pain. Limb-length discrepancy was measured by tape with an accurate measurement of 1 mm at 1 year post-operation. All the patients were placed in the supine position at the point where the hip and knee achieved maximal extension. The line connecting the anterior superior iliac spine and most prominent point of the medial ankle represented the limb length, with a difference of equal to or more than 5 mm between the two limbs being considered limblength discrepancy. Radiographs were reviewed for evidence of osteointegration, subsidence and heterotopic ossification by a senior consultant with no direct knowledge of the specific cases. Serial follow-up radiographs were compared, and scores of stability and fixation were tabulated based on the system described by Engh et al [28]. The results were analyzed using paired t test using SPSS software (Predictive Analytics Company, Chicago). Results Four patients had been confirmed to have chronic bacterial infection before salvage THA and were successfully treated by hardware removal and insertion of antibiotic spacers as stage I then THA as stage II operations. The mean follow-up after salvage THA was 47.5 months (range, 13–83). At the most recent follow-up, 3 of 31 patients had died of unrelated diseases with the implant intact. There was no infection, postoperative fracture, loosening, or revision for any reason in any hip after salvage THA. The average duration of the surgery was 136 min (range, 100–210), and the average blood loss was 850 mL (range, 400–1650). Detailed data on the patients are summarized in Table 2.
Fig. 1. Intraoperative photograph showing reconstruction of abductor mechanism. Black arrow means reconstruction of the trochanteric bony fragments along with soft tissue attachment using cerclage wiring; white arrow means reconstruction insertion of gluteus medius, the most import factor of hip stability.
Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
X. Shi et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
Complications
Table 2 Results. Bearing Ceramic–Ceramic Ceramic–Polyethylene Metal–Polyethylene Harris hip score Before salvage THA After salvage THA Osteointegration Bony ingrowth Stable fibrous ingrowth Fracture union Union Non-union Complications Intraoperative fracture Dislocation Delirium Pneumonia congestive heart failure
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8 13 10 28.4 (range, 18–42) 85.6 (range, 75–92) 31 0 31 0 2 2 1 1 1
Functional Outcomes All patients reported remarkable pain relief and return to ambulation after the salvage THA. 25 patients had no pain (VAS = 0), and 6 patients complained of some residual trochanteric low-grade pain with no compromise of activities (VAS = 1–3). Nineteen patients could ambulate without any support, 10 patients used a cane, and 2 patients used a walker for ambulation. The mean HHS score increased from 28.4 points preoperatively to 85.6 points at the last follow-up; the mean improvement value was 57.2 (P b 0.05). Twelve patients had limb-length discrepancy with a mean value of 7 mm (range, 5–15). Trendelenburg sign was positive in all patients up to 3 months postoperatively, and progressively diminished until becoming negative in all patients. Radiographic Results Radiographic evaluation was performed to assess osteointegration of the femoral stem. According to the criteria in Engh et al [28], all stems had stable bony ingrowth, one stem had subsidence of 3 mm at postoperative 1 month and there was no progressive subsidence. All patients demonstrated successful bony union of the fracture and five had Brooker I or II heterotopic ossification with no influence on function (Fig. 2).
Seven patients had an intraoperative complication or an early medical complication related to the operation. Two patients had an intraoperative nondisplaced femoral fracture and were treated successfully with cerclage wire. Two patients had dislocations at the second and fourteenth day postoperatively and were treated successfully with closed reduction and bracing. One patient had delirium, one had pneumonia, and one had congestive heart failure. There were no cases of nerve palsy or perioperative deaths. Discussion Salvage THA after failed internal fixation of intertrochanteric fracture faces several tricky problems, including removal of previous internal fixation devices, prevention of intraoperative re-fracture and rigid fixation of the new femoral component. Preparation of special instruments for the removal of internal fixation devices is important to simplify this process. Dislocating the head with the metalwork in situ is beneficial to prevent re-fracture. Structural defects and modification of bony landmarks due to deformation and displacement of fragments, combined with poor bone quality and presence of screw holes not only enhance the risk of intraoperative fractures, but also lead to difficult fixation of new femoral components [5,7,11,29,30]. Several authors have reported the use of cemented arthroplasty, and good to excellent results have been reported in 66% to 100% of cases [5,7,15,19,31]. However, extravasation of cement through screw holes and fracture lines is inevitable, which may lead to suboptimal pressurization of cement and poor remodeling of the cortical bone, higher risk of trochanteric nonunion or postoperative periprosthetic fracture [32]. In the largest series to date, Haidukewych et al [5] reported salvage hip arthroplasty with cemented components. Only 57% of the patients had osseous union of the greater trochanter, 16% patients suffered from trochanteric nonunion with N 1 cm of proximal migration, 16% patients had moderate or severe pain in the region of the greater trochanter and 8% patients were re-operated on. Due to the limitations of cemented fixation, cementless prosthesis seems more attractive, especially modular versatile systems. Recently, several studies have reported salvage THA with modular cementless prosthesis for failed intertrochanteric fractures [6,18–22]. Abouelela et al [21] reported 16 patients treated with Revitan stem (Zimmer, Winterthur, Switzerland). At a mean follow-up period of 60 months, all patients demonstrated clinically significant pain relief and return to
Fig. 2. Anteroposterior radiograph of a 65-year-old female showing type A2.3 intertrochanteric fracture treated with internal fixation (A and B). Nonunion result in fracture of the internal device (C), Anteroposterior radiograph 1 year after salvage THA using nonmodular cementless stem showing excellent osteointegration, full fracture union and Booker II heterotopic ossification (D).
Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
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ambulation, and 8 patients had slight awareness of lateral trochanteric pain. Radiographic evaluation demonstrated stable stem and bony ingrowth in all patients, and one nonunion of the greater trochanter. Thakur et al [22] treated 15 patients with distally fixed MP stem (Link MP, Hamburg, Germany). After a follow-up period of 2.8 years, all patients except two demonstrated significant pain relief, fourteen stems had stable bone ingrowth, one stem subsided by 5 mm, and 1 patient demonstrated nonunion of greater trochanter. Talmo et al [19] reported the results of 10 cementless S-ROM prostheses (DePuy, Warsaw, Ind) in the salvage THA. All patients reported good pain relief after a follow-up period of 30 months. Nine stems had stable bone ingrowth and one stem had subsidence of 10 mm and significant radiolucency. Laffosse et al [18] treated 29 patients using the Puget prosthesis (Système, Montbonnot, France). Patients (52%) ambulated independently without support or a cane, 48% patients required two canes/walker or were bedridden, 13% cases had stem subsidence greater than 5 mm, and 8.7% patients had nonunion of the greater trochanter. However, without adequate proximal osseous support because of nonunion of intertrochanteric fracture, the fracture of modular cementless femoral stems at the mid-stem junction is an intractable problem [23–25]. In recently published literature, Lakstein et al [25] reported that inadequate proximal osseous support in revision hip arthroplasty using modular implants is a risk factor for femoral stem fracture at the mid-junction. Prevention of this catastrophic outcome may be achieved by choosing suitable femoral stem and getting long-term proximal fixation such as medial strut grafts. In this study, we used non-modular cementless Solution stem with variable lengths and diameters for bypassing screw holes and bone defects to manage these complex cases. The implants have 7/8 titanum porous-coating with rigid rough surfaces, which are beneficial not only for initial fixation within the diaphysis but also for bone ingrowth enabling biological fixation with both the metaphysis and diaphysis (Fig. 3). Previous studies with this system have yielded satisfactory results in revision THA [33,34]. Chung et al [33] reported 96 femoral revisions with Solution stem for Paprosky femoral type III defects, at a mean follow-up period of 67.5 months, and no significant subsidence or mechanical failure of the femoral implants was detected. In addition, no further revision was required during the same follow-up period. The
Fig. 3. Photograph of non-modular cementless stem (Solution, Depuy, Indiana, USA), which has 7/8 titanum porous-coating with rigid rough surface.
