Patients’ basic data are presented in Table 1. Group 1 included 136 out of 190 patients (33 female, 103 male), group 2 included the remaining 54 patients (17 female, 37 male). Mean age of patients was 45.3 ± 16.3 years in group 1 versus 56.4 ± 17.7 years in group 2 and ranged from 18 to 94 years. In 135 out of 190 patients, initial fracture care was performed in an outside institution, whereas in the remaining 55 patients, initial treatment was carried out at our hospital.
According to the AO/OTA classification, group 1 demonstrated a distribution pattern of 9 A1, 20 A2, and 14 A3 fractures. According to the Seinsheimer classification, 29 Grade 1, 12 Grade 2a, 12 Grade 2c, 17 Grade 3a, 17 Grade 3b, and 6 Grade 4 fractures were coded. In 86 cases, a single cephalomedullary nail was used in the initial procedure. Seventeen patients received a cephalomedullary nail with additional cerclage. Nineteen fractures were treated initially using an antegrade femoral nail with additional cerclage. In seven patients, a retrograde nail was used. In four cases, fractures were fixed by Dynamic Hip Screw (DHS), in two cases by a curved condylar plate, and in one case by an angled blade plate. In group 1, nonunion was classified as hypertrophic in 117 cases and as atrophic in 19 cases.
In group 2, 9 patients had an A1 fracture, 12 patients an A2 fracture, and 13 patients an A3 fracture. According to the Seinsheimer classification, 12 Grade 1, 1 Grade 2a, 3 Grade 3b, and 4 Grade 4 fractures were coded. In group 2, 20 patients were treated initially using a cephalomedullary nail. In 19 patients, an auxiliary cerclage was applied to the intramedullary nail. Seven fractures were treated using an antegrade femoral nail with additional cerclage. A retrograde nail was used in three patients, and a DHS in two patients. Two patients were treated by a curved condylar plate and one remaining patient by an angled blade plate. In group 2, nonunion was classified as hypertrophic in 50 patients and as atrophic in four patients.
Prior to surgical revision, in group 1, 20 patients reported permanent pain, 101 patients reported pain on exertion, and 15 patients were not able to move without walking aids. In group 2, 19 patients described permanent pain, 32 patients reported pain on exertion, and 3 patients were able to move only with the use of crutches before revision surgery.
Revision intramedullary nailing without auxiliary plate fixation in group 1 was performed after 11.5 ± 8.4 months following initial fracture stabilization using an extended cephalomedullary nail in 114 patients (91 × Gamma3 280–440 mm; 23 × TRIGEN INTERTAN 260–460 mm). In 7 patients, an antegrade femoral nail (T2 GTN, Stryker Corp., Kalamazoo, MI, USA) and in 15 patients an extended cephalomedullary nail with supplemental cerclage was used. Supplemental osteoinductive autologous cancellous bone from the iliac crest was applied in 30 patients. Twenty-five hypertrophic and 5 atrophic nonunion cases were found in these 30 patients.
In group 2, intramedullary nail replacement combined with auxiliary plate fixation was performed 16.2 ± 15 months following initial surgical fracture treatment (p = 0.04). Auxiliary plate fixation without replacement of the initial intramedullary nail was carried out in 10 patients . In 33 patients, the previously inserted nail was replaced using an extended Gamma3 cephalomedullary nail. T2 GTN antegrade femoral nailing was used in the remaining 11 patients. Autologous cancellous bone graft was additionally applied in 36 patients, in 34 cases of hypertrophic and in 2 cases of atrophic nonunion.
The mean CDA was 124° ± 3.1° preoperatively versus 125° ± 2.6° postoperatively with a mean valgus correction of 1° in group 1 (p = 0.072) and 123° ± 2.1° preoperatively versus 130° ± 4.8° postoperatively with a mean valgus correction of 7° in group 2 (p = 0.001) (Table 1).
One year after surgical revision, radiologic follow-up examination of group 1 demonstrated nonunion healing in 129 out of 136 patients (95%). In seven patients (3 × AO/OTA 31A1, 1 × 31A2, 2 × 31A3, 1 × Seinsheimer 2a), there was no healing tendency. Fifteen patients underwent one or more additional revision surgeries in the postoperative course due to implant failure or persistent pain (Table 2). In group 2, nonunion healing was assessed radiologically in 51 out of 54 patients (94%; p = 0.23; Table 2). In three remaining patients (1 × AO/OTA 31A3, 1 × Seinsheimer 2a, 1 × Seinsheimer 3b), there was no healing tendency. In this group, the fixation material had to be replaced once again in nine patients due to implant failure or persistent pain (p = 0.29).
In the final follow-up, functional outcomes correlated with these results (Table 2): In group 1, unrestricted ROM of the hip joint was achieved in 88 patients and was still restricted in 48 patients. In group 2, ROM was free in 34 patients and still restricted in 20 patients (p = 0.25). Functional outcome according to the LEFS demonstrated 56 points in group 1 compared with 55 points in group 2 (p = 0.55).