Malunions of the Proximal Femur

Proximal femur fractures are among the most frequently encountered by orthopaedic surgeons. Due to the high forces around the proximal femur and the difficulty associated with treating many of these fracture patterns, malunions of the proximal femur can occur. While some proximal femur malunions cause severe functional limitations, a number of others remain minimally symptomatic, which has led to proximal femur malunions receiving less attention in the literature to date than other proximal femoral complications, such as nonunions. A variety of causes including nonoperative management or neglect, iatrogenic malreduction, and loss of fixation with subsequent loss of reduction can lead to a proximal femur malunion. The majority of proximal femur malunions are in varus and short with some containing significant rotational components as well. Consequently, correction of these malunions typically involves a valgus intertrochanteric osteotomy to restore length and alignment, but some malunions require multiplanar correction while others benefit more from salvage arthroplasty. As in most cases, prevention of malunion is the best treatment. Therefore, during the initial management of femoral head, femoral neck, intertrochanteric, and subtrochanteric fractures, providers should always aim for anatomic reconstruction with avoidance of malreduction. A stable fixation construct will aid in prevention of hardware failure, which minimizes the need for and morbidity associated with revision surgery.