Abstract
The Failed Femoral Neck Fracture
For the young patient: Attempt to preserve patient's own femoral head. Clinical results reasonably good even if there are patches of avascular necrosis. Preferred methods of salvage: valgus-producing intertrochanteric femoral osteotomy: puts the nonunion under compression. Other treatment option: Meyer's vascularised pedicle graft.
For the older patient: Most reliable treatment is prosthetic replacement. Decision to use hemiarthroplasty (such as bipolar) or THA based on quality of articular cartilage, perceived risk of instability problem. In most patients THA provides higher likelihood of excellent pain relief. Specific technical issues: (1) hardware removal: usually remove after hip has first been dislocated (to reduce risk of femur fracture); (2) Hip stability: consider methods to reduce dislocation risk: larger diameter heads/dual mobility/anteriorly-based approaches; (3) Acetabular bone quality: poor because it is not sclerotic from previous arthritis; caution when impacting a pressfit cup; low threshold to augment fixation with screws; don't overdo reaming; just expose the bleeding subchondral bone. A reasonable alternative is a cemented cup.
The Failed Intertrochanteric Hip Fracture
For the young patient: Attempt to salvage hip joint with nonunion takedown, autogenous bone grafting and internal fixation.
For the older patient: Decision to preserve patient's own hip with internal fixation versus salvage with hip arthroplasty should be individualised based on patient circumstances, fracture pattern, bone quality. THA is an effective salvage procedure for this problem in older patients. If prosthetic replacement is chosen special considerations include:
THA vs. hemiarthroplasty: hemiarthroplasty better stability; THA more reliable pain relief.
Removal of hardware: be prepared to remove broken screws in intramedullary canal.
Management of bone loss: bone loss to level of lesser trochanter common. Often requires a calcar replacement implant. Proximal calcar build-up size dictated by bone loss.
Length of stem: desirable to bypass screw holes from previous fixation, if possible.
Stem fixation: cemented or uncemented fixation depending on surgeon preference, bone quality. If uncemented, consider diaphyseal fixation.
Greater trochanter: often a separate piece, be prepared to fix with wires or cable grip. Residual trochanteric healing, hardware problems not rare after THA.
