We report an intertrochanteric fracture in a patient who had undergone hip arthrodesis 30 years previously. A 53-year-old man was injured in a head-on car crash and was referred to our hospital for treatment. Plain radiographs showed an intertrochanteric fracture of the right proximal femur and deformity of the right hip joint. He had undergone hip arthrodesis surgery 30 years previously at another hospital. Computed tomography scan showed marked atrophy of the gluteus and iliopsoas muscles. He preferred undergoing total hip arthroplasty (THA) to internal fixation. THA was performed using the anterolateral approach with the patient in the supine position as he had undergone hip arthrodesis through the Smith–Petersen approach, and we were concerned about damaging the gluteus muscle and dislocation if we took the posterolateral approach. The femoral head was removed using curved chisels under fluoroscopy. A cementless THA (J Taper stem, Aquala polyethylene liner; Kyocera Medical Corporation, Osaka, Japan) was inserted and fixed appropriately. Full weight-bearing using a walking frame was allowed 2 weeks after the surgery. Six months after the operation, he was able to walk independently and had good range of movement of the hip joint but continued to have weakness in the abductor muscles. Very few cases of proximal femur fracture in a previously arthrodesed hip have been reported. Manzotti et al. reported a similar case but they performed open reduction and internal fixation. No previous reports in the literature describe THA for intertrochanteric fracture in an arthrodesed hip. The conversion of an arthrodesed hip to THA is technically challenging. It has a high risk of complications such as nerve injuries and hip instability. We were able to treat the patient successfully, but surgeons should carefully decide the treatment method depending on the case

Introduction. Fracture of the proximal femur frequently occur in children with osteogenesis imperfecta(O.I.) or fibrous dysplasia and may lead to progressive coxa vara and a “shepherds crook” deformity. In adults, these changes introduce difficulties that are not ordinarily encountered with routine osteosynthesis. There is minimal literature on this topic and the cases reported are few in number. Objective. The purpose of this case report was to describe a intertrochanteric fracture in a elderly woman with O.I. successfully treated by 115 degrees hip osteotomy plate and cannulated screws. Methods. We present a case of a 82-year-old female who was injured by falling. She had O.I. type â�£ A according to Sillence. Radiographs showed a intertrochanteric fracture of the femur with severe deformity. The femoral shaft had 25 degrees angular deformity and moderate rotation at the proximal. The angle between femoral neck and shaft was 105 degrees (severe coxa vara) and the proximal femur had a “shepherds crook” deformity (See Figure 1). She had presented 70 years previously ipsilateral fractures of the femur which had healed. These mal-united fracture involved anatomical changes such as medicalization of the femoral canal and intramedullary remodeling and sclerosis (See Figure 2). Recognizing the anatomical changes before and during surgery, standard dynamic hip screw or AO angled blade plate could not fit the femur and not provide stability. Using 115 degrees hip osteotomy plate and cannulated screws, osteosynthesis was performed (See Figure 3). Results. Twelve months postoperatively, the fracture united without complications and the patient felt comfortable and satisfied with gait. Conclusion. An unusual case was presented in which a 82-year-old woman was successfully treated with 115 degrees hip osteotomy plate and cannulated screws for a intertrochanteric fracture of the femur with osteogenesis imperfecta. Standard plate osteosynthesis was unlikely to provide sufficient stable fixation in this case

The first case was that of an 89-year-old woman with advanced dementia. After falling onto the left hip, she was admitted to the emergency room. Standard x-rays revealed an unstable intertrochanteric fracture. Closed reduction and internal fixation was performed using the long PFNA with a 105-mm helical blade, the second patient treated with this implant in our series. The operation was performed by an attending surgeon who was experienced with treatment of trochanteric fractures with intramedullary devices. Six weeks later the patient presented again with severe pain after she had fallen onto her left hip for a second time. Follow-up x-rays showed a perforation of the helical blade through the cortex of the femoral head after a shortening of the femoral neck by 2 cm. CCD angle was still 129 degrees, and there were no radiological signs of rotational displacement. The acetabular cartilage appeared intact. At her second operation, a replacement of the blade was performed using a shorter 95-mm implant. Postoperatively the patient was again mobilized under full weight bearing, and at 12 weeks follow-up, we found cut through again, we replaced hip with biopolar hemiarthroplasty

