FRACTURES ABOUT THE HIP
When femoral fracture fixation fails SALVAGE OPTIONS
J. Petrie, A. Sassoon, G. J. Haidukewych From Orlando Regional Medical Center, Orlando, Florida, United States
Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies. Cite this article: Bone Joint J 2013;95-B, Supple A:7–10.
The number of hip fractures continues to increase, and although the vast majority will heal, failures occasionally occur and require revision.1,2 This review will address both the avoidance of failure and the options for treatment when failure occurs, including revision, open reduction and internal fixation (ORIF), osteotomy, and joint replacement. The selection of a particular salvage procedure in these circumstances depends primarily on patient activity and fracture location. Any discussion of salvage options depends on the age of patients, and whether the fracture occurs in the femoral neck or intertrochanteric region. J. Petrie, MD, President A. Sassoon, MD, Trauma Fellow G. J. Haidukewych, MD, Consultant Orlando Regional Medical Center, Orlando health Orthopedic Institute, 1222 S Orange Ave, Orlando Florida 32806, USA. Correspondence should be sent to Dr G. J. Haidukewych; e-mail: [email protected] ©2013 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.95B11. 32896 $2.00 Bone Joint J 2013;93-B, Supple A:7–10. Received 5 September 2013; Accepted after revision 6 September 2013
Failure prevention Outcomes of treating fractures of the femoral neck are related to fracture displacement, patient age, and quality of reduction.1,3,4 For the older patient with a displaced fracture of the femoral neck, choosing the most appropriate initial operation can minimise the need for revision surgery. It is believed a high proportion of displaced fractures of the femoral neck in older individuals treated with ORIF will fail.5,6 These fractures are better addressed by some form of hip replacement, which have lower rates of re-operation when compared with ORIF.5,6 Ten-year data on cemented hemiarthroplasty describes a rate of survivorship of 94% free of re-operation for any reason, whereas the rate of failure would have been nearly ten times higher if internal fixation
VOL. 95-B, No. 11, NOVEMBER 2013
was performed in this cohort.7 Recent data suggests a lower re-operation rate and fewer implant-related complications for cemented versus uncemented hemiarthroplasty, with similar rates of mortality at up to 19 years’ follow-up.8-10 When deciding between total hip replacement (THR) and hemiarthroplasty, the condition of the acetabular articular cartilage and patient age are the main factors considered by the senior author (GJH). In patients aged > 80 years with normal appearance of their acetabular articular cartilage, a cemented hemiarthroplasty is preferred. In most other instances the senior author uses a THR. In an active, elderly population, despite a higher dislocation rate, THR patients score significantly higher on patient outcomes when compared with patients with a hemiarthroplasty.11,12 A national database study has shown that, over time, the in-hospital dislocation rates after THR relating to a fracture of the femoral neck have approached those following elective THR.13 Other factors to consider include the functional and cognitive abilities of the patient and the presence of antecedent hip pain prior to fracture. Younger patients with displaced fractures of the femoral neck present several challenges. If the fracture is reduced anatomically and stable fixation is obtained, the outcomes are predominantly good.14 In a recent study evaluating the survivorship of the hip in young patients with 7
8
J. PETRIE, A. SASSOON, G. J. HAIDUKEWYCH
Fig. 1a
Fig. 1b
Fig. 1c
Radiographs of a 66-year-old woman who was struck by an car while riding a scooter a) at presentation, showing an unstable intertrochanteric fracture of the right hip with subtrochanteric extension of the fracture and involvement of the lesser trochanter, b) intra-operatively, showing the fracture anatomically reduced with the aid of a bone clamp, and c) immediately following surgery, showing implantation of a long cephalomedullary nail that was locked distally.
