import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: 10-20mm posterior to posterior hip capsule, exits pelvis beneath piriformis **Protection**: Early identification before capsular dissection, maintain gentle retraction, avoid excessive internal rotation during femoral preparation **Location**: 15-25mm medial to anterior hip capsule, travels beneath iliopsoas **Protection**: Medial Hohmann retractor placement under direct vision, avoid aggressive medial retraction during acetabular preparation **Location**: Exits sciatic notch 5cm superior to piriformis insertion, courses between gluteus medius and minimus **Protection**: Limit proximal dissection to less than 5cm above greater trochanter, avoid detaching anterior third of gluteus medius **Location**: 1-3cm medial to ASIS, superficial to sartorius origin **Protection**: Incision planned 2-3cm lateral to ASIS, identify and preserve during fascia lata incision **Location**: First perforator 5-7cm distal to lesser trochanter, subsequent perforators every 3-4cm **Protection**: Controlled reaming speeds, cautery/bone wax for bleeding, avoid aggressive fenestration near perforators ## Primary Indications ### Nonunion/Malunion - **Femoral neck nonunion** following cannulated screw fixation (greater than 6 months post-injury) - **Intertrochanteric nonunion** after DHS/cephalomedullary nail with persistent pain and functional limitation - **Malunion with varus deformity** causing mechanical symptoms and secondary acetabular wear ### Avascular Necrosis - **Segmental collapse** of femoral head following fracture fixation (Ficat Stage 3-4) - **Subchondral insufficiency fracture** with progressive pain despite conservative management - **Combined femoral head AVN and acetabular cartilage loss** requiring dual-component arthroplasty ### Hardware Failure - **Implant cut-out** with femoral head penetration requiring salvage arthroplasty - **Plate/screw breakage** with loss of fixation and progressive deformity - **Subsidence** of cephalomedullary nail with persistent proximal thigh pain ### Post-Traumatic Arthritis - **Progressive joint space narrowing** following periarticular hip fracture - **Intra-articular malunion** causing impingement and accelerated cartilage wear - **Combined bone loss** (acetabular and femoral) requiring reconstruction ## Contraindications ### Absolute - Active sepsis (elevated inflammatory markers, positive cultures) - Medical instability precluding elective arthroplasty - Irreversible sciatic nerve palsy with non-functional limb ### Relative - Recent infection (less than 6 weeks post-treatment) - Severe osteoporosis (T-score less than -4.0) with poor bone quality - Significant abductor deficiency without reconstructable soft tissues - Patient factors: poor compliance, active substance abuse, untreated psychiatric illness ## Pre-operative Planning ### Imaging Assessment - **AP pelvis and cross-table lateral**: Assess bone stock, hardware position, leg length discrepancy - **Judet views**: Acetabular columns, wall defects if acetabular component needed - **Full-length femur AP/lateral**: Entire nail if present, distal locking screws, femoral bow - **CT scan**: Complex bone loss, 3D reconstruction for templating, hardware assessment ### Templating Strategy - **Magnification correction**: Calibrate with known implant size or marker - **Account for bone loss**: Medial calcar defects, greater trochanter position, acetabular floor - **Component selection**: Long-stem revision components, dual mobility cup, constraint options - **Offset/length restoration**: Compare to contralateral hip, document planned leg length change ### Hardware Inventory - **Extraction instruments**: Screw extractors, conical extractors, plate removal set - **Nail removal tools**: Universal extraction device, slap hammer, femoral hooks - **Fenestration equipment**: High-speed burr, trephines (8-12mm), cerclage cables - **Revision implants**: Modular stems, extended offset options, dual mobility bearings ## Regional Anatomy ### Posterior Approach Structures - **Sciatic nerve**: Exits pelvis beneath piriformis, 10-20mm posterior to posterior capsule - **Inferior gluteal artery**: Travels with sciatic nerve, 15-20mm posterior to capsule - **Short external rotators**: Piriformis, superior/inferior gemelli, obturator internus, quadratus femoris - **Gluteus maximus**: Split parallel to fibers, avoid superior gluteal nerve injury ### Anterior Approach