Effectiveness of revision surgery for unstable intertrochanteric fractures after intramedullary nailing internal fixation failure_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

TENG Lin ¹ , LI Haibo ¹ , LI Liang ¹ , XIAO Yongchuan ¹ , LIU Dahai ¹ ,  ZHONG Gang ²

1. Department of Orthopedics, the First People’s Hospital in Shuangliu District/West China Airport Hospital, Sichuan University, Chengdu Sichuan 610200, P. R. China;
2. Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding author：

ZHONG Gang, Email: zg730927@163.com

Keywords：

Intertrochanteric fracture; intramedullary nailing; internal fixation failure; revision surgery

DOI：

10.7507/1002-1892.202202085

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Objective To investigate the causes of intramedullary nailing internal fixation failure for unstable intertrochanteric fractures, the selection of revision methods, and the effectiveness. Methods A clinical data of 16 patients with unstable intertrochanteric fractures, who were treated with intramedullary nail and failed between June 2015 and May 2019, were retrospectively analyzed. There were 9 males and 7 females with an average age of 62.5 years (range, 34-90 years). The fractures were caused by falling injury in 11 cases, traffic accident in 3 cases, and falling from height in 2 cases. According to the AO/Association for the Study of Internal Fixation (AO/OTA) classification, the intertrochanteric fractures were classified as type A2.2 in 6 cases, type A2.3 in 7 cases, and type A3 in 3 cases. The average interval between fixation failure and initial internal fixation was 10.8 months (range, 5-18 months). Hip arthroplasty or internal fixation revision with bone grafting was used, including total hip arthroplasty in 5 cases, bipolar hemiarthroplasty in 4 cases, proximal femoral locking plate in 4 cases, and intramedullary nail 3 cases. The operation time, intraoperative blood loss and complications were recorded, and the shortened length of the affected limb was measured. X-ray films were used to analyze the position of prosthesis and internal fixation. The Harris score was used to evaluate the hip function. Results The average operation time was 113.7 minutes (range, 78-146 minutes) and the average intraoperative blood loss was 411.6 mL (range, 200-650 mL). All incisions healed by first intension. All patients were followed up for an average of 24.7 months (range, 12 -36 months). The average time of fracture union was 6.9 months (range, 5-9 months). One case of hemiarthroplasty had intraoperative femoral shaft fracture at the distal of prosthesis stem and healed after corresponding treatment; 1 case of hip prosthesis dislocation occurred after operation, and did not dislocate again after manual reduction. There were no complications such as internal fixation failure again, screw cutting-out, prosthesis infection, or loosening during follow-up. At last follow-up, the shortened length of the affected limb was (0.20±0.21) cm, compared with the preoperative (2.06±0.64) cm, the difference was significant (t=11.045, P<0.001). And the Harris score was 81.8±9.7, compared with preoperative (33.8±6.4), the difference was significant (t=-16.618, P<0.001). The results were classified as excellent in 2 cases, good in 10, fair in 2, and poor in 2, with the excellent and good rate of 75%. The operation time, intraoperative blood loss, and shortened length of the affected limb were significantly lower in arthroplasty group than in internal fixation group (P<0.05), while there was no significant difference of Harris score between groups (P>0.05). Conclusion For unstable intertrochanteric fractures after internal fixation failure of intramedullary nail, elderly patient and patient with destroyed femoral head could be treated with arthroplasty in order to restore walking function quickly, while young patient could accept revision with proximal femoral locking plate or intramedullary nail and autograft to promote fracture healing.

