Managing Bone Deficiency and Nonunions of the Proximal Femur John J. Perry, MD, Brent Winter, MD, Jeffrey W. Mast, MD  Orthopedic Clinics  Volume 41, Issue 1, Pages 105-118 (January 2010) DOI: 10.1016/j.ocl.2009.08.001 Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 1 Preshaped allograft cortical bone dowels are stacked sequentially into the screw head defect to augment blade plate fixation. Dowels are then placed in the trochanter, lateral femur, and subtrochanteric canal to stop egress of cancellous graft from the holes left by the nail. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 2 Depicts two short oblique osteotomies below the captured proximal segment of a nonunion that can then allow translation of the intecallary segment laterally to facilitate gaining leg lengths approaching 2 cm. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 3 AP hip radiograph showing nonunion of 50-year-old female as described in Case 1. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 4 Lateral hip radiograph showing nonunion of 50-year-old female as described in Case 1. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 5 Depicts an alternative plan for a long oblique osteotomy that may allow good mismatch of the osteotomy surfaces therefore improving stability but would not allow rotational correction. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 6 Depicts a short oblique osteotomy which allows excellent compression and rotational correction and easily affords access to the subtrochanteric canal for grafting. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 7 The guide rod for the RIA is bent and placed in the distal femur to obtain reamings from both condyles. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 8 AP hip floroscan demonstrating guide pin placement and seating chisel advancements. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 9 Lateral hip floroscan demonstrating guide pin placement and seating chisel advancement. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 10 The plate is reduced to the shaft thereby correcting the deformity and then the osteotomy is compressed with the articulated tensioning device. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 11 The Schuli nut (Synthes) in this case helped to fine tune the valgus angulation by acting as a blocking screw. The Schuli nut can also be used to convert a nonlocking screw to a locking screw in the plate if desired due to bone quality. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 12 Case 1. Postoperative radiographs confirm reduction comparable to the preoperative plan. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 13 Postoperative radiographs (see Fig. 12) confirm reduction comparable to the preoperative plan. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 14 Case 1. Twenty-month postoperative AP pelvis radiograph confirms union of both nonunion and osteotomy sites. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 15 Case 1. Twenty-month postoperative lateral radiographs confirm union of both nonunion and osteotomy sites. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 16 Case 2. AP hip radiograph of a 29-year-old male with painful nonunion and limp. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 17 Case 2. Lateral hip radiograph of a 29-year-old male with painful nonunion and limp. Notice extension deformity. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 18 Demonstrates the preoperative plan that corrects the significant sagittal plan deformity that can be seen when treating nonunions encountered after initial treatment of proximal femur fractures with cephalomedullary nails. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 19 Case 2. Preoperative plan to correct varus and shortening encountered after initial failed treatment with cephalomedullary nail and bone grafting as described. The long oblique osteotomy also allows a long surface area for mismatch compression. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 20 Allograft dowels and RIA grafting are planned to fill the proximal defects left by the nail. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 21 Case 2. Nineteen-month AP pelvis radiograph confirms union with restoration of length and valgus angulation of the neck. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 22 (A) Case 2. Nineteen-month lateral hip radiograph confirms union with correction of extension deformity. (B) Case 3. One-year AP pelvis radiograph confirms union with restoration of length and proximal femoral geometry. (C) Case 3. One-year lateral hip radiograph confirms union and proximal femoral geometry. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 23 Case 3. A 57-year-old female with deformity after removal of an infected cephalomedullary nail. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 24 Functional views include abduction radiographs to suggest correctability. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 25 Functional views include adduction radiographs to suggest correctability. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 26 Preoperative plan includes capture of a long proximal segment to ensure stability in this extreme correction in an obese patient and short closing wedge osteotomy for correction and ease of compression. Orthopedic Clinics 2010 41, 105-118DOI: (10.1016/j.ocl.2009.08.001) Copyright © 2010 Elsevier Inc. Terms and Conditions