Pertrochanteric fractures in elderly patients. Treatment with a long-stem/long-neck endoprosthesis

The long-stem, long-neck endoprosthesis is used in the treatment of pertrochanteric hip fractures in the elderly. Between 1978 and 1984, 157 patients 70 years of age and over were treated at our clinic for fresh unstable pertrochanteric hip fractures. Fifty-five patients had internal fixation. Because of the high incidence of mechanical complications, the long spherostem endoprosthesis became the treatment of choice between 1980 and 1984. Thus, 102 patients were treated with this type of arthroplasty. They were compared with the 55 patients treated with osteosynthesis, and we concluded that: (1) in comparison with osteosynthesis, the procedure of endoprosthetic replacement is no more extensive and the mortality is no higher; (2) the incidence of mechanical complications is significantly lower in the endoprosthesis group; (3) even if the dynamic hip screw is now the treatment of choice for pertrochanteric fractures, the long spherostem endoprosthesis is still indicated in arthrotic hip fractures or in the case of reintervention after implant failure.     

Follow-up analysis of total hip endoprosthesis after femoral neck fracture with and without previous operation]

Damage occurring after joint-preserving surgical treatment of femoral neck--mostly femoral head necrosis of pseudoarthrosis-necessitates endoprosthetic joint replacement. In the case of inferior bone quality and unfavorable fracture forms as well as after failed conservative therapy, surgical treatment consists of implanting a total hip endoprosthesis. Between 1971 and 1989, 120 patients received total hip replacement after suffering fractures of the femoral neck: 61 patients did not have previous surgery, 59 patients had had joint-preserving surgery. Statistical analysis of the results showed that the primary stabilizing operation to preserve the joint did not have a negative influence on the survival probability of the total hip replacement in comparison with primary implantation. If the joint-preserving primary intervention fails, total hip replacement is a good choice for secondary surgery. In the case of complications such as femoral head necrosis or pseudoarthrosis the indication for total hip replacement should therefore be made early on.     

Malignant fibrous histiocytoma at the site of a total hip arthroplasty

Malignant fibrous histiocytoma is the most frequent sarcoma in adults. Predisposing factors for malignant fibrous histiocytoma are Paget's disease, bone infarcts, malignant disorders of the hematopoetic system, or prolonged intake of corticosteroids. Malignant fibrous histiocytoma has been described as occurring with increasing frequency after endoprosthetic therapy and has been attributed to the implants or to their alloy constituents. Malignant fibrous histiocytoma at the site of an endoprosthesis of the hip constitutes a distinct rarity. To our knowledge, only 13 cases have been described to date. In this report, we present the case of a 66-year-old woman with rheumatoid joint disease. Eight years after primary endoprosthetic surgery, loosening of the implant with severe osteolysis of the surrounding bone required replacement surgery. Histopathologic evaluation of resected tissue revealed scar and granulation tissue and Grade 3 malignant fibrous histiocytoma. The patient died 1 year after revision arthroplasty because of diffuse pulmonary and cerebral metastases. In patients with loosening of a total hip endoprosthesis in combination with severe periprosthetic osteolysis an accompanying malignancy should be in the differential diagnosis. The histopathologic examination of the resected tissue should be obligatory.     

Prothetische Versorgung der proximalen Femurfrakturen

The endoprosthetic replacement of the hip joint or its components in fractures of the proximal femur is a standard method. Indications for replacement are strongly dislocated intracapsular femoral neck fractures in elderly patients, fractures with an existing arthritis of the hip joint, and profound osteoporosis. Improved perioperative management and more gentle anesthetic techniques have helped to reduce perioperative mortality from nearly 50% to 11.5% over the last 40 years. As routine treatment options, the bipolar endoprosthesis without replacement of the acetabular joint surface and total hip replacement in case of degenerative arthritis of the acetabular joint surface are commonly used. The mere replacement of the femoral head with a simple femoral head prosthesis should be reserved for exceptional cases. For the implantation of a hip joint prosthesis and its uncomplicated post-treatment and long-term durability, careful preoperative planning is essential together with the selection of a suitable implant, its optimal bony fixation, avoidance of intra-operative complications and restoration of the anatomical landmarks such as the centre of rotation of the hip joint, the offset of the prosthetic shaft as well as leg length. Despite the high standard of endoprosthetics in Germany, the results are still improvable in comparison to other countries. Measures which preserve the joint as well as the bone will be increasingly important in prophylaxis of further complications. In addition, more attention should be paid to the prophylaxis of falls and a sufficiently guide-lined therapy of osteoporosis for the prophylaxis of fractures of the elderly.     

