Review Question - QID 219869

This patient presents with a cut-out of the proximal lag screw in the treatment of a proximal femur fracture. There is intra-articular screw penetration with subsequent acetabular erosion, making conversion to total hip arthroplasty the best treatment in a geriatric patient

Intertrochanteric proximal femur fractures are treated with sliding hip screws or cephalomedullary nail constructs depending on the type of fracture and required stability. The most common complication in the treatment of intertrochanteric femur fractures is implant cut-out, leading to varus nonunion. An optimal lag screw tip-to-apex distance at the time of index surgery can help prevent this complication; however, it remains a relatively common occurrence. Additional complications include implant breakage, medial screw migration, and the z-effect in non-integrated dual screw implants. In young patients with proximal femur nonunion or malunion, revision open reduction and internal fixation can be considered. However, in older patients, hip arthroplasty remains the preferred salvage option. In patients with intraarticular screw penetration and acetabular erosion, total hip arthroplasty is indicated to address the acetabular-sided wear.

Liu et al. present a case series of 18 geriatric patients treated with conversion total hip arthroplasty after failed intertrochanteric proximal femur fracture fixation. 2 patients died within the follow-up period (average 26 months), but the rest of the patients had a significant improvement in Harris hip scores. They conclude that salvage total hip arthroplasty is a reasonable option to allow geriatric patients to mobilize effectively after failed treatment of intertrochanteric proximal femur fractures.

Haidukewych et al. present a case series of 60 patients who underwent conversion to hip arthroplasty for failed intertrochanteric proximal femur fractures, 30 of which received a total hip arthroplasty. Before salvage arthroplasty, all patients had moderate or severe pain in the hip and were unable to walk or had minimal walking ability. Forty out of 41 patients followed for two years postoperatively could walk. Despite this, the procedure is a significantly challenging one, with an average blood loss of 1125 mL and operative time of 4 hours within this cohort. 5 patients underwent reoperation, with two requiring component revision. 10 patients died within the first two years. Overall, the authors present a challenging but effective treatment for the salvage of failed intertrochanteric proximal femur fracture care.

Figure A and B are the AP and lateral hip radiographs demonstrating sliding hip screw fixation of a proximal femur fracture with evidence of implant cutout.

Incorrect Answers:
Answer 1: Exchange of the implant to a cephalomedullary nail with an improved tip-to-apex distance will not resolve the bone defects in the femur or acetabulum.
Answer 2: Valgus osteotomy and blade plate fixation may be a salvage option in young patients, but in geriatric patients, arthroplasty is preferred to allow for early mobilization and address acetabular-sided pathology.
Answer 3: Although proximal femoral replacement will likely improve the patient's symptoms, there is still adequate bone stock and thus unnecessary
Answer 4: Hip hemiarthroplasty would not address the significant acetabular erosion and is unlikely to resolve the patient's pain completely.