Skip to main content

Conversion total hip arthroplasty for early failure following unstable intertrochanteric hip fracture: what can patients expect?

Abstract

Purpose

To report surgical outcomes in patients treated with conversion total hip arthroplasty (CTHA) for early failure of cephalomedullary nails (CMNs).

Methods

A retrospective review was conducted of CTHA for treatment of failed CMN within 1 year of initial surgery for intertrochanteric (IT) hip fractures. The cohort was matched 1:5 to patients who underwent elective primary THA (PTHA). Patient demographics, mechanism of CMN failure, surgical outcomes, and complication rates were assessed.

Results

22 patients met criteria with a mean time to failure of 145 days. Modes of failure included: lag screw cut-out with superior migration (9, 40.9%), or medialization (8, 36.4%), and aseptic nonunion with implant failure (2, 9.0%) and without implant failure (3, 13.6%). Fourteen of the patients (63.6%) had acetabular-sided damage secondary to lag screw penetration, all in the screw cut-out groups. Patient demographics were similar between cohorts. Compared to PTHA, CTHA patients had increased operative time, blood loss, LOS, and readmission rates. After IMN failure, the operative leg was shorter than the contralateral leg in all cases. CTHA restored leg lengths to <  = 10 mm in 15 (68.1%) of patients, with an average leg length discrepancy after CTHA of 6.7 mm. CTHA patients had increased rates of overall surgical complications and medical complications, specifically anemia (all p < 0.01). Tranexamic acid was used less often in the CTHA group (p < 0.01). Rate of periprosthetic joint infection (PJI), dislocation, and revision were all higher in the CTHA, though did not reach statistical significance.

Conclusion

The majority (77.3%) of CMN implant failure for nonunion within 1 year was due to screw cut-out. CTHA is a salvage option for early failed IT hip fracture repair, but expected surgical outcomes are more similar to revision THA than primary THA, with increased risk of readmission, longer surgery and LOS, increased blood loss, and higher complication rates.

Level of evidence

III, Retrospective comparative study.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

Abbreviations

CTHA:

Conversion total hip arthroplasty

THA:

Total hip arthroplasty

CMNs:

Cephalomedullary nails

IT:

Intertrochanteric

PTHA:

Primary THA

PJI:

Periprosthetic joint infection

LOS:

Length of hospital stay after surgery

DVT:

Deep venous thromboembolism

PE:

Pulmonary embolism

AKI:

Acute kidney injury

UTI:

Urinary tract infections

LLD:

Leg length discrepancy

References

  1. 1.

    Mariani EM, Rand JA (1987) Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation. Results of second attempts to gain union. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-198705000-00013

    Article  PubMed  Google Scholar 

  2. 2.

    Sarathy MP, Madhavan P, Ravichandran KM (1995) Nonunion of intertrochanteric fractures of the femur. Treatment by modified medial displacement and valgus osteotomy. J Bone Joint Surg Br 77(1):90–92

    Article  CAS  Google Scholar 

  3. 3.

    Schwarzkopf R, Baghoolizadeh M (2015) Conversion total hip arthroplasty: primary or revision total hip arthroplasty. World J Orthop 6(10):750–753

    Article  Google Scholar 

  4. 4.

    Schwarzkopf R, Chin G, Kim K, Murphy D, Chen AF (2017) Do conversion total hip arthroplasty yield comparable results to primary total hip arthroplasty? J Arthroplasty 32(3):862–871

    Article  Google Scholar 

  5. 5.

    Haidukewych GJ, Berry DJ (2003) Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 85(5):899–904

    Article  Google Scholar 

  6. 6.

    Smith A, Denehy K, Ong KL, Lau E, Hagan D, Malkani A (2019) Total hip arthroplasty following failed intertrochanteric hip fracture fixation treated with a cephalomedullary nail. Bone Joint J 101-B(6_Supple_B):91–96

    Article  CAS  Google Scholar 

  7. 7.

    Qin CD, Helfrich MM, Fitz DW, Oyer MA, Hardt KD, Manning DW (2018) Differences in post-operative outcome between conversion and primary total hip arthroplasty. J Arthroplasty 33(5):1477–1480

    Article  Google Scholar 

  8. 8.

    DeHaan AM, Groat T, Priddy M, Ellis TJ, Duwelius PJ, Friess DM et al (2013) Salvage hip arthroplasty after failed fixation of proximal femur fractures. J Arthroplasty 28(5):855–859

    Article  Google Scholar 

  9. 9.

    Lee Y-K, Kim JT, Alkitaini AA, Kim K-C, Ha Y-C, Koo K-H (2017) Conversion hip arthroplasty in failed fixation of intertrochanteric fracture: a propensity score matching study. J Arthroplasty 32(5):1593–1598

    Article  Google Scholar 

  10. 10.

    Archibeck MJ, Carothers JT, Tripuraneni KR, White RE (2013) Total hip arthroplasty after failed internal fixation of proximal femoral fractures. J Arthroplasty 28(1):168–171

    Article  Google Scholar 

  11. 11.

