How to manage a 2months old non union intertrocganteric fracture
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intertrochanteric fracture AND nonunion
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intertrochanteric fracture nonunion management review revision fixation arthroplasty
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https://pmc.ncbi.nlm.nih.gov/articles/PMC7443291/
At 2 months, an intertrochanteric fracture is often better described as delayed healing or failed fixation, not definite nonunion. A study definition of primary intertrochanteric nonunion uses persistent fracture line and absent/nonbridging callus at 15 weeks or more, with motion at the fracture site. This review describes the definition.
This needs prompt assessment by an orthopaedic trauma or hip-revision surgeon, especially if there is increasing pain, inability to bear weight, shortening/external rotation, or an implant that is failing.
Assessment
- AP pelvis and full-length femur X-rays, including lateral hip.
- Look for loss of reduction, varus collapse, lag-screw cut-out/cut-through, nail or plate breakage, and callus.
- CT scan with metal-artifact reduction if union, fracture gap, rotation, or implant position is uncertain.
- Review the initial fracture pattern, reduction quality, implant type/position, weight-bearing history, smoking, diabetes, nutrition, vitamin D status, and osteoporosis.
- Exclude infection, particularly with wound drainage, fever, raised ESR/CRP, or unexplained early loosening. If suspected, obtain cultures during revision before antibiotics when clinically safe.
Management depends on the current X-ray and patient factors
| Situation | Usual direction of management |
|---|---|
| Fixation stable, alignment maintained, and progressive callus | Continue protected or surgeon-directed weight bearing, optimize bone health/nutrition, and repeat imaging in 4-6 weeks. |
| Loss of fixation, varus collapse, screw cut-out, broken implant, painful mobile fracture, or no radiographic progression | Usually revision surgery rather than waiting. |
| Physiologically younger patient with viable femoral head and adequate bone stock | Head-preserving revision fixation: remove failed implant as needed, restore reduction and medial support, correct varus, use a stable implant suited to the pattern, and add autologous bone graft/biologic augmentation when indicated. A valgus-producing corrective osteotomy can be considered in selected varus nonunions. |
| Frail older adult, severe osteoporosis, poor proximal femoral bone stock, articular damage, or failed fixation not reliably reconstructible | Conversion hemiarthroplasty or total hip arthroplasty, selected according to acetabular status, activity level, and surgical risk. It may permit earlier mobilization but is technically more complex than a primary hip replacement. |
The main salvage choices after failed fixation are revision osteosynthesis or conversion arthroplasty. Choice is driven by physiological age, functional demand, life expectancy, fracture configuration, deformity, femoral-head/hip-joint status, and remaining bone stock. Current review of revision strategy supports revision fixation for selected patients with good bone stock, while arthroplasty is generally favored in frail older patients with poor bone quality or damaged joint surfaces.
Practical points
- Do not allow unrestricted weight bearing if the construct is unstable or failing, unless the operating surgeon specifically directs it.
- Treat contributing factors: stop smoking/nicotine, ensure adequate protein and calcium intake, measure and correct vitamin D deficiency, and assess/treat osteoporosis.
- Bone stimulators are sometimes considered for delayed union, but they do not correct mechanical instability, varus deformity, implant cut-out, or infection.
- A 2-month problem after surgery often reflects inadequate stability/reduction, fracture pattern, or early implant failure. The X-ray findings determine whether observation is reasonable or revision is urgent.
Seek urgent review or emergency care for sudden worsening hip/thigh pain, a snap or new deformity, inability to stand after previously standing, wound discharge, fever, or new calf swelling/breathlessness.
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