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Neverthe-less, because the number of hip frac-tures is large and continually increas-ing, a small percentage of patients experience nonunion or early fixation failure.1,2 Unfavorable frac

George J Haidukewych, MD, and Daniel J Berry, MD

Abstract

With contemporary techniques of open

reduction and internal fixation, most

femoral neck and intertrochanteric hip

fractures heal uneventfully

Neverthe-less, because the number of hip

frac-tures is large and continually

increas-ing, a small percentage of patients

experience nonunion or early fixation

failure.1,2 Unfavorable fracture

pat-terns, poor implant placement, and

poor bone quality all increase the

like-lihood of failure of fracture fixation.1,3,4

Effective salvage is important because

patients typically are severely disabled

The main management options are

re-vision internal fixation (with or

with-out bone grafting) and prosthetic

re-placement The choice of salvage

method depends on whether the

frac-ture occurred at the femoral neck or

at the intertrochanteric level Treatment

is then individualized, according to

physiologic age, activity level,

remain-ing bone quality, viability of the

fem-oral head, and status of the hip joint

articular surface

Preoperative Evaluation

Although most nonunions with failed fixation devices and persistent frac-ture instability are easy to diagnose, occasionally nonunion can be subtle and difficult to recognize Several months after internal fixation, patients may present with persistent pain and difficulty with ambulation Radio-graphs may demonstrate settling of the fracture or backing out of hard-ware (Fig 1, A) Alho et al5reviewed the radiographic signs that predict failure in patients with internally fixed femoral neck fractures; they consid-ered 3 months to be the critical time for prognosis Change in fracture sition by 10 mm, change in screw po-sition by 5%, backing out of the screws by 20 mm, and perforation of the femoral head each correlated with

a high rate of revision When plain ra-diography is equivocal, computed to-mography (CT) can help determine whether bony union has occurred

(Fig 1, B) Usually, revision is con-sidered for acute failure of fracture fixation, unacceptable fracture align-ment, or established fracture non-union Although 3 months is a rea-sonable time to expect union in most patients, fixation failure may be ev-ident much earlier; in some patients, however, especially those with radio-graphic evidence of progressive but incomplete healing, a longer period

of observation may be necessary

In evaluating any patient with failed internal fixation of a hip frac-ture, occult infection should be con-sidered as a potential cause of the fail-ure Prudent preoperative evaluation includes complete blood count with manual differential count, erythrocyte sedimentation rate, and C-reactive

Dr Haidukewych is Orthopaedic Traumatologist and Adult Reconstructive Surgeon, Florida Or-thopedic Institute, Tampa, FL Dr Berry is Pro-fessor of Orthopaedics, Mayo Clinic College of Medicine, and Consultant, Orthopaedic Surgery, Mayo Clinic, Rochester, MN.

Neither Dr Haidukewych nor the department with which he is affiliated has received anything of

val-ue from or owns stock in a commercial company

or institution related directly or indirectly to the subject of this article Dr Berry or the department with which he is affiliated has received research

or institutional support from DePuy, Zimmer, and Stryker Dr Berry or the department with which

he is affiliated has received royalties from DePuy Reprint requests: Dr Haidukewych, Florida Or-thopedic Institute, 13020 Telecom Parkway, Tem-ple Terrace, FL 33637.

Copyright 2005 by the American Academy of Orthopaedic Surgeons.

Typically, patients with failed internal fixation of a hip fracture have marked pain

and disability These patients may present treatment challenges Salvage is tailored

to the anatomic site of the nonunion, the quality of the remaining bone and articular

surface, and patient factors such as age and activity level In younger patients with

either a femoral neck or intertrochanteric fracture nonunion with a satisfactory hip

joint, treatment typically involves revision internal fixation with or without osteotomy

or bone grafting In older patients with poor remaining proximal bone stock or a

badly damaged hip joint, conversion to hip arthroplasty can restore function

effec-tively and reduce pain For femoral head salvage procedures, choosing a fixation

de-vice and accurate preoperative planning are the major challenges in decision

mak-ing For conversion to arthroplasty, the major challenges are assessing the need for

acetabular resurfacing, selecting the femoral implant, and managing the greater

tro-chanter Technical challenges include broken hardware, deformity, and femoral bone

defects Attention to technical details can minimize potential complications.

