**5. THR for failed intertrochanteric fracture fixation**

Preoperative templating, paying particular attention to the length of the proposed femoral component is essential to bypass bone defects or screw tracks. An attempt should be made to recreate the patients' normal anatomy; it is essential to restore offset, length, and centre of rotation. If acetabular bone loss is noted as autogenous bone graft, allograft or a fixation device may be necessary to reconstruct or span a marginal, cavitary, or combined defect.

**Figure 5.** AP radiograph demonstrating screw cut out of post ORIF of neck of femur fracture.

**Figure 4.** Demonstrating subsequent revision to hybrid THR following failed internal fixation.

90 Total Hip Replacement - An Overview

Patients with failed internal fixation of intertrochanteric fractures present with significant functional disability and pain. In these patients revision of the fixation device will often be considered as a first option, but these surgeries are often complicated by bone loss and the presence of avascular bone at the nonunion site. Hip arthroplasty offers a good salvage option for selected patients as it obviates the need for fracture healing and establishes immediate skeletal continuity allowing early, progressive weight bearing. **Figure 7** shows a nonunion of a subtrochanteric femur fracture following cephalomedullary fixation which was successfully revised to a modular THR as seen in **Figure 8**.

Technical issues such as difficulty of implant removal, bone loss, trochanteric nonunion, anticipated haemorrhage and suboptimal bone quality must be considered. A common mode of

**Figure 7.** AP radiograph demonstrating non union of a subtrochanteric femur fracture following cephalomedullary fixation.

of the fragments, and a high-speed burr can be used to expose bleeding cancellous bone. The excised femoral head is often a useful source of autograft, and applying an acetabular reamer to the femoral head will rapidly morselise the fragment. Patients with cephalomedullary nails in situ may exhibit neocortex formation and sclerosis around the nail, and broaching the canal in these cases can be facilitated by using a high-speed burr. Calcar replacing and fully coated stems may be considered in those with loss of proximal bone. Modular implants may also play a role in the setting of severe proximal bone loss. Reattachment of the trochanter in cases of nonunion is a crucial step towards regaining stability, and trochanteric cable plates are

Arthroplasty for Proximal Femur Fracture http://dx.doi.org/10.5772/intechopen.77053 93

Lee et al. recommended the use of total hip arthroplasty for failed internal fixation of intertrochanteric fractures. They report a 3% 1 year mortality rate in the conversion group. At 3 years of follow-up, there was no significant difference in clinical scores or component loosening

Of patients with advanced cancer, 50% develop bony metastases, and 30% of metastatic deposits occur within the proximal femur. Due to the high mechanical forces directed through the hip, surgery is often required for pain palliation, to restore function and to allow immediate unrestricted weight bearing. Current treatment options include intramedullary nailing, osteosynthesis with a plate-screw construct and endoprosthetic replacements—taking the form of

For patients expected to live greater than 6 months, the literature supports curettage of the lesion with cemented hemiarthroplasty [41–43]. Those patients demonstrating a

when compared to a matched cohort who received hemiarthroplasties [40].

hemiarthroplasties, total hip arthroplasties, and proximal femoral replacements.

**6. THR for pathological or impending fracture**

particularly useful in many of these cases.

**Figure 8.** Demonstrating subsequent revision to a modular prosthesis.

failure in intertrochanteric fractures is cut-out of the lag screw which consequently damages the acetabular cartilage and often necessitates acetabular replacement during the conversion arthroplasty.

It is imperative that the surgeon eliminates infection as a cause of failure and preoperative evaluation should include measurements of CRP and ESR levels and aspiration or biopsy if inflammatory marker levels are concerning. If infection is demonstrated, a two-stage procedure should be performed with the removal of components and the femoral head during the first stage, with the use of an antibiotic-impregnated cement prosthesis.

During revision of a failed intertrochanteric fracture, it is again advisable to leave the fixation in place until surgical dislocation of the hip is performed. Access is often determined by trochanteric anatomy: gained either between ununited fragments or with mobilisation of malunited fragments. If some continuity is maintained with the fibres of vastus lateralis, the exposure resembles a trochanteric slide. In these cases, the risk of mechanical complications such as fractures and cortical perforations is increased due to reduced bone quality, loss of bone stock, presence of screw holes from previous fixation devices, and distorted bony landmarks. If trochanteric nonunion is encountered, fibrous tissue is debrided from the cancellous surface

**Figure 8.** Demonstrating subsequent revision to a modular prosthesis.

of the fragments, and a high-speed burr can be used to expose bleeding cancellous bone. The excised femoral head is often a useful source of autograft, and applying an acetabular reamer to the femoral head will rapidly morselise the fragment. Patients with cephalomedullary nails in situ may exhibit neocortex formation and sclerosis around the nail, and broaching the canal in these cases can be facilitated by using a high-speed burr. Calcar replacing and fully coated stems may be considered in those with loss of proximal bone. Modular implants may also play a role in the setting of severe proximal bone loss. Reattachment of the trochanter in cases of nonunion is a crucial step towards regaining stability, and trochanteric cable plates are particularly useful in many of these cases.

Lee et al. recommended the use of total hip arthroplasty for failed internal fixation of intertrochanteric fractures. They report a 3% 1 year mortality rate in the conversion group. At 3 years of follow-up, there was no significant difference in clinical scores or component loosening when compared to a matched cohort who received hemiarthroplasties [40].