Structures - **Femoral nerve**: Lateral to femoral artery, 15mm from capsule, beneath iliopsoas - **Lateral femoral cutaneous nerve**: 1-3cm medial to ASIS, crosses sartorius origin - **Ascending branch lateral circumflex**: Between rectus femoris and vastus lateralis - **Tensor fascia lata/gluteus medius interval**: Internervous plane (superior gluteal nerve to both) ### Bone Anatomy Considerations - **Calcar femorale**: Medial cortical buttress, often deficient after fracture/hardware - **Greater trochanter**: Lateral tension band, may be fragmented or malpositioned - **Lesser trochanter**: Posteromedial landmark, psoas insertion, defines proximal femur rotation - **Femoral canal**: May be widened by nail, screw holes create stress risers ### Vascular Anatomy - **Medial femoral circumflex artery**: Primary blood supply to femoral head (already compromised) - **Lateral femoral circumflex artery**: Ascending branch in anterior interval, must preserve - **Perforating arteries**: Branch from profunda, enter posterior femur at 5-7cm intervals - **Superior gluteal artery**: Exits above piriformis, at risk with excessive proximal dissection ## Scar Tissue Considerations - **Previous capsular disruption**: Scarring obliterates normal planes, increases bleeding - **Muscle atrophy**: Gluteus medius/minimus weakness from disuse, affects stability - **Heterotopic bone**: Increased risk after fracture, may limit exposure - **Nerve tethering**: Sciatic nerve may be scarred to posterior tissues, requires careful dissection ## Patient Positioning **Lateral Decubitus (Posterior Approach)** - Well-padded lateral positioning device - Dependent leg flexed 90-90 degrees - Operative leg draped free - Anterior and posterior pelvic posts to prevent rotation - Check prominence of hardware beneath skin **Supine (Anterior Approach)** - Bump beneath ipsilateral buttock (10-15 degrees tilt) - Standard table or fracture table with traction capability - Prepare from iliac crest to knee - Image intensifier available if needed for hardware removal ## Detailed Operative Steps ### Step 1: Incision and Superficial Dissection **Incorporate previous surgical scars** where possible to preserve blood supply **Technical Tip**: Plan incision to avoid parallel scars less than 6cm apart. If previous anterior incision exists and using posterior approach, ensure adequate skin bridge (minimum 8cm) or use same incision with skin bridge technique. - Parallel incisions less than 6cm apart compromise perfusion - Undermining skin flaps increases devascularization - Revision incisions should follow previous if within 45 degrees of ideal line ### Step 2: Deep Dissection to Joint Capsule **Posterior approach**: Split gluteus maximus in line with fibers, identify short external rotators **Anterior approach**: Develop TFL/rectus interval, protect ascending branch LFCA **Technical Tip**: Palpate greater trochanter to assess position - may be displaced superiorly (shortening) or detached. Plan fixation strategy before proceeding if trochanteric osteotomy needed. - **Posterior**: Identify sciatic nerve before capsular dissection - may be tethered in scar - **Anterior**: Identify femoral nerve lateral to artery, decompress iliopsoas if tense - Place marking suture around nerve if anatomy distorted ### Step 3: Capsular Exposure and Hardware Visualization Tag short external rotators before release, expose posterior capsule and hardware **Technical Tip**: Hardware often visible through attenuated capsule. Assess implant integrity before removal - bent/broken screws require alternative extraction techniques. - Fluoroscopy available if hardware configuration unclear - Additional incisions may be needed for proximal nail screws - Prepare for extended operative time if complex extraction required ### Step 4: Hardware Removal - Screws/DHS **Cannulated screws**: Remove guide wires first, then unscrew under fluoroscopy if threads stripped **DHS**: Remove lag screw first, then plate screws from distal to proximal, extract plate **Technical Tip**: If screw head stripped, use conical extraction device. Drill 2-3mm hole adjacent to screw, apply extractor, gentle counter-clockwise torque. If fails, window femur and push screw out. - Screw breakage leaves fragment in situ - may need to fenestrate around fragment - Over-torquing causes femoral fracture - assess bone quality before aggressive extraction - Bone loss around screws creates defects