RECONSTRUCTION 2023, Jan, 16 | 12:00 am

Total Hip Arthroplasty for Salvage of Failed Intertrochanteric Fracture Fixation

Background                       

Intertrochanteric fractures of the femur are common injuries in elderly patients, and most are treated successfully using internal fixation.1,2 With advances in internal fixation devices and techniques, ambulation with full weightbearing can be resumed earlier, thus, significantly reducing the morbidity related to these fractures.3 However, nonunion or early loss of fracture fixation occurs in some cases most often in patients with unstable fracture patterns, poor bone quality, or suboptimal position of internal fixation devices.1,2,4-7 Zhang et al8 reported an overall failure rate after open reduction and internal fixation in the range of 3 to 12%. Unstable intertrochanteric fractures with poor bone quality may heal with excessive collapse leading to a decrease in the height and offset of the proximal femur. This can cause pain and limp secondary to abductor dysfunction. Failure of internal fixation may result in delayed healing or nonunion leading to pain, functional disability, and complications of prolonged recumbence. Revision internal fixation for nonunited fractures has been reported to lead to high union rates in younger patients with good general condition and bone quality.9-12 However, in the older patient with poor bone quality and acetabular degenerative changes, total hip arthroplasty (THA) has been advocated as an effective salvage procedure.13-20 The goal of arthroplasty is to achieve relief of pain with early mobilization and weightbearing. Depending on the age and activity level of the patient, either THA or hemiarthroplasty can be performed.

 

Technical                    Challenges                   

Conversion of internal fixation to hip arthroplasty is a technically demanding procedure. One should always rule out the possibility of infection. Preoperative planning should include the previous skin incision and internal fixation hardware. When possible, templating should be done on the contralateral hip to help restore leg-length and offset. Presence of greater trochanteric comminution may result in abductor deficiency, increasing the risk of unsatisfactory functional outcome and dislocation. Distorted proximal femoral anatomy frequently obscures important bony landmarks, increasing the possibility of intraoperative complications, including perforation during stem preparation. Removal of hardware may leave behind screw holes which are potential stress risers. Care must be taken to sufficiently bypass all potential stress risers with the femoral stem. Some cases also develop varus/flexion remodeling of the proximal femur, which may need correction at the time of surgery.

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Stem                       Options                      

Various types of prosthesis have been utilized for management of these cases and are enlisted below.

 

CEMENTED STEMS

Total Hip Arthroplasty

 

Several authors have reported on the use of cemented arthroplasty for salvage of proximal femoral nonunion with variable results.7,8,12 Good to excellent results have been reported in 66 to 100% of cases using cemented total hip arthroplasty or hemiarthroplasty.14 Reported complications have included trochanteric nonunion, lateral hip pain, or an increased dislocation rate. Haidukewych and Berry13 reviewed the results of prosthetic replacement in 60 patients of failed internal fixation (32 total hip arthroplasty and 28 hemiarthroplasty). Fifty-seven of these patients were treated with a cemented femoral component. At a mean follow-up of 65 months, 39 (89%) of the 44 surviving patients had no or mild pain. Ninety-one percent were able to walk; 59% were ambulating with one arm support or less. Zhang et al8 have reported a high incidence of complications after cemented arthroplasty. Their overall complication rate was 47% with 31% incidence of intraoperative fracture and postoperative dislocation in 16%. The mean Harris hip score at 2 years was 79.8. It is evident that use of a cemented stem in these cases is associated with significant operative difficulties such as extravasation of cement (from the fracture site, screw holes, or defects left after previous hardware removal) leading to suboptimal pressurization of cement and poor remodeling of the cortical bone in the areas of transcortical extrusion of cement.21

 

METAPHYSEAL FIXATION STEMS

These work on the principle of achieving uncemented fixation in intact metaphyseal bone. Moreover, modularity allows adjustment of anteversion, length and offset. However, when the fracture extends distal to the lesser trochanter, or has an element of subtrochanteric extension, the metaphyseal bone stock is compromised and use of distal fixation is recommended. Talmo and Bono14 reported the results of 10 uncemented SROM prostheses (DePuy Orthopedics Inc, Warsaw, Ind) in the salvage of patients with intertrochanteric fracture nonunion. All patients reported good pain relief and were ambulatory at average follow-up of 30 months. The mean Harris hip score in this study was 86. Nine of the 10 had stable ongrowth with one patient having subsidence of 10 mm and significant radiolucency. The results were better in patients with pure intertrochanteric fractures than in patients with subtrochanteric involvement.