fractures of the femoral neck, avascular necrosis (AVN) and nonunion rates were low for well-reduced fractures.14 The selection of the type of fixation is important in younger patients, because many if not most of the fracture patterns have a relatively vertical configuration. The Pauwels’ classification14 can help guide treatment and implant selection. The higher the shear angle, the more likely the fixation will fail if the load is not shared with the bone and the device is not in some way cantilevered to share loads.15 With a vertical fracture line, the calcar does not offer enough support to prevent the femoral head from shearing and displacing into varus. The authors prefer a sliding hip screw in the management of these fractures, as the barrel and side plate help to neutralise shear across the femoral neck. Additionally, a supplementary anti-rotational screw is often used to help prevent torque and hence rotational malalignment during lag screw insertion. Intertrochanteric fracture fixation has a potential for failure as well, and as with femoral neck fractures, reduction and implant selection are important. If a fracture is returned to an anatomical position and supported with appropriate hardware, it is very unlikely that the fixation will fail. Sliding hip screw devices are still used, however, there has been a huge increase in the popularity of cephalomedullary nails. Intramedullary fixation performs better than plate-based devices in situations where the lateral femoral wall is fractured, or in fractures with reverse obliquity, subtrochanteric extension, or large posteromedial fragments (Fig. 1).4,16 Understanding these radiological features of unstable fractures is essential in implant selection. Fixation into the femoral head, whether associated with a side plate or a nail, should be centred in both planes. The ‘tip to apex’ distance has been described as a method to quantify a deep and central position of the lag screw in the femoral head, and should be used as a guideline in these instances.3
Salvage of fixation failure Following failure of fixation in young patients with fractures of the femoral neck, efforts should be focused on saving the native femoral head. Valgus intertrochanteric osteotomies are useful in retrieving failures associated with vertical femoral neck fractures (Fig. 2). This technique converts a high shear-angle fracture into a more horizontal configuration, which encourages compression forces across the ununited fracture site, facilitating healing with impressive rates of union reported.17 Pedicle grafts of various types are generally used in developing countries where it is thought delayed presentations of fractures of the femoral neck in young patients are common. Failed fixation of fractures of the femoral neck in older patients is best treated with either THR or hemiarthroplasty, both of which have been shown to be effective.18,19 A key technical point for either procedure is to be aware of severe osteopenia. Some patients present following an extended period of time during which they were not walking. In these circumstances an uncemented acetabular component should be supported with supplementary screw fixation. On the femoral side the authors prefer collared, extensively coated uncemented stems, because they can be effective even in cases with compromised, osteopenic proximal bone stock. Occasionally, a cemented femoral stem is chosen. A high-speed burr can be useful in removing sclerotic tracks from prior screws that can otherwise deflect a broach and cause fractures in weak bone. Failure of fixation of intertrochanteric fractures in young patients is exceedingly rare. Revision through ORIF preserves the native femoral head. Plates with 95° blades are very useful because they target bone in the inferior portion of the femoral head, which typically has not been violated by prior fixation devices. It is important to avoid a varus malreduction and obtain stable fixation of the proximal fragment. CCJR SUPPLEMENT TO THE BONE & JOINT JOURNAL
WHEN FEMORAL FRACTURE FIXATION FAILS
Fig. 2a
9
Fig. 2b
Radiographs of a 32-year-old female with a Pauwel type 3 fracture of the femoral neck, a) showing initial fixation with percutaneous screws, with a resulting nonunion secondary to the increased shear forces created by the vertical fracture line, and b) after revision fixation with a valgus osteotomy, which converted these shear forces into compressive forces and facilitated a successful fracture union.
Fig. 3a
Fig. 3b
Radiographs of a 50-year-old female with a basi-cervical fracture of the femoral neck at a) ten months after open reduction and internal fixation with a sliding hip screw, showing failure of fixation, with shortening and varus alignment, and b) after removal of hardware and a total hip replacement implanted, bypassing the most distal screw hole by two cortical diameters.
