Salvage of failed hip fracture fixation

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.

Primary Cementless Femoral Stems in Conversion Hip Arthroplasty After Failed Fixation of Intertrochanteric Fractures

Salvage conversion hip arthroplasty is a viable solution to restore function and reduce pain after failed intertrochanteric hip fracture fixation. Our primary objective was to assess early outcomes achieved with primary cementless metaphyseal-engaging femoral stems for conversion hip arthroplasty compared with revision diaphyseal-engaging stems. This was a retrospective review of 70 patients with failed intertrochanteric hip fractures subsequently managed with conversion total hip arthroplasty or hemiarthroplasty. Thirty-five patients who underwent conversion using a primary cementless stem were compared with 35 patients who underwent conversion using a revision stem. The groups were similar regarding sex, body mass index, American Society of Anesthesiologists classification, preoperative diagnosis, and implants removed. Clinical and radiographic outcomes and complications were compared over a mean follow-up of 6 years. The primary stem cohort had a shorter mean hospital stay (3.03 vs 4.34 days, P=.028). There were no significant differences between the primary and revision cohorts regarding mean time to conversion (2.26 vs 1.75 years, P=.671), operative time (127 vs 131 minutes, P=.611), incidence of discharge to home (54.3% vs 37.1%, P=.23), postoperative complications (5.71% vs 5.71%, P=1.0), reoperations (5.71% vs 11.4%, P=.669), leg length discrepancy (5.33 vs 7.38 mm, P=.210), subsidence (20.0% vs 23.3%, P=.981), and Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (78.6 vs 81.9, P=.723). We report comparable outcomes of conversion hip arthroplasty with the use of primary cementless and revision stems. Current primary cementless femoral stems may be considered for conversion hip arthroplasty for failed intertrochanteric fracture fixation. [Orthopedics. 2024;47(1):e6-e12.].

Is Sliding Compression Necessary for Intramedullary Nailing Fixation of AO/OTA Type A3.3 Intertrochanteric Fracture?

OBJECTIVES

The intramedullary nail is considered the gold standard for treating AO/OTA type A3.3 intertrochanteric fractures. However, it still faces a significant rate of failure, mainly due to the critical factor of comminuted lateral wall defects leading to inadequate proximal sliding compression. The primary objective of this study is to investigate the requirement of sliding compression in the treatment of unstable AO/OTA type A3.3 intertrochanteric fractures. To achieve this, we conduct a comparative analysis between two approaches: InterTAN alone and proximal femoral anti-rotation blade nailing (PFNA) combined with lateral wall reconstruction for treating AO/OTA type A3.3 intertrochanteric fractures with lateral wall damage.

METHODS

A retrospective analysis was conducted on the clinical data of patients who underwent intramedullary nailing fixation for AO/OTA type A3.3 intertrochanteric fractures at our hospital from January 2012 to January 2022. Patient characteristics as well as treatment details, including operative time, intraoperative blood loss, weight-bearing time, fracture healing time, tip apex distance (TAD) loss, Harris hip scores (HHS), Parker-Palmer mobility score (PPMS), and postoperative complications, were collected and analyzed. Continuous variables were analyzed using independent sample t-tests, while categorical variables were examined using the chi-square test. For group comparisons, variance analysis was applied, and pairwise comparisons were conducted using the LSD-t test.

RESULTS

These patients were divided into PFNA combined with lateral wall reconstruction group (sliding compression group) and InterTAN fixation group (static fixation group) based on surgical methods. The operation time, intraoperative bleeding loss, HHS at 12 months and PPMS at 12 months in the sliding compression group were significantly higher than those in the static fixation group, and time to weight-bearing and fracture healing time were significantly lower than those in the static fixation group (p < 0.05). There were no significant differences between two groups in terms of the TAD at 2 days, 2, and 12 months postoperatively, the incidence of complications (p > 0.05). At 6 months postoperatively, femoral neck length was shortened compared to 2 days postoperatively in both groups, and the sliding compression group had a significantly greater degree of femoral neck shortening than the static fixation group (p < 0.05).

CONCLUSION

The use of PFNA with lateral wall reconstruction for A3.3 intertrochanteric fractures demonstrated superior mobility, efficiency, and reduced internal fixation failure rates compared to InterTAN. These findings suggest that sliding compression may be required for intramedullary nailing treatment.

Open reduction and internal fixation of irreducible displaced femoral neck fracture with femoral Neck System: a preliminary study

BACKGROUND

Most displaced femoral neck fractures can achieve satisfactory anatomical reduction by closed reduction, but there are still some that cannot reset satisfactorily after closed reduction, and open reduction are required. Such fractures that cannot be repositioned successfully by closed reduction are called irreducible displaced femoral neck fractures in this study. The objective of our study was to evaluate the efficacy of direct anterior incision with the Femoral Neck System in the treatment of irreducible displaced femoral fractures.

METHODS

A total of 16 young and middle-aged patients with irreducible displaced femoral neck fractures involving Garden type III and IV were treated using Femoral Neck System fixation by open reduction through Direct Anterior Approach between January 2020 to September 2021. Functional outcomes and postoperative complications were assessed during follow-up. Clinical outcomes were evaluated by the Hip Harris score. The postoperative reduction was evaluated by the Garden Index. Observe postoperative complications.

RESULTS

All patients were followed up with a mean follow-up time of 21.1(12-30) months, and according to radiological results, all patients achieved fracture healing, with a mean healing time of 4.25 months. All 16 patients received grade Garden I and II reductions, and there was no significant difference in the anteroposterior Garden reduction index between the first day after surgery (166.13 ± 5.61) and the 12th month after surgery(164.94 ± 4.49) (P>0.05) and no significant difference in lateral Garden index between the first day after surgery(171.06 ± 4.46) and the 12th month after surgery(169.38 ± 3.98) (P<0.05). According to the Hip Harris score scale, 13 patients received excellent and 3 patients received good. The postoperative Hip Harris Score(17.19 ± 4.8) was significantly higher than the preoperative score(92.19 ± 3.4), and the difference was statistically significant (P < 0.05). No or mild femoral neck shortness occurred in 12 (75%) patients, moderate shortening occurred in 3 (18.75%) patients, and severe shortening occurred in 1 (6.25%) patient. None of the patients experienced femoral head necrosis, fracture nonunion, or incision infection. One patient developed deep venous thrombosis of the lower extremity.

CONCLUSIONS

The Direct Anterior Approach combined with Femoral Neck System is an excellent treatment for irreducible displaced femoral neck fracture and achieved good functional outcomes and anatomical reduction with low complications.

Total hip arthroplasty following the failure of intertrochanteric nailing: First implant or salvage surgery?

BACKGROUND

Proximal femur fractures, including both intracapsular (femoral neck fractures) and extracapsular fractures (intertrochanteric femoral fractures, IFFs), affect around 1.5 million people per year worldwide. Mechanical failures of intertrochanteric nailing in IFFs could be managed with revision total hip arthroplasty (THA).

AIM

To describe the surgical complexity and the procedure-related complication rates in patients with trochanteric nailing failure and treated with THA.

METHODS

Patients referred to our level I trauma center between April 2012 and July 2018 with failed cephalomedullary nailing following trochanteric fractures were retrospectively recruited. All patients underwent a salvage surgical procedure, i.e., cephalomedullary nail removal and conversion to THA. The same surgical and anesthesiology team performed the surgical procedures under spinal anesthesia. All patients underwent clinical and radiographic follow-ups for at least 24 mo. Complications and re-operations were recorded.