radiologic findings of this study demonstrated healed trochanteric fractures in all patients and adequate bone ingrowth around the stem in 100% of femora. Therefore, osseointegration into a well-designed and successfully implanted cementless femoral stem can be achieved with good results despite the decreased osteogenic potential in these patients [35,36]. Dislocation and lateral trochanteric pain after salvage THA in these patients were the other intractable problems because of the ruin of hip stability. Mokka et al [37] reported that the overall dislocation rate was 16% after salvage hip arthroplasty following failed nailing of proximal femoral fracture. Mehlhoff et al [11] reported that 3 patients had dislocation and 2 patients had to undergo reoperation because of instability in 13 patients who had an arthroplasty after failed internal fixation of intertrochanteric fracture. Some authors suggest avoiding trochanteric fixation devices due to the concern about cause of pain and reoperation [19]. However, this procedure may compromise the abductor mechanism and lead to high incidence of dislocation or instability. In the current study, dislocation rate and lateral trochanteric pain were much lower than in the published literature [5,7,11,37]. This may be attributed to appropriate relative orientation of the components and avoidance of abductor dysfunction through restoration of adequate soft tissue tension by repairing the short external rotators and reconstructing the abductor mechanism using cerclage wiring and/or heavy sutures These were the two most important factors to prevent dislocation, although other factors such as head size maybe associated with dislocation [30,38,39]. According to the present study, transosseous cerclage wire and/or heavy sutures have proved to be effective approaches to reconstruction of abductor mechanism without increasing the rate of trochanteric pain and reoperation. This finding was confirmed by Laffosse et al, who also reported low incidence rates of trochanteric pain and dislocation after reconstruction of abductor mechanism with the similar transosseous cerclage wire [18]. Nonunion of trochanteric fracture is not common, because this area is cancellous bone and has a rich vascular supply. Once it occurred, infection is an important factor that should be considered other than mechanical failure. Reoperation is an important risk factor for infection [40,41]. Haidukewych et al [9,14] reported that the rate of infection in patients with failed internal fixation of trochanteric fracture was 7.5%. In this study, 4 of 31 patients (12.9%) were confirmed to have active infection and were successfully treated with two-staged operations, which demonstrated that infection was a major cause of internal fixation failure after trochanteric fracture. The diagnosis of infection should be based on incorporation of clinical symptoms/signs, laboratory/ imaging examination and surgical finding. Sometimes, it is difficult to discern whether a clinic symptom such as pain is being caused by infection, fracture nonunion or both, but rest pain is a positive indication for infection which is present in all the four infected patients. Preoperative inflammatory cytokine detection such as CRP and ESR is an effective pathway to auxiliary diagnosis, for example, 3 of 4 infected patients in this study have persistent elevation of CRP preoperatively. Surgical finding and frozen section are also important reference indexes to exclude infection [42]. Synovial fluid culture is very important because it can direct the usage of sensitive antibiotics if a positive culture is acquired. In the present study, no patients had periprosthetic infection after salvage THA. This may be attributed to the fact that we considered all these patients as having potential infection and performed synovial fluid culture, thorough debridement and disinfectant immersion. All patients in this study had THA rather than hemiarthroplasty, because acetabular erosion is the major risk associated with hemiarthroplasty. Compromised articular cartilage in the hips of normal elderly patients puts them at a greater risk and may lead to limited activity resulting in higher revision surgery [43]. Moreover, THA demonstrates superior longevity when compared to hemiarthroplasty [44,45]. On the other hand, we agree with Sidhu et al [46] that prefracture activity of the patient should be taken into consideration when making a decision for surgery. All patients in this study were community ambulators before injury and were not dependent for self-care.
Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
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Such patients are expected to regain an active life after total hip arthroplasty. This may be the reason for the low complication rates and mortality in this study. The strength of this study is the use of uniform non-modular cementless stems. Furthermore, all procedures were performed by the same senior arthroplasty surgeon with the same surgical approach. The weakness of this study includes the diversity of AO classification for fracture and diversity of internal fixation methods in the primary operation. Besides, the study is a retrospective study with limited sample size and lack of control group such as revision internal fixation. Further studies may be needed to better understand how to manage these tough cases. In conclusion, our results indicate that stable fixation of the implant can be achieved with good functional outcome in a reproducible fashion. We believe that THA using non-modular porous-coated cementless long-stem distal fixation revision represents an effective salvage procedure after failed intertrochanteric fixation. Acknowledgements This work was supported by Health Industry Special Scientific Research Projects of China—The safety and effectiveness evaluation of arthroplasty (No. 201302007), National Natural Science Foundation of China (No. 81401788) and Science and Technology Fund of Sichuan Province (No. 2015JY0150). References 1. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am 1979;61:216. 2. Baumgartner MR, Solberg BD. Awareness of tip–apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg (Br) 1997;79:969. 3. 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;113:222. 4. Geiger F, Zimmermann-Stenzel M, Heisel C, et al. Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality. Arch Orthop Trauma Surg 2007;127:959. 5. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 2003;5:899. 6. Weiss RJ, Karrholm J, Hailer NP, et al. Salvage of failed trochanteric and subtrochanteric fractures using a distally fixed, modular, uncemented hip revision stem: 30 patients followed for a mean of 4 years. Acta Orthop 2012;83(5):488. 7. Zhang B, Shiu KY, Wang M. Hip arthroplasty in failed internal fixation of intertrochanteric fractures. J Arthroplasty 2004;19:329. 8. Mariani EM, Rand JA. Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation: results of second attempts to gain union. Clin Orthop Relat Res 1987;218:81. 9. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 2003;85:899. 10. Kim YH, Oh JH, Koh YG. Salvage of neglected unstable intertrochanteric fracture with cementless porous-coated hemiarthroplasty. Clin Orthop Relat Res 1992;277:182. 11. Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures. Clin Orthop Relat Res 1991;269:32. 12. Sarathy MP, Madharan P, Ravichandran KM. Nonunion of intertrochanteric fractures of the femur treated by modified medial displacement and valgus osteotomy. J Bone Joint Surg (Br) 1995;77:90. 13. Wu CC, Shih CH, Chen WJ, et al. Treatment of cutout of a lag screw of a dynamic hip screw in an intertrochanteric fracture. Arch Orthop Trauma Surg 1998;117:193. 14. Haidukewych GJ, Berry DJ. Salvage of failed internal fixation of intertrochanteric hip fractures. Clin Orthop Relat Res 2003;412:184. 15. Said GZ, Farouk O, El-sayed A, et al. Salvage of failed dynamic hip screw fixation of intertrochanteric fractures. Injury 2006;37:194. 16. Angelini M, Mckee MD, Waddell JP, et al. Salvage of failed hip fracture fixation. J Orthop Trauma 2009;23(6):471.
