ORIGINAL RESEARCH |
https://doi.org/10.5005/jojs-10079-1112 |
Functional Outcome of Treatment after Failed Intertrochanteric Fracture Fixation
1-5Department of Orthopaedics Surgery, Rex Ortho Hospital, Coimbatore, Tamil Nadu, India
Corresponding Author: Rex Chandrabose, Department of Orthopaedics Surgery, Rex Ortho Hospital, Coimbatore, Tamil Nadu, India, Phone: +91 9894790910, e-mail: rexchandrabose@gmail.com
Received on: 11 May 2022; Accepted on: 04 January 2023; Published on: 07 July 2023
ABSTRACT
Background: Failed intertrochanteric (IT) fractures are the most common fractures seen in an elderly population. It causes more morbidity and mortality in old people. Hence fixation of failed IT fractures is necessary. The aim of our study is to assess the functional outcome of failed IT fracture fixation like a dynamic hip screw and bone grafting, total hip replacement (THR), hemiarthroplasty, and exchange nailing and bone grafting.
Materials and methods: It is a prospective study done between June 2020 and May 2022 in Rex Ortho Hospital. Our study consists of 57 patients who had IT fractures primarily fixed with anyone of the following—like proximal femoral nailing (PFN) and dynamic hip screw fixation, and then failed due to various reasons like unstable fracture pattern, poor reduction techniques, implant failure, or loosening. Patient functional outcomes were assessed by Modified Harris Hip Score (MHHS), and the pain was assessed by visual analog scale (VAS) score at regular intervals preoperatively (pre-op), 3 months, 6 months, and 1 year.
Results: Our study population comprised 27 males and 30 females with failed IT fractures. The average follow-up was 12–24 months. Out of 57 patients, 18 had cemented THR, 17 had a dynamic hip screw and bone grafting, 13 had cemented hemiarthroplasty, and nine patients had exchange nailing and bone grafting. At the end of 12 months, among 11 patients with cemented THR patients, three (27.2%) had excellent outcomes and eight (72.7%) had good outcomes. Among eight patients with dental bone graft (DHS) and bone grafting, six (75%) had good outcomes and two (25%) had fair outcomes. Among seven patients with cemented hemiarthroplasty, six (85.7%) had good outcomes and one (14.2%) had a fair outcome. Among nine patients with exchange nailing and bone grafting, two had good outcomes, and five had poor outcomes.
Out of refixation, 25 out of 26 nonunions were healed. One nonunion again went for nonunion, which was a case of exchange nailing and bone grafting, and had revision cemented hemiarthroplasty. All patients are free of pain. Two patients had hyponatremia postoperatively (post-op) and three patients had post-op pain due to hardware impingement, but they were ambulatory. One had a superficial wound infection and one had a greater trochanter (GT) fracture intraoperatively.
Conclusion: In the selected group of patients who had refixation with bone grafting in the young population, all had excellent outcomes. The elderly who underwent THR had an excellent outcome, and patients with bipolar hemiarthroplasty scored less. Thus, we recommended head-conserving surgery where ever possible, and if not THR, and last option being bipolar hemiarthroplasty.
How to cite this article: S G, Vaiyapuri MK, Selvaraj AG, et al. Functional Outcome of Treatment after Failed Intertrochanteric Fracture Fixation. J Orth Joint Surg 2023;5(2):79-85.
Source of support: Nil
Conflict of interest: None
Keywords: Dynamic hip screw and bone grafting, Exchange nailing and bone grafting, Hemiarthroplasty, Intertrochanteric fracture, Modified Harris Hip, Total hip replacement score, Visual analog scale score.
