This document discusses the evaluation and treatment of trochanteric and subtrochanteric femoral nonunions. It notes that nonunion must be considered for persistent pain after fixation or hardware failure. CT can help differentiate nonunion from malunion when hardware obscures radiographs. Treatment depends on factors like age, hardware status, and femoral head/neck quality. Younger patients may be treated with bone grafting or hardware revision while older patients may be candidates for arthroplasty. Various fixation methods are discussed like intramedullary nails, blade plates, and locking plates. Hardware failure, malreduction, and deformity correction are also addressed.

1. TROCHANTERIC AND SUBTROCHANTERIC NON
UNION
PROF DR MAHMOUD M.HADHOUD

2. The metaphyseal area with its good blood
supply promotes healing.
nonunion must be in the differential if the
patient has persistent pain after fixation or
if the hardware fails.
TROCHANTERIC FRACTURES

3. VISUALIZATION OF THE NONUNION
may be difficult due to hardware
obscuring the fracture line, which also
may be out of the plane of standard
radiographs.
Computerized tomography is used in
differentiating nonunion from malunion.

4. DECISION-MAKING DEPENDS ON
patient age and functional status,
the status of previous hardware, the quality of
the femoral head and neck, and
critically whether the acetabulum is intact.

5. AGE
In the younger, more active patient
achieving union is preferred,
in the older, lower demand patient
arthroplasty should be considered.

6. BONE GRAFT
 satisfactory alignment with intact hardware
and hip articulation, the option for simple
bone grafting with or without hardware
revision can be successful.
Otherwise, the hardware should be revised.

7. BIOMECHANICS
 An intramedullary device offers a biomechanical
advantage and provide bone graft from reaming.
 The intramedullary device lies in the axis of force
of the proximal femur
 side plate is more lateral,so cantilevering when
the side plate is loaded with weight bearing.

8. A BLADE PLATE
A blade plate offers alternate fixation of the
proximal segment entering very proximally
laterally while taking advantage of the often-
pristine area of the inferior head and neck.
It can also allow for compression axially while
correcting the varus deformity.

9. PROXIMAL FEMUR-LOCKING PLATES
The use of proximal femur-locking plates may
be successful . but has been associated with a
number of reported failures

10. HARDWARE FAILURE
Varus deformity and lucency around the
implant are signs of nonunion.
Hardware failure may be seen in the form of
pull out or breakage

11. INTRAMEDULLARY DEVICES BREAKDOWN
Intramedullary devices may fracture at the
junction of the lag screw and the rod.

12. BROKEN NAIL

13. DYNAMIC HIP SCROW
 X-ray right hip anteroposterior
view (a) 4 months after injury
showing sclerotic margins. (b)
Follow-up X-ray after 1 year
showing DHS in situ and union
at the fracture site

14. DHS
 Abduction–adduction
anteroposterior X-rays (a and
b) showing hypermobile
nonunion in a 62-year-old
female (c and d) X-rays
anteroposterior and lateral
views at 6 months showing
union

15. 6 MONTHS
 X-ray right hip anteroposterior
view 61/2 months after injury
showing (a) nounion (b) 6
weeks after surgery

16. VARUS NONUNION (NECK SHAFT ANGLE 85°) OF TROCHANTERIC FRACTURE IN A 63-YEAR-
OLD MALE TREATED WITH VALGUS INTERTROCHANTERIC OSTEOTOMY AND DHS WXATION
WITHOUT ADDITIONAL BONE GRAFT

17. ARTHROPLASTY
 In the elderly patient or when the hip articulation is
damaged, arthroplasty offers a reliable method for restoring
mobility
 A hemiarthroplasty can be used if the acetabulum is intact.
 A unipolar head allows for improved stability compared to a
total arthroplasty at the risk of acetabular wear and arthritis.

18. A CALCAR-REPLACING STEM CAN BE USED

19. CONVENTIONAL OR REVISION
ARTHROPLASTY
 , When planning for the arthroplasty, restoration of normal
biomechanics with restoration of length and offset will
provide optimal results.
 However, changes from the surgery and subsequent
deformation may lead to contracted soft tissues and weak
abductors.

