INTRODUCTION

Background

Intertrochanteric femur fractures are among the most common injuries encountered in trauma care [1]. In unstable fracture patterns, intramedullary fixation devices provide superior biomechanical stability and improved clinical outcomes [2]. The proximal femoral nail (PFN) is associated with favorable clinical, radiological, and functional results [3]. However, with its expanded use, complications such as interlocking screw migration, varus collapse, nonunion, delayed union, screw cutout, and peri-implant fractures have increasingly been reported, with failure rates in unstable fractures reaching up to 31% [4]. Management of PFN failure typically involves either re-osteosynthesis or arthroplasty, each offering distinct advantages and limitations. Total hip arthroplasty (THA) and bipolar hemiarthroplasty (BA) are recognized as effective salvage procedures for maintaining mobility [5], although conversion arthroplasty remains technically demanding because of hardware removal and the presence of bone defects, and it carries higher complication rates [6]. This study aimed to assess the surgical challenges, operative techniques, and clinical and radiological outcomes of arthroplasty following failed PFN fixation.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of Indus International Hospital (No. IEC/IIH/012/2025). Written informed consent for publication of the research details and clinical images was obtained from the patients.

Study design

This retrospective multicenter cohort study utilized data from an internal clinical audit of patients who underwent surgical management for failed PFN fixation between 2018 and 2022. A total of 59 patients who met the inclusion criteria were included in the analysis. PFN failure was defined as screw or blade backout, implant breakage, cutout, varus collapse, or nonunion. Among 296 patients who had undergone fracture fixation or re-osteosynthesis with PFN, 59 (19.9%) experienced failed fixation or re-osteosynthesis requiring arthroplasty.

Inclusion and exclusion criteria

Eligible patients were aged >18 years and had undergone either BA or THA as a single-stage procedure for failed PFN osteosynthesis or re-osteosynthesis. Patients were excluded if they were medically unfit for surgery, had femoral neck fractures, infected implants, iatrogenic or pathological fractures, fixation with implants other than PFN, or were unavailable for a minimum follow-up of 24 months.

Clinical and radiological assessment

All patients presented with hip pain and difficulty with ambulation following the index surgery, and some exhibited screw impingement on the skin or intra-articular protrusion. None of the patients showed clinical or laboratory evidence of infection. Preoperative evaluation included demographic information, comorbidities, and American Society of Anesthesiologists (ASA) physical status classification. Functional outcomes were assessed using the Harris Hip Score (HHS) at 24 months postoperatively. Radiographic evaluation was performed using anteroposterior pelvic radiographs with internal rotation of the hip, supplemented by computed tomography (CT) when indicated. Implant failure patterns were documented, and radiological signs of infection were reviewed.

Surgical management

All patients underwent implant removal followed by hip arthroplasty. The choice between BA and THA depended on patient age, acetabular erosion, hip arthritis, and functional demand. Patients >70 years with limited functional expectations underwent BA, whereas patients <70 years with inflammatory arthritis, osteoarthritis, or acetabular erosion underwent THA. Cemented or uncemented stems were selected based on femoral canal morphology: uncemented stems for Dorr type A and B canals and cemented stems for Dorr type C canals. Greater trochanteric fragments were stabilized using stainless steel wire or a locking plate.

A posterior approach was used for all surgeries. Intraoperative parameters included operative duration, blood loss, and complications. Postoperative management involved immediate full weight-bearing mobilization with a walker, documentation of time to full mobilization, length of hospital stay, blood transfusion requirements, HHS outcomes, radiological findings at 12 months, and postoperative complications.

Implant removal

Implant removal was performed through the previous surgical incision using specialized or universal extraction instruments. The most common failure pattern involved blade or screw cutout through the femoral head with displacement of fracture fragments. Removal challenges depended on the specific failure pattern. Cases of cutout or backout were relatively straightforward, whereas screw breakage required removal of the femoral head. Proximal nail breakage was less complex, but distal nail extraction required dedicated techniques, such as cutting distal threads in cases of impaction. Blade removal often required the use of vise grips, and extraction of proximal screws or blades was facilitated by dislocating the femoral head and removing it in pieces. Tissue from the medullary canal and fracture site was sent for histopathological examination and culture. The femoral head was preserved for autografting when bone defects were present.

Hip arthroplasty

Arthroplasty was performed using Moore approach with the patient in the lateral decubitus position. The fracture site was accessed with minimal disruption to maintain fracture integrity and preserve the abductor muscles and trochanteric fragments. Removal of the femoral head and neck required additional dissection compared with arthroplasty for femoral neck fractures.

