Conversion Hip Arthroplasty in Failed Fixation of Intertrochanteric Fracture: A Propensity Score Matching Study

Optimizing Stem Length in Conversion Total Hip Arthroplasty: An Expanded Finite Element Analysis

Background/Objectives: Stress concentration around distal screw-removal holes confers a major risk for periprosthetic fractures following conversion total hip arthroplasty (cTHA) for intertrochanteric femoral fractures. Optimal stem-selection criteria and guidelines for cTHA can improve clinical outcomes. We determined the influence of the cementless stem length on the stress distribution around distal screw-removal holes. Methods: For the finite element analysis, institutional data from preoperative CT scans of contralateral femurs of patients who underwent THA were used. To replicate the post-nail-removal state, we used 3D registration of standard triangulated language data of the intramedullary nail as an unused material to simulate distal screw-removal holes, located 135 mm from the proximal end of the intramedullary nail. Cementless stems of 130, 140, 150, and 160 mm were individually registered using STL data, and cTHA models were constructed accordingly. Using simulations under load conditions representing normal walking and stair climbing, the mean and maximum equivalent stress values around the distal screw-removal holes were calculated. For multiple comparisons, repeated-measures ANOVA with Bonferroni correction was employed. Results: Compared to the 130 mm stem, the 150 mm and 160 mm stems similarly reduced the maximum equivalent stress around the distal screw-removal holes, although the 140 mm stem showed no significant difference with other stems. Conclusions: A ≥150 mm stem length reliably mitigated stress concentration around distal screw-removal holes post-cTHA; it is the optimal choice for balancing effectiveness and risk of complications and may contribute to improved long-term clinical outcomes. This study provides practical evidence for stem selection in cTHA and offers valuable insights for future treatment guidelines.

Key Decision-Making in Post-Failed Internal Fixation of Intertrochanteric Fractures Hip Arthroplasty: A Multicenter Retrospective Study on Fracture Healing's Impact on Femoral Component Selection

PURPOSE

Following failed internal fixation of intertrochanteric fractures (FIF-ITF), the decision to use a long-stem or standard-stem femoral implant in hip arthroplasty is still debated. This study aimed to explore how the healing status of fractures after FIF-ITF failure affects the choice of femoral stem and clinical outcomes.

METHODS

Our retrospective cohort study reviewed 105 cases of patients with FIF-ITF who underwent hip arthroplasty at three tertiary Grade A hospitals between December 2012 and December 2022. We compared the clinical outcomes between patients with healed and unhealed fractures, focusing on the selection of femoral stems in relation to proximal medial support and the healing status of the greater trochanter. The primary outcomes measured were functional results, operative time, blood loss, and incidence of complications. A subgroup analysis was conducted to further evaluate the influence of the proximal medial buttress and greater trochanteric healing on femoral stem selection. Statistical analysis included binary and ordinal logistic regression to identify factors influencing the choice of femoral stems. Additionally, a decision tree model was developed to visually represent and explore the relationship between fracture healing status and the selection of femoral components.

RESULTS

The study included 38 patients with healed fractures and 67 patients with unhealed fractures. Patients in the healed group predominantly chose standard stems and experienced better functional outcomes (p < 0.001, p = 0.002). In contrast, the unhealed group preferred long stems, resulting in longer surgical durations and increased blood loss (p = 0.008, p < 0.001). Binary logistic regression analysis revealed that nonunion of the proximal femoral medial buttress was an independent risk factor for long stems (p < 0.0001, OR = 10.402).

CONCLUSION

The selection of femoral prostheses following FIF-ITF is influenced by the fracture healing status, particularly the presence of proximal femoral medial buttress. The decision tree model suggested that long-stem prostheses are more appropriate when there is inadequate fracture healing and the proximal femoral medial buttress is absent.

Comparative Outcomes of Early Versus Late Conversion to Total Hip Arthroplasty Following Hip Fracture Fixation

BACKGROUND

Hip fractures are prevalent orthopaedic injuries with substantial morbidity and mortality. Failed primary treatments of these fractures often necessitate conversion to total hip arthroplasty (THA), a complex procedure requiring extensive exposure and hardware removal. It poses major challenges and is associated with high rates of complications such as infection, dislocation, and periprosthetic fractures. Despite the documented risks, there are limited data comparing complication rates between early (within 1 year) and late (after 1 year) conversion THA (CTHA). This study aimed to compare early and late CTHA and hypothesized that early CTHA was associated with higher complication rates than late CTHA.

METHODS

A retrospective cohort study was conducted using an administrative claims database. The time from primary fixation of the proximal femur fracture to CTHA was used to identify patients who underwent early (n = 1,205) and late (n = 6,455) CTHA. Rates of joint complications within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions.

RESULTS

Early CTHA patients exhibited significantly higher rates of reoperation (8.3 versus 5.1%; odds ratio [OR]: 1.72), periprosthetic infections (7.1 versus 5.2%; OR: 1.50), periprosthetic fractures (5.4 versus 2.6%; OR: 1.73), mechanical complications (5.2 versus 3.1%; OR: 1.60), and dislocations (7.7 versus 3.9%; OR: 1.97). Overall, 19.4% of early conversion patients experience an orthopaedic complication, compared to 12.4% of late conversions. Medical complications within 90 days included higher rates of deep vein thrombosis in early CTHA patients (1.7 versus 0.8%; OR: 1.99), transfusions (5.6 versus 3.1%; OR: 1.50), and hospital readmission (13.9 versus 9.3%; OR: 1.39).

CONCLUSIONS

Early CTHA was associated with higher rates of complications compared to late conversion. Understanding these risks allows surgeons to better prepare patients for the surgery and ensure that patients have a realistic understanding of their prognosis and are adequately prepared for the challenges of recovery.

Stress Analysis in Conversion Total Hip Arthroplasty: A Finite Element Analysis on Stem Length and Distal Screw Hole

Background/Objectives: Proximal femoral fractures are particularly common in older adults, and cases requiring conversion to total hip arthroplasty may arise because of treatment failure or osteoarthritis. Fractures around the distal screw removal holes can be problematic. This study aimed to analyze the relationship between stem length and femoral stress distribution to determine the optimal stem length. Methods: A finite element analysis simulation was conducted using pre-existing femoral computed tomography data, an intramedullary nail, and three types of stems of varying lengths. Loads simulating normal walking and stair climbing were applied, and the average and maximum equivalent stresses were measured on both the medial and lateral sides of the distal screw removal hole for each stem length. Statistical analysis was then performed to evaluate the stress distributions. Results: The average stress around the distal screw removal hole tended to decrease as stem length increased. The maximum stress was significantly lower with the 160-mm stem, which provides a 40-mm bridging length, compared to the 120-mm and 130-mm stems, where the stem tip aligned with or only slightly extended past the distal screw removal hole (bridging lengths of 0 mm and 10 mm, respectively). Conclusions: In conversion hip total arthroplasty following proximal femoral fractures, using a sufficiently long stem can help avoid stress concentration around the distal screw removal hole, thereby potentially reducing the risk of periprosthetic fractures.

Immediate weight bearing as tolerated versus delayed weight bearing following intramedullary fixation for geriatric intertrochanteric fractures: a post hoc analysis

BACKGROUND

Early weight bearing is crucial for fracture healing after osteosynthesis for intertrochanteric fractures (ITFs). The optimal period to start weight bearing after surgery is still under debate. The aim of this study was to compare immediate weight bearing (IWB) as tolerated with delayed weight bearing (DWB) following intramedullary fixationin elderly ITF patients.

METHODS

This post hoc analysis included patients aged ≥ 65 years with X-ray-confirmed ITFs who were admitted within 21 days after injury and who underwent intramedullary fixation surgery. The primary outcome was the EQ-5D score at 120 days after surgery. The secondary outcomes included the EQ-5D score at 30 days and 365 days after surgery, the complication rate and the mortality rate.

RESULTS

Among 410 patients (190 IWB, 220 DWB), those in the IWB group had higher EQ-5D scores at 30 (P < 0.001) and 120 days (P = 0.002) but lower scores at 365 days (P = 0.012) than did those in the DWB group. There were no significant differences in the complication rates, reoperation rates, or one-year mortality rates between the groups.

CONCLUSIONS

Compared with delayed weight bearing, immediate weight bearing improves early functional outcomes without increasing the complication or mortality rates in elderly ITF patients.

Perioperative Outcomes of Intramedullary Nail vs Hemiarthroplasty vs Total Hip Arthroplasty for Intertrochanteric Fracture: An Analysis of 31,519 Cases

Background

The purpose of this study is to compare 30-day perioperative outcomes following treatment of intertrochanteric (IT) fractures with intramedullary nail (IMN), total hip arthroplasty (THA), or hemiarthroplasty (HA).

Methods

Using the National Surgical Quality Improvement Program database, we conducted a retrospective cohort study of patients who had sustained an IT fracture treated with primary IMN, THA, or HA between 2017 and 2020. International Classification of Diseases, 10th Revision codes S72.141-S72.146, subtypes A through C, were used to identify eligible patients and were cross-referenced to primary Current Procedural Terminology codes, used to identify the following procedure types: 27245: IMN; 27130: THA; and 27236: HA. Revision cases and patients who underwent arthroplasty for osteoarthritis were excluded. Outcomes of interest included reoperation, readmission, operative time, length of stay, and major and minor complications. Multivariate regression was used to evaluate differences in postoperative outcomes between groups.