INTRODUCTION
Intertrochanteric (IT) fracture of the hip is mostly seen in the elderly osteoporotic population. It comprises half of the hip fractures and creates a great burden to the treating surgeon and the patient.1,3 These fractures are more common in females when compared with males due to postmenopausal decrease in bone density. The ratio is 2:1–8:1, with female predominance.4
The surgical options are either intramedullary fixation and extramedullary fixations like sliding slip screws or proximal femoral locking plating.5 Despite the controversy of using fixation devices, intramedullary fixations are the choice of implants because of their superior advantages.6 Changes in implant design and reduction methods are made to achieve stability of the fracture. Although it is treated with the above fixations, the fixation failure rate ranges from 3 to 12%.7-9 Fracture pattern, preexisting chronic comorbidities, and bone density are some factors that determine the fracture union. Failed IT fractures can cause significant pain and disability and always needs surgery.10 Indications for surgery are nonunion, malunion, implant failure, refracture, dislocations, femoral head necrosis, and infection.11
Salvage hip arthroplasty and revision osteosynthesis are the two main treatment options for failed IT fractures. Salvage hip arthroplasty includes total hip arthroplasty and hemiarthroplasty.12,13 Many technical challenges one must overcome before doing revision procedures, like poor bone stock, residual bone deformity, removable of broken implant, altered soft tissue anatomy after primary fixation, and proximal femoral deficiency. Due to these technical challenges, revision surgeries have been related to increased perioperative morbidity, more blood loss, more operative time, intraoperative fractures, and high chances of early dislocations.14
The usage of new fixator devices and advanced techniques and reduced hospital stays may reduce the operation-related adverse effects. Currently, there are no guidelines present for the treatment of failed IT fractures regarding revision osteosynthesis and salvage conversional arthroplasty. Our study is to compare the functional and clinical outcomes of the patients with IT fracture fixation with revision osteosynthesis and hip arthroplasty, either cemented THR or cemented hemiarthroplasty.
AIMS AND OBJECTIVES
To assess the functional outcomes following revision osteosynthesis like DHS and bone grafting, exchange nailing, or conversional hemiarthroplasty like total hip arthroplasty, hemiarthroplasty due to failed primarily treated IT fractures.
To record the improvement in pain and to assess the functional outcomes using VAS and MHHS, which is recorded pre-op and post-op at 3 months, 6 months, 1 year, and thereafter yearly.
MATERIALS AND METHODS (TABLES 1 AND 2)
| Patient age 50–90 years Patient with IT fractures with implant failure Patient with nonunion IT fractures with implant in situ Patient with no neurovascular injury after primary procedure |
| Patient with associated femoral fractures Patient age <50 years Patient with clinical and hematological evidence of infection Patient with nonunion treated conservatively |
It is a longitudinal follow-up study done prospectively using questionnaires and pro forma at Rex Ortho Hospital, Coimbatore, Tamil Nadu, India, between June 2020 and May 2022 on 57 patients who had IT fractures which were initially treated with primary fixation and failed due to various reasons and undergone revision osteosynthesis or salvage hip arthroplasty, a written informed consent received from all the participants in the study with the following inclusion and exclusion criteria.
All the consecutive patients with failed IT fractures were confirmed by X-ray and magnetic resonance imaging with computed tomography guidance and admitted for revision fixation with either dynamic hip screw, exchange nailing, or conversional arthroplasties like hemiarthroplasty and THR.
A detailed evaluation of the patient’s symptoms and physical examination were done and documented. The severity of hip pain was assessed by the VAS, while the pre-op functional status was evaluated with MHHS.
RESULTS
Case 1—a 58-year-old female IT fracture treated with PFN 3 months ago presented with complaints of pain over her right hip and difficulty in walking. She was diagnosed with a nonunion IT fracture with the loosening of screws (Z effect). Treated with dynamic hip screw and bone grafting from the iliac crest and GT cerclage wiring (Figs 1A to C).
Figs 1A to C: (A) Preoperative (pre-op) X-ray shows nonunion of fracture fragment with loosening of screws (Z effect)— modified hip score was 5; (B) 6 months post-op X-ray shows well-formed callus between fracture site—modified hip score was 63; (C) 12 months post-op X-ray. Patient is mobile and pain free—modified hip score was 85
Case 2—a 70-year-old male had an IT fracture 2 months ago and was treated with dynamic hip screw fixation and came with complaints of pain over the left hip. He was diagnosed with a nonunion IT fracture with implant failure. THR and cerclage wiring for GT (Figs 2A to C).
