Nonunion of intertrochanteric fractures of the femur following open reduction and internal fixation. Results of second attempts to gain union.

A retrospective review was performed on 20 patients treated at the authors' hospital between 1961 and 1981 with noninfected nonunions following primary open reduction and internal fixation (ORIF) of intertrochanteric femoral fractures. All patients were available for follow-up examination. Each patient was interviewed at an average follow-up period of 6.6 (0.8-11.9) years. The group consisted of 15 women and five men with an average age at the time of fracture of 63 (36-86) years. Only one fracture was "stable" while 19 were "unstable" with loss of medial support. The initial fixation device was a sliding nail or screw in four patients, fixed nail plate in 11, Smith-Petersen in two, Deyerle pins in one, and was unrecorded in two. Of the 20 cases, it was possible to obtain the original postoperative roentgenograms in 12. Anatomic reduction had been achieved in four, medial displacement osteotomy had been used in two, varus positioning in one, and valgus positioning in five. Subsequent operative treatment for the nonunions consisted of three endoprostheses, six total hip arthroplasties, and 11 repeated attempts at ORIF. Of those treated with repeat ORIF, nine (82%) achieved radiographic union at an average time of six months. Of the remaining two who did not achieve union with the second ORIF, one achieved union following removal of internal fixation and bone grafting (five months) and one required a total hip arthroplasty. The postoperative functional results, as determined by a modified Harris hip score, were improved over the preoperative functional results for each treatment mode. Functional results were best in those patients who achieved union with a second surgical attempt.