Arthroplasty for Pertrochanteric Hip Fractures




The mainstay of treatment of pertrochanteric fractures is internal fixation using a sliding hip screw or a cephalomedullary device. However, in patients with ipsilateral hip osteoarthritis or avascular necrosis of the femoral head, or inflammatory arthritis, arthroplasty should be considered as the primary treatment modality to reduce the likelihood of a secondary procedure. Unstable fracture patterns with concomitant poor bone quality represent a challenge for internal fixation, with high rates of lag screw cut-out and hardware failure. Prosthetic replacement for unstable pertrochanteric fractures has therefore been considered as an alternative primary treatment option. Further prospective randomized trials are required.





  • Arthroplasty is associated with higher postoperative blood transfusion rates, but a shorter time to weight bearing and a lower failure rate.





  • Arthroplasty is associated with higher postoperative blood transfusion rates, but a shorter time to weight bearing and a lower failure rate.






  • Arthroplasty should be considered as a primary treatment option in a carefully selected and small patient population with pertrochanteric fractures ( Box 1 ). Patients with preexisting hip osteoarthritis, inflammatory arthritis, or avascular necrosis are good candidates for total hip arthroplasty even at younger ages because it reduces the likelihood of subsequent reoperations. In these patients, the diminished range of motion of the hip joint increases the loads at the fracture site, possibly increasing the failure rate of internal fixation. In low-functioning elderly patients (age >75 years) with unstable fracture pattern and poor bone quality, arthroplasty may be particularly useful to avoid the extended periods of protected weight bearing required when there is tenuous internal fixation. Appropriate fracture features include grossly unstable fracture patterns, marked fracture comminution, poor bone quality shown by thin cortices and wide intramedullary canal, and significant fracture displacement indicating a more severe insult to surrounding soft tissue structures.



    Box 1





    • Ipsilateral hip osteoarthritis



    • Ipsilateral avascular necrosis of the femoral head



    • Inflammatory arthritis



    • Unstable fracture pattern with poor bone quality



    • Complications of internal fixation (ie, lag screw cut-out)



    • Neglected fractures



    Indications for arthroplasty in pertrochanteric fractures








    All patients should receive some form of deep vein thrombosis prophylaxis (mechanical and/or pharmacologic) according to the current recommendations. Patients are encouraged to mobilize early with assistance of physiotherapy and are allowed to weight bear as tolerated on postoperative day 1. If a trochanteric slide osteotomy is used, active leg abduction is restricted for 8 weeks to allow for healing of the abductor mechanism. Clinical and radiographic follow-up is maintained at 6-week intervals to assess the union of the osteotomy. Hip precautions are maintained for a total of 3 months.




    References



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    Feb 23, 2017 | Posted by in ORTHOPEDIC | Comments Off on Arthroplasty for Pertrochanteric Hip Fractures
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