Figs 2A to C: (A) Preoperative (pre-op) X-ray shows varus nonunion with implant failure—modified hip score was 15; (B) Immediate post-op X-ray showing good construct of implants; (C) 12 months post-op X-ray—modified hip score was 84
Case 3—a 58-year-old female was treated for an IT fracture with PFN 1 month ago. After failed IT fracture with screws and nail loosening, she was treated with hemiarthroplasty (Figs 3A to C).
Figs 3A to C: (A) IT fracture with implant failure (proximal nail migration and complete loosening of screws)—modified hip score was 20; (B) 3 months post-op X-ray of hemiarthroplasty—modified hip score was 53; (C) 12 months post-op X-ray of hemiarthroplasty—modified hip score was 80
In our study, we have noticed that 33.5% of the population belongs to 61–70 years of age, 31.5% to 71–80 years of age, 21% to 51–60 years of age, and 14% to 81–90 years of age. This shows that the majority of failed IT fractures are in the age-group of 61–70 years of age (Table 3). In our study, 40 patients underwent PFN (70.1%), and 17 patients underwent dynamic hip screw (29.8%) as their index surgery (Table 4). The most common cause for failure was varus reduction which was seen in 16 patients (28%). The next cause was implanted loosening, seen in 14 patients (24.6%). Screw cut-off was seen in 10 patients (17.5%), screw penetration was seen in eight patients (14%), and the unstable fracture pattern was seen in nine patients (15.7%) (Table 5).
| Age | Frequency | Percentage |
|---|---|---|
| 51–60 | 12 | 21 |
| 61–70 | 19 | 33.3 |
| 71–80 | 18 | 31.5 |
| 81–90 | 8 | 14 |
| Total | 57 | 100 |
| Index surgery | Frequency | Percent |
|---|---|---|
| DHS | 17 | 29.8 |
| PFN | 40 | 70.1 |
| Total | 57 | 100.0 |
| Reason | Frequency | Percentage |
|---|---|---|
| Implant loosening | 14 | 24.6 |
| Screw cut-off | 10 | 17.5 |
| Screw penetration | 8 | 14 |
| Varus reduction | 16 | 28 |
| Unstable fracture pattern | 9 | 15.7 |
| Total | 57 | 100 |
Among 57 failed IT fractures, 13 patients underwent cemented hemiarthroplasty, including bipolar hemiarthroplasty for three patients (5.2%) and unipolar hemiarthroplasty for 10 patients (17.5%). Cemented THR was done for 18 patients (31.5%), dynamic hip screw with bone grafting was done for 17 patients (29.8%), and exchange nailing with bone grafting was done for nine patients (15.8%) (Table 6).
| Revision surgery | Frequency | Percent |
|---|---|---|
| Cemented bipolar hemiarthroplasty | 3 | 5.2 |
| Cemented Thompson’s unipolar hemiarthroplasty | 10 | 17.5 |
| Cemented THR | 18 | 31.5 |
| DHS with bone grafting | 17 | 29.8 |
| Exchange nailing with bone grafting | 9 | 15.8 |
| Total | 57 | 100.0 |
Modified Harris Hip Score (MHHS) was assessed pre-op and post-op at 3 months, 6 months, and 12 months. The mean MHHS score at pre-op was 11.52 [standard deviation (SD) = 7.39]; at the end of 3 months post-op was 46.22 (SD = 9.58); at the end of 6 months, post-op was 68.93 (SD = 8.42). At the end of 1 year, the MHHS for our study population was 83.33 (SD = 5.82). The mean score was found to be increasing in every follow-up, which correlated with the clinical condition of our patients. The statistical test of MHHS at different follow-up intervals was found to be significant (p < 0.0001) (Table 7).
