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

Is there a role for cementless primary stem in hip arthroplasty for early or late fixation failures of intertrochanteric fractures?

Background

The choice of femur stems during the hip arthroplasty procedures for patients with treatment failure of intertrochanteric fractures (ITF) remains controversial. We aimed to compare the surgical complication and reoperation rates between cementless primary and revision stems in the early (≤3 months) and late (> 3 months) fixation failures of ITF.

Methods

This was a retrospective, cohort study conducted in a single, tertiary referral hospital of Taipei, Taiwan. We included hip arthroplasty procedures for failed ITF using cementless primary or revision stems. There were 40 and 35 patients who had early and late fixation failure of ITF, respectively. The patient demographics, time to fixation failure, surgical complications and medical complications were recorded for analysis.

Results

We included 75 patients that underwent hip arthroplasty procedure for failed ITF using cementless primary (n = 38) or revision (n = 37) stems. The mean age was 79.3 years and 56% of the patients were female. In the early fixation failure group, the complication rate was similar between the primary and revision stems (44% vs. 29%, p = 0.343). However, there was a trend toward a higher reoperation rate (31% vs. 8%, p = 0.061) of using the primary stem, compared with the revision stem. In the late fixation failure group, the rate of complication and reoperation was similar between the two stem types.

Conclusion

For early fixation failures of ITFs, we caution against the use of cementless primary stems due to a trend towards an increased risk of reoperations compared to the use of cementless revision stems. However, in late fixation failures of ITFs, there is a role for cementless primary stems.

Level of evidence

III, retrospective cohort study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05223-x.

Stabilisation of AO OTA 31-A unstable proximal femoral fractures: Does the choice of intramedullary nail affect the incidence of post-operative complications? A systematic literature review and meta-analysis

OBJECTIVE

To determine if there was a difference in the risk of post-operative complications associated with the use of different intramedullary (IM) devices in the treatment of unstable AO OTA 31-A trochanteric fractures.

DESIGN

Systematic literature review and meta-analysis.

METHODS

A systematic literature review was carried out in January 2022 in the Embase, MEDLINE and Cochrane databases. Studies comparing INTERTAN™ to other intramedullary nails for the treatment of AO OTA 31-A trochanteric fractures were selected for inclusion. After data extraction, meta-analyses were carried out on postoperative outcomes, with specific focus placed on unstable fracture patterns.

RESULTS

Twenty-three studies were suitable for inclusion, of which seventeen reported on outcomes in unstable fractures. INTERTAN reduced the risk of revision/reoperation by 64% (RR 0.36, 95% CI 0.25 to 0.54, p <0.0001), implant failures by 62% (RR 0.38, 95% CI 0.25 to 0.57, p<0.0001) and hip and thigh pain by 50% (RR 0.50, 95% CI 0.35 to 0.71, p=0.0001) in unstable fractures. No differences were noted between IM nail designs for infection rates, healing time, non-union rates, femoral shortening, or Harris Hip Score.

CONCLUSIONS

The INTERTAN IM nail may reduce incidence of implant-related complications, hip and thigh pain, and the need for revision/reoperation without compromising clinical and functional outcomes.

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.

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.

[Arthroplasty in patients with osteoporosis]

Arthroplasty has become a very successful operation with excellent long-term results. A dedicated diagnostic set-up to exclude osteoporosis prior to a joint replacement and the use of drugs to improve the outcome of a joint replacement are currently not recommended. Knee arthroplasty should always be cemented in patients with known osteoporosis. The same is recommended for hip joint replacement, even if the cement-free acetabular component yields good results. Rapid loading and mobilization appear beneficial also with respect to the osteoporosis and its systemic treatment.