Purpose. To observe the follow-up results of standard cemented bipolar hemiarthroplasty with double loop and tension band wiring technique for treatment of unstable intertrochanteric hip fractures in elderly patients with osteoporosis. Materials and Methods. From May 2000 to May 2006, 86 cemented bipolar hemiarthroplasties were performed in elderly patients who had unstable intertrochanteric fractures. The mean age at the time of surgery was 82 years old. The average follow-up period were 5.3 years. We evaluated post-operative results after operation by clinical and radiographic methods. Results. Clinically, the final follow-up of Harrsi hip score was noted 79.2. The mean time needed for full weight bearing following surgery was 4.2 weeks and 82.5% of patients regained their preoperative ambulatory level. All patients achieved union in lesser trochanter fracuture, but great trochanter displacement were observed in 4 cases. There was one case of acetabular erosion. Post-operative superficial infections were found in 2 cases. 1 case with stem subsidence(<5 mm) showed satisfactory results without further subsidence in follow-ups. Conclusion. If we properly apply indications in technique with cemented bipolar hemiarthroplasty in the treatment of unstable intertrochanteric hip fracture in elderly, we will achieve systematic postoperative rehabilitation, pain control and handy nursing which is its one of merits

Introduction. Lag screw cut-out following fixation of unstable intertrochanteric fractures in osteoporotic bone remains an unsolved challenge. A novel new device is the X-Bolt which is an expanding type bolt that may offer superior fixation in osteoporotic bone compared to the standard DHS screw type device. Aims. The aim of this study was to test if there was a difference in cut-out using the X-Bolt implant compared with the standard DHS system. Methods. Specimens of low density surrogate bone (5pcf) were inserted into a simplified biomechanical fracture model and had either an X-Bolt or DHS implant inserted. There were eight samples in each group. The fracture model was tested with an incremental cyclical loading programme in a Material Test System. Displacement, cycle count and force exerted were continuously recorded until cut-out of the implant. Results. All of the specimens failed by varus collapse with superior cut-out and resulted in an automatic stop of the MTS. Specimens with the X-Bolt implant inserted lasted longer on cyclical count and withstood a greater force at cut-out compared with DHS specimens. The mean number of cycles to cutout in the DHS specimens was 4345 and in specimens with the X-Bolt inserted was 6898. The mean force at which cutout occurred in the DHS group was 1.025kN and in specimens with the X-Bolt inserted was 1.275kN. A statistically significant difference was observed with a P-value of 0.005 and a power of 87.2% with respect to cycle count and a P-value of 0.008 and power 84.8% with respect to force exerted at failure when comparing between the two groups. Conclusion. This study shows that the X-Bolt device demonstrated superior cut-out resistance and withstood greater loads compared to the DHS in low density surrogate bone in an unstable fracture model under cyclical axial loading

Failure of cephalomedullary fixation for proximal femur fractures is an uncommon event associated with significant morbidity to the patient and cost to the healthcare system. This institution changed nailing system from the PFNA (DePuy Synthes) to InterTan (Smith and Nephew) in February 2020. To assess for non-inferiority, a retrospective review was performed on 247 patients treated for unstable proximal femur fractures (AO 31 A2; A3). Patients were identified through manual review of fluoroscopic images. Stable fracture patterns were excluded (AO 31 A1). Pre/post operative imaging, demographic data, operative time and ASA scores assessed. Internal/external imaging and national joint registry data were reviewed for follow up. No significant difference was found in overall failure rate of PFNA vs InterTan (4.84% vs 3.23%; p = 0.748). Overall, short nails were more likely to fail by cut-out than long nails (7.5% vs 1.2%; p = 0.015). Nails which failed by varus cut-out had a higher tip/apex distance (TAD) (26.2mm vs 17.0mm; p < 0.001). Of concern, varus cut-out occurred in two InterTan nails with TAD of <25mm. The PFNA enjoyed a shorter operative time for both the short (59.1 vs 71.8 mins; p = 0.022) and long nails (98.8 vs 114.3 mins; p = 0.016) with no difference in 120-day survival rate. Overall failure rates of the PFNA and InterTan nailing systems were comparable. However, the failure rate of short nails in this study is concerning. Using long nails with a lag screw design for unstable intertrochanteric femoral fractures may reduce failure rates. Cumulative frequency analysis suggests stringent tip-apex distances of less than 21mm may reduce failure rates in lag-screw design cephulomedullary nails. This dataset suggests that unstable intertrochanteric fractures may be more reliably managed with a long cephalomedullary device

