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ORIGINAL ARTICLE

Outcome of Revision Surgery for Failed Sliding Hip Screw Fixation

 Kansal A* , Michael A L R**, Zachariah S***, Elliott J R M#,Kumar N*#                         

*Specialist Trainee 3, Trauma and Orthopaedics, Altnagelvin Hospital, Londonderry
**Specialist Registrar, Trauma and Orthopaedics,
  Musgrave Park Hospital, Belfast.
***Staff Grade, Trauma Surgery.  Royal Victoria Hospital, Belfast
#Consultant Orthopaedic Surgeon, Royal Victoria Hospital, Belfast
*#Consultant Trauma and Orthopaedics, New Cross Hospital, Wolverhampton

Address for Correspondence:  

Amit Kansal
3 The Beaches,
Altnagelvn Hospital,
Londonderry, BT47 6SB

 

J.Orthopaedics 2008;5(4)e1
Introduction:

Sliding Hip Screw (SHS) fixation is commonly performed for a proximal femoral fracture. In most instances it is successful (1, 2) and SHS is considered the gold standard against which other methods of fixation are evaluated (3). In a small percentage of patients the fixation fails because of an unstable fracture pattern, sub-optimal fracture fixation and/or reduction. Failure rates as high as 56% have been reported (4). 

Failure of fixation leads to pain, loss of function and shortening. The surgical options for revision include arthroplasty (total or hemi), repeat osteosynthesis, and removal of metalwork. Revision of fixation may not be possible if patients are unfit for major surgery. Salvage with internal fixation has been attempted in physiologically younger patients with good preservation of the femoral head, acetabular cartilage and minimal bone loss. There are a number of factors that may make arthroplasty a better option. These include destruction of the femoral head, acetabular cartilage damage, lag screw impingement and bone loss. However, arthroplasty is not without complications. Despite an extensive literature search we have come across only a few studies that have attempted to assess this problem. None analysed the outcome of the range of procedures used for revision of failed sliding hip screw (4- 10).

Material and Methods :

We retrospectively studied patients who required revision surgery for failure of SHS fixation of proximal femoral fractures (intra and extra-capsular) between 1995 and 2004 in two different centres. The study was carried out at a large district general hospital and at a university teaching hospital. Patients were identified through the theatre database in both centres. Prospective approval for the study was obtained from the audit department in each of the hospitals. We did not study the fracture configuration before the primary SHS fixation. A total of sixty-nine patients were identified for the study. There were 89% females with ages ranging from 34 to 97 years (mean - 76 years). Case notes and radiographs were obtained from the medical records department for analysis. The authors collected data on the mode of failure, method of revision, grade of the surgeon performing the revision procedure, complications following revision and the period of follow-up. The data was analysed to note the common complications in SHS surgery and the common methods of revision used.

Table 1: Consolidation Sheet of the Modes of Failure

Mode of Failure

Centre 1

Centre 2

Total

Screw Cut Out

10

15

25

Peri-prosthetic Fracture

8

3

11

Avascular Necrosis

5

5

10

Non Union

2

7

9

Painful Hip

5

2

7

Implant Failure

2

3

5

Infection

1

1

2

Table 2: Consolidation sheet of Methods of Revision

Method of Revision

Centre 1

Centre 2

Total

Revision of Internal Fixation

10

9

19

Total Hip Arthroplasty

10

8

18

Removal of Metalwork

8

7

15

Hemiarthroplasty

4

11

15

Peri-prosthetic Fracture Fixation

1

1

2

Results :

There were 69 patients included in the study from both the centres. The mean age at the time of the study was 76 years (36 to 94), of which 89% were females. The mean age at first surgery was 74 years (21 to 97) and at revision 76 years (33 to 93). The mean interval between primary procedure and revision was 28.5 months (11 days to 20 years). The commonest mode of failure (see table 1) was screw cut out - 25 cases (36%). Next were 11 cases of peri-prosthetic fracture (15.9%), all due to a fall. Ten patients had Avascular Necrosis (14.4%), nine patients (13%) had a non- union, seven patients (10%) had hip pain and in another five (7%) implant breakage (either the plate or its screws) were noted. There were two cases of infection following the primary procedure that required revision.  Various procedures were used for revision surgery and have been enumerated in table 2. 

