Surgical Treatment of Internal Fixation Failure of Femoral Peritrochanteric Fracture

Abstract

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.

Keywords: Arthroplasty; Failure; Intertrochanteric fracture; Revision; Subtrochanteric fracture.

Fig. 1

A 76‐year‐old female patient with initial left intertrochanteric fracture (type A2) 14 months after fixation with proximal femur nail anti‐rotation (PFNA) accepted total hip arthroplasty (THA) for initial fixation failure. (A) Preoperative anteroposterior X‐rays of pelvic and injured hip. (B) Anteroposterior and lateral X‐rays at immediate after the internal fixation of PFNA. (C) Anteroposterior and lateral X‐rays at 14 months after fixation of PFNA, showed femoral head necrosis. (D) Anteroposterior X‐ray of pelvic at immediate after THA. (E) Anteroposterior and lateral X‐rays of the hip at immediate after THA. (F) Anteroposterior and lateral X‐ray films of the hip at 3 months after THA.

Fig. 2

A 50‐year‐old male patient with initial left subtrochanteric fracture (Seinsheimer type IV). (A) Preoperative anteroposterior X‐ray of injured hip. (B) Anteroposterior and lateral X‐rays at immediate after the initial internal fixation of PFLP. (C) Anteroposterior and lateral X‐rays after 6 months showed the fracture had not healed and PFLP had loosened. (D) Remove of the PFLP. (E) The first revision surgery with InterTan and autograft. (F) Anteroposterior and lateral X‐rays of hip showing the InterTan had broken 2 years after the first revision. (G) The second revision with PFLP and autograft. (H) The PFLP had broken 6 months after the second revision. (I) Anteroposterior and lateral X‐rays of the third revision with PFNA and free vascularized fibular grafting. (J) Anteroposterior X‐ray of at 24 months after the third revision, showed the fracture had healed.

Fig. 3

A 52‐year‐old male patient with initial left intertrochanteric fracture (type A2) 18 months after fixation with PFNA accepted the second surgery with PFLP revision for the failure of initial fixation. (A) Preoperative anteroposterior X‐ray of pelvic. (B) Anteroposterior and lateral X‐rays at immediate after the internal fixation of PFNA. (C) Anteroposterior and lateral X‐rays at 18 months after fixation of PFNA, showed the failure of PFNA. (D) Anteroposterior X‐ray of pelvic at 3 months after revision with PFLP. (E) Anteroposterior and lateral X‐rays of the hip at 6 months after revision with PFLP. (F) Anteroposterior and lateral X‐rays of the hip at 2 years months after revision, showed the fracture had healed.