Salvage of failed trochanteric fracture fixation using the Revitan curved cementless modular hip arthroplasty

Outcomes of total hip arthroplasty using dual mobility cups following failed internal fixation of proximal femoral fractures at a mean follow-up of 6 years

INTRODUCTION

Performing total hip arthroplasty (THA) after failed internal fixation of proximal femoral fractures (PFF) is known to be associated with high rates of complications. Dual mobility cups (DMC) are known to lower dislocation events in high-risk patients. Very few reports investigated the outcomes of THA using DMC following failure of internal fixation for PFF.

METHODS

This is a retrospective monocentric continuous study of 31 patients who underwent THA with DMC after failed internal fixation of PFF. The clinical assessment was based on the modified Harris hip score (mHHS) at the last follow-up. The complication rates and radiological analyses were recorded.

RESULTS

The mean follow-up period was 5.96 ± 4.2 years. At the last follow-up, the mean mHHS was 92.9 ± 9.1 with 71% of the patients describing their operated hip as a forgotten hip. No dislocation or aseptic loosening events were noted. One patient developed a septic loosening of the implant. No significant radiological changes were recorded. Sixteen stems (51.6%) were placed in a neutral position, 13 (42%) in valgus (2.74 ± 1.72°), and 2 (6.4%) in varus (6.94 ± 2.02°).

CONCLUSION

This study emphasizes the advantage of using DMC following failed internal fixation of PFF in reducing dislocation and complication events in this high-risk population.

The role of internal fixation in the treatment of femoral head necrosis with ipsilateral hip fracture

Whether internal fixation or hip arthroplasty is the most appropriate initial treatment for patients with ipsilateral hip fracture and osteonecrosis of the femoral head remains unknown. In this study, the prognoses of patients who underwent internal fixation or hip arthroplasty were analyzed and compared to explore the role of internal fixation in treating such patients. We retrospectively reviewed 69 patients diagnosed with osteonecrosis of the femoral head and ipsilateral hip fracture from 1999 to 2018. They were divided into the hip arthroplasty or internal fixation group. The visual analog scale and Harris score were used. The incidence of complications and the conversion to arthroplasty were also investigated to further explore the role of internal fixation. Male patients (male/female: 25/31 vs 20/38, P = .015), younger patients (average age: 46.80 ± 13.14 vs 61.07 ± 15.61, P < .001), and patients with femoral neck fractures (fracture type, femoral neck/trochanter: 21/31 vs 12/38, P = .003) were more likely to receive 1-stage hip arthroplasty. Of 38 patients undergoing internal fixation, fracture nonunion was identified in 9, and progression of osteonecrosis was identified in 16. Meanwhile, conversion to secondary hip arthroplasty occurred in 13 patients. Four independent risk factors for conversion to secondary hip arthroplasty were identified: age of ≤60 years (odds ratio [OR] = 9.786, 95% confidence interval [CI] = 2.735-35.015), male sex (OR = 6.790, 95% CI = 1.718-26.831), collapse of the femoral head before injury (OR = 7.170, 95% CI = 2.004-25.651), and femoral neck fracture (OR = 8.072, 95% CI = 2.153-30.261). A new scoring system was constructed for predicting conversion to hip arthroplasty in patients undergoing internal fixation treatment. A cutoff of ≤2 points indicated low risk for conversion, 3 to 4 points indicated moderate risk, and ≥5 points indicated high risk. Patients who underwent internal fixation had worse prognoses than those who underwent 1-stage hip arthroplasty. However, in this study, hip arthroplasty conversion did not occur in most patients who received internal fixation. Using the new scoring system to identify patients who may require conversion to replacement may help make appropriate patient management and clinical decisions.

Treatment of Osteoarthritis Secondary to Severe Coxa Vara with Modular Total Hip Arthroplasty

Objective

We aimed to demonstrate the methods of treatment for coxa vara with modular total hip arthroplasty (THA) and evaluate clinical and radiographic outcomes, and further survivorship at the midterm follow-up.

Methods

We retrospectively reviewed 33 patients (42 hips) who underwent modular THA for coxa vara deformity from May 2008 to December 2019. The clinical and radiographic results, including Harris Hip Score (HHS), leg length discrepancy (LLD), greater trochanteric height, femoral offset, abductor lever arm, stem alignment and limp, and complications, were evaluated.

