Nonunion of intertrochanteric fractures

The nonunion of intertrochanteric fractures incidence is 1-2%. The most common causes of nonunion are mechanical failure due to inaccurate fracture reduction or inadequate choice and placement of the fixation device; posteromedial comminution; and osteoporosis. The diagnosis of nonunion should be suspected when, 15 weeks or more after the injury, there remains a fracture line on radiographs, with either no callus (atrophic) or with callus that does not bridge the fracture site (hypertrophic); and when the patient has persistent pain after fixation or hardware failure. Visualization of the nonunion on radiographs can be difficult due to hardware obscuring the fracture line. Computed tomography is of value in confirming the diagnosis. In young, active patients, we should attempt to heal the nonunion by revision internal fixation, valgization and bone grafting; however, in older, less functionally demanding patients, arthroplasty should be considered. In cases of relevant varus axis deviation and comminuted or atypical fracture configurations, limited open auxiliary plate fixation can be a reasonable option, regardless of the patient’s age. The trochanteric buttress plate can be used to augment, fix or buttress the lateral trochanteric wall. Short cephalomedullary nail revision fixation in well-aligned nonunions with sufficient bone stock is a simpler and potentially less morbid therapeutic option than open surgery with fixed-angle devices. Arthroplasty should be used in nonunions with insufficient bone stock in the proximal femur. A hemiarthroplasty (if the acetabulum is intact) or total hip arthroplasty may be implanted.