What are the treatment options for a patient 12 months post-femoral nailing with a visible fracture line on both lateral and anteroposterior (AP) views?

Management of Persistent Fracture Line at 12 Months Post-Femoral Nailing

At 12 months post-femoral nailing with a visible fracture line on both AP and lateral radiographs, this represents a nonunion requiring revision surgery, with the posterior approach or circumferential fusion demonstrating superior outcomes compared to anterior revision alone.

Defining the Problem

A visible fracture line at 12 months post-operative indicates established nonunion rather than delayed union 1. This distinction is critical because:

• Nonunion at this timeframe will not heal without intervention 1
• Patients with persistent nonunion who do not achieve solid fusion ultimately require revision surgery 1
• The presence of a fracture line on both orthogonal views (AP and lateral) confirms the diagnosis radiographically 1

Assessment of Hardware Status

Before proceeding with revision, evaluate for:

• Hardware failure or fatigue: Nail failure occurs in <2% of cases but significantly impacts revision planning 2
• Quality of original reduction: Poor reduction quality (varus positioning, inadequate neck-shaft angle restoration) results in significantly earlier failure (p=0.027) 2
• Tip-Apex Distance (TAD): Should be <25mm; inadequate TAD with poor three-point fixation increases failure risk 2
• Signs of infection: Must be excluded before revision 3

Revision Surgical Options

Primary Recommendation: Revision with Enhanced Fixation

Revision intramedullary nailing or plate fixation should be performed, with the specific approach determined by:

1. Revision CMN (Cephalomedullary Nail): Lowest mortality rates at 12 months among revision options 2

   • Appropriate when bone stock is adequate 2
   • Requires assessment of canal diameter and bone quality 3

2. Proximal Femoral Locking Plate (PFLP): Alternative option but carries higher subsequent revision rates 2

3. Arthroplasty options (long-stem or restoration arthroplasty, femoral endoprosthesis): Reserved for cases with:

   • Severe bone loss 2
   • Poor bone quality precluding internal fixation 2
   • Elderly patients with significant comorbidities 2

Evidence for Revision Approach Selection

The literature on pseudarthrosis management demonstrates:

• Posterior approach: Achieves solid fusion in 94% of patients, with 77% improvement in axial pain and 83% improvement in appendicular pain 1
• Anterior revision alone: Only 45% fusion rate with 45% hardware failure rate 1
• Circumferential approach: 100% fusion rate, though with 28% hardware failure 1

Critical Technical Considerations

Avoiding Previous Errors

The original fixation likely failed due to 4:

• Inadequate preoperative analysis of fracture pattern 4
• Undetected intraoperative comminution during reaming 4
• Inappropriate use of dynamic vs. static locking 4
• Poor reduction quality at index surgery 2

Revision Surgery Requirements

• Static interlocking fixation is mandatory for revision cases 4
• Dynamic fixation should never be used in nonunion revision 5, 4
• Bone grafting may be necessary to promote union 1
• Ensure adequate reduction before final fixation 2, 4

Perioperative Management

Preoperative Planning

• Confirm complete assessment of nonunion on radiographs 3
• Assess for implant loosening or additional failure 3
• Consider advanced imaging (CT) if fracture morphology unclear for surgical planning 1

Anesthetic Approach

• Spinal/epidural anesthesia preferred to reduce postoperative confusion 3
• Prophylactic antibiotics within one hour of incision 3
• Consider peripheral nerve blockade for pain control 3

Postoperative Protocol

• Thromboprophylaxis per protocol 3
• Weight-bearing status depends on fixation stability - typically protected weight-bearing initially 5
• Close radiographic follow-up to assess union progression 1

Expected Outcomes and Prognosis

• 12-month mortality after revision: 30%, equivalent to primary hip fracture mortality risk 2
• Functional outcomes: Barthel Functional Index scores show no significant difference between revision techniques at 3 and 12 months 2
• Union rates: Vary by technique but posterior/circumferential approaches superior 1
• Patients achieving solid fusion report excellent or good outcomes 1

Critical Pitfall to Avoid

Do not adopt a "wait and see" approach at 12 months - this represents established nonunion requiring intervention 1. Continued observation without surgical revision will result in persistent symptoms, potential hardware failure, and ultimately necessitate more complex revision surgery 1, 2.