Results

The follow-up time was mean 69.9±43.7 months. Clinically, the HHS improved significantly (p<0.001) on average from 42.90±14.44 points to 89.54±4.75 points. The mean LLD decreased from 33.3±19.4 mm to 5.0±5.8 mm (p<0.001), and 27 patients (82%) thought that total equality of the lower limbs was obtained. Patients demonstrated diminished or no limping in 88% (29/33) of hips and a significant improvement of biomechanics. At the final follow-up, all stems of hips were in clinical neutral alignment and the prostheses survivorship rates for all-causes revisions was 97.6%.

Conclusion

Modular THA is a valuable alternative to render favorable outcomes for treatment of osteoarthritis secondary to severe coxa vara.

Cementless total hip arthroplasty for failed treatment of subtrochanteric fracture

Background

Failed treatment of subtrochanteric fractures commonly leads to pain, limping, and poor limb function. Cementless total hip arthroplasty (THA) could serve as an efficient salvage procedure in such cases. This study aimed to evaluate the outcomes and complications of salvage THA in failed subtrochanteric fracture fixation cases.

Methods

From January 2001 to December 2017, cementless THA for failed treatment of subtrochanteric fractures was performed in 18 hips of 11 men and 7 women (average age, 74 years; age range, 57.0–89.0 years). Patients were followed up for clinical and radiological assessments in terms of implant survival and complications after a minimum follow-up of 2 years. The Wagner femoral stems (Zimmer, Warsaw, USA) were used in all 18 patients (100%), with the long-length stem (Wagner SL stem) and standard-length stem (Wagner cone stem) used in 11 and 7 patients, respectively.

Results

The mean follow-up period was 5.2 years (range: 2.2–10.8 years). The mean Harris hip score (HHS) was 38.2 (range: 24–56) preoperatively and 85.4 (range: 79–92) at the last follow-up. The mean postoperative limb length discrepancy was 6.4 mm (range: 4–9 mm). Only one patient underwent revision due to bone in-growth failure of the femoral stem. One patient had an episode of postoperative dislocation and was treated with closed reduction without reoccurrence. Delayed union of the fracture site occurred in one patient. Patients who were previously treated with an intramedullary nail had a significantly shorter surgical duration, lesser intraoperative blood loss, and fewer blood transfusions than those who were previously treated with plate and screws. Kaplan–Meier survival rate with an endpoint of revision was 94.4% (95% confidence interval 72.7–99.9) at 5 years.

Conclusion

Our results indicate that cementless THA is a beneficial and effective procedure for salvaging the failed treatment of subtrochanteric fractures. The Wagner conical prosthesis has shown satisfactory function outcomes, stable fixation, and survival rate for these complex situations. However, attention should be paid to increased operation time, blood loss, and complications when performing THA for subtrochanteric fractures with failed fixation devices especially, plates and screws.

Case series and finite element analysis of PFNA combined with cerclage wire for treatment of subtrochanteric fracture of femur

Objective

To retrospectively analyze the clinical efficacy of PFNA combined with a cerclage wire in the treatment of 52 patients with unstable subtrochanteric fracture of the femur and to analyze the biomechanical effect of ligature on a fracture model.

Methods

In this study, 52 patients with unstable subtrochanteric fractures were treated in our orthopedic trauma center from June 2013 to July 2018. The Seinsheimer type IV fracture model was established using the patient’s CT data, and the joint surface of the distal femoral condyle and the external condyle were restrained. The femoral head was used as the loading point, and a force of 500 N was applied vertically along the long axis of the femoral shaft.

Results

All 52 patients were followed up for 12 to 37 months, with an average of 18.07 ± 4.38 months. According to the Sanders hip function score, 28 cases were excellent (55–60 points), 22 cases were good (45–54 points), and 2 cases were poor (35–44 points), with an excellent and good rate of 96.15%. Postoperative deep vein thrombosis occurred in 3 cases, and fracture nonunion occurred in 1 case. No infection, loose fracture of internal fixation or hip varus deformity occurred. The finite element analysis indicated that the displacement of the whole model decreased slightly and the relative sliding of the fracture block decreased, but the maximum stress of the femur increased after the addition of the cerclage wire.

