51: Total Hip Replacement for Intertrochanteric Hip Fractures

PROCEDURE 51 Total Hip Replacement for Intertrochanteric Hip Fractures



Hans J. Kreder



image


Indications



image All indications should be considered relative as the decision to perform total joint replacement surgery for intertrochanteric hip fractures remains controversial.

image Patient factor prerequisites:
• No major cardiovascular comorbidity (i.e., that would preclude a primary total hip replacement under elective circumstances)

• A patient who is at least community ambulatory

image Relative injury-related indications (in the presence of an intertrochanteric or subtrochanteric fracture):
• Pre-existing symptomatic hip joint arthritis

• Complex proximal femoral fracture through osteopenic bone(fixation likely to result in significant malunion, including femoral neck shortening, weakness, and decreased function in a community ambulator)

• Pathologic fracture

• Nonunion or significant malunion with weakness and functional loss after previous fixation attempts



PITFALLS



• Replacement is a more extensive surgical procedure than fracture fixation and may not be appropriate in the following situations:
image Bedridden individuals or wheelchair users

image Limited household ambulators or low-demand patients

image Patients with major cardiovascular comorbidity or other surgical risk factors

image Patients with pathologic fractures and life expectancy less than 6 weeks (not expected to survive past the early recovery phase following replacement surgery and thus the added surgical morbidity of replacement would not be expected to provide any benefit)



Controversies



• Total joint replacement for intertrochanteric hip fractures remains a controversial treatment option at this time. The lack of good quality information regarding the following issues hinders the resolution of this controversy:
image What is the relative mortality and morbidity of total joint replacement versus fracture fixation?

image How do various degrees of proximal femoral malunion affect patient pain and function?

image Does immediate total hip replacement result in a better outcome than salvage after failed fixation attempts?

image What type of replacement should be performed: cemented versus uncemented? unipolar, bipolar, or total hip replacement? calcar replacement/short-stemmed implant/long-stemmed implant? trochanteric fixation method?



Treatment Options



• Fracture fixation
image Intramedullary

image Extramedullary

image With or without bone augmentation—cement or bone substitute

• Replacement (implants and fixation)
image Femoral and acetabular side

image Bipolar

image Unipolar

image Short or long femoral stem

image Cemented or uncemented femoral stem

image Trochanteric fixation: claw device attached to femoral component, short claw secured with cables, or long claw/plate secured with cables and screws


Examination/Imaging



image Careful templating is mandatory to avoid hip instability and leg length inequality. It is better to template the intact side as the fracture significantly distorts the radiographic landmarks on the injured side. The following plain radiographic films are required for this purpose:
• Anteroposterior (AP) pelvis radiograph centered low to show both hip joints and the affected and intact proximal femurs, as in the AP pelvis radiograph in Figure 1, showing a complex osteopenic proximal femur fracture.

• Lateral radiograph of the affected hip.

• Full-length femur AP and lateral views to include the knee should be considered. On these views, one should:
♦ Note the presence of deformity or hardware.

♦ Pay particular attention to the femoral bow if a long-stemmed implant is considered.

♦ Look for additional lesions if dealing with a pathologic fracture (Fig. 2).

image Pathologic fractures demand a complete local and systemic workup to detect other lesions locally or in other body regions, and to stage the disease overall (prognosis and systemic treatment requirements).

image

FIGURE 1


image

FIGURE 2




PEARLS



• Drape the affected leg free from just above the iliac crest, with the entire leg covered with a “leg stocking” up to approximately 10 cm below the groin.

• An adhesive drape folded in half (adhesive side out), placed into the groin and joined by a second adhesive drape from the top (lateral) side of the leg, allows complete isolation of the groin.


Surgical Anatomy



image Bone (Fig. 3)
• Greater trochanter

• Lesser trochanter

• Medial calcar

image Muscles (Fig. 4)
• Gluteus medius

• Vastus lateralis

• Iliopsoas tendon

• Effects of deforming forces (Fig. 5A and 5B)

image

FIGURE 3


image

FIGURE 4


image

FIGURE 5



Positioning



image Regular operating room table

image Lateral decubitus position (must be held securely to avoid cup malposition) (Fig. 6).

image Bottom knee padded under peroneal nerve

image Padding between legs

image

FIGURE 6



Portals/Exposures



image A modified Hardinge or lateral approach is used.

image An oblique incision is made from 2 to 5 cm above the posterior margin of the greater trochanter distally for approximately 8–10 cm (Fig. 7). The incision can be enlarged proximally and distally if needed depending on the size of the patient.

image The iliotibial band is split from distal to proximal, extending into the interval between the tensor fascia lata and the gluteus maximus or into the lateral aspect of the gluteus maximus (Fig. 8).

image The deep dissection depends on the precise nature of the fracture. The principles are as follows:
• The surgeon should spend some time analyzing the bone fragments and soft tissue attachments before detaching soft tissues. The gluteus medius is identified, and the gluteus minimus tendon palpated from anteriorly deep to the abductors. The relationship of muscle disruption to the trochanteric fragments is noted, and if possible areas of muscle disruption are worked through (using a transtrochanteric approach but without dividing the posterior soft tissue attachments from the trochanter).
image

FIGURE 7 Cadaveric Dissection


image

FIGURE 8


Related posts:

16: Perilunate Injuries 29: Proximal Tibia Fractures: Intramedullary Nailing 11: Open Reduction and Internal Fixation of Olecranon Fractures 48: Treatment of Open Fractures 8: Terrible Triad Injuries of the Elbow 5: Humeral Shaft Fractures

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 51: Total Hip Replacement for Intertrochanteric Hip Fractures

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