Aim. The most frequent mechanical failure in the osteosynthesis of intertrochanteric fractures is the cut-out. Fracture pattern, reduction quality, tip-apex distance or the position of the cervico-cephalic screw are some of the factors that have been associated with higher cut-out rates. To date, it has not been established whether underlying bacterial colonization or concomitant infection may be the cause of osteosynthesis failure in proximal femur fractures (PFF). The primary objective of this study is to assess the incidence of infection in patients with cut-out after PFF osteosynthesis. Method. Retrospective cohort study on patients with cut-out after PFF osteosynthesis with endomedullary nail, from January 2007 to December 2020. Demographic data of patients (such as sex, age, ASA), fracture characteristics (pattern, laterality, causal mechanism) and initial surgery parameters were collected (time from fall to intervention, duration of surgery, intraoperative complications). Radiographic parameters were also analyzed (tip-apex distance and Chang criteria). In all cut-out cases, 5 microbiological cultures and 1 anatomopathological sample were taken and the osteosynthesis material was sent for sonication. Fracture-related infection (FRI) was diagnosed based on Metsemakers et al (2018) and McNally et al (2020) diagnostic criteria. Results. Of the 67 cut-out cases, 16 (23.9%) presented clinical, analytical or microbiological criteria of infection. Of these sixteen patients, only in 3 of them the presence of an underlying infection was suspected preoperatively. A new osteosynthesis was performed in 24 cases (35.8%) and a conversion to arthroplasty in the remaining 43 (64.2%). A comparative analysis was performed between cases with and without infection. The groups were comparable in terms of demographic data and postoperative radiological data (using Chang criteria and tip-apex distance). Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs 22%, p = 0.014), higher rates of leukocytes counts (11.560 vs 7.890, p = 0.023) and time to surgery (5.88 vs 3.88 days, p = 0.072). Conclusions. One out of four osteosynthesis failure in PFF is due to underlying FRI and in almost 20% were not unsuspected before surgery. In PFF osteosynthesis failures, underlying infection should be taken into account as a possible etiological factor and thus a preoperative and intraoperative infection study should be always performed

Introduction. Osteoporotic intertrochanteric fracture (ITF) is frequent injuries affecting elderly, osteoporotic patients leading to significant morbidity and mortality. Successful prognosis including union and alignment is challenging even though initial successful reduction with internal fixation. Although many factors are related to the patient's final prognosis. Well reduction with stable fracture fixation is still the goal of treatment to improve the quality of life and decrease morbidity in patients with hip fractures, but this in turn depends on the type of fracture and bone quality. Poor bone quality is responsible for common complications, such as failure of fixation, varus collapse and lag screw cut-out, in elderly patients. Kim et al. found that the complication rate when using conventional DHS in unstable ITFs can be as high as 50% because of screw cut-out. We used the dynamic hip screws (DHS) strengthened by calcium phosphate cement (CPC) for treatment femoral intertrochanteric fracture and review the prognosis of our patients. Materials and Methods. From January of 2011 to January of 2014, 42 patients with femoral intertrochanteric fracture underwent surgery with DHS strengthened by CPC. Comparisons were made between the DHS plus CPC group with the other patients with only DHS used in our department. All patients were followed up for an average time of 14.8(6 to 24) months. X-ray was reviewed for the conditions of union and implant failure. Results. In DHS group, fixation failure happened in 3 case, delayed union and coax varus deformity in 2 cases. IN DHS plus CPC group, all fractures healed uneventfully, there is no non-union or malunion in this group. There is only 1 fixation cut-out and 1 secondary lag screw sliding was noted, however, union was still well over fracture site in this case, the patient had no clinical symptoms. Discussion. Residual bony defects present after DHS fixation in intertrochanteric fracture may lead to postoperative complications, including nonunion or implant failure. DHS strengthened by CPC is reliable fixation for old patients with intertrochanteric fracture, We demonstrated that augmentation of the bony defect with dynamic hip screw by reinforced calcium phosphate cement significantly improved the strength of osteoporotic bone, prevent screw loosening, and promote early healing of fracture. The patients can be decreased the risk of refracture and allow early weight bearing, especially in elderly patients with osteoporotic bone

