Salvage of failed dynamic hip screw fixation of intertrochanteric fractures

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1 Injury, Int. J. Care Injured (2005) xxx, xxx xxx Salvage of failed dynamic hip screw fixation of intertrochanteric s G.Z. Said, O. Farouk *, A. El-Sayed, H.G. Said Department of Orthopaedic Surgery and Traumatology, Assiut University Hospitals, Assiut, Egypt Accepted 19 September 2005 KEYWORDS Failed DHS; Intertrochanteric ; Trochanteric nonunion Introduction Primary insertion of dynamic hip screw (DHS) for trochanteric s is not always successful, especially in unstable s. 3,6 Madsen et al. 9 reported significant secondary displacement in 34% of cases, leading to a varus malunion, * Corresponding author. Tel.: ; fax: address: osama_farouk@yahoo.com (O. Farouk) /$ see front matter # 2005 Published by Elsevier Ltd. doi: /j.injury Summary Twenty-six patients with failed dynamic hip screw fixation of intertrochanteric s were included in this study. The mean age of the patients was 61 years (range, years). Average limb shortening was 2.4 cm; 18 patients were treated with revision internal fixation and eight patients with prosthetic replacement. The decision depended on the physiological age of the patient, quality of bone, and condition of the femoral head and the acetabulum. The revision internal fixation group included DHS reinsertion in eight patients, and revision DHS fixation in six, while four patients were treated by and insertion of single-angled 1308 plate. The prosthetic replacement group included cemented Thompson endoprothesis in five patients and cemented total hip arthroplasty in three. The mean follow-up period was 31 months (range, months). All patients of revision internal fixation group achieved healing without bone grafting. Time to union averaged 17 weeks. Average gain in length was 2 cm Avascular necrosis of the femoral head occurred in one patient. Six patients of the prosthetic replacement group achieved good functional outcome and pain-free gait. The remaining two had unsatisfactory result. # 2005 Published by Elsevier Ltd. lag screw cutout, or excessive lag screw sliding with medialisation of the distal fragment. Buciuto et al. 2 reported significant technical failures in their series. Mechanical stability after internal fixation is dependent on the quality of bone, personality, quality of reduction and choice of the implant. Implant placement in the biomechanically ideal position, however, is probably the most important factor. 8 The aim of this study is to report on surgical salvage for failed DHS fixation of intertrochanteric s

2 2 G.Z. Said et al Patients and methods Between January 1998 and January 2004, twenty-six patients with failed DHS fixation of intertrochanteric were referred to our institution. All patients were preoperatively assessed, surgically treated and followed up by the authors. Inclusion criteria Early and late DHS failures with un-united intertrochanteric s in adults and elderly patients were included. The exclusion criteria were active infection and united s with accepted functional outcome. All patients were evaluated both clinically and radiologically. Fractures were classified according to the AO classification. 11 Causes of DHS failure were analyzed. Treatment groups The patients were sorted under four subgroups according to the method of surgical treatment applied (Table 1). In the revision internal fixation group, the implant was inserted to near the subchondral bone for good purchase. In one patient of group I, in addition to reinsertion of DHS, a narrow six-hole DCP was laterally mounted like a trochanteric stabilizing plate to prevent medialisation of the shaft (Fig. 1). In this case, a 1-cm shorter DHS screw was introduced deep into the neck to allow for the sliding mechanism inside the plate barrel. Bone grafting was not added in any patient. Assessment i. Fracture union in groups I and II was considered radiographically if callus formation was seen in three of four cortices on anteroposterior and lateral views. Clinical union was considered when there was painless hip range of movement and painless full weight bearing. ii. Functional assessment was done using subjective and objective information, based on pain, limb shortening, and walking ability. Results Details of the patients are shown in Table 2. The patients were aged years (mean 61 years) with a male to female ratio of The mean period of follow-up was 31 months (range, months). Eight s were stable type A1 and 18 were unstable (type A2 in 15 and type A3 in three) according to AO classification. DHS failure Time between initial surgery and DHS failure ranged between 2 and 52 weeks and averaged 22 weeks. Causes of DHS failure were inadequate placement of the DHS in eight patients, instability with secondary varus displacement in 10 patients and severe of the femoral head in eight patients. Fracture union All patients in groups I and II achieved union. The osteotomy also united in all patients of group II. The mean time to union was 17 weeks (range, weeks). Bone grafting was not needed in any case. All had satisfactory radiological result (Figs. 1 and 2) without any implant failure. Functional outcome 1. Pain: Twenty patients were pain free at the last follow up. Four patients from group II had occasional hip pain that did not interfere with their daily activities. The remaining two patients were from group III, and had persistent hip and anterior thigh pain. 2. Limb shortening: Preoperative average limb shortening measured 2.4 cm (range, 1 6 cm). Table 1 The four groups of patients according to the type of surgery Surgical group Number Indications I. Repeat DHS 8 Short screw, good bone stock II. Subtrochanteric 10 Varus neck DHS re-fixation 6 Good bone stock of femoral head Single angled 1308 plate 4 Good bone stock in infero-medial quadrant III. Haemiarthroplasty 5 Excavated femoral head IV. Total hip replacement 3 Osteoporosis, acetabular damage