For THA, the acetabulum was reamed, and an uncemented cup was implanted. The femoral canal was prepared with appropriate reamers, followed by trial reduction to evaluate limb length, offset, and hip stability. The greater trochanter was stabilized with stainless steel wire, and bone grafting was performed when required. Cemented stems were used when indicated. The hip joint was thoroughly irrigated, and the posterior capsule and short external rotators were repaired.

Postoperatively, radiographs were obtained to confirm implant position. Deep vein thrombosis prophylaxis was administered according to institutional protocol. Mobilization began on the first postoperative day depending on patient tolerance, progressing to full weight-bearing using a walker. Hemoglobin levels were monitored, and transfusions were administered when values fell below 8 g/dL. The number of intraoperative and postoperative transfusions was recorded. All patients were followed for a minimum of 24 months, with serial radiographs and HHS assessment at the final visit. During follow-up, five patients (8.5%) died within 24 months of surgery.

Statistical analysis

Data analysis was performed using IBM SPSS ver. 24.0 (IBM Corp). Continuous variables were assessed for normality using the Shapiro-Wilk test. Normally distributed data were presented as mean±standard deviation, whereas non-normally distributed variables were reported as median with interquartile range (IQR). Categorical variables were summarized as absolute counts and percentages. Comparisons between categorical variables, such as type of arthroplasty and complication rates, were performed using the chi-square test or the Fisher exact test when expected cell counts were <5. Continuous variables were compared between groups using the independent samples t-test for normally distributed data or the Mann-Whitney U-test for skewed data. Paired comparisons of preoperative and postoperative functional scores were conducted using the paired t-test or the Wilcoxon signed rank test, depending on data distribution. Correlations between continuous variables, such as operative duration and blood loss, were evaluated using Pearson or Spearman rank correlation coefficients as appropriate.

Given the retrospective design and the fixed sample size of 54 patients, no a priori power calculation was feasible. However, a post hoc power analysis was performed to estimate the detectable effect size for the primary outcome, defined as the difference in HHS between BA and THA groups, using an α level of 0.05 and a power of 80%. Statistical significance was set at P<0.05 for all comparisons.

RESULTS

Demographic parameters

A total of 59 patients were initially enrolled; however, 5 died within the 2-year postoperative period and were therefore excluded from the final functional outcome analysis, leaving 54 patients (19 men, 35 women) for evaluation (Table 1). The mean age was 65.8±7.5 years (range, 42–90 years), and the average ASA physical status was 3.5. Shapiro-Wilk testing confirmed that age data were normally distributed (W=0.974, P=0.640). The median age was 64.04 years (IQR, 61.29–68.39 years). Hypertension, diabetes mellitus, hypothyroidism, chronic kidney disease, chronic obstructive pulmonary disease, and asthma were common comorbidities, frequently occurring in combination. The mean interval from injury to PFN fixation was 5.6±1.2 days (range, 1–11 days), with normal distribution confirmed by the Shapiro-Wilk test (W=0.986, P=0.941); the median was 5.46 days (IQR, 4.76–6.17 days). The mean interval from injury to hip arthroplasty was 11.6±2.3 months (range, 6–24 months), with normal distribution also confirmed (W=0.962, P=0.332); the median was 11.81 months (IQR, 10.39–13.48 months).

Fracture morphology and management

All patients sustained unstable intertrochanteric fractures. According to the Boyd and Griffin classification, 9 patients had type 2 fractures, 25 had type 3 fractures, and 20 had type 4 fractures. Based on the AO/OTA classification, 45 patients had 31A2.3 fractures and 9 had 31A2.2 fractures. Chi-square analysis showed no statistically significant association between fracture classifications and the type of arthroplasty performed (χ²=0.72, P=0.395). CT scans confirmed implant failure and nonunion in all cases.

PFN and failure pattern

All patients were initially treated with open or closed reduction and stabilization using PFN. Twenty-three patients were managed with PFN using two screws (Traffon nail, Yogeshwar Implants), whereas 31 patients received PFN with a helical blade (PFNA antirotation II [PFNA-II]; Traffon II, Yogeshwar Implants). The most commonly used nail size was 10×240 mm, with additional nail sizes of 9, 11, 12, and 220/240 mm titanium nails also used. Seventeen patients who experienced PFN failure were revised with PFNA-II. The average age of these patients was 47.8±1.8 years (range, 42–58 years). None of the patients demonstrated evidence of infection during any procedure.

