• Josh E Shroeder, Rami Mosheiff, Amal Khoury, Meir Liebergall, and Yoram A Weil.
• Orthopaedic Trauma Service, Hadassah Hebrew University Hospital, Jerusalem IL-91120, Israel.
• J Orthop Trauma. 2009 Oct 1; 23 (9): 653-7.

ObjectiveTo determine the effectiveness of closed, intramedullary exchange nailing with reamed insertion for the treatment of femoral shaft nonunions previously treated with an intramedullary nail.DesignRetrospective cohort study.SettingAcademic level I trauma center.PatientsForty-two patients whose femoral shaft fracture was initially managed with an intramedullary nail, were subsequently treated by closed, intramedullary exchange nailing with reamed insertion for their femoral nonunion in our center. Seven patients had an infected nonunion as proved by intraoperative cultures.InterventionClosed, intramedullary exchange nailing with reamed insertion of a larger diameter nail.Main Outcome MeasurementsRadiographic and clinical evidence of fracture healing.ResultsThirty-six patients (86%) had their fracture heal without further intervention. The average time to achieve union was 4 months after surgery. Of the 6 cases of exchange nailing failure, 3 were aseptic and 3 were septic. All these 6 patients healed after additional procedures. Lack of immediate weight bearing, open fractures, atrophic/oligotrophic nonunions, and infection were associated with treatment failure. A second nail larger by 2 mm or more than the original nail was associated with a higher success rate.ConclusionsClosed, intramedullary exchange nailing with reamed insertion for femoral shaft nonunions previously treated with intramedullary nails has proved to be a successful sole procedure in most cases. A nail at least 2 mm larger in diameter than the first nail should be used if possible. Risk factors of treatment failure should alert the surgeon to consider an alternative treatment to closed exchange nailing.

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