Results

There were 29,809 IT fractures treated with IMN (94.6%), 1493 treated with HA (4.7%), and 217 treated with THA (0.70%). There was a statistically significant increase in 30-day reoperation rates (adjusted odds ratio [aOR] = 1.99 [95% confidence interval = 1.51, 2.63], P < .001) when combining all arthroplasty patients compared to IMN. There was no statistically significant difference in the overall complication rate between IMN (13.58%) and HA (14.60%, aOR = 1.09, P = .315) or THA (11.98%, aOR = 1.00, P = .998). When compared to IMN (0.12%), there was a statistically significantly decreased need for transfusion in the HA group (aOR = 0.71 [95% confidence interval = 0.61, 0.80], P < .001).

Conclusions

Primary HA is associated with an increased 30-day reoperation rate and decreased need for blood transfusion, but there were no other significant differences in postoperative morbidity identified among IMN, THA, and HA in the treatment of IT fractures. Given the challenges and inferior outcomes associated with conversion arthroplasty, the lack of significant difference in morbidity between the 3 groups suggests that primary arthroplasty may be a safe and viable treatment option in selected patients with IT fractures. Comparative studies with longer clinical follow-up will be necessary to establish the appropriate indications and further evaluate the clinical outcomes of primary arthroplasty in the treatment of IT fractures.

Latent infections in conversion total hip arthroplasty following internal fixation of femoral neck fractures: a systematic review and meta-analysis of diagnostic methods

BACKGROUND

Accurate diagnosis of latent infections prior to conversion total hip arthroplasty (THA) following internal fixation of femoral neck fractures is crucial for successful surgical outcomes. This systematic review aimed to provide a comprehensive evaluation of the current literature regarding the diagnosis of latent infections before conversion THA.

METHODS

Systematic search of PubMed, EMBASE, and Cochrane (CENTRAL) databases was conducted, and the diagnostic accuracy of various markers and techniques was assessed. The quality of the included studies was evaluated using the QUADAS-2 instrument.

RESULTS

Five studies comprising 661 patients were included in the review. Pooled analysis using C-reactive protein (CRP) as a diagnostic marker resulted in a sensitivity and specificity of 72% and 76%, respectively, while using erythrocyte sedimentation rate (ESR) yielded a sensitivity and specificity of 75% and 78%, respectively. Fibrinogen and platelet count showed lower sensitivity and specificity compared to CRP and ESR. The best combined markers were CRP and serum platelet count, with a sensitivity of 76% and specificity of 86% based on one study.

CONCLUSION

Our review underscored the limitations and inconsistencies present in current diagnostic methods for latent infections in conversion surgery. Future research needs to focus on standardizing threshold values, exploring the potential of synovial fluid analysis, imaging techniques, and molecular methods, as well as developing tailored diagnostic algorithms.

PROSPERO

CRD42023394757.

Hip arthroplasty following failure of internal fixation in intertrochanteric femoral fractures: classification decision-making for femoral stem selection and clinical validation

AIMS

Following Failed Internal Fixation of Intertrochanteric Fractures (FIF-ITF), the choice of treatment remains a clinical challenge. This study introduces a novel classification system to guide the selection of femoral prostheses in hip arthroplasty (HA) and validates its clinical efficacy.

METHODS

Retrospectively, we analyzed 108 cases from three university-affiliated hospitals between December 2012 and February 2023 involving patients who underwent hip arthroplasty due to Failed Internal Fixation of Intertrochanteric Fractures (FIF-ITF). Patients were classified into three categories based on fracture healing, proximal femoral support, and the severity of femoral cortical defects, with subtypes identified. Surgical outcomes and complication rates were compared between the Classification-based Decision Group and the Non-classification Decision Group.

RESULTS

The Classification-based Decision Group did not differ significantly from the Non-classification Decision Group in operation time, blood loss, or the use of cemented stems. However, the classification system markedly reduced the risk of periprosthetic fractures intraoperatively from 22.5 to 4.4% and postoperatively from 10 to 1.4%. The Classification-based Decision Group also demonstrated higher postoperative Harris Hip Score (HHS) and Visual Analog Scale (VAS) scores.

CONCLUSION

The proposed classification system serves as an innovative clinical tool for femoral prosthesis selection in hip arthroplasty post-FIF-ITF, effectively reducing complications and enhancing hip function in the Classification-based Decision Group, underscoring its significant clinical utility.

Cement Filling Technique to Prevent Greater Trochanter Displacement in Hip Arthroplasty for Femoral Intertrochanteric Fracture: A Technical Note

With the increasing use of primary hip arthroplasty for management of intertrochanteric fractures, firm fixation and union of the greater trochanteric (GT) fragment are required during hip arthroplasty for management of intertrochanteric fractures. Various methods have been suggested to address this issue. However, displacement of the GT is a frequent occurrence. We have introduced a cement-filling technique for performance of hip arthroplasty of the proximal femur for achievement of immediate firm fixation of the GT. Cement filling during performance of hip arthroplasty for management of femoral intertrochanteric fractures is a valuable technique for preventing displacement of the GT and to encourage early mobilization.

Conversion Birmingham Hip Resurfacing in Managing Post-traumatic Arthritis With Retained Femoral Hardware: A Case Report

CASE

A 70-year-old man with a year-long history of arthritic pain in his left hip presented to our clinic. He had a left intertrochanteric hip fracture 6 years ago, fixed with an open reduction internal fixation with a cephalomedullary nail. He underwent a conversion Birmingham Hip Resurfacing (BHR) with removal of the proximal helicoidal blade and retention of the intramedullary nail. At 7-year follow-up, the patient reported satisfactory clinical outcomes and excellent radiographic fixation.

CONCLUSION

This case highlights using conversion BHR in patients with post-traumatic arthritis with retained femoral hardware as an alternative to conventional total hip arthroplasty.

Augmented versus non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails for treating trochanteric fractures in patients over sixty-five years of age

PURPOSE

Intramedullary nailing is a common treatment for pertrochanteric fractures. However, implant-related mechanical failures, such as cut-out and cut-through, lead to higher rates of revision surgery, loss of autonomy, and mortality. Cemented augmentation enhances the bone-implant interface. This study compared the frequency of mechanical failures between augmented and non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails.

METHODS

This descriptive, retrospective study at a level 1 trauma centre included patients aged > 65 years with pertrochanteric fractures treated by a short augmented or non-augmented TFNA nail. The primary outcome was the comparison of cut-out or cut-through rates between groups at three and six months postoperatively.

RESULTS

Of the 181 patients analysed, 103 had augmented TFNA nails and 78 had non-augmented TFNA nails. There were no statistically significant differences between groups in terms of demographic characteristics, AO/OTA classification, or quality of reduction. The failure rate was significantly lower in the augmented group than in the non-augmented group: 1 (0.97%) versus 9 (11.54%) (p = 0.005). At six months postoperatively, there was no significant difference between the two groups concerning functional recovery, as measured by the Parker and EuroQoL 5-Dimensions scores.

CONCLUSIONS

For patients aged over 65 years, the use of the augmented TFNA nail may reduce the risk of fixation failures such as cut-out.

Mid-Term Follow-Up Results After Hemiarthroplasty Using Long Femoral Stem Prosthesis (Peerless-160) for Intertrochanteric Fractures in Octogenarians

Purpose

To analyze the clinical effect and imaging data of cementless bipolar hemiarthroplasty employing a long femoral stem (peerless-160) and 2 reconstructed femoral titanium wires to repair intertrochanteric fractures among the octogenarians.

Methods

Between June 2014 and August 2016, 58 octogenarians with femoral intertrochanteric fractures underwent the long femoral stem (peerless-160) cementless bipolar hemiarthroplasty by the same surgeon. We assessed clinical and radiological outcomes such as operative time, bleeding volume, blood transfusion volume, length of hospital stay, full weight-bearing walking time, walking ability calculated by Koval classification and Harris Hip Score (HHS), including fracture healing and greater trochanter fragments subsidence.

Result

The surgery was successfully performed in all patients. The average operation time was 72.8 ± 13.2 min, the average blood loss during surgery was 225.0 ± 91.4 mL, 200 mL of blood was transfused, the mean duration of hospitalization was 11.9 ± 4.0 days, the mean time of full weight bearing was 12.5 ± 3.8 days. Patients were followed up for 24-68 months, averagely 49.4 ± 10.3 months. During follow-up, 4 (6.9%) patients died, and 1 (1.7%) was completely lost to ask about the recent situation. The average Harris Hip Score at the last follow-up was 87.8 ± 6.1, most of the patients recovered walking ability, under radiological examination, the prosthesis showed no signs of loosening. All trochanteric fractures gradually healed, the clinical and radiographic signs of healing occurred at average of 4.0 ± 1.1 months postoperatively.

Conclusion

For osteoporotic unstable intertrochanteric fractures in octogenarians, this study confirmed that the Cementless Bipolar Hemiarthroplasty Using a Long Femoral stem (peerless-160) with double cross binding technique is a satisfactory and safe choice for the octogenarians.