Conclusion

The treatment of unstable subtrochanteric fracture of the femur with PFNA combined with cerclage wire has the advantages of simple operation, satisfactory reduction of fracture, stable fixation, and good recovery of limb function. The finite element analysis suggested that the biomechanical strength fixation was enhanced after the addition of cerclage wire. However, the local stress concentration of the tie may increase the risk of failure.

Outcomes of Total Hip Arthroplasty for Healed Intertrochanteric Hip Fractures. A Matched Retrospective Cohort Study

BACKGROUND

Many studies have analyzed the outcomes of total hip arthroplasty (THA) after failed intertrochanteric fracture fixation, but not after healed fracture. The objective is to investigate the influence of a prior healed intertrochanteric fracture fixation on the outcomes of a subsequent THA for osteoarthritis.

METHODS

This is a matched retrospective cohort study of THA between 43 patients who suffered a prior intertrochanteric fracture successfully managed with internal fixation and 43 patients without prior hip fracture. Mean age was 73.6 vs 74.2 years. A conventional cementless THA was used in both groups. Functional outcome was assessed by the Harris hip score (HHS) and reduced Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Radiological assessment was also performed.

RESULTS

Mean follow-up was 6.6 (range, 5-8) years. The mean operative time and blood transfusion rate were significantly higher in the fracture group (P = .001), but there was no significant difference in the length of stay. HHS significantly improved in both groups. At final follow-up, HHS was significantly higher in nonfracture group (P = .008), but the rate of patients with excellent and good outcomes was similar (P = .616). Western Ontario and McMaster Universities Osteoarthritis Index score at the final follow-up was not different between groups (P = .058). Complication rate was similar between groups. There were no revisions, dislocations, or loose implants in the study group.

CONCLUSION

Cementless THA provided successful functional outcomes and implant durability at medium term in patients treated for osteoarthritis following healed intertrochanteric fracture fixation, comparable to those without prior fracture who underwent primary THA. Surgical complexity and complication rate were low.

Revision of a Fractured Titanium Modular Revision Hip Stem Without Removal of the Well-Fixed Part of the Stem: A New Approach Using a Cemented Tube

Component fracture is a rare cause for revision in total hip arthroplasty. For a fractured well-fixed long femoral stem, the options are limited. We sought to develop a technique to address this problem with lower morbidity. A newly developed cemented tube was constructed and cemented onto a fractured Revitan revision hip femoral stem to retain the distal well-fixed component. At the 2-year follow-up, the Harris Hip Score, pain level, and radiographic images were analyzed. At the 2-year follow-up, no radiological signs of loosening or failure could be observed. The patient's preoperative Harris Hip Score improved from 42.8 to 97 points. The pain level improved from 7/10 to 0/10. Our case report depicts excellent clinical and radiographic outcomes at 2-year follow-up by a newly developed cemented tube technique. This technique is a potential new option for revision of fractured well-fixed diaphyseal stems without major bone loss. Our successful results suggest this technique is worthy of consideration and further study.

Trochanteric femoral nonunion in patients aged over 60 years treated with dynamic condylar screw

INTRODUCTION

Nonunions of trochanteric femoral fractures are uncommon due to a good blood supply of the cancellous bone of the trochanteric region. Nevertheless, if a nonunion occurs, complex revision procedures usually become necessary. The purpose of this study was to evaluate a series of aseptic trochanteric nonunions in patients aged 60 years or older, looking at outcomes regarding healing rate, implant-related complications and secondary surgeries.

MATERIAL AND METHODS

We conducted a retrospective chart review of patients with aseptic femoral trochanteric nonunions aged over 60 years. Nonunion treatment consisted of implant removal, debridement of the nonunion, and restoration of the neck shaft angle, followed by DCS plating. An additional 4.5-mm limited contact dynamic compression plate was placed in twelve patients anteriorly. The primary outcome measure was bony healing and time to healing in months. Secondary outcome measures included postoperative complications related to the index procedure, range of motion of the affected hip and postoperative mobility.

