Salvage of Failed Hip Fracture Fixation

Abstract

Nonunion of fractures about the femoral neck and intertrochanteric hip regions is uncommon. Patients who develop nonunions of these fractures typically exhibit marked pain and disability, thereby presenting a treatment challenge to the orthopaedic surgeon. Factors that guide the choice of salvage treatment include the anatomic site of the nonunion, the quality of the remaining proximal bone and articular surface, and patient factors (such as age and activity level). In the younger patients with a well-preserved hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. However, in older patients, it is more common to encounter poor remaining proximal bone stock or a badly damaged hip joint from hardware cutout. As such, conversion to hip arthroplasty is intended to help effectively restore function and relieve pain. With respect to salvage procedures for the femoral head, the major challenges in decision making include the choice of both internal fixation device and accurate preoperative planning. The challenges involved in planning to convert to hip arthroplasty include the need for acetabular resurfacing, selecting the femoral implant, and managing discontinuity of the greater trochanter. Furthermore, there are additional technical challenges that may be encountered, such as broken hardware, deformity, and femoral bone defects. Overall, salvage of nonunions of femoral neck and intertrochanteric hip fractures in properly selected patients can provide patients with good to excellent results.

Treatment and Displacement Affect the Reoperation Rate for Femoral Neck Fracture

“…Other associated risks of fixation include increased contralateral hip fractures [49] and complications and technical difficulties associated with salvage of failed fixation [16,23,34]. Despite the higher reoperation rates for internal fixation, advocates of this procedure argue this risk is offset by the benefits of preservation of the native femoral head and avoidance of potential complications of arthroplasty [2,13,31]. No clinical consensus exists regarding how to best treat FNFs with the primary intention of avoiding reoperation to avoid additional risks to patients.…”

“…The use of internal fixation in FNFs has been associated with reoperation rates ranging from 10% to 49% [18,21,22,24,42,44] compared with 0% to 24% for hemiarthroplasty [5,18,36,44], resulting in a more costly treatment strategy than hemiarthroplasty [1,25]. Despite increased complications and technical difficulties associated with salvage of failed fixation [16,23,34], some argue the higher reoperation rate is offset by the benefits of preservation of the native femoral head and avoidance of potential complications associated with arthroplasty [2,13,31]. Mortality at 1 year ranges from 14% to 36% but without differences in mortality between fixation and hemiarthroplasty at 1, 5, and 10 years [8,18,19,31,36,37].…”

Hip screw migration testing: First results for hip screws and helical blades utilizing a new oscillating test method

“…8,9 Varus collapse and screw migration may cause loss of reduction, eventually leading to pain, limited joint mobility, leg length discrepancy, and limping. 6 Morbidity is reported to be closely related to the fracture healing complication rate.…”

Osteosynthesis of femoral-neck nonunion with angle blade plate and autogenous fibular graft

“…Union rates >90% can be seen with free vascularised fibular grafting [6][7][8]. Jun et al achieved union in 92.3% (24 of 26) cases in 5.3 months [6].…”

“…The technique involved nonvascular fibular graft with a cannulated cancellous screw [4]. Other studies report using two to three screws as supplemental fixation with a fibular graft [5][6][7][8][9]. Union rates with this technique in two different studies were 69% and 95% [4,5].…”