Prosthetic care of proximal femur fractures

The endoprosthetic replacement of the hip joint or its components in fractures of the proximal femur is a standard method. Indications for replacement are strongly dislocated intracapsular femoral neck fractures in elderly patients, fractures with an existing arthritis of the hip joint, and profound osteoporosis. Improved perioperative management and more gentle anesthetic techniques have helped to reduce perioperative mortality from nearly 50% to 11.5% over the last 40 years. As routine treatment options, the bipolar endoprosthesis without replacement of the acetabular joint surface and total hip replacement in case of degenerative arthritis of the acetabular joint surface are commonly used. The mere replacement of the femoral head with a simple femoral head prosthesis should be reserved for exceptional cases. For the implantation of a hip joint prosthesis and its uncomplicated post-treatment and long-term durability, careful preoperative planning is essential together with the selection of a suitable implant, its optimal bony fixation, avoidance of intra-operative complications and restoration of the anatomical landmarks such as the centre of rotation of the hip joint, the offset of the prosthetic shaft as well as leg length. Despite the high standard of endoprosthetics in Germany, the results are still improvable in comparison to other countries. Measures which preserve the joint as well as the bone will be increasingly important in prophylaxis of further complications. In addition, more attention should be paid to the prophylaxis of falls and a sufficiently guide-lined therapy of osteoporosis for the prophylaxis of fractures of the elderly.     

Nonself-centering Bateman bipolar endoprosthesis for nontraumatic osteonecrosis of the femoral head: a 12- to 18-year follow-up study

We studied the long-term results of bipolar endoprosthetic replacement in 12 patients (12 hips) 12 to 18 years after surgery. These patients had Ficat stage III nontraumatic osteonecrosis of the femoral head. The original Bateman universal proximal femoral endoprosthesis, which did not have a self-centering mechanism, was inserted without cement as a primary surgical intervention. Three patients underwent revision surgery, 3, 17, and 17 years after surgery, respectively. The reasons for revision surgery were migration of the stem in 2 patients and migration of both the stem and the outer cup in 1. In the remaining 9 patients, the total Merle d'Aubigné and Postel score was 16.1 ± 1.3 at the time of follow-up. Radiographs showed migration of the endoprosthesis in 1 of these 9 patients. Thus, 11 of the 12 patients retained the endoprosthesis 12 years or more after implantation. We concluded that the original Bateman endoprosthesis was effective in delaying the need for total hip replacement for more than 10 years in patients with Ficat stage III nontraumatic osteonecrosis of the femoral head. Received: May 15, 2001 / Accepted: August 24, 2001     

Stellenwert der Revisions- und Tumorendoprothetik bei der Versorgung periprothetischer Frakturen der unteren Extremität

Periprosthetic fractures of hip and knee prostheses are gaining clinical significance due to the increasing numbers of of primary arthroplasties. Additionally, these fractures are often associated with poor bone quality or present in patients after multiple revision procedures and concomitant excessive bone defects precluding those patients to be adequately treated by conventional osteosynthesis. Revision implants provide a wide range of options for the treatment of these fractures in order to achieve good clinical results. In the acetabular region cavitary defects associated with periprosthetic fractures can be treated by the use of megacups. Extensive segmental defects and pelvic discontinuity necessitate the use of cups with additional iliac support or even customized implants. Proximal femoral fractures can usually be fixed with modular stems and diaphyseal anchorage. Periprosthetic knee joint fractures can be treated with revision implants with modular sleeves or augment-combinations allowing sufficient bridging of bony defects. Functional reconstruction or refixation of the extensor mechanism is of crucial importance.     

Treatment of acetabular fractures

Experience in the treatment of 60 patients is generalized. Operative interventions are recommended for improving the outcomes of treatment in marked incongruence of the articular surfaces. Open reduction and osteosynthesis of the fragments is advisable in the first 21 days after the trauma. In neglected fractures of bones forming the acetabulum, the operation is performed with consideration for the condition of both components of the hip joint. The authors believe the following operations to be most indicated in this case: modeling resection of the hip joint, total endoprosthesis, arthrodesis. The late-term results were studied in 50 patients, among whom 31 were treated by surgery and 19 by nonoperative methods. The results were excellent in 6, good in 18, and satisfactory in 15 patients.     

