Salvage of failed subtrochanteric fracture fixation in the elderly: revision internal fixation or hip arthroplasty?

Purpose This study aimed to compare reoperation rate and clinical outcomes between revision open reduction and internal fixation and hip arthroplasty following failed subtrochanteric fracture fixation. Methods A retrospective review was conducted of patients > 50 years old treated for failed fixation of subtrochanteric fractures with revision ORIF or hip arthroplasty from 2003 to 2023. Primary outcomes included rate of fracture union and reoperations after initial salvage therapy. Secondary outcomes included complications (infection, dislocation, bursitis, implant prominence, implant failure, nonunion), pain, and gait-aid requirements by final follow-up. Results Forty-four patients were identified: 34 treated with revision ORIF and 10 with hip arthroplasty. The arthroplasty cohort was older (75.4 vs. 66.0 years, p = 0.016) but did not differ from the ORIF cohort in sex, type of initial fixation, or reason for fixation failure. Patients treated with revision ORIF and patients treated with arthroplasty had similar rates of fracture union (85.3% vs. 80.0%, p = 0.772) and reoperation (35.3% vs. 30.0%, p = 0.710). There was no significant difference in rate of additional complications not requiring reoperation (0.0% vs. 40.0%, p = 0.071). The arthroplasty cohort achieved full weightbearing in significantly shorter time than the revision ORIF cohort (3.8 vs. 6.8 weeks, p = 0.005). Conclusion Both revision ORIF and hip arthroplasty are acceptable options for salvage of failed subtrochanteric fracture fixation in patients greater than 50 years old, but patients should be counseled that although the rate of fracture union is high whether revision ORIF or hip arthroplasty is selected, the rate of reoperation can exceed 1-in-4 patients. Level of Evidence: Level III, Retrospective Comparative Study.