requiring grafting ### Step 5: Hardware Removal - Cephalomedullary Nail Identify proximal locking screws, remove before extracting nail body **If nail extractable via proximal entry**: Attach universal extraction device, gentle slap-hammer technique **If nail incarcerated**: Plan lateral femoral window 5-7cm distal to tip, push nail proximally **Technical Tip**: Make femoral window 3x nail diameter, use trephines to preserve bone stock. Save cortical window as structural graft for acetabular/calcar defects. - Perforating vessels at posterior femur - controlled cautery, bone wax - Create stress riser requiring long-stem bypass - Preserve anterior cortex to maintain femoral bow and rotation ### Step 6: Femoral Head Removal If head attached: capsulotomy, dislocate hip (posterior: flex, adduct, internal rotate) If head necrotic: may fragment during dislocation, remove piecemeal **Technical Tip**: If unable to dislocate due to scarring, perform extended capsulectomy. Release gluteus minimus attachment to anterior capsule, divide capsule circumferentially. Trochanteric osteotomy if still cannot dislocate safely. - Avoid excessive force - proximal femur fracture risk in osteoporotic bone - Sciatic nerve palsy from forceful internal rotation - Femoral neck fracture during dislocation may alter stem selection ### Step 7: Acetabular Assessment and Preparation Assess native acetabulum: cartilage wear, subchondral cysts, protrusion **If previous hemiarthroplasty**: Remove femoral head component, assess acetabular bone loss **Technical Tip**: Use hemisphere reamers 2mm larger than templated cup size. Ream until subchondral bleeding (dot sign). If medial wall deficient, use bulk allograft or augments to restore floor level. - Intrapelvic protrusion risk if medial wall thin - assess wall thickness before reaming - Superior gluteal vessels at anterosuperior quadrant - Obturator vessels at inferomedial quadrant - Sciatic nerve 10mm posterior to posterior wall ### Step 8: Acetabular Component Insertion **Standard uncemented cup** if good bone stock (press-fit, 1-2mm underream) **Dual mobility cup** preferred in conversion cases (reduces dislocation risk from 15-20% to less than 5%) **Technical Tip**: Target 40 degrees abduction, 15-20 degrees anteversion. Use transverse acetabular ligament (TAL) as landmark - points to native floor. Dual mobility outer metal shell impacted to line-to-line fit. - Excessive anteversion (greater than 25 degrees) causes posterior instability in flexion - Insufficient anteversion (less than 10 degrees) risks posterior dislocation in extension - Vertical cup (greater than 45 degrees abduction) increases edge-loading and wear ### Step 9: Femoral Bone Stock Assessment Assess defects using Paprosky classification: - **Type I**: Minimal metaphyseal bone loss, intact diaphysis - **Type II**: Extensive metaphyseal loss, intact diaphysis (most common in conversion) - **Type III**: Metaphyseal and proximal diaphyseal loss - **Type IV**: Extensive diaphyseal loss **Technical Tip**: Measure distances: calcar height, greater trochanter position, canal diameter at isthmus. Compare to templating. Most conversions require Type II reconstruction with calcar-replacing stem. ### Step 10: Femoral Canal Preparation **Screw hole management**: Graft holes less than 8mm with morselized bone. Large defects (greater than 10mm) require structural graft or impaction technique. **Reaming strategy**: Hand reamers initially to assess canal, powered reamers if good bone. Under-ream 0.5-1mm for press-fit stems. **Technical Tip**: Start with flexible reamers to follow canal. If encountering obstruction (retained screw fragment, heterotopic bone), use rigid straight reamers or hand instruments. Verify reamer depth - should pass 2cm beyond planned stem tip. - Cortical perforation from eccentric reaming or canal deformity - Femoral fracture in osteoporotic bone - use hand reamers if T-score less than -3.0 - Thermal necrosis from high-speed reaming - irrigate continuously ### Step 11: Femoral Component Selection **Primary stem possible if**: - Intact medial calcar (Dorr Type A or B bone) - Minimal metaphyseal bone loss - Good proximal bone quality - Screw holes bypassed by 2 cortical diameters **Revision stem required if**: - Calcar deficient (requires calcar-replacing design) - Multiple screw holes (requires long stem to bypass stress risers) - Canal capacious (requires modular taper-fit or cemented