Hemiarthroplasty for Unstable Intertrochanteric Hip Fractures: A Matched Cohort Study

BACKGROUND

Geriatric intertrochanteric fractures remain a major public health concern due to the considerable disability, morbidity, mortality, and health care costs associated with these injuries. The underlying poor bone quality and unstable nature of these fractures makes them difficult to treat. The main purpose of this study was to evaluate the outcome of hemiarthroplasty for unstable intertrochanteric hip fractures when compared to the traditional treatment options of open reduction internal fixation (ORIF).

METHODS

A retrospective 1:1 matched cohort of 150 patients who had intertrochanteric fractures treated with either hemiarthroplasty or ORIF was developed using a local institutional database. Demographic, perioperative, and postoperative variables were collected with at least 1 year of patient follow-up. Statistical analyses were performed with use of Student's t-tests, chi-square tests, and analysis of variance.

RESULTS

Unstable intertrochanteric fractures treated with ORIF were associated with significantly more blood loss and an increased need for revision surgery. This effect was most pronounced in Arbeitsgemeinschaft für Osteosynthesefragen Orthopaedic Trauma Association classification type 31.A3 fractures, as patients treated with ORIF experienced significantly slower postoperative mobilization, increased blood loss, increased readmission, and revision surgery rates. Hemiarthroplasty was associated with an increased risk of greater trochanter escape, which did not appear to effect outcomes in this subset of patients.

CONCLUSION

Hemiarthroplasty may improve outcomes for patients with unstable intertrochanteric fractures. The benefit of this technique is likely maximized in Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association type 31.A3 fractures. It remains a good option in the hands of experienced surgeons.

Conversion arthroplasty after failed extracapsular hip fracture fixation is associated with high complication rates

Background/Aim: There is no standard treatment of choice that addresses all extracapsular fractures, which account for approximately half of the elderly hip fractures. Arthroplasty is mostly favored secondary to unsuccessful fixation or unstable primary fractures. However, conversion arthroplasty complication rates are high in the literature. This study compares arthroplasty performed after unsuccessful fixation and primary arthroplasty for unstable extracapsular hip fractures. Methods: In this retrospective study, we compared the first-year results of the groups that underwent conversion arthroplasty (cHA) and the primary arthroplasties (pHA) for extracapsular hip fractures. In the cHA group, patients were indicated for operation if there was a failure of fixation after extracapsular hip fractures (n=44). In the pHA group, patients were for unstable extracapsular hip fractures (n=44). In the cHA group, failure of fixation causes were cut-out of lag screws (54.5%), cut-through of lag screws (9.1%), non-union of fractures (27.3%), and osteonecrosis of femoral heads (9.1%). While total hip replacement was applied to all patients in the cHA group, total hip replacement was applied to ten patients in the pHA group and hemiarthroplasty to 34 patients. In comparing groups, duration of operation, amount of bleeding, intraoperative complications, post-operative complications, mobilization capacities, functional status, and mortality rates were used. Results: There were 44 patients in both groups. The surgical time (134.3 [34.5)] vs. 66 [16], [P<0.001]), the amount of bleeding (1000 ml [400] vs. 300ml [200], [P<0.001]), the need for red blood cell transfusion in the operations (80% vs. 32%, [P<0.001]), and the frequency of intraoperative femur fracture (30% vs. 0%, [P<0.001]) were larger or longer in the cHA group compared to pHA group (P<0.001). While 14 complications requiring surgical intervention were observed in 12 of 44 patients in the CHA group in the post-operative 1st year, four complications were observed in four of 44 patients in the pHA group. There was no difference in mortality rates (3 vs. 3, [P =1]), mobilization capacities (5.9 [2.1] vs. 5.7 [2.0], [P=0.597]), and functional status (12.5 [3.3] vs. 13.0 [2.7], [P=0.434]) between the groups. Conclusion: Arthroplasty performed as conversion surgery after unsuccessful fixation has a higher risk of intraoperative and post-operative complications than primary arthroplasty performed after extracapsular hip fractures. We believe the cases prone to implant failure, non-union, or restricted mobilization because of the patient and fracture-type reasons should be treated with primary arthroplasty.

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery

BACKGROUND

Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.

METHODS

Patients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.

RESULTS

Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar.

CONCLUSION

Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision-making.

Salvage hip replacement after cut-out failure of cephalomedullary nail fixation for proximal femur fractures: a case series describing the technique and results

BACKGROUND

Cut-out failure following proximal femoral fracture fixation is a compromising complication warranting surgical treatment. We describe 24 patients with cut-out failure after cephalomedullary nail fixation managed with salvage hip replacement.

METHODS

Twenty-four consecutive patients who had sustained a proximal femoral fracture from December 2009 to December 2019, were managed with cephalomedullary nail fixation and experienced a cut-out failure were reviewed retrospectively. Data on demographics, comorbidities, injury characteristics, treatment, and post-operative course were analysed.

RESULTS

Among 2802 proximal femoral fractures assessed, 28 fixations failed due to cut-out, with 24/28 patients subsequently undergoing salvage hip replacement. Intertrochanteric fractures (66.7%) managed with short nails predominated (79.2%). The median tip-to-apex distance (TAD) was 19 mm, but only two fractures had a good quality of reduction. Inverse correlations were identified between patient age and the time from fixation to cut-out (r =  - 0.57; p = 0.02), and between the time of nailing to failure among patients with a greater TAD (r =  - 0.43; p = 0.04). Most patients were managed via cemented hemiarthroplasty (66.7%). Surgical time was longer for total hip replacements (175.4 vs. 136.8 min; p < 0.01), but no bleeding or blood transfusion requirement differences were found. Two patients had orthopaedic complications, and three patients died within the first follow-up year.

CONCLUSION

In our series, 1% of the proximal femoral fractures managed with a cephalomedullary nail failed due to cut-out. Salvage hip replacement appeared to be a relatively safe and reliable procedure for managing this challenging complication in patients who typically are elderly and physically frail.

Conversion total hip arthroplasty for early failure following unstable intertrochanteric hip fracture: what can patients expect?

PURPOSE

To report surgical outcomes in patients treated with conversion total hip arthroplasty (CTHA) for early failure of cephalomedullary nails (CMNs).

METHODS

A retrospective review was conducted of CTHA for treatment of failed CMN within 1 year of initial surgery for intertrochanteric (IT) hip fractures. The cohort was matched 1:5 to patients who underwent elective primary THA (PTHA). Patient demographics, mechanism of CMN failure, surgical outcomes, and complication rates were assessed.

RESULTS

22 patients met criteria with a mean time to failure of 145 days. Modes of failure included: lag screw cut-out with superior migration (9, 40.9%), or medialization (8, 36.4%), and aseptic nonunion with implant failure (2, 9.0%) and without implant failure (3, 13.6%). Fourteen of the patients (63.6%) had acetabular-sided damage secondary to lag screw penetration, all in the screw cut-out groups. Patient demographics were similar between cohorts. Compared to PTHA, CTHA patients had increased operative time, blood loss, LOS, and readmission rates. After IMN failure, the operative leg was shorter than the contralateral leg in all cases. CTHA restored leg lengths to <  = 10 mm in 15 (68.1%) of patients, with an average leg length discrepancy after CTHA of 6.7 mm. CTHA patients had increased rates of overall surgical complications and medical complications, specifically anemia (all p < 0.01). Tranexamic acid was used less often in the CTHA group (p < 0.01). Rate of periprosthetic joint infection (PJI), dislocation, and revision were all higher in the CTHA, though did not reach statistical significance.

CONCLUSION

The majority (77.3%) of CMN implant failure for nonunion within 1 year was due to screw cut-out. CTHA is a salvage option for early failed IT hip fracture repair, but expected surgical outcomes are more similar to revision THA than primary THA, with increased risk of readmission, longer surgery and LOS, increased blood loss, and higher complication rates.

LEVEL OF EVIDENCE

III, Retrospective comparative study.

Conversion Hip Arthroplasty Using Standard and Long Stems after Failed Internal Fixation of Intertrochanteric Fractures

OBJECTIVE

Failed internal fixation of intertrochanteric fractures (FIF-ITF) is often treated by conversion hip arthroplasty (CHA). This study aimed to evaluate the results and complications of using standard and long femoral stems in this operation.

METHODS

This retrospective, multi-center study enrolled 31 total hip arthroplasty (THA) and 23 hemiarthroplasties (HA) cases (30 women, 24 men; mean age 76 years) after FIF-ITF between 2012 and 2019, divided into two groups: standard stem group (n = 20) and long stem group (n = 34). The initial internal fixation includes 38 cases of proximal femoral nail anti-rotation (PFNA), eight cases of the dynamic hip screw (DHS), and eight cases of locking proximal femoral plate (LPFP). The indications for CHA included 38 cases of failure of fixation, seven cases of nonunion, and nine cases of avascular necrosis or posttraumatic osteoarthritis. Perioperative data and complications related to fracture and operation were collected, and preoperative and postoperative clinical and radiological data were analyzed. Clinical outcomes were assessed using Harris hip score (HHS) and 36-item Short Form survey (SF-36: including physical function (PF) score and body pain (BP) score). Statistical analyses were performed using the chi-square or Fisher's exact test, and the 2-sample t-test or Wilcoxon rank sum test.

