الفهرس 
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Abstract
Failed treatment of intertrochanteric fractures typically leads to profound functional disability and pain. The two main treatment options for patients who have an intertrochanteric hip fracture that has failed to respond to previous treatment are revision of internal fixation or salvage treatment with a hip arthroplasty. Most surgeons prefer total hip arthroplasty as a salvage procedure in elderly patients these fractures are often associated poor bone quality, a damaged femoral head due to previous internal fixation, damaged articular cartilage, or limb-shortening. Also the arthroplasty allows early mobilization and pain relief needed in this age group.
This study included patients with non united trochanteric fracture and failed metalwork studied prospectively. Patients were covered over the period from 2012 to 2014 with minimum follow up of 6 monthes.
Failure of metal work is defined in this study as either penetration of the scews into the hip joint, cutting through of the lag screws into the femoral head, backing out of screws away from the plate or faigue breakage of the screws or side plate.
The cause of failure in some patients was deep infection with or without presence of natively draining sinus. In planning the strategy of management several factors were taken into consederation . First, is infection supercoded the site of non union or not. Second, was there arthritis or damage to the femoral head or acetabular cartilage.The third was the presence of adequate bone stock within the head of femur that allows for refixation of the fracture and finally, age of the patient and bone quality of proximal femur Based of the previous factors 22 patients were included when athroplasty was performed in 20 patients and revision of fixation was achieved in only 2 patients
All patients were evaluated at 2, 6, 12 weeks, 6 months and yearly thereafter. The presence of pain at rest as well as on ambulation and the range of motion of the hip were measured. The Harris hip score (HHS) was evaluated preoperatively as well as at 3 and 12 months then yearly with average 6 monthes. The mean age of this group of patients was 48.9 years (range 26–74 years). The mean duration between the initial fracture fixation and presentation was 16 months (range 8–36 months).
Two-tailed Student’s t test was used for statistical analysis. Statistical significance was set at 95 % confidence with P < 0.05.
We got bone healing in the two patients with revision fixation after six months.The average score in Harris for them was 96 .
Ten patients who had infected nonunion trochanteric fracture because of infection treated with a staged protocol for total hip arthroplasty. The infecting organism was identified in patients by the preoperative aspiration in 7 cases, or specimens collected during the first stage in 3 patients. Methicillin resistant staph aureus (MRSA) was the most commonly found organism, also other organisms were found like E. coli and Klebsiella .
The average duration between first and second stages was 10 weeks . All patients were given antibiotics for 6 weeks according to the culture and sensitivity results. The staged protocol for THR as a salvage for infected nonunion was successful in eradicating infection on the follow up they completed their treatment . None of the patients had recurrence of infection or further revision surgery The Harris hip score of the patients had improved significantly from 29 ± 6 (mean ± STD) preoperatively to 85 ± 9 postoperatively. Leg length discrepancy ranged from(0-1 cm).None of the patients have had or are waiting revision.
On the basis of this study, total hip arthroplasty seems to be a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture in (elderly patients, initial fracture pattern, poor bone quality) . However, this procedure performed as a revision of an intertrochanteric fracture is technically more difficult than routine primary total hip arthroplasty with a longer operative time and an increased incidence of postoperative complications. Despite the technical challenges, in our series there is few serious orthopaedic complications and the clinical outcomes were acceptable.