Failure of fixation of intertrochanteric fractures in older patients is usually salvaged with some form of hip replacement. Lag screw cut-out has usually occurred and little proximal bone remains. Hemiarthroplasty and THR can both be effective, depending on the status of the acetabular articular surface. Hip replacement after intertrochanteric fixation failure presents several unique challenges. Typically, the calcar bone deficiency will be lower than the standard resection level for a primary THR, therefore, having ‘calcar replacing’ or modular stems may be necessary. Additionally, one must bypass the most distal shaft stress riser by two diaphyseal diameters (about 6 cm), which VOL. 95-B, No. 11, NOVEMBER 2013
necessitates longer femoral components (Fig. 3).18 The status of the greater trochanter is important; it can be malunited and occluding the intramedullary canal, or completely ununited. In cases where malunion prevents adequate preparation of the femur, a trochanteric slide technique, which maintains the continuity of the abductors and the vastus lateralis, can be useful. This facilitates removal of the overhanging trochanter as an obstacle during femoral preparation, which with its subsequent reattachment at the end of the case without compromising soft-tissue attachments, is important in maintaining hip stability. It is wise to dislocate the hip before removing any
10
J. PETRIE, A. SASSOON, G. J. HAIDUKEWYCH
hardware to minimise the risk of iatrogenic fracture of the femoral shaft. It can be difficult to determine the correct level of the femoral reconstruction, but restoring the relationship of the tip of the greater trochanter and the centre of femoral head rotation can provide a reasonable reference point. Careful intra-operative trialing and intra-operative radiographs are recommended. The authors generally favour uncemented fixation, either with extensively coated monobloc stems or with fluted, modular tapered titanium stems. The use of modular titanium, diaphyseal-engaging stems has facilitated management of several difficulties. By employing the diaphysis for fixation, the previously violated metaphysis is bypassed. Additionally, proximal malunions can be osteotomised without compromising fixation, even in capacious osteopenic canals. Finally, modularity allows fine-tuning of length and version, which can be difficult to assess initially during complex revisions. Published outcomes have demonstrated good survivorship with these techniques.20,21
Conclusion In summary, minimise failures and re-operations when treating patients with hip fractures by choosing the most appropriate operation for the right patient. If the fracture is anatomically reduced and the fixation device is implanted accurately, the rate of fixation failures will be low. For older patients with displaced fractures of the femoral neck, a hip replacement of some sort is a better choice than internal fixation. When fixation failure occurs one must have effective, proven strategies for salvage. Young patients presenting with femoral neck failures usually have vertical nonunions, and repeat ORIF is probably a good tactic. Typically a valgus osteotomy is chosen to convert shearing forces into compression and promote fracture healing. For older patients with femoral neck failures, THR is preferred. These patients often suffer from disuse osteopenia, which is an important consideration when selecting components. For young patients with intertrochanteric failures, repeat ORIF is preferred. One might suggest supporting the inferior femoral head bone with a fixed angle device, such as a blade-plate. Finally, in older patients with intertrochanteric failures, hip replacement remains the best option. Femoral reconstruction in this setting presents many challenges, including stress risers, bone loss, and greater trochanteric malunion. Careful attention to indications, techniques, and avoiding common pitfalls is important for a logical, effective salvage strategy. The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. This paper is based on a study which was presented at the 29th Annual Winter 2012 Current Concepts in Joint Replacement® meeting held in Orlando, Florida, 12th – 15th December.