RESULTS

At an average of 5.6 years with a minimum of 2 years follow-up. A significant overall surgeon-related complication rate was detected (27.8% [15/54]), five cases had an intraoperative femur fracture, one case had a late periprosthetic femoral fracture, two cases had a stem penetration, one case had a cement leakage, and two patients had an early postoperative dislocation, one infection and three cases of stem loosening or subsidence. Long stems had an increased risk of complication (13/34) compared to standard stems (2/20) (P = 0.031). The operation time and blood loss in the long stem group were higher than those in the standard stem group (P = 0.002; 0.017). HHS and SF-36 significantly improved in both groups from preoperative to the final follow-up and did not present significant differences at the final follow-up (P > 0.05).

CONCLUSION

CHA following FIF-ITF showed a successful mid-term clinical result, long stem arthroplasty should be approached with caution for the risks of higher complication rate, especially intraoperative femoral fractures.

A bone-conserving revision stem for unstable intertrochanteric fractures of the geriatric osteoporotic population

Purpose

Primary hemiarthroplasty is gaining popularity for the treatment of unstable intertrochanteric fractures in geriatric patients with severe osteoporosis. This study evaluated early clinical and radiographic outcomes by using a bone-conserving revision stem for unstable intertrochanteric fractures in the geriatric osteoporotic population.

Methods

A retrospective study involving 31 patients with unstable intertrochanteric fractures was conducted. The patients were aged 82.1 years on average. All patients underwent primary hemiarthroplasty using bone-conserving, fully porous-coated revision stem. The operative time, intraoperative blood loss, length of hospitalization, and need for blood transfusion were noted during the hospital stay. Postoperative complications, including dislocations, deep venous thrombosis, infections, peri-prosthetic fractures, and frontal thigh pain were also recorded. Koval's category was used to quantify activity level, and Harris hip score (HHS) was used for functional assessment. Radiographic outcomes, including osteolysis, bone ingrowth, subsidence of the femoral component, lower limb length discrepancy, and heterotopic ossification, were collected at each follow-up.

Results

The 31 patients were followed for an average time of 23 months postoperatively. The average operative time lasted for 74.2 min, while the mean intraoperative blood loss was 200.1 ml, with an average hemoglobin decrease of 11.1 g/L after the procedure. The mean visual analog scale (VAS) score for pain dropped from 7.4 preoperatively to 2.4 at the 4-week follow-up. At the latest follow-up, the mean Harris hip score was 82.1, and the VAS was 1.7. No intraoperative or postoperative peri-prosthetic fractures were noted. Postoperative complications included one case of thrombosis formation in the posterior tibial vein and one case of congestive heart failure. Both patients were discharged uneventfully after treatment. Radiographically, none of the hips had evidence of stem loosening or osteolysis. Within the follow-up period of 23 months, the mortality rate was 3.2% (1/31), and no revision surgeries were required.

Conclusion

Primary hemiarthroplasty using a bone-conserving, cementless revision stem could serve as a reliable alternative for the treatment of unstable intertrochanteric fractures in the geriatric population with osteoporosis.

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.

Conversion total hip arthroplasty following extracapsular hip fracture fixation with a cephalomedullary device: a comprehensive review

With the annual incidence of hip fractures and hip fracture fixation rising, the need for conversion total hip arthroplasty has also risen. About half of the 280,000 hip fractures that occur annually in the United States are extracapsular. Commonly extracapsular hip fractures are treated with either cephalomedullary nails (CMNs) or sliding hip screws (SHS). More recently, there has been a shift toward increased CMN use due to increased training with this fixation method as well as perioperative and biomechanical benefits. Given this shift, orthopedic surgeons need to understand the factors that lead to CMN failure. Failed CMN treatment leaves both patients and surgeons with few management options including revision fixation with or without osteotomy, conversion total hip arthroplasty, and conversion hemiarthroplasty. Surgeons must consider the patient and injury characteristics before deciding the best treatment plan. Conversion total hip arthroplasty is indicated in younger patients without femoral head and/or acetabular articular injury, degenerative joint disease, or avascular necrosis. Conversion total arthroplasty is a technically demanding and resource-intensive surgery associated with lower success rates and outcomes than primary total hip arthroplasty. Orthopedic surgeons should have thorough understanding of preoperative workup needed prior to surgery, implant selection associated with best outcomes, most common surgical approaches used, intraoperative considerations, and complications associated with conversion total hip arthroplasty. A comprehensive understanding of these concepts gives patients the best chance of having a successful outcome.

Complications and survival of conversion to total hip arthroplasty after failed primary osteosynthesis compared to primary total hip arthroplasty in femoral neck fractures

INTRODUCTION

Surgical treatment options for patients with an intracapsular fracture of the femoral neck (FFN) are primary osteosynthesis as a femoral head-spearing technique or primary (hemi)arthroplasty. The most common complications after primary osteosynthesis, such as avascular necrosis (AVN) or non-union, can result in conversion to Total Hip Arthroplasty (cTHA). Data concerning complications and survival rates of cTHA in comparison to primary Total Hip Arthroplasty (pTHA) after FFN are limited due to the absence of well-designed studies.

METHODS

A multicentre retrospective cohort study was conducted in three Dutch hospitals comparing the rate of postoperative dislocations, periprosthetic fractures, prosthetic joint infections, blood loss during surgery (>1000 mL), postoperative cardiac- and pulmonary complications after pTHA and cTHA in the first year after surgery. As a secondary outcome implant survival of pTHA and cTHA in terms of revision rates was evaluated.

RESULTS

In total 548 patients were included (pTHA n = 264 and cTHA n = 284) with a mean follow-up of 5 years (±3.5 SD). No significant differences were found in postoperative complications rates. The revision rate in the pTHA group was 7.2% in comparison to 7.7% in the cTHA group (p = 0.81). No difference in the short-term implant survival was found between both groups (p = 0.81).

CONCLUSION

This study showed no significant differences in terms of postoperative complication rates in the first year after pTHA and cTHA in patients with FFN. Also, no significant difference in short-term implant survival of primary and conversion total hip arthroplasty was found.

Outcome and technical consideration of conversion total hip arthroplasty after failed fixation of intracapsular and extracapsular hip fractures: Are they really that different?

INTRODUCTION

Conversion Total Hip Arthroplasty (cTHA) is a rescue strategy for proximal femur osteosynthesis failures. However, it is unclear whether cTHAs performed for extra-capsular fracture fixation failures (ECF) or for intra-capsular fracture fixation failures (ICF) share the same complexity and efficacy. The purpose of our study was to compare cTHAs performed on pre-existing ICFs and pre-existing ECFs, focusing on surgical complications and functional outcomes in both groups.

METHODS

An observational retrospective study was conducted on cTHA patients, treated between 2014 and 2018, divided into 2 groups: ICF-group and ECF-group. The main outcomes were: type of implant used, duration of surgery, need for transfusions, incidence of complications, functional outcomes.

RESULTS

28 patients were included (15 in the ECF group and 13 in the ICF group); the average follow-up was of 31 ± 17.3 months. No significant differences were identified in terms of the type of implant used and duration of surgery. The number of transfused patients was 4 in the ICF group and 12 in the ECF group (p = 0.02); the average transfused units were 0.4 ± 0.7 in the ICF group and 1.3 ± 0.9 in the ECF group (p = 0.01). The incidence of complications - an infection and a dislocation, both of which occurred in the ICF group - and functional outcomes did not present significant differences.

CONCLUSION

The conversion surgery on ECFs patients is technically more difficult for the surgeon and prone to greater blood loss. The outcomes are satisfactory and overlap between the two groups.

Primary Arthroplasty or Internal Fixation in Intertrochanteric Femur Fractures: A Survey of Surgical Attitudes of Orthopedic Surgeons in Turkey

This study aimed to examine the primary arthroplasty attitudes of Turkish orthopedics and traumatology specialists and residents to patients with intertrochanteric fractures, of various ages, comorbidity situations and fracture types, using an internet-based questionnaire. Between March and April 2021, a cross-sectional survey was conducted with a total of 159 orthopedics and traumatology specialists and residents in Turkey, using an online questionnaire that consisted of 16 different patient scenarios of varying intertrochanteric fracture types, ages, and comorbidity conditions. Respondents’ preference ratio for primary arthroplasty was 24.1% in the scenarios with patients over the age of 71, while it was 8.4% in the scenarios with patients aged between 50 and 70. The ratios of primary arthroplasty preference were 12.4%, 21% and 27.3% in 2-part, 3-part and 4-part fracture scenarios, respectively. The primary arthroplasty preferences of respondents with 10 years or more of professional experience were observed to be statistically significantly different to those of the respondents with 1 to 10 years of experience in the 4-part fracture scenario where the patient was aged 71 years and above with an ASA (American Society of Anesthesiologists) score of 3–4 (p < 0.05). Despite varying opinions in the literature in recent years, primary arthroplasty can be considered a valuable alternative approach for Turkish surgeons, and in older adult patients with unstable intertrochanteric fractures, particularly those who need early mobilization and have high ASA scores.

Use of a Trochanteric Fixation Nail-Advanced (TFNA) with cement augmentation for treatment of trochanteric fractures in patients greater than sixty five years of age

PURPOSE

Intramedullary nailing is the standard treatment of trochanteric fractures. Mechanical failure such as cut-out and cut-through are associated with high rates of revision surgery, functional impairment, and mortality. The aim of the study was to evaluate the rate of mechanical failure of the cement augmented screws of Trochanteric Fixation Nail-Advanced (TFNA) nails.