| MHHS | Mean | SD | p-value |
|---|---|---|---|
| Pre-op | 11.52 | 7.39 | <0.0001 |
| 3 months | 46.22 | 9.58 | |
| 6 months | 68.93 | 8.42 | |
| 12 months | 83.33 | 5.82 |
The mean VAS score pre-op was 8.49 (SD = 0.93), the post-op mean at 3 months was 3.93 (SD = 1.38), and at 6 months, the mean was 1.59 (SD = 1.31). The post-op mean at the end of 1 year was 0.37 (SD = 0.63). The p-value was <0.0001, which was statistically significant. This shows that pain is in decreasing tendency following revision surgery which also correlates with MHHS and clinical observation (Table 8).
| VAS | Mean | SD | p-value |
|---|---|---|---|
| Pre-op | 8.44 | 0.93 | <0.0001 |
| 3 months | 3.93 | 1.38 | |
| 6 months | 1.59 | 1.31 | |
| 12 months | 0.37 | 0.63 |
In a group of 17 patients with DHS and bone grafting as a revision procedure, we found that MHHS gradually increased in subsequent follow-ups. At the end of 12 months of follow-up, 15 patients (88.2%) had good outcomes, and two patients (11.7%) had fair outcomes (Table 9). A total of 18 revision THR patients had improvement based on MHHS at 3 months, 6 months, and 12 months follow-up. At the end of 1 year, 3 patients (16.7%) had “excellent” outcomes, and 15 patients (83.3%) had “good” outcomes as per the MHHS system. No patient had poor or fair results in a 1-year follow-up (Table 10). A total of 13 patients who had cemented hemiarthroplasty as their revision surgery had satisfactory results based on MHHS, which was observed from 6 months post-op. At the end of a 1-year maximum, 10 patients (77%) had “good” outcomes. Only three patients (23%) had “fair” outcomes as per the MHHS system. No patients had poor outcomes (Table 11). Two out of nine patients who underwent exchange nailing with bone grafting as a revision procedure had “good” outcomes (22.2%), and the remaining 7 (77.7%) had fair outcomes at the end of 1 year, according to the MHHS system (Table 12).
| MHHS categories [frequency (column percentage)] | Pre-op | Post-op 3 months | Post-op 6 months | Post-op 12 months |
|---|---|---|---|---|
| Poor (<70 points) | 17 (100%) | 17 (100%) | 12 (70.5%) | – |
| Fair (70–79 points) | – | – | 5 (29.4%) | 2 (11.7%) |
| Good (80–89 points) | – | – | – | 15 (88.2%) |
| Excellent (90–91 points) | – | – | – | – |
| Missing | – | – | – | – |
| MHHS categories [frequency (column percentage)] | Pre-op | Post-op 3 months | Post-op 6 months | Post-op 12 months |
|---|---|---|---|---|
| Poor (<70 points) | 18 (100%) | 18 (100%) | 3 (16.7%) | – |
| Fair (70–79 points) | – | – | 9 (50%) | – |
| Good (80–89 points) | – | – | 6 (33.3%) | 15 (83.3%) |
| Excellent (90–91 points) | – | – | – | 3 (16.7%) |
| Missing | – | – | – | – |
| MHHS categories [frequency (column percentage)] | Pre-op | Post-op 3 months | Post-op 6 months | Post-op 12 months |
|---|---|---|---|---|
| Poor (<70 points) | 13 (100%) | 13 (100%) | 4 (30.7%) | – |
| Fair (70–79 points) | – | – | 9 (69.2%) | 3 (23%) |
| Good (80–89 points) | – | – | – | 10 (77%) |
| Excellent (90–91 points) | – | – | – | – |
| Missing | – | – | – | – |
| MHHS categories [frequency (column percentage)] | Pre-op | Post-op 3 months | Post-op 6 months | Post-op 12 months |
|---|---|---|---|---|
| Poor (<70 points) | 9 (100%) | 9 (100%) | 6 (66.7%) | – |
| Fair (70–79 points) | – | – | 3 (33.3%) | 7 (77.7%) |
| Good (80–89 points) | – | – | – | 2 (22.2%) |
| Excellent (90–91 points) | – | – | – | – |
| Missing | – | – | – | – |
CONCLUSION
Failed IT fractures produce severe pain and disability in the elderly population. Our aim for such a group of patients is to give a stable, pain-free, and mobile joint for the patient. This would improve the functional ability of the patient, provides pain relief, and increases the survival rate. Haidukewych and Berry,13 in their study, reported that those who had undergone hip arthroplasty for failed IT fractures had a 100% survival rate for the next 7 years and 87.5% for the next 10 years. Also, 70% of patients had pain relief and functional improvement. One failure was observed in one patient who had exchange nailing for failed IT fracture and revised with unipolar hemiarthroplasty.