References 1. Kyle RF, Cabanela ME, Russell TA, et al. Fractures of the proximal part of the femur. Instr Course Lect 1995;44:227–253. 2. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg [Am] 1979;61-A:216–221. 3. Baumgaertner 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-B:969– 971. 4. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg [Am] 2001;83-A:643–650. 5. Chammout GK, Mukka SS, Carlsson T, et al. Total hip replacement versus open reduction and internal fixation of displaced femoral neck fractures: a randomized long-term follow-up study. J Bone Joint Surg [Am] 2012;94-A:1921–1928. 6. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty: treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg [Am] 2006;88-A:249–260. 7. Haidukewych GJ, Israel TA, Berry DJ. Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res 2002;403:118–126. 8. Taylor F, Wright M, Zhu M. Hemiarthroplasty of the hip with and without cement: a randomized clinical trial. J Bone Joint Surg [Am] 2012;94-A:577–583. 9. Viberg B, Overgaard S, Lauritsen J, Ovesen O. Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture: 12- to 19-year follow-up of patients aged 75 years or more. Acta Orthop 2013;84:254–259. 10. Gjertsen JE, Lie SA, Vinje T, et al. More re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck: an observational study of 11,116 hemiarthroplasties from a national register. J Bone Joint Surg [Br] 2012;94-B:1113–1119. 11. Macaulay W, Nellans KW, Garvin KL, et al. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. J Arthroplasty 2008;23(Suppl):2–8. 12. Avery PP, Baker RP, Walton MJ, et al. Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial. J Bone Joint Surg [Br] 2011;93-B:1045–1048. 13. Sassoon A, D’Apuzzo M, Sems S, Cass J, Mabry T. Total hip arthroplasty for femoral neck fracture: comparing in-hospital mortality, complications, and disposition to an elective patient population. J Arthroplasty 2013;Epub. 14. Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg [Am] 2004;86-A:1711–1716. 15. Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg [Am] 2008;90A:1654–1659. 16. Sadowski C, Lubbeke A, Saudan M, et al. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg [Am] 2002;84A:372–381. 17. Anglen JO. Intertrochanteric osteotomy for failed internal fixation of femoral neck fracture. Clin Orthop Relat Res 1997;341:175–182. 18. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg [Am] 2003;85-A:899–904. 19. Mabry TM, Prpa B, Haidukewych GJ, Harmsen WS, Berry DJ. Long-term results of total hip arthroplasty for femoral neck fracture nonunion. J Bone Joint Surg [Am] 2004;86-A:2263–2267. 20. Palumbo BT, Morrison KL, Baumgarten AS, et al. Results of revision total hip arthroplasty with modular, titanium-tapered femoral stems in severe proximal metaphyseal and diaphyseal bone loss. J Arthroplasty 2013;28:690–694. 21. Restrepo C, Mashadi M, Parvizi J, Austin MS, Hozack WJ. Modular femoral stems for revision total hip arthroplasty. Clin Orthop Relat Res 2011;469:476–482.
CCJR SUPPLEMENT TO THE BONE & JOINT JOURNAL
When femoral fracture fixation fails SALVAGE OPTIONS
J. Petrie, A. Sassoon, G. J. Haidukewych From Orlando Regional Medical Center, Orlando, Florida, United States
Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies. Cite this article: Bone Joint J 2013;95-B, Supple A:7–10.
The number of hip fractures continues to increase, and although the vast majority will heal, failures occasionally occur and require revision.1,2 This review will address both the avoidance of failure and the options for treatment when failure occurs, including revision, open reduction and internal fixation (ORIF), osteotomy, and joint replacement. The selection of a particular salvage procedure in these circumstances depends primarily on patient activity and fracture location. Any discussion of salvage options depends on the age of patients, and whether the fracture occurs in the femoral neck or intertrochanteric region. J. Petrie, MD, President A. Sassoon, MD, Trauma Fellow G. J. Haidukewych, MD, Consultant Orlando Regional Medical Center, Orlando health Orthopedic Institute, 1222 S Orange Ave, Orlando Florida 32806, USA. Correspondence should be sent to Dr G. J. Haidukewych; e-mail: [email protected] ©2013 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.95B11. 32896 $2.00 Bone Joint J 2013;93-B, Supple A:7–10. Received 5 September 2013; Accepted after revision 6 September 2013
Failure prevention Outcomes of treating fractures of the femoral neck are related to fracture displacement, patient age, and quality of reduction.1,3,4 For the older patient with a displaced fracture of the femoral neck, choosing the most appropriate initial operation can minimise the need for revision surgery. It is believed a high proportion of displaced fractures of the femoral neck in older individuals treated with ORIF will fail.5,6 These fractures are better addressed by some form of hip replacement, which have lower rates of re-operation when compared with ORIF.5,6 Ten-year data on cemented hemiarthroplasty describes a rate of survivorship of 94% free of re-operation for any reason, whereas the rate of failure would have been nearly ten times higher if internal fixation
VOL. 95-B, No. 11, NOVEMBER 2013
