Bulletin of the Hospital for Joint Diseases 2014;72(2):159-63

159

Intramedullary Nailing of Subtrochanteric Fractures

Does Malreduction Matter?
John T. Riehl, M.D., Kenneth J. Koval, M.D., Joshua R. Langford, M.D., Mark W. Munro, M.D.,
Stanley J. Kupiszewski, M.D., and George J. Haidukewych, M.D.

Abstract
Introduction: Subtrochanteric femur fractures remain
challenging injuries to treat. Historically, varus malreduction has been linked to the development of nonunion; however, there is a paucity of literature evaluating the impact
of sagittal plane malreduction. The purpose of this study
was to evaluate the influence of coronal and sagittal plane
malreductions on time to union of subtrochanteric femur
fractures treated with an intramedullary device.
Methods: A retrospective study was performed of all subtrochanteric fractures (AO/OTA type 32) treated at a single
institution. Inclusion criteria consisted of: 1. 18 or more years
of age, and 2. fracture stabilization using an intramedullary
device. All patients included were followed to union or revision surgery. Radiographic evidence of healing was defined as
bridging callus on three of four cortices on AP and lateral views.
Delayed union was defined as lack of radiographic healing by
4 months postoperatively and nonunion as lack of healing by 6
months. The definition of malreduction was coronal or sagittal
plane deformity greater than 10 at the fracture site.
Results: Thirty-five patients met inclusion criteria; 20
men and 15 women with an average age of 55 years (range
19 to 100 years). Mean clinical follow up was 7 months
(range 3 to 18 months). Thirty-four of 35 fractures (97%)
healed without need for additional surgery. Twenty-one of
the 35 fractures (60%) healed within 4 months of surgery.
Thirteen fractures (37%) had delayed union, and 1 (2.9%)
developed nonunion requiring reoperation.
Seven of 35 fractures (20.0%) had a malreduction of

greater than 10, defined as varus (2 fractures), flexion (4

fractures), or both (1 fracture). Of the seven fractures with
a malreduction, all (100%) developed a delayed (6) or
nonunion (1). Of the 28 fractures without malreduction, 21
(75%) healed within 4 months, 7 (25%) had a delayed union,
and none had a nonunion. The presence of a malreduction
greater than10 in any plane resulted in a significantly
higher rate of delayed or nonunion (p = 0.0005).
Conclusion: For patients with subtrochanteric fractures
treated with an intramedullary device, malreduction in any
plane of greater than 10 resulted in a significantly increased
rate of delayed or nonunion or both.

John T. Riehl, M.D., is in the Department of Orthopaedic Surgery,

University of Louisville Kentucky. Kenneth J. Koval, M.D., Joshua
R. Langford, M.D., Mark W. Munro, M.D., Stanley J. Kupiszewski,
M.D., George J. Haidukewych, M.D., are at the Orlando Regional
Medical Center, Orlando, Florida.
Correspondence: John T. Riehl, M.D., University of Louisville Department of Orthopaedic Surgery, 550 South Jackson Street, ACB
First Floor, Louisville, Kentucky 40202; jtriehl@hotmail.com.

Methods

he treatment of subtrochanteric femur fractures has

changed substantially over the past two decades.
With the widespread use of intramedullary (IM) nails
and indirect reduction, secondary fracture healing is the
primary goal; however, nonunion remains a well described
complication in the treatment of these difficult fractures.1,2
Historically, varus malreduction on the anterior-posterior
view of the proximal femur has been linked to the development of nonunion.1,2 We believe this has led to neglect of
sagittal plane deformity seen on the lateral view with IM
nail stabilization. It has been our experience that malreduction in either the coronal or sagittal plane leads to prolonged
time to union for these fractures. This study was performed
to evaluate the influence of both coronal and sagittal plane
malreduction on nonunion of subtrochanteric femur fractures
that have been treated with an intramedullary device.
A retrospective review was performed on patients who
sustained a subtrochanteric femur fracture (AO/OTA type
32) and were stabilized using a statically locked intramedullary nail between January 1, 2008, and August 1, 2011, at a
level 1 trauma center. The study was Institutional Review
Board-approved.

Riehl JT, Koval KJ, Langford JR, Munro MW, Kupiszewski SJ, Haidukewych GJ. Intramedullary nailing of subtrochanteric fractures: Does malreduction
matter? Bull Hosp Jt Dis. 2014;72(2):159-63.