J Am Acad Orthop Surg 2005;13:101-109

protein level Aspiration of the

non-union site does not need to be

per-formed routinely because it is

tech-nically difficult to obtain an adequate

specimen, and the reliability of the

re-sults of such aspirates has not been

well documented Intraoperative

tis-sue from the nonunion site is obtained

for frozen-section histology When

there is evidence of infection, all

hardware should be removed, deep

cultures obtained, and necrotic

tis-sue débrided; antibiotic-impregnated

polymethylmethacrylate beads or

spa-cers may be placed If arthroplasty is

contemplated as the final method of

reconstruction, then a Girdlestone

resection with placement of an

antibiotic-impregnated spacer may be

considered when the femoral head is

thought to be infected The definitive

reconstruction is then performed

af-ter a period of organism-specific

in-travenous antibiotic administration

A staged approach is usually

prefer-able when infection is present,

wheth-er arthroplasty or an attempt to

sal-vage the femoral head is planned

Symptomatic malunion is

uncom-mon following hip fracture

Howev-er, shortening of the femoral neck,

shortening through the

intertrochan-teric area, and malunion of the

great-er trochantgreat-er all can occur aftgreat-er hip fracture Any of these can lead to limb-length discrepancy or adverse hip biomechanics, resulting in limp

or pain In most cases, moderately suboptimal hip biomechanics are ac-cepted as the trade-off to gain good bone apposition in a stable position and fracture union Little information

is available about the options for sal-vage of a severe malunion; most data have been gathered from the treat-ment of neglected intertrochanteric hip fractures In one series of 48

treat-ed hips,6 corrective osteotomy was recommended for symptomatic inter-trochanteric malunions in younger patients, whereas older patients were treated with hip arthroplasty More studies are needed to determine the ideal methods to prevent and salvage malunions after hip fracture

Generally, the viability of the fem-oral head can be assessed with plain radiographs, using the radiographic criteria described for osteonecrosis.7

If necessary, bone scintigraphy or magnetic resonance imaging (when titanium implants are present) can be useful.7However, such additional im-aging modalities are rarely required because in the younger patient with-out collapse of the femoral head,

ev-ery attempt is made to preserve the femoral head, even if small areas of avascular bone are present

When evaluating the patient with

a failed hip fracture, certain patient-specific issues also should be ad-dressed When osteosynthesis is at-tempted, tobacco use in any form should be discontinued Achieving optimal medical and nutritional sta-tus, especially in elderly, debilitated patients, also is critical

Salvage of Failed Femoral Neck Fractures

Young Patients

Usually, femoral neck fracture non-unions in physiologically young pa-tients are treated with methods de-signed to salvage the femoral head and preserve the hip joint Preserving the femoral head is preferable to

prosthet-ic replacement The most common techniques used for femoral neck non-unions in young patients fall into two categories: those designed to improve the mechanical environment at the fracture site (ie, valgus-producing os-teotomies) and those designed to im-prove the biologic environment of the nonunion site by bone grafting (non-vascularized, free (non-vascularized, or muscle pedicle–type grafts).7The Mey-ers quadratus femoris pedicle graft, the most widely studied graft, pro-vides a vascularized local bone graft

to improve the biology at the nonunion site.8-10Its use may be indicated when there is loss of bone stock

posterior-ly or when patients have well-aligned fractures with low shear angles Sev-eral series have evaluated

individu-al methods of bone grafting for fem-oral neck nonunions8,9,11-17(Table 1) The indications for these techniques have yet to be fully elucidated; how-ever, they may be useful for

neglect-ed fractures, failneglect-ed fixation attempts,

or well-aligned nonunions with os-teonecrosis The clear superiority of any of the bone grafting choices is un-substantiated by the current literature

Figure 1 A,Anteroposterior radiograph demonstrating femoral neck nonunion in a

35-year-old woman She continued to have groin pain with ambulation for more than 1 year

post-operatively Note the varus alignment and the backing out of the cannulated screws B,

Coro-nal CT scan demonstrating nonunion.