RESULTS

Seventy-four patients met the inclusion criteria (male: 29; female: 45; mean age: 73.8-years-old; range: 65-89) and were included in the current study. The average operative time was 117 min (76-192 min). The average blood loss was 585 mL (430-1720 mL). Among the 74 patients, 43 (58.1%) required transfusion of three or more blood units. Two patients died within the 4th d after surgery because of pulmonary embolism, and 1 patient died 9 mo after surgery due to ischemic myocardial infarction. The complication rate in the 71 patients who completed the minimum 24-mo follow-up was 22.5%. In 3 cases out of 71 (4.2%) periprosthetic acetabular fracture was observed during the follow-up. One of these periacetabular fractures occurred intraoperatively. An intraoperative periprosthetic femur fracture was observed in 5 patients out of 71 (7.0%). Four of these patients needed a re-operation to fix the fracture with plates and cerclages; in one of these patients, femoral stem revision was also necessary. In 4 patients out of 71 (5.6%), an early THA dislocation was observed, whereas in 1 case (1.4%) a late THA dislocation was observed. Three patients out of 71 (4.2%) developed a periprosthetic joint infection during the study follow-up.

CONCLUSION

The present study demonstrated that salvage options for IFF fixation failure are complex procedures with a relevant intraoperative and postoperative complication rate.

A biomechanical investigation of a novel intramedullary nail used to salvage failed internal fixations in intertrochanteric fractures

PURPOSE

The ideal approach for revision surgery following femoral head salvage treatments for an intertrochanteric fracture is still up for debate. A novel variety of proximal femoral bionic intramedullary nail (PFBN) has been created in clinical practice. We aimed to compare the biomechanical results of the novel implant to conventional intramedullary and extramedullary fixation in the treatment of intertrochanteric fracture following primary internal fixation failure.

METHODS

Using finite element analysis, we created a three-dimensional model of the intertrochanteric fracture's helical blade cut-out for this investigation. The PFBN 1 group, the PFBN 2 group, the PFNA group, and the DHS group were our four test groups. For each fracture group, the von Mises stress and displacements of the femur and internal fixation components were measured under 2100 N axial loads.

RESULTS

The values for the femoral displacement in the PFBN1 group, PFBN2 group, PFNA group, and DHS group were 6.802 mm, 6.716 mm, 8.080 mm, and 8.679 mm, respectively. The internal implant displacement values were 6.201 mm, 6.138 mm, 7.396 mm, and 8.075 mm in the PFBN1 group, PFBN2 group, PFNA group, and DHS group, respectively. The maximum von Mises Stress in the femoral was 187.2 MPa, 85.18 MPa, 106.6 MPa, and 386.2 MPa in the PFBN1 groups, PFBN2 groups, PFNA groups, and DHS groups, respectively. In the PFBN1 groups, PFBN2 groups, PFNA groups, and DHS groups, the maximum von Mises Stress in internal fixation was 586.7 MPa, 559.8 MPa, 370.7 MPa, and 928.4.8 MPa, respectively.

CONCLUSION

Our biomechanical research demonstrates that intramedullary fixation is more stable than extramedullary fixation when salvaging failed internal fixations in intertrochanteric fracture. Compared with PFNA and DHS, PFBN showed better biomechanical stability in the treatment of patients with revised intertrochanteric fractures. In light of this, we advocate PFBN fixation as the method of choice for intertrochanteric fracture revision. This result still has to be confirmed in more clinical research.

Which non-infection related risk factors are associated with impaired proximal femur fracture healing in patients under the age of 70 years?

BACKGROUND/PURPOSE

Impaired healing is a feared complication with devastating outcomes for each patient. Most studies focus on geriatric fracture fixation and assess well known risk factors such as infections. However, risk factors, others than infections, and impaired healing of proximal femur fractures in non-geriatric adults are marginally assessed. Therefore, this study aimed to identify non-infection related risk factors for impaired fracture healing of proximal femur fractures in non-geriatric trauma patients.

METHODS

This study included non-geriatric patients (aged 69 years and younger) who were treated between 2013 and 2020 at one academic Level 1 trauma center due to a proximal femur fracture (PFF). Patients were stratified according to AO/OTA classification. Delayed union was defined as failed callus formation on 3 out of 4 cortices after 3 to 6 months. Nonunion was defined as lack of callus-formation after 6 months, material breakage, or requirement of revision surgery. Patient follow up was 12 months.

RESULTS

This study included 150 patients. Delayed union was observed in 32 (21.3%) patients and nonunion with subsequent revision surgery occurred in 14 (9.3%). With an increasing fracture classification (31 A1 up to 31 A3 type fractures), there was a significantly higher rate of delayed union. Additionally, open reduction and internal fixation (ORIF) (OR 6.17, (95% CI 1.54 to 24.70, p ≤ 0.01)) and diabetes mellitus type II (DM) (OR 5.74, (95% CI 1.39 to 23.72, p = 0.016)), were independent risk factors for delayed union. The rate of nonunion was independent of fracture morphology, patient's characteristics or comorbidities.

CONCLUSION

Increasing fracture complexity, ORIF and diabetes were found to be associated with delayed union of intertrochanteric femur fractures in non-geriatric patients. However, these factors were not associated with the development of nonunion.

Femoral neck fractures in non-geriatric patients: femoral neck system versus cannulated cancellous screw

BACKGROUND

The fractures of femoral neck account for 50% among hip fractures with around 3%-10% occurring in younger population of below 65 years. The newly introduced FNS as management approach appears to be a potential alternative to the traditional CCS. The aim of this study was to compare the clinical efficacy and outcome of the femoral neck system (FNS) and the cannulated cancellous screw (CCS) in the treatment of femoral neck fractures in adult below 65 years of age.

METHODS

Data of 114 patients between 18-65 years, admitted in our department for femoral neck fracture from January 2019 to March 2021 were retrospectively studied and ranged into two groups based on the surgical methods: FNS group (56 patients) and CCS group (58 patients). The variables of interest including demographic and clinical variables (age, gender, fracture mechanism, injury side and classification), perioperative parameters(operation time, intraoperative bleeding, incision length and hospitalization time), postoperative outcomes and complications (fracture healing time, nonunion rate, femoral neck avascular necrosis, aseptic screw loosening and the Harris Hip Score), were analyzed and compared between the two groups.

RESULTS

All 114 patients presented satisfactory reduction and were followed-up for a period of 12 to 36 months (mean 27 ± 2.07 months); there were no significant differences between both groups in terms of age, gender, fracture classification, side of injury, mechanism of injury, the operative time, intraoperative blood loss and the hospital length of stay. However, the fracture healing time between FNS group and CCS group was statistically significant (p < 0.05), respectively 2.86 ± 0.77 and 5.10 ± 0.81 months. The significant differences were also found in terms of numbers of fluoroscopies 8.34 ± 1.38 Vs 17.72 ± 2.19, the HHS 87.80 ± 1.92 Vs 84.28 ± 2.24, postoperative complications 8 (14.28%) Vs 26 (44.82) respectively in FNS and CCS group.

CONCLUSION

FNS presented satisfactory outcomes had significantly lower complications rate, therefore, can be one of the alternatives for internal implantation devices in treatment of femoral neck fracture in non-geriatric population.

Trochanteric fracture pattern is associated with increased risk for nonunion independent of open or closed reduction technique

PURPOSE

Soft tissue injury and soft tissue injury as risk factors for nonunion following trochanteric femur fractures (TFF) are marginally investigated. The aim of this study was to identify risk factors for impaired fracture healing in geriatric trauma patients with TFF following surgical treatment with a femoral nail.