PATIENTS AND METHODS

A descriptive, retrospective, multi-operator, single-centre study was performed at our level 1 trauma centre between June 2019 and June 2020. Patients were included if they were > 65 years of age, presented with a trochanteric fracture treated with an augmented TFNA nail with 6 months of follow-up. The primary outcome was fixation failure rate (cut-out or cut-through) at three and six post-operative months. Secondary endpoints were intra-operative data, clinical scores, and radiographic analysis.

RESULTS

Forty-five patients (38 women and 7 men) were analysed. The mean age was 82.84 years (65-102, 9.50). There were no instances of mechanical failure in our series, after either three or six months of follow-up. No patient exhibited cut-out or cut-through. The mean amount of cement injected was 4.72 mL (3-6; 1.05). The mean length of surgery was 37.59 min (25-55; 6.48), and the mean intra-operative radiation exposure was 91.47 cGycm² (25.04-201.81; 51.40) for a mean duration of 43.11 s (17-86; 16.81). The mean duration of hospitalisation was 6.38 days (2-11; 2.27).

CONCLUSIONS

Our clinical results suggest that cement-augmented TFNA screws can be successfully used in the management of trochanteric fractures in patients > 65 years of age.

The fate of positive intraoperative cultures following conversion total hip arthroplasty

INTRODUCTION

The objectives of this study are to report the rates of positive intraoperative cultures obtained during conversion total hip arthroplasty (THA) according to index surgery, and to describe the natural history of treatment for a consecutive series of patients with unexpected positive intraoperative cultures during conversion THA.

METHODS

We reviewed all patients at 2 institutions undergoing conversion THA from prior open reduction and internal fixation (ORIF) of acetabular and hip fractures or hemiarthroplasty for displaced femoral neck fractures from 2011 to 2018. Intraoperative cultures were taken in 105 patients. Positive intraoperative cultures during conversion were recorded and managed with an infectious diseases consult. The outcomes including PJI at 90 days and 1 year follow-up were documented.

RESULTS

Overall, 19 of 105 patients (18%) undergoing conversion THA had positive intraoperative cultures, with the highest rates in the hemiarthroplasty 7/16 (44%) and acetabular ORIF 9/48 (19%) groups. All 19 patients were initially treated conservatively: 8 received IV antibiotics, 10 received no additional therapy, and 1 received oral antibiotics. 4/9 acetabular fracture conversions developed PJI at 1 year, with 3 requiring multiple irrigation and debridement/polyethylene exchanges to control the infection while the 4th patient required 2-stage exchange. There were no 1-year PJI from any of the other index procedures after conversion. All 7 hemiarthroplasty patients with positive cultures were treated to resolution with 4-8 weeks IV antibiotics alone.

CONCLUSIONS

Patients undergoing conversion THA from prior hip or acetabular fracture have a high rate of positive intraoperative cultures. As such, all patients undergoing conversion THA from prior hip or acetabular fracture fixation should undergo thorough diagnostic workup prior to surgery, and have intraoperative cultures obtained during surgery if infection remains suspicious. Further work should be performed to develop MSIS criteria for preoperative management of patients undergoing conversion THA.

Treatment of Osteoarthritis Secondary to Severe Coxa Vara with Modular Total Hip Arthroplasty

Objective

We aimed to demonstrate the methods of treatment for coxa vara with modular total hip arthroplasty (THA) and evaluate clinical and radiographic outcomes, and further survivorship at the midterm follow-up.

Methods

We retrospectively reviewed 33 patients (42 hips) who underwent modular THA for coxa vara deformity from May 2008 to December 2019. The clinical and radiographic results, including Harris Hip Score (HHS), leg length discrepancy (LLD), greater trochanteric height, femoral offset, abductor lever arm, stem alignment and limp, and complications, were evaluated.

Results

The follow-up time was mean 69.9±43.7 months. Clinically, the HHS improved significantly (p<0.001) on average from 42.90±14.44 points to 89.54±4.75 points. The mean LLD decreased from 33.3±19.4 mm to 5.0±5.8 mm (p<0.001), and 27 patients (82%) thought that total equality of the lower limbs was obtained. Patients demonstrated diminished or no limping in 88% (29/33) of hips and a significant improvement of biomechanics. At the final follow-up, all stems of hips were in clinical neutral alignment and the prostheses survivorship rates for all-causes revisions was 97.6%.

Conclusion

Modular THA is a valuable alternative to render favorable outcomes for treatment of osteoarthritis secondary to severe coxa vara.

Fracture and Patient Characteristics Associated With Early Conversion Total Hip Arthroplasty After Acetabular Fracture Fixation

OBJECTIVES

To determine risk factors for early conversion total hip arthroplasty (THA) after operative treatment of acetabular fractures.

DESIGN

Retrospective cohort.

SETTING

Level I trauma center.

PATIENTS AND INTERVENTION

We reviewed 685 operative acetabular fractures at our institution from 2011 to 2017, with a median follow-up of 12 months (range, 4-105 months).

MAIN OUTCOME MEASURE

Multivariable regression analysis was performed after univariate analysis to identify independent risk factors for conversion THA. Sensitivity analysis was performed with minimum follow-up set at 6 and 12 months.

RESULTS

One hundred eight patients (16%) underwent conversion THA, with 52% of conversions occurring within 1 year, an additional 27% within 2 years, and the remaining 21% within 6 years of the index acetabular open reduction internal fixation. The median time to conversion THA was 11.5 months (range, 0.5-72 months). The risk of conversion THA by fracture pattern was 53 of 196 (27%) for transverse posterior wall (TPW), 12 of 52 (23%) for T shaped, 10 of 68 (15%) for posterior column with posterior wall, and 25 of 207 (12%) for posterior wall. Independent risk factors for early conversion included the following: TPW fracture, protrusio, hip dislocation, increased body mass index, increased age, infection, and dislocation after open reduction internal fixation. Independent risk factors for early conversion THA specific to patients with TPW fractures include only increased age and body mass index. Sensitivity analysis showed no change in results using either 6 or 12-month minimum follow-up.

CONCLUSION

Transverse posterior wall fractures have a high risk of early conversion THA compared with other acetabular fracture patterns, especially when in combination with other significant risk factors. Consideration for different and novel management options warrants further study in this subset of acetabular fracture patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of Wedge Effect on Outcomes of Intertrochanteric Fractures Treated with Intramedullary Proximal Femoral Nail

The purpose of this study is to investigate the risk factors for wedge effect and its relevance between blade cut-out in patients with intertrochanteric fractures (ITF) treated with proximal femoral nail antirotation II (PFNA-II). A total of 113 patients with ITF treated with PFNA-II between 2012 and 2016 were retrospectively analyzed. Radiographic variables including preoperative fracture pattern, fracture classification, lateral wall fracture, and postoperative neck–shaft angle (NSA), femoral offset (FO), blade cut-out, and Parker’s ratio were measured for analysis. An average of 4.16° of varus malalignment in NSA and 5.5 mm of femoral shaft lateralization in FO was found post-operatively. The presence of lateral wall fracture was significantly related to post-operative varus change of NSA (p < 0.05). After at least one year of follow up, the blade cut-out rate was 2.65% (3/113), and Parker’s ratio was significantly higher in patients with blade cut-out (p = 0.0118). This study concluded that patients with ITF-present preoperative lateral wall fracture and postoperative higher Parker’s ratio in AP radiography showed higher incidence of wedge effect that might increase risk of blade cut out.

Surgical Treatment of Internal Fixation Failure of Femoral Peritrochanteric Fracture

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.

The majority of conversion total hip arthroplasties can be considered primary replacements - a matched cohort study

The success of conversion Total Hip Arthroplasty (THA) among primary THA and revision THA re- mains unclear. We hypothesized that most conversion THAss can be performed using primary implants and will have an uncomplicated post-operative course. Thirty-six patients (23 females, mean age 68,0y) who underwent conversion THA for failed interventions for proximal femur fractures in the period 2006-2018 were matched sequentially against patients of the same sex and age who underwent primary THA or revision THA. Data was collected on implants used, major complications, and mortality. PROMs used included the Western Ontario and McMaster Osteoarthritis Index, Harris Hip Score, Visual Analogue Scale and the EQ-5D Health Questionnaire. Seventy- two percent of patients who underwent conversion THA were treated with primary implants and never suffered from a major complication. PROMs were excellent for this group of patients. The distinction primary / conversion / revision THA could not explain differences in outcomes, however the necessity of using revision implants and the development of major complications could. The majority of conversion total hip arthroplasties can be considered a primary replacement. Predicting outcomes for THA should focus on patient frailty and technical difficulties dealing with infection, stability and loss of bone stock and should discard the conversion versus revision terminology.

Cementless total hip arthroplasty for failed treatment of subtrochanteric fracture

Background

Failed treatment of subtrochanteric fractures commonly leads to pain, limping, and poor limb function. Cementless total hip arthroplasty (THA) could serve as an efficient salvage procedure in such cases. This study aimed to evaluate the outcomes and complications of salvage THA in failed subtrochanteric fracture fixation cases.

Methods

From January 2001 to December 2017, cementless THA for failed treatment of subtrochanteric fractures was performed in 18 hips of 11 men and 7 women (average age, 74 years; age range, 57.0–89.0 years). Patients were followed up for clinical and radiological assessments in terms of implant survival and complications after a minimum follow-up of 2 years. The Wagner femoral stems (Zimmer, Warsaw, USA) were used in all 18 patients (100%), with the long-length stem (Wagner SL stem) and standard-length stem (Wagner cone stem) used in 11 and 7 patients, respectively.

