Complex Femoral Reconstruction in an Osteoporotic Elderly Patient: From Trochanteric Femoral Nailing Fixation to Hemiarthroplasty.

Hip fractures in elderly patients with poor bone quality carry a high risk of complications such as malunion and per-implant fractures, especially in the presence of pre-existing implants. We report an 82-year-old male patient with multiple comorbidities and prior distal femoral fixation in 2011 who initially underwent trochanteric femoral nailing (TFNA) for a right intertrochanteric fracture, resulting in good recovery. One year later, he sustained a new fall, resulting in a peri-implant fracture and a right distal radius fracture. CT imaging revealed an occult malunion of the prior femoral neck fracture, leading to mechanical instability. Given poor bone quality and overlapping hardware, he underwent hardware removal, plating, and conversion to uncemented hemiarthroplasty via a lateral approach. Postoperatively, he was mobilized with a walker but required a wheelchair for longer distances due to lower-limb weakness and limitations from the wrist injury. This case highlights the value of advanced imaging in detecting occult malunion and the need for individualized surgical planning in elderly patients with complex fractures and prior hardware. Conversion arthroplasty remains an effective solution for per-implant fractures and malunion, facilitating early mobilization and functional recovery in high-risk patients.