Osteosynthese und Pfannenwechsel bei periprothetischer Azetabulumfraktur über einen Kocher-Langenbeck-Zugang

Objective

Reconstruction/stable fixation of the acetabular columns to create an adequate periacetabular requirement for the implantation of a revision cup.

Indications

Displaced/nondisplaced fractures with involvement of the posterior column. Resulting instability of the cup in an adequate bone stock situation.

Contraindications

Periprosthetic acetabulum fractures with inadequate bone stock. Extended periacetabular defects with loss of anchorage options. Isolated periprosthetic fractures of the anterior column. Septic loosening.

Surgical technique

Dorsal approach. Dislocation of hip. Mechanical testing of inlaying acetabular cup. With unstable cup situation explantation of the cup, fracture fixation of acetabulum with dorsal double plate osteosynthesis along the posterior column. Cup revision. Hip joint reposition.

Postoperative management

Early mobilization; partial weight bearing for 12 weeks. Thrombosis prophylaxis. Clinical and radiological follow-ups.

Results

Periprosthetic acetabular fracture in 17 patients with 9 fractures after primary total hip replacement (THR), 8 after revision THR. Fractures: 12 due to trauma, 5 spontaneously; 7 anterior column fractures, 5 transverse fractures, 4 posterior column fractures, 1 two column fracture after hemiendoprosthesis. 5 type 1 fractures and 12 type 2 fractures. Operatively treated cases (10/17) received 3 reinforcement ring, 2 pedestal cup, 1 standard revision cup, cup-1 cage construct, 1 ventral plate osteosynthesis, 1 dorsal plate osteosynthesis, and 1 dorsal plate osteosynthesis plus cup revision (10-month Harris Hip Score 78 points). Radiological follow-up for 10 patients: consolidation of fractures without dislocation and a fixed acetabular cup. No revision surgeries during follow-up; 2 hip dislocations, 1 transient sciatic nerve palsy.

     

Christiansen replacement hemiarthroplasty in femoral neck fractures of the elderly

A total of 108 femoral neck fractures were operated on by Christiansen hemiarthroplasty. Primary mortality was 4.8%, but after an average of 61 months only one-third of the patients were alive. Sixteen of the 40 hips of the living patients showed a poor result as evaluated by the Harris score or subjective outcome. Only four hips were wholly satisfactory at follow-up. It appears that Christiansen hemiarthroplasty has no advantages over other hemiendoprosthetic devices. It is suggested that undisplaced or minimally displaced fractures should not be treated by hemiarthroplasty but by compression osteosynthesis. The problem of displaced fractures still remains open. It appears, however, that primary total hip arthroplasty should be performed in cases of rheumatoid arthritis or even initial osteoarthritis, if an endoprosthetic replacement is considered.     

Management of unstable pertrochanteric femoral fracture by alloarthroplastic joint replacement

The treatment of trochanteric fractures of the femur should aim at the reconstruction of the joint function and should allow early weight bearing. In the case of unstable fractures and advanced osteoarthritis of the hip joint the advantages and risks of a total hip replacement have to be compared with different methods of osteosynthesis. We report on 35 patients with trochanteric fractures primarily treated with a total hip replacement. Their perioperative mortality was 9%, the most common complication was a luxation of the replaced hip joint in 3 cases. 1 patient had to be reoperated because of a soft tissue infection. Comparing the literature the primary total hip replacement shows a lower morbidity and mortality rate than complicated methods of osteosynthesis.     

The motility of hip joint endoprostheses (author's transl)

The motility of a healthy hip joint normally seems to be better than the motility of an endoprosthesis. The movement of all models of endoprostheses must fulfill minimum requirements as well in total motility as in each way. The arithmetical investigation of the motility of commercial total endoprostheses shows good locomotion for most cases. Decisive is the relation between prosthesis head- and prosthesis neck diameter. Insufficient motility of endoprosthetic models results if especial--redundant--constructive details of the socket are selected. It seems to be more problematical to produce double cup endoprostheses which reveal sufficient function. Normally the motility of double cup prostheses must be essentially less than that of total endoprostheses or of a healthy hip joint. A special implant technique and various constructive assumptions are necessary to reach a sufficient functional result.     

