What is the treatment for an impacted fracture of the cortices of the lateral aspect of the greater trochanter in a patient with a history of total hip replacement (THR)?

Treatment of Impacted Greater Trochanter Fracture Post-THR

For an impacted fracture of the lateral cortex of the greater trochanter in a patient with prior total hip replacement, conservative management with protected weight-bearing for 6-12 weeks and avoidance of active abduction is the recommended treatment approach, as these fractures are typically stable and heal without operative intervention. 1, 2

Initial Diagnostic Approach

Radiographs are the first-line imaging modality for evaluating periprosthetic fractures and greater trochanter pathology in patients with symptomatic hip prostheses 3. However, radiographs have important limitations:

• Radiographs help assess periprosthetic fractures, greater trochanter avulsions, and heterotopic ossification 3
• If radiographs are negative or equivocal but clinical suspicion remains high, CT or MRI should be obtained for fracture detection and characterization 3
• MRI is particularly valuable as seemingly isolated greater trochanter fractures on radiography frequently have occult intertrochanteric extension 3

Conservative Management Protocol (First-Line Treatment)

The vast majority of greater trochanter fractures after THR should be managed non-operatively, based on multiple studies demonstrating excellent outcomes 1, 2, 4:

Treatment Components:

• Protected weight-bearing for 6-12 weeks 1
• Strict avoidance of active hip abduction until union is complete or pain resolves 1
• Serial radiographic monitoring to assess for displacement and healing 1, 2

Expected Outcomes with Conservative Treatment:

• 90% of fractures remain non-displaced (displacement ≤2.5 cm) 2
• Only 10% show progressive displacement beyond 2 months after recognition 2
• 60% of patients remain asymptomatic throughout healing 2
• Bone healing or stable fibrous union occurs in all cases when properly managed 1
• No increased dislocation risk with conservative management 2

Key Clinical Point:

Even when occult intertrochanteric extension is present on MRI, conservative treatment remains effective and does not lead to complete fracture displacement, regardless of the percentage of extension into the intertrochanteric area 4

Indications for Surgical Intervention

Operative repair should be reserved for the minority of cases meeting specific criteria 1, 2:

Surgical Indications:

• Displacement >2 cm with persistent pain or significant limp at 1 year 2
• Hip instability or dislocation (displacement ≥38 mm) 1
• Associated osteolytic lesions requiring concurrent acetabular revision 5
• Failure of conservative management with progressive symptoms 2

Surgical Technique When Required:

• Wire or cable fixation with morselized allogeneic bone graft for fractures with osteolysis 5
• Postoperative abduction orthosis and protected weight-bearing for ≥3 months 5
• Average healing time of 5 months with surgical treatment 5

Critical Management Pitfalls to Avoid

Do not rush to surgical intervention for minimally displaced or asymptomatic fractures, as 90% remain stable with conservative care 2. The natural history shows:

• Displacement direction is medially and superiorly toward the femoral head, not directly superior as in trochanteric osteotomy 2
• Progressive improvement occurs over several months even in symptomatic cases 2
• Pain and limp improve spontaneously in 50% of symptomatic patients 2

Do not assume all greater trochanter fractures are isolated - obtain advanced imaging (MRI preferred) to rule out occult intertrochanteric extension, which changes prognostic counseling but not necessarily treatment 3, 4

Follow-Up Protocol

• Regular clinical assessment for hip pain, instability, range of motion, and Trendelenburg gait 1
• Serial radiographs (AP and lateral views) to evaluate fracture migration and bone healing 1
• Average follow-up duration of 40 months demonstrates sustained good outcomes with conservative management 1
• Functional outcomes are excellent, with Harris hip scores averaging 86-91 points at final follow-up 6, 5