Introduction
Hip arthroplasty may be indicated for certain complications of intertrochanteric hip fractures, such as failed fixation, nonunion, post-traumatic osteoarthrosis, perforation of the acetabulum by an internal fixation device and, rarely, avascular necrosis of the femoral head. The technique of hip arthroplasty after failed fixation is technically demanding, and it may introduce difficulties that are not ordinarily encountered with the procedure. The difficulty of the procedure is attributed to the presence of a previous implant, poor bone stock, bone deformity, scarred tissues and increased risk of infection. The challenges include the selection of the type of prostheses and managing the discontinuity of the greater trochanter. Moreover, the loss of anatomical landmarks makes assessment of limb length more difficult.
Aim of the work
The study was conducted to assess the results and complications of hemiarthroplasty or total hip arthroplasty after mechanical failure of internally fixed intertrochanteric hip fractures.
Patients and methods
Fifteen patients with failed treatment of intertrochanteric hip fractures were treated with hip arthroplasty. There were 10 women and five men with a mean age of 63 years (range 59–72 years). The study includes fractures that were primarily stabilized with dynamic hip screw in 13 patients and with condylar AO blade plate in two patients. The mean interval from initial fracture fixation to conversion arthroplasty was 7 months (range 3–19 months). In 11 out of 15 patients, bipolar hemiarthroplasty with cemented long-stem and calcar substitution design was performed, whereas cemented total hip arthroplasty was carried out in four cases.
Results
One patient died within 2 months, and the remaining 14 patients were followed up for a mean duration of 18 months (average, 7–30 months). There was marked pain relief in all the patients, but five patients had mild to moderate pain concentrated around the greater trochanter. Before surgery, all patients were unable to walk or had minimal walking ability with crutches; however, after surgery, only one patient needed the help of a walker, whereas four used a walking stick for ambulation. The mean Harris hip score was 34 (range 30–44) preoperatively and 83 (range 64–86) postoperatively. A statistically significant improvement was found on comparing preoperative and postoperative conditions ( < 0.05). One patient suffered a fracture in the proximal femoral canal during reaming and was treated with cerclage wires. Two patients presented an early dislocation after bipolar hemiarthroplasty: one patient was successfully treated by closed reduction, whereas the other underwent revision with an antidislocatable acetabular (constrained liner) cup because of recurrent dislocation. Deep wound infection was seen in one patient, which was treated with surgical debridement. Superficial wound infection was seen in another case and was treated conservatively.
Conclusion
Hip arthroplasty performed after failed internally fixed intertrochanteric hip fractures is a technically difficult procedure with a relatively high rate of perioperative complications and difficulties. However, despite that, it is an effective salvage procedure that markedly alleviated pain and improved function in the majority of these patients.