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Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture Xiaojun Shi, MD, Zongke Zhou, MD, PhD, Jing Yang, MD, Bin Shen, MD, Pengde Kang, MD, PhD, Fuxing Pei, MD Orthopedic Department, West China Hospital, Sichuan University, Chengdu, China
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Article history: Received 10 February 2015 Accepted 21 May 2015 Available online xxxx Keywords: total hip arthroplasty intertrochanteric fracture nonunion internal fixation failure non-modular stem
a b s t r a c t Thirty one patients were treated with salvage total hip arthroplasty (THA) for failed internal fixation of intertrochanteric fracture. After a mean follow-up of 47.5 months, all patients reported remarkable pain relief and return to ambulation. Twenty five patients had no pain, and 6 patients complained of residual trochanteric low-grade pain without compromise of activities. The Harris Hip score increased from a preoperative average of 28.4 points to a postoperative average of 85.6 points. All patients demonstrated successful bony union and five had Brooker I or II heterotopic ossification. Seven patients had intraoperative or early complications and were treated successfully. There was no infection, re-fracture, loosening, or revision for any reason. Salvage THA using non-modular cementless long-stem prosthesis represents an effective procedure after failed intertrochanteric fixation. © 2015 Elsevier Inc. All rights reserved.
Intertrochanteric fractures are common in the elderly people, and most can be treated successfully with open or closed reduction and internal fixation [1,2]. However, nonunion or early loss of fracture fixation occurs occasionally, and the reported overall failure rates with internal fixation are in the range of 3%–13% [3,4]. Most patients with internal fixation failure have marked pain and dysfunction, which may result in complications related to prolonged recumbency and may affect the vital prognosis of these fragile patients; therefore, an effective salvage procedure allowing immediate ambulation is particularly important. However, the management of fixation failure before fracture union is a challenge for orthopedic surgeons and the reported incidence rate of complications is up to 47%, including trochanteric nonunion, infection, lateral hip pain, and dislocation [5–7]. Various salvage procedures including revision internal fixation and hip arthroplasty have been reported [8–13]. Revision internal fixation has been reported to lead to high union rates in younger patients with excellent general condition and good bone quality, while total hip arthroplasty (THA) is considered for older patients, patients with severely compromised bone inadequate for fixation, or patients with severe articular cartilage wear [5,14–17]. Recently, several studies have reported the successful treatment of failed intertrochanteric fixation with salvage THA using modular cementless implants, which is allegedly adapted for proximal femoral bone loss, osteoporotic bone quality, altered anatomy, offset,
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.05.041. Reprint requests: Fuxing Pei, M.D., Orthopedic Department, West China Hospital, Sichuan University, Chengdu, China.
anteversion, and limb length discrepancy [6,18–22]. However, the modular femoral stem may consume more operative time, which may increase the incidence rate of postoperative medical complications. Most important of all, the fracture of modular cementless femoral stems at the mid-stem junction is an intractable problem, especially in these patients with inadequate proximal osseous support because of nonunion of intertrochanteric fracture [23–25]. It seems that non-modular cementless revision stems are more suitable for these patients, without the need for complex intraoperative assembly or worry about fracture of the modular stem at the mid-stem junction. However, to our knowledge, there is no published study analyzing the result of non-modular cementless revision stems in the treatment of failed intertrochanteric fracture fixation. The purpose of the current study was to evaluate the results, technical problems, and complications associated with THA using non-modular porous-coated cementless distal fixation stem as a salvage procedure for failed internal fixation of intertrochanteric fracture in our institute. Materials and Methods The institutional review board approval was obtained prior to the study. Between January 2006 and August 2012, 31 patients (12 males and 19 females) were treated at our university hospital with salvage THA following failed fixation of intertrochanteric or subtrochanteric hip fracture. The mean age at the time of salvage surgery was 72.4 years (range, 58.5–84.8 years). The mean interval from initial fracture fixation to conversion arthroplasty was 8.2 months (range, 5– 16 months). Seventeen patients had failed treatment with a dynamic hip screw for intertrochanteric or subtrochanteric fractures, 8 patients
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Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
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Table 1 Demographic Data of Patients. Age (year) Gender Male Female BMI (kg/m2) Interval between internal fixation and salvage THA (month) Average follow-up (month) Fixation used Intramedullary (γ) nail Dynamic hip screw Anatomic plate Indication(failure of fixation) nonunion with severe hip pain and varus deformity nonunion with secondary acetabular erosion by a penetrated lag screw nonunion with breakage of the side plate and screws AO classification A1.1/A1.2/A1.3 A2.1/A2.2/A2.3 A3.1/A3.2/A3.3
72.4 (range, 58.5–84.8) 12 19 26.7(range, 20.4–34.5) 8.2 (range, 5–16) 47.5 (range, 13–83) 8 17 6 16 8 7 1/0/1 2/9/10 2/3/3
AO indicates Arbeitsgemeinschaft für Osteosynthesefragen.