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Bulletin of the Hospital for Joint Diseases 2014;72(2):159-63

Inclusion criteria consisted of: 1. age 18 years or older, 2.

presence of a nonpathologic subtrochanteric femur fracture
(from level of lesser trochanter to 5 cm distal), and 3. fracture
stabilization using a statically locked intramedullary device.
Patients were excluded if they had less than 3 months of
follow-up. All included patients were followed to clinical
and radiographic union or revision surgery.
Surgeries were performed using manufacturers suggested
technique for nail placement. A fracture table was utilized in
all cases with the patient in the supine position. Supplemental
use of cerclage wiring was recorded as well as nail type (hip
nail, reconstruction, or standard locked nail). All nails placed
were from the trochanteric starting point. Patients were allowed to bear weight as tolerated following the procedure.
Patients were found through a review of the institutions
trauma database. Charts for all patients treated with an IM
nail for intertrochanteric, subtrochanteric, or peritrochanteric fractures during the study period were evaluated for
inclusion and exclusion criteria. Demographic information,
mechanism of injury, medical comorbidities, the presence
or absence of open fracture, and orthopaedic implant were
recorded from the medical record. Preoperative and all postoperative x-rays were reviewed to determine fracture type
and final reduction. Alignment of the immediate postoperative plain x-rays were evaluated and measured digitally on
the PACS system (Fig. 1). Angulation was measured and
recorded at the fracture site on both anteroposterior and
lateral views. Angulation of 10 or greater in the coronal or
sagittal plane was defined as malreduction.
The main outcome measure was fracture healing. Healing
was defined as bridging callus on three of four cortices as
determined on the AP and lateral views. Fractures healing
between 4 and 6 months were defined as delayed unions,

Figure 1 Digital measurement of angular deformity at the subtrochanteric fracture site.

while fractures not healed by 6 months or those with hardware failure were defined as nonunions. Fractures nailed
with malreduction were compared to those without. Statistical significance was set at p < 0.05.

Results
During the study period, 75 patients were treated with an IM
nail for a subtrochanteric femur fracture. Forty patients were
lost to follow-up, leaving 35 patients available for analysis.
There were 20 males and 15 females with an average age of
55 years (range 19 to100).
The mechanism of injury was classified as high energy in
22/35 (63%) patients. Eighteen patients (51.4%) sustained
injury from some form of motorized vehicle accident (10
MVC, 4 MCC, 2 pedestrian vs. auto, 1 ATV, 1 jet ski). Four
patients (11.4%) sustained a fall from an elevated distance.
Eleven patients (31.4%) sustained a fall from standing
height. Finally, two patients (5.7%) sustained their injury
from gunshot wounds.
Three patients had open fractures (8.6%). Two of these
were due to gunshot wounds and one from an ATV accident.
Tobacco usage at the time of fracture was found in 9/35
patients (26%). Fourteen of 35 patients (40%) sustained
polytrauma, and 17/35 patients (49%) had one or more
medical comorbidities. The majority of patients were treated
within 1 day of injury (range 0 to 3). Two of 35 fractures
(6%) had an open reduction and cerclage placement at the
fracture site. Hip nails were used in 19/35 cases (54%),
reconstruction nails in 15/35 cases (43%), and standard
proximal interlocking in one case (3%).
Mean clinical follow up was 7 months (range 3 to18
months). Thirty-four of 35 fractures (97%) healed without
need for additional surgery. Twenty-one of the 35 fractures
(60%) healed within 4 months of surgery. Thirteen fractures
(37%) had delayed union, and one (2.9%) developed nonunion requiring reoperation (Fig. 2).
Seven of 35 fractures (20.0%) had a malreduction greater
than or equal to 10, defined as varus (2 fractures), flexion (4
fractures), or both (1 fracture). Of the seven fractures with a
malreduction, all (100%) developed a delayed (6 fractures)
or nonunion (1 fracture) (Table 1). Of the 28 fractures
without malreduction, 21 (75%) healed within 4 months, 7
(25%) had a delayed union, and none had a nonunion. The
presence of a malreduction greater than or equal to 10 in
any plane resulted in a significantly higher rate of delayed
or nonunion (p = 0.0005) (Fig. 3).
No association was found between delayed union or
nonunion and open fracture, presence of polytrauma, open
reduction at the fracture site, or the presence of medical
comorbidities. Both of the fractures treated with open reduction and cerclage wiring were reduced without deformity
and healed within the specified time period.

Discussion
In this study, we examined a cohort of patients who sustained
a subtrochanteric femur fracture treated with an intramedul-

Bulletin of the Hospital for Joint Diseases 2014;72(2):159-63

lary device. When postoperative radiographs showed malreduction greater than or equal to 10 in any plane, there was
a statistically significant higher rate of delayed or nonunion.
Traditional ORIF of subtrochanteric femur fractures relied
on medial cortical contact and the tension band principle of a
plate placed along the lateral cortex of the proximal femur. In
many instances today, IM nailing is the treatment of choice
for subtrochanteric fractures. This relies on secondary bone
healing and callus, whereas compression plating relies on
primary bone healing. The reliance on secondary bone healing negates the need for a perfectly anatomic reduction of the

161

fracture. Furthermore, as IM nailing techniques have evolved,

trochanteric starting point nails have developed widespread
use among many orthopaedic surgeons. Varus malreduction
on the anterior-posterior view is often discussed as being a risk
factor for nonunion of these fractures and can be particularly
problematic when trochanteric nails are used with a starting
point lateral to the tip of the trochanter. An unacceptable
amount of varus deformity with IM nail treatment, to our
knowledge, has not been quantified prior to now. Additionally, the focus on varus malreduction that is present in the
orthopaedic literature has led in part, we believe, to neglect

Figure 2 Varus and flexion (A, B) malreduction, leading to nonunion (C, D) at 5 months. Revision surgery was performed with blade
plate fixation and patient went on to heal uneventfully (E, F).

