Conversion total hip arthroplasty with a proximally modular, distal fixation reconstruction prosthesis following cephalomedullar nail failure

Outcomes of conversion total hip arthroplasty for failed fixation of intertrochanteric fractures with monoblock distal-loading reconstruction stem

PURPOSE

The aim of our study was to analyze the clinical and radiological outcomes of conversion total hip arthroplasty (THA) for failed fixation of proximal femur fractures with monoblock grit-blasted titanium reconstruction stem (Wagner self-locking stem, Zimmer).

PATIENTS AND METHODS

Thirty-nine patients were included in this retrospective analysis undergoing conversion THA for failed cephalomedullary nail or dynamic hip screw fixation for intertrochanteric fractures from January 2017 to January 2022. The clinical evaluation was done using Harris hip score. The radiological outcomes measured were subsidence, level of osteointegration, stem-canal fill ratio and heterotopic bone formation. The complications were noted postoperatively and during the follow-up.

RESULTS

The mean follow-up at the end of the study was 27.8 months (range, 14-72 months). There was a significant improvement in the Harris hip score over serial follow-ups (p < 0.001), but after 2 years, there was no statistically significant difference (p = 0.46). According to Engh's criteria, stable ingrowth was noted in 35 stems, fibrous stable ingrowth was noted in 4 stems and no patients had progressive subsidence and unstable stem. The mean stem-canal fill percentages were 91.8 ± 5.4% at the mid-stem and 80.3 ± 11.5% at the stem tip. Heterotopic ossification Brooker grade 2 was noted in 8 patients, and no patients had grade 3 or 4 heterotopic ossification. There were 7 (17.9%) intraoperative periprosthetic fractures, and greater trochanteric avulsion was noted in 2 patients in the follow-up.

CONCLUSION

Conversion THA using monoblock tapered distal loading stems bypasses the calcar deficiency and gives stable fixation in failed fixation of intertrochanteric fractures. It gives good radiological outcome and significant improvement in the clinical outcomes compared to the preoperative disability. However, caution should be noted for risk of intraoperative periprosthetic fractures in this subgroup of patients.

Functional outcome of conversion total hip arthroplasty (CTHA) using uncemented distally loading femoral stem for failed fixation of proximal femoral nail - A case series

Introduction and aims

There is paucity of prospective studies on conversion total hip arthroplasty (CTHA) for failed proximal femoral nailing. The objective of this study is to evaluate the functional outcome of CTHA using extensively porous coated distal loading stem for failed proximal femoral nailing.

Patients and methods

Fifteen consecutively operated patients for failed proximal femoral nail treated with single stage procedure of nail extraction and CTHA were included in this prospective observational study. All patients received metal-on-polyethylene bearing with uncemented press-fit acetabular cup (Pinnacle cup; DePuy, Warsaw [IN], USA) and extensively porous coated distally loading revision stem (Solution stem; DePuy, Warsaw [IN], USA). All patients were assessed preoperatively and postoperatively at one, three, six and more than twelve months using the Harris Hip Score (HHS). The responsiveness of HHS was assessed using Effect Size (ES) and Standardised Response Mean (SRM). ES and SRM >0.8 indicates adequate responsiveness.

Results

The mean duration of follow-up was 16.9 months for the overall cohort (SD: 7.9; range: 6-28 months). The mean preoperative HHS was 32 ± 6.1, the mean HHS at six months follow-up was 89.7 ± 4.0 and the mean HHS at final follow-up of atleast one year was 93.7 ± 3.0. There was a statistically and clinically significant improvement in the HHS from preoperatively to final follow-up postoperatively (p < 0.0001). At the final follow-up, twelve patients (80%) had an excellent outcome and three patients (20%) had a good outcome as per HHS grading. The ES was 9.87 and the SRM was 8.86 thereby suggesting adequate responsiveness. One patient developed surgical site infection and another patient developed dislocation. Both were successfully treated and subsequently the patients made uneventful recovery. None of the patients required revision surgery.

Conclusion

HHS has adequate responsiveness for assessing the functional outcome of CTHA. We recommend the use of an uncemented cup and uncemented extensively porous coated, distal loading stem for failed PFN fixation in intertrochanteric hip fractures.

A Comparative Study of Hip Arthroplasty and Closed Reduction Proximal Femur Nail in the Treatment of Elderly Patients with Hip Fractures

Objective

To compare the clinical effect of hip arthroplasty and closed reduction intramedullary nailing of proximal femur in the treatment of elderly hip fracture patients.

Methods

There are 90 elderly hip fracture patients being recruited in the present study. Fifty patients in Group A received closed reduction intramedullary nailing of proximal femur, and 40 patients in Group B received hip arthroplasty. All patients were followed up for 12 months after surgery, clinical outcomes included surgical indicators, visual analog scale (VAS) score, Harris score, quality of life, mental status, and complications.