In our study, we found 48% of patients were male and 52% of female patients with slight female dominance. On reviewing the literature, a study done by Jain et al.,4 about failed IT fractures observed that 52 patients were female (56.5%) and 40 patients were male (43.4). Also, Koyuncu et al.,15 in their study, observed 85 female (55.9%) and 67 male (44.1%) patients with failed IT fractures. This shows that failed IT fractures are common in the female population due to osteoporosis and hormonal factors.
In our study, failed IT fractures are more common in the 60–70 years of age-group, with 33.3% followed by 31.5% in the 70–80 years of age-group. A similar study done by Jain et al.,4 depicts failed IT fractures were seen mostly between 60 and 70 years (33.69%) followed by 71–80 years (31.53%) with the mean age-group of 71.9 years. Luthringer et al.,16 depicted that age and sex had a strong association with failure, especially in the elder population due to osteoporosis. Kim et al.,17 also observed osteoporosis was one of the main key factors in the failure of intertrochanter fractures.
On reviewing the literature, we found various reasons for failed IT fracture fixation, like implant loosening, screw cut-off, screw penetration into the joint, varus reduction, and unstable fracture pattern. Zhong et al.,18 in their study, concluded that failure of IT fracture fixation following intramedullary nailing was due to unstable fracture pattern, unsatisfied reduction, improper implant position, poor quality of bone, and inappropriate choice of implant.
The main reason for the failure of index surgery in our study population was the varus reduction of the fracture site, which consists of 16 patients (28%). Failure related to implant loosening, screw cut-off, screw penetration, and unstable fracture pattern had 14 (24.6%), 10 (17.5%), eight (14%), and nine patients (15.7%), respectively. Jain et al.,4 in their study, described that failure due to pulling out of the screw was 11.9%, malunion due to varus deformity was 4.3%, perforation of the screw into the femoral head was 1%, and broken implant in 3.2%.
Liu et al.,19 in their study, observed that in five patients with PFN, seven patients had to lock proximal femoral plating, and six patients had dynamic hip screws as their index procedure. Among the 13 patients of extramedullary fixation LPFP/DHS, he observed failure due to internal fixation loosening in three, cutting off the femoral head in three, fixation fracture in five, and varus deformity in two patients. Among five intramedullary nailing failures, the reason for failure was three with implant loosening and two with femoral head cutting. Taheriazam and Saeidinia,20 in their study about the salvage of failed dynamic hip screw fixation of fractures, observed failure rate following IT fracture fixation was 3–12%, with nonunion consisting of 2–5%, implant penetration consisting of 2–12%, varus malunion consist of 5–11%.
In our study, we found PFN related varus deformities in 8 patients (36%). Tylliankis et al.,21 observed PFN-related varus deformities in 0.8%–8.6% of patients. Koyuncu et al.,15 also reported 8.5% of PFN-related varus deformity among 13 patients in their study. This study’s results favor our study. Z effect and reverse Z effect were observed in three and two patients, respectively, due to poor holding of the screw and poor bone stock because of preexisting osteoporosis. Z effect is specific to PFN. It is defined as the migration of the hip screw into the joint during the post-op period. The reverse Z effect is described as the lateral migration of the antirotating hip screw. Papapismos et al.,22 observed the Z effect and reverse Z effect in four patients and one patient, respectively. Boldin et al.,23 observed three patients with the Z effect and two patients with the reverse Z effect. Tylianakis et al.,21 also observed five patients with the Z effect and one patient with the reverse Z effect.