METHODS

This retrospective cohort study included geriatric trauma patients (aged > 70 years) with TFF who were treated with femoral nailing. Fractures were classified according to AO/OTA. Nonunion was defined as lack of callus-formation after 6 months, material breakage, and requirement of revision surgery. Risk factors for nonunion included variables of clinical interest (injury pattern, demographics, comorbidities), as well as type of approach (open versus closed) and were assessed with uni- and multivariate regression analyses.

RESULTS

This study included 225 geriatric trauma patients. Nonunion was significantly more frequently following AO/OTA 31A3 fractures (N = 10, 23.3%) compared with AO/OTA type 31A2 (N = 6, 6.9%) or AO/OTA 31A1 (N = 3, 3.2%, p < 0.001). Type 31A3 fractures had an increased risk for nonunion compared with type 31A1 (OR 10.3 95%CI 2.2 to 48.9, p = 0.003). Open reduction was not associated with increased risk for nonunion (OR 0.9, 95%CI 0.1 to 6.1. p = 0.942) as was not the use of cerclage (OR 1.0, 95%CI 0.2 to 6.5, p = 0.995). Factors such as osteoporosis, polytrauma or diabetes were not associated with delayed union or nonunion.

CONCLUSION

The fracture morphology of TFF is an independent risk factor for nonunion in geriatric patients. The reduction technique is not associated with increased risk for nonunion, despite increased soft tissue damage following open reduction.

Conversion Total Hip Arthroplasty in the Era of Bundled Care Payments: Impacts on Costs of Care

BACKGROUND

Conversion hip arthroplasty is defined as a patient who has had prior open or arthroscopic hip surgery with or without retained hardware that is removed and replaced with arthroplasty components. Currently, it is classified under the same diagnosis-related group as primary total hip arthroplasty (THA); however, it frequently requires a higher cost of care.

METHODS

A retrospective study of 228 conversion THA procedures in an orthopaedic specialty hospital was performed. Propensity score matching was used to compare the study group to a cohort of 510 primary THA patients by age, body mass index, sex, and American Society of Anesthesiologists score. These matched groups were compared based on total costs, implants used, operative times, length of stay (LOS), readmissions, and complications.

RESULTS

Conversion THA incurred 25% more mean total costs compared to primary THA (P < .05), longer lengths of surgery (154 versus 122 minutes), and hospital LOS (2.1 versus 1.56 days). A subgroup analysis showed a 57% increased cost for cephalomedullary nail conversion, 34% increased cost for sliding hip screw, 33% for acetabular open reduction and internal fixation conversion, and 10% increased costs in closed reduction and percutaneous pinning conversions (all P < .05). There were 5 intraoperative complications in the conversion group versus none in the primary THA group (P < .01), with no statistically significant difference in readmissions.

CONCLUSION

Conversion THA is significantly more costly than primary THA and has longer surgical times and greater LOS. Specifically, conversion THA with retained implants had the greatest impact on cost.

Treatment of postoperative non-union with internal fixation loosening of Garden IV femoral neck fracture with teriparatide in a young adult: A case report

BACKGROUND

Postoperative non-union of femoral neck fracture often needs secondary operation. We report a case of a postoperative non-union of femoral neck fracture treated with teriparatide.

CASE PRESENTATION

A young male patient with Garden IV femoral neck fracture who showed no obvious signs of healing 3 months after percutaneous hollow nail fixation in which the fracture line was enlarged and the hollow nail was withdrawn. Bone non-union healed after 6 months of continuous subcutaneous injection of teriparatide at a dosage of 20 mg/day after the patient refused a secondary surgery. As far as we know, there have been no relevant reports on this type of fracture yet.

CONCLUSIONS

Teriparatide is expected to be beneficial in treating young patients with a displaced femoral neck fracture who have difficulty in healing from non-union and who are keen on avoiding secondary surgery.

Multi-stage treatment for malunion and avascular necrosis of the femoral head following reverse oblique pertrochanteric fracture: A case report and literature review

Femoral reverse oblique intertrochanteric fractures are successfully treated using intramedullary devices. Poor fracture reduction and the use of the inaproppriate implant can lead to implant failure and subsequent malunion or non-union. We present the case of a 21-year-old polytrauma female who, among other injuries, sustained a reverse oblique intertrochanteric fracture that was primarily operated on with the dynamic hip screw. After implant failure the patient developed malunion with bone defect and avascular necrosis of the femoral head. Successful salvage of the bone stock in the inter- and subtrochanteric region was achieved using the two-stage induced membrane technique. The uncemented total hip arthroplasty was performed to address the osteonecrosis of the femoral head.

Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis

Background

Methods

Results

Conclusions

Distally-fixed non-modular monoblock fluted long-stem hemiarthroplasty versus proximal femoral nailing for elderly patients with an osteoporotic intertrochanteric fracture: a retrospective comparative study

BACKGROUND

The treatment of Intertrochanteric fractures in the elderly osteoporotic patient is still controversial. The aim of this study was to compare the outcomes of proximal femoral nailing (PFN) and a distally-fixed non-modular monoblock fluted long-stem hemiarthroplasty (HA) in elderly patients with an osteoporotic intertrochanteric fracture.

METHODS

This retrospective study included patients who had undergone surgery for an unstable intertrochanteric fracture. The patients were separated into PFN and HA groups. The demographic features of the 2 groups were compared. All patients were evaluated using the Singh index, ASA score, AO/OTA classification, Harris Hip Score (HHS), and Parker and Palmer mobility score.

RESULTS

The most common complications were nonunion (12.0%) and cut-out of the screw (10.7%) in the PFN group, and dislocation of the prosthesis (6.7%) and wound infection (5.7%) in the HA group. Overall, the 2-year mortality rate was 29.3%. Mortality, particularly within the first 3 months, was 2.4 times higher in the PFN Group than in the HA group (40% vs. 19.75%). Although the HHS was significantly higher in the first year for the HA group, no significant difference was seen between the 2 groups at 24 months.

CONCLUSIONS

Although PFN and HA have similar good outcomes at 2 years, HA allows earlier mobilisation and has fewer complications and a lower mortality rate.

CT scans better assess lateral wall morphology of "stable appearing" intertrochanteric (IT) femur fractures and predict early failure of sliding hip screw (SHS) fixation

To compare the efficacy of plain x-ray images and computed tomography (CT) to assess the morphology of the lateral wall (LW) component of intertrochanteric (IT) femur fractures and determine predictors of early fixation failure.

DESIGN

Retrospective cohort study.

SETTING

Level-one trauma center.

PATIENTS/PARTICIPANTS

One hundred forty-two adult patients with IT fractures treated with either a sliding hip screw (SHS) or a cephalomedullary nail (CMN) who had both pre-op plain x-ray images and CT scans with at least 6 weeks of follow-up were reviewed.

INTERVENTION

Preoperative CT scan and plain radiographs of the affected hip.

MAIN OUTCOME MEASUREMENTS

Lateral wall assessment based on plain x-rays versus CT imaging in relation to implant failure.

RESULTS

One hundred forty-two patients met inclusion criteria, 105 patients treated with a CMN, and 37 with a SHS. There was a poor correlation between the assessment of the LW on plain x-ray images and CT scans. Failures in the SHS group were significantly associated with all CT measurements (P < .05) but not with plain film LW assessment (P = .66). Fifteen patients had an early implant failure (6 CMN, 9 SHS). There were no statistically significant associations between any radiographic measurement (plain images and CT) and CMN failures.