Results

The mean follow-up period was 5.2 years (range: 2.2–10.8 years). The mean Harris hip score (HHS) was 38.2 (range: 24–56) preoperatively and 85.4 (range: 79–92) at the last follow-up. The mean postoperative limb length discrepancy was 6.4 mm (range: 4–9 mm). Only one patient underwent revision due to bone in-growth failure of the femoral stem. One patient had an episode of postoperative dislocation and was treated with closed reduction without reoccurrence. Delayed union of the fracture site occurred in one patient. Patients who were previously treated with an intramedullary nail had a significantly shorter surgical duration, lesser intraoperative blood loss, and fewer blood transfusions than those who were previously treated with plate and screws. Kaplan–Meier survival rate with an endpoint of revision was 94.4% (95% confidence interval 72.7–99.9) at 5 years.

Conclusion

Our results indicate that cementless THA is a beneficial and effective procedure for salvaging the failed treatment of subtrochanteric fractures. The Wagner conical prosthesis has shown satisfactory function outcomes, stable fixation, and survival rate for these complex situations. However, attention should be paid to increased operation time, blood loss, and complications when performing THA for subtrochanteric fractures with failed fixation devices especially, plates and screws.

The Cost and Consequences of Failed Osteosynthesis of Intertrochanteric Femur Fractures: A Matched Cohort Study

BACKGROUND

We aimed to evaluate the cost and consequences of failed osteosynthesis of intertrochanteric femur fracture (ITFF) patients and compare with primary ITFF patients.

METHODS

We retrospectively evaluated 689 patients who underwent surgery due to ITFF via cephalomedullary nail. 31 patients (5.8%) had revision surgery because of osteosynthesis failure of ITFF. Each revision case included in the study was matched with four primary ITFF cases as control group based on age, gender, year of operation, type of fracture and American Society of Anesthesiologists (ASA) grade. Total cost for the admission that patients underwent surgery, mortality rate at first year, infection rate, length of stay at hospital, length of stay at intensive care unit, and erythrocyte transfusion amounts were recorded from hospital registry records. Tip apex distances (TAD) were noted.

RESULTS

The mean total cost of the revision cases and primary cases was 10,027 ± 6387 and 5261 ± 1773 Turkish Liras, respectively (p < 0.001). TAD was ≥ 20 mm in 32.3% (10/31) of patients in revision group while 2.4% (3/124) of the patients in control group (p < 0.001). The mean length of stay at hospital, length of stay at intensive care unit, erythrocyte transfusion amounts, infection rate and mortality rate at first year were significantly higher in revision cases compared to matched primary control cases (p < 0.05).

CONCLUSION

Revision surgeries due to failed osteosynthesis of ITFFs with cephalomedullary nail have at least two times higher mean total cost than primary cases. The awareness of the cost, morbidity and mortality of the revision surgeries may reduce the modifiable risk factors of osteosynthesis failure including maintenance of TAD below 20 mm, obtaining optimal lag screw position and reduction quality.

LEVEL OF EVIDENCE

Level 3, retrospective cohort study.

The majority of conversion total hip arthroplasties can be considered a primary replacement: a matched cohort study

Background and study aims

The success of conversion total hip arthroplasty (THA) among primary THA and revision THA remains unclear. We hypothesized that most conversion THA’s can be performed using primary implants and will have an uncomplicated post-operative course.

Materials and methods

Thirty-six patients (23 females, mean age 68,0y) who underwent conversion THA for failed interventions for proximal femur fractures in the period 2008–2018 were matched sequentially against patients of the same sex and age who underwent primary THA or revision THA. Data were collected on implants used, major complications, and mortality. PROMs used included the Western Ontario and McMaster Osteoarthritis Index, Harris Hip Score, Visual Analogue Scale and the EQ-5D Health Questionnaire.

Results

Seventy-two percent of patients who underwent conversion THA were treated with primary implants and never suffered from a major complication. PROMs were excellent for this group of patients. The distinction primary/conversion/revision THA could not explain differences in outcomes; however, the necessity of using revision implants and the development of major complications could.

Conclusions

The majority of conversion total hip arthroplasties can be considered a primary replacement. Predicting outcomes for THA should focus on patient frailty and technical difficulties dealing with infection, stability and loss of bone stock and should discard the conversion versus revision terminology.

Decision making in the management of malunion and nonunion of intertrochanteric fractures of the hip

AIM

Intertrochanteric fractures account for almost 50% of hip fractures.Nonunion and malunion of these fractures are relatively uncommon. This study reviews the outcome of 31 cases of intertrochanteric fracture failures. An algorithm for the management of these injuries is also proposed.

METHODS

19 patients with intertrochanteric malunion and 12 patients with non-union were included in this study. Treatment of these injuries was initiated according to the algorithm proposed in this study. Treatment outcomes were evaluated by assessing union, pre and postoperative shortening and HSA (head-shaft angle). Functional outcomes were assessed by the Parker mobility scale and presence or absence of pain.

RESULTS

All the patients with intertrochanteric malunion with follow-up had united. The postoperative shortening in all patients were ⩽2.5 cms. Patients having intertrochanteric nonunion with follow-up, who underwent internal fixation had united with an acceptable Parker mobility scale score, except in 1 patient who sustained an ipsilateral distal femur fracture. The average HSA correction obtained was 21° (range 3-60°).

CONCLUSION

The algorithm proposed in this study helps streamline the treatment according to each case scenario.It helps in planning and managing patients with intertrochanteric fracture failures.

Total Hip Arthroplasty With Trochanteric Ostectomy for Patients With Angular Deformity of the Proximal Femur

BACKGROUND

Total hip arthroplasty (THA) of patients with a proximal femoral deformity is technically demanding. This deformity poses the risk of femoral fracture or perforation; stem malposition; and failed stem fixation. To insert a femoral stem in neutral position with a good fit, we removed the greater trochanter in case of a varus deformity, and the lesser trochanter in case of valgus deformity, while performing THA. We aimed to evaluate stem position, implant stability, clinical results, and radiological changes after THAs using this technique.

METHODS

Fifteen patients (17 hips; 11 varus hips and 6 valgus hips) underwent cementless THA using the trochanteric osteotomy technique in one institution. We evaluated procedure-specific complications: intraoperative femoral fracture, stem malposition, weakness of the abductor power and limp. Modified Harris Hip Score, radiological changes, and the stability of stems were assessed at a mean of 7.1 years of follow-up (range 2.0-15.5).

RESULTS

Femoral fracture occurred during the insertion of the stem in 4 hips. All stems were aligned in neutral position. At the latest follow-up, the mean power of the abductor was 4.3 (range 3-5). Eleven patients had slight limp and 4 patients had moderate limp. All stems had bone-ingrown stability and no stem was revised. The mean modified Harris Hip Score improved from 50 points at the preoperative evaluation to 81 points at the final follow-up.

CONCLUSION

The trochanteric excision enabled neutral insertion of cementless stem in patients with varus/valgus deformity of the proximal femur, and THA using this technique rendered favorable results.

Outcomes of Total Hip Arthroplasty for Healed Intertrochanteric Hip Fractures. A Matched Retrospective Cohort Study

BACKGROUND

Many studies have analyzed the outcomes of total hip arthroplasty (THA) after failed intertrochanteric fracture fixation, but not after healed fracture. The objective is to investigate the influence of a prior healed intertrochanteric fracture fixation on the outcomes of a subsequent THA for osteoarthritis.

METHODS

This is a matched retrospective cohort study of THA between 43 patients who suffered a prior intertrochanteric fracture successfully managed with internal fixation and 43 patients without prior hip fracture. Mean age was 73.6 vs 74.2 years. A conventional cementless THA was used in both groups. Functional outcome was assessed by the Harris hip score (HHS) and reduced Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Radiological assessment was also performed.

RESULTS

Mean follow-up was 6.6 (range, 5-8) years. The mean operative time and blood transfusion rate were significantly higher in the fracture group (P = .001), but there was no significant difference in the length of stay. HHS significantly improved in both groups. At final follow-up, HHS was significantly higher in nonfracture group (P = .008), but the rate of patients with excellent and good outcomes was similar (P = .616). Western Ontario and McMaster Universities Osteoarthritis Index score at the final follow-up was not different between groups (P = .058). Complication rate was similar between groups. There were no revisions, dislocations, or loose implants in the study group.

CONCLUSION

Cementless THA provided successful functional outcomes and implant durability at medium term in patients treated for osteoarthritis following healed intertrochanteric fracture fixation, comparable to those without prior fracture who underwent primary THA. Surgical complexity and complication rate were low.

The Use of Standard Cemented Femoral Stems in Total Hip Replacement After Failed Internal Fixation of Intertrochanteric Femoral Fractures

BACKGROUND

Total hip replacement (THR) after failed internal fixation of intertrochanteric femoral fractures is challenging. The aim of this study is to show the reliability of using standard cemented femoral stems in this operation.

