Hip Fracture Nonunions: Diagnosis, Treatment, and Special Considerations in Elderly Patients

In the United States, more than 300,000 hip fractures occur annually in the elderly population with associated significant morbidity and mortality. Both intracapsular and extracapsular hip fractures have inherent treatment challenges and therefore are at risk of nonunion complications. A systematic assessment including radiographic, metabolic, and infectious evaluations should be completed for all patients suspected of nonunion. Failed internal fixation of intracapsular hip fractures is typically treated with arthroplasty, while extracapsular proximal femur nonunions may be amenable to revision internal fixation or arthroplasty. While not a classic hip fracture, bisphosphate associated subtrochanteric femur fractures affect a similar patient population and are historically difficult to treat. Atypical subtrochanteric femur fractures are at increased risk of nonunion given the altered biologic environment secondary to bisphosphonate use; therefore adjuvant therapies may be beneficial in setting of revision fixation. Having a thorough understanding of nonunion risks, recognition, evaluation, and treatment is necessary for appropriate patient care.