The patient has a incompletely united femoral shaft fracture, failure of fixation of a femoral neck fracture, and a femoral neck fracture nonunion. Something must be done operatively, for without an operation the situation will deteriorate. Once the fixation has failed and the deformity appears it inevitably goes from bad to worse. Re-reduction and fixation alone is unlikely to be successful since there will be less bone for fixation than initially. What failed once will not likely succeed when used a second time. Fibular strut grafts have not been very successful. Both vascularized fibula grafts and muscle pedicle grafts are technically demanding and have poor success rates outside of a few centers. Joint replacement is not an attractive alternative in one so young. Intertrochanteric osteotomy offers the best success rate and the opportunity to preserve the patient’s own hip joint. Figure 5.
Preoperative planning is very important with any osteotomy, in order to evaluate the correct location and angle for cuts, as well as selection of the appropriate implant. The pre-operative plan consists of three parts: a drawing of the pre-operative position and alignment, a drawing of the post-operative position and alignment with implants in place, and the written surgical tactic to get from one point to the other.
Precise correction of the force vectors across the hip has been advocated by some authors, but the degree of correction has not been shown to be related to success rate. Typically, a 200 - 300 wedge is removed laterally from the intertrochanteric region to change the weight transmission axis across the fracture site, and convert shear forces to compression forces. In addition to improving the mechanical environment of the nonunion, biological factors may be important. Rotational deformities are assessed clinically and correction is planned at the time of surgery.
Since the femoral shaft fracture was not healed, the nail must be removed and replaced with anther fixation device. This could either be a retrograde nail or a percutaneous submuscular plate.