In our study, screw cut-off was observed in 10 patients. Koyuncu et al.,15 in his study, also observed screw cut off in four patients due to malpositioning or inappropriate position and size of screw.
Implant failure is another reason for failure in IT fracture fixation. We observed 14 patients (24.6%) with implant failure due to loosening. Simmermacher et al.,24 reported failure rate due to mechanical failure was 4.6%. Fogagnolo et al.,25 in their study, observed mechanical failure in 23.4% of patients. We found nine patients (15.7%) had a failure due to unstable fracture patterns because of the wrong selection of implant. Jain et al.,4 in their study, found that failure due to unstable fracture was around 18 out of 65 patients (27.69%).
In our study population of 57 patients who had failed IT fractures were treated according to age, bone quality after the failure of the index procedure, economic status of the patient, prior fixation procedure, functional level of the patient, preexisting comorbidities, acetabular damage, and implant penetration into the joint.
For those physiologically young patients with nonunions, adequate bone stock and good bone quality, we did DHS with bone grafting; and for older age with nonunions and poor bone quality, screw penetration into the joint, acetabular erosion, deformed head, we did hip arthroplasty. Babu et al.,26 in their study, concluded that hip arthroplasty for nonunions with poor bone quality and DHS and bone grafting for young physiological patients with good bone stock. Liu et al.,27 in their study, concluded hip arthroplasty for the elderly population for failed IT fractures, in view of early mobilization to reduce pain-related morbidity and mortality. He also advised physiologically young patients with good bone stock treatment strategies to preserve the femoral head blood supply by salvaging internal fixation.
Luthringer et al.,16 in his study, concluded that failure rates for IT fracture revision surgery were 4–17% due to osteoporosis. He also mentioned age and sex also contribute to the failure rate in an elderly population. He also added that the success with revision osteosynthesis for failed fractures was limited by the patient’s bone healing capacity. So, they advise salvage arthroplasty as the main treatment option for the elderly population.
Revision surgeries following failed IT fractures were always a challenging procedure. The surgeon should face the following difficulties during the procedures like difficult surgical exposure due to altered anatomy, removal of previous fixation devices, removal of broken screws, revision of internal fixation with new devices, bone deformity of the proximal femur, femoral canal preparation for revision surgery, GT reattachment, and acetabular preparation in patients with poor bone quality.
In our study, only one patient who had failed IT fracture underwent exchange nailing and bone grafting scored fair at the end of 12 months follow-up because of poor union and morbidity related to fracture. This patient had revision surgery with cemented unipolar hemiarthroplasty. Two patients had hyponatremia post-op. Three patients had post-op pain due to hardware impingement. One patient had a superficial wound infection, which was treated by higher IV antibiotics and regular dressing. One patient had a GT fracture intraoperatively, which was fixed with cerclage wiring of GT.
In elderly patients with post-surgical failed IT fractures, conversion to cemented THR had excellent to good outcomes. The same group of patients who had cemented hemiarthroplasty scored good outcomes, which was next in order. Younger patients who had head preserving procedures of dynamic hip screw fixation and bone grafting had good outcomes, according to MHHS.
Overall, patients with cemented THR scored excellent outcomes. Patients with cemented hemiarthroplasty and dynamic hip screw with bone grafting had functional outcomes inferior to THR in midterm follow-up. All the patients were mobile without pain in daily activities with continuous improvement for a period of 1 year, and thereafter it remained the same.
To conclude, we recommended cemented THR in elderly failed IT fracture as the first choice in medically fit patients, followed by cemented hemiarthroplasty. Dynamic hip screw and bone grafting in physiologically younger individuals.
ORCID
Vijaya A Sivaji https://orcid.org/0000-0002-3397-8377
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