Revision Strategies for Subtrochanteric Femur Non-Union: A Case Series of Surgical Management.

Abstract

Subtrochanteric fracture non-unions present significant surgical challenges due to complex biomechanics, muscle forces, and limited vascularity, often leading to malunion, nonunion, and implant failure. We aim to present diverse approaches to the management of subtrochanteric fracture nonunions. We reviewed surgically managed subtrochanteric femoral nonunion cases aged 18-80 years while excluding infected nonunions and periprosthetic fractures. Preoperative planning involved identifying nonunion contributing factors and devising a plan for biomechanical and biological optimization, including realignment, margin freshening, compression and bone grafting. Implant choice was individualized based on the failure mechanism. The primary outcome was progression to union, and secondary outcomes included time to union, Merle d'Aubigne scores, and complications. 44 eligible cases underwent revision surgeries, with all achieving union by the last follow-up. The mean patient age was 42.82 years. Twin-screw proximal femur nails were the most common initial fixation device. Pre-existing mechanical factors contributing to non-union included a fracture gap and malalignment. Revision fixation modalities (with bone grafting) mostly included the use of 95° angled blade plates, augmentation with an anterior plate with previous implant retention and use of proximal femur locking plates. The mean follow-up was 17.30 months, and functional outcomes were good with minimal complications. A comprehensive, individualized approach that addresses mechanical alignment, fracture compression, rigid fixation, and biological healing is crucial for subtrochanteric nonunion. High union rates and good functional outcomes may be achieved through well-planned fixation strategies, considering altered bony morphology and appropriate implant selection based on the extent of malalignment and loosening.