CONCLUSIONS

Plain film images are not accurate for assessing lateral wall morphology/integrity and are not predictive of SHS implant failures. Our novel CT measurements were effective at detecting lateral wall patterns at risk for treatment failure with SHS implants.Level of Evidence: Level III.

Femoral neck system versus inverted cannulated cancellous screw for the treatment of femoral neck fractures in adults: a preliminary comparative study

BACKGROUND

The femoral neck system (FNS) may be a valid alternative for treating femoral neck fractures, but few studies have compared the outcomes between FNS and cannulated cancellous screws. This study aimed to compare the clinical efficacy and complications of FNS with those of inverted cannulated cancellous screws (ICCS) for the treatment of femoral neck fractures in adults.

METHODS

This retrospective study evaluated patients with femoral neck fractures who underwent FNS or ICCS internal fixation between June 2019 and January 2020. The operative time, intraoperative blood loss, number of fluoroscopies, length of surgical incision, length of hospital stay, time to fracture healing, and other indicators were compared between the two groups. The incidence of complications such as nonunion, avascular necrosis of the femoral head, loosening of the internal fixation, and shortening of the femoral neck during follow-up was also assessed in both groups.

RESULTS

Among the 92 patients included, 47 and 45 patients were categorized into the FNS and ICCS groups, respectively. Follow-up ranged from 14 to 24 months. There were no significant between-group differences in sex, age, side of the injured limb, and type of fracture and in operative time, intraoperative blood loss, incision length, and length of hospital stay (all P > 0.05). The incidence of complications such as fracture nonunion, avascular necrosis of the femoral head, and screw loosening was also comparable between the two groups. However, the number of fluoroscopies was significantly lower in the FNS group than in the ICCS group (P < 0.05). The fracture healing time was also significantly lower in the FNS group than in the ICCS group (P < 0.05). Furthermore, the femoral neck shortening and Harris hip score at the last follow-up were significantly better in the FNS group than in the ICCS group (P < 0.05).

CONCLUSIONS

FNS for femoral neck fractures improves hip functional recovery and reduces the femoral neck shortening rate and fluoroscopy exposure postoperatively. Thus, FNS can be an alternative to ICCS for the treatment of femoral neck fractures.

Osteosynthesis of non-displaced femoral neck fractures in the elderly population using the femoral neck system (FNS): short-term clinical and radiological outcomes

Background

Femoral neck fractures (FNF) are frequent in the elderly population, and surgical management is indicated in the vast majority of cases. Osteosynthesis is an alternative to arthroplasty for non-displaced FNF. Triple screw construct (TS) and the dynamic hip screw system (DHS) are considered gold standards for osteosynthesis. The newly available femoral neck system (FNS) currently lacks evidence as to whether it is a valid alternative to TS and DHS. The purpose of this study was to evaluate the short-term clinical and radiological outcomes after non-displaced (Garden I and II) FNF osteosynthesis using TS, DHS, and FNS.

Methods

All the patients of the author’s institution aged ≥ 75 years with a non-displaced (Garden I and II) FNF eligible for osteosynthesis between November 2015 and December 2019 were included in this single-center retrospective non-randomized study. Patients were treated with either TS, DHS, or FNS depending on the surgeon’s preference. Clinical data (age, gender, ASA score, duration of surgery, need for blood transfusion and number of packed red blood cells transfused, surgical site complications, length of stay, discharge location, postoperative medical complications and readmission within 30 days, and mortality within 3 months) were extracted from the patients’ charts. The radiological analysis assessed the fracture classification, fracture impaction, and proximal femur shortening at 3 and 6 months using the institutional imaging software.

Results

Baseline characteristics in the TS (n = 32), DHS (n = 16), and FNS (n = 15) groups were similar with respect to age (mean 85 years), gender (female to male ratio 4:1), and ASA score. There were no significant differences across the groups for the need for blood transfusion, surgical site complications, length of stay, postoperative medical complications and readmission within 30 days, discharge location, and mortality within 3 months. The duration of surgery was significantly lower in the FNS group (43.3 vs 68.8 min; p < 0.001). The radiological assessment found similar impaction (5.2 mm ± 4.8) and shortening (8.6 mm ± 8.2) in all groups that did not seem to progress after 3 months.

Conclusion

The FNS appears to be a valid alternative implant for FNF osteosynthesis and is associated with a shorter operative time than TS and DHS. Short-term clinical and radiological outcomes of FNS are similar to TS and DHS implants. Further long-term multicenter randomized studies are however necessary to confirm these first results.

Proximal femoral replacement: A salvage treatment of cephalomedullary nails' mechanical failures in the elderly population

BACKGROUND

The use of proximal femoral replacements (PFR) has been recently described for catastrophic internal fixation failures. PFR is an attractive treatment option because it is technically straightforward and allows for immediate mobilization of the patient. The aim of the study was to determine the survivorship, functional outcome and complications' rate in a group of elderly patients who underwent proximal femoral replacement as a salvage treatment after femur cephalomedullary nails' mechanical failures.

METHODS

We evaluated 21 patients who underwent salvage of a failed cephalomedullary nail by using a single design PFR at our institution between 2014-2017. A cemented stem was used in all cases. Radiographs were assessed for fractures, sign of loosening, presence of heterotopic ossification and leg length discrepancy. Functional evaluation was performed through Harris Hip Score (HHS), FIM™ and Time Up and Go test (TUG). Kaplan-Meier estimator was used to determine the overall implants' survival.

RESULTS

The average age at the time of surgery was 83years. The mean follow-up was 3.1years. We recorded 3 dislocations of which 2 required a revision. No case of septic or aseptic failure was reported. Two patients died respectively at 11 and 14 months after surgery. At the last follow-up the mean HHS, FIM™, and the TUG improved significantly (p<0.05).

CONCLUSION

Immediate weight bearing, good functional outcomes, low complications' and one-year mortality rate make the proximal femur replacement with megaprostheses a potential first line treatment of intertrochanteric/subtrochanteric fixations' failures among elderly, osteoporotic, frail patients. Dislocation is the most common complication to bear in mind within the first six months after surgery.

Surgical Treatment of Internal Fixation Failure of Femoral Peritrochanteric Fracture

Objective

To investigate the factors, surgical treatment methods and clinical effect of internal fixation failure of intertrochanteric and subtrochanteric fractures.

Methods

From June 2015 to May 2019, arthroplasty and internal fixation revision were used to treat 18 cases of internal fixation failure of intertrochanteric and subtrochanteric fractures. There were 10 males and eight females, with an average age of 67.3 years (38–92 years). The 16 cases of initial intertrochanteric fractures were classified according to AO/OTA:13 cases of A2 and 3 cases of A3, the other 2 cases were subtrochanteric fractures (Seinsheimer type IV). The internal fixation failure was treated with total hip arthroplasty (6 cases), bipolar hemiarthroplasty (4 cases), revision with proximal femoral lockingplate (4 cases) and extend intramedullary nail (4 cases).

Results

All patients were followed up for an average of 24.7 months (range, 12 to 36 months). The average operative time was 111.4 min (range, 72 to 146 min) and the average intraoperative blood loss was 403.6 mL (range, 200 to 650 mL). The average time of fracture union was 6.9 months (range, 5 to 9 months) for cases of internal fixation revision. The operative time of the arthroplasty group was shorter than the revision group (P < 0.001), and the intraoperative blood loss of the arthroplasty group was less than the revision group (P = 0.001). The affected limb shortening of postoperative (0.21 ± 0.19 cm) was better than preoperative (2.01 ± 0.60 cm) (P < 0.001), while the limb shortening of the arthroplasty group (0.11 ± 0.21 cm) was less than the revision group (0.33 ± 0.09 cm) (P = 0.015). At the last follow‐up, all injured limbs regained walking function, and the Harris hip score was 81.3 ± 9.4 points. The Harris score of postoperative was better than preoperative (33.4 ± 5.9 points) (P < 0.001), while there were no significant differences between the arthroplasty group and the revision group at 3 months (76.5 ± 8.5 vs 71.1 ± 10.6, P = 0.249), 6 months (80.9 ± 7.9 vs 78.9 ± 12.9,P = 0.687) postoperative and the last follow‐up (80.5 ± 8.3 vs 82.3 ± 11.7, P = 0.716) respectively.