RESULTS

A total of 21 patients with a mean age of 69.1 years met the inclusion criteria. After a mean follow-up of 21.62 months, 17 of the 21 nonunions healed successfully. The mean healing time was 6.59 months. A total of six of the 21 patients needed secondary revision surgery. At the final follow-up, a full range of motion of the hip was seen in 17 of the 21 hips.

CONCLUSIONS

DCS treatment and preservation of the patient's femoral head can be successful for patients aged over 60 years with a well-preserved femoral head and acetabulum. However, preservation of the hip joint and revision plating might be associated with higher revision rates.

A systematic review and meta-analysis of complications in conversion arthroplasty methods for failed intertrochanteric fracture fixation

BACKGROUND

Conversion arthroplasty for failed primary fixation of intertrochanteric fractures can be achieved using various methods, including cemented total hip arthroplasty, uncemented total hip arthroplasty, hybrid total hip arthroplasty, and hemiarthroplasty. Complication rates vary between each conversion method. The purpose of this paper is to examine the effect of conversion method on total conversion complication rates.

METHODS

We performed a meta-analysis of five studies with sufficient data for analysis. We created a null hypothesis stating that the expected distribution of complications across conversion methods would reflect the distribution of conversion method used for failed primary fixation. Using a z test, we compared proportions of the expected distribution of complications to the observed distribution of complications.

RESULTS

A total of 138 cases of conversion arthroplasty with 49 complications were available for analysis. The mean age was 73 (range, 32-96) years. 19 males and 48 females were included, with one study not including patient gender. The mean time from primary fixation failure to conversion was 11 months, and the mean duration of conversion surgery was 132 min. Expected and observed complication rate distributions were as follows: cemented total hip arthroplasty, 6.5% versus 4.1% (p = 0.79); uncemented total hip arthroplasty, 77.5% versus 81.6% (p = 0.69); hybrid total hip arthroplasty, 2.9% versus 2.0% (p = 1); and hemiarthroplasty, 13% versus 12.2% (p = 1).

CONCLUSIONS

Our findings suggest that the method of conversion arthroplasty following failed primary intertrochanteric femur fracture fixation does not influence complication rate.

Total hip arthroplasty after failed fixation of a proximal femur fracture: Analysis of 59 cases of intra- and extra-capsular fractures

INTRODUCTION

The indications for total hip arthroplasty (THA) after failed internal fixation of a proximal femur fracture vary. Published studies on this topic are broad-ranging and do not distinguish between intracapsular and extracapsular fractures. This led us to conduct a retrospective analysis comparing the clinical outcomes, radiological outcomes, technical problems and complications between these two types of fractures.

HYPOTHESIS

The functional outcomes of THA after an extracapsular fracture will be worse than the ones after an intracapsular fracture.

MATERIAL AND METHODS

This was a retrospective, single-center study of 59 THA cases performed after internal fixation of a proximal femur fracture. These procedures were performed between 2002 and 2013 in 58 patients (22 men, 36 women). There were 40 intracapsular fractures and 19 extracapsular fractures. The initial fracture fixation involved a screw-plate (n=50), intramedullary nail (n=6) or screws (n=3). The mean patient age at the time of THA was 67 years [22-94]. The THA was performed an average of 2.8 years [0.2-28] after the fracture. The posterolateral approach was used in 55 cases (93%). Ten patients (17%) had the fixation hardware removed before the THA procedure, on average at 30 months [1-240] after the fracture. During the THA procedure, a cemented stem was used in 31 cases (53%) and a cementless stem in 28 cases (47%). A cementless press-fit cup was used in 56 cases (95%), of which 35 were dual mobility cups (60%), and a cemented cup was used in the other 3 cases (5%). All patients were reviewed by a physician not involved in the surgical procedures who performed a clinical and radiological examination.

RESULTS

No patients were lost to follow-up; two patients died. Ten patients suffered an intraoperative femur fracture (17%) and four suffered a dislocation (2 early, 2 late) (6.8%). Nine hips had to be reoperated (15%), of which five required an implant change (8.5%). There were significantly more intraoperative fractures and postoperative complications in the THA cases after extracapsular fracture. With a mean follow-up of 38 months [12-149], the mean PMA and Harris scores were 14.6 [3-18] and 74 [10-100], respectively; these scores were significantly lower in the THA cases after extracapsular fracture (p<0.05). With an endpoint of revision with implant change, the overall 40-month survival was 94% (95% CI: 0.25-0.55); it was 97% (95% CI: 0.62-0.85) for the intracapsular fracture cases and 84% (95% CI: 0.39-0.75) for the extracapsular fracture cases (p<0.05).