Laffosse et al15 treated 29 elderly patients (mean age, 81.1 years) after failed internal

fixation of trochanteric femoral fractures with conversion to arthroplasty using the Puget prosthesis (Système PP; Tornier, Montbonnot, France). This is a cementless modular stem with meta-diaphyseal anchorage. Twenty-two of the patients underwent a hemiarthroplasty, and 7 patients had conversion to a total hip arthroplasty. Of the surviving 23 patients at a mean follow-up of 20 months, they reported significant pain relief and improved function. Twenty patients were ambulatory and 3 were bedridden. Stem subsidence was greater than 5 mm in 3 patients but did not interfere with ambulation. Two patients had nonunion of greater trochanter and another 2 patients presented with early dislocation after bipolar hemiarthroplasty.

 

DISTALLY FIXING THA

Tapered, fluted, modular, distally fixing stems take advantage of intact diaphyseal bone to achieve fixation when proximal bone is compromised. In addition, modularity allows adjustment of anteversion, leg length and offset. After malunion, there is frequently a meta-diaphyseal mismatch and standard nonmodular uncemented stems may not be suitable. This

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Total Hip Arthroplasty for Salvage of Failed Intertrochanteric Fracture Fixation

 

particular stem design has been used in more complex reconstruction in patients with proximal femoral bone loss and in femoral periprosthetic fractures with a documented low rate of subsidence.22,23 A number of options in modular, titanium, grit-blasted stem designs are currently on the market that may be used in this clinical setting, but the techniques of insertion will be variable and implant specific. This is our preferred prosthesis for performance of arthroplasty in failed intertrochanteric fracture fixation and the operative technique would be described. Our experience indicates that stable fixation of the implant can be achieved with good functional outcome in a reproducible fashion.24

 

Operative                    Technique                   

Anteroposterior and lateral radiographs of the femur including the pelvis are obtained. Implant templates were used to predict the necessary length and diameter of the implant, optimal site of cortical fixation, and proximal body options best suited to re-establish the desired offset and neck length. Assessment of limb length is done using the interteardrop line and the distance to lesser trochanter. We prefer to use the posterolateral approach. Tissue specimens are taken for bacteriologic testing, and frozen sections may be used to confirm absence of active infection. In some cases, abundant posterior fracture callus may need to be removed with a saw to gain access to the joint. The femoral head is dislocated out before hardware removal in cases where the fracture united. In cases of nonunion and implant cutout, the internal fixation device is removed first and the head-neck fragment is extracted. After this, the greater trochanteric fragment, if ununited, along with the attached musculature is gently retracted anteriorly to allow exposure. Care was taken to maintain the muscular attachments to the bone, thereby, preserving vascularity.

The femoral canal may be entered with a high-speed burr and hand reamed using the reamer length chosen on preoperative templating to achieve an optimal endosteal contact in the distal diaphyseal part of the femur. Because previous fracture and surgery can lead to distortion of the proximal femoral anatomy, medullary canal obstruction, and stress-riser formation, the femoral canal is preferably reamed under mini C-arm guidance. Optimal distal fixation into the normal diaphyseal bone is the goal, so as to allow load transfer and unrestricted weightbearing. For this reason, proximal fracture callus or overhanging bone (especially the medial greater trochanter) sometimes needs to be reamed away to achieve proper placement of the distal stem within the diaphysis, as assessed using the mini C-arm.

Greater trochanteric healing can occur variably, and in cases where the trochanter heals in a manner that overhangs the entry point of the femoral canal, the options for hardware removal and reaming and instrumentation are more complex. One choice would be to perform an osteotomy of the trochanter for access, engendering the risk of nonunion. Another option would be to use the trochanteric entry point of the cephalomedullary nail to remove the nail, and with a muscle splitting incision longitudinally within the medius, perform reaming and implantation in a transmuscular fashion. As long as the posterior tendinous insertion of the medus on the trochanter is preserved, the muscle can be repaired quite readily.

