High rate of complications with exchange nailing for femoral nonunions

Objectives: To evaluate rates of nonunion repair, osseous healing, and outcomes in femoral nonunions with contemporary healing. Design: Retrospective review. Setting: Five academic level 1 trauma centers. Patients/Participants: This study includes adult patients (age older than 18) seen at one of the participating institutions between 2012 and 2019 who sustained a femur fracture (OTA/AO 31, 32, 33) initially treated with intramedullary fixation that developed nonunion and were treated with exchange nailing for the index nonunion surgery. Seventy-nine patients with femoral nonunion met inclusion criteria. Intervention: Exchange nailing for treatment of femoral nonunion. Main Outcome Measurements: The primary outcome measure was radiographic osseous union. We further analyzed union rates by OTA/AO classification, nonunion type, implants used, graft used, time from the initial procedure, and infection status. Results: Seventy-nine patients met inclusion criteria. Rates of osseous union were similar by OTA/AO classification ( P = 0.48), nonunion type (hypertrophic, oligotrophic, atrophic) ( P = 0.52), implant/biologic used ( P = 0.45), and time from the initial procedure until exchange nail procedure ( P = 0.09). Forty-two patients had inflammatory laboratory markers (C-reactive protein, erythrocyte sedimentary rate) and cultures obtained during the first nonunion surgery with no significant differences in union ( P = 0.29) based on laboratory and culture results. However, a considerable number of complications were encountered (n = 32; 41%). Common complications included reoperation (n = 30; 38%) secondary to recalcitrant nonunion, readmission, implant failure, and infection. Conclusions: This large, multicenter study with modern implants, instruments, and techniques for exchange nailing of femoral nonunions demonstrates high rates of reoperation (n = 30; 38%), but higher rates of osseous healing (n = 68; 86% healed) than previously reported data in the literature. Level of Evidence: III.