CONCLUSION

Secondary THA after failed fixation of proximal femur fractures has more complications than primary THA. Subgroup analysis identified more technical problems in the THA cases after extracapsular fracture and a higher number of complications, particularly dislocation and periprosthetic fractures.

LEVEL OF EVIDENCE

IV - Retrospective study.

Conversion vs Primary Total Hip Arthroplasty: Increased Cost of Care and Perioperative Complications

BACKGROUND

With the increasing incidence of hip fractures and hip preservation surgeries, there has been a concomitant rise in the number of conversion total hip arthroplasties (THAs) performed. Prior studies have shown higher complication rates in conversion THA. However, there is a paucity of data showing differences in cost between these 2 procedures. Currently, the Center for Medicare and Medicaid Services bundles primary and conversion THA in the same Medicare Severity-Diagnosis Related Group for hospital reimbursement. More evidence is needed to support the reclassification of conversion THA.

METHODS

The cohort provided by the institutional database included 163 conversion THAs between January 1, 2012 and December 31, 2015. Intraoperative complications, estimated blood loss, operative time, postoperative complications, and perioperative cost data were analyzed for 163 primary THA patients matched to the conversion THA cohort.

RESULTS

Compared with primary THA, conversion THA had significantly (P < .05) greater cost for direct labor, other direct costs, intermediate nursing services, other diagnostic/therapy, surgery services, physical/occupational/speech therapy, radiology, laboratories, blood, medical/surgical supply, and total direct costs. In addition, the conversion THA group had significantly greater operative times, estimated blood loss, length of stay, intraoperative complications, and postoperative complications.

CONCLUSION

Conversion THA, as compared with primary THA, is associated with greater costs (approximately 19% greater), increased surgical times, and perioperative complications. To prevent these additional expenses from creating patient selection bias and a barrier to care, the conversion THA Medicare Severity-Diagnosis Related Group should be reclassified, or modifiers created.

Conversion Hip Arthroplasty in Failed Fixation of Intertrochanteric Fracture: A Propensity Score Matching Study

BACKGROUND

Conversion hip arthroplasty is a salvage procedure for failed internal fixation of intertrochanteric fractures. However, the technical difficulties and perioperative morbidity of conversion arthroplasty are uncertain.

METHODS

We compared the type of arthroplasty (total hip arthroplasty or hemiarthroplasty), operative parameters, perioperative morbidity, 1-year mortality, implant stability, and clinical results of 33 conversion hip arthroplasties due to a failed internal fixation of intertrochanteric fracture with those of a matched control group of 33 primary hip arthroplasties due to the same fracture. Propensity score was used for the control matching of gender, age, and body mass index.

RESULTS

Total hip arthroplasty was more frequently performed in the conversion group (10/33) compared to the primary group (3/33) (P = .016). The operation time, perioperative blood loss, amount of transfusion, and risk of femoral fracture during the operation were increased in the conversion group. The overall 1-year mortality was 3% (1 patient) in the conversion group and 9% (3 patients) in the primary group (P = .307). At a mean of 3-year follow-up, there was no significant difference in clinical results and none of the implants were loose in both groups.

CONCLUSION

In patients with failed internal fixation of intertrochanteric fracture, conversion hip arthroplasty should be planned and executed, bearing in mind the increased operative morbidities corresponding to operation time, perioperative blood loss, requirement of transfusion, and intraoperative femoral fracture.

Total hip arthroplasty after failed treatment of proximal femur fracture

INTRODUCTION

Total hip arthroplasty (THA) is a good option as a salvage procedure after failed treatment of proximal femur fracture. The anatomy of the proximal femur, however, makes this surgery complicated and challenging. The purpose of this study was to evaluate the radiographic and clinical outcomes of THA after failed treatment of proximal femur fractures.