Valgus intertrochanteric

osteoto-mies can convert shear forces at the

nonunion site to compressive forces,

which then promote fracture healing

(Fig 2) Marti et al18reported on a

se-ries of 50 patients (mean age, 53 years)

who were treated with valgus

inter-trochanteric osteotomy for femoral

neck nonunion Eighty-six percent of

nonunions united in a mean of 4

months Of the 22 patients who had

radiographic evidence of

osteonecro-sis (without collapse) at the time of

osteotomy, only 3 (14%) showed

pro-gressive collapse of the femoral head

requiring hip replacement Anglen19

reported on a series of 13 patients

fol-lowed up for a mean of 25 months

af-ter valgus osteotomy for failed inaf-ter-

inter-nal fixation of a femoral neck fracture

All fractures healed, and 11 of the 13 patients (85%) had good to excellent results Later, two patients (15%) un-derwent arthroplasty because of os-teonecrosis

Ballmer et al20reported on a series

of 17 patients with nonunions of the femoral neck treated with valgus-producing osteotomies Twelve of 17 (71%) healed with one procedure

Three patients required revision fix-ation but eventually healed, increas-ing the overall union rate to 88% Three patients (18%) had progressive os-teonecrosis and required hip arthro-plasty Thus, even with areas of os-teonecrosis, the results of salvage of the femoral head can be good When

segmental collapse of the femoral head

is present, valgus osteotomy is

rare-ly a satisfactory alternative because the results are then less predictable Additionally, the osteotomy deforms the proximal femur, which may make later revision to total hip arthroplasty,

if needed, more difficult

Wu et al21compared the use of a sliding compression screw with and without subtrochanteric valgus os-teotomy for femoral neck nonunions

in 32 patients (mean age, 38 years) All of the nonunions healed at a mean

of 4.6 months Even though there were fewer complications in the nonosteotomy group, the authors rec-ommended valgus osteotomy for pa-tients with shortening of more than

Table 1

Bone Grafting Techniques for Nonunion of the Femoral Neck: Summary of Results

Study

No of Patients

Mean Follow-Up (mo)

Mean Age (yrs)

No (%) Preoperative Osteonecrosis Type of Graft

No

(%) Fracture Union

No (%) Progression

of Osteo-necrosis

No (%) Converted

to Total Hip Ar-throplasty

and II,

6 (27) stage III and higher

Free vascularized fibula

20 (91) 13 (59) 2 (9)

fibula

38 (93) 7 (18) 3 (8)

(deep circumflex iliac artery)

Leung and

(deep circumflex iliac artery)

15 (100)

nonvascularized

I and II

Quadratus femoris muscle-pedicle

42 (75) 2 (4) Not stated

followed

>1 yr

16-79* Not stated Quadratus femoris

muscle pedicle

23 (72) Not

stated

Not stated

Bonfiglio and

strut, nonvascu-larized

72 (94) Not

stated

Not stated

followed

to union

46 Not stated Autograft fibula or

tibia, nonvascu-larized

46 (67) Not

stated

Not stated

* Mean not stated; therefore, the range is given.

1.5 cm because the valgus osteotomy

helps gain leg length

Although studies of valgus

os-teotomy have focused on union rates

and progression of osteonecrosis,

lit-tle has been written about clinical

func-tion after such salvage procedures

Re-cently, Mathews et al22evaluated the

functional outcome in 15 patients with

valgus-producing osteotomies for

fem-oral neck nonunions at a mean of 4

years after surgery Although fracture

union without progression of

osteone-crosis was achieved in most patients,

a persistent limp was common,

prob-ably caused by loss of femoral offset

and abductor moment arm (Fig 2)

Most femoral neck nonunions in

younger patients result primarily from

mechanical, not biologic, factors The

original fractures and subsequent

non-unions typically have high shear

an-gles (Pauwels type III18), have become

shortened, and are aligned in varus

The preferred salvage operation

there-fore should be the valgus-producing

intertrochanteric osteotomy

The technique of valgus-producing intertrochanteric osteotomy has been well described.23It involves convert-ing a vertically oriented fracture to a more horizontal orientation, thus min-imizing the shear forces at the frac-ture site and promoting union The recommended horizontality of the nonunion after osteotomy should be approximately 20° to 30°.18Thus, the size of the intertrochanteric wedge re-moved would be calculated as the dif-ference between the current nonunion verticality and the desired horizon-tality For example, a patient with a 70° nonunion verticality would have

a 40° to 50° wedge resected from the intertrochanteric region to properly reposition the proximal fragment