Introduction. Failure of intertrochanteric fracture fixation often occurs in patients, who have poor bone quality, severe osteoporosis, or unstable fracture patterns. Hip arthroplasty is a good replacement procedure even though it involves technical issues such as implant removal, bone loss, poor bone quality, trochanteric nonunion and difficulty of surgical exposure. The purpose of this study is to evaluate the outcomes of total hip arthroplasty (THA) as the replacement for failed fixation of intertrochanteric fractures of the femur. Patients and Methods. 203 patients of failed intertrochanteric fractures between April 2009 and October 2014 were included in the study. All of them underwent total hip arthroplasty through direct lateral approach. 150 patients were male (73.8%) and 53 patients (26.1%) were female and the mean of age was 59.02±10.34 years old (range: 56–90 years). The indications of the failure were nail cut out in 174 (85.7%), non-union in 15 (7.3%), plate failure in 14 cases (6.8%). One patient underwent two-stage protocol due to infection. We evaluated the possible clinical and radiological complications and measured functional outcome with modified Harris hip score (MHHS). We used cementless cup in nearly all of patients (95.2%), cementless long stem in 88.1% of patients. Results. We followed patients for the mean time of 4.43±1.11 years (range 3–5 years). The mean (MHHS) was improved from 45.32±12.41 (range 40–49) to 89.37±7.41 (range 85–98) significantly (P=0.002). There was no infection, no reoperation, no dislocation, no nerve palsy, no avascular necrosis, no pulmonary embolism (PTE) and deep vein thrombosis (DVT). There was only one intra-operative fracture which was treated. All patients were ambulatory at the final follow up. There were no significant differences in hospital stay, operating time, and transfusion volume between the 2 groups (P>0.05). Conclusions. We showed in a large population study that functional outcome can be achieved by hip arthroplasty excellently in elderly patients with failed intertrochanteric fractures. Though technically demanding, properly performed hip arthroplasty can be a good replacement option for this patient group

Objective. Failures of internal fixation after intertrochanteric fractures pose great challenge to orthopaedic surgeons. Hip arthroplasty can be a remedy for such failures, however, the selection of femoral stem length is controversial. This study aims to report our experience of managing failed internal fixation after intertrochanteric fractures with standard femoral stem arthroplasty. Methods. A retrospective review of patients who were managed with hip arthroplasty for failed internal fixation after intertrochanteric fractures in the First Affiliated Hospital of Fujian Medical University, P.R. China between January 2001 to December 2013 was performed. Patients’ age, gender, pre- and postoperative Harris Hip Score (HHS), femoral stem types and surgical outcomes were traced and analyzed. Results. 14 patients were included. The average age at the time of internal fixation and hip arthroplasty was 74.6 years old (Range, 56–89) and 75.8 years old (Range, 58–90), respectively. The time duration between internal fixation and hip arthroplasty ranged from 3 to 26 months. 5 were total hip arthroplasty while 9 were hemiarthroplasty. 4 were implanted with long femoral stems while 10 with standard stems, including 4 cementless (SL-PLUS, Smith & Nephew)and 6 cemented stems. Standard femoral stems were defined as ones that are designed to be used in primary hip replacement, with the length of which ranging from 120 to 140mm. The distal ends of these stems did not exceed the distal screw hole levels of 2 cortical diameters. After a mean follow-up time of 6.4 years (Range, 1–13), 2 patients lost to follow-up and 2 died of non-surgically related diseases. For the 8 cases with standard stems, at the latest follow-up, no periprosthetic fractures or periprosthetic joint infections were observed. A total of 3 hip dislocations happened in 2 patients but were managed successfully with manipulative reduction followed by hip brace. The HHS score increased from an average of 35.6 preoperatively to 79.4 after surgery. Conclusions. Hip arthroplasty can be performed as revision for failed internal fixation after intertrochanteric fractures. Use of standard femoral stems is less invasive, reduces expenditure and can also achieve similar satisfactory clinical outcomes as long femoral stems. However, the long-term clinical outcomes required further follow-up