MATERIALS AND METHODS

We retrospectively analysed 50 consecutive THAs (42 women, 8 men; mean age 77 years) after failed treatment of a proximal femur fracture. Mean postoperative follow-up was 58.1 months. Preoperative diagnoses were femoral neck fracture in 18 hips and trochanteric fracture in 32 hips, including three that were infected. Failure resulted from cutout in 22 cases, osteonecrosis in 12, non-union with failed fixation in nine, postoperative osteoarthritis in four, and infection in three. Factors compared included radiographic assessment, complication rate, visual analogue scale (VAS), and Harris Hip Scores (HHS). Radiographic variables included femoral neck anteversion and cup and stem alignment.

RESULTS

Absolute values of the differences in femoral neck anteversion between the affected and healthy sides were 6.0° in the femoral neck fracture group and 19.2° in the trochanteric fracture group (p = 0.01). There were no significant differences in cup anteversion (p = 0.20) or stem anteversion (p = 0.08). The complication rate was significantly higher in the trochanteric fracture group than in the femoral neck fracture group (25 vs 0%, p < 0.0001). Postoperative complications in the trochanteric fracture group included three periprosthetic fractures (9.4%), two dislocations (6.3%), two surgical-site infections (6.3%), and one stem penetration (3.1%). Although no significant differences between groups were seen in the VAS or HHS at final follow-up (p = 0.32, 0.09, respectively), these measures were significantly improved at final follow-up in both groups (p < 0.0001 for both).

CONCLUSIONS

Performing THA after failed treatment of trochanteric fractures requires consideration of complication risk and incorrect femoral neck anteversion.

Total Hip Arthroplasty Using Non-Modular Cementless Long-Stem Distal Fixation for Salvage of Failed Internal Fixation of Intertrochanteric Fracture

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.

Total hip arthroplasty after previous fracture surgery

Total hip arthroplasty can be a very effective salvage treatment for both failed fracture surgery and hip arthritis that may occur after prior fracture surgery. The rate of complications is significantly increased including especially infection, dislocation, and loosening. Complications are more likely to occur after failed open reduction and internal fixation than after posttraumatic arthritis. Adequately ruling out infection before hip arthroplasty can be difficult. The best predictor of infection is a prior infection. Long-term outcomes can be comparable to outcomes in other conditions if complications are avoided.

Salvage of failed hip osteosynthesis for fractures with modular hip prosthesis

BACKGROUND/PURPOSE

Treating options of failed internal fixation include revision fixation and salvage arthroplasty. The purpose of this study was to evaluate the results, complications and the final functional outcome associated with modular hip arthroplasty.

METHODS

Modular arthroplasty was performed in 11 patients due to failed treatment of peritrochanteric fracture. Each patient examination included Trendelenburg test, Harris Hip Score, SF-36, and X-rays of the hip. Examinations were recorded and a paired t test was applied for further statistic analysis.

RESULTS

Two years postoperatively, four patients referred no hip pain, seven patients claimed for slight or mild pain, and three patients presented with moderate pain. Statistical analysis revealed a statistically significant difference equally for Harris Hip Score and SF-36.

CONCLUSION

The use of modular stems during salvage arthroplasty can decrease the risk of intraoperative and postoperative complications. The final outcome for the patient is satisfactory with functional improvement of the hip.

Clinical outcome of endoprosthetic replacement for failed treatment of intertrochanteric fractures: A retrospective case series

Objective: The treatment methods for the failed internal fixation in elderly patients suffering from several osteoporostic fractures are still inconclusive. We aimed to evaluate the clinical effects of endoprosthetic replacement for failure treatment of intertrochanteric fracture.

Methodology: A total of 13 patients with failed internal fixation for intertrochanteric fracture were collected between January 2002 and October 2009. All of them were treated with endoprosthetic replacement and followed up till October 2010. Four of them received total hip replacement and the remained nine received artificial bipolar femoral head replacement. Clinical and functional outcomes of patients were assessed.

Results: Of 13 patients, nine were females and four were males with the mean age of 76.5 years (SD, 11.7, range, 58-92 years) at the time of fracture. The average time of operation and follow-up was 124 minutes (89-187minutes) and 31 months (14-68 months), respectively. The average blood loss during the operation was 631 ml (450-1560 ml). All patients showed good pain relief and functional improvement. Final post-operative Harris and WOMAC scores were significantly improved from pre-operative levels (P<0.05). Only five patients showed operative complications.