Results

The surgery time, bleeding volume, infusion volume of patients in Group A are all significantly lower than those in Group B (p < 0.05), while the weight-bearing activity time and first workout time of Group A are all significantly higher than those in Group B (p < 0.05). The VAS score in patients of Group A at 1 week postoperative is significantly lower than that in patients of Group B (p < 0.05). The Harris score in patients of Group A at 3, 6, and 12 months postoperative are all significantly higher than those in patients of Group B (p < 0.05), and the excellent and good rate of hip function recovery at 12 months postoperative in patient of Group A is significantly lower than that in patients of Group B (80% vs. 95%, p < 0.05). Furthermore, The score of SF-36 standardized physical component, SF-36 standardized mental component and Barthel in patients of Group A at 6 months postoperative are significantly lower than those in patients of Group B (p < 0.05), and the score of mini-mental state examination is significantly higher (p < 0.05), while there are not significantly different at 12 months postoperative (p > 0.05). The incidence of postoperative complications in Group A was significantly lower than that in Group B (10% vs. 27.5%, p < 0.05).

Conclusion

Elderly hip fracture patients treated with closed reduction intramedullary nailing of proximal femur has less surgical trauma and lower complication rates, but slower postoperative recovery compared with hip arthroplasty.

Combination of CRP with NLR is a sensitive tool for screening fixation-related infection in patients undergoing conversion total hip arthroplasty after failed internal fixation for femoral neck fracture

AIMS

Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture.

METHODS

We retrospectively included 340 patients who underwent conversion THA after internal fixation for femoral neck fracture from January 2008 to September 2020. Those patients constituted two groups: noninfected patients and patients diagnosed with FRI according to the 2013 International Consensus Meeting Criteria. Receiver operating characteristic (ROC) curves were used to determine maximum sensitivity and specificity of these two preoperative ratios. The diagnostic performance of the two ratios combined with preoperative CRP or ESR was also evaluated.

RESULTS

The numbers of patients with and without FRI were 19 (5.6%) and 321 (94.4%), respectively. Areas under the ROC curve for diagnosing FRI were 0.763 for MLR, 0.686 for NLR, 0.905 for CRP, and 0.769 for ESR. Based on the Youden index, the optimal predictive cutoffs were 0.25 for MLR and 2.38 for NLR. Sensitivity and specificity were 78.9% and 71.0% for MLR, and 78.9% and 56.4% for NLR, respectively. The combination of CRP with MLR showed a sensitivity of 84.2% and specificity of 94.6%, while the corresponding values for the combination of CRP with NLR were 89.5% and 91.5%, respectively.

CONCLUSION

The presence of preoperative FRI among patients undergoing conversion THA after internal fixation for femoral neck fracture should be determined. The combination of preoperative CRP with NLR is sensitive tool for screening FRI in those patients. Cite this article: Bone Joint J 2021;103-B(9):1534-1540.

How Does Conversion Total Hip Arthroplasty Compare to Primary?

BACKGROUND

Recent institutional evidence suggests that conversion total hip arthroplasty (THA) incurs higher complication rates and costs when compared to primary THA. These findings contrast with the current reimbursement system as conversion and primary THAs are classified under the same diagnosis-related group. Thus, a national all-payer database was utilized to compare complication rates up to 2 years, 30-day readmission rates, and 90-day costs between conversion THA and matched primary THA patients.

METHODS

A retrospective review of the PearlDiver database between 2010 and second quarter of 2018 was performed using Current Procedural Terminology (CPT) codes to compare conversion THA (CPT 27132) to primary THA (CPT 27130). Patients were matched at a 1:3 ratio based on age, gender, Charlson Comorbidity Index, body mass index, tobacco use, and diabetes (conversion = 8369; primary = 25,081 patients).

RESULTS

Conversion THA had higher rates of periprosthetic joint infections (conversion: 7.7% vs primary: 1.4%), hip dislocations (4.5% vs 2.0%), blood transfusions (2.0% vs 1.0%), mechanical complications (5.5% vs 1.0%), and revision surgeries (4.0% vs 1.5%) (P < .001 for all) by 90 days. The 30-day readmission rate for conversion THA was significantly higher compared to the primary group (7.3% vs 3.3%) (P < .001). Median cost at 90 days for conversion THA was significantly higher compared to primary THA ($18,800 vs $13,611, P < .001).

CONCLUSION

This study revealed increased complication rates, revisions, readmissions, and costs among conversion THA patients compared to matched primary THA patients. These results support the reclassification of conversion into a diagnosis-related group separate from primary THA.