had failed treatment with γ nailing, and 6 patients had failed treatment with anatomic plate. All fractures were evaluated using the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification for intertro-chanteric fractures [26]. The fracture fixation failure modes in the study sample were as follows: nonunion with severe hip pain and varus deformity in 16 patients, nonunion with secondary acetabular erosion by a penetrated lag screw in 8 patients, nonunion with breakage of the side plate and screws in 7 patients. All patients underwent detailed preoperative clinical examination and evaluation for medical comorbidities, including complete blood count with white cell count, Creactive protein (CRP), and erythrocyte sedimentation rate (ESR) to rule out occult infection as a cause of failure. All the patients had femoral reconstruction using a non-modular Solution stem (DePuy, Indiana, USA). Patient demographic data are summarized in Table 1. Operative Technique Radiographs with 100% amplification were taken for all patients in order to facilitate meticulous preoperative templating and planning, including the determination of necessary length and diameter of the implant, optimal site of cortical fixation, and assessment of limb length. All patients were operated on in the lateral decubitus position by the same team of surgeons using the posterolateral approach. Once the joint was opened, synovial fluid was harvested immediately for bacterial culture into a blood culture bottle as a routine procedure. Frozen sections were prepared only if active infection was suspected during surgery, which did not add to operative time because we firstly performed thorough debridement, then the wounds were immersed in hydrogen peroxide and undiluted povidone-iodine for 15 min and rinsed using pulsed irrigation for all patients. The femoral head was dislocated out before hardware removal in order to prevent further fracture. Care was taken to maintain the muscular and perisosteal attachments to the bone, thereby preserving vascularity and preventing disruption of small fragments. Fragments of the greater trochanter were fixed by cerclage wire. Thereafter, the hardware and femoral head were removed, then the femoral canal was prepared by graduated reaming using rasps until an optimal endosteal contact in the distal diaphyseal part of the femur was achieved. Finally, the femoral component was inserted into the canal until rigid fixation was accomplished. Reconstruction of the trochanteric bony fragments along with soft tissue attachment was reinforced with an elastic system of cerclage wires passed transosseously into the metaphyseal region so as to also distalize
the greater trochanter; this careful reconstruction provided good tension for the abductor musculature (Fig. 1). The wound was irrigated and short external rotators were reinserted transosseously. All patients received the same postoperative anticoagulation therapy with low molecular weight heparin (LMWH). The breathing exercises and static exercises for calves, quadriceps and gluteal muscles were executed after anesthesia recovery. Patients were encouraged to start walking with a walker on the second day, with full weight bearing as tolerated, and to avoid excessive flexion and adduction. Postoperative Follow-Up All patients were followed up clinically and radiographically after the arthroplasty at regular intervals of 1, 2, 3, 6, 12 months, and annually thereafter. The clinical status was evaluated by a single joint surgeon (Shi) using the Harris Hip score (HHS) combined with examination of the Trendelendurg sign [27]. Visual Analogue Scale (VAS) was used to evaluate hip pain. Limb-length discrepancy was measured by tape with an accurate measurement of 1 mm at 1 year post-operation. All the patients were placed in the supine position at the point where the hip and knee achieved maximal extension. The line connecting the anterior superior iliac spine and most prominent point of the medial ankle represented the limb length, with a difference of equal to or more than 5 mm between the two limbs being considered limblength discrepancy. Radiographs were reviewed for evidence of osteointegration, subsidence and heterotopic ossification by a senior consultant with no direct knowledge of the specific cases. Serial follow-up radiographs were compared, and scores of stability and fixation were tabulated based on the system described by Engh et al [28]. The results were analyzed using paired t test using SPSS software (Predictive Analytics Company, Chicago). Results Four patients had been confirmed to have chronic bacterial infection before salvage THA and were successfully treated by hardware removal and insertion of antibiotic spacers as stage I then THA as stage II operations. The mean follow-up after salvage THA was 47.5 months (range, 13–83). At the most recent follow-up, 3 of 31 patients had died of unrelated diseases with the implant intact. There was no infection, postoperative fracture, loosening, or revision for any reason in any hip after salvage THA. The average duration of the surgery was 136 min (range, 100–210), and the average blood loss was 850 mL (range, 400–1650). Detailed data on the patients are summarized in Table 2.