Conclusion

For internal fixation failure of peritrochanteric fractures, young patients could accept internal fixation revision to restore normal anatomical structure, correct varus deformity and autograft; while elderly patients and patients with damaged femoral head could be treated with arthroplasty to restore walking function.

Decision making in the management of malunion and nonunion of intertrochanteric fractures of the hip

AIM

Intertrochanteric fractures account for almost 50% of hip fractures.Nonunion and malunion of these fractures are relatively uncommon. This study reviews the outcome of 31 cases of intertrochanteric fracture failures. An algorithm for the management of these injuries is also proposed.

METHODS

19 patients with intertrochanteric malunion and 12 patients with non-union were included in this study. Treatment of these injuries was initiated according to the algorithm proposed in this study. Treatment outcomes were evaluated by assessing union, pre and postoperative shortening and HSA (head-shaft angle). Functional outcomes were assessed by the Parker mobility scale and presence or absence of pain.

RESULTS

All the patients with intertrochanteric malunion with follow-up had united. The postoperative shortening in all patients were ⩽2.5 cms. Patients having intertrochanteric nonunion with follow-up, who underwent internal fixation had united with an acceptable Parker mobility scale score, except in 1 patient who sustained an ipsilateral distal femur fracture. The average HSA correction obtained was 21° (range 3-60°).

CONCLUSION

The algorithm proposed in this study helps streamline the treatment according to each case scenario.It helps in planning and managing patients with intertrochanteric fracture failures.

Revision surgery due to failed internal fixation of intertrochanteric femoral fracture: current state-of-the-art

Failed treatment of intertrochanteric (IT) femoral fractures leads to remarkable disability and pain, and revision surgery is frequently accompanied by higher complication and reoperation rates than primary internal fixation or primary hip arthroplasty. There is an urgent need to establish a profound strategy for the effective surgical management of these fragile patients. Salvage options are determined according to patient physiological age, functional level, life expectancy, nonunion anatomical site, fracture pattern, remaining bone quality, bone stock, and hip joint competency. In physiologically young patients, care should be taken to preserve the vitality of the femoral head with salvage internal fixation; however, for the elderly population, conversion arthroplasty can result in early weight bearing and ambulation and eliminates the risks of delayed fracture healing. Technical challenges include a difficult surgical exposure, removal of broken implants, deformity correction, critical bone defects, poor bone quality, high perioperative fracture risk, and prolonged immobilization. Overall, the salvage of failed internal fixations of IT fractures with properly selected implants and profound techniques can lead to the formulation of valuable surgical strategies and provide patients with satisfactory clinical outcomes.

Comparison of dynamic hip screw and antirotation screw with cannulated screw in the treatment of transcervical collum femoris fractures

OBJECTIVES

This study aims to compare the results of internal fixation with dynamic hip screw (DHS)/antirotation screw and conventional cannulated screw (CS) for femoral neck fracture.

PATIENTS AND METHODS

This retrospective study included a total of 78 patients (57 males, 21 females) with collum femoris fractures treated with internal fixation between January 2015 and January 2019. Group 1 comprised 41 patients with a mean age of 45.7 years (range, 19 to 62 years) treated with DHSs/antirotation screws, while group 2 comprised 37 patients with a mean age of 41.9 years (range, 17 to 75 years) treated with CSs. The patients were evaluated for union, avascular necrosis (AVN), femoral neck shortness, operation time, duration of fluoroscopy exposure, and functional outcomes.

RESULTS

Age, gender, and Garden classification stages were similar in both groups. No significant difference was found between the groups in respect of AVN and non-union rates. The non-union rate was 12.2% in group 1 and 21.6% in group 2 (p>0.05). The duration of fluoroscopy exposure was statistically significantly higher in group 2 (p=0.001) and the operation time was statistically significantly longer in group 1 (p=0.001). In group 2, femoral neck shortness stature was significantly higher (p=0.007). At the final follow-up examination, the Harris hip score was statistically significantly higher in group 1 (p=0.04).

CONCLUSION

Dynamic hip screw/antirotation screw was a more relevant treatment method for transcervical femoral neck fractures compared to CS with more favorable functional outcomes and less fluoroscopy exposure.

Salvage treatment of failed internal fixation of intertrochanteric fractures: What factors determine the failure of treatment?

INTRODUCTION

The purpose of this study is to evaluate the clinical and radiographic result in patients who got salvage treatment for the failed fixation of intertrochanteric fracture and to evaluate the factors that may affect healing of these treatment.

PATIENTS AND METHODS

Between 1997 and 2016, 39 patients who could be followed up for more than 1 year after treatment were enrolled. For determining of factor that may affect healing of treatment, the primary outcome was based on union. There were success group which achieved a restored union and failure group which had an additional revisional surgery because of another complication for analysis. And neck-shaft angle (NSA) was measured with a goniometer.

RESULTS

Fracture healing as a primary outcome (after revision surgery) was achieved 31 out of 39 patients (80%). There were no statistically significant differences between two groups in terms of age, sex, BMI and laterality. In the clinical outcomes, four categories of outcomes were compared between the success and failure groups and significant improvements were observed. In measurements at final follow-up, it the angle was 133.4° in the success group and 123.4° in the failure group.

CONCLUSION

The clinical and radiographic results of the salvage treatment for the failed fixation of intertrochanteric fracture were satisfactory in our study. Restoration of femoral neck-shaft angle of failed intertrochanteric fracture is key factors for obtaining successful results.

The utility of the angled blade plate in hip fracture nonunion treatment: A report of three cases and review of the literature

Objectives:

We report the radiographic and clinical outcome of patients treated with an angled blade plate (ABP) for hip fracture nonunion. We also provide a review of the literature on joint preserving treatment approaches to hip fracture nonunions.

Design:

Retrospective, case series.

Setting:

Tertiary academic hospital.

Patients/Participants:

Three.

Intervention:

We treated three patients with varied hip fracture nonunions using a joint preserving approach with an ABP.

Main outcome measurements:

Radiographic union and clinical outcome.

Results:

All three patients achieved radiographic union, and were ambulating without pain at final follow-up.

Conclusions:

The treatment approach to hip fracture nonunions is either restorative (joint preserving) or reconstructive (joint replacing). The primary restorative approach to nonunions around the hip consists of revision open reduction and internal fixation with or without bone grafting. Though a variety of implants and treatment techniques have demonstrated excellent success in this setting, revision open reduction and internal fixation with an ABP remains an efficacious implant selection in hip nonunion surgery.

Vascularized Fibular Grafting in Treatment of Femoral Neck Nonunion: A Prognostic Study Based on Long-Term Outcomes

BACKGROUND

The purpose of this study was to evaluate the long-term efficacy and prognostic factors predicting success of revision surgery with free vascularized fibular grafting (FVFG) for treatment of femoral neck nonunion.