Reaming is performed by hand, such that the tactile information generated can guide the decision to progress. When moderate resistance to hand reaming is achieved, and optimal bony contact is confirmed (with image intensifier), the distal implant size is chosen. The distal part of the prosthesis is then impacted and checked for stable diaphyseal fixation in the femur. The proximal trial components were used to adjust leg length, offset, and femoral anteversion. Trial reduction is done to assess length, soft tissue tension and stability and once this is found to be satisfactory, the final proximal components are implanted. If the greater trochanter is fractured as a separate fragment, it should be reconstructed either with Ethibond sutures, bone wire or trochanteric claw plate. Postoperatively, patients can be full weight bearing because body weight is transmitted to the intact diaphyseal bone bypassing the deficient metaphysis.

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In summary, management of failed trochanteric fractures is challenging. Options include revision internal fixation with or without bone grafting and conversion to either hemi or total hip arthroplasty. Patients after failed fixation have pain with severely restricted function. Revision fixation may entail a period of restricted weight bearing that is difficult in the elderly. Hip arthroplasty offers the advantage of early weightbearing and mobilization. It also offers the prospect of improving the biomechanical condition of the hip in malunited fractures. The main concerns are of dislocation, infection, and failure of the implant secondary to aseptic loosening and fracture.

Although clinical results of hip arthroplasty are satisfying with good pain relief and early resumption of ambulation, hip arthroplasty after failed internal fixation of trochanteric hip fractures remains a technical challenge.12,13 Structural defects and modification of bony landmarks due to deformation and displacement of fragments8,13,25 combined with poor bone quality, loss of bone stock, and presence of holes after removal of internal fixation hardware26 all enhance the risk of intraoperative mechanical complications.25 We believe that salvage with arthroplasty using a modular, distally fixing, fluted titanium prosthesis offers a reliable alternative method for managing this difficult and challenging group of patients.

 

Total Hip Arthroplasty

 

Illustrative                      Case                     

 

 

CASE EXAMPLE 1 (FIGS 33.1A TO H)

 

 

 

Figure 33.1A: AP radiograph of a 73-year-old patient with right intertrochanteric fracture and failed gamma nail fixation. The patient was referred to us 2 weeks after fracture fixation surgery. Note poor fracture reduction, loss of lateral cortical buttress, lesser trochanter avulsion and greater trochanter fracture

 

Figure 33.1B: Incision was planned to incorporate previous lateral incision. An extensile posterolateral approach was utilized

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Total Hip Arthroplasty for Salvage of Failed Intertrochanteric Fracture Fixation

 

Figure 33.1C: Removal of the lag screw of gamma nail

 

 

 

Figure 33.1D: Acetabular exposure and cup implanted

 

Figure 33.1E: Fractured greater trochanter with soft tissue attachments is retracted anteriorly to expose the entry to femoral diaphysis and before reaming is initiated. Note: extensive metaphyseal damage precluding use of metaphyseal fixation stem

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Total Hip Arthroplasty

 

Figure 33.1F: The proximal segment of the tapered, fluted, modular stem being implanted in appropriate version

 

Figure 33.1G: Fixation of greater trochanter with trochanteric claw plate and cerclage cables. The vastus lateralis has been split along its fibers for plate insertion

 

 

 

Figure 33.1H: Radiograph at 2 year follow-up

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CASE EXAMPLE 2 (FIGS 33.2A TO C)

 

 

 

 

 

 

 

Figure 33.2A: AP pelvis radiograph of a 82-year-old patient with 4 month old left intertrochanteric fracture with failed dynamic hip screw fixation

 

Total Hip Arthroplasty for Salvage of Failed Intertrochanteric Fracture Fixation

 

Figure 33.2B: AP pelvis radiograph approximately 1 year after conversion to total hip replacement using tapered, fluted, modular, distally fixing cementless stem (Link MP reconstruction stem, Waldemar Link, Hamburg, Germany). Note: excellent reconstitution of offset and leg length. The patient went back to being a community ambulator

 

 

 

 

Figure 33.2C: Lateral radiograph of the same patient

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Total Hip Arthroplasty

 

CASE EXAMPLE 3 (FIGS 33.3A TO C)

 

Figure 33.3A: 81-year-old patient with impending failure of gamma nail osteosynthesis of comminuted intertrochanteric-subtrochanteric fracture

 

 

 

 

Figure 33.3B: Follow-up AP radiograph 18 months after conversion to total hip replacement using the Link MP reconstruction stem (Waldemar Link, Hamburg, Germany)

Figure 33.3C: Lateral radiograph of the same patient demonstrating healed fracture with solid distal fixation of the prosthesis

 

References                       

  1. Kyle RF, Gustilo RB, Premer RF. Analysis of 622 intertrochanteric hip fractures. J Bone Joint Surg Am 1979;61:216.

  2. Kyle RF, Cabanela ME, Russell TA, et al. Fractures of theproximal part of the femur. Instr Course Lect 1995;44:227.

  3. Bonnevialle P, Feron JM. Symposium SOFCOT. Fractures in elderly after 80-year-old (French). Rev Chir Orthop 2003;27:197.

