Commentary & Perspective

Commentary & Perspective on
"Hip Arthroplasty for Salvage of Failed Treatment of Intertrochanteric Hip Fractures"
by George J. Haidukewych, MD, and Daniel J. Berry, MD

Commentary & Perspective by
John J. Callaghan, MD*,
Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA

As more people live well into their seventies and eighties, the prevalence of intertrochanteric hip fractures will escalate, and we might presume that treatment of these fractures with closed reduction or open reduction and internal fixation will fail in a percentage of these older patients. In this paper, Haidukewych and Berry have evaluated the results of treatment of failed intertrochanteric fractures with hip arthroplasty performed as a salvage procedure.

The authors reported a low prevalence of prosthetic implant failure and marked pain relief in this group of patients whose average age at the time of surgery was 78 years. The low demands of this elderly patient group should allow for durable results of total hip arthroplasty. Intraoperative and early postoperative complication rates were low, with only one death in the first month (due to aspiration pneumonia). This is especially surprising when one considers the mean operative time of 4 hours and the mean estimated blood loss of 1125 mL. The good results can be partially attributed to the physical abilities of the small percentage of patients who seek operative intervention after failed treatment of intertrochanteric hip fractures. These patients are functionally limited but healthy enough to undergo another operation. In addition, the institution where these procedures were performed has excellent preoperative and postoperative medical management programs. Also, all patients received warfarin or low-molecular-weight heparin for prophylaxis against thromboembolism.

The authors noted the frequent need for calcar replacement to accommodate proximal femoral bone loss and for long-stem implants to bypass cortical defects in the femoral shaft that were created by screw holes from side plates used in failed fixation devices. The authors did not report any late periprosthetic fractures in this series, which is probably a credit to the application of the principle of bypassing shaft defects with sufficiently long stems.

There was an extremely low prevalence of dislocation (1.7%) in this study, which is lower than the 10% rate that the authors reported for total hip replacements performed to treat acute femoral neck fractures¹. This may be related to the use of the transtrochanteric approach, which provided the ability to tighten the gluteus medius sleeve and to use bipolar replacements rather than acetabular component reconstructions when acetabular cartilage was still present.

In summary, this article is helpful to the surgeon performing hip arthroplasty in patients with previous intertrochanteric femoral fractures and to the patients and families of the patients considering this operation. For the patient disabled by the failure of internal fixation of an intertrochanteric femoral fracture, hip arthroplasty can provide durable fixation and pain relief (although the surgeon should explain to the patients that they may have some residual pain in the greater trochanter). Addressing the patients’ preoperative and postoperative medical problems are paramount, as long operative times and large amounts of blood loss are not uncommon with this procedure. Trochanteric osteotomy may be required to provide adequate exposure, and hardware should probably be removed after dislocating the hip to prevent fractures of the femoral shaft. The surgeon should compensate for proximal bone loss with a calcar-replacement implant and bypass any screw-holes in the femoral shaft with use of a long-stem prosthesis. If acetabular cartilage is preserved, a bipolar replacement may aid hip stability. If a total hip arthroplasty is chosen, and hip stability is problematic, a constrained implant can be used (because of low patient demands), especially if the abductor musculature is compromised. Postoperative prophylaxis against thromboembolism should be utilized. If these principles, outlined by Haidukewych and Berry, are followed, satisfying results of salvage hip arthroplasty in patients who have had failed treatment of an intertrochanteric fracture can be obtained.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Lee BP, Berry DJ, Harmsen MS, Sim FH. Total hip arthroplasty for the treatment of an acute fracture of the femoral neck: long-term results. J Bone Joint Surg Am. 1998;80:70-5.