METHODS

We prospectively enrolled patients who underwent revision surgery with FVFG between January 2001 and January 2013 in a tertiary hospital in China. A total of 98 patients with a minimum 5-year follow-up were included for analysis. The criteria for FVFG failure were conversion to hip arthroplasty, recommendation for a hip arthroplasty, or a Harris hip score of <80 points. Demographic information, the preoperative neck shortening ratio (NSR), the fixation method, and postoperative radiographic parameters including the postoperative NSR and neck-shaft angle (NSA) were recorded for prognostic analysis.

RESULTS

At an average of 9.8 ± 3.5 years (range, 3 to 17 years) postoperatively, the overall success rate of this surgical procedure was 77% (75 of 98). The success and failure groups had no significant differences in age, fixation method, interval between initial fixation and revision surgery, or postoperative NSA. The success group had a significantly higher NSR than the failure group both preoperatively (77.8% versus 62.4%, p < 0.001) and postoperatively (87.6% versus 78.4%, p = 0.001). The receiver operating characteristic (ROC) curve analysis revealed an optimal cutoff for preoperative NSR of 60% to predict the outcome. Patients with a preoperative NSR of >60% had a success rate of 91% (68 of 75).

CONCLUSIONS

Revision surgery with FVFG and internal fixation is an effective and important option for treating nonunion of the femoral neck in young patients without severe preoperative shortening and neck resorption (preoperative NSR of >60%).

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Treatment Strategies for Failed Fixation of Intertrochanteric Fractures

INTRODUCTION

Despite the generally successful outcome of intertrochanteric fracture fixation, the treatment is challenging when fixation failure occurs. Some studies have reported a systemic treatment strategy for salvaging failed intertrochanteric fracture fixation. This prospective study with a retrospective review of data aimed to evaluate and validate the efficacy of an evidence-based protocol developed for the treatment of failed intertrochanteric fractures.

PATIENTS AND METHODS

Between 1997 and 2016, 83 patients who could be followed up for more than 1 year after treatment were enrolled at an academic medical centre. An evidence-based protocol was established in July 2008 and was implemented prospectively. The treatment protocol was determined keeping in mind the condition of the femoral head, the deformation of the fracture site and the bone defect. Clinical results were evaluated, and fracture union and femoral neck-shaft angle were evaluated radiographically for patients in valgus osteotomy and re-fixation subgroups.

RESULTS

The Pain score, leg length discrepancy, Koval score for ambulatory levels and modified Harris Hip Score showed statistically significant improvement after the implementation of the new protocol. The radiographic success rate was 73% (27 of 37 patients) in the pre-protocol group and 91% (42 of 46 patients) in the post-protocol group, which shows statistically significantly improvement.

CONCLUSION

The new treatment strategy for failed intertrochanteric fracture fixation based on the condition of the femoral head, deformation of the fracture site and bone defect is successful based on clinical and radiographic results. Restoration of NSA of failed intertrochanteric fractures is a key factor for obtaining successful results.

High rate of reoperation and conversion to total hip arthroplasty after internal fixation of young femoral neck fractures: a population-based study of 796 patients

Background and purpose - Most often, the goal of non-geriatric femoral neck fracture surgery is to preserve the native hip joint. However, reoperations for painful implants, osteonecrosis, and nonunion are common. We determined the reoperation rate and time-to-reoperation following internal fixation of these fractures in a large population cohort. Patients and methods - This retrospective cohort study included patients between the ages of 18 and 50 years old who underwent internal fixation for a femoral neck fracture during 1997-2013. Patients were followed until December 2013. Primary outcomes were reoperation rate and time-to-reoperation. Time-to-event analysis was performed to estimate the rate of any reoperation and for THA specifically, while testing the dependency of time-to-reoperation on secondary variables. Results - 796 young femoral neck fracture patients were treated with internal fixation during the study period (median age 43 years, 39% women). Median follow-up was 8 years (IQR 4-13). One-third underwent at least 1 reoperation at a median 16 months after the index surgery (IQR 8-31). Half of reoperations were for implant removal, followed by conversion to total hip arthroplasty. 14% of the cohort were converted to THA. The median time to conversion was 2 years (IQR 1-4). Neither female sex nor older age had a statistically significant effect on time-to-reoperation or time-to-THA conversion. Interpretation - Following internal fixation of young femoral neck fracture, 1 in 3 patients required a reoperation, and 1 in 7 were converted to THA. These data should be considered by patients and surgeons during treatment decision-making.

Principles of Valgus Intertrochanteric Osteotomy (VITO) after Femoral Neck Nonunion

Nonunion is a relatively rare, yet challenging problem after fracture of the femoral neck. Risk factors include verticality of the fracture line and presence of comminution of the posteromedial calcar, as well as quality of reduction. Treatment options consist of valgus intertrochanteric osteotomy versus arthroplasty. Treatment should be tailored to the individual patient, taking into account patient age and activity demands. This review outlines the principles and technical considerations for valgus osteotomy of the proximal femur in the setting of femoral neck nonunion.

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.

Salvage for intramedullary nailing breakage after operative treatment of trochanteric fractures

BACKGROUND

Trochanteric fractures are one of the most common fractures in elderly people. The use of intramedullary nails is an option for their treatment, especially in unstable patterns. Nail breakage is a rarely reported complication. The aim of this study was to determine the prevalence of nail breakage in our center. Secondary objectives are to show the management of this complication in our institution as well as the technical problems, complications and final outcomes of these patients in our hands.

MATERIAL AND METHODS

In a retrospective case series review between 2010 and 2015, we analyzed 1481 patients with trochanteric and subtrochanteric fractures who had been treated by cephalomedullary nailing in our centre. 13 patients with nail breakage were identified.

RESULTS

The percentage failure rate in our institution is 0.87%. 9 (69.2%) patients were women and 4 (3.8%) were men, with a mean age of 74.6 years (range 47-90). In all cases the mechanism of injury was a simple fall from standing height. Initial fracture types were: 1 case of AO/OTA 31A1, 6 cases of AO/OTA 31A2 and 6 cases of AO/OTA 31A3. Only 3 cases had a good overall reduction with a correct TAD, an optimal femoral neck-shaft angle and absence of fracture gaps >5 mm after surgery. The average time from the first surgery to the diagnosis of implant breakage was 333 days (range 70-1460), 11 months. Breakage occurred at the nail junction with the lag screw in 11 cases and in the distal nail aperture in 2 cases.

CONCLUSIONS

An insufficient reduction with varus and fracture gaps >5 mm, the use of short nails in unstable patterns with subtrochanteric involvement and patients with certain comorbidities are facts observed that can contribute to the development of delayed or nonunion with subsequent nail breakage. Different salvage treatments, conversion to hip arthroplasty or revision osteosynthesis, may be considered but we think that prevention has to be the best treatment.

Alternative Payment Models Should Risk-Adjust for Conversion Total Hip Arthroplasty: A Propensity Score-Matched Study

BACKGROUND

For Medicare beneficiaries, hospital reimbursement for nonrevision hip arthroplasty is anchored to either diagnosis-related group code 469 or 470. Under alternative payment models, reimbursement for care episodes is not further risk-adjusted. This study's purpose was to compare outcomes of primary total hip arthroplasty (THA) vs conversion THA to explore the rationale for risk adjustment for conversion procedures.

METHODS

All primary and conversion THAs from 2007 to 2014, excluding acute hip fractures and cancer patients, were identified in the National Surgical Quality Improvement Program database. Conversion and primary THA patients were matched 1:1 using propensity scores, based on preoperative covariates. Multivariable logistic regressions evaluated associations between conversion THA and 30-day outcomes.