Vitamin D is vital for bone health because it assists in the absorption and utilisation of calcium. Vitamin D deficiency may predispose individuals to developing osteoporosis and subsequent osteoporotic fracture. There are various studies in elderly females with hip fractures correlating the low bone mineral density (BMD) with vitamin D levels. But very few studies have evaluated the influence on elderly males. Therefore this study was conducted. All male patients aged more than 50 years presenting to orthopaedic department, in JIPMER, Puducherry, with either fracture neck of femur or intertrochanteric fracture were included. Serum vitamin D level was assessed in them and BMD of both the hips was evaluated by DEXA scan. The vitamin D levels, T-scores, Z-scores were then analysed and correlated. Of the total 41 patients evaluated 21 (51%) had fracture neck of the femur and 20 (49%) patients had intertrochanteric fractures. We found that 11 (26.8%) patients had osteoporosis, 17 (41.5%) had osteopenia, and 13 (31.7%) had normal values. The mean value of total T-scores on fracture side was −1.55 and on no fracture side was −1.88. Among them 9 (22%) patients had vitamin D level <20 ng /mL, 15 (36%) had levels between 20ng–30ng/mL and 17 (41%) had >30ng/mL. Total T-score and Z-score on fracture side and no fracture side showed no correlation with vitamin D (p value >0.05) in these patients. We found significant osteoporosis in both neck and trochanteric regions on both fracture and no fracture sides, yet we had some patients with trochanteric fracture and some with neck fracture on only one side. In view of this other factors like mode of injury, velocity of injury, muscle wasting might have contributed significantly to the type of fracture and side involved. The BMD was found to be lower in patients with neck of femur fracture compared to intertrochanteric fracture, but no correlation was found between vitamin D and BMD scores at neck and trochanteric region. From this study it appears that there is no direct relationship between the vitamin D level and BMD in elderly males with hip fractures. It may emphasise that in male patients with hip fractures vitamin D may not have critical role in development of osteoporosis. The treatment of such patients with vitamin D supplements to prevent hip fractures is still debatable. However further studies in very large groups and controls may bring more light on this subject

Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for VTE prophylaxis with lower incidence of bleeding complication than the recommended 10 mg dose. Rivaroxaban is recommended to be given 6–8 hours after operation. However, many surgeons are hesitated to follow this guideline since it might increase post-operative blood loss and wound complication. Elderly patients, such as hip fracture patients, are generally at more risk of bleeding and wound complications. These patients may benefit from using the delayed and reduced-dose regimen. Methods. Since July 2011, all eligible hip fracture patients treated by single group of surgeons were given 5mg daily dose of rivaroxaban for VTE prophylaxis. Initial dose of rivaroxaban was given after drain had been removed (24–36 hours post-operatively) and continued for 14 days. Inclusion criteria are femoral neck fracture or intertrochanteric fracture in patients age 60 and over. Exclusion criteria are pathologic fracture, reoperation for failed fixation, chronic anticoagulant therapy, and allergy to rivaroxaban. Criteria by Aniwan and Rojnackarin were used for clinical diagnosis of DVT and PE. Suspected case of DVT and PE were sent for confirmation with Doppler U/S and Pulmonary Artery CT scan, respectively. All bleeding and wound complications were recorded. Numbers of blood transfusion were also recorded. Patients were followed for at least 6 weeks, all complications were recorded. Results. There were 79 hip fracture patients matching our criteria. They were composed of 54 femoral neck fractures and 25 intertrochanteric fractures. Mean age of patients was 76.3 years. All femoral neck fractures were treated with bipolar hemiarthroplasty and intertrochanteric fractures were treated with short cephalomedullary nail. Two patients (2.6%) were compatible with clinical criteria of DVT. However, Doppler ultrasound examinations do not demonstrate thrombus or intraluminal filling defect. There was no suspected case of PE. There was no major hemorrhagic wound complication requiring reoperation. Minor wound complications include 7 (8.9%) cases of prolong serous oozing and 1 (1.3%) superficial wound infection. Extrasurgical site bleeding includes 1 (1.3%) upper GI bleeding and 2 (2.5%) hematuria. None of the patients received more than 2 units of blood transfusion. Discussion and Conclusion. Delayed and reduced-dose regimen of rivaroxaban is effective for VTE prophylaxis in hip fracture patients. There is no major hemorrhagic wound complication. Nonetheless, extrasurgical site bleeding is frequent. Further randomized comparative study with larger number of patients should be performed to demonstrate whether the benefits of the modified regimen existed or not

