Hip arthroplasty after intramedullary hip screw fixation: a perioperative evaluation.

OBJECTIVES: Although literature exists regarding surgery after hip screw/side plate devices, we are unaware of any reports of hip arthroplasty after intramedullary devices. DESIGN: This is a retrospectively reviewed case series. SETTING: Tertiary care medical center. PATIENTS/PARTICIPANTS: A consecutive unselected series. INTERVENTION: Hip arthroplasty surgery after failed hip fracture fixation surgery using an intramedullary nail device. MAIN OUTCOME MEASUREMENTS: Twenty cases of conversion surgery after intramedullary fixation for hip fractures were retrospectively reviewed. RESULTS: The indications for hip arthroplasty were nonunion with failed fixation in 15, avascular necrosis with secondary hip arthritis in three, and progression of hip arthritis in four. Average operative time and blood loss were 166 minutes and 621 mL, respectively. Of note, nine of 20 patients ultimately developed a nonunion of the greater trochanter after hip arthroplasty. In only one of these cases of nonunion was the greater trochanter refractured intraoperatively and this as part of a trochanteric osteotomy. CONCLUSION: Patients undergoing hip arthroplasty after failed hip fracture fixation using an intramedullary nail device are at high risk for greater trochanteric fracture and nonunion. The average operative time and blood loss for these procedures were greater than reported for primary but less than for revision arthroplasty. We now consider treating these cases with a trochanteric plate with or without a trochanteric slide osteotomy to minimize fracture of the remaining, damaged trochanteric bone. LEVEL OF EVIDENCE: Therapeutic Level IV. See page 128 for a complete description of levels of evidence.