Salvaging the Failed Hip Fracture Fixation
In the abstract of his presentation at ICJR’s Pan Pacific Orthopaedic Congress, Dr. Daniel Berry provides his tips for managing this often-challenging scenario in younger and older patients.
By Daniel J. Berry, MD
A failed hip fracture fixation is not something that can be ignored – it generally causes pain and profound disability, and effective salvage strategies, therefore, are essential.
When a failed femoral neck fracture occurs in a young patient, the strategy generally is to attempt to salvage the patient’s femoral head. Clinical results are reasonably good even if there are patches of avascular necrosis.
The preferred method of salvage is a valgus-producing intertrochanteric femoral osteotomy. This puts the non-union under compression to achieve healing. Another treatment option in this patient population is a Meyer’s vascularized pedicle graft.
Most cases of failed femoral neck fracture occur in older patients, not younger patients. Conversion to arthroplasty is the standard salvage treatment in the older population.
The decision on whether to perform a hemiarthroplasty (such as bipolar) or a total hip arthroplasty (THA) depends on the quality of the articular cartilage and the perceived risk of an instability problem. In most patients, THA provides a greater likelihood of excellent pain relief.
The consensus is to use THA in cases of articular cartilage damage and in more active patients. Most surgeons use large-diameter femoral heads, and some give consideration to dual-mobility implants to optimize stability, as dislocation is one of the biggest problems in this patient population.
Specific technical issues with THA include:
- Hardware removal: In these patients, the hardware should generally be removed after the hip has first been dislocated to reduce risk of femur fracture.
- Hip stability: Consider using anterolateral approach in older, at-risk patients.
- Poor acetabular bone quality: The bone is soft, not sclerotic as in osteoarthritis, so use caution with impacting a press-fit cup, and have a low threshold for augmenting fixation with screws. Reaming should be done just to the point of exposing the bleeding subchondral bone. A reasonable alternative is a cemented cup.
A more challenging situation is the failed intertrochanteric hip fracture. In a young patient, attempt to salvage the femoral head with non-union takedown, autogenous bone grafting, and internal fixation. A blade plate is usually the favored internal fixation device.
The more common scenario is the older patient with the failed intertrochanteric hip fracture. The surgeon must decide whether to attempt another internal fixation or do a salvage arthroplasty procedure. In our practice at Mayo Clinic, 80% of these patients have a salvage procedure.
This decision should be individualized based on patient circumstances, fracture pattern, and bone quality. Factors that suggest an arthroplasty is more appropriate include:
- Advanced age
- Poor proximal bone with limited fixation options
- Damaged acetabulum
If prosthetic replacement is chosen special considerations include the following:
- Removal of hardware: Dislocate the hip, relocate it, and then remove the hardware. Also, be prepared to remove broken screws in intramedullary canal.
- Management of bone loss: Bone loss to the level of the lesser trochanter is common, often necessitating a calcar replacement implant. Proximal calcar build-up size dictated by bone loss.
- Length of the stem: Bypass screw holes from the previous fixation if possible. Avoid and check for cement extrusion.
- Stem fixation: The type of fixation – cemented or uncemented – depends on on surgeon preference and bone quality. If uncemented fixation is chosen, consider using an extensively coated implant.
- Greater trochanter: The greater trochanter is often non-united and frequently juxtaposed over the femoral canal. Be prepared to fix it with wires or cable grip. Residual trochanteric healing and hardware problems are a minor but persistent problem after THA.
- Bone deformity/heterotopic bone: Manage this on an individual basis.
In conclusion, retaining the native hip joint is the goal with younger patients who have a failed femoral neck or intertrochanteric hip fracture.
Prosthetic replacement is a good salvage procedure for many older patients with these fractures. Although the procedure is technically demanding, it provides good pain relief and functional improvement in patients who have been unable to walk for a long time.
Daniel J. Berry, MD, is the LZ Gund Professor in the Department of Orthopaedic Surgery at Mayo Clinic, Rochester, Minnesota
Haidukewych GJ, Berry DJ: Hip Arthroplasty for Salvage of Failed Treatment of Intertrochanteric Hip Fractures. J Bone Joint Surg 85A(5):899-904, May 2003
Haidukewych GJ, Berry DJ: Salvage of Failed Treatment of Hip Fractures. J Am Acad Ortho Surg 13(2):101-9, Mar-Apr 2005.
Tabsh I. Waddell JP, Morton J: Total Hip Arthroplasty for Complications of Proximal Femoral Fractures. J Orthop Trauma 11:166-169, 1997.