RESULTS

A total of 2018 conversions were matched to 2018 primaries. There were no differences in preoperative covariates. Conversions had longer operative times (148 vs 95 minutes, P < .001), more transfusions (37% vs 17%, P < .001), and longer length of stay (4.4 vs 3.1 days, P < .001). Conversion THA had increased odds of complications (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.37-2.24), deep infection (OR 4.21; 95% CI 1.72-10.28), discharge to inpatient care (OR 1.52; 95% CI 1.34-1.72), and death (OR 2.39; 95% CI 1.04-5.47). Readmission odds were similar.

CONCLUSION

Compared with primary THA, conversion THA is associated with more complications, longer length of stay, and increased discharge to continued inpatient care, implying greater resource utilization for conversion patients. As reimbursement models shift toward bundled payment paradigms, conversion THA appears to be a procedure for which risk adjustment is appropriate.

Dynamic hip system blade versus cannulated compression screw for the treatment of femoral neck fractures: A retrospective study

OBJECTIVE

The aim of this study was to compare clinical outcomes of patients with femoral neck fractures treated with the dynamic hip system blade (DHS-BLADE) or cannulated compression screws.

METHODS

Eighty-six patients with femoral neck fractures were treated by closed reduction internal fixation with a DHS-BLADE (n = 42; 18 males and 24 females; mean age: 56.3 years (37-87)) or cannulated compression screws (n = 44; 20 males and 24 females; mean age: 53.8 years (26-83)) between March 2011 and August 2013. The groups were compared with Harris hip score, operation time, surgical blood loss, incision size, hospital stay, and related complications.

RESULTS

The average follow-up time was 27 months (range, 24-36 months). There was no significant difference for the operation time, incision size, hospital stay, and Harris hip score between the groups. Also, no statistically significant differences in the rates of nonunion (4.5% vs. 0) and avascular necrosis of the femoral head (9.1% vs. 7.1%) were observed. However, the screw group experienced significantly less surgical blood loss (32.4 ± 24.7 ml) than the blade group (87.2 ± 46.6 ml; P = 0.041). The incidence of femoral neck shortening above 10 mm in the screw group was significantly higher than that in the blade group (15.9% vs. 2.4%, P = 0.031). The blade group had a significantly lower incidence of screw migration than the screw group (4.8% vs. 22.7%, P = 0.016).

CONCLUSION

The DHS-BLADE and cannulated compression screws might be equally effective in terms of postoperative fracture union. However, the DHS-BLADE has advantages over cannulated compression screws for preventing femoral neck shortening, screw migration, and cut-out.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Intertrochanteric Osteotomy for Femoral Neck Nonunion: Does "Undercorrection" Result in an Acceptable Rate of Femoral Neck Union?

OBJECTIVES

To analyze the radiographic outcomes of intertrochanteric osteotomy for the treatment of femoral neck nonunion with "undercorrection" of the Pauwels angle and relative preservation of the proximal femoral anatomy.

DESIGN

Retrospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Thirty-two patients with established femoral neck nonunions that had been treated with intertrochanteric osteotomy were retrospectively identified through Current Procedural Terminology codes. Seven patients were treated with 30 degree closing wedge osteotomy and 25 with a 20 degree or smaller osteotomy.

INTERVENTION

Valgus-producing intertrochanteric osteotomy with a blade plate.

MAIN OUTCOME MEASUREMENTS

Femoral neck and intertrochanteric osteotomy osseous union.

RESULTS

Thirty-one of 32 patients (97%) went on to osseous union of the femoral neck and all intertrochanteric osteotomies healed. There was no significant difference in the rate of union of the femoral neck between those patients treated with 30 versus 20 degree or less osteotomies. After osteotomy, the mean Pauwels angle decreased from 71 degrees (range 52-95 degrees) to 47 degrees (range 23-67 degrees) and the mean proximal femoral offset decreased by 11 mm (range 0-23 mm). Seven patients developed radiographic signs of avascular necrosis after osteotomy (22%). Three patients of these patients were converted to total hip arthroplasty (9%). Patients treated with a 30 degree osteotomy were more likely to develop avascular necrosis (67% vs. 12%, P-value = 0.014).

CONCLUSIONS

Valgus-producing intertrochanteric osteotomy with a smaller degree of correction than has been traditionally described leads to an excellent rate of radiographic union while preserving more of the native proximal femoral anatomy.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis

BACKGROUND

The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ≤65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario.

METHODS

A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis.

RESULTS

THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs.

CONCLUSIONS

Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group.

LEVEL OF EVIDENCE

Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Total Hip Arthroplasty for Implant Rupture after Surgery for Atypical Subtrochanteric Femoral Fracture

Treatment methods for delayed union and nonunion of atypical femoral fracture are still controversial. Moreover, no treatment method has been established for implant rupture caused by delayed union and nonunion. We encountered a 74-year-old female in whom nonunion-induced implant rupture occurred after treatment of atypical subtrochanteric femoral fracture with internal fixation using a long femoral nail. It was unlikely that sufficient fixation could be obtained by repeating osteosynthesis alone. Moreover, the patient was elderly and early weight-bearing activity was essential for early recovery of ADL. Based on these reasons, we selected one-stage surgery with total hip arthroplasty and osteosynthesis with inverted condylar locking plate as salvage procedures. Bone union was achieved at 6 months after surgery. This case illustrated that osteosynthesis-combined one-staged total hip arthroplasty could be considered as one of the options for nonunion-induced implant rupture of atypical femoral subtrochanteric fracture.

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 for Failed Internal Fixation After Femoral Neck Fracture Versus That for Acute Displaced Femoral Neck Fracture: A Comparative Study

The outcome of total hip arthroplasty (THA) for failed internal fixation after femoral neck fracture (FNF) versus that for acute displaced femoral neck fracture is still controversial. This study retrospectively analyzed a consecutive series of 130 THAs for acute displaced FNF (64, group I) and for failed internal fixation (66, group II). Results showed THAs in group II were more technically demanding procedures with longer operative time and larger amounts of drainage compared to that in group I. Furthermore, multivariate analysis revealed that the associations between THAs (group II) and hip complications were notable (OR=4.15, P=0.017). These increased risks should be paid much attention to, not only for choosing the appropriate treatment option, but also for providing effective perioperative care.

Salvage for nail breakage in femoral intramedullary nailing

Proximal fractures of femur represent an important cause of hospitalization, morbidity and mortality for elderly patients. Femoral intramedullary nailing is an option to achieve a stable osteosynthesis but the breakage is a rare complication. The aim was to determinate the prevalence, causes, management and functional outcomes of this patients in our hands. Retrospective review of 1246 proximal femur fractures operated between 2003 and 2012. We analyse epidemiological data, fracture type and the quality of closed reduction and fixation by preoperative and postoperative radiology. Type of salvage procedure chosen for each case is presented. Functional outcome and quality of life questionnaire was obtained by Barthel index and Short Form 12 version 2. 11 cases (0.88%) were identified. The type of initial fracture was 7 cases AO/OTA 31A3 and 4 cases AO/OTA 31A2. The implant failure was detected at 11 months after surgery (SD 6.39). Nail breakage occurred in three different points: 7 cases in the proximal aperture, 3 cases in cervicocephalic screw and 1 case in the distal aperture of the nail. The association of nonunion at fracture site and progressive hip pain was observed in all cases. Different salvage procedures were performed: 7 cases osteosynthesis revision (nail or dynamic condilar screw plate), 2 cases arthroplasty and 2 cases conservative treatment. The main Barthel score before the salvage procedure was 63.2 (SD 13). At final follow-up, this score improved to 72.8 (SD 20.38). To the best of our knowledge, this study represents the largest series of cases of trochanteric nail breakage due to material fatigue. This complication is rare (0.88%) that can foresee in unstable fractures with delayed union. The type of salvage should be individualized showing acceptable functional outcome in our series.