Fracture shear angles may be quite dif-ficult to measure accurately because

of leg rotation and should be measured from a line perpendicular to the fem-oral shaft.19

These osteotomies should be per-formed on a fracture table that allows excellent fluoroscopic visualization of

the proximal femur Careful preoper-ative templating is performed to de-termine the appropriate blade plate angle Blade plates with multiple gles are available, and the selected an-gle of the plate should allow excel-lent fixation of the proximal fragment and the appropriate neck shaft angle after correction After the original hardware is removed, the proximal femur is prepared with the seating chisel to accept the blade plate before the osteotomy is performed (Fig 2, C) It is important to mark the correct leg rotation, usually with Kirschner wires in the proximal and distal frag-ments or before making the

osteoto-my The chisel that creates a path for the blade is seated to the appropri-ate depth and is then removed The osteotomy is then performed parallel to the chisel tract, taking care

to leave at least 2 cm of bone between the inferior aspect of the blade tract and the superior aspect of the os-teotomy This minimizes the chance

of fracture of this inferior bony bridge

Figure 2 A,Early postoperative anteroposterior radiograph following valgus-producing intertrochanteric osteotomy Note the

medializa-tion of the femoral shaft, which should be minimized if possible B, Femoral neck nonunion with the typical foreshortening and verticality

of the nonunion site C, Appropriate seating of the chisel in the proximal fragment based on templating To avoid fixation failure, it is

im-portant to leave sufficient bone between the planned blade plate and the osteotomy In this situation, the intertrochanteric wedge size

re-moved is planned to allow horizontal orientation of the nonunion site D, Nonunion verticality has been decreased from 70° (panel B) to

approximately 30° Note the lateralization of the femoral shaft and fixation with the angled blade plate.

(Fig 2, C) Commercially available

pro-tractors are available for exact

calcu-lation of the intertrochanteric wedge

These are typically placed along the

anterior femur, and a fluoroscopic

im-age is taken (Fig 3) Kirschner wires

are then used to mark the

appropri-ate wedge trajectory, and the

os-teotomy is performed with a saw It

is important to cool the saw with

pe-riodic irrigation because the bone in

this anatomic region can be dense, and

thermal necrosis could occur

After the appropriate wedge has

been removed, a blade plate of

appro-priate length and angle is impacted

into the femoral head A secondary

proximal screw is placed below the

blade; then, distal screws are placed

in the usual fashion (Fig 2, D) Good

compression across the osteotomy site

usually results as the distal screws are

placed because of the osteotomy

obliq-uity Care should be taken to keep the

bone both proximal and distal to the

osteotomy well aligned on the

later-al view to avoid creating a

deformi-ty that would be difficult later to

con-vert to a hip arthroplasty It is wise

to place bone graft at the osteotomy

site by morcellizing the cancellous

bone from the resected wedge and

placing this along the osteotomy line

The wound is closed in the usual

layered fashion Patients should be

cautioned that, although union rates

are high, a persistent limp is common

The amount of femoral shaft

medi-alization should be minimized when

performing such osteotomies This

can be accomplished by choosing a

slightly longer blade When seated to

the appropriate depth, the plate

re-mains lateral, which helps keep the

shaft lateral Shaft medialization

de-creases offset, thereby decreasing

ab-ductor muscle efficiency and

increas-ing the joint reactive force In addition,

excessive shaft medialization may

cause valgus alignment at the knee

Occasionally, despite all efforts to

preserve the femoral head in the

young patient, there may be no

rea-sonable alternative to hip

arthroplas-ty or hip arthrodesis For example,

a patient with total collapse of the femoral head and a nonunion would not be a good candidate for a joint-preserving procedure Hip arthro-plasty in young patients should be re-served for those in whom several well-done attempts to preserve the joint have failed and for those with collapse of the femoral head

