[One- or two-stage approach after osteosynthesis failure in proximal femur fracture-a narrative review]

Failure of osteosynthesis following proximal femur fracture represents an increasing challenge in geriatric traumatology. In these cases, conversion total hip arthroplasty (cTHA) is often required. It remains unclear whether a single-stage or a two-stage approach is superior in terms of infection risk and clinical outcomes.

A systematic literature search was conducted in PubMed for the period 1995-2025. Included were original articles, systematic reviews, and meta-analyses investigating single-stage or two-stage procedures following osteosynthesis failure of the proximal femur. Case reports, editorials, and studies unrelated to hip arthroplasty were excluded. A total of 17 publications were included in the analysis. Based on the findings, a clinical decision-making algorithm for treatment planning was developed in our own clinic.

The available evidence is predominantly based on retrospective studies with small sample sizes. Reported infection rates after cTHA vary widely between studies (0-8.6%). Some studies indicate advantages of the two-stage approach in terms of infection control, while others report comparable outcomes for both strategies. Positive microbiological findings despite the absence of clinical signs of infection are common, but their clinical relevance remains unclear.

Current evidence does not allow a definitive recommendation in favor of either a single-stage or two-stage approach. Individual risk stratification, considering clinical, laboratory, and radiological parameters, is crucial. The clinical algorithm presented provides a practical approach for decision-making. Prospective multicenter studies are needed to derive robust recommendations.