Use of medialized trochanteric-entry intramedullary nail to improve alignment in proximal femur nonunions.

Purpose: Proximal femur shaft nonunion is a challenging problem, often occurring after malreduction that results in postoperative malalignment and decreased healing potential. Correction of malalignment is critical to achieving osseous union. Here we present a novel technique for treating proximal femur nonunions with varus malalignment using an intramedullary nail inserted through a medialized trochanteric entry point.

Methods: Patients who underwent a proximal femur shaft (subtrochanteric or proximal third shaft) nonunion operation at a single level 1 academic referral centre by two attending surgeons between 1/1/2014 and 1/1/2022 were identified. Radiographic imaging was reviewed to determine initial fracture classification and calculation of coronal plane alignment (CPA), which was measured on preoperative, immediate postoperative, and final follow-up radiographs. Postoperative complications, reoperations, infections, and osseous union were also collected.

Results: Twenty-one patients with a mean age of 49.9 years (66% male) were identified. Mean preoperative CPA was 125.6 degrees, immediate postoperative mean CPA was 132.6 degrees, and mean final follow-up CPA was 131.5 degrees. Mean change in CPA from immediate postoperative films to final follow-up was a decrease of 0.4 degrees. 17 patients had follow up for a minimum of 12 months or until osseous union, and all achieved union without any major complications.

Conclusion: Exchange nailing with an antegrade trochanteric entry nail through a medialized trochanteric starting point is a safe and effective technique in the treatment of proximal femur nonunions. This technique results in improved postoperative alignment that is sustained throughout the postoperative course, and may lead to increased rates of osseous union.