  4. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643.

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  5. Bendo JA, Weiner LS, Strauss E, et al. Collapse of intertrochanteric hip fractures fixed with sliding screws. Orthop Rev 1994(suppl);30.

  6. Koval KJ, Zuckerman JD. Hip fractures: a practical guide to management. New York, (NY): Springer-Verlag; 1999.

  7. Steinberg GG, Desai SS, Kornwitz NA, et al. The intertrochanteric hip fracture: a retrospective analysis. Orthopaedics 1988;11:265.

    Total Hip Arthroplasty for Salvage of Failed Intertrochanteric Fracture Fixation

     

  8. Zhang B, Shiu KY, Wang M. Hip arthroplasty in failed internal fixation of intertrochanteric fractures. J Arthroplasty 2004;19:329.

  9. Anglen JO. Intertrochanteric osteotomy for failed internal fixation of femoral neck fracture. Clin Orthop Relat Res 1997;175.

  10. 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.

  11. Alvarez DB, Aparicio JP, Fernandez EL, et al. Implant breakage, a rare complication with Gamma nail. A review of 843 fractures of the proximal femur treated with Gamma nail. Acta Orthop Belg 2004;70:435.

  12. Said GZ, Farouk O, El-Sayed A, et al. Salvage of failed dynamic hip screw fixation of intertrochanteric fractures. Injury 2006;37:194.

  13. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 2003;85:899.

  14. Talmo CT, Bono JV. Treatment of intertrochanteric nonunion of proximal femur using the S-ROM prosthesis. Orthopaedics 2008;31:125.

  15. Laffosse JM, Molinier F, Tricoire JL, et al. Cementless modular hip arthroplasty as a salvage operation for failed internal fixation of trochanteric fractures in elderly patients. Acta Orthop Belg 2007;73:729.

  16. Haentjens P, Casteleyn PP, Opdecam P. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly patient. Arch Orthop Trauma Surg 1994;113:222.

  17. Huo MH, Jay PR, Buly RL. Total hip replacement following prior surgeries. In: Bono JV, McCarthy JC, Thornhill TS, Bierbaum BE, Turner RH (Eds). Revision total hip arthroplasty. New York, (NY): Springer-Verlag; 1999.p.477.

  18. 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.p.81.

  19. Mears DC, Durbhakula SM, Velyvis JH. Reconstructive total hip replacement after proximal femoral injuries. In: Browner BD, Jupiter JB, Levine AM, Trafton PG (Eds). Skeletal trauma. Philadelphia, (PA): Saunders; 2003.p.1817.

  20. Goldstein WM, Branson JJ. Modular femoral component for conversion of previous hip surgery in total hip arthroplasty. Orthopaedics 2005.

  21. Patterson BM, Salvati EA, Huo MH. Total hip arthroplasty for complications of intertrochanteric fracture: a technical note. J Bone Joint Surg Am 1990;72:776.

  22. Rodriguez JA, Fada R, Murphy SB, et al. Two-year to five year follow-up of femoral defects in femoral revision treated with the Link MP Modular Stem. J Arthroplasty 2009;24:751.

  23. Rodriguez JA, Goyal A, Thakur RR, Deshmukh AJ, Ranawat AS, Ranawat CS. Preoperative planning and surgical technique in the management of periprosthetic femoral fractures using a tapered modular fluted prosthesis with distal fixations. Oper Tech Orthop 2009;19:137.

  24. Thakur RR, Deshmukh AJ, Goyal A, Ranawat AS, Rasquinha VJ, Rodriguez JA. Management of failed trochanteric fracture fixation with cementless modular hip arthroplasty using a distally fixing stem. J Arthroplasty 2010; Epub ahead of print

  25. Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures. Clin Orthop 1991;269:32.

  26. Hesse B, Gachter A. Complications following the treatment of trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg 2004;124:692