was performed in this cohort.7 Recent data suggests a lower re-operation rate and fewer implant-related complications for cemented versus uncemented hemiarthroplasty, with similar rates of mortality at up to 19 years’ follow-up.8-10 When deciding between total hip replacement (THR) and hemiarthroplasty, the condition of the acetabular articular cartilage and patient age are the main factors considered by the senior author (GJH). In patients aged > 80 years with normal appearance of their acetabular articular cartilage, a cemented hemiarthroplasty is preferred. In most other instances the senior author uses a THR. In an active, elderly population, despite a higher dislocation rate, THR patients score significantly higher on patient outcomes when compared with patients with a hemiarthroplasty.11,12 A national database study has shown that, over time, the in-hospital dislocation rates after THR relating to a fracture of the femoral neck have approached those following elective THR.13 Other factors to consider include the functional and cognitive abilities of the patient and the presence of antecedent hip pain prior to fracture. Younger patients with displaced fractures of the femoral neck present several challenges. If the fracture is reduced anatomically and stable fixation is obtained, the outcomes are predominantly good.14 In a recent study evaluating the survivorship of the hip in young patients with 7
8
J. PETRIE, A. SASSOON, G. J. HAIDUKEWYCH
Fig. 1a
Fig. 1b
Fig. 1c
Radiographs of a 66-year-old woman who was struck by an car while riding a scooter a) at presentation, showing an unstable intertrochanteric fracture of the right hip with subtrochanteric extension of the fracture and involvement of the lesser trochanter, b) intra-operatively, showing the fracture anatomically reduced with the aid of a bone clamp, and c) immediately following surgery, showing implantation of a long cephalomedullary nail that was locked distally.
fractures of the femoral neck, avascular necrosis (AVN) and nonunion rates were low for well-reduced fractures.14 The selection of the type of fixation is important in younger patients, because many if not most of the fracture patterns have a relatively vertical configuration. The Pauwels’ classification14 can help guide treatment and implant selection. The higher the shear angle, the more likely the fixation will fail if the load is not shared with the bone and the device is not in some way cantilevered to share loads.15 With a vertical fracture line, the calcar does not offer enough support to prevent the femoral head from shearing and displacing into varus. The authors prefer a sliding hip screw in the management of these fractures, as the barrel and side plate help to neutralise shear across the femoral neck. Additionally, a supplementary anti-rotational screw is often used to help prevent torque and hence rotational malalignment during lag screw insertion. Intertrochanteric fracture fixation has a potential for failure as well, and as with femoral neck fractures, reduction and implant selection are important. If a fracture is returned to an anatomical position and supported with appropriate hardware, it is very unlikely that the fixation will fail. Sliding hip screw devices are still used, however, there has been a huge increase in the popularity of cephalomedullary nails. Intramedullary fixation performs better than plate-based devices in situations where the lateral femoral wall is fractured, or in fractures with reverse obliquity, subtrochanteric extension, or large posteromedial fragments (Fig. 1).4,16 Understanding these radiological features of unstable fractures is essential in implant selection. Fixation into the femoral head, whether associated with a side plate or a nail, should be centred in both planes. The ‘tip to apex’ distance has been described as a method to quantify a deep and central position of the lag screw in the femoral head, and should be used as a guideline in these instances.3
Salvage of fixation failure Following failure of fixation in young patients with fractures of the femoral neck, efforts should be focused on saving the native femoral head. Valgus intertrochanteric osteotomies are useful in retrieving failures associated with vertical femoral neck fractures (Fig. 2). This technique converts a high shear-angle fracture into a more horizontal configuration, which encourages compression forces across the ununited fracture site, facilitating healing with impressive rates of union reported.17 Pedicle grafts of various types are generally used in developing countries where it is thought delayed presentations of fractures of the femoral neck in young patients are common. Failed fixation of fractures of the femoral neck in older patients is best treated with either THR or hemiarthroplasty, both of which have been shown to be effective.18,19 A key technical point for either procedure is to be aware of severe osteopenia. Some patients present following an extended period of time during which they were not walking. In these circumstances an uncemented acetabular component should be supported with supplementary screw fixation. On the femoral side the authors prefer collared, extensively coated uncemented stems, because they can be effective even in cases with compromised, osteopenic proximal bone stock. Occasionally, a cemented femoral stem is chosen. A high-speed burr can be useful in removing sclerotic tracks from prior screws that can otherwise deflect a broach and cause fractures in weak bone. Failure of fixation of intertrochanteric fractures in young patients is exceedingly rare. Revision through ORIF preserves the native femoral head. Plates with 95° blades are very useful because they target bone in the inferior portion of the femoral head, which typically has not been violated by prior fixation devices. It is important to avoid a varus malreduction and obtain stable fixation of the proximal fragment. CCJR SUPPLEMENT TO THE BONE & JOINT JOURNAL
