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

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

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

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

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

first stage, with the use of an antibiotic-impregnated cement prosthesis.

arthroplasty.

92 Total Hip Replacement - An Overview

fixation.

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 hemiarthroplasties, total hip arthroplasties, and proximal femoral replacements.

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 radioresistant tumour may necessitate en bloc excision and proximal femoral replacement [44]. Intramedullary fixation should be utilised in those with a life expectancy less than 6 months as it has been demonstrated to provide reliable fracture fixation up to 12 months post-procedure [45, 46]. The use of a hemiarthroplasty to treat pathologic or impending pathologic fractures of the proximal femur has an acceptable rate of complications, reoperations, and functional outcomes as demonstrated by Houdek et al., who studied 199 patients treated with a hemiarthroplasty for metastatic femoral neck disease. They demonstrated a 1% conversion rate to THR due to degenerative changes and groin pain. [47].

**References**

Research. 1980;**152**:35-43

(10 Suppl):S1-S133

2002;**91**:140-146

1993;**64**(2):173-174

and Related Research. 1990;**254**:242-246

and Related Research. 1990;**260**:232-241

[1] Cornwall R, Gilbert MS, Koval KJ, Strauss E, Siu AL. Functional outcomes and mortality vary among different types of hip fractures: A function of patient characteristics. Clinical

Arthroplasty for Proximal Femur Fracture http://dx.doi.org/10.5772/intechopen.77053 95

[2] Lewinnek GE, Kelsey J, WHITE III AA, Kreiger NJ. The significance and a comparative analysis of the epidemiology of hip fractures. Clinical Orthopaedics and Related

[3] Hung WW, Egol KA, Zuckerman JD, Siu AL. Hip fracture management: Tailoring care

[4] Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertro-

[5] Haidukewych GJ, Berry DJ. Salvage of failed internal fixation of intertrochanteric hip

[6] Sancheti KH, Sancheti PK, Shyam AK, Patil S, Dhariwal Q, Joshi R. Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly: A retrospective

[7] Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the elderly. Journal of the American Academy of Orthopaedic Surgeons. 2004;**12**(3):179-190

[8] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. Journal of Orthopaedic Trauma. 2007;**21**

[9] Larsson S. Treatment of osteoporotic fractures. Scandinavian Journal of Surgery.

[10] Bannister GC, Gibson AGF, Ackroyd CE, Newman JH. The fixation and prognosis of trochanteric fractures: A randomised prospective controlled trial. Clinical Orthopaedics

[11] Chinoy MA, Parker MJ. Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: A meta analysis of 14 studies. Injury. 1999;**30**(3):157-163

[12] Flores LA, Harrington IJ, Heller M The stability of intertrochanteric fractures treated

[13] Sernbo I, Fredin H. Changing methods of hip fracture osteosynthesis in Sweden: An epidemiological enquiry covering 46,900 cases. Acta Orthopaedica Scandinavica.

[14] Larsson S, Friberg S, Hansson LI. Trochanteric fractures mobility, complications, and mortality in 607 cases treated with the sliding-screw technique. Clinical Orthopaedics

with a sliding screw-plate. Bone & Joint Journal. 1990;**72**(1):37-40

fractures. Clinical Orthopaedics and Related Research. 2003;**412**:184-188

Orthopaedics and Related Research. Aug 2004;**425**:64

for the older patient. JAMA. 2012;**307**(20):2185-2194

case series. Indian Journal of Orthopaedics. 2010;**44**(4):428

chanteric hip fractures. JBJS. 2003;**85**(5):899-904

With advances in medical management of metastatic disease and concomitant increase in patient's life expectancy, the durability of these implants has become increasingly important. Due to the poor survival rates in this cohort of patients, it has been difficult to compare implant survival rates for patients with metastatic disease with those utilised in primary joint replacement. However, in series comparing THR with osteosynthesis in the setting of pathologic fracture, THR has demonstrated a lower rate of mechanical failure as well as a higher rate of implant survival [48].