Implantatwahl am proximalen Femur

The objective of any surgical treatment of hip fractures should be stable osteosynthesis, allowing early full weightbearing mobilisation of the patient. Particular attention must be paid to the collo-diaphyseal and antetorsion angles in reduction and fracture stabilization in order not to impair the functional interaction between the hip and knee joint. Non-impacted femoral neck fractures are highly unstable. Intracapsular fractures and trochanteric fractures without rotational instability are generally stable after reduction, such that an extramedullary implant can ensure full weightbearing stability. With a more distal fracture course and greater intertrochanteric comminution zone, rotational instability and pivot transfer of the fracture area lateral and caudal ensues with increasing dislocating forces. Only these kinds of fractures benefit from an intramedullary and rotationally stable osteosynthesis. Primary total hip arthroplasty is a potential option for the surgical care of femoral fractures in elderly patients and trochanteric fractures with relevant coxarthrosis. Due to the increased complication rate in unstable fractures, a primary osteosynthesis is recommended followed by total hip arthroplasty following fracture consolidation.     

Pertrochant?re Femurfrakturen

The objective of any surgical care of a trochanteric femoral fracture should be the achievement of a stable osteosynthesis that allows early full weight-bearing mobilisation of the patient, because long-term immobilisation soon becomes a vital threat to the affected patients who are usually elderly with correlating comorbidities. The anatomical references of the proximal femur and the structure of the hip joint contain some specifics that play an essential role in the incurrence of a trochanteric femoral fracture and the planning of the osteosynthesis as well. With reposition and fracture stabilisation particular importance must be attached to the collo-diaphyseal and the antetorsion angle so that they do not interfere with the functional interaction of the hip and knee joint. Uncomplex trochanteric fractures ordinarily stabilise sufficiently after reposition so that even an extramedullary implant can ensure full weight-bearing stability. With evermore distal fracture course and intertrochanteric comminution zone, rotational instability and pivot transfer of the fracture area to lateral and caudal are followed by an increase of the dislocating forces. These kinds of fractures (A2 and A3 according to the AO/ASIF classification) profit from an intramedullary and rotationally stable osteosynthesis. Basically primary total hip arthroplasty is a potential option for surgical care of a trochanteric fracture in elderly patients with relevant coxarthrosis. However this procedure can only be recommended in cases of a stable uncomplex fracture. The more the medial interlocking of the proximal femur is destroyed the more difficult it will be to primarily implant a total hip prosthesis with good offset and without a varus and rotational failure in the fracture zone.The current studies in the main show disadvantages due to increased complications in these patients, so that in cases of an unstable trochanteric fracture a primary osteosynthesis should be performed followed by total hip arthroplasty after fracture consolidation has occurred.     

Treatment of femoral neck fractures]

Due to the high incidence (600-900 patients/year >65 years old), the expected increase in frequency by a factor of five by 2050, and the proportionately shrinking capacity in trauma centers, femoral neck fractures are relevant to health care both economically and politically. Surgical treatment within 6 h improves results of osteosynthesis, within 24 h reduces general complications, and within 48 h reduces mortality. The literature displays great regional differences in methods and results. There is however general agreement that the hip joint should be preserved in young, active patients, regardless of fracture type and dislocation and that endoprosthesis is desirable for elderly patients with severe dislocation. The controversies begin with compressed fracture, determination of the degree of dislocation, and age and physical condition of patients who would profit from endoprosthesis. Total endoprostheses show better results in more active patients than do hemiarthroconstructions. Cemented endoprostheses are preferable in older patients due to their better function and lower postoperative pain. The DGU recommends prophylactic osteosynthesis for impacted fracture and osteosynthesis for nondislocated fracture or when closely following slightly dislocated fracture.     

