Internal Fixation of an Intertrochanteric Fracture after Resurfacing Arthroplasty: A Case Report

Early complication of a subtrochanteric periprosthetic fracture following hip resurfacing. Is varus healing acceptable? A case report and literature review

BACKGROUND

The increase in the incidence of osteoarthritis of the hip (coxarthrosis) in young patients with high functionality requirements and the development of new materials in the last twenty years have resulted in an increase in the number of surgeries involving hip resurfacing procedures. There has also been an increase in associated periprosthetic fractures, which currently occur in 1%-2% of cases. According to the medical literature, fractures of this type can be treated conservatively, using reduction and synthesis or through prosthetic revision.

CASE REPORT

Patient aged 69 years who had undergone resurfacing of the right hip ten years previously, who came to our attention as a result of direct contusion trauma with x-ray evidence of a periprosthetic fracture in the subtrochanteric region. We treated the fracture by preserving the prosthesis and performing osteosynthesis using a plate and screws. After two months the synthesis was complicated by breakage of a proximal screw and varus collapse of the fracture. We treated this complication conservatively by adjusting the weight-bearing regime and administering physical and drug therapy. Six months after the fracture, despite the residual varus displacement and the less than stellar x-ray result, the clinical outcome was satisfactory. Discussion and conclusions: Treatment of periprosthetic fractures following hip resurfacing is often technically complex. The major difficulties arise from the presence of prosthetic components and the limited bone stock available. Fractures often affect the neck of the femur and the trochanteric region, and in rare cases there is involvement of the subtrochanteric region. Our review confirms this trend and raises the question as to which method of synthesis is ideal for a fracture pattern so rarely described in the literature.

Fixation and Implant Retention of Extracapsular Femoral Neck Periprosthetic Fractures Around Hip Resurfacing Arthroplasty - A Case Series

BACKGROUND

Extracapsular femoral neck fractures in the presence of a resurfacing hip arthroplasty (RHA) appear to be independent of suboptimal technique during the initial implantation of the RHA and present with a similar etiology as native hip fractures - that is, a fragility fracture related to pathological or age-related osteoporosis, as a consequence of trauma. In the presence of a well-fixed and previously well-functioning RHA, the options for management include revision arthroplasty or open reduction and internal fixation (ORIF). In the absence of loosening through mechanisms of wear, infection, metallosis, or suboptimal prosthesis positioning, many authors have advocated ORIF with implant retention. However, there is often debate regarding the use of total hip arthroplasty in these cases.

CASE SERIES

The authors conducted a thorough assessment of the literature followed by a retrospective review of outcomes for three patients treated by ORIF with implant retention for extracapsular femoral neck fractures around a RHA, using a standardized technique. All patients were independently mobile and active with well-fixed and well-functioning RHAs before the date of injury. All patients suffered low-energy trauma resulting in the fracture. There were no intraoperative or perioperative complications. All patients achieved full weight-bearing status and independent mobility. Two patients achieved radiographic union and returned to full range of movement and independent mobilization comparable to their preoperative state. One patient was lost to follow-up.

CONCLUSION

The authors believe that fixation of extracapsular proximal femoral fractures distal to a well-fixed, well-functioning RHA is a good management option in an independent and active patient. A higher level of evidence is needed to investigate the surgical management options of these injuries comparing osteosynthesis with revision arthroplasty.