METHODS

This work included 107 THRs performed in 107 patients after failed treatment of intertrochanteric femoral fractures. The etiology of failure included 67 cases of failure of fixation, 16 cases of nonunion, 15 cases of avascular necrosis, and 9 cases of post-traumatic osteoarthritis. There were 48 males and 59 females. The mean age was 66 years (range 58-81). Failed dynamic hip screws were removed at the time of THR, and the screw holes were blocked with cement. All cases had cemented standard stem femoral prostheses.

RESULTS

At an average 7.4 years with a minimum of 5 years of follow-up, 102 cases had good clinical and radiological outcomes and 5 cases had fair outcomes. One patient was infected and required 2 stages of revision arthroplasty. Two cases had intraoperative proximal femoral crack, and were treated by cerclage wires. Two patients had early postoperative dislocations. No patients had late periprosthetic femoral fractures or implant loosening.

CONCLUSION

Standard cemented femoral stems are reliable and cost-effective prostheses in such cases. It is not necessary to bypass the distal screw hole by doubling the femoral canal diameter as long as the bone holes are covered by cement.

Revision surgery due to failed internal fixation of intertrochanteric femoral fracture: current state-of-the-art

Failed treatment of intertrochanteric (IT) femoral fractures leads to remarkable disability and pain, and revision surgery is frequently accompanied by higher complication and reoperation rates than primary internal fixation or primary hip arthroplasty. There is an urgent need to establish a profound strategy for the effective surgical management of these fragile patients. Salvage options are determined according to patient physiological age, functional level, life expectancy, nonunion anatomical site, fracture pattern, remaining bone quality, bone stock, and hip joint competency. In physiologically young patients, care should be taken to preserve the vitality of the femoral head with salvage internal fixation; however, for the elderly population, conversion arthroplasty can result in early weight bearing and ambulation and eliminates the risks of delayed fracture healing. Technical challenges include a difficult surgical exposure, removal of broken implants, deformity correction, critical bone defects, poor bone quality, high perioperative fracture risk, and prolonged immobilization. Overall, the salvage of failed internal fixations of IT fractures with properly selected implants and profound techniques can lead to the formulation of valuable surgical strategies and provide patients with satisfactory clinical outcomes.

Triaging Total Hip Arthroplasty During the COVID-19 Pandemic

PURPOSE OF REVIEW

The purpose of this review was to evaluate the available literature to determine what may be considered urgent indications for total hip arthroplasty, in the unprecedented setting of the worldwide COVID-19 pandemic.

RECENT FINDINGS

SARS-CoV-2 is a novel coronavirus currently presenting in the form of a global pandemic, referred to as COVID-19. In this setting, multiple states have issued executive orders prohibiting "elective" surgery, including arthroplasty, in order to preserve healthcare resources. However, during this unprecedented reduction in elective surgery, there is likely to be some controversy as to what constitutes a purely "elective" procedure, versus an "urgent" procedure, particularly regarding hip arthroplasty. We reviewed the available literature for articles discussing the most commonly encountered indications for primary, conversion, and revision hip arthroplasty. Based upon the indications discussed in these articles, we further stratified these indications into "elective" versus "urgent" categories. In patients presenting with hip arthroplasty indications, the decision to proceed urgently with surgery should be based upon (a) the potential harm incurred by the patient if the surgery was delayed and (b) the potential risk incurred by the patient in the context of COVID-19 if surgery was performed. The authors present a decision-making algorithm for determining surgical urgency in three patients who underwent surgery in this context. Urgent total hip arthroplasty in the setting of the COVID-19 pandemic is a complex decision-making process, involving clinical and epidemiological factors. These decisions are best made in coordination with a multidisciplinary committee of one's peers. Region-specific issues such as hospital resources and availability of PPE may also inform the decision-making process.

The Value of Serological Screening Prior to Conversion Total Hip Arthroplasty

BACKGROUND

This study sought (1) to assess the value of serological testing prior to conversion total hip arthroplasty (THA) in predicting infection and (2) to identify optimal serological values for routine diagnostic workup prior to conversion THA.

METHODS

All patients at our tertiary referral center undergoing conversion THA after hip/acetabular fracture procedure from 2013 to 2018 were retrospectively reviewed. Inclusion criteria were patients previously undergoing hemiarthroplasty or open reduction and internal fixation of acetabular, intertrochanteric, and subtrochanteric fractures that progressed to conversion THA due to post-traumatic arthritis having erythrocyte sedimentation rate/C-reactive protein (CRP) prior to conversion. Infection was defined as positive intraoperative cultures not deemed contaminant in collaboration with infectious disease consult and/or development of PJI within 1 year postoperatively.

RESULTS

Twelve of 87 (14%) patients undergoing conversion THA developed infection. The mean erythrocyte sedimentation rate (37.2 vs 24.4 mm/h, P = .2062) and CRP (22.4 vs 9.0 mg/L, P = .0026) in the infected cohort were elevated compared to the noninfected group. An optimal cutoff value for CRP of 12 mg/L (area under the curve = 0.77, 95% confidence interval 0.58-0.97) revealed 75% sensitivity, 84% specificity, 43% positive predictive value, and 95% negative predictive value (P < .0001) in the entire cohort.

CONCLUSIONS

Even without clinical signs and symptoms, patients undergoing conversion THA from internal fixation of hip/acetabular fractures are still at high risk for developing periprosthetic joint infection. All patients undergoing conversion THA should have CRP measured preoperatively as a part of the diagnostic workup for underlying infection. Further research should be devoted to creating a preoperative diagnostic algorithm incorporating CRP, similar to Musculoskeletal Infection Society criteria, dedicated to patients undergoing conversion THA.

LEVEL OF EVIDENCE

Level III, Diagnostic retrospective cohort study.

Early mechanical complications following fixation of proximal femur fractures: From prevention to treatment

Proximal femur fractures have significant functional repercussions in both older adults (sometimes life-threatening) and younger adults (socioeconomic). This study will review the early mechanical complications (EMC) associated with the fixation of femoral neck (FNF) and trochanteric (TF) fractures. What is the nature of these complications? They consist of incorrect fracture fixation, secondary displacement and/or fixation failure (FNF: 3-10%; TF: 5-7%), and more rarely, secondary fractures distal to the implant. What are the risk factors and how can they be controlled? They are related to the patient (osteoporosis), to the type of fracture (FNF: posterior comminution, magnitude of displacement, vertical fracture line, fracture of calcar/TF: comminution of calcar, lesser trochanter fracture, metaphyseal comminution, lateral cortex fracture, greater trochanter comminution), to the chosen treatment (FNF: triple screw fixation or screw-plate are preferable/TF: all implants suitable for simple fractures, cervicomedullary implants for complex fractures), and to the surgical technique (quality of reduction, implant positioning). How should they be treated? Early revision of internal fixation can be difficult and increases the infection risk. Inter- or subtrochanteric valgus osteotomy leads to satisfactory results but is difficult to carry out. Secondary arthroplasty, which is the preferred option in older adults, leads to good outcomes but is technically more difficult, and has a higher complication rate in EMC of trochanteric fractures. LEVEL OF EVIDENCE: V.

Mid-term survivals of cemented calcar-replacement bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients

BACKGROUND

The literature has limited evidence regarding the mid-term survivals of cemented calcar-replacement bipolar hemiarthroplasty (HA) in elderly patients with unstable intertrochanteric (IT) fracture. The purpose of the present study was to evaluate clinical and radiological outcomes of cemented calcar-replacement bipolar HA for unstable IT fractures in elderly patients.

METHODS

One hundred and twenty-two patients with the mean age of 80.6 years were enrolled in this retrospective study after they met the selection criteria. Demographics, main clinical characteristics, and operative data were recorded for all patients. Functional outcomes were assessed according to Koval's categories. Clinical and radiological evaluations were performed. Kaplan-Meier survival analysis was used to construct the cumulative survival rate. The mean follow-up time was 25.7 ± 2.9 months (ranges 0-72 months).

RESULTS

Based on Koval's categories, 3 or 4-level decrease was detected in 21 patients (17%). Three patients (2 periprosthetic infections, 1 periprosthetic fracture) underwent reoperation during follow-up. No patient underwent revision of bipolar HA prosthesis. Femoral stem loosening and stem subsidence was the most common complication, observed in 22 patients (18%), followed by acetabular erosion that was seen in 12 patients (9.8%). The mean cumulative survival rate of prosthesis was 56.5% (95% confidence interval: 51.3-61.6).

CONCLUSION

Based on the results of our study, cemented calcar-replacement HA is an appropriate treatment option in elderly patients with unstable IT fractures owing to the advantages of satisfactory functional outcomes and lower reoperation rates. However, orthopedic surgeons should consider the low survival rates of cemented calcar-replacement HA prosthesis because of the increased femoral loosening in osteoporotic elderly patients.

The Treatment Strategies for Failed Fixation of Intertrochanteric Fractures

INTRODUCTION

Despite the generally successful outcome of intertrochanteric fracture fixation, the treatment is challenging when fixation failure occurs. Some studies have reported a systemic treatment strategy for salvaging failed intertrochanteric fracture fixation. This prospective study with a retrospective review of data aimed to evaluate and validate the efficacy of an evidence-based protocol developed for the treatment of failed intertrochanteric fractures.

PATIENTS AND METHODS

Between 1997 and 2016, 83 patients who could be followed up for more than 1 year after treatment were enrolled at an academic medical centre. An evidence-based protocol was established in July 2008 and was implemented prospectively. The treatment protocol was determined keeping in mind the condition of the femoral head, the deformation of the fracture site and the bone defect. Clinical results were evaluated, and fracture union and femoral neck-shaft angle were evaluated radiographically for patients in valgus osteotomy and re-fixation subgroups.

