Session VI - Geriatrics
Salvage of Failed Internal Fixation of Intertrochanteric Hip Fractures: Revision Internal Fixation or Hip Arthroplasty?
George J. Haidukewych, MD; Daniel J. Berry, MD; Mayo Clinic and Mayo Foundation; Rochester, Minnesota, USA
Purpose: Most intertrochanteric hip fractures treated with contemporary methods of internal fixation heal. If nonunion or early fixation failure occurs, salvage options include revision open reduction internal fixation (ORIF) or prosthetic replacement. At our institution, most younger patients with well-preserved hip joints and good proximal bone stock were treated with revision ORIF, whereas physiologically older patients with implant cutout, hip joint damage, or inadequate proximal bone stock were treated with hip arthroplasty. The purpose of this study was to evaluate the results of salvage of failed internal fixation of intertrochanteric hip fractures with revision ORIF or hip arthroplasty.
Methods: Between 1981 and 2000, 80 patients with intertrochanteric nonunion or acute fixation failure were treated with a salvage operation. Sixty patients with a mean age of 77 years (range, 54 to 96 years) were treated with hip arthroplasty, and 20 patients with a mean age of 58 years (range, 21 to 86 years) were treated with revision ORIF. The mean follow-up for the arthroplasty group was 5 years (range, 2 to 13 years), and the mean follow-up for the revision ORIF group was 27 months (range, 3 to 120 months). Results and complications were retrospectively reviewed. Total hip arthroplasty was performed in 33 patients and bipolar hemiarthroplasty in 27. A calcar replacing design was necessary in 58% of patients. Revision ORIF was performed with a blade plate in 11 patients, dynamic hip screw in 5, dynamic condylar screw in 3, and a Zickel nail in 1. Autograft bone grafting was performed in 17 patients and allograft in 3.
Arthroplasty: Ten patients died within 2 years and six were lost to follow-up. The remaining 44 were followed for a mean of 5 years (range, 2 to 13 years). At follow-up, 39 patients had no or mild pain and 5 had moderate to severe pain, all related to the greater trochanter. Forty patients were ambulatory, 26 with one arm support or less. Only two hips were revised for loosening at 8 and 10 years, respectively. Implant survivorship free of revision for any reason was 100% at 7 years and 88% at 10 years. Trochanteric complaints were common. There was one dislocation.
Revision ORIF: Nineteen of 20 nonunions healed (95%). Of the patients with healed fractures, 16 of 19 reported no pain, and 3 had mild pain, all related to trochanteric hardware. All patients were ambulatory.
Conclusions: For older patients with proximal bone inadequate for revision internal fixation, multiple failed internal fixation attempts, or implant cutout with hip joint damage, hip arthroplasty provided reliable salvage with predictable pain relief and low complication rates. Calcar-replacing designs and long stem implants were commonly needed. Trochanteric complaints were common. For younger patients with adequate proximal bone stock and a well preserved hip joint, revision ORIF provided predictable union rates and a low complication rate. Fixed-angle devices were useful in achieving stable proximal fragment fixation. Proper patient selection is paramount to the success of either procedure, and the rate of surgical complications was surprisingly low.