Management of Failed Fixation of Extracapsular Hip Fractures

Background Extracapsular hip fractures are routinely treated with fixation, and the majority heal without complication. The fixation fails in a minority of cases, typically either by 'cutting out' of the superior femoral head or through breakage of the metalwork following non-union. In such cases, if operative treatment is thought appropriate, there are two major treatment options: revision fixation of the fracture or joint replacement surgery. Methods Medline on OvidSP was searched using relevant medical-specific subject headings (MeSH) and keywords. The inclusion criteria were: study regarding management of failed extracapsular hip fracture fixation (not osteoarthritis alone, following such surgery), mean age >60 years, comparative study of joint replacement vs. revision fixation. The search returned 1053 results, of which two were relevant. Both studies were considered poor quality and neither study was randomised. Instead, outcomes from the current Hospital Trust were used instead through a prospectively generated trauma database. Results From the trauma database, 37 patients (mean age 81), of whom 21 had received cephalomedullary nails and the remainder dynamic hip screw (DHS), were identified. Fourteen patients underwent revision fixation (seven cephalomedullary nail; seven blade plate), while 23 underwent hip replacement (17 total hip replacement; six hemiarthroplasty). Although the difference did not reach statistical significance according to the log-rank test (p = 0.233), there is a trend towards lower re-operation rate following joint replacement, with the difference becoming apparent after over one year's follow-up. Conclusion  Despite the quality of evidence, the default operation for failed extracapsular hip fracture fixation should be joint replacement, based on a likely lower re-operation rate and permitting immediate full-weight-bearing. In selected instances, particularly younger patients and those who can partially-weight-bear, revision fixation would still be considered. As the number of hip fractures continues to increase both within the UK and worldwide, we can expect to see more patients with previous failed fixations, and more evidence regarding the advantages and disadvantages of different treatment strategies is required.