What are the indications for hip arthroplasty in trochanteric fractures?

Indications for Hip Arthroplasty in Trochanteric Fractures

Hip arthroplasty is strongly indicated for unstable intertrochanteric fractures in elderly patients with severe osteoporosis, ipsilateral femoral head necrosis, or pre-existing hip arthritis. 1

Primary Indications for Hip Arthroplasty in Trochanteric Fractures

Patient-Related Factors

• Severe osteoporosis that would prevent adequate fixation and full weight bearing with internal fixation methods 1, 2
• Pre-existing hip arthritis that would likely require future arthroplasty 2
• Elderly patients with limited physiological reserve who would benefit from immediate full weight bearing 2
• Frail patients may benefit from hemiarthroplasty due to shorter operative time and lower dislocation risk 3

Fracture-Related Factors

• Unstable intertrochanteric fractures (Evans classification stage 4 or 5) with significant comminution 4
• Fractures with greater trochanter bony fragments that require specialized fixation techniques 4
• Failed internal fixation of trochanteric fractures 5

Decision Algorithm for Hip Arthroplasty in Trochanteric Fractures

1. For stable intertrochanteric fractures:

   • Primary recommendation: Sliding hip screw or cephalomedullary device 3
   • Arthroplasty is generally not indicated 3

2. For unstable intertrochanteric fractures:

   • Primary recommendation: Cephalomedullary nail 3
   • Consider arthroplasty when:
     • Severe osteoporosis prevents adequate fixation 1
     • Pre-existing hip arthritis is present 2
     • Early mobilization and full weight bearing are critical 2

3. For subtrochanteric or reverse obliquity fractures:

   • Primary recommendation: Cephalomedullary device 3
   • Consider arthroplasty only in cases with:
     • Severe comminution preventing stable fixation 4
     • Pre-existing hip pathology 2

Type of Arthroplasty Selection

• Hemiarthroplasty is preferred in frail elderly patients due to:

  • Shorter operative time 3
  • Lower dislocation risk compared to total hip arthroplasty 2
  • Acceptable functional outcomes 3

• Total hip arthroplasty may be considered in:

  • More active, independent elderly patients 3
  • Patients with pre-existing hip arthritis 2
  • Cases where improved long-term function is a priority 3

Greater Trochanter Management During Arthroplasty

• Rigid fixation of the greater trochanter is critical for successful outcomes 1, 4
• Fixation options include:
  • Locking plates with cables for complex fracture patterns 1
  • Claw plate and cable systems for floating greater trochanters 5
  • Specialized greater trochanter reattachment devices 4

Clinical Pearls and Pitfalls

• Cemented femoral stems are strongly recommended in arthroplasty for hip fractures to improve outcomes 3
• Dislocation risk is significantly higher with total hip replacement compared to hemiarthroplasty, especially in unstable fractures 2
• Trochanteric nonunion remains a challenging complication with rates up to 31.4% even with modern fixation systems 6
• Wire breakage can occur in up to 28.6% of cases with cable-plate systems 6
• Mortality risk is influenced by age, gender, and comorbidities, but not significantly different between arthroplasty and internal fixation approaches when properly selected 2

Postoperative Considerations

• Early mobilization is a key advantage of arthroplasty in these fractures 4
• Weight bearing can typically be immediate after arthroplasty, unlike with internal fixation 2
• Rehabilitation protocols should be initiated early to maximize functional outcomes 4