Dear Editor, I read with interest the paper “Nonoperative management of periprosthetic fractures associated with Birmingham hip resurfacing procedure” by Cossey et al. [1]. I agree with authors that, with reliable patients, regular follow-up and good patient education, such fractures could go on the full clinical and radiological union with no compromise to overall function of the prosthesis. I would like to share an unfavourable outcome of conservative treatment resulting in a varus malunion of a periprosthetic femoral neck fracture after metal-on-metal resurfaced hip [2]. Failure to closely observe and poor compliance in the young and active group of the patients contributed to such an unfavourable outcome. A 45-year-old woman underwent metal-on-metal surface hip arthroplasty for advanced osteoarthritis of the left hip. The resurfacing was performed through the posterior approach. The medical history, drugs, and family history were insigniWcant. Cornet 2000 implants (uncementeted 50-mm dual coated cup and cemented 44-mm femoral head) were used. Bone quality was good, and no technical diYculties or neck notching was encountered intraoperatively. She was admitted 4 months later with a painful left hip after sustaining a fall. The X-ray conWrmed left periprosthetic femoral neck fracture with resurfacing prosthesis in situ (Fig. 1) The acetabular component was well Wxed. The available options, namely revision of the femoral component and conservative treatment, were explained. She elected to go to home and was subsequently lost to follow-up. She selfreferred to the orthopaedic clinic after 30 months of her fracture with shortening and slightly painful limp. The clinical examination revealed 1.5 cm of true limb shortening with restricted terminal range of abduction and rotational movements. The X-ray revealed a varus malunited fracture with proximal migration of greater trochanter (Fig. 1). The acetabular component was well Wxed in situ. B. Saccomanni (&) Orthopaedic and Traumatologic Surgery, Gabriele d’Annunzio University, Via dei Vestini, 66013 Chieti Scalo, Italy e-mail: bernasacco@yahoo.it Fig. 1 The anteroposterior X-ray of the left hip revealing malunited periprosthetic femoral neck fracture complicating metal-on-metal surface hip arthroplasty