Blade or screw cephalic cutout through the femoral head occurred in 18 patients (Fig. 1), while screw breakage with nail protrusion was observed in 8 patients (Fig. 2). Nail breakage at the proximal screw insertion site occurred in 7 patients (Fig. 3). Backout or lateral migration of the proximal screws or blade was identified in 14 patients. Screw penetration through the head with medial migration into the acetabulum occurred in 4 patients, and breakage of distal locking screws was observed in 3 patients.

Hip arthroplasty

All patients ultimately underwent hip arthroplasty. Uncemented THA was performed in 18 patients, hybrid THA with a cemented stem in 14 patients, and cemented BA in 22 patients. Long stems were used in 25 cases (Fig. 4). The greater trochanter fragment was stabilized with stainless steel wire in 18 patients (Fig. 5) and with a locking plate in 4 patients (Fig. 6). The implants included uncemented hemispherical acetabular cups (cluster/multihole; Signature NX Cup, Biorad Medisys), uncemented hydroxyapatite-coated double-taper stems (Signature Stem, Biorad Medisys), and polished tapered cemented stems (Avatar NXT Stem, Biorad Medisys). In all THA cases, a metal CoCr Head (32/36 mm; Biorad Medisys) with highly cross-linked polyethylene liners (Signature Liner, Biorad Medisys) was used.

Surgical outcomes and complications

The mean operative duration was 108±16 minutes (range, 90–196 minutes) for BA and 136±12 minutes (range, 120–210 minutes) for THA. The Mann-Whitney U-test showed that operative duration was significantly longer in the THA group (U=9.0, P<0.001). Mean blood loss was 120±24 mL (range, 90–380 mL) for BA and 150±30 mL (range, 110–400 mL) for THA, with a statistically significant difference between groups (U=55.0, P=0.011). A weak positive correlation was found between operative duration and blood loss (Pearson r=0.346, P=0.057). Intraoperative complications occurred in three BA patients: two cases of hypotension requiring fluid resuscitation and one metaphyseal periprosthetic fracture stabilized with a screw.

Postoperatively, all patients remained in the intensive care unit for 48 hours. The mean hemoglobin decrease was 2.1±0.8 g/dL (range, 1–3.2 g/dL). Eighteen patients required 1 unit of blood intraoperatively; postoperatively, 21 required 1 unit and 7 required 2 units. The mean time to full weight-bearing with a stick or walker was 2.5±1.2 days (range, 1–10 days), and mean hospital stay was 4.4±2.3 days (range, 3–7 days).

Postoperative complications

Postoperative complications were observed in 10 patients (18.5%). Dislocation occurred in one BA patient (1.9%) 4 weeks after surgery following a stair-climbing jerk and was treated with closed reduction without recurrence. Deep vein thrombosis occurred in two patients (3.7%; one BA, one THA). Superficial surgical site infection occurred in two BA patients (3.7%). Urinary tract infection developed in three patients (5.6%; one BA, two THA). Pulmonary complications occurred in one BA patient (1.9%), and cardiac complications occurred in one THA patient (1.9%). All were managed conservatively. Limb length discrepancy (<1.5 cm) occurred in three patients (5.5%; two BA, one THA) and was corrected with a shoe raise (Table 2). No neurovascular deficits were noted.

Chi-square analysis comparing complication rates between BA and THA groups demonstrated no statistically significant difference (χ²=1.74, P=0.187). When grouping all medical complications (deep vein thrombosis, infection, urinary tract infection, pulmonary, and cardiac) versus none, the relative risk for the BA group compared with THA was 1.28 (95% confidence interval, 0.58–2.82), showing no significant association.

Five patients died before the minimum 24-month follow-up: three patients with multiple comorbidities died from cardiopulmonary arrest, one died in a road traffic accident, and one died following abdominal surgery. Mortality did not differ significantly between BA and THA groups (Fisher exact test, P=0.622).

Follow-up and functional outcomes

The mean follow-up duration was 28.4 months (range, 24–34 months). At the final follow-up, the mean HHS was 79.2 (range, 67–88), which was significantly higher than the preoperative value of 54.4 (paired t-test, P<0.05). No reoperations were required, and radiographs demonstrated stable implants with no evidence of loosening or subsidence (Table 3). Post hoc power analysis for the HHS difference between BA and THA yielded a power of 72.4% at α=0.05.