Fig. 1. Intraoperative photograph showing reconstruction of abductor mechanism. Black arrow means reconstruction of the trochanteric bony fragments along with soft tissue attachment using cerclage wiring; white arrow means reconstruction insertion of gluteus medius, the most import factor of hip stability.
Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
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Complications
Table 2 Results. Bearing Ceramic–Ceramic Ceramic–Polyethylene Metal–Polyethylene Harris hip score Before salvage THA After salvage THA Osteointegration Bony ingrowth Stable fibrous ingrowth Fracture union Union Non-union Complications Intraoperative fracture Dislocation Delirium Pneumonia congestive heart failure
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8 13 10 28.4 (range, 18–42) 85.6 (range, 75–92) 31 0 31 0 2 2 1 1 1
Functional Outcomes All patients reported remarkable pain relief and return to ambulation after the salvage THA. 25 patients had no pain (VAS = 0), and 6 patients complained of some residual trochanteric low-grade pain with no compromise of activities (VAS = 1–3). Nineteen patients could ambulate without any support, 10 patients used a cane, and 2 patients used a walker for ambulation. The mean HHS score increased from 28.4 points preoperatively to 85.6 points at the last follow-up; the mean improvement value was 57.2 (P b 0.05). Twelve patients had limb-length discrepancy with a mean value of 7 mm (range, 5–15). Trendelenburg sign was positive in all patients up to 3 months postoperatively, and progressively diminished until becoming negative in all patients. Radiographic Results Radiographic evaluation was performed to assess osteointegration of the femoral stem. According to the criteria in Engh et al [28], all stems had stable bony ingrowth, one stem had subsidence of 3 mm at postoperative 1 month and there was no progressive subsidence. All patients demonstrated successful bony union of the fracture and five had Brooker I or II heterotopic ossification with no influence on function (Fig. 2).
Seven patients had an intraoperative complication or an early medical complication related to the operation. Two patients had an intraoperative nondisplaced femoral fracture and were treated successfully with cerclage wire. Two patients had dislocations at the second and fourteenth day postoperatively and were treated successfully with closed reduction and bracing. One patient had delirium, one had pneumonia, and one had congestive heart failure. There were no cases of nerve palsy or perioperative deaths. Discussion Salvage THA after failed internal fixation of intertrochanteric fracture faces several tricky problems, including removal of previous internal fixation devices, prevention of intraoperative re-fracture and rigid fixation of the new femoral component. Preparation of special instruments for the removal of internal fixation devices is important to simplify this process. Dislocating the head with the metalwork in situ is beneficial to prevent re-fracture. Structural defects and modification of bony landmarks due to deformation and displacement of fragments, combined with poor bone quality and presence of screw holes not only enhance the risk of intraoperative fractures, but also lead to difficult fixation of new femoral components [5,7,11,29,30]. Several authors have reported the use of cemented arthroplasty, and good to excellent results have been reported in 66% to 100% of cases [5,7,15,19,31]. However, extravasation of cement through screw holes and fracture lines is inevitable, which may lead to suboptimal pressurization of cement and poor remodeling of the cortical bone, higher risk of trochanteric nonunion or postoperative periprosthetic fracture [32]. In the largest series to date, Haidukewych et al [5] reported salvage hip arthroplasty with cemented components. Only 57% of the patients had osseous union of the greater trochanter, 16% patients suffered from trochanteric nonunion with N 1 cm of proximal migration, 16% patients had moderate or severe pain in the region of the greater trochanter and 8% patients were re-operated on. Due to the limitations of cemented fixation, cementless prosthesis seems more attractive, especially modular versatile systems. Recently, several studies have reported salvage THA with modular cementless prosthesis for failed intertrochanteric fractures [6,18–22]. Abouelela et al [21] reported 16 patients treated with Revitan stem (Zimmer, Winterthur, Switzerland). At a mean follow-up period of 60 months, all patients demonstrated clinically significant pain relief and return to
Fig. 2. Anteroposterior radiograph of a 65-year-old female showing type A2.3 intertrochanteric fracture treated with internal fixation (A and B). Nonunion result in fracture of the internal device (C), Anteroposterior radiograph 1 year after salvage THA using nonmodular cementless stem showing excellent osteointegration, full fracture union and Booker II heterotopic ossification (D).
Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
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ambulation, and 8 patients had slight awareness of lateral trochanteric pain. Radiographic evaluation demonstrated stable stem and bony ingrowth in all patients, and one nonunion of the greater trochanter. Thakur et al [22] treated 15 patients with distally fixed MP stem (Link MP, Hamburg, Germany). After a follow-up period of 2.8 years, all patients except two demonstrated significant pain relief, fourteen stems had stable bone ingrowth, one stem subsided by 5 mm, and 1 patient demonstrated nonunion of greater trochanter. Talmo et al [19] reported the results of 10 cementless S-ROM prostheses (DePuy, Warsaw, Ind) in the salvage THA. All patients reported good pain relief after a follow-up period of 30 months. Nine stems had stable bone ingrowth and one stem had subsidence of 10 mm and significant radiolucency. Laffosse et al [18] treated 29 patients using the Puget prosthesis (Système, Montbonnot, France). Patients (52%) ambulated independently without support or a cane, 48% patients required two canes/walker or were bedridden, 13% cases had stem subsidence greater than 5 mm, and 8.7% patients had nonunion of the greater trochanter. However, without adequate proximal osseous support because of nonunion of intertrochanteric fracture, the fracture of modular cementless femoral stems at the mid-stem junction is an intractable problem [23–25]. In recently published literature, Lakstein et al [25] reported that inadequate proximal osseous support in revision hip arthroplasty using modular implants is a risk factor for femoral stem fracture at the mid-junction. Prevention of this catastrophic outcome may be achieved by choosing suitable femoral stem and getting long-term proximal fixation such as medial strut grafts. In this study, we used non-modular cementless Solution stem with variable lengths and diameters for bypassing screw holes and bone defects to manage these complex cases. The implants have 7/8 titanum porous-coating with rigid rough surfaces, which are beneficial not only for initial fixation within the diaphysis but also for bone ingrowth enabling biological fixation with both the metaphysis and diaphysis (Fig. 3). Previous studies with this system have yielded satisfactory results in revision THA [33,34]. Chung et al [33] reported 96 femoral revisions with Solution stem for Paprosky femoral type III defects, at a mean follow-up period of 67.5 months, and no significant subsidence or mechanical failure of the femoral implants was detected. In addition, no further revision was required during the same follow-up period. The
Fig. 3. Photograph of non-modular cementless stem (Solution, Depuy, Indiana, USA), which has 7/8 titanum porous-coating with rigid rough surface.
radiologic findings of this study demonstrated healed trochanteric fractures in all patients and adequate bone ingrowth around the stem in 100% of femora. Therefore, osseointegration into a well-designed and successfully implanted cementless femoral stem can be achieved with good results despite the decreased osteogenic potential in these patients [35,36]. Dislocation and lateral trochanteric pain after salvage THA in these patients were the other intractable problems because of the ruin of hip stability. Mokka et al [37] reported that the overall dislocation rate was 16% after salvage hip arthroplasty following failed nailing of proximal femoral fracture. Mehlhoff et al [11] reported that 3 patients had dislocation and 2 patients had to undergo reoperation because of instability in 13 patients who had an arthroplasty after failed internal fixation of intertrochanteric fracture. Some authors suggest avoiding trochanteric fixation devices due to the concern about cause of pain and reoperation [19]. However, this procedure may compromise the abductor mechanism and lead to high incidence of dislocation or instability. In the current study, dislocation rate and lateral trochanteric pain were much lower than in the published literature [5,7,11,37]. This may be attributed to appropriate relative orientation of the components and avoidance of abductor dysfunction through restoration of adequate soft tissue tension by repairing the short external rotators and reconstructing the abductor mechanism using cerclage wiring and/or heavy sutures These were the two most important factors to prevent dislocation, although other factors such as head size maybe associated with dislocation [30,38,39]. According to the present study, transosseous cerclage wire and/or heavy sutures have proved to be effective approaches to reconstruction of abductor mechanism without increasing the rate of trochanteric pain and reoperation. This finding was confirmed by Laffosse et al, who also reported low incidence rates of trochanteric pain and dislocation after reconstruction of abductor mechanism with the similar transosseous cerclage wire [18]. Nonunion of trochanteric fracture is not common, because this area is cancellous bone and has a rich vascular supply. Once it occurred, infection is an important factor that should be considered other than mechanical failure. Reoperation is an important risk factor for infection [40,41]. Haidukewych et al [9,14] reported that the rate of infection in patients with failed internal fixation of trochanteric fracture was 7.5%. In this study, 4 of 31 patients (12.9%) were confirmed to have active infection and were successfully treated with two-staged operations, which demonstrated that infection was