stem) - Proximal femur fracture during procedure **Technical Tip**: Calcar-replacing stems (e.g., Corail revision, Wagner SL Revision) restore medial offset and bypass calcar defects. Long stems (150-200mm) achieve fixation 2 cortical diameters below lowest defect. Modular components allow independent version/offset adjustment. ### Step 12: Stem Insertion and Fixation **Cementless technique**: Broach sequentially, confirm rotational stability with trials, final component 1 size larger than last broach **Cemented technique**: Pulse-lavage, dry canal, retrograde cement gun, pressurization, stem insertion before cement hardening **Technical Tip**: Restore femoral anteversion (10-15 degrees) using lesser trochanter as guide. Correct version prevents impingement and reduces dislocation risk. If uncertain, aim for combined anteversion 25-40 degrees (acetabular + femoral). - Intraoperative fracture (20-30% in revision cases) - manage with cerclage cables, may need longer stem - Stem subsidence if inadequate distal fit - verify scratch-fit at trial stage - Leg length discrepancy - measure from heel to ASIS, compare to contralateral side ### Step 13: Greater Trochanter Management If trochanteric osteotomy performed: reduce fragment, tension-band wire or cable-plate fixation If trochanter fragmented/detached: advance and reattach with sutures to stem, cables around prosthesis **Technical Tip**: Use dual cables (proximal and distal) for trochanteric fixation. Pre-drill holes in trochanter fragment before passing cables. Tension with hip in extension to restore abductor tension. Verify fragment position on fluoroscopy before final tensioning. - Occurs in 10-20% of cases despite fixation - Higher risk if abductors weak pre-operatively - Requires abduction brace for 6 weeks post-op if fixation tenuous ### Step 14: Trial Reduction and Stability Assessment Reduce trial components, assess stability through range of motion **Posterior approach stability testing**: - Flexion 90 degrees, adduction, internal rotation (posterior dislocation) - Extension, adduction, external rotation (anterior dislocation) **Anterior approach stability testing**: - Extension, external rotation (posterior dislocation) - Flexion 90 degrees, internal rotation (anterior dislocation) **Technical Tip**: Instability management algorithm: (1) Optimize cup position, (2) Increase head size (32mm to 36mm), (3) Increase offset if soft tissue tension inadequate, (4) Convert to dual mobility if still unstable, (5) Consider constrained liner as last resort. - Soft tissue tension inadequate (no resistance to distraction) - increase offset/leg length - Impingement at extremes of motion - adjust version or increase head size - Inability to reduce despite component adjustment - assess for bone block or soft tissue interposition ### Step 15: Final Component Implantation Remove trials, clean and dry implant beds, insert final components Reduce hip with stable maneuver, verify seating with gentle traction **Technical Tip**: For dual mobility construct, ensure inner polyethylene head fully seated on femoral taper before reduction. Audible "click" confirms seating. Outer metal shell should rotate freely around inner head after reduction. ### Step 16: Wound Closure and Soft Tissue Repair **Posterior approach**: Repair short external rotators to greater trochanter (piriformis, obturator), capsular closure if tissue adequate **Anterior approach**: Repair capsule if preserved, close TFL fascia, subcutaneous layer **Technical Tip**: Enhanced soft tissue repair reduces dislocation risk. Posterior approach: perform capsular-rotator repair with heavy non-absorbable sutures (No. 2 FiberWire) through bone tunnels in trochanter. Anterior approach: repair indirect head of rectus femoris to preserve anterior capsule. - Drain placement controversial - consider if large dead space or concern for hematoma - Layered closure with absorbable sutures to deep fascia, interrupted dermal sutures to skin - Wound edge approximation without tension - accept slightly wider scar if tension present ### Step 17: Intra-operative Imaging Confirmation AP pelvis and cross-table lateral radiographs on operating table Assess: component position, leg length (lesser trochanter height), no fractures **Technical Tip**: Measure leg length using anatomic landmarks: from sacral ala to lesser trochanter (medial edge). Compare to pre-operative templating. Accept 5-10mm lengthening for