1.	Utrilla AL, Reig JS, Muñoz FM, et al. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma, 2005, 19(4): 229-233.
2.	Verettas DA, Ifantidis P, Chatzipapas CN, et al. Systematic effects of surgical treatment of hip fractures: gliding screw-plating vs intramedullary nailing. Injury, 2010, 41(3): 279-284.
3.	Adams CI, Robinson CM, Court-Brown CM, et al. Prospective randomized controlled trail of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma, 2001, 15(6): 394-400.
4.	Knobe M, Drescher W, Heussen N, et al. Is helical nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures? Clin Orthop Relat Res, 2012, 470(8): 2302-2312.
5.	Geller JA, Saifi C, Morrison TA, et al. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop, 2010, 34(5): 719-722.
6.	Davis TR, Sher J, Horsman A, et al. Intertrochanteric femoral fractures. Mechanical failure after internal fixation. J Bone Joint Surg (Br), 1990, 72(1): 26-31.
7.	聂少波, 张伟, 张里程, 等. 股骨转子间骨折术后内固定失效的危险因素研究进展. 中华创伤骨科杂志, 2021, 23(3): 233-238.
8.	张伟, 李建涛, 陈华, 等. 股骨转子间骨折初次手术失败的翻修策略和研究进展. 中华创伤骨科杂志, 2021, 23(3): 239-245.
9.	张世民, 余斌. AO/OTA-2018版股骨转子间骨折分类的解读与讨论. 中华创伤骨科杂志, 2018, 20(7): 583-587.
10.	张世民, 胡孙君, 杜守超, 等. 股骨转子间骨折的稳定性重建概念演化与研究进展. 中国修复重建外科杂志, 2019, 33(10): 1203-1209.
11.	Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg (Am), 1969, 51(4): 737-755.
12.	Haidukewych GJ, Berry DJ. Salvage of failed treatment of hip fractures. J Am Acad Orthop Surg, 2005, 13(2): 101-109.
13.	Iwakura T, Niikura T, Lee SY, et al. Breakage of a third generation gamma nail: a case report and review of the literature. Case Rep Orthop, 2013, 2013: 172352.
14.	Dziadosz D. Considerations with failed intertrochanteric and subtrochanteric femur fractures: how to treat, revise, and replace. J Orthop Trauma, 2015, 29 Suppl 4: S17-S21.
15.	Karampinas PK, Kollias G, Vlamis J, et al. Salvage of failed hip osteosynthesis for fractures with modular hip prosthesis. Eur J Orthop Surg Traumatol, 2015, 25(6): 1039-1045.
16.	陈鹏, 傅德皓. 股骨近端防旋髓内钉治疗老年股骨转子间骨折内固定失败原因分析. 中国修复重建外科杂志, 2019, 33(10): 1270-1274.
17.	Zhang W, Antony Xavier RP, Decruz J, et al. Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA Ⅱ): a study in a Southeast Asian population. Arch Orthop Trauma Surg, 2021, 141(4): 569-575.
18.	Hsu KH, Chang CH, Su YP, et al. Radiographic risk factors for predicting failure of geriatric intertrochanteric fracture treatment with a cephalomedullary nail. J Chin Med Assoc, 2019, 82(7): 584-588.
19.	姜钰, 黄鑫, 朱颖波, 等. 成人股骨转子间骨折术后股骨头坏死研究进展. 中国修复重建外科杂志, 2020, 34(11): 1458-1461.
20.	Min BW, Lee KJ, Oh JK, et al. The treatment strategies for failed fixation of intertrochanteric fractures. Injury, 2019, 50(7): 1339-1346.
21.	覃勇志, 周凯, 王端, 等. 股骨转子间骨折内固定失败后人工全髋关节置换术治疗的安全性及有效性分析. 中国修复重建外科杂志, 2019, 33(2): 160-165.
22.	Cho CH, Yoon SH, Kim SY. Better functional outcome of salvage THA than bipolar hemiarthroplasty for failed intertrochanteric femur fracture fixation. Orthopedics, 2010, 33(10): 721.
23.	孙林, 毛玉江, 吴新宝, 等. 股骨转子间骨折术后内固定失效的再次内固定治疗. 中华创伤骨科杂志, 2008, 10(12): 1108-1111.
24.	Tucker A, Warnock M, McDonald S, et al. Fatigue failure of the cephalomedullary nail: revision options, outcomes and review of the literature. Eur J Orthop Surg Traumatol, 2018, 28(3): 511-520.

