Failed nonunion subtrochanteric femur fracture managed with uncemented total hip replacement

Abstract

Subtrochanteric fracture is a fracture between the lesser trochanter and 5 cm distal to the lesser trochanter. It accounts approximately for 10%–30% of all hip fractures and affects persons more than 60 years of age. Bimodal distribution has greater incidences in 20–40 years of age and persons more than 60 years of age. Deforming forces on the proximal fragment are abduction by the gluteus medius and minimus, flexion by iliopsoas, and external rotation by short external rotators; whereas, deforming forces on the distal fragment are adduction and varus by adductors. Failure of subtrochanteric fracture treatment is frequently associated with unstable fracture patterns, poor bone quality, or suboptimal position of fixation devices. Such complications following treatment failure may result in nonunion, leading to pain or malunion, severe bone defects, infection, articular cartilage damage, and even post-traumatic arthritis hip, which poses a significant challenge in subsequent surgeries. Therefore, in this particular case, we were left with only two options, such as (1) re-osteosynthesis using limb reconstruction surgeries (LRS) and (2) and prosthetic replacement. We opted for uncemented long stem total hip replacement to get diaphyseal hold as it has many advantages over LRS like a high success rate, a better quality of life, improved early mobility, and life-long lasting results. LRS was not opted as a choice of surgery as it has some disadvantages like pin-tract infection, more maintenance and compliance needed, the frame being bulky and cumbersome, and the risk of fracture at the pinhole site. Moreover, in this particular case, bone grafts from all accessible sites were used from previous surgeries. Uncemented long-stem total hip replacement can serve as an efficient salvage procedure in such cases. Post-operatively on follow-up at 2 months, the patient was able to fully bear weight without support. The range of motion at the right hip joint where the patient was able to do flexion 100ʹ, abduction 50ʹ, and adduction 30ʹ. We were able to correct limb length discrepancy by 5 cm (pre-operative discrepancy was 7 cm). Our achievement shows that uncemented long stem total hip replacement is a beneficial and effective procedure for salvaging the failed treatment of subtrochanteric fractures. Such procedures have shown satisfactory functional outcomes, stable fixation, and survival rates for these complex situations.