DISCUSSION

Despite the relatively low incidence of proximal femur fracture fixation failure (3%–31%), it remains a significant cause of morbidity and poses substantial surgical challenges that require the expertise of highly skilled surgeons [4,7–9]. Management typically involves either revision osteosynthesis or conversion to hip arthroplasty, with the current literature increasingly favoring arthroplasty because of its superior clinical and functional outcomes [6]. However, both approaches carry inherent risks, making meticulous patient selection essential [6,9,10].

Types and challenges of fixation failure

Fixation failure can present in multiple forms, with screw cutout being a particularly common complication, especially in osteoporotic bone [11]. Poor bone quality may fail to support the helical blade, allowing perforation of the femoral neck and head, which leads to pain, instability, and loss of implant function. Screw backout, often related to the Z-effect, and lateral migration of the helical blade due to inadequate bone purchase are also recognized complications. Improper tip-to-apex distance represents another major contributor to screw failure. Nonunion can result from inadequate vascularity, infection, or excessive fracture motion, and prolonged mechanical stress in such cases may induce metal fatigue, leading to screw or nail breakage [7,12]. Posttraumatic arthritis may develop from altered joint mechanics, while avascular necrosis of the femoral head, although more common in femoral neck fractures, may occur if blood supply is compromised [4,12,13].

Osteoporosis further increases the risk of implant failure by compromising fixation stability. Additional contributing factors include inadequate fracture reduction, varus or negative reduction, comminution, malpositioned PFNs, incorrect entry points, and suboptimal screw placement. Patient-related factors such as smoking, obesity, diabetes, and chronic steroid use also negatively affect healing [7,14].

BA vs. THA

BA is commonly selected for elderly patients because it requires shorter operative time and results in lower blood loss, whereas THA may provide improved functional outcomes in appropriately selected cases [15]. Complication rates, including dislocation, need for revision, and fracture, are generally comparable between the two procedures. BA offers a lower risk of dislocation due to its larger head size and greater jump distance. Mortazavi et al. [16] reported that salvage hip arthroplasty yields better outcomes for intracapsular fixation failures than for extracapsular ones, largely because the absence of bone loss permits the use of primary stems. THA, however, may be required for patients with acetabular erosion or inflammatory arthropathy. Therefore, the choice between BA and THA depends on overall health status, activity expectations, and functional demands. Key challenges in arthroplasty include preventing dislocation, managing bone defects, and minimizing the risk of periprosthetic fractures.

Technical challenges in extracapsular fracture failures

Conversion to arthroplasty for extracapsular fixation failure is technically demanding because of unstable fracture patterns, proximal femoral bone loss, acetabular erosion from lag screw cutout, calcar comminution, and difficulties with implant removal [6,17–20]. Implant extraction may produce fractures, malunions, or nonunions, which can further alter proximal femoral anatomy. In cases with poor bone stock or Dorr type C canals, cemented stems are typically preferred [21]. Modular stems may be necessary to optimize neck angle, limb length, and femoral offset [20,22–24]. Intraoperative fractures can occur during acetabular reaming or femoral canal broaching, especially in osteoporotic bone or after hardware removal [6,25]. Greater trochanter fractures may also result from bone loss, lateral lag screw entry, or excessive mechanical stress. Dislocation rates after salvage arthroplasty for fixation failure are higher than those observed after primary THA or salvage arthroplasty for femoral neck fractures because of abductor insufficiency, limb shortening, and malalignment [6,26].

Complications and mitigation strategies

Dislocation is the most common postoperative complication and is associated with prior surgical approach, abductor muscle weakness, or insufficient medial offset [10,22,25,27]. Dual mobility cups may reduce the risk of dislocation in high-risk patients, although concerns remain regarding operative time, cost, and potential local reactions [28,29]. Increasing combined anteversion, reducing cup inclination, and stabilizing the greater trochanter help improve postoperative stability. Matching both vertical and horizontal offsets during preoperative planning is essential.

Periprosthetic fractures, reported in up to 39% of cases [6,18–20,25], may be minimized by dislocating the hip before implant removal, positioning the stem well distal to the fracture site, and using preventive cerclage wiring [6,18,19]. In this study, stems were placed at least 1 cm distal to the distal screw hole to reduce fracture risk. When necessary, the femoral head was used as an autograft.

Periprosthetic infection remains a severe complication, particularly in older patients with bone loss, and may require complex revision procedures [18,20,25]. Preventive strategies include meticulous aseptic technique and appropriate perioperative antibiotic therapy. Mahmoud et al. [23] reported higher complication rates for THA performed after failed fixation compared with primary THA, whereas DeHaan et al. [24] found that technical complexity and complications were more strongly associated with the fixation device than with the fracture pattern.