1. Utrilla AL, Reig JS, Muñoz FM, et al. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma, 2005, 19(4): 229-233.
2. Verettas DA, Ifantidis P, Chatzipapas CN, et al. Systematic effects of surgical treatment of hip fractures: gliding screw-plating vs intramedullary nailing. Injury, 2010, 41(3): 279-284.
3. Adams CI, Robinson CM, Court-Brown CM, et al. Prospective randomized controlled trail of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma, 2001, 15(6): 394-400.
4. Knobe M, Drescher W, Heussen N, et al. Is helical nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures? Clin Orthop Relat Res, 2012, 470(8): 2302-2312.
5. Geller JA, Saifi C, Morrison TA, et al. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop, 2010, 34(5): 719-722.
6. Davis TR, Sher J, Horsman A, et al. Intertrochanteric femoral fractures. Mechanical failure after internal fixation. J Bone Joint Surg (Br), 1990, 72(1): 26-31.
7. 聂少波, 张伟, 张里程, 等. 股骨转子间骨折术后内固定失效的危险因素研究进展. 中华创伤骨科杂志, 2021, 23(3): 233-238.
8. 张伟, 李建涛, 陈华, 等. 股骨转子间骨折初次手术失败的翻修策略和研究进展. 中华创伤骨科杂志, 2021, 23(3): 239-245.
9. 张世民, 余斌. AO/OTA-2018版股骨转子间骨折分类的解读与讨论. 中华创伤骨科杂志, 2018, 20(7): 583-587.
10. 张世民, 胡孙君, 杜守超, 等. 股骨转子间骨折的稳定性重建概念演化与研究进展. 中国修复重建外科杂志, 2019, 33(10): 1203-1209.
11. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg (Am), 1969, 51(4): 737-755.
12. Haidukewych GJ, Berry DJ. Salvage of failed treatment of hip fractures. J Am Acad Orthop Surg, 2005, 13(2): 101-109.
13. Iwakura T, Niikura T, Lee SY, et al. Breakage of a third generation gamma nail: a case report and review of the literature. Case Rep Orthop, 2013, 2013: 172352.
14. Dziadosz D. Considerations with failed intertrochanteric and subtrochanteric femur fractures: how to treat, revise, and replace. J Orthop Trauma, 2015, 29 Suppl 4: S17-S21.
15. Karampinas PK, Kollias G, Vlamis J, et al. Salvage of failed hip osteosynthesis for fractures with modular hip prosthesis. Eur J Orthop Surg Traumatol, 2015, 25(6): 1039-1045.
16. 陈鹏, 傅德皓. 股骨近端防旋髓内钉治疗老年股骨转子间骨折内固定失败原因分析. 中国修复重建外科杂志, 2019, 33(10): 1270-1274.
17. Zhang W, Antony Xavier RP, Decruz J, et al. Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA Ⅱ): a study in a Southeast Asian population. Arch Orthop Trauma Surg, 2021, 141(4): 569-575.
18. Hsu KH, Chang CH, Su YP, et al. Radiographic risk factors for predicting failure of geriatric intertrochanteric fracture treatment with a cephalomedullary nail. J Chin Med Assoc, 2019, 82(7): 584-588.
19. 姜钰, 黄鑫, 朱颖波, 等. 成人股骨转子间骨折术后股骨头坏死研究进展. 中国修复重建外科杂志, 2020, 34(11): 1458-1461.
20. Min BW, Lee KJ, Oh JK, et al. The treatment strategies for failed fixation of intertrochanteric fractures. Injury, 2019, 50(7): 1339-1346.
21. 覃勇志, 周凯, 王端, 等. 股骨转子间骨折内固定失败后人工全髋关节置换术治疗的安全性及有效性分析. 中国修复重建外科杂志, 2019, 33(2): 160-165.
22. Cho CH, Yoon SH, Kim SY. Better functional outcome of salvage THA than bipolar hemiarthroplasty for failed intertrochanteric femur fracture fixation. Orthopedics, 2010, 33(10): 721.
23. 孙林, 毛玉江, 吴新宝, 等. 股骨转子间骨折术后内固定失效的再次内固定治疗. 中华创伤骨科杂志, 2008, 10(12): 1108-1111.
24. Tucker A, Warnock M, McDonald S, et al. Fatigue failure of the cephalomedullary nail: revision options, outcomes and review of the literature. Eur J Orthop Surg Traumatol, 2018, 28(3): 511-520.

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