We found a high complication rate after the revision procedure. Five out of the eighteen cases (28%) that underwent total hip arthroplasty had complications. Of these, one had a superficial infection, one developed heterotopic ossification that did not cause functional compromise and one developed a deep infection necessitating excision arthroplasty. Another two suffered recurrent dislocation but due to high co-morbidities and age, they went on to have excision arthroplasty. Out of 15 patients with hemiarthroplasty, 4 patients (26%) had complications. Two dislocated, of which one patient refused further treatment. The other case had re-exploration of the hip with removal of soft tissue from the acetabulum and had no further problems. There was one case of superficial infection, which settled with antibiotics and one of deep infection that developed a chronic discharging sinus. However, again due to existing co-morbidities, no further surgical procedures were carried out.

The highest complication rate was encountered in the refixation group. Fourteen patients out of nineteen (73.6 %) had complications which required a third procedure. The indications were - hip pain, deep infection and a periprosthetic fracture after a fall on the ward. One patient had weak abductors following the intra-operative dissection, which lead to a dislocation after the refixation procedure. The dislocation was reduced under general anaesthesia but the patient continued to have hip pain. Due to multiple co-morbidities, no further procedure was undertaken. 3 patients had superficial infection, which settled with antibiotics. There was one case of implant breakage, which was subsequently revised to a bipolar hemiarthroplasty. However, this was complicated by recurrent dislocation and ultimately required an excision arthroplasty. In the 15 patients who had removal of metal work, the indication was hip pain and most patients settled following the secondary procedure. In one patient the metal work was removed because of deep infection. This patient was awaiting a further procedure for fracture non-union at the time of the study. One had a superficial infection, which settled with antibiotics and one developed a deep infection and was awaiting a further procedure at the time of the study. The other 12 were asymptomatic and discharged at the final review.

Discussion :

Failed treatment of a proximal femoral fracture presents difficult and unique challenges to the orthopaedic surgeon. The pattern of failure, the general health of the patient and the quality of the bone should be taken into account when planning the revision procedure. The revision surgeries are technically very demanding and, in our experience and according to the published literature (4), have an inherently high complication rate.  

The strength of our study is the use of data from a relatively large number of patients from two different centres. This provides a good mix of cases covering the relevant clinical scenarios. The weaknesses of our study, which by no means undermine our conclusions, include the diversity of implant and fixation methods used, the diversity in grade of surgeons and subjectivity in the choice of revision procedures. Based on our experience, revision of failed sliding hip screw fixation is a complicated procedure at the best of times. It requires careful planning and it is difficult to lay down strict guidelines. 

There are published studies for both re-osteosynthesis as well as arthroplasty following failed sliding screw fixation. Haidukewych GJ et al treated 20 patients with re-fixation of the fracture along with bone grafting. They state that in properly selected patients, revision internal fixation with bone grafting for failed open reduction and internal fixation of intertrochanteric hip fractures can provide a high rate of union and good clinical results with a low complication rate (5). In another study, Haidukewych GJ et al reported on sixty patients with failed treatment of an intertrochanteric fracture that had arthroplasty as the salvage procedure. Thirty-nine patients had mild or no pain while five had moderate to severe pain. Twelve of these patients had medical complications, and five had re-operations including two revisions of the hip arthroplasty (6). They state that hip arthroplasty is an effective salvage procedure after failed internal fixation of an intertrochanteric fracture in an older patient. Mariani and Rand reported on twenty patients in whom an intertrochanteric non-union had been treated between 1961 and 1981. 9 patients underwent subsequent arthroplasty, and 11 had repeat internal fixation with bone grafting. At a mean of six years, there was functional improvement for all patients who had an arthroplasty (7). Of those treated with repeat internal fixation, nine (82%) achieved radiographic union at an average time of six months. Of the remaining two who did not achieve union, one achieved union following removal of internal fixation and further bone grafting (five months) and one required a total hip arthroplasty. Mehlhoff et al, reported on 13 patients who had an arthroplasty after failed internal fixation of an intertrochanteric fracture; after a mean follow up of thirty four months, only five patients had good or excellent results. Three patients had had a dislocation, and two of these patients had required a re-operation because of instability (8).  

