Authors: David Jacofsky, M.D.; Heyu Zhang, M.D.; Franklin Sim, M.D.; George Haidukewych, M.D.
Title: Hip Arthroplasty for Salvage of Failed Internal Fixation of Malignant Pathologic Proximal Femoral Fractures
Address: Mayo Clinic 200 First Street SW, Rochester, MN
Purpose: The treatment of pathologic fractures of the proximal femur resulting from neoplasm remains controversial. The purpose of this study was to evaluate the results and complications of a large consecutive series of patients treated with hip arthroplasty to salvage failed internal fixation of pathological fractures of the proximal femur secondary to a malignant neoplasm.
Methods: Between 1980 and 2000, 42 patients (20 females and 22 males) with a mean age of 63 years (range 20-84) were treated at our Level 1 trauma center with hip arthroplasty to salvage failed internal fixation (nonunion, tumor progression, or hardware failure) of a pathologic proximal femur fracture. Total hip arthroplasty was performed in 16 and bipolar hemiarthroplasty in 26 patients. A modular proximal femoral replacement was required in 15 patients due to massive bone loss. Patients were followed prospectively by a total joint registry. Clinical and radiographic data were retrospectively reviewed and results and complications analyzed. Implant survivorship was calculated using the Kaplan-Meier method with end points of revision for any reason and revision for aseptic loosening or mechanical failure (radiographic failure). Six patients died within two years and none were lost to follow-up. Patients were followed to revision, death, or a minimum of two years with a mean clinical follow-up of 5.8 years (15 days to 20 years).
Results: At follow-up 27 patients had died from their disease, and 15 were alive. Four hips required reoperation, (9.5%) all for infection. Three were resected and one underwent a single stage exchange arthroplasty. Most recent radiographs demonstrated probable femoral component loosening in only one patient. No acetabular component loosening or erosion was noted. Six of 42 patients (14%) had a postoperative medical complication. There was one dislocation. The Harris Hip score improved from a mean of 42 preoperatively to a mean of 83 postoperatively. Implant survivorship free of revision for any reason at five years was 89.6% (65%-96%) and free of revision for aseptic failure or radiographic failure was 97.1% (64%-99%).
Discussion: Hip arthroplasty is an effective method of salvage of failed internal fixation of pathologic fractures of the proximal femur. There were surprisingly few postoperative medical complications. The most concerning finding was the rate of deep infection, nearly 10% in this series. This was the main mechanism of failure in this patient population, despite the use of intravenous perioperative antibiotics in all patients. Patients should be counseled and surgeons cognizant of the fact that although functional improvement is predictable, infection rates remain concerning after such complex reconstructions.
Significance: There exists no previous series evaluating the outcome of hip arthroplasty for salvage of failed internal fixation of malignant pathologic proximal femoral fractures. The infection rate in this group is extremely high.