20. SUBTROCHANTERIC NONUNION
union rates of 100% using a blade plate and
indirect reduction techniques .
modern standard and cephalomedullary nails
noted union rates of 92–100%

21. ASSESSMENT
 The radiographic evaluation of this region is more
straightforward
 computerized tomography may be useful to evaluate the
location and extent of the nonunion.
 Clinical and radiographic assessment of length, angulation,
and rotation for creating the surgical plan and informing
the patient of expected outcomes.

22. THE SURGEON MUST TAKE INTO ACCOUNT
Previous factors
the status of the existing hardware present.

23. NAIL
 In many cases of nonunion with a preexisting nail, exchange
reamed nailing allows for use of previous approaches while
the reaming provides bone graft when no significant
deformity is present.
 in larger diameters of 13 and even 15 mm upon request
from the manufacturers enhancing not only the strength of
the nail but also the fill within the canal.

24.  The use of dynamic interlocking can further enhance
compression at the fracture.
 Alternatively, bone graft in situ can be considered when
the fracture implant, nail, or plate is intact
 the surgeon must be satisfied that the construct provides
appropriate stability and no significant deformity is
present.

25. A BLADE PLATE OR A 95° CONDYLAR PLATE
A blade plate or a 95° condylar plate
placed centrally into the inferior femoral
head is a useful alternative device
particularly when alternate control of the
proximal segment is felt to be necessary

26. ANGLED BALADE PLATE AND FIBULAR GRAFT

28. DEFORMITY
 When shortening is noted, restoration of native
length can be achieved in one stage with use of
bone graft and an intramedullary nail.
 Decision-making should be based on the ability to
correct deformity if present and maintain fixation in
the proximal segment to achieve union.

29. BROKEN NAIL
 Atypical fracture of the proximal femur:
 a nonunion with broken nail (initially fixed in
slight varus),
 b healed after revision fixation with larger nail

30. PLATE OVER NAIL

32. in a very unusual circumstance,
proximal femoral replacement can
be considered as a reconstructive
option.
Stability of the hip joint and the
function of the hip abductors are a
challenge to restore.

33. 83 YEARS OLD

34. VASCULARIZED FIBULA
 In cases where the biologic environment for healing is severely
compromised due to the presence of segmental bone loss or from
devascularization from multiple surgical procedures, infection, or
irradiation, a vascularized fibula strut may allow for bypassing of
the affected segment into an environment that allows for healing.
In addition to the technical challenge of the vascular anastomosis,
 a stable construct must be created for both the fibular strut and
the femur as whole.

35.  The fibula may be inset into the medullary
canal or into a trough anteriorly or even
medially. A plate may then stabilize the femur.
 Union must be achieved of the fibula to the
proximal and distal femur segments.
 The segment may then gradually hypertrophy
in response to physiologic stress of loading
the femur.
 Weight bearing and activity must be limited
and gradually advance in the course of the
healing process.

36. Another scenario for delayed or nonunion
of the proximal femur occurs in
association with the so-called atypical
fractures femur in association with
prolonged bisphosphonate use .

37.  At the time of initial treatment, bisphosphonate treatment
should be terminated. The use of dynamic interlock allows for
compression with weight bearing. In the event of nonunion,
exchange reamed nailing will typically result in success.
 varus alignment, the use of a blade plate or dynamic condylar
plate can correct the deformity and compress across the
fracture.

38. MEDIAL CORTICAL SUPPORT
 Risk factors for nonunion after
intramedullary nailing of subtrochanteric
femoral fractures
 intraoperative correction of varus
malalignment and restoration of the medial
cortical support are the most critical factors
to prevent nonunion after intramedullary
nailing of subtrochanteric femoral fractures.
In addition, autodynamisation of the nail
within the first 3 months post-surgery is a
strong predictor for failure and should
result in revision surgery .

39. MALREDUCTION
 Nonunion of subtrochanteric
fractures: Comminution or
Malreduction
 When displacement is present after
performing internal fixation for
comminuted subtrochanteric
fractures, the probability that stable
fixation will not be achieved appears
to be higher, meaning that the risk
of non-union will increase .

40.  Various treatment strategies can be effective,
however, all share common principles:
restoration of the neck-shaft angle—avoiding
varus, obtaining stable fixation of the proximal
fragment, and obtaining good apposition of
viable bony surfaces. Both intramedullary and
plating techniques can be effective, and they are
typically chosen based on prior failed fixation
strategies, bony defects, and, importantly, the
length of the remaining proximal segment .

41. Thank you