WHEN FEMORAL FRACTURE FIXATION FAILS
Fig. 2a
9
Fig. 2b
Radiographs of a 32-year-old female with a Pauwel type 3 fracture of the femoral neck, a) showing initial fixation with percutaneous screws, with a resulting nonunion secondary to the increased shear forces created by the vertical fracture line, and b) after revision fixation with a valgus osteotomy, which converted these shear forces into compressive forces and facilitated a successful fracture union.
Fig. 3a
Fig. 3b
Radiographs of a 50-year-old female with a basi-cervical fracture of the femoral neck at a) ten months after open reduction and internal fixation with a sliding hip screw, showing failure of fixation, with shortening and varus alignment, and b) after removal of hardware and a total hip replacement implanted, bypassing the most distal screw hole by two cortical diameters.
Failure of fixation of intertrochanteric fractures in older patients is usually salvaged with some form of hip replacement. Lag screw cut-out has usually occurred and little proximal bone remains. Hemiarthroplasty and THR can both be effective, depending on the status of the acetabular articular surface. Hip replacement after intertrochanteric fixation failure presents several unique challenges. Typically, the calcar bone deficiency will be lower than the standard resection level for a primary THR, therefore, having ‘calcar replacing’ or modular stems may be necessary. Additionally, one must bypass the most distal shaft stress riser by two diaphyseal diameters (about 6 cm), which VOL. 95-B, No. 11, NOVEMBER 2013
necessitates longer femoral components (Fig. 3).18 The status of the greater trochanter is important; it can be malunited and occluding the intramedullary canal, or completely ununited. In cases where malunion prevents adequate preparation of the femur, a trochanteric slide technique, which maintains the continuity of the abductors and the vastus lateralis, can be useful. This facilitates removal of the overhanging trochanter as an obstacle during femoral preparation, which with its subsequent reattachment at the end of the case without compromising soft-tissue attachments, is important in maintaining hip stability. It is wise to dislocate the hip before removing any
10
J. PETRIE, A. SASSOON, G. J. HAIDUKEWYCH
hardware to minimise the risk of iatrogenic fracture of the femoral shaft. It can be difficult to determine the correct level of the femoral reconstruction, but restoring the relationship of the tip of the greater trochanter and the centre of femoral head rotation can provide a reasonable reference point. Careful intra-operative trialing and intra-operative radiographs are recommended. The authors generally favour uncemented fixation, either with extensively coated monobloc stems or with fluted, modular tapered titanium stems. The use of modular titanium, diaphyseal-engaging stems has facilitated management of several difficulties. By employing the diaphysis for fixation, the previously violated metaphysis is bypassed. Additionally, proximal malunions can be osteotomised without compromising fixation, even in capacious osteopenic canals. Finally, modularity allows fine-tuning of length and version, which can be difficult to assess initially during complex revisions. Published outcomes have demonstrated good survivorship with these techniques.20,21
Conclusion In summary, minimise failures and re-operations when treating patients with hip fractures by choosing the most appropriate operation for the right patient. If the fracture is anatomically reduced and the fixation device is implanted accurately, the rate of fixation failures will be low. For older patients with displaced fractures of the femoral neck, a hip replacement of some sort is a better choice than internal fixation. When fixation failure occurs one must have effective, proven strategies for salvage. Young patients presenting with femoral neck failures usually have vertical nonunions, and repeat ORIF is probably a good tactic. Typically a valgus osteotomy is chosen to convert shearing forces into compression and promote fracture healing. For older patients with femoral neck failures, THR is preferred. These patients often suffer from disuse osteopenia, which is an important consideration when selecting components. For young patients with intertrochanteric failures, repeat ORIF is preferred. One might suggest supporting the inferior femoral head bone with a fixed angle device, such as a blade-plate. Finally, in older patients with intertrochanteric failures, hip replacement remains the best option. Femoral reconstruction in this setting presents many challenges, including stress risers, bone loss, and greater trochanteric malunion. Careful attention to indications, techniques, and avoiding common pitfalls is important for a logical, effective salvage strategy. The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. This paper is based on a study which was presented at the 29th Annual Winter 2012 Current Concepts in Joint Replacement® meeting held in Orlando, Florida, 12th – 15th December.
