We evaluated 30 patients who had been operated with a modular revision THA as a salvage procedure after failed hip fractures. Most hips showed fracture union, restoration of proximal bone, bony ingrowth of the uncemented stem, and only limited subsidence. However, 7 patients needed further surgery during follow-up. The cumulative 3-year survival for revision was 96% and for reoperation it was 83%.
Chirodian et al. (2005)
reported on the outcome of 1,024 surgical procedures with the sliding hip screw for trochanteric hip fractures. The authors found a complication rate related to the surgical procedure of 4%, with a 2% incidence of cutout of the femoral neck screw. A meta-analysis involving 3,279 extracapsular proximal femoral fractures noted a cutout rate of 2–3% after ORIF (Jones et al. 2006
). The rate of avascular necrosis in patients operated for trochanteric fractures has been reported to be less than 1% (Bartonicek et al. 2007
). Overall, the rate of complications after surgical treatment of extracapsular hip fractures is low; however, the total amount of fractures treated is high (Stern 2007
). Moreover, some authors have documented cutout rates of up to 8% (Simpson et al. 1989
) and Haidukewych et al. (2001)
described a failure of fracture healing or fixation in 15 of 47 patients with problematic fracture patterns.
Salvage procedures include revision internal fixation and prosthetic replacement. In younger patients and active older patients with good remaining bone stock and a well-preserved hip joint, revision internal fixation with bone grafting may be the best choice. With properly selected patients, a high rate of success can be achieved (Haidukewych and Berry 2003
). Patients with poor bone quality in the proximal femur and/or older patients with lower demands and signs of osteoarthritis may be treated with THA (Haidukewych and Berry 2003
Several reports have documented varying results using conventional hip stems as a salvage procedure (Mehlhoff et al. 1991
, Haentjens et al. 1994
, Tabsh et al. 1997
, Haidukewych and Berry 2003
, Zhang et al. 2004
, Hammad et al. 2008
, Mortazavi et al. 2012
). Often, the conversion to THA does not allow the use of conventional femoral components for various reasons. Uncemented modular revision implants therefore provide several potential advantages. They allow separate preparation of the proximal and distal bone in the femur to maximize prosthesis fill. In addition, individual adjustment of leg length, offset, and anteversion can be obtained. Modular stems such as the MP Link prosthesis are designed to bypass the regions of proximally deficient bone and achieve stability and fixation in more distal femoral bone (Weiss et al. 2011b
Our radiographic results are satisfactory, and confirm the results of other studies with modular implants (Laffosse et al. 2007
, Talmo and Bono 2008
, D’Arrigo et al. 2010
, Abouelela 2011
, Thakur et al. 2011
). Still, we observed more revisions/reoperations in our cohort. Other authors (Talmo and Bono 2008
, Abouelela 2011
) only studied patients who had had 1 previous surgical procedure before the index operation, whereas almost half of our patients had undergone at least 2 surgical procedures before their prosthetic replacement, which might have influenced the risk of complications. Moreover, 7 of 10 patients with trochanteric fractures had an unstable fracture pattern and 12 of 20 subtrochanteric fractures included the greater trochanter. Many orthopedic clinics were involved in the surgical treatment of these patients, which may also have influenced the rate of complications.
Deep infection was the major cause of reoperation. This is not surprising, since the patients had undergone previous fracture surgery which failed. A more careful laboratory screening and examination of the clinical history of these patients, concentrating especially on previous wound healing problems and suspicion of postoperative infection, might be of value in these cases. Such patients might benefit from preoperative cultures from the joint, removal of the failed osteosynthesis, and joint debridement in a first session before implantation of the prosthesis. Strict adherence to the timing of antibiotic prophylaxis and a choice of agent(s) with a broader spectrum than that of the commonly used cloxacillin may also reduce the incidence of infections in these high-risk patients.
The weaknesses of our study include the short follow-up and the lack of some clinical data (e.g. pain levels and functional scores). The strength was the use of only 1 design of hip prosthesis. Moreover, in terms of numbers this is the largest analysis to date of an uncemented modular THA for salvage of proximal femoral fracture failures.
In summary, in patients with failure of internal fixation of trochanteric and subtrochanteric fractures and for whom THA is necessary, the use of a modular revision arthroplasty appears to be an attractive solution. The uncemented stem allows fixation distally in the femur. Our results indicate that stable fixation of the implant can be achieved with a good radiographic outcome. However, the rate of complications was high, especially from infection, which suggests that a more careful preoperative screening for low-virulence infections should be considered.