Total Hip Arthroplasty for Proximal Femoral Nonunion and Malunion

  • Adam Sassoon
  • Jeff Petrie
  • George J. Haidukewych


Nonunions and malunions may complicate the treatment of proximal femur fractures. These sequelae often occur in the setting of poor bone stock or a compromised host, thereby adding to the complexity of their presentation. Hip arthroplasty after failed fracture treatment (often referred to as “conversion arthroplasty”) can often be employed as a salvage procedure in these difficult clinical scenarios to improve pain and limitations in mobility. However, previously placed hardware may alter patient anatomy, create potential stress risers, and confer a higher risk for postoperative complications including infection and instability. These surgeries often require revision components and adjunctive techniques including trochanteric osteotomies or bone grafting. This chapter will outline the indications for conversion arthroplasty in the setting of proximal femoral nonunions and malunions, discuss technical pearls and pitfalls of these surgical interventions, and present their reported clinical outcomes.


Hip Hip fractures Nonunion Malunion Total hip arthroplasty Hemiarthroplasty Conversion arthroplasty Fragility fractures Osteoporosis Trochanteric osteotomy Bone grafting Salvage arthroplasty 


  1. 1.
    Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P, Obremskey W, Koval KJ, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg. 2003;85-A(9):1673–81.CrossRefPubMedGoogle Scholar
  2. 2.
    Jakob, Rosso, Weller, Babst, Regazzoni. Avascular necrosis of the femoral head after open reduction and internal fixation of femoral neck fractures: an inevitable complication? Swiss Surg. 1999;5(6):257–64.CrossRefPubMedGoogle Scholar
  3. 3.
    Rogmark C, Carlsson A, Johnell O, Sernbo I. A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years. J Bone Joint Surg Br. 2002;84(2):183–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Blomfeldt R, Törnkvist H, Ponzer S, Söderqvist A, Tidermark J. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg. 2005;87(8):1680–8.PubMedGoogle Scholar
  5. 5.
    Strömqvist B, Hansson LI, Nilsson LT, Thorngren KG. Hook-pin fixation in femoral neck fractures. A two-year follow-up study of 300 cases. Clin Orthop Relat Res. 1987;218:58–62.Google Scholar
  6. 6.
    Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008;90(8):1654–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Chammout GK, Mukka SS, Carlsson T, Neander GF, Stark AWH, Skoldenberg OG. Total hip replacement versus open reduction and internal fixation of displaced femoral neck fractures: a randomized long-term follow-up study. J Bone Joint Surg Am. 2012;94(21):1921–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg. 2006;88(2):249–60.CrossRefPubMedGoogle Scholar
  9. 9.
    Bartoníček J, Skála-Rosenbaum J, Douša P. Valgus intertrochanteric osteotomy for malunion and nonunion of trochanteric fractures. J Orthop Trauma. 2003;17(9):606–12.CrossRefPubMedGoogle Scholar
  10. 10.
    Haidukewych GJ, Berry DJ. Nonunion of fractures of the subtrochanteric region of the femur. Clin Orthop Relat Res. 2004;419:185–8.CrossRefGoogle Scholar
  11. 11.
    Barquet A, Mayora G, Fregeiro J, López L, Rienzi D, Francescoli L. The treatment of subtrochanteric nonunions with the long gamma nail: twenty-six patients with a minimum 2-year follow-up. J Orthop Trauma. 2004;18(6):346–53.CrossRefPubMedGoogle Scholar
  12. 12.
    Haidukewych GJ, Berry DJ. Salvage of failed internal fixation of intertrochanteric hip fractures. Clin Orthop Relat Res. 2003;412(412):184–8.CrossRefGoogle Scholar
  13. 13.
    Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg. 1995;77(7):1058–64.CrossRefPubMedGoogle Scholar
  14. 14.
    Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg. 1979;61(2):216–21.CrossRefPubMedGoogle Scholar
  15. 15.
    Caruso G, Bonomo M, Valpiani G, Salvatori G, Gildone A, Lorusso V, et al. A six-year retrospective analysis of cut-out risk predictors in cephalomedullary nailing for pertrochanteric fractures: can the tip-apex distance (TAD) still be considered the best parameter? Bone Joint Res. 2017;6(8):481–8.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Yam M, Chawla A, Kwek E. Rewriting the tip apex distance for the proximal femoral nail anti-rotation. Injury. 2017;48(8):1843–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Qin CD, Helfrich MM, Fitz DW, Oyer MA, Hardt KD, Manning DW. Differences in post-operative outcome between conversion and primary total hip arthroplasty. J Arthroplast. 2017:1477–80.Google Scholar
  18. 18.
    McLawhorn AS, Schairer WW, Schwarzkopf R, Halsey DA, Iorio R, Padgett DE. Alternative payment models should risk-adjust for conversion total hip arthroplasty: a propensity score-matched study. J Arthroplast. 2017:2025–30.Google Scholar
  19. 19.
    Mabry TM, Prpa B, Haidukewych GJ, Harmsen WS, Berry DJ. Long-term results of total hip arthroplasty for femoral neck fracture nonunion. J Bone Joint Surg. 2004;86-A(10):2263–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Winemaker M, Gamble P, Petruccelli D, Kaspar S, de Beer J. Short-term outcomes of total hip arthroplasty after complications of open reduction internal fixation for hip fracture. J Arthroplast. 2006;21(5):682–8.CrossRefGoogle Scholar
  21. 21.
    Archibeck MJ, Carothers JT, Tripuraneni KR, White RE. Total hip arthroplasty after failed internal fixation of proximal femoral fractures. J Arthroplast. 2013;28(1):168–71.CrossRefGoogle Scholar
  22. 22.
    Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg. 2006;88(12):2583–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Blomfeldt R, Törnkvist H, Eriksson K, Söderqvist A, Ponzer S, Tidermark J. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br. 2007;89(2):160–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Yu L, Wang Y, Chen J. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures: meta-analysis of randomized trials. Clin Orthop Relat Res. 2012;470(8):2235–43.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Mortazavi SMJ, R Greenky M, Bican O, Kane P, Parvizi J, Hozack WJ. Total hip arthroplasty after prior surgical treatment of hip fracture is it always challenging? J Arthroplast. 2012;27(1):31–6.CrossRefGoogle Scholar
  26. 26.
    Jando VT, Greidanus NV, Masri BA, Garbuz DS, Duncan CP. Trochanteric osteotomies in revision total hip arthroplasty: contemporary techniques and results. Instr Course Lect. 2005;54:143–55.PubMedGoogle Scholar
  27. 27.
    Pui CM, Bostrom MP, Westrich GH, Valle Della CJ, Macaulay W, Mont MA, et al. Increased complication rate following conversion total hip arthroplasty after cephalomedullary fixation for intertrochanteric hip fractures: a multi-center study. J Arthroplast. 2013;28(8 Suppl):45–7.CrossRefGoogle Scholar
  28. 28.
    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. 2002;84-A(11):2010–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Srivastav S, Mittal V, Agarwal S. Total hip arthroplasty following failed fixation of proximal hip fractures. Indian J Orthop. 2008;42(3):279–86.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg. 2003;85-A(5):899–904.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Adam Sassoon
    • 1
  • Jeff Petrie
    • 2
  • George J. Haidukewych
    • 2
  1. 1.Department of Orthopedics and Sports MedicineNorthwest Hospital University of WashingtonSeattleUSA
  2. 2.Department of Orthopedic SurgeryOrlando Regional Medical CenterOrlandoUSA

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