Abstract
Despite the best of technique when faced with a sub-capital or per-trochanteric fracture, inevitably there are failures of proximal fixation. These situations provide unique challenges for the reconstructive surgeon.
While there are specific issues related to either sub-capital or per-trochanteric fractures, there also are many commonalities. The causes of failure are nonunion, malunion, failure of fixation or avascular necrosis. In all cases, it is imperative to rule out infection. Since the surgery is now elective, the patient's medical status must be optimised prior to the intervention. Basic surgical principles apply to both fracture types. Use the old incision (if possible) and choose an approach that can be extensile. Of course, the old hardware needs to be removed – this task can be quite frustrating, so good preparation and patience is imperative. Retrieve old OP notes to identify the type of hardware so that any special tools needed are available. Hardware can be intra-osseous in location and excavation of the hardware may require bone osteotomy. These patients are at higher risk of postoperative dislocation, so absolute hip stability must be achieved and confirmed in the OR. Bigger heads and dual mobility options improve stability provided that the components are properly positioned and offset and leg length are restored.
Subcapital fractures provide certain specific issues related to stem choice. While, my bias is towards total hip arthroplasty because of better chance of complete pain relief, especially in community ambulators, certainly bipolar arthroplasties can be a satisfactory solution. Stem fixation can be either cemented or cementless.
For per-trochanteric fractures in younger patients, repeat osteosynthesis should be considered if the femoral head is viable. Bone deformity – trochanteric overhang, shaft offset – may necessitate an osteotomy as part of the reconstruction. While proximal fixation primary type stems are often possible, distal fixation revision stems may be required. Any bone defects related to screw holes should be bypassed by the femoral component.
