The clinical presentation is consistent with a femoral neck nonunion, which is supported by the presence of new varus collapse and shortening which was not noted on prior radiographs. The most appropriate method to treat this complication is valgus intertrochanteric osteotomy of the femur with blade plate fixation.
Valgus intertrochanteric osteotomies function by making a vertical fracture more horizontal, converting shear into compressive forces. It also helps correct the varus position of the fracture nonunion.
Watson et al performed a retrospective review of the complications associated with combination femoral neck/shaft fractures and found 13 patients who had healing complications develop after their index surgical procedure. Eight femoral neck nonunions occurred, and these healed after either valgus intertrochanteric osteotomy (seven patients) or compression hip screw fixation (one patient).
Jackson et al state that nonunion may occur in up to 43% of displaced intracapsular femoral neck fractures. The authors present an evidence-based algorithm regarding procedures for treatment of femoral neck nonunion and the roles of refixation, osteotomy, grafting, and prosthetic replacement when indicated.
Angelini et al provide a review on salvage procedures after failed fixation of hip fractures. The authors state that in the setting of a nonunion in the younger patients with a well-preserved hip joint, treatment should typically involve revision internal fixation with or without osteotomy or bone grafting. They conclude that overall, salvage of nonunions of femoral neck and intertrochanteric hip fractures in properly selected patients can provide patients with good to excellent results.
Figure A shows a femoral neck nonunion with varus collapse. Illustration A shows an example of a valgus intertrochanteric osteotomy with blade fixation.
Watson JT, Moed BR. Ipsilateral femoral neck and shaft fractures: complications and their treatment. Clin Orthop Relat Res. 2002 Jun;(399):78-86.
PMID:12011697 (Link to Abstract)
Jackson M, Learmonth ID. The treatment of nonunion after intracapsular fracture of the proximal femur. Clin Orthop Relat Res. 2002 Jun;(399):119-28. Review.
PMID:12011700 (Link to Abstract)
Angelini M, McKee MD, Waddell JP, Haidukewych G, Schemitsch EH. Salvage of failed hip fracture fixation. J Orthop Trauma. 2009 Jul;23(6):471-8. Review.
PMID:19550237 (Link to Abstract)