Revision surgery due to failed internal fixation of intertrochanteric femoral fracture: current state-of-the-art

Abstract

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.

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

“…The distorted anatomy of proximal femur, incompetent abductor mechanism, deficient bone stock, osteoporotic bone quality and stress risers after implant removal are some of the challenges that is encountered during a hip arthroplasty procedure for failed ITFs [ 6 ]. As a result, most of the surgical complications ( n = 20 of 22, 91%) in this study were associated with the femoral component or fractures around proximal femur, including intraoperative femur fracture, stem subsidence or loosening, greater trochanter fracture and periprosthetic fracture.…”

“…On the other hand, an increased risk of intraoperative femur fracture may be attributed to malunion around the meta-diaphysis, eccentric stem implantation due to endosteal sclerotic bone, use of revision stem with large diameter, osteoporotic bone quality, and a mismatch of the implant design and femur anatomy (e.g. coronal and sagittal femoral bowing in the Asian population) [ 3 , 6 , 24 – 27 ]. Despite the routine use of intraoperative fluoroscopy and flexible reamer during femoral canal preparation and implantation, we still observed a trend toward higher overall risk of intraoperative femur fracture associated with the use of revision stem.…”

“…The distorted soft tissue and bony anatomy, osteoporotic bones, critical bone defects, and stress risers after implant removal make this a technically demanding procedure that is associated with a high incidence of intraoperative and postoperative surgical complications. For instance, intra-operative femur fracture, stem subsidence or loosening, greater trochanter fracture, periprosthetic fracture or dislocation are some of the complications that may occur [ 3 , 6 – 9 ]. Currently, primary and revision femur stems with a cementless or cemented techniques have been utilized in the conversion procedure with satisfactory functional outcome and implant survival [ 8 , 10 – 16 ].…”

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

“…Despite the advances made in operative intervention, failure rates of up to 56% have been reported in the literature depending on fracture severity and implant type [9] . Fixation failure can lead to increased pain, immobility, and the need for additional surgical intervention [10] . Besides failure of fixation, other causes for re-intervention include non-union, infection, re-fracture, dislocation and femoral head osteonecrosis [10] .…”

“…Fixation failure can lead to increased pain, immobility, and the need for additional surgical intervention [10] . Besides failure of fixation, other causes for re-intervention include non-union, infection, re-fracture, dislocation and femoral head osteonecrosis [10] . Interestingly, secondary procedures within this predominantly elderly population can result in further clinical and radiological complications (such as nonunion; mal-union) as a result of the underlying bone fragility [ 10 , 11 ].…”