3 Salvage of failed dynamic hip screw fixation 3 Figure 1 (a) A 38-year-old man (case no. 1) presented 8 months after DHS operation. Note translucency around the screw and barrel, excessive backing of the screw and medialisation. (b) Lateral view confirmed poor reduction and non-union. (c and d) The united after reduction of the fragments and reinsertion of DHS to near the subchondral bone. A narrow DCP was put as a trochanter-stabilizing plate.

4 Table 2 Summary of patients data, pre-operative clinical evaluation, surgical procedure and outcome of all patients Patients Initial DHS fixation Pre-operative clinical evaluation Fracture type (AO classification) Surgical procedure No. Age Sex Time to failure (weeks) Cause of failure Limb shortening (cm) Femoral head Acetabular state Complications Functional outcome 1 38 Male 32 Mal-placed DHS 1.5 Good Good A2 DHS reinsertion 2 55 Female 22 Unstable 3 Good Good A2 DHS reinsertion Female 16 Unstable 2.5 Good Good A2 DHS reinsertion + Occasional Without 4 40 Female 12 Mal-placed DHS 1.5 Good Good A3 DHS reinsertion 5 58 Male 18 Unstable 6 Good Good A2 DHS reinsertion Male 2 Mal-placed DHS 1 Good Good A2 DHS reinsertion 7 70 Female 24 Femoral head 1.5 Excavated Good A1 Thompson 8 60 Female 20 Unstable 3.5 Good Good A2 DHS reinsertion Female 20 Femoral head 2 Excavated Good A1 Thompson Free One-arm Male 16 Unstable 3 Good inferomedial Good A Plate + valgus quadrant osteotomy Male 12 Mal-placed DHS 1.5 Good Good A3 DHS reinsertion Female 32 Femoral head 2 Excavated Abraded A1 Total hip replacement Free One-arm Female 12 Mal-placed DHS 1.5 Good Good DHS reinsertion Female 40 Femoral head 2 Excavated Severe A1 Total hip replacement Free One-arm Female 16 Mal-placed DHS 1.5 Good Good A2 DHS reinsertion Male 24 Unstable 3 Good infero-medial Good A Plate + valgus quadrant osteotomy Female 14 Mal-placed DHS 2 Good Good A3 DHS reinsertion Pain Walking 4 G.Z. Said et al. DTD 5

5 18 72 Male 36 Femoral head 1.5 Excavated Osteoporosis A1 Thompson Persistent Indoor + walker Female 16 Mal-placed DHS 2 Good Good A2 DHS reinsertion Female 30 Femoral head 2 Excavated Osteoporosis A1 Thompson Free One-arm Female 28 Femoral head 3 Excavated Good A1 Thompson Periprosthetic Persistent Indoor + walker Male 20 Unstable 4 Good infero-medial Good A Plate + valgus Avascular necrosis Occasional Without quadrant osteotomy of femoral head Female 52 Femoral head 3 Excavated Severe A1 Total hip replacement DVT Free One-arm Female 24 Unstable 3 Good inferomedial Good A Plate + valgus Occasional Without quadrant osteotomy Female 16 Unstable 2.5 Good Good A2 DHS reinsertion + valgus Occasional Without osteotomy Male 20 Unstable 2.5 Good Good A2 DHS reinsertion + Salvage of failed dynamic hip screw fixation 5 DTD 5