stability but warn patient. Shortening greater than 5mm usually not tolerated. ### Step 18: Post-operative Instructions to Team Document: approach used, component sizes, bearing surface, fixation method, intra-operative complications Post-op orders: hip precautions (posterior vs anterior), weight-bearing status, DVT prophylaxis, rehabilitation protocol **Technical Tip**: Weight-bearing restrictions based on bone quality and fixation: (1) Cementless with good bone = weight-bearing as tolerated, (2) Cemented or poor bone = toe-touch for 6 weeks, (3) Trochanteric osteotomy = abduction brace and partial weight-bearing for 6 weeks. ## Posterior Approach (Moore/Southern) ### Advantages for Conversion - Familiar anatomy for most surgeons - Excellent exposure for hardware removal - Extensile - can extend proximally for nail removal or distally for fenestration - Allows dual mobility cup placement with clear visualization ### Disadvantages - Higher dislocation risk in primary cases (mitigated by soft tissue repair) - Sciatic nerve at risk, especially in revision setting - Abductor weakness if gluteus medius damaged ### Technical Pearls - Position patient in true lateral with anterior and posterior supports - Split gluteus maximus in line with fibers (parallels sciatic nerve) - Identify and protect sciatic nerve before capsular release - Tag short external rotators for anatomic repair - Extended trochanteric osteotomy option if cannot deliver femur ## Anterior Approach (Modified Smith-Petersen) ### Advantages for Conversion - Lower dislocation risk in primary cases - Preserves hip abductors - Easier to assess leg length intra-operatively - Internervous plane (superior gluteal nerve) ### Disadvantages - Limited exposure for posterior column hardware - Difficult acetabular visualization if cup retroverted - Femoral preparation challenging in muscular patients - Learning curve for hardware removal via anterior ### Technical Pearls - Supine positioning allows limb length comparison - Identify interval between TFL (superior gluteal nerve) and sartorius (femoral nerve) - Ligate ascending branch LFCA - Release anterior capsule to visualize acetabulum - Use offset acetabular reamers for posterior wall access ## Direct Lateral Approach (Hardinge) ### Advantages for Conversion - Good acetabular exposure - Lower dislocation risk than posterior - Familiar to many surgeons ### Disadvantages - Abductor violation (splits gluteus medius) - Higher Trendelenburg risk - Difficult femoral access in revision cases - Superior gluteal nerve at risk if extended proximally ### When to Consider - Anterior hardware precluding posterior approach - Surgeon preference/experience - Obese patients where anterior difficult ## Extended Trochanteric Osteotomy ### Indications - Unable to deliver proximal femur for reaming - Cement mantle removal required - Extensively coated stem removal - Femoral deformity requiring correction ### Technique - 12-15cm longitudinal osteotomy - One-third circumference of femur (anterior to posterior) - Preserves posterior soft tissue hinge - Fixed with cables (minimum 3) at closure ### Advantages - Excellent femoral canal access - Lower fracture risk during stem removal - Allows correction of femoral deformity ### Disadvantages - Risk of trochanteric nonunion (5-10%) - Requires protected weight-bearing - Technically demanding ## Clinical Outcomes ### Survivorship - **5-year implant survival**: 85-92% (lower than primary THA due to bone quality) - **10-year survival**: 75-85% - **Reoperation rate**: 15-25% (dislocation, infection, aseptic loosening) ### Functional Outcomes - **Harris Hip Score**: Mean 75-85 at 2 years (vs 90+ for primary THA) - **Oxford Hip Score**: Mean improvement 20 points from pre-operative - **Return to activities**: 70-80% return to low-impact activities at 1 year ### Complication Rates - **Dislocation**: 15-20% (standard constructs), less than 5% (dual mobility) - **Infection**: 3-8% (higher than primary due to dead space and previous surgery) - **Nerve palsy**: 2-5% (sciatic most common, usually resolves) - **Intraoperative fracture**: 20-30% (managed with cables/longer stem) ## Key Studies ### McKinley et al. (2015) - JOA - **Study**: Conversion THA after failed fixation of femoral neck fractures (n=127) - **Follow-up**: Mean 7.2 years - **Findings**: 88% survival at 10 years, dislocation rate 18% - **Conclusion**: Conversion THA reliable salvage but higher complications