Conclusions: Our finding indicated that endoprosthetic replacement is an effective salvage procedure for failed internal fixation of intertrochanteric fracture in elderly patients with effective pain relief and functional improvement as well as few serious complications.

Breakage of a third generation gamma nail: a case report and review of the literature

The use of intramedullary nails to treat trochanteric fractures of the femur has increased with the increasing size of the elderly population. The third generation Gamma nail is currently one of the most popular devices for the treatment of trochanteric fractures. Nail breakage is a rare complication, possibly resulting from fatigue fracture of the implant. We present the first reported case of breakage of a third generation Gamma nail that was not used to treat a pathological fracture. An 83-year-old woman with an unstable trochanteric fracture of the femur was treated using a third generation Gamma nail. She was referred to our hospital 14 months postoperatively with nail breakage at the opening for the lag screw. The breakage was secondary to nonunion, which was thought to be mainly due to insufficient reduction of the fracture. The broken nail was removed, and the patient underwent cemented bipolar hemiarthroplasty. At followup 18 months later, she was mobile with a walker and asymptomatic with no complications. This case shows that inadequate operation such as insufficient reduction of the trochanteric fracture may result in nonunion and implant breakage, even when using a high-strength, well-designed implant.

Augmentation of implant fixation in osteoporotic bone

Osteoporosis presents a dilemma for the orthopedic surgeon. Screw fixation within the bone is crucial for mechanical stabilization, maintenance of reduction, and ultimately, fracture healing. For the patient, soft bones and physiological fragility usually benefit from immediate weight bearing and mobility to avoid further disuse osteoporosis, deconditioning, and immobility. For implant companies, traditional screws, plates, and nails function for simple fractures and compliant patients. Locked plating has improved screw purchase in osteoporotic bone and has expanded fracture fixation capabilities but is not the panacea for all fractures. For orthopedic surgeons, traditional surgical augmentation for osteoporosis consisting of dual plating, augmentation with polymethyl methacrylate, joint replacement, and now locked plating are beneficial. In order to advance orthopedic care in the expanding population of elderly osteoporotic patients, modern solutions utilizing the dual properties of secure fixation and relatively flexible implants are required. Endosteal substitution, extraosteal substitution, and combined nail/plate combinations are methods of utilizing traditional implants in a nontraditional way. Nonsurgical augmentation of fracture fixation is also paramount.

Salvage of failed trochanteric and subtrochanteric fractures using a distally fixed, modular, uncemented hip revision stem

BACKGROUND AND PURPOSE

Treatment options for failed internal fixation of hip fractures include prosthetic replacement. We evaluated survival, complications, and radiographic outcome in 30 patients who were operated with a specific modular, uncemented hip reconstruction prosthesis as a salvage procedure after failed treatment of trochanteric and subtrochanteric fractures.

PATIENTS AND METHODS

We used data from the Swedish Hip Arthroplasty Register and journal files to analyze complications and survival. Initially, a high proportion of trochanteric fractures (7/10) were classified as unstable and 12 of 20 subtrochanteric fractures had an extension through the greater trochanter. Modes of failure after primary internal fixation were cutout (n = 12), migration of the femoral neck screw (n = 9), and other (n = 9).

RESULTS

Mean age at the index operation with the modular prosthesis was 77 (52-93) years and the mean follow-up was 4 (1-9) years. Union of the remaining fracture fragments was observed in 26 hips, restoration of proximal bone defects in 16 hips, and bone ingrowth of the stem in 25 hips. Subsidence was evident in 4 cases. 1 patient was revised by component exchange because of recurrent dislocation, and another 6 patients were reoperated: 5 because of deep infections and 1 because of periprosthetic fracture. The cumulative 3-year survival for revision was 96% (95% CI: 89-100) and for any reoperation it was 83% (68-93).

INTERPRETATION

The modular stem allowed fixation distal to the fracture system. Radiographic outcome was good. The rate of complications, however-especially infections-was high. We believe that preoperative laboratory screening for low-grade infection and synovial cultures could contribute to better treatment in some of these patients.