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. 2024 Jan;34(1):167-173.
doi: 10.1007/s00590-023-03627-6. Epub 2023 Jun 29.

Subtrochanteric nonunion after intramedullary nailing due to pathological fracture: proximal femoral replacement as a salvage approach

Moses I Markowitz  1 , Waleed Al-Hardan  2 , David S Constantinescu  2 , Juan Pretell-Mazzini  2 , Sheila A Conway  2
Affiliations

Subtrochanteric nonunion after intramedullary nailing due to pathological fracture: proximal femoral replacement as a salvage approach

Moses I Markowitz et al. Eur J Orthop Surg Traumatol. 2024 Jan.

Abstract

Purpose: To assess proximal femoral replacement as a treatment solution for nonunion of pathologic subtrochanteric fractures after cephalomedullary nailing in patients with pathological fracture and previously irradiated bone.

Methods: Retrospective review of five patients with pathological subtrochanteric femoral fractures that were treated with cephalomedullary nailing and developed a nonunion, which was revised with conversion to a proximal endoprosthetic replacement.

Results: All five patients had previously been treated with radiation. One patient had the latest follow-up at 2 months postoperatively. At that time, the patient was walking with a walker for assistance, with no evidence of hardware failure or loosening on imaging. The remaining four patients had the latest follow-up ranging from 9 to 20 months after surgery. At their latest follow-up, three of the four patients were ambulatory with no pain, using only a cane for assistance with longer distances. The other patient demonstrated pain in his affected thigh, utilizing a walker for assistance with ambulation at latest follow-up, but not requiring further surgical interventions. There were no hardware failures or implant loosening through the follow-up period. None of the patients required revision, and there were no postoperative complications observed at their last follow-up.

Conclusions: In patients with pathological fractures in the subtrochanteric region that is treated with cephalomedullary nailing and developed a nonunion, treatment with conversion to a proximal femoral replacement with a mega prosthesis is a valuable treatment with good functional results and low risk for complications.

Level of evidence: Therapeutic level IV.

Keywords: Endoprosthetic replacement; Intramedullary nail nonunion; Metastatic bone disease; Pathologic fracture; Proximal femoral replacement; Subtrochanteric fracture nonunion.

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