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Pathologic Hip Fractures

- See: General Discussion

- Hyperparathyroidism
    - incidence of hip frx is about 10%;
    - in younger pts with good bone stock, consider ORIF;
    - in elderly pts consider primary THR;
              - note, however, when when hyperparathyroidism occurs as a consequence of renal failure, there will be a relatively high risk of infection (from blood born septicemia due to dialysis);
    - ref:
              Fractures of the femoral neck in elderly patients with hyperparathyroidism.

- Metastatic Dz:
    - consider cemented solid stem ATM prosthetic hemiarthroplasty or cemented total hip arthroplasty;
    - x-ray evaluation is performed to make certain that the acetabulum and distal femoral shaft are not involved;
    - if a lesion is noted further done the femoral shaft, a long stem shaft should be used;

- Pagets Disease:
    - non displaced fractures may be treated with internal fixation
          - frx's in these pts often do not heal during the sclerotic phase, but may heal rapidly during the vascular phase;
          - possibility of excessive bleeding in the vascular phase of Paget's disease should be considered;
    - for displaced fractures, prosthetic replacement is preferred;
         - if there were prefracture symptoms of hip pain in the presence of acetabular degeneration, THR is indicated;
         - if no acetabular degeneration is present, cemented hemi-arthroplasty should be performed;
         - before considerations for THR, a complete x-ray of the femoral shaft should be made to determine if there is excessive bowing;
         - look for preexisting acetabular degeneration & deformity of proximal femur;

- Neurologic Disease:
    - if a prosthetic replacement is chosen, correction of a hip adduction contracture by tenotomy & anterior approach are considered;

- Parkinson's Disease: w/ femoral neck frx;
    - following femoral neck frx, 6 month mortality of 60%;
    - osteoporosis and contractures may make surgical exposure, rigid nail fixation, and secure prosthetic insertion difficult;
    - consider primary endoprosthetic replacement w/ displaced fractures;
         - decision between hemiarthroplasty or THR depends on age, activity, and life expectancy;
         - w/ prosthetic replacement there may be a 37% dislocation rate;
         - consider release of hip adduction contracture & anterior approach both of which may decrease posterior dislocations;
    - signs of Parkinson's disease, range from mild tremor to complete incapacitation secondary to rigidity and tremor;
    - ref:
          - Amputations and Artificial Limbs--General Orthopaedics: Hip: Hip
                 Fractures and Parkinson's Disease. A Clinical Review of 94 Fractures Treated Surgically.

- Spastic Hemiplegia: (Stroke)
    - may occur in up to 10% of hemiplegics;
    - frx usually occurs on hemiplegic side, & pt presents w/ varying degrees of flexion & adduction contracture associated w/ hypertonicity of muscles;
    - due to the hypertonicity, muscle forces about the hip make  reduction of femoral neck fractures different;
    - in pts w/ minimal spasticity & minimal flexion or adduction deformity who have been ambulatory before the injury, consider internal fixation;
          - if ORIF is planned, then the flexion and adduction deformity must be renduced by tenotomy before reduction;
          - release the contracted muscles inserting into the ASIS inorder to regain full hip extension, which is necessary before reduction;
    - in pts w/ marked spastic hemiplegia after CVA, consider hemiarthroplasty;
          - in these pts, consider anterior approach which will decrease incidence of posterior dislocation, & will decrease wound infection;
          - also consider tenotomy of hip contractures;

- Rheumatoid Arthritis
    - Treatment of hip fractures in rheumatoid arthritis.

Fractures of the femoral neck in elderly patients with hyperparathyroidism.

Hip fractures and Parkinson's disease. A clinical review of 94 fractures treated surgically.