Fracture of the femur during or after hip replacement has been the subject of numerous published reports. 4,11,22,23,26 However, there is no specific report describing fracture of just the greater trochanter in patients with hip replacement. The reports available describing all types of femur fractures state that fractures at the trochanteric level are benign and do not require stabilization. 4,11,22,26 Some surgeons have used the literature on trochanteric osteotomy and nonunion of the greater trochanter after osteotomy to decide treatment of greater trochanteric fractures. However, there may be distinct differences, such as the relative integrity of the blood supply, soft tissues, and lack of the use of a saw. A more analogous situation may be fracture of the greater trochanter in an otherwise normal femur.
There are a few reports of an isolated fracture of the greater trochanter recorded in the English literature starting just after radiographs became available. 2,19,20 The first series of cases was reported by Milch in 1939. 20 Milch’s report was written to answer questions of medical and legal significance. All of his eight patients healed perfectly without residual deformity. He concluded that healing may occur even without immobilization, and operative intervention usually was not necessary. Although Milch did not perform any procedure, he suggested that suture of the fragment might be necessary in cases of wide separation.
The largest reported series of isolated fracture of the greater trochanter was reported by Merlino and Nixon. 19 This study and that of Milch are quoted in textbooks. 12,17,27 They concluded that the prognosis for the fracture was good and that these fractures would heal no matter how, or even if, they were treated. Most patients returned to normal function in 2 months or less. 19,20 The purpose of the current study was to determine whether the presence of the hip prosthesis suggests a need for more aggressive treatment.
MATERIALS AND METHODS
Thirty patients presented with fracture of the greater trochanter after hip replacement. All patients were evaluated with radiographs, review of their medical records, including operative reports, and physical examination. The patients were followed up for a median of 40 months (range, 24–91 months) and form the basis of this study. The median age at the time of the hip replacement was 69 years (range, 48–84 years). There were 21 women and nine men.
Migration was determined by comparison with the contralateral greater trochanter or comparison of each film to the immediate postoperative radiograph. The trochanter may migrate and still achieve bony healing. Alternatively, the trochanter may stabilize in its position with or without migration by fibrous union.
All of the patients were shown their radiographs. The patients progressed along the usual rehabilitative protocol without additional restrictions and were encouraged about their rehabilitation potential.
There were four patients with previous surgery, including two previous open reductions and internal fixations for femoral neck fractures, a Chiari osteotomy, and an arthrotomy. Five patients had diabetes, and three patients had osteopenia by bone densitometry. Four patients had received systemic steroids, and four patients had received trochanteric injections.
The posterior approach had been used in 16 patients and the anterior, or anterolateral, in 14 patients. The operation was a hybrid total hip replacement in 13 patients and a cementless hip replacement in 10 patients. A cemented hemiarthroplasty was used in seven patients.
The diagnosis necessitating the hip replacement was degenerative joint disease in 13 patients and osteonecrosis in four patients. Developmental hip dysplasia was the diagnosis in three patients and acute femoral neck fracture in six patients. Failed femoral neck fracture fixation was the diagnosis in two patients, and rheumatoid arthritis and posttraumatic arthritis were the diagnoses in one patient.
The average time from the hip replacement to diagnosis of the fractured greater trochanter was 8 months. Six fractures were seen at the time of surgery, and five fractures were seen on the first postoperative radiograph. Seven were seen within the first 3 months after surgery, bringing the total seen within the first 90 days to 18 (60%). Five fractures were seen during the subsequent 9 months remaining in the first postoperative year. Seven fractures occurred more than 1 year later, as many as 60 months after the replacement operation.
The fractures that were seen at the time of surgery were treated by Dall-Miles (Howmedica Co, Rutherford, NJ) cables (one patient), wire (one patient), or suture using Number 5 Ethibond (Ethicon Co, Somerville, NJ) (four patients). None of the other patients were treated within the first year. No patients were treated with bracing, activity restriction, or restricted weightbearing. There were no dislocations in this series. Six of the 30 patients had a positive Trendelenburg sign at 1 year.
Four patients fell, and one patient stumbled but did not fall but did feel pain. Two patients felt pain after a twisting maneuver, and one patient experienced a pop while walking.
For 10 patients, the fracture remained nondisplaced or was displaced less than 1 cm. These patients had no symptoms. In 12 patients, the fracture was displaced 1 to 2 cm. Five of these patients also had no symptoms. In eight patients, the fracture was displaced by 2 cm or more. The maximum displacement was 3 cm (one patient). One of the patients with 2.5-cm displacement and two patients with displacements of at least 2 cm had no symptoms. One patient considered the hip with the fracture the stronger and better hip of the bilateral replacements (Fig 1). Only three patients had an increase in displacement more than 2 months after diagnosis of the fracture (3 months, 3 months, and 6 months). The displacement was medially and superiorly in each case (Fig 2). The maximum increase in displacement was 2 cm in one patient at 3 months.
Bony healing occurred in nine patients with as much as 2.5 cm displacement. In 15 patients, there was a nonunion. In six patients, it was not clear whether there was a bony union or a fibrous union.
