Total hip arthroplasty for failed osteosynthesis of proximal femoral fractures: Clinical outcomes from a low- and middle-income country

Introduction: Total hip arthroplasty (THA) has a demonstrated utility in the surgical management of patients with proximal femoral fractures that fail internal fixation, with good outcomes reported from high-income countries. Given the lack of data from resource-limited settings, this work sought to report the clinical outcomes of THA for failed proximal femoral osteosynthesis from a low- and middle-income country (LMIC). Methods: The work was conducted and reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. A retrospective cohort study was carried out on all patients who underwent rescue THA for failed osteosynthesis of proximal femoral fractures, from January 2016 to June 2020, at a tertiary care center in Northern India. Primary study outcomes were functional outcomes as assessed by Harris Hip Score (HHS) at 1-year postoperatively and the frequency of perioperative complication as assessed by Clavien-Dindo-Sink Grading System. Results: Twenty-eight patients with mean age of 43.25 ± 10.5 years were included, with 18 males and 10 females. For their femur fracture stabilization, the most common method used had been dynamic hip screw (n = 16, 57.1%), followed by cannulated cancellous screw (n = 6, 21.5%), proximal femoral nail (n = 3, 10.7%), dynamic condylar screw (n = 2, 7.1%), and Schanz Screw (n = 1, 3.6%). Causes of failure had included cut-out of screw (n = 14, 50.0%), avascular necrosis (n = 8, 28.6%), back-out of screw (n = 3, 10.7%), non-union (n = 2, 7.1%), and secondary osteoarthritis (n = 1, 3.6%). THA was carried out after mean 26.64 ± 9.01 months after index procedure. HHS improved significantly from 39.71 ± 10.89 preoperatively to 79.54 ± 4.22 at 1-year follow-up (mean difference 39.82, 95% confidence interval 43.66-35.98, P < 0.001). Perioperative complications occurred in two patients of Clavien-Dindo-Sink Grade III and another of Grade II, with no mortality occurring by 1 year. Conclusions: In resource-limited settings like LMICs, THA may be a safe and efficacious surgical modality for failed osteosynthesis of proximal femoral fractures.