Conclusions

PFN fixation remains an effective primary treatment modality for proximal femur fractures; however, fixation failure is not uncommon. In such cases, conversion to hip arthroplasty often provides superior functional outcomes compared with re-osteosynthesis, although the procedure presents considerable technical challenges. Achieving optimal results requires careful patient selection, comprehensive preoperative planning, and precise intraoperative execution to minimize complications such as implant removal difficulties, periprosthetic fractures, and dislocations. Further large-scale, prospective randomized studies are needed to validate the long-term efficacy of hip arthroplasty in managing PFN failures.

ARTICLE INFORMATION

Author contributions

Conceptualization: BH; Data curation: DS; Formal analysis: DS; Methodology: all authors; Project administration: SA; Writing–original draft: BH; Writing–review & editing: DS, SA. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Radiograph showing backout of the proximal screws (black arrow) and breakage of the proximal screws (white arrow) with proximal migration of the nail. Nonunion at the fracture site with varus collapse is also noted (yellow arrow).

Fig. 2.

Radiograph depicting backout of the helical blade (proximal femoral nail antirotation II [PFNA-II]; Traffon II, Yogeshwar Implants; arrow) with comminution and nonunion at the fracture site.

Fig. 3.

Radiograph showing breakage of the proximal screws (arrow) associated with varus collapse at the fracture site.

Fig. 4.

Radiograph depicting a hybrid total hip arthroplasty, consisting of a long cemented stem and uncemented acetabular cup, with stabilization of the greater trochanter using multiple stainless steel wires (arrow).

Fig. 5.

Radiograph showing cemented bipolar hemiarthroplasty with stainless steel wire stabilization of the greater trochanter (arrow).

Fig. 6.

Radiograph showing cemented bipolar hemiarthroplasty with stabilization of the greater trochanter using a locking plate (arrow).