In our experience, during the salvage procedure, the failed internal fixation device has to be removed. Removal of broken screws may present a lot of difficulty and may need special instruments. The proximal femur has to be aligned with the shaft to permit preparation for stem implantation. Careful mobilisation of scar tissue is required to avoid nerve and muscle (abductors) injury. Bone loss at the neck-resection level for hip arthroplasty is common. Calcar-replacement implants may be required (5). In patients with severe acetabular damage, bone preparation needs to be meticulous. Bone graft augmentation or custom components may be necessary. 

For repeat osteosynthesis, patient selection is of paramount importance. The surgery needs to be individually planned. Bone grafting should be carried out in all cases of delayed or non-union to augment biology (6). Our data showed the highest complication rate in the group of patients undergoing repeat osteosynthesis. Fourteen of nineteen patients (73.6%) needed further surgery.  

Implant removal was performed for two main reasons in our study- non specific hip pain and infection. When it is being undertaken for hip pain, care should be taken to ensure that fracture union has occurred. After removal of the implant, weight bearing should be protected till the screw holes heal. Patients with infection should be managed according to the general principles for infected prostheses.  

In conclusion, hip arthroplasty (total or hemi) is an effective salvage procedure after failed SHS fixation of proximal femoral fracture. Re-osteosynthesis as a revision procedure is associated with a very high rate of complication. Whichever procedure is used, the patient must be counselled that there is a significant risk of complication.

Reference :

  1. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. Journal of Bone and Joint Surgery [Am]. 1979; 61: 216-21

  2. Kyle RF, Cabanela ME, Russell TA, Swiontkowski MF, Winquist RA, Zuckerman JD, Schmidt AH, Koval KJ. Fractures of the proximal part of the femur. Instrument Course Lectures. 1995; 44: 227-53

  3. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus intramedullary implants for extracapsular hip fractures in adults. Cochrane Database Systematic Review. 2005 October 19; (4): CD000093

  4. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. Journal of Bone and Joint Surgery [Am] 2001; 83: 643-50

  5. Haidukewych GJ and Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. Journal of Bone and Joint Surgery 2003; 899-905

  6. Haidukewych GJ and Berry DJ. Salvage of failed internal fixation treatment of intertrochanteric hip fractures. Clinical Orthopaedia. 2003 Jul; 412: 184-8

  7. Miriani EM, Rand JA. Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation. Results of second attempt to gain union. Clinical Orthopaedia. 1987; 218: 81-9

  8. Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures. Clinical Orthopaedia. 1991; 269: 37-9

  9. Lenich A, Mayr E, Ruter A. Hip replacement after failed internal fixation in patients with proximal femur fracture--a simple procedure? Zentralbl Chir. 2002 Jun; 127(6): 503-6

  10. Lee PC, Yu SW, Hsieh PH, Chuang TY, Tai CL, Shih CH. Treatment of early cut-out of a lag screw using a trochanter supporting plate: 11 consecutive patients with unstable intertrochanteric fractures. Arch Orthop Trauma Surgery. 2004 March; 124 (2): 119-22.

 

This is a peer reviewed paper 

Please cite as : Kansal A: Outcome of Revision Surgery for Failed Sliding Hip Screw Fixation

J.Orthopaedics 2008;5(4)e1

URL: http://www.jortho.org/2008/5/4/e1

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