6 6 G.Z. Said et al Figure 2 (a) A 58-year-old man (case no. 5) had DHS fixation for trochanteric. The DHS lag screw cutout. The DHS was removed. (b) The patient presented to our institution 6 weeks later with coxa vara, full external rotation and 6 cm shortening. (c) Reinsertion of DHS and was done after correction of external rotation and shortening. (d) Follow-up 10 months postoperatively with complete union of the. Average gain in length was 2 cm (range, 1 4 cm) postoperatively. Residual shortening of 2 cm remained in two patients. 3. Walking ability: All patients of groups I and II could walk without at the latest follow up. Two patients from group III were walking with one arm and one patient was able to walk without. The remaining two could walk indoors using walker with difficulty, and were listed for conversion to total joint replacement. The three patients of group IV could walk with one arm. Complications Two patients had post-operative complications. One had DVT and the other had a periprosthetic in the early postoperative period, which was treated successfully with plate fixation. Avascular necrosis of the femoral head occurred in one patient who had and 1308 plate fixation. The blade penetrated the femoral head gradually and became intra-articular. Hardware removal was done after complete union of and osteotomy site (Fig. 3)

7 Salvage of failed dynamic hip screw fixation 7 Figure 3 (a) A 66-year-old man (case no. 22) presented with non-union of basi-trochanteric and cutout of DHS lag screw. (b) DHS removal, and insertion of 1308 blade-plate were done. (c) Follow-up 8 months postoperatively; the blade penetrated the femoral head with radiological picture of avascular necrosis. (d) Good healing of the non-union and osteotomy sites after metal removal.

8 8 G.Z. Said et al Re-operations Two re-operations were reported. The first was plate fixation of a periprosthetic in the early postoperative period. The second was hardware removal after union because of intraarticular penetration of the implant. Discussion The results of salvage procedures after failed DHS fixation are few in the orthopaedic literature. Wu et al. 14 reported on 14 intertrochanteric s with failed DHS. All were treated by reinsertion of a lag screw inferiorly in the femoral head, cement augmentation and subtrochanteric. All healed at a mean of 5 months. Haidukewych and Berry 4 6 reported the largest series for salvage of trochanteric s after failed initial fixation using different types of implants in two retrospective studies over 20 years. They reported successful treatment of 20 patients with revision internal fixation and 60 patients with prosthetic replacement. In the current study we report on salvage procedures for failed DHS fixation of intertrochanteric s. The following points are to be discussed. DHS failure The result of DHS fixation depends on patient and surgeon factors. The patient related factors include: (1) stability, (2) bone quality, and (3) femoral neck shaft angle. Unstable s, with loss of medial calcar continuity, tend to fall into varus displacement when stabilized. Severe allows cutting of the lag screw through the hollow femoral head and loss of reduction. The neck shaft angle decreases gradually with age. The average neck-shaft angle was found to be 1258 in a population with an average age of 69.9 years. 12 To insert DHS of 1358 angle in that hip, the lag screw will take a superolateral position inside the femoral head facilitating its cutout. In these cases, it is preferable to insert the lag screw in the long axis of neck and head. The plate will stick out about 108 away from the shaft and of 108 below the hole of screw insertionshouldbedone.thesurgeonrelatedfactors to prevent DHS failure include: (1) adequate reduction with good contact of bone fragments, (2) correction of varus displacement, and (3) proper placement of the lag screw. Poor reduction with lack of good bone contact across the site or persistent varus position will lead to non-union and loss of fixation. The lag screw should be inserted in a central position inside the femoral head and should be advanced to near the subchondral bone for best purchase. 7,11 Improper placement of the lag screw may lead to loss of fixation and DHS failure. Patient selection The type of surgical treatment after failed DHS fixation depended on the physiological age of the patient, quality of bone, and condition of the femoral head and the acetabulum. The policy followed was that whenever the patient was young and fit, and there was still good bone stock in the femoral head, revision internal fixation was done. If the patient was fragile and the femoral head was found excavated from the previous internal fixation, replacement arthroplasty was decided. Implant selection The implant used for revision internal fixation was selected according to the quality and location of remaining bone stock in the femoral head. It was possible to reinsert a DHS when there was still good bone stock in the femoral head to hold the threads of another screw. A single-angled 1308 plate was inserted when there was good bone stock only in the infero-medial quadrant of the femoral head. Haemiarthroplasty was done, if the femoral head was excavated, but with healthy acetabulum. Total hip replacement was decided when the acetabulum was abraded by a protruding screw and in severe. Repositioning osteotomy A subtrochanteric was added to facilitate bringing the plate of the implant to the shaft of the femur. The osteotomy also helped in stabilization of the and correction of the shortening. 1,10,13,14 Müller 10 and Bartonicek et al. 1 used double-angled plate to fix the subtrochanteric. Single-angled 1308 plate was used in this series. Fixation of the subtrochanteric osteotomy by a single-angled plate allowed lateralization and normal orientation of the femoral shaft, to counteract the medialisation and the vertical orientation of the femoral shaft produced by the osteotomy. 13 Bone grafting Haidukewych and Berry 5 reported on open reduction and bone grafting in all their patients with