REFERENCES

• 1. Somersalo A, Paloneva J, Kautiainen H, Lönnroos E, Heinänen M, Kiviranta I. Incidence of fractures requiring inpatient care. Acta Orthop 2014;85:525–30.ArticlePubMedPMC
• 2. Socci AR, Casemyr NE, Leslie MP, Baumgaertner MR. Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations. Bone Joint J 2017;99-B:128–33.ArticlePubMed
• 3. Swart E, Makhni EC, Macaulay W, Rosenwasser MP, Bozic KJ. Cost-effectiveness analysis of fixation options for intertrochanteric hip fractures. J Bone Joint Surg Am 2014;96:1612–20.ArticlePubMed
• 4. Hohendorff B, Meyer P, Menezes D, Meier L, Elke R. Treatment results and complications after PFN osteosynthesis. Unfallchirurg 2005;108:938–53.ArticlePubMed
• 5. Mohanty SS, Agashe MV, Sheth BA, Dash KK. Outcome of total hip arthroplasty as a salvage procedure for failed infected internal fixation of hip fractures. Indian J Orthop 2013;47:87–92.ArticlePubMedPMC
• 6. Archibeck MJ, Carothers JT, Tripuraneni KR, White RE. Total hip arthroplasty after failed internal fixation of proximal femoral fractures. J Arthroplasty 2013;28:168–71.Article
• 7. Mittal R, Banerjee S. Proximal femoral fractures: Principles of management and review of literature. J Clin Orthop Trauma 2012;3:15–23.ArticlePubMedPMC
• 8. Fischer H, Maleitzke T, Eder C, Ahmad S, Stöckle U, Braun KF. Management of proximal femur fractures in the elderly: current concepts and treatment options. Eur J Med Res 2021;26:86.ArticlePubMedPMC
• 9. Zhang B, Chiu KY, Wang M. Hip arthroplasty for failed internal fixation of intertrochanteric fractures. J Arthroplasty 2004;19:329–33.ArticlePubMed
• 10. D'Arrigo C, Perugia D, Carcangiu A, Monaco E, Speranza A, Ferretti A. Hip arthroplasty for failed treatment of proximal femoral fractures. Int Orthop 2010;34:939–42.ArticlePubMed
• 11. Wu CC, Shih CH, Chen WJ, Tai CL. Treatment of cutout of a lag screw of a dynamic hip screw in an intertrochanteric fracture. Arch Orthop Trauma Surg 1998;117:193–6.ArticlePubMed
• 12. Harna B, Kapoor A, Verma T, Sabat D. Cemented bipolar hemiarthroplasty for unstable intertrochanteric fracture in elderly patients over 70 years: boon or bane? Eur J Orthop Surg Traumatol 2024;34:1449–56.ArticlePubMed
• 13. Barquet A, Mayora G, Guimaraes JM, Suárez R, Giannoudis PV. Avascular necrosis of the femoral head following trochanteric fractures in adults: a systematic review. Injury 2014;45:1848–58.ArticlePubMed
• 14. Sahin S, Ertürer E, Oztürk I, Toker S, Seçkin F, Akman S. Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures. Acta Orthop Traumatol Turc 2010;44:127–34.ArticlePubMed
• 15. Haidukewych GJ, Berry DJ. Salvage of failed treatment of hip fractures. J Am Acad Orthop Surg 2005;13:101–9.ArticlePubMed
• 16. Mortazavi SM, Greenky MR, Bican O, Kane P, Parvizi J, Hozack WJ. Total hip arthroplasty after prior surgical treatment of hip fracture is it always challenging? J Arthroplasty 2012;27:31–6.ArticlePubMed
• 17. Luthringer TA, Elbuluk AM, Behery OA, Cizmic Z, Deshmukh AJ. Salvage of failed internal fixation of intertrochanteric hip fractures: clinical and functional outcomes of total hip arthroplasty versus hemiarthroplasty. Arthroplast Today 2018;4:383–91.ArticlePubMedPMC
• 18. Boulat S, Neri T, Boyer B, Philippot R, Farizon F. Dual mobility cups in total hip arthroplasty after failed internal fixation of proximal femoral fractures. Orthop Traumatol Surg Res 2019;105:491–5.ArticlePubMed
• 19. Angelini M, McKee MD, Waddell JP, Haidukewych G, Schemitsch EH. Salvage of failed hip fracture fixation. J Orthop Trauma 2009;23:471–8.ArticlePubMed
• 20. Chen DW, Lin CL, Hu CC, Tsai MF, Lee MS. Biomechanical consideration of total hip arthroplasty following failed fixation of femoral intertrochanteric fractures: a finite element analysis. Med Eng Phys 2013;35:569–75.ArticlePubMed
• 21. Neri T, Philippot R, Klasan A, et al. Dual mobility acetabular cups for total hip arthroplasty: advantages and drawbacks. Expert Rev Med Devices 2018;15:835–45.ArticlePubMed
• 22. Smith A, Denehy K, Ong KL, Lau E, Hagan D, Malkani A. Total hip arthroplasty following failed intertrochanteric hip fracture fixation treated with a cephalomedullary nail. Bone Joint J 2019;101-B:91–6.Article
• 23. Mahmoud SS, Pearse EO, Smith TO, Hing CB. Outcomes of total hip arthroplasty, as a salvage procedure, following failed internal fixation of intracapsular fractures of the femoral neck: a systematic review and meta-analysis. Bone Joint J 2016;98-B:452–60.ArticlePubMed
• 24. DeHaan AM, Groat T, Priddy M, et al. Salvage hip arthroplasty after failed fixation of proximal femur fractures. J Arthroplasty 2013;28:855–9.ArticlePubMed
• 25. Dorr LD, Faugere MC, Mackel AM, Gruen TA, Bognar B, Malluche HH. Structural and cellular assessment of bone quality of proximal femur. Bone 1993;14:231–42.ArticlePubMed
• 26. Koyuncu Ş, Altay T, Kayalı C, Ozan F, Yamak K. Mechanical failures after fixation with proximal femoral nail and risk factors. Clin Interv Aging 2015;10:1959–65.ArticlePubMedPMC
• 27. Krause PC, Braud JL, Whatley JM. Total hip arthroplasty after previous fracture surgery. Orthop Clin North Am 2015;46:193–213.ArticlePubMed
• 28. Tetsunaga T, Fujiwara K, Endo H, et al. Total hip arthroplasty after failed treatment of proximal femur fracture. Arch Orthop Trauma Surg 2017;137:417–24.ArticlePubMed
• 29. Morice A, Ducellier F, Bizot P. Total hip arthroplasty after failed fixation of a proximal femur fracture: analysis of 59 cases of intra- and extra-capsular fractures. Orthop Traumatol Surg Res 2018;104:681–6.ArticlePubMed

Figure & Data

References

Citations

Citations to this article as recorded by