Developments in the treatment of fractures of the coxal end of the femur

The therapeutic concept for proximal femur fractures has changed to varying degrees from 1978 to 1988 in the Department of Traumatology and Reconstructive Surgery at Steglitz Medical Center. In general, conservative therapy has been abandoned. Alloplastic joint replacement is performed in patients with coxarthrosis in the fracture area. A head prosthesis is chosen for those with a life expectancy of less than eight years. Clearly favourable results have been achieved in our department with the Duokopf prosthesis. Patients with a higher life expectancy are submitted to a total hip endoprosthesis, preference being given in cases of collum femoris fractures to the combination of a Spotorno shaft and a Morscher acetabulum. Loading should only be partial for five weeks in patients treated with this cement-free total endoprosthesis. We use the Duokopf prosthesis in the combination of a Spotorno shaft with a Uni-Hip head. We submit these patients to full loading primarily. --We have completely abandoned Ender nailing. We prefer the dynamic hip screw for per- and intertrochanteric femur fractures. For subtrochanteric femur fractures, we use the condyl plate. For lateral collum femoris fractures we have used the four-hole angle plate until 1988. Since 1989 we also use the dynamic hip screw. The one-hole angle plate is used for osteosynthesis in cases of medial collum femoris fractures.     

Austin-Moore hemiarthroplasty for failed osteosynthesis of intracapsular proximal femoral fractures

We studied the outcome of 100 uncemented Austin-Moore hemiarthroplasties used as a revision procedure for failed osteosynthesis of intracapsular femoral fractures. This group was compared with 730 patients in whom an uncemented Austin-Moore prosthesis had been used as the primary treatment for an intracapsular femoral fracture. The results indicate that the study group had more pain at 1-year post-fracture. There were also significantly more revision procedures in those who had the arthroplasty performed as a salvage procedure. In general, the results of uncemented Austin-Moore hemiarthroplasty used as a revision procedure for failed osteosynthesis are inferior to that for primary hemiarthroplasty. We would advocate that for any case in which there are signs of acetabular damage a total hip replacement might be a better procedure. For the remainder, an alternative arthroplasty should be considered with an uncemented Austin-Moore prosthesis reserved for only the very frail.     

Operative treatment of femoral neck fractures in elderly patients

Experience of the hip joint endoprosthesis for the femur colli fracture in 186 elderly patients is presented. The hip joint endoprosthesis expediency and its advantages in comparison with the femur osteosynthesis were substantiated.     

Hip dislocation with femur head fracture

It is talked about the classification, the therapy and the late results of the traumatic dislocation of the hip joint with a fracture of the femoral head. Twelve patients with an average age of 36 years (from 18 to 77 years) were treated between the years 1972 and 1982. The rarer anterior dislocation of the hip including a fracture of the femoral head should be specifically classified, in order not to cause any errors for the therapeutic and prognostic assessment following the Pipkin classification. Type I and II with posterior dislocation justify a closed trial of reposition. The miscarried trial, and a continuing fragmental dislocation with a disturbance of the joint's function, or fragments participating in the load area of the femoral head necessitate an open reposition. Small fragments may be taken away, the larger ones require the screwing osteosynthesis. Smaller fragments from the load area must be sustained in an anterior dislocation ("IIb"). The type III injury gives primarily--in exceptional cases sometimes secondarily--an indication for an alloplastic false hip joint. Injuries of type IV should be restored operatively, respectively, it is necessary to perform a secondary operation to set in an endoprosthetic substitute. With the operative therapy--that is: 5 times extirpation of fragments, 4 times screwing osteosynthesis of the femoral head, twice screwing osteosynthesis of the acetabulum--we obtained good results in injuries of type I, II and IV. We performed 3 times a primary total false hip joint in type III injuries.     

Behandlung der Schenkelhalsfrakturen

Due to the high incidence (600–900 patients/year >65 years old), the expected increase in frequency by a factor of five by 2050, and the proportionately shrinking capacity in trauma centers, femoral neck fractures are relevant to health care both economically and politically. Surgical treatment within 6 h improves results of osteosynthesis, within 24 h reduces general complications, and within 48 h reduces mortality. The literature displays great regional differences in methods and results. There is however general agreement that the hip joint should be preserved in young, active patients, regardless of fracture type and dislocation and that endoprosthesis is desirable for elderly patients with severe dislocation. The controversies begin with compressed fracture, determination of the degree of dislocation, and age and physical condition of patients who would profit from endoprosthesis. Total endoprostheses show better results in more active patients than do hemiarthroconstructions. Cemented endoprostheses are preferable in older patients due to their better function and lower postoperative pain. The DGU recommends prophylactic osteosynthesis for impacted fracture and osteosynthesis for nondislocated fracture or when closely following slightly dislocated fracture.