The use of endosteal substitution in the treatment of recalcitrant nonunions of the femur: report of seven cases.

Seven patients, with an average age of 53 years, were treated for bone loss or recalcitrant nonunions of the femur. The average duration from initial injury to presentation was 37 months (range 4-92 months). The patients had undergone one to eight (mean, 3.9) previous surgical attempts at achieving union. The nonunion involved the diaphysis in three patients, the diaphyseal-supracondylar junction in three patients, and the pertrochanteric region in one patient. All patients were treated using a standard lateral plate in combination with an endosteal plate and primary iliac crest bone grafting. The mean surgical time was 6.3 h, and the average blood loss was 1.7 L. There were three complications, including one superficial wound infection, one nonfatal pulmonary embolism, and one wound hematoma. At a mean follow-up of 12.6 months (range 4-24 months), all fractures had healed with an average time to union of 19.2 weeks (range 15-36 weeks). Knee flexion averaged 118 degrees (range 100-135 degrees), and all patients were satisfied with the operative procedure. Endosteal plating, in combination with a standard lateral plate and iliac crest bone-grafting, can successfully treat difficult nonunions of the femur.