Should trochanteric fractures in elderly patients be treated by arthroplasty or internal fixation?

Most trochanteric fractures are treated by fixation, most often intramedullary. Nevertheless, the desire to have patients walk as soon as possible and the fear of fixation failure has driven some surgeons to carry out an arthroplasty instead, especially for unstable fractures and/or in patients with severe osteoporosis, in order to avoid the difficult conversion to arthroplasty later on if the fixation fails. The aim of this review was to specify the role, technique and results of performing arthroplasty in this context. In which fractures? Unstable fractures (A2.2, A2.3 and A3), especially in osteoporotic bone, which are the most difficult to reduce and fix, and in cases with associated osteoarthritis. For which patients? Arthroplasty should not be done in patients who have ASA≤3 due to greater blood loss and longer operative time. Since the postoperative Parker score often drops, arthroplasty should not be done in patients having a Parker score<6. What are the technical problems? Arthroplasty must be done by an experienced surgeon because of the lack of anatomical landmarks, although fracture fixation has its own demands (satisfactory reduction, appropriate length and position of cervicocephalic screw). What are the results and complications? Despite several comparative studies (randomized trials, meta-analysis and prospective studies), it is difficult to draw any conclusions. These studies show worse performance of dynamic hip screws relative to intramedullary nails. The complication and revision rates were higher for nails than arthroplasty, but not in every study, while the functional outcomes with nails (with or without immediate weightbearing) were better than those of arthroplasty beyond 6 months. What is the mortality rate? It was lower after nailing in a few studies but was mainly determined by the patient's comorbidities and preoperative Parker score. The best indication for arthroplasty may be self-sufficient patients over 70 years of age who have an unstable fracture with severe osteoporosis. Nevertheless, new studies should be done to compare arthroplasty to nailing with immediate return to weightbearing in patients having the same type of fracture, defined using 3D CT scan. Level of evidence: Expert advice.

Trans trochanteric approach with coronal osteotomy of the great trochanter: A new technique for extra-capsular trochanteric fracture patients treated by total hip arthroplasty (THA) in elderly.

Several surgical approaches could be used in hip arthroplasty or trauma surgery: anterior, anterolateral, lateral, posterior (with or without trochanterotomy), using or not an orthopedic reduction table. Subtrochanteric and extra-capsular trochanteric fractures (ECTF) are usually treated by internal fixation with mandatory restrictions on weight bearing. Specific complications have been widely described. Mechanical failures are particularly high in unstable fractures. Hip fractures are a major public health issue with a mortality rate of 12%-23% at 1 year. An alternative option is to treat ECTF by total hip arthroplasty (THA) to prevent decubitus complications, to help rapid recovery, and to permit immediate weight bearing as well as quick rehabilitation. However, specific risks of THA have to be considered such as dislocation or cardiovascular failure. The classical approach (anterior or posterior) requires the opening of the joint and capsule, weakening hip stability and the repair of the great trochanter is sometimes hazardous. For 15 years, we have been treating unstable ECTF by THA with cementless stem, dual mobility cup (DMC), greater trochanter (GT) reattachment, and a new surgical approach preserving capsule, going through the fracture and avoiding joint dislocation. Bombaci first described a similar approach in 2008; our trans fractural digastric approach (medial gluteus and lateral vastus) is different. A coronal GT osteotomy is performed when there is no coronal fracture line. It allows easy access to the femoral neck and acetabulum. The THA is implanted without femoral internal rotation to avoid extra bone fragment displacement. With pre-operative planning, cup implantation is easy and stem positioning is adjusted referring to the top of the GT after trial reduction and preoperative planning. The longitudinal osteotomy and trochanteric fracture are repaired with wires and the digastric incision is closed. This variant of Bombaci approach could be use routinely for hemiarthroplasty or THA in the cases of unstable ECTF. It reduces complications usually linked to this procedure. Blood loss, operating time, and pain are limited, allowing fast recovery in order to decrease morbidity and mortality.

Cementless dual-mobility cup in total hip arthroplasty revision.

PURPOSE: Dislocation is a frequent complication in total hip arthroplasty (THA) revision. Cup fixation is the second concern. In order to know outcomes at two years, we prospectively followed a continuous series of 78 patients to demonstrate that cementless dual-mobility cup (DMC) used in revision THA is safe as regards dislocation risk and bone fixation. METHOD: We enrolled 78 consecutive patients (79 cases) in a prospective study. Mean interval between index surgery and revision was 12.9 years. Mean age at revision was 75.5 years. Two types of cementless DMC were used: a standard DMC in 68 cases with low-grade bone defect (Paprosky grade 1 and 2), and a specific design reconstruction DMC in 11 cases with severe bone loss (Paprosky grade 3). RESULTS: At two years of follow-up, 68 patients were reviewed; four were lost to follow-up., and six patients were deceased. We identified three types of situations at risk:standard risk (33 cases), Paprosky grade 1 or 2; medium risk (37 cases), revision for recurrent instability (21), periprosthetic fractures (14) or severe loosening Paprosky grade 3 without femorotomy (2); high risk (nine cases), revision for severe loosening with a femorotomy. One (1.3%) patient dislocated her hip at one month without recurrence. Revision rate for dislocation was 0%; two (2.7%) early mechanical failures occurred. CONCLUSION: Considering outcomes of this series, cementless DMC can be suggested in THA revision surgery.