Failed fixation of hip fracture with subsequent conversion to hemiarthroplasty

Hip Nail Failure Case

This case involves an elderly female who fell at home and fractured her hip. She was evaluated with x-rays and found to have an intertrochanteric hip fracture. Here are the initial x-rays:

I consider this fracture pattern to be unstable due to the reverse obliquity of the fracture line. The patient was optimized and underwent intramedullary fixation with a cephalomedullary device (Zimmer Natural Nail). Here are the intra-operative fluoroscopy images.

As seen above, the cephalomedullary nail is in excellent position and the fracture is well reduced and aligned. Here are x-rays taken at routine follow up evaluations:

Here are x-rays at a later date:

You can see evidence of screw migration and fixation failure. At this point the patient had severe symptoms. A CT of the hip was obtained. Here are the coronal and sagittal reconstructions:

As seen, the hip screw has penetrated the femoral head and failed. There is a nonunion of the fracture as well. This patient required additional surgical treatment. Removal of the hip nail and placement of a partial hip replacement or hemiarthroplasty was recommended. Revision fixation was not considered advisable due to damage to the head and high risk of failure.

Here are the final x-rays showing the long stemmed partial hip replacement. The Zimmer/Biomet Arcos Modular Femoral Revision system was used.

The patient recovered well from the surgery and has regained functional abilities. I have noticed a higher incidence of these kinds of failures over the last few years. I suspect it is related to an aging population with more severe osteoporosis. Nevertheless, I think there is room for improvement in implant design to improve the success rate.