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Bulletin of the Hospital for Joint Diseases 2014;72(2):159-63

Table 1 Patients with Malreduction in the Coronal or

Sagittal Plane
Coronal Plane
Angulation

Sagittal Plane
Angulation

10

29

10

40

27

22

11

15

Nonunion

10

18

11

25

16

54

Patient

Time to Union
(weeks)

of sagittal plane deformity seen on the lateral view.

The anatomy of the subtrochanteric region of the femur
creates several issues that affect fracture healing.3,4 When
compared to the metaphyseal bone of the intertrochan-

teric region, diminished blood flow to the subtrochanteric

region results in slower healing. This combined with the
high concentration of stresses and deforming forces in this
portion of the bone5,6 has made subtrochanteric fractures a
challenging problem that has been made evident throughout the orthopaedic literature.1-4,7-10 Intramedullary nail
treatment has been advocated for these fractures due to the
biomechanical advantages of a nail (decreased bending lever
arm and torsional force), as well as decreased surgical dissection in most instances.11,12 With nail treatment, however,
the proximal femoral anatomy in subtrochanteric fractures
(wide canal and short proximal segment) can make fixation
with intramedullary devices challenging.13,14
The typical deformity in subtrochanteric femur fractures is a proximal fragment that is flexed, abducted, and
externally rotated. The distal fragment is adducted and
shortened. This results in an overall varus and apex anterior
deformity at the fracture site. Several reduction maneuvers

Figure 3 Isolated flexion malreduction (A, B),

leading to delayed union at 5 months (C, D).

Bulletin of the Hospital for Joint Diseases 2014;72(2):159-63

have been described to correct these deformities.15,16 Varus

malreduction can be particularly problematic in cases where
a trochanteric start nail has been used with a starting point
that has been placed lateral to the tip of the trochanter.17
Wiss and Brien14 noted 6 malunions in 95 patients in their
series of subtrochanteric femur fractures treated with an IM
device. No patient reportedly had sagittal plane deformity.
In this series, each case of malunion was due to the fracture being nailed in a malreduced position. Delayed union
(defined as lack of healing by 6 months) was not correlated
with malreduction, rather with the presence of open fracture
in each case of delayed union.
In contrast, the current study demonstrates a highly statistically significant increase in delayed union in fractures
with immediate postoperative malreduction (p = 0.0005).
In fact, of the seven fractures demonstrating malreduction
in any plane, all seven (100%) of those fractures developed
delayed union or nonunion. Despite the majority of these
fractures eventually going on to heal, we believe that reduction of the deformity to less than 10 in any plane at the
time of definitive treatment with an IM device will reduce
postoperative healing time as well as reduce postoperative
pain and the rehabilitation time.
There are several shortcomings to the current study. Some
limitations of our study include the retrospective study design, with inherent surgeon variability and lack of treatment
protocols, as well as difficulty in complete data retrieval. For
example, 53.3% of patients were excluded from the current
study due to lack of radiographic follow up at three months.
We have relatively short follow up for many of the patients
included in the study, again due in part by the retrospective nature of the study and a lack of any standardization
as to when x-rays are obtained in follow up for this injury.
This lack of standardization as to time intervals in between
when x-rays were taken makes it difficult to determine
exactly when healing took place. In this study, the date of
the earliest x-rays showing bridging callus on three of four
cortices was used as the date of healing. With regard to our
radiographic analyses, angles were measured at the fracture
site on AP and lateral radiographs. Depending on the rotation of the leg, different measurements could be obtained
in this analysis. Despite this shortcoming, the angle would
not be less than that measured in this study, and all (100%)
of the cases with a measured malreduction greater than 10
in either plane resulted in delayed union. Additionally, no
patient subjective clinical outcomes data was available to
compare the effects of nonunion on patient functioning and
quality of life. Finally, we had a small sample size, although
it was large enough to obtain statistical significance in our
primary outcome.
In conclusion, we recommend close attention be given
to deformity of subtrochanteric femur fractures not only in
the coronal plane but also in the sagittal plane. Although this
study did not look specifically at rotational deformity, this
should be corrected intraoperatively as well. If an acceptable
reduction cannot be obtained with percutaneous techniques,

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we recommend open reduction and nailing for treatment of

these difficult fractures in order to avoid the complications
of delayed union and nonunion.
Disclosure Statement
The institution of the authors has received funding for fellowship
support from Synthes. Kenneth J. Koval, M.D., receives royalties and consultant fees from Biomet and consultant fees from
Stryker. Joshua R. Langford, M.D., receives consultant fees from
Stryker. Mark W. Munro, M.D., receives consultant fees from