a major cause of internal fixation failure after trochanteric fracture. The diagnosis of infection should be based on incorporation of clinical symptoms/signs, laboratory/ imaging examination and surgical finding. Sometimes, it is difficult to discern whether a clinic symptom such as pain is being caused by infection, fracture nonunion or both, but rest pain is a positive indication for infection which is present in all the four infected patients. Preoperative inflammatory cytokine detection such as CRP and ESR is an effective pathway to auxiliary diagnosis, for example, 3 of 4 infected patients in this study have persistent elevation of CRP preoperatively. Surgical finding and frozen section are also important reference indexes to exclude infection [42]. Synovial fluid culture is very important because it can direct the usage of sensitive antibiotics if a positive culture is acquired. In the present study, no patients had periprosthetic infection after salvage THA. This may be attributed to the fact that we considered all these patients as having potential infection and performed synovial fluid culture, thorough debridement and disinfectant immersion. All patients in this study had THA rather than hemiarthroplasty, because acetabular erosion is the major risk associated with hemiarthroplasty. Compromised articular cartilage in the hips of normal elderly patients puts them at a greater risk and may lead to limited activity resulting in higher revision surgery [43]. Moreover, THA demonstrates superior longevity when compared to hemiarthroplasty [44,45]. On the other hand, we agree with Sidhu et al [46] that prefracture activity of the patient should be taken into consideration when making a decision for surgery. All patients in this study were community ambulators before injury and were not dependent for self-care.
Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
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Such patients are expected to regain an active life after total hip arthroplasty. This may be the reason for the low complication rates and mortality in this study. The strength of this study is the use of uniform non-modular cementless stems. Furthermore, all procedures were performed by the same senior arthroplasty surgeon with the same surgical approach. The weakness of this study includes the diversity of AO classification for fracture and diversity of internal fixation methods in the primary operation. Besides, the study is a retrospective study with limited sample size and lack of control group such as revision internal fixation. Further studies may be needed to better understand how to manage these tough cases. In conclusion, our results indicate that stable fixation of the implant can be achieved with good functional outcome in a reproducible fashion. We believe that THA using non-modular porous-coated cementless long-stem distal fixation revision represents an effective salvage procedure after failed intertrochanteric fixation. Acknowledgements This work was supported by Health Industry Special Scientific Research Projects of China—The safety and effectiveness evaluation of arthroplasty (No. 201302007), National Natural Science Foundation of China (No. 81401788) and Science and Technology Fund of Sichuan Province (No. 2015JY0150). References 1. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am 1979;61:216. 2. Baumgartner MR, Solberg BD. Awareness of tip–apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg (Br) 1997;79:969. 3. 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;113:222. 4. Geiger F, Zimmermann-Stenzel M, Heisel C, et al. Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality. Arch Orthop Trauma Surg 2007;127:959. 5. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 2003;5:899. 6. Weiss RJ, Karrholm J, Hailer NP, et al. Salvage of failed trochanteric and subtrochanteric fractures using a distally fixed, modular, uncemented hip revision stem: 30 patients followed for a mean of 4 years. Acta Orthop 2012;83(5):488. 7. Zhang B, Shiu KY, Wang M. Hip arthroplasty in failed internal fixation of intertrochanteric fractures. J Arthroplasty 2004;19:329. 8. Mariani EM, Rand JA. Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation: results of second attempts to gain union. Clin Orthop Relat Res 1987;218:81. 9. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 2003;85:899. 10. Kim YH, Oh JH, Koh YG. Salvage of neglected unstable intertrochanteric fracture with cementless porous-coated hemiarthroplasty. Clin Orthop Relat Res 1992;277:182. 11. Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures. Clin Orthop Relat Res 1991;269:32. 12. Sarathy MP, Madharan P, Ravichandran KM. Nonunion of intertrochanteric fractures of the femur treated by modified medial displacement and valgus osteotomy. J Bone Joint Surg (Br) 1995;77:90. 13. Wu CC, Shih CH, Chen WJ, et al. Treatment of cutout of a lag screw of a dynamic hip screw in an intertrochanteric fracture. Arch Orthop Trauma Surg 1998;117:193. 14. Haidukewych GJ, Berry DJ. Salvage of failed internal fixation of intertrochanteric hip fractures. Clin Orthop Relat Res 2003;412:184. 15. Said GZ, Farouk O, El-sayed A, et al. Salvage of failed dynamic hip screw fixation of intertrochanteric fractures. Injury 2006;37:194. 16. Angelini M, Mckee MD, Waddell JP, et al. Salvage of failed hip fracture fixation. J Orthop Trauma 2009;23(6):471.
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Please cite this article as: Shi X, et al, Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.041