Older Patients

Typically, in physiologically older patients, femoral neck fracture non-unions are salvaged with hip arthro-plasty, either hemiarthroplasty or to-tal hip arthroplasty Hemiarthroplasty has the advantage of being a less ex-tensive surgery and likely has a lower risk of instability In cases of badly damaged articular cartilage of the hip (from degenerative arthritis or erosion because of hardware penetration), to-tal hip arthroplasty is usually pre-ferred When the articular cartilage of the acetabulum is well preserved, the decision between hemiarthroplasty and total hip arthroplasty is at the

sur-geon’s discretion Scrutiny of preop-erative radiographs and intraopera-tive inspection of the acetabular cartilage may guide decision making Either bipolar or unipolar compo-nents may be used, based on surgeon preference A bipolar implant is more commonly used if total hip arthro-plasty is not performed because of the excellent hip stability and low rates

of acetabular erosion it offers If hemi-arthroplasty is planned, it is wise to have total hip arthroplasty compo-nents available as well because pre-operative radiographs may underes-timate the amount of articular surface damage

Several important technical issues must be considered when a total hip arthroplasty is done for failed femo-ral neck fracture The original hard-ware usually needs to be removed, thereby leaving a defect in the shaft

of the femur Also, acetabular bone quality in patients with femoral neck nonunion often is very poor because

of disuse osteopenia Most of these pa-tients do not have degenerative hip

Figure 3 Anteroposterior fluoroscopic image demonstrating calculation of intertrochan-teric wedge and placement of Kirschner wires.

arthritis and so do not have the

scle-rotic subchondral bone typically

present in patients undergoing

elec-tive hip replacement for degeneraelec-tive

arthritis Therefore, when a

cement-less cup is used, poor press-fit

fix-ation or even acetabular fracture

during implant insertion can occur

Judicious acetabular reaming, with an

effort made to preserve the

subchon-dral bone, is recommended Care

should be taken to avoid forceful

ac-etabular component impaction, and

augmentation of fixation with screws

should be considered Standard

fem-oral components typically can be used;

however, proximal defects from

pri-or hardware can pose intraoperative

fracture risk during canal preparation

Little has been written about the

results and complications of hip

ar-throplasty for failed treatment of

fem-oral neck fractures.24-28McKinley and

Robinson29reported a matched-pair

series of 214 patients: 107 patients

with failed open reduction and

inter-nal fixation of a femoral neck fracture

were treated with early-salvage

ce-mented total hip arthroplasty; another

group of 107 patients with fracture

were treated with arthroplasty The

salvage arthroplasty group had

sig-nificantly higher dislocation rates

(21% versus 8%) and more superficial

infections (P < 0.05) than did the

pri-mary arthroplasty group Functional

scores and implant survivorship were

inferior for the salvage group, as well

Mabry et al30reported on the

long-term follow-up of 99 patients with

femoral neck nonunions treated with

Charnley hip arthroplasties between

1970 and 1977 The mean age at time

of arthroplasty was 68 years (range,

36 to 92 years) At a mean 12-year

follow-up of 84 patients, 12 had

un-dergone revision arthroplasty

Im-plant survivorship free of revision for

any reason was 93% at 10 years and

76% at 20 years Implant survivorship

was better for older patients (age >65

years) Instability occurred in 9% of

patients, half of whom had recurrent

dislocation Thus, reported results

clearly document the value of total hip arthroplasty for salvage of fem-oral neck nonunion in older patients

The use of larger-diameter femoral heads and surgical approaches that reduce dislocation risk may be use-ful to reduce the risk of dislocation

in this patient population, although

no published data substantiate this speculation

Salvage of Failed Intertrochanteric Hip Fractures

Young Patients

Nonunion of the intertrochanteric hip fracture in young patients is un-common For those with proximal bone quality adequate for internal fix-ation, the most common treatment is revision internal fixation with

select-ed bone grafting.31A fixed-angle de-vice, such as the angled blade plate

or dynamic condylar screw, is pre-ferred, usually accompanied by au-togenous bone grafting These

devic-es can target the bone in the inferior region of the femoral head, which usually has not been violated by

pri-or implants (Fig 4)

Few studies of intertrochanteric nonunions have been published.32,33 Mariani and Rand34reported on 11 pa-tients (mean age, 53 years) whose in-tertrochanteric nonunions were

treat-ed with repeat open rtreat-eduction and internal fixation Nine of 11 (82%) achieved union at a mean of 6 months