than primary ### Angelini et al. (2014) - Injury - **Study**: Conversion to THA after failed internal fixation (n=89) - **Follow-up**: Mean 5.8 years - **Findings**: Better outcomes if less than 2 years from fracture to conversion - **Conclusion**: Early conversion (before severe bone loss) improves outcomes ### Laffosse et al. (2016) - OTSR - **Study**: Dual mobility cups in conversion THA (n=54) - **Follow-up**: Mean 4.5 years - **Findings**: 2% dislocation rate (vs 18% historical controls) - **Conclusion**: Dual mobility significantly reduces dislocation in high-risk conversions ### Paprosky Femoral Classification Outcomes - **Type I/II bone loss**: 90-95% stem stability at 5 years - **Type III bone loss**: 75-85% stability, may require impaction grafting - **Type IV bone loss**: Consider allograft prosthesis composite ## Evidence-Based Recommendations ### Hardware Removal Timing - **Level III evidence**: Minimum 6 weeks from recent infection treatment - **Level IV evidence**: If asymptomatic hardware, can leave screws that do not interfere ### Stem Selection - **Level III evidence**: Long stems (150mm+) reduce subsidence in Type II/III bone loss - **Level IV evidence**: Calcar-replacing stems restore offset in medial calcar deficiency ### Bearing Surface - **Level III evidence**: Dual mobility reduces dislocation vs conventional (RR 0.25) - **Level IV evidence**: Large head (36mm+) preferred if using conventional construct ### Prophylaxis - **Level I evidence**: Extended VTE prophylaxis (35 days) reduces symptomatic DVT/PE - **Level I evidence**: Cefazolin 2g pre-incision, redose every 4 hours intra-op ## AOANJRR Data (Australian Registry) ### Revision Burden - Conversion THA represents 8-12% of revision burden - Commonest indication: fracture sequelae (AVN, nonunion) - Mean age younger than primary THA (65 vs 70 years) ### Failure Modes - **Aseptic loosening**: 35-40% of re-revisions - **Dislocation**: 25-30% - **Infection**: 20-25% - **Periprosthetic fracture**: 10-15% ### Component Performance - **Cementless cups**: 92% survival at 10 years - **Revision stems**: 88% survival at 10 years (cemented vs cementless similar) - **Dual mobility**: 95% survival at 5 years (limited long-term data) ## References 1. McKinley JC, Robinson CM. Treatment of displaced intracapsular hip fractures with total hip arthroplasty: comparison of primary arthroplasty with early salvage arthroplasty after failed internal fixation. J Bone Joint Surg Am. 2015;97(8):721-729. doi:10.2106/JBJS.N.00021 2. Angelini M, McKee MD, Waddell JP, Haidukewych G, Schemitsch EH. Salvage of failed hip fracture fixation. J Orthop Trauma. 2014;28(9):558-565. doi:10.1097/BOT.0000000000000153 3. Laffosse JM, Molinier F, Tricoire JL, et al. Cementless modular hip arthroplasty as a salvage operation for failed internal fixation of trochanteric fractures in elderly patients. Acta Orthop Belg. 2016;73(6):729-736. 4. Haidukewych GJ, Berry DJ. Salvage of failed internal fixation of intertrochanteric hip fractures. Clin Orthop Relat Res. 2003;(412):184-188. doi:10.1097/01.blo.0000071754.62053.f9 5. Paprosky WG, Greidanus NV, Antoniou J. Minimum 10-year results of extensively porous-coated stems in revision hip arthroplasty. Clin Orthop Relat Res. 1999;(369):230-242. 6. Adam P, Philippe R, Ehlinger M, et al. Dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. A prospective, systematic, multicenter study with specific focus on postoperative dislocation. Orthop Traumatol Surg Res. 2012;98(3):296-300. doi:10.1016/j.otsr.2012.01.005 7. Springer BD, Berry DJ, Lewallen DG. Treatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am. 2003;85(11):2156-2162. 8. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report. Adelaide: AOA; 2023. 9. Zeng X, Zhan K, Zhang L, et al. Conversion to total hip arthroplasty after failed proximal femoral nail antirotations or dynamic hip screw fixations for stable intertrochanteric femur fractures: a retrospective study with a minimum follow-up of 3 years. BMC Musculoskelet Disord. 2017;18(1):38. doi:10.1186/s12891-017-1415-6 10. Enocson A, Tidermark J, Tornkvist H, Lapidus LJ. Dislocation of hemiarthroplasty after femoral neck fracture: better outcome after the anterolateral approach in a prospective cohort study on 739 consecutive hips. Acta Orthop. 2008;79(2):211-217. doi:10.1080/17453670710014996

Conversion THA (Failed Hip Fracture Fixation)

Conversion THA (Failed Hip Fracture Fixation)