Purpose. To compare the clinical and radiological results between internal fixation using the proximal femoral nail system and bipolar hemiarthroplasty in reverse oblique intertrochanteric hip fracture in elderly patients. Materials and Methods. From January 2005 to July 2012, we reviewed 53 patients who had been treated surgically for reverse oblique intertrochanteric fracture and been followed up on for a minimum of 2 years. The patients, all over 70 years old, were divided into two groups for retrospective evaluation: one group was treated with open reduction and internal fixation using the proximal femoral nail system (31 cases), and the other group was treated with bipolar hemiarthroplasty (22 cases). Results. Early ambulation postoperatively and less pain at postoperative three months were significantly superior in the bipolar hemiarthroplasty group. However, by 24 months postoperatively, the open reduction and internal fixation group had higher Harris scores and correspondingly less pain than the bipolar hemiarthroplasty group. There were no significant differences in union rate, duration of hospitalization or lateral wall fracture healing between the two groups. Four patients in the open reduction and internal fixation group underwent reoperation. Conclusions. In the treatment of intertrochanteric fracture of the reverse oblique type, if the patient's health and bone quality are good, open reduction and internal fixation is considered to be the better choice. However, in cases of severe communition of fracture and poor bone quality along with high risk of early reduction failure, bipolar hemiarthroplasty is an alternative offering advantages in terms of early ambulation, less pain at early stages, and lower risk of reoperation

Introduction. The reverse obliquity fractures of the proximal femur are anatomically and mechanically different from most intertrochanteric fractures. These fractures are complex and very difficult to treat. To evaluate the results of the treatment of reverse obliquity intertrochanteric fractures with cephalomedullary nails. Materials and Methods. Between 2005 and 2009, 1179 extracapsular fractures of the proximal femur were treated at our institution. Retrospective review of these x-rays identified 59 patients with reverse obliquity fracture pattern. We analysed our results of cephalomedullary nailing of these complex fractures and evaluated factors responsible for failure of fixation. Results. Of the 59 patients with reverse oblique fracture pattern, one patient was treated with DHS, and two other patients didn't have post-operative x-rays and therefore were excluded from the study. Of the remaining 56 patients treated with cephalomedullary nails, forty eight were treated with gamma nails, five with PFNA and three with ATN. There were 40 females and 16 males with median age of 81.3 years (17–103 years). Six of the fifty six (10.7%) failed to heal or had failure of fixation. The failure rate was four of forty eight for the gamma nails, one of five of the PFNA and one of three of ATN. One of thirty seven (2.7%) of anatomically reduced fractures and five of nineteen (26.3%) of non-anatomically reduced fractures had failure of treatment (p = 0.01). Three of thirteen (23.1%) with femoral medialisation and three of forty three (6.9%) without femoral medialisation had failure of treatment (p = 0.13). Four of forty four (9.1%) with avulsed lesser trochanter and two of twelve (16.6%) without avulsion had failure of treatment (p = 0.59). Three of thirty seven (8.1%) with tip apex distance (TAD) of less than twenty and three of nineteen (15.7%) with TAD more than twenty had failure of treatment (p = 0.65). Conclusion. Inspite of the recent advances in the methods of internal fixation available to surgeons, reverse obliquity intertrochanteric fractures continue to be a challenge for orthopaedic surgeons. In our study, although poor fracture reduction was observed to be the only significant factor associated with a high failure rate, femoral medialisation and tip apex distance of more than 20 had a high association with poor outcome