A variety of implants was used suc-cessfully, based on the location of re-maining bone stock in the femoral head Wu et al35reported on 14 inter-trochanteric fractures with cutout of

a lag screw of a dynamic hip screw fixation All were treated with rein-sertion of a lag screw inferiorly in the femoral head, cement augmentation, and valgus-producing subtrochanteric osteotomy All nonunions healed at

a mean of 5 months Sarathy et al36 reported on seven patients with in-tertrochanteric nonunions treated with valgus osteotomy, medial displace-ment, and 130° blade plate fixation

Figure 4 A,Anteroposterior radiograph demonstrating failure of internal fixation of an in-tertrochanteric fracture 3 weeks postoperatively in a 52-year-old woman Note the excellent

remaining proximal bone stock B, Anteroposterior radiograph in another patient

demon-strating salvage with a 95° angled blade plate Note the fixation targeting the inferior fem-oral head bone (Reproduced with permission from Haidukewych GJ, Berry DJ: Salvage of

failed internal fixation of intertrochanteric hip fractures Clin Orthop 2003;412:184-188.)

Six of seven healed Haidukewych and

Berry31reported on a series of 20

in-tertrochanteric nonunions revised with

open reduction and internal fixation

and selected bone grafting Fixed-angle

devices were used in 75% of cases

Nineteen of 20 nonunions healed The

available literature therefore suggests

that a variety of different implants may

be used successfully to salvage the

in-tertrochanteric nonunion as long as

stable fixation of the proximal

frag-ment is obtained

Older Patients

Most intertrochanteric hip fracture

nonunions occur in older patients

with poor proximal bone quality and

fail by implant cutout from the

fem-oral head.1The decision to perform

revision internal fixation versus

pros-thetic replacement is based on patient

characteristics, fracture pattern,

re-maining bone quality, and status of

the hip joint In older patients,

arthro-plasty has some advantages because

it allows earlier patient mobilization

When hip arthroplasty is

per-formed for salvage of failed

intertro-chanteric fractures, specific technical

considerations must be addressed

The initial decision is whether to

per-form a total hip arthroplasty or a

hemiarthroplasty It is not uncommon

to have had the cutout of the

previ-ous internal fixation cause secondary

damage to the hip joint Usually, in

this circumstance or in patients with

markedly severe preexisting arthritis,

a total hip arthroplasty is performed

With well-preserved articular

carti-lage, hemiarthroplasty may be

con-sidered The same advantages and

disadvantages of hemiarthroplasty

versus total hip arthroplasty

dis-cussed for salvage of femoral neck

nonunion also pertain to

intertro-chanteric nonunion

Defects from previous internal

fix-ation devices on the lateral femoral

shaft create stress risers that can lead

to intraoperative fracture of the

fe-mur, particularly with torsion

Pre-liminary dislocation of the hip before

hardware is removed may reduce fe-mur fracture risk in these hips, which often are quite stiff and can require much force to dislocate Frequently, broken screws are present It is help-ful to keep instruments, including tre-phines and grasping tools, available

to remove broken screws

Most patients with failed intertro-chanteric fracture fixation have bone loss below the standard resection level for a routine, primary total hip arthroplasty Therefore, many need

a calcar-replacing implant to restore leg length and hip stability To pre-vent the chance of subsequent frac-ture when using longer stems, it is wise to bypass screw holes in the fe-mur by two cortical diameters37(Fig

5) Successful femoral component fixation can be obtained with either cemented or cementless implants

For many older patients,

cement-ed fixation is advantageous, particu-larly when bone quality is poor and the canal diameter is large

Cement-ed fixation also allows rapid

mobili-zation in this patient population If a cemented stem is chosen, the surgeon needs to be aware that cement can ex-trude from the empty screw holes.38 Bone graft from the resected femoral head can be used to graft large lat-eral defects, such as those created by the barrel of a sliding hip screw

If a cementless implant is used, ex-tensively porous-coated stems have the advantage of providing fixation

in the diaphysis of the femur, bypass-ing the damaged, deformed, or defi-cient proximal bone Intraoperative fracture is possible with insertion of large cementless implants,

especial-ly in patients with poor bone with multiple previous bicortical screw holes Intraoperative radiographs af-ter implant placement are recom-mended, regardless of the type of femoral fixation chosen