RESULTS

The Pain score, leg length discrepancy, Koval score for ambulatory levels and modified Harris Hip Score showed statistically significant improvement after the implementation of the new protocol. The radiographic success rate was 73% (27 of 37 patients) in the pre-protocol group and 91% (42 of 46 patients) in the post-protocol group, which shows statistically significantly improvement.

CONCLUSION

The new treatment strategy for failed intertrochanteric fracture fixation based on the condition of the femoral head, deformation of the fracture site and bone defect is successful based on clinical and radiographic results. Restoration of NSA of failed intertrochanteric fractures is a key factor for obtaining successful results.

Total hip arthroplasty following failed intertrochanteric hip fracture fixation treated with a cephalomedullary nail

AIMS

Cephalomedullary nails (CMNs) are commonly used for the treatment of intertrochanteric hip fractures. Total hip arthroplasty (THA) may be used as a salvage procedure when fixation fails in these patients. The aim of this study was to analyze the complications of THA following failed intertrochanteric hip fracture fixation using a CMN.

PATIENTS AND METHODS

Patients who underwent THA were identified from the 5% subset of Medicare Parts A/B between 2002 and 2015. A subgroup involving those with an intertrochanteric fracture that was treated using a CMN during the previous five years was identified and compared with the remaining patients who underwent THA. The length of stay (LOS) was compared using both univariate and multivariate analysis. The incidence of infection, dislocation, revision, and re-admission was compared between the two groups, using multivariate analysis adjusted for demographic, hospital, and clinical factors.

RESULTS

The Medicare data yielded 56 522 patients who underwent primary THA, of whom 369 had previously been treated with a CMN. The percentage of THAs that were undertaken between 2002 and 2005 in patients who had previously been treated with a CMN (0.346%) more than doubled between 2012 and 2015 (0.781%). The CMN group tended to be older and female, and to have a higher Charlson Comorbidity Index and lower socioeconomic status. The mean LOS was 1.5 days longer (5.3 vs 3.8) in the CMN group (p < 0.0001). The incidence of complications was significantly higher in the CMN group compared with the non-CMN group: infection (6.2% vs 2.6%), dislocation (8.1% vs 4.5%), revision (8.4% vs 4.3%), revision for infection (1.1% vs 0.37%), and revision for dislocation (2.2% vs 0.6%).

CONCLUSION

The incidence of conversion to THA following failed intertrochanteric hip fracture fixation using a CMN continues to increase. This occurs in elderly patients with increased comorbidities. There is a significantly increased risk of infection, dislocation, and LOS in these patients. Patients with failed intertrochanteric hip fracture fixation using a CMN who require THA should be made aware of the increased risk of complications, and steps need to be taken to reduce this risk. Cite this article: Bone Joint J 2019;101-B(6 Supple B):91-96.

Correlation between perioperative surgical factors and complications after hip arthroplasty, as a salvage procedure, following failure of internal fixation of osteoporotic intertrochanteric fractures

Background and purpose

Salvage hip arthroplasty (SHA) in patients presenting with failed internal fixation after intertrochanteric fracture (FIF-ITFx) is a difficult procedure, and the incidence of perioperative mortality and complications following SHA are high. To our knowledge, no information related to the correlation between perioperative surgical factors and post-SHA perioperative complications in these patients has been demonstrated. This study aimed to identify the predictive factors for post-SHA perioperative complications in patients with FIF-ITFx.

Materials and methods

A total of 32 patients with FIF-ITFx who underwent SHA between 2010 and 2017 were retrospectively reviewed. All patients had been followed for 1 year post-operatively. Perioperative data and complication details related to fracture and treatment were collected. Predictive factors for post-SHA perioperative complications were analyzed via logistic regression analysis.

Results

Two (6%) patients died after SHA during the admission period. Perioperative complications were found in 16 (50%) patients, including surgical (n=3, 9%) and medical (n=15, 47%) complications, respectively. By univariate analysis, age (P=0.043), American Society of Anesthesiologist (ASA) grade 4 (P=0.016), Charlson Comorbidity Index (CCI; P=0.014), lymphocyte cell count (P=0.064), and serum albumin level (P=0.146) were correlated with the perioperative complications. However, multivariate regression analysis showed that CCI was the only significant independent predictor for post-SHA perioperative complications in these patients (OR=1.87; 95% CI, 1.14-2.07, P=0.014).

Conclusion

Our study showed that post-SHA perioperative complications in patients with FIF-ITFx are very common and predictable with a simple preoperative factor CCI. Therefore, special perioperative attention must be paid to patients with FIF-ITFx undergoing SHA and having multiple severe comorbid diseases or high CCI.

Total Hip Arthroplasty for Posttraumatic Conditions

Posttraumatic arthritis accounts for a notable share of secondary osteoarthritis about the hip joint. Compared with total hip arthroplasty for primary osteoarthritis or inflammatory arthritis, total hip arthroplasty for posttraumatic arthritis offers greater technical challenges because of bone deformities and retained implants. Careful preoperative evaluation is necessary to prepare the approach, hardware removal strategy, and implants necessary to address bone deficiencies. Although arthroplasty is a highly successful procedure for posttraumatic arthritis, the results are less favorable than surgery for primary osteoarthritis. It is associated with a higher incidence of intraoperative and postoperative complications, including periprosthetic fractures, infection, instability, and decreased survivorship.

[Safety and efficacy of total hip arthroplasty following failed internal fixation of intertrochanteric fractures]

Objective

To evaluate the safety and efficacy of total hip arthroplasty (THA) following failed internal fixation of intertrochanteric fractures.

Methods

Between January 2007 and January 2016, THAs were performed in 32 patients (33 hips) for failed internal fixation of intertrochanteric fractures. There were 15 males and 17 females, with mean age of 74.0 years old (range, 65-87 years). There were 3 hips of Evans-Jensen type Ⅱ, 10 hips of type Ⅲ, 8 hips of type Ⅳ, and 12 hips of type Ⅴ. The fractures were fixed with dynamic hip screw in 18 hips, proximal femoral nail antirotation in 9 hips, locking plate in 5 hips, and hollow screw in 1 hip. The internal fixation failure caused by fracture displacement and nonunion in 22 patients, traumatic arthritis in 6 patients, fracture nonunion and infection in 3 patients, and avascular necrosis of the femoral head in 2 patients. The mean interval from initial fracture fixation to THA was 20 months (range, 2-48 months). The safety evaluation indicators included operation time, amount of operative bleeding and postoperative drainage, blood transfusion, and perioperative complications. The efficacy indexes included the hip Harris score, the range of motion (ROM), visual analogue scale (VAS) score, and the length difference between both legs; the X- ray films were taken to assess the prosthesis survival condition.

Results

The average operation time was 92 minutes (range, 55-135 minutes). The average amount of operative bleeding and postoperative drainage were 480 mL (range, 360-620 mL) and 350 mL (range, 220-520 mL), respectively. Intraoperative proximal femur fissure fracture occurred in 2 hips. After operation, 10 cases received allogeneic blood transfusion, 1 case occurred cerebral infarction, 2 hips experienced dislocation, 1 hip occurred greater trochanter re-fracture and dislocation because of spraining, and 1 case died of myocardial infarction. Twenty-nine patients (30 hips) were followed up 2-10 years (mean, 4.9 years). At last follow-up, there was no infection recurrence in 3 infected hips, and there was no prosthesis loosening, subsidence, or rupture in all cases. The Harris score, ROM, VAS score, and the length difference between both legs were significantly superior to preoperative ones ( P<0.05).

Conclusion

THA is an effective salvage procedure after failed internal fixation of intertrochanteric fracture. But its perioperative risks and complications are pretty high. Adequate preoperative evaluation, elaborate and individualized perioperative management are keys to make sure the patient can safely survive the perioperative period.

Poor outcomes for osteoporotic patients undergoing conversion total hip arthroplasty following prior failed dynamic hip screw fixation: a nationwide retrospective cohort study

Objectives

This study was performed to compare the long-term clinical and radiological outcomes of conversion total hip arthroplasty (CTHA) following prior failed InterTan nail (IT) fixation or dynamic hip screw (DHS) fixation in Asian patients with osteoporotic intertrochanteric hip fractures (IHFs) and to clarify which implant tends to be more favourable for CTHA.

Methods

Records of consecutive Asian patients with osteoporosis who underwent conversion of failed primary unilateral IT or DHS fixation to THA from 2010 to 2013 were extracted from the comprehensive database of the China Pacific Insurance Company Ltd. All consecutive procedures were managed by high-volume surgeons. The primary endpoint was the clinical outcome. The secondary endpoint was the radiological outcome.

Results

In total, 447 Asian patients with osteoporotic IHFs (DHS, n = 223; IT, n = 224) were assessed during a median follow-up of 46 months (range, 39–53 months). The two groups showed a significant difference in the Harris hip score at final follow-up and in the orthopaedic complication rate (DHS, 20.2%; IT, 9.8%).

Conclusion

Conversion to THA following prior failed DHS fixation tends to be associated with poorer clinical and radiological outcomes in Asian patients with osteoporotic IHFs than that following prior failed IT fixation.