9 Salvage of failed dynamic hip screw fixation revision internal fixation. Bone grafting was not found necessary in any of our patients. We believe that the problem is mechanical rather than biological, as the intertrochanteric region of the femur is well vascularised and has excellent surrounding soft tissue coverage. The limitations of the current study include the retrospective design and the possible selection bias. However, the limitations do not undermine the conclusion that for salvage of failed DHS we can achieve union with revision internal fixation for physiologically younger patients with good remaining bone stock, while older patients with lowdemand activities and poor bone quality, or a damaged hip articular surface are treated with hip arthroplasty. References 1. Bartonicek J, Skala-Rosenbaum J, Dousa P. Valgus osteotomy for malunion and nonunion of trochanteric s. J Orthop Trauma 2003;17(9): Buciuto R, Uhlin B, Hammerby S, Hammer R. RAB-plate versus Richards CHS plate for unstable trochanteric hip s: a randomised study of 233 patients with 1-year follow-up. Acta Orthop Scand 1998;69: Ecker ML, Joyce III JJ, Kohl EJ. The treatment of trochanteric hip s using a compression screw. J Bone Joint Surg 1975;57(A): Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip s. J Bone Joint Surg 2003;8(A): Haidukewych GJ, Berry DJ. Salvage of failed internal fixation of intertrochanteric hip s. Clin Orthop 2003;412: Haidukewych GJ, Berry DJ. Salvage of failed treatment of hip s. J Am Acad Orthop Surg 2005;13: Jacobs RR, McClain O, Armstrong HJ. Internal fixation of intertrochanteric hip s: a clinical and biomechanical study. Clin Orthop 1980;146: Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop 1980;146: Madsen JE, Naess L, Aune AK, et al. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral s: a comparative study with the gamma nail and compression hip screw. J Orthop Trauma 1998;12(4): Müller ME. Intertrochanteric osteotomy: indication, preoperative planning, technique. In: Schatzker J, editor. The intertrochanteric osteotomy. Berlin: Springer-Verlag, Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of internal fixation: techniques recommended by the AO-ASIF group. Berlin: Springer-Verlag, Noble PC, Alexander JW, Lindhal LJ. The anatomical basis of femoral component design. Clin Orthop 1988;235: Said GZ, Gaballa MA, Said HZ, Elkady H. Subtrochanteric fixation by single or double angled plate. Pan Arab J Orthop Trauma 1999;3(2): Wu CC, Shih CH, Chen WJ, Tai CL. Treatment of cutout of a lag screw of a dynamic hip screw in an intertroch anteric. Arch Orthop Trauma Surg 1998;117:

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