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.

Functional outcome after successful internal fixation versus salvage arthroplasty of patients with a femoral neck fracture

OBJECTIVES

To determine patient independency, health-related and disease-specific quality of life (QOL), gait pattern, and muscle strength in patients after salvage arthroplasty for failed internal fixation of a femoral neck fracture.

DESIGN

Secondary cohort study to a randomized controlled trial.

SETTING

Multicenter trial in the Netherlands, including 14 academic and nonacademic hospitals.

PATIENTS

Patients after salvage arthroplasty for failed internal fixation of a femoral neck fracture were studied. A comparison was made with patients who healed uneventfully after internal fixation.

INTERVENTION

None (observatory study).

MAIN OUTCOME MEASUREMENTS

Patient characteristics, SF-12, and Western Ontario McMaster osteoarthritis index scores were collected. Gait parameters were measured using plantar pressure measurement. Maximum isometric forces of the hip muscles were measured using a handheld dynamometer. Differences between the fractured and contralateral leg were calculated. Groups were compared using univariate analysis.

RESULTS

Of 248 internal fixation patients (median age, 72 years), salvage arthroplasty was performed in 68 patients (27%). Salvage arthroplasty patients had a significantly lower Western Ontario McMaster osteoarthritis index score (median, 73 vs. 90; P = 0.016) than patients who healed uneventfully after internal fixation. Health-related QOL (SF-12) and patient independency did not differ significantly between the groups. Gait analysis showed a significantly impaired progression of the center of pressure in the salvage surgery patients (median ratio, -8.9 vs. 0.4, P = 0.013) and a significant greater loss of abduction strength (median, -25.4 vs. -20.4 N, P = 0.025).

CONCLUSIONS

Despite a similar level of dependency and QOL, salvage arthroplasty patients have inferior functional outcome than patients who heal after internal fixation of a femoral neck fracture.

LEVEL OF EVIDENCE

Therapeutic level III.

Cannulated Screw Fixation For Femoral Neck Fractures : A 5-year Experience In A Single Institution

Cannulated screw fixation is a widely accepted surgical method for management of fractures of the neck of femur especially in patients with poor premorbid conditions, minimally displaced fractures and those from a younger age group. A five year retrospective study was carried out in 53 consecutive patients between 2006 to 2010 to determine the pattern of injuries, management, outcomes and the associated predictive factors.All the patients underwent cannulated screw fixation, with 37 (69.8%) having had surgery within 24 hours and the remaining 16 (30.2%) 24 hours after the initial injury. All patients were followed up to union of fractures and complications thereafter if any. Good outcome was observed in 43 (81.1%) patients leaving only 10 (18.9%) patients with a poor outcome, of whom nine developed avascular necrosis (90%) and one non-union (10%). We found no significant relationship between the incidence of avascular necrosis and age of patient, fracture displacement, numbers of cannulated screws used, fracture reduction acceptability and anatomical location of the fracture. The time interval from injury to surgery and the presence of posterior comminution did seem to influence the rate of avascular necrosis but due to the small number of patients, was not statistically significant.We conclude that cannulated screw fixation is a viable option of treatment for fractures of the neck of femur.

Modified Pauwels’ intertrochanteric osteotomy in the management of nonunion of a femoral neck fracture following failed osteosynthesis

We report the outcome of 39 patients who underwent a modified Pauwels’ intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels’ classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d’Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed.

Cite this article: Bone Joint J 2014;96-B:1198–1201.

Management of femoral neck fractures in the young patient: A critical analysis review

Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls. Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures. However, for the physiologically young patients, preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands. The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures. Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population. Furthermore, other management variables such as surgical timing, the role of capsulotomy and the choice of implant for fixation remain controversial. This review will focus both on the demographics and injury profile of young patients with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.

Incidence of bacterial contamination in primary THA and combined hardware removal: analysis of preoperative aspiration and intraoperative biopsies

Prior fracture surgery in the setting of subsequent arthroplasty may confer an increased risk of infection. The current authors retrospectively reviewed 122 patients from 2006 to 2010. Joint aspirations performed preoperatively in two of 52 patients revealed bacterial growth. Preoperative CRP levels were elevated in 22.8% with a mean value of 10.4 mg/L (range 5.5 to 33.3). Intra-operative cultures were performed in 109 patients, with a single patient sample exhibiting bacterial growth (0.9%). Preoperative aspiration showed a sensitivity of 1.0 and specificity of 0.98 (P<0.039) for bacterial contamination. There was no postoperative periprosthetic infection noted. In conclusion the retrieval of internal fixation devices and total hip arthroplasty can be performed safely as a single stage procedure without significantly increasing the risk of periprosthetic infection.

Treatment and displacement affect the reoperation rate for femoral neck fracture

BACKGROUND

Femoral neck fractures (FNFs) comprise 50% of geriatric hip fractures. Appropriate management requires surgeons to balance potential risks and associated healthcare costs with surgical treatment. Treatment complications can lead to reoperation resulting in increased patient risks and costs. Understanding etiologies of treatment failure and the population at risk may decrease reoperation rates.

QUESTIONS/PURPOSES

We therefore (1) determined if treatment modality and/or displacement affected reoperation rates after FNF; and (2) identified factors associated with increased reoperation and timing and reasons for reoperation.

METHODS

We reviewed 1411 records of patients older than 60 years treated for FNF with internal fixation or hemiarthroplasty between 1998 and 2009. We extracted patient age, sex, fracture classification, treatment modality and date, occurrence of and reasons for reoperation, comorbid conditions at the time of each surgery, and dates of death or last contact. Minimum followup was 12 months (median, 45 months; range, 12-157 months).

RESULTS

Internal fixation (hazard ratio [HR], 6.38) and displacement (HR, 2.92) were independently associated with increased reoperation rates. The reoperation rate for nondisplaced fractures treated with fixation was 15% and for displaced fractures 38% after fixation and 7% after hemiarthroplasty. Most fractures treated with fixation underwent reoperation within 1 year primarily for nonunion. Most fractures treated with hemiarthroplasty underwent reoperation within 3 months, primarily for infection.

CONCLUSIONS

Overall, hemiarthroplasty resulted in fewer reoperations versus internal fixation and displaced fractures underwent reoperation more than nondisplaced. Our data suggest there are fewer reoperations when treating elderly patients with displaced FNFs with hemiarthroplasty than with internal fixation.

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.

Salvage hip arthroplasty after failed fixation of proximal femur fractures

We reviewed 46 patients who underwent salvage hip arthroplasty (SHA) for revision of failed cannulated screws (CS), sliding hip screws (SHS), or intramedullary nails (IMN). The primary objective was to determine differences in operative difficulty. SHA after failed femoral neck fixation was associated with lower intra-operative demands than after failed peri-trochanteric fractures. Similarly, analysis by the index implant found that conversion arthroplasty after failed CSs was associated with lower intra-operative morbidity than failed SHSs or IMNs; differences between SHS and IMN were not as clear. Importantly, intra-operative data in cases of failed SHSs were similar regardless of the original fracture type, showing the device played a larger role than the fracture pattern. Complications and revision surgery rates were similar regardless of fracture type or fixation device. Our results suggest that operative demands and subsequent patient morbidity are more dependent on the index device than the fracture pattern during SHA.