Proximal Femur Nonunions

Abstract

Hip fractures in adults are common among the elderly with low-energy falls but also occur in younger patients with high-energy mechanisms. Most of these fractures are treated surgically generally proceeding to union when surgery is performed correctly. In the proximal femur, the femoral neck is most prone to nonunion but occurs in the intertrochanteric and subtrochanteric regions as well. The surgeon should suspect nonunion if there is persistent pain in the region or loss of reduction. Varus deformity should particularly be scrutinized. Hardware failure is typically associated with nonunion. In addition to radiographs, CT scans can be useful to define the nonunion. The nonunion should then be analyzed for contributing factors. Not only should mechanical factors be taken into account, but also biologic factors both local and systemic should also be assessed to generate a treatment plan. Revision surgery may entail alternate fixation, bone graft, osteotomy, arthroplasty, or resection. The strategy chosen depends on nonunion location, causative factors, and patient needs. In the femoral neck, the valgus intertrochanteric osteotomy corrects varus and has a high success rate. It is technically demanding but somewhat less than a vascularized fibula, which has been advocated for nonunions with avascular necrosis. Arthroplasty has gained popularity in the older patient as a treatment for nonunion but is associated with lower success rates compared to primary arthroplasty. Intertrochanteric and subtrochanteric nonunions although uncommon are successfully treated with revision fixation.