yst ar S em ul : C c u s r u r e M n t & R Orthopedic & Muscular System: c e i Khira, Orthop Muscular Syst 2016, 5:3 s d e e a p ISSN: 2161-0533r o c h h DOI: 10.4172/2161-0533.1000221 t r O Current Research Research Article Open Access Total Hip Replacement after Failed Internal Fixation of Trochanteric Femoral Fractures Yousuf Mohammad Khira* Faculty of Medicine, Orthopedic Surgery Department, Zagazig University, Egypt *Corresponding author: Yousuf Mohammad Khira, Faculty of Medicine, Orthopedic Surgery Department, Zagazig University, Egypt, Tel: 20-553668921; E-mail: [email protected] Received date: June 06, 2016; Accepted date: June 30, 2016; Published date: July 07, 2016 Copyright: © 2016 Khira YM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. Abstract Background: Failure of fixation of trochanteric fractures of the femur results in great disability and pain. Hip arthroplasty is a helpful reconstructive procedure in patients with poor bone stock, avascular necrosis of the femoral head, associated with damaged acetabular articular cartilage. Objective: This prospective study is to evaluate clinically and radiologically, the early results of total hip arthroplasty in a group of patients with failed internal fixation of trochanteric femoral fractures. Patients and Methods: Total hip replacement was done for fifty patients with failed treatment of proximal femoral fractures, only forty two patients 29 males and 13 females completed the follow up and eight were lost. The procedure was carried out through a lateral exposure in all cases. Harris Hip Score (HHS) was used for clinical evaluation preoperatively, postoperatively. Radiographic evaluation comprising anteroposterior radiographic views of the pelvis and femur and a lateral view of the femur were performed at follow-up visits. Results: The mean time of follow up was 42 months (range from 30-72 months). The mean Harris Hip Score was improved from a mean of 24 points preoperative to 88 points at final follow up. Pain relief and gait correction were noted at the final follow up. Thirty patients (72%) could freely walk outdoors using a cane or elbow crutch; eight patients (19%) had a limited walking ability using two axillary crutches, and four patients (9%) were able to walk indoors only. Conclusion: Total hip arthroplasty is an accepted procedure after failed internal fixation of trochanteric femoral fractures. Individualization of the implant selection according to patient age, level of activity, the bone stock of proximal femur, and the condition of the acetabulum. Keywords: Total hip; Replacement; Trochanteric fracture; Failure of arthroplasty such as extraction of implants, bone deformity, bone loss, fixation poor bone quality and associated trochanteric nonunion [11-13]. The purpose of this prospective study is to evaluate clinically and Introduction radiologically, the early results of total hip arthroplasty in a group of Stable trochanteric femoral fractures can be treated by internal patients with failed internal fixation of trochanteric femoral fractures. fixation methods with union rates as high as 100% when optimal implant and good reduction have been achieved. Failure rates have Patients and methods been reported in literature due to comminution, osteoporosis and All patients included in this study have given informed written suboptimal fixation [1]. Functional disability and pain are the end consent for participating in the research before operation. result of failed fixation of trochanteric femoral fractures. Failure rates may be due to failure of the device (3-12%); device penetration in (2% This prospective study was conducted at Zagazig University and 12%), nonunion (2-5%) and malunion with varus deformity in Hospitals, after approval of our ethical committee for research in (5-11%). Certain unstable fracture patterns have been reported to have accordance with the ethical standards laid down in the 1964 failure rates as high as 56% [2-6]. Revision of internal fixation for declaration of Helsinki and its later amendments. nonunited trochanteric fractures of the femur has been reported to From January 2004 to December 2010, fifty patients with failed have good results in younger patients with good bone stock [6-10]. treatment of proximal femoral fractures were treated by total hip Total hip arthroplasty is considered as a salvage procedure for older replacement as a salvage procedure. Only forty two patients available patients, patients with poor bone stock, avascular necrosis of the for this study and eight patients were lost during the period of follow femoral head, associated with damaged acetabular articular cartilage up. The mean age of the patients was 52 years (range: 44–68 years) and [7]. There are many technical difficulties during conversion hip the sex distribution was 29 males and 13 females (Table 1). The type of fracture was intertrochanteric in 30 