In 11 patients, the fracture was comminuted. These fractures displaced and healed similarly to those that were not comminuted. Eight comminuted fractures healed without migration, and three fractures displaced after diagnosis.
Eighteen patients had no symptoms after the fracture. In 12 patients, there was a painful hip or a significant limp or both. Four patients reported an increase in pain or limp after being advised of their fracture. In six patients, the pain and the limp subsided during a period of several months. In the other six patients, the pain and limp persisted, and the displacement was 2 cm or greater. Three of these patients also had a clicking sensation. In these six patients, surgical repair of the trochanter was offered.
Three patients proceeded to surgery. The other three patients thought their symptoms were not severe enough to require surgery and continued to experience improvement. One operative repair resulted in healing and a good result. In another, healing did not occur, but the patient felt improvement, although the Dall-Miles cable grip system required removal before the patient felt improvement (Fig 3). The cables in this case were seen to be wearing grooves in the femur. In one patient, the trochanter healed, but the pain persisted. This patient was involved in a third party claim for a slip and fall.
Although fracture of the femur after hip replacement is not rare, relatively few greater trochanteric fractures are reported. 4,11,22,23,26 In cementless arthroplasty, cracks involving the calcar and lesser trochanter are common and generally have no significance. 18 This series suggests that fracture of the greater trochanter does not compromise the result in most instances. Like greater trochanter fractures in a normal femur, it is not clear if they require any specific treatment.
Soft tissues usually are intact in the case of trochanteric fractures. The blood supply in the trochanteric area is altered by hip replacement. 13 Dall-Miles cables have an additional deleterious effect on the blood supply and, if possible, should be avoided, particularly in cases of cementless hip replacement where osteointegration is desirable. Many fractures of the greater trochanter with hip replacement are comminuted and do not lend themselves to fixation with the Dall-Miles or wiring techniques. As the fracture heals, the comminution becomes less, and fixation later, if necessary, is more feasible.
Merlino and Nixon 19 concluded that the disruptive force for displacement comes from the external rotators, rather than the abductors. The trochanter moves medially and superiorly with fractures (Fig 2). Charnley 6 thought that in addition to the cephalad pull of the adductors, the gluteus minimus tended to displace the greater trochanter in an anterior and posterior shearing motion with flexion and extension of the hip. Inman et al 15,16 experimentally proved that the force of the abductors, specifically the gluteus medius and minimus, along with the tensor fascia femoris, and the passive resistance of the iliotibial tract were the principle factors in maintaining body equilibrium and preventing pelvic rotation. Inasmuch as these structures generally are not disturbed significantly in isolated greater trochanteric fractures, this explains why the gluteal limp and lurch and a positive Trendelenburg sign persisted in only six of 30 patients in the current series at 1 year.
Charnley popularized the long-held concept of trochanteric osteotomy. He routinely performed this procedure with his low-friction arthroplasty. 5,6 Charnley’s technique has reported nonunion rates of 7% to 32%. 7,21 Several authors have reported on their technique and results. 3,5,8,14
In the opinion of Charnley and others, fibrous union of the greater trochanter has little effect on the quality of the result of the hip replacement. 1,3,5,6,14,25 Charnley thought it was a trap to assume that pain after hip replacement is attributable to trochanteric nonunion. Other sources of pain should be investigated before recommending exploration or repair of an ununited trochanter.
However, there are indications for operative treatment of fractures of the greater trochanter after hip replacement surgery. Dislocation or instability are indications. A severe limp, weakness with pain, and a widely separated trochanter are other indications.
Several wiring and cable techniques also have been suggested. 1,3,8,10,14 Suture repair has been a common technique for treating greater trochanteric fracture. This usually has been described for acute injuries, and wire and cable techniques have been used extensively for osteotomies and nonunions. 1,3,8,10,14 Cables and the cable grip system are the strongest. 10,24 They also are the most bulky and require removal in many cases. 9 The cable system produces union in as many as 80% of cases. Wires and cables often break. 21,24 Ritter et al 25 suggested that wires offer no additional fixation after the first 6 weeks.
Fractures of the greater trochanter usually heal in 4 to 6 weeks. Migration or additional displacement usually does not occur after 2 months. Displacement of the greater trochanter may occur and usually is not important if it is 2 cm or less. 1,8,14,21 Most patients with displacement greater than 2 cm do clinically well, but some authors suggest that 3 cm of displacement will have a significant impairment of abductor function. 1,21
The patients in the current series were examined carefully to see if there were any preventative measures that should be adopted. There was an equal number of anterolateral compared with posterolateral approaches, suggesting the approach was not a significant variable. In addition, there was no type of stem or insertion tool that seemed to produce a fracture. Cemented and cementless cases were seen in the current series. No surgical misadventures were seen in any of the patients. Overall, no preventative strategies were identified.
In most instances, fracture of the greater trochanter does not compromise the final clinical result. In a few cases, the result is not acceptable. Late repair seems to be a satisfactory method of treating the few patients for whom the result is not acceptable.
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