References 1. Kyle RF, Cabanela ME, Russell TA, et al. Fractures of the proximal part of the femur. Instr Course Lect 1995;44:227–253. 2. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg [Am] 1979;61-A:216–221. 3. Baumgaertner 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-B:969– 971. 4. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg [Am] 2001;83-A:643–650. 5. Chammout GK, Mukka SS, Carlsson T, et al. Total hip replacement versus open reduction and internal fixation of displaced femoral neck fractures: a randomized long-term follow-up study. J Bone Joint Surg [Am] 2012;94-A:1921–1928. 6. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty: treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg [Am] 2006;88-A:249–260. 7. Haidukewych GJ, Israel TA, Berry DJ. Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res 2002;403:118–126. 8. Taylor F, Wright M, Zhu M. Hemiarthroplasty of the hip with and without cement: a randomized clinical trial. J Bone Joint Surg [Am] 2012;94-A:577–583. 9. Viberg B, Overgaard S, Lauritsen J, Ovesen O. Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture: 12- to 19-year follow-up of patients aged 75 years or more. Acta Orthop 2013;84:254–259. 10. Gjertsen JE, Lie SA, Vinje T, et al. More re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck: an observational study of 11,116 hemiarthroplasties from a national register. J Bone Joint Surg [Br] 2012;94-B:1113–1119. 11. Macaulay W, Nellans KW, Garvin KL, et al. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. J Arthroplasty 2008;23(Suppl):2–8. 12. Avery PP, Baker RP, Walton MJ, et al. Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial. J Bone Joint Surg [Br] 2011;93-B:1045–1048. 13. Sassoon A, D’Apuzzo M, Sems S, Cass J, Mabry T. Total hip arthroplasty for femoral neck fracture: comparing in-hospital mortality, complications, and disposition to an elective patient population. J Arthroplasty 2013;Epub. 14. Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg [Am] 2004;86-A:1711–1716. 15. Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg [Am] 2008;90A:1654–1659. 16. Sadowski C, Lubbeke A, Saudan M, et al. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg [Am] 2002;84A:372–381. 17. Anglen JO. Intertrochanteric osteotomy for failed internal fixation of femoral neck fracture. Clin Orthop Relat Res 1997;341:175–182. 18. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg [Am] 2003;85-A:899–904. 19. Mabry TM, Prpa B, Haidukewych GJ, Harmsen WS, Berry DJ. Long-term results of total hip arthroplasty for femoral neck fracture nonunion. J Bone Joint Surg [Am] 2004;86-A:2263–2267. 20. Palumbo BT, Morrison KL, Baumgarten AS, et al. Results of revision total hip arthroplasty with modular, titanium-tapered femoral stems in severe proximal metaphyseal and diaphyseal bone loss. J Arthroplasty 2013;28:690–694. 21. Restrepo C, Mashadi M, Parvizi J, Austin MS, Hozack WJ. Modular femoral stems for revision total hip arthroplasty. Clin Orthop Relat Res 2011;469:476–482.
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