Introduction. In comminuted intertrochanteric fractures, various operative options have been introduced. The purpose of this study was to determine whether there were differences in clinical and radiologic outcomes among bipolar hemiarthroplasty(BH), compression hip screw(CHS) and proximal femur nail antirotatory(PFNA) in treating comminuted intertrochanteric fractures(AO type, A2(21, 22, 23)). Materials and Methods. We retrospectively evaluated total 150 patients(BH:50, CHS:50, PFNA: 50) who were operated due to intertrochanteric fractures from March 2010 to Dec 2012 and were older than 65 years at the time of surgery. We compared these three groups for radiologic and clinical outcomes at 12 months postoperatively, including Harris hip score, ability of ambulation(Koval stage), visual analogue scale and radiologic limb length discrepancy(shortening). Landmark and radiologic length was checked. –A: postoperative length. –A’: POD 1year. –B: immediate posteopative contralateral length(from hip center to distal tip of lesser trochanter). –B’: POD 1year contralateral length(from hip center to distal tip of lesser trochanter). –. Limb length(shortening) was adjusted considering difference of magnification. = {A × (B’/B)}− A’. Results. There was no statistical significance among three groups in clinical outcomes including Harris hip score, ability of ambulation(Koval stage), visual analogue scale. However, there was significant differences in radiologic limb discrepancy in plain radiographs at 12 months postoperatively.(radiologic shortening- BH: 2.3mm, PFNA: 3.0mm, CHS:5.1mm, p=0.000). Conclusions. There were no clinical differences among BH, PFNA and CHS in this study. However, notable differences were observed in limb length discrepancy according to selection of operative methods

Although the vast majority of fractures of the proximal femur will heal with well-done internal fixation, occasionally failure of fixation will occur. Having effective salvage options is important to restore function and minimise complications. In general, it is logical to separate salvage options into those for fractures of the femoral neck, and those for fractures of the intertrochanteric region. Additionally, patient age and remaining bone stock should be considered. Femoral neck fracture fixation failure salvage, young patients: All efforts are focused on preserving the native femoral neck. Valgus producing osteotomy is typically indicated, and can be successful even with small patches of AVN. Femoral neck fracture fixation failure salvage, older patients: Total hip arthroplasty is generally most predictable. Be prepared for very poor bone quality. Supplement uncemented acetabular component with multiple screws. Be prepared to cement femoral component, if necessary. Intertrochanteric fracture fixation failure salvage, young patients: Repeat internal fixation attempts with fixed angle devices (such as a 95-degree blade plate) and bone grafting generally preferred. Avoid varus of proximal fragment and target inferior femoral head bone. Intertrochanteric fracture fixation failure salvage, older patients: Total hip arthroplasty preferred. Long stems to bypass femoral shaft stress risers and “calcar replacement” stems may be necessary due to proximal bone defects. Trochanteric fixation must be stable. Results are generally good but trochanteric complaints are common

Although the vast majority of fractures of the proximal femur will heal with well-done internal fixation, occasionally failure of fixation will occur. Having effective salvage options is important to restore function and minimise complications. In general, it is logical to separate salvage options into those for fractures of the femoral neck, and those for fractures of the intertrochanteric region. Additionally, patient age and remaining bone stock should be considered. Femoral neck fracture fixation failure salvage, young patients: All efforts are focused on preserving the native femoral neck. Valgus producing osteotomy is typically indicated, and can be successful even with small patches of AVN. Femoral neck fracture fixation failure salvage, older patients: Total hip arthroplasty is generally most predictable. Be prepared for very poor bone quality. Supplement uncemented acetabular component with multiple screws. Be prepared to cement femoral component, if necessary. Intertrochanteric fracture fixation failure salvage, young patients: Repeat internal fixation attempts with fixed angle devices (such as a 95 degree blade plate) and bone grafting generally preferred. Avoid varus of proximal fragment and target inferior femoral head bone. Intertrochanteric fracture fixation failure salvage, older patients: Total hip arthroplasty preferred. Long stems to bypass femoral shaft stress risers and “calcar replacement” stems may be necessary due to proximal bone defects. Trochanteric fixation must be stable. Results are generally good but trochanteric complaints are common

Although the vast majority of fractures of the proximal femur will heal with well-done internal fixation, occasionally failure of fixation will occur. Having effective salvage options is important to restore function and minimize complications. In general, it is logical to separate salvage options into those for fractures of the femoral neck, and those for fractures of the intertrochanteric region. Additionally, patient age and remaining bone stock should be considered. Femoral neck fracture fixation failure salvage, young patients: All efforts are focused on preserving the native femoral neck. Valgus producing osteotomy is typically indicated, and can be successful even with small patches of AVN. Femoral neck fracture fixation failure salvage, older patients: Total hip arthroplasty is generally most predictable. Be prepared for very poor bone quality. Supplement uncemented acetabular component with multiple screws. Be prepared to cement femoral component if necessary. Intertrochanteric fracture fixation failure salvage, young patients: Repeat internal fixation attempts with fixed angle devices (such as a 95 degree blade plate) and bone grafting generally preferred. Avoid varus of proximal fragment and target inferior femoral head bone. Intertrochanteric fracture fixation failure salvage, older patients: Total hip arthroplasty preferred. Long stems to bypass femoral shaft stress risers and “calcar replacement” stems may be necessary due to proximal bone defects. Trochanteric fixation must be stable. Results are generally good but trochanteric complaints are common