Management of the greater tro-chanter has been problematic and warrants special discussion The greater trochanter may be a separate, ununited piece of bone, or it may be

Figure 5 A,Anteroposterior radiograph demonstrating intertrochanteric nonunion with

cut-out and poor proximal bone stock in a 78-year-old woman B, Anteroposterior radiograph

in another patient showing salvage with a long-stem, calcar-replacing bipolar hemiarthro-plasty and fixation of the greater trochanter.

malunited, preventing entrance into

the femoral canal for femoral

prep-aration In these circumstances, the

trochanteric slide technique is

pre-ferred because it retains the vastus

lat-eralis muscle, greater trochanter, and

abductor muscles as a single sleeve

of tissue Patients should be

coun-seled in advance that trochanteric

problems relating to either persistent

nonunion or painful trochanteric

fix-ation devices are not infrequent after

such reconstructions.39

Finally, bone deformity of the

prox-imal femur related to fracture callus,

fracture translation, or malunion

of-ten is present, which increases the risk

of femoral fracture during canal

prep-aration Shaping of the proximal bone

with a high-speed burr is safer than

performing the same procedure with

a rasp The tracts of previously placed

fixation devices often are sclerotic and

can deflect reamers or broaches,

lead-ing to proximal fracture or femoral

perforation

There are few published series on

the results of hip arthroplasty for

re-vision after intertrochanteric

non-unions Mariani and Rand34reported

on nine patients with

intertrochan-teric nonunions treated with hip

ar-throplasty At an average follow-up

of 6.6 years, all patients had functional

improvement Stoffelen et al40

re-ported on seven hip arthroplasties for intertrochanteric nonunion Seventy-two percent (5 patients) had good to excellent results Mehlhoff et al41 re-ported on 13 patients followed for a mean of 34 months; only 5 had good

to excellent results Three patients had dislocations and two of them required revision for instability

More recently, Haidukewych and Berry39reported on 60 patients (mean age, 78 years) treated between 1985 and 1997 with hip arthroplasty for failed treatment of intertrochanteric hip fractures Thirty-two total hip arthroplasties and 27 bipolar hemiar-throplasties were performed Forty-four patients were followed for a mean of 5 years Two hip arthroplas-ties were revised for aseptic loosen-ing at 8 and 10 years There was one dislocation The 7-year survivorship

of the arthroplasties free of revision for any reason was 100%; 10-year sur-vivorship was 88% Importantly, a calcar-replacing stem or extra long neck-length stem was needed in 65%

of cases, and long-stemmed implants were used in a high percentage of pa-tients, as well A standard prosthesis was suitable only in 15% of cases Se-rious complications were uncommon, and most patients’ ambulatory status and pain were markedly improved

The most common persistent

com-plaint was discomfort over the

great-er trochantgreat-er, which was present in 11% of hips

Summary

In younger patients, salvage of the failed hip fracture typically involves efforts to preserve the hip joint with internal fixation, whereas in most

old-er patients, prosthetic replacement is

a reliable salvage option The location

of the nonunion, physiologic age of the patient, quality of the remaining proximal bone, presence of

deformi-ty, status of the hip joint, and viabil-ity of the femoral head all influence decision making Regardless of the salvage method chosen, attention to specific technical details can improve the success rate and reduce the com-plications of treating these challeng-ing problems

The OKO video″Approaches

to Total Hip Arthroplasty,″ by Bassam

A Masri, MD, Philip Mitchell, MD, and Clive Duncan, MD, is available

at http://www5.aaos.org/oko/jaaos/ main.cfm

References

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et al: Fractures of the proximal part of

the femur Instr Course Lect 1995;44:

227-253.

2 Kyle RF, Gustilo RB, Premer RF:

Anal-ysis of 622 intertrochanteric hip fractures.

J Bone Joint Surg Am 1979;61:216-221.

3 Baumgaertner MR, Solberg BD:

Aware-ness of tip-apex distance reduces

fail-ure of fixation of trochanteric fractfail-ures

of the hip J Bone Joint Surg Br 1997;79:

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