patients and subtrochanteric in 12 Orthop Muscular Syst Volume 5 • Issue 3 • 1000221 ISSN:2161-0533 OMCR, an open access journal Citation: Khira YM (2016) Total Hip Replacement after Failed Internal Fixation of Trochanteric Femoral Fractures. Orthop Muscular Syst 5: 221. doi:10.4172/2161-0533.1000221 Page 2 of 6 patients. The implants used to treat these fractures primarily were: to avoid cement extrusion through the screw holes which may cause Dynamic Hip Screw in (DHS: 33 cases), proximal femoral nail in subsequent fracture through this stress riser. (PFN: 6 cases), dynamic condylar screw in (DCS: 3 cases). The mean time from primary fixation to the salvage arthroplasty was 22 months (range, 9 to 36 months). Mean Age (range) 52 (44-68) years Male: 29 Sex Female: 13 Right: 17 Side affected Left: 25 *DHS: 33 Implant in first operation **PFN:6 ***DCS: 3 Mean duration between first 22 (9-36) months operation and salvage Cement less: 32 Figure 1: Female patient 62 years old (Case No. 12): A&B) preoperative X-ray with screw penetration and hip ankylosis; C&D) Type of prosthesis (fixation method) Cemented: 5 postoperative X-ray with hybrid THR (cementless cup and Hybrid: 5 cemented stem). Standard stem: 34 Stem used Long stem: 8 Bearing surfaces Metal on polyethylene : 42 cases *(dynamic hip screw) **(proximal femoral nail) ***(dynamic condylar screw) Table 1: All patients data preoperative. Intraoperative cultures did not grow organisms in thirty four patients and positive in 8 patients were operated on in two stages. One stage revision was done in 34 cases with aseptic failure (Figure 1A and 1B), and two stages in eight cases where infection was the cause of nonunion and implants failure (Figure 2A and 2B). The inclusion criteria of patients included in this study were either one or a combination of the following: • Nonunion and or loss of fixation with avascular necrosis of the femoral head, • Screw penetration of the acetabulum, • Chondrolysis or hip incongruity. Figure 2: Male patient 58 years old (Case No. 3): A&B) preoperative X-ray 9 months after metal extraction; C&D) postoperative X-ray Patients with implant failure with normal acetabulum were excluded (cementless THR); E) 2 years postoperative. as bipolar prosthesis was done, also cases with active infection not done until debridement and cure of infection at least nine months after skin closure and no sinuses then second stage was done for them after Harris Hip Score (HHS) [15] was used for clinical evaluation laboratory investigations to ensure no microbial activity. preoperatively, postoperatively and at last follow up. The score has a The selection of the implant type depended on patient age and bone maximum of 100 points (best possible outcome) covering pain (1 item, quality with intraoperative evaluation according to bone stock after 0-44 points), function (7 items, 0-47 points), absence of deformity removal of implant. Hybrid prosthesis was used in 5 hips (Cementless (1item, 4points) and range of motion (2 items, 5points). The score of cup and cemented stem) (Figure 1C and 1D), cementless prosthesis (90-100 points) HHS is excellent, good (80-90), fair (70-80), and poor was used in 32 hips (Figure 2C,2D and 2E), and cemented prosthesis in (below 70 points) [16]. Limb length measurement. Preoperative 5 hips and (Figure 3A and 3B). A 28 mm metal head was used in all clinical examination and, hematological investigations as complete cases. In cemented stem the principle of Patterson et al. [14] was used blood count, Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) were done for all patients regarding occult infections. Orthop Muscular Syst Volume 5 • Issue 3 • 1000221 ISSN:2161-0533 OMCR, an open access journal Citation: Khira YM (2016) Total Hip Replacement after Failed Internal Fixation of Trochanteric Femoral Fractures. Orthop Muscular Syst 5: 221. doi:10.4172/2161-0533.1000221 Page 3 of 6 on table. Intraoperative fracture extension or new fracture occurred in 6 patients, in four cases calcar replacement stem was used, and plate fixation in two cases as the fracture was distal to the stem end. Prophylaxis for Deep Vein Thrombosis (DVT) using medical and mechanical methods was done for all patients. Clexane 40 units subcutaneous were used 24 hours preoperative and from second day through 3weeks postoperative in all patients. Closure of the wound over suction drains which kept in situ for 2 days. Patients stay in hospital ranged from 8 to 17 days. After removal of stitches by 2 weeks regular monthly visits for six months, and every six months up to the end of follow up. Results The mean time of follow up was 42 months (range from 30-72 months). The operative time ranged from 130 to 210 minutes (Average 150), with a mean blood loss of 1000 ml (range from 600 to 2000 ml). The minimum follow up period was 2.5 years (ranged from 2.5 to 6 Figure 3: Male patient 68 years old (Case No.