Hip arthroplasty in failed intertrochanteric fractures in elderly

Abstract

Background: Failed intertrochanteric fractures in elderly patients are surgical challenge with limited options. Hip arthroplasty is a good salvage procedure even though it involves technical issues such as implant removal, bone loss, poor bone quality, trochanteric nonunion and difficulty of surgical exposure.

Materials and methods: 30 patients of failed intertrochanteric fractures where hip arthroplasty was done between May 2008 and December 2011 were included in study. 13 were males and 17 were females with average age of 67.3 years. There were 2 cemented bipolar arthroplasties, 19 uncemented bipolar, 4 cemented total hip arthroplasty and 5 uncemented total hip arthroplasties. 16 patients had a trochanteric nonunion, which was treated by tension band principles. Total hip was considered where there was acetabular damage due to the penetration of implant.

Results: The average followup was 20 months (range 6-48 months). Patients were followed up from 6 to 48 months with average followup of 20 months. None of the patients were lost to followup. There was no dislocation. All patients were ambulatory at the final followup.

Conclusion: A predictable functional outcome can be achieved by hip arthroplasty in elderly patients with failed intertrochanteric fractures. Though technically demanding, properly performed hip arthroplasty can be a good salvage option for this patient group.

Keywords: Failed intertrochanteric fracture; hip arthroplasty; trochanteric nonunion; trochanteric wiring.

Figure 1

(a,b) X-ray anteroposterior and lateral views of hip with thigh in an 80 year old female with 6 months old failed intertrochanteric fracture with enders nail and cannulated screws in situ. (c) Preoperative computed tomography scan shows nonunion of intertrochanteric fracture and trochanteric nonunion. (d) Immediate postoperative radiograph anteroposterior view shows fully coated stem with distal fixation and trochanteric wiring. Postoperative 2 years anteroposterior (e) and lateral (f) radiograph showing union of trochanter with no subsidence of femoral stem

Figure 2

(a) Anteroposterior and (b) lateral radiograph of 72 years female with failed proximal femoral nail done for intertrochanteric fracture femur. Proximal two lag screws were removed due to penetration and cut out. (c) Immediate postoperative cemented total hip replacement with acetabular graft done for the defect in posterior-superior acetabular region due to penetration of the screws. (d) Two years postoperative anteroposterior and lateral (e) followup radiographs showing good graft incoporation

Figure 3

Preoperative anteroposterior radiograph showing (a) Failed intertrochanteric fracture with broken 95° angled blade plate (b) Immediate postoperative anteroposterior radiograph shows fully coated stem used to bypass stress riser screw holes. (c) Postoperative anteroposterior (c) and lateral (d) radiographs showing no subsidence of stem