    Luthringer TA, Elbuluk AM, Behery OA, Cizmic Z, Deshmukh AJ (2018) Salvage of failed internal fixation of intertrochanteric hip fractures: clinical and functional outcomes of total hip arthroplasty versus hemiarthroplasty. Arthroplast Today 4(3):383–391

    Article  Google Scholar 

  12. 12.

    Kaplan K, Miyamoto R, Levine BR, Egol KA, Zuckerman JD (2008) Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures. J Am Acad Orthop Surg 16(11):665–673

    Article  Google Scholar 

  13. 13.

    Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF (2018) Fracture and dislocation classification compendium-2018. J Orthop Trauma 32(Suppl 1):S1-170

    Article  Google Scholar 

  14. 14.

    Kjellberg M, Al-Amiry B, Englund E, Sjödén GO, Sayed-Noor AS (2012) Measurement of leg length discrepancy after total hip arthroplasty. The reliability of a plain radiographic method compared to CT-scanogram. Skeletal Radiol 41(2):187–191

    Article  Google Scholar 

  15. 15.

    Austin PC (2011) An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res 46(3):399–424

    Article  Google Scholar 

  16. 16.

    Pui CM, Bostrom MP, Westrich GH, Della Valle CJ, Macaulay W, Mont MA et al (2013) Increased complication rate following conversion total hip arthroplasty after cephalomedullary fixation for intertrochanteric hip fractures: a multi-center study. J Arthroplasty 28(8 Suppl):45–47

    Article  Google Scholar 

  17. 17.

    Gazzotti G, Matino G, Tsatsis C, Sacchetti G, Baudi P, Catani F (2014) Causes and treatments of lag screw’s cut out after intramedullary nailing osteosinthesis for trochanteric fractures. Acta Biomed 85(2):135–143

    PubMed  Google Scholar 

  18. 18.

    Takasago T, Goto T, Toki S, Hamada D, Yoshioka S, Tonogai I et al (2014) Intrapelvic migration of the lag screw in intramedullary nailing. Case Rep Orthop 2014:519045

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Fryhofer GW, Ramesh S, Sheth NP (2020) Acetabular reconstruction in revision total hip arthroplasty. J Clin Orthop Trauma 11(1):22–28

    Article  Google Scholar 

  20. 20.

    Klima ML (2021) Comparison of early fatigue failure of the TFNa and gamma 3 cephalomedullary nails in the United States from 2015 to 2019. J Orthop Trauma 35(2):e39-44

    Article  Google Scholar 

  21. 21.

    Exaltacion JJF, Incavo SJ, Mathews V, Parsley B, Noble P (2012) Hip arthroplasty after intramedullary hip screw fixation: a perioperative evaluation. J Orthop Trauma 26(3):141–147

    Article  Google Scholar 

  22. 22.

    Patel S, Soler JA, El-Husseiny M, Pegg DJ, Witt JD, Haddad FS (2012) Trochanteric fixation using a third-generation cable device–minimum follow-up of 3 years. J Arthroplasty 27(3):477–481

    Article  Google Scholar 

  23. 23.

    Austin MS, Hozack WJ, Sharkey PF, Rothman RH (2003) Stability and leg length equality in total hip arthroplasty. J Arthroplasty 18(3 Suppl 1):88–90

    Article  Google Scholar 

  24. 24.

    Maloney WJ, Keeney JA (2004) Leg length discrepancy after total hip arthroplasty. J Arthroplasty 19(4 Suppl 1):108–110

    Article  Google Scholar 

  25. 25.

    Dou Y, Zhou Y, Tang Q, Yang D, Liu J (2013) Leg-length discrepancy after revision hip arthroplasty: are modular stems superior? J Arthroplasty 28(4):676–679

    Article  Google Scholar 

  26. 26.

    Hines JT, Hernandez NM, Amundson AW, Pagnano MW, Sierra RJ, Abdel MP (2019) Intravenous tranexamic acid safely and effectively reduces transfusion rates in revision total hip arthroplasty. Bone Joint J 101-B(6_Supple_B):104–109

    Article  CAS  Google Scholar 

Download references

Funding

Kenneth Egol—Smith & Nephew: Paid presenter or speaker; Synthes & Acumed: Research support; Exactech: Royalties, Paid Consultant; Wolters Kluwer: Royalties. Ran Schwarzkopf—Smith & Nephew: IP royalties; Paid consultant; Research supports.

Author information

Affiliations

Authors

Contributions

BS: data gathering and analysis, and manuscript preparation. CS, AP: data gathering and analysis, statistics, and manuscript preparation. KE, RS: idea generation, project oversight, and manuscript preparation.

Corresponding author

Correspondence to Kenneth A. Egol.

Ethics declarations

Ethical approval

Approved- NYU SOM IRB number i17-01223.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Schultz, B.J., Sicat, C., Penev, A. et al. Conversion total hip arthroplasty for early failure following unstable intertrochanteric hip fracture: what can patients expect?. Arch Orthop Trauma Surg (2021). https://doi.org/10.1007/s00402-021-04215-1

Download citation

Keywords

  • Conversion total hip arthroplasty
  • Conversion arthroplasty
  • Failed intertrochanteric hip fractures
  • Screw cut-out
  • Implant failure