Introduction. Failed operated intertrochanteric fractures (with screw cutout, joint penetration, varus collapse, nonunion, or femoral head avascular necrosis) pose treatment dilemmas. The ideal approach is re-osteosynthesis with autologous bone grafting. When the femoral head is unsalvageable, conversion to a prosthetic hip replacement is necessary. Materials/Methods. Thirty-seven patients with failed dynamic hip screw fixation (and unsalvageable femoral heads) were treated with cementless hip arthroplasty (13 underwent Bipolar Arthroplasty, 24 had Total Hip Arthroplasty) over a 5-year period (Dec 2005 to Nov 2010). Seven needed a modified trochanteric split, and the rest were managed by standard anterolateral approach. Abductor mechanism was reconstructed using strong nonabsorbable sutures (ethibond 5) or stainless steel wires. The calcar was partially reconstructed using remnant femoral head and cerclage wiring in a few cases. Results. Clinico-radiological assessment was done at three, six, 12 months and yearly thereafter over an average 36 months (range, three to 60 months). Stem loosening, lysis, subsidence and trochanteric union were studied. At last follow-up, one patient had died, and there were two instances each of stem subsidence and trochanteric nonunion. Clinical results using Harris hip scores were good or excellent. Conclusion. Management of nonsalvageable femoral heads after failed intertrochanteric fracture fixation is possible with cementless hip arthroplasty. Successful outcomes depend on functional abductor reconstruction, fracture and femoral shaft penetration prevention. Autograft, allograft or head/neck replacement components are necessary sometimes

Purpose. The purpose of this study is to report the results of the first 1000 cases hip arthroplasty using the Bencox. ®. hip stem, the first hip prosthesis developed and manufactured in Korea. Material & Method. This study reviewed 1000 cases retrospectively who underwent arthroplasty using Bencox. ®. hip system. The Bencox. ®. hip stem is the first hip prosthesis developed and manufactured in Korea. This stem have a double-tapered, wedge shape figure with a rectangular-shaped cross-section and specially designed neck shape, which is design to achieve normal stress pattern of the proximal femur and to increase initial stability and to increase range of motion. Surface is treated with MAO (Micro Arc Oxidation) coating. From the first arthroplasty with this system in September 2006, sequentially 1000 arthroplasties were performed by single surgeon until the July 2014. This material included 439 men and 561 female. Average age of patients was 65 year old. Follow up period was average 72.1 month (minimum 34 months to maximum 120 months). 1000 cases consisted of 569 hips in patients with femoral neck or intertrochanteric fracture or subtrochanteric fracture (fracture group), 155 hips in osteoarthritis, 192 hips in patients with osteonecrosis of the femoral head (arthritis group), 84 hips in revision surgery (revision group). Revision cases consisted of 58 hips with aseptic loosening and 26 hips with loosening due to infection sequelae. They were underwent hip arthroplasty using a Bencox. ®. hip stem in combination with Bencox. ®. bipolar cup and Bencox. ®. acetabular cup. Patients in the fracture group usually underwent bipolar hip arthroplasty, and those in the arthritis group and revision group underwent total hip arthroplasty. They were reviewed by medical records, clinically and radiologically. Results. During the follow-up period, there were no cases of revision of the femoral stem. Radiographically, there were no cases of radiolucent line except very proximal part of the stem endosteal bone ongrowth was found in most cases. Postoperative complications such as stem loosening, infection, dislocation, and ceramic breakage were not noted. But periprosthetic fracture was encountered in 7 hips due to slip down. They were treated by open reduction and internal fixation with plate and cables. There were no cases of failure of these treatments. Conclusion. Clinical and radiographic evaluations of hip arthroplasty using the Bencox. ®. hip system showed excellent outcomes with average 72.1 month follow-up in 1000 case