• Michael J Millar, Andrew Wilkinson, Pierre Navarre, Joel Steiner, Ashray Vohora, Andrew Hardidge, and Elton Edwards.
• Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia.
• J Orthop Trauma. 2018 May 1; 32 (5): 245-250.

ObjectivesTo evaluate patient-independent risk factors for aseptic femoral hypertrophic nonunion requiring exchange nailing, with particular reference to the fit of the nail at the isthmus within the canal.DesignRetrospective case control study.SettingLevel 1 trauma center.Main Outcome MeasurementsBetween 2008 and 2012, 211 patients without any patient-dependent risk factors for nonunion were treated with a locked reamed intramedullary nail for a femoral shaft fracture. Twenty-three cases went on to hypertrophic nonunion requiring exchange nailing (treatment group) and 188 cases went on to union (control group). Patient-independent risk factors for exchange nailing were documented.ResultsPatient-independent risk factors for exchange nailing were poor fracture reduction [Odds ratio (OR): 11.5, 95% confidence interval (CI), 4.0-33.4, P < 0.001], open fracture (OR: 7.6, 95% CI, 3.0-19.6, P = 0.004), Winquist classification of 4 (OR: 4.4, 95% CI, 1.9-6.7, P = 0.016), and poor nail fit (OR: 10.3, 95% CI, 5.1-28.4, P < 0.001). Multivariate analysis revealed nail fit as an independent predictor of femoral nonunion requiring exchange nailing (OR: 11.4, 95% CI, 6.9-15.2, P < 0.001). Moreover, we found a direct relationship between increasingly poor nail fit and increased risk of exchange nailing, with the criterion occurring at a nail fit ratio <70%.ConclusionWhen proceeding to femoral fracture reamed intramedullary nailing, we recommend a minimum nail fit of 70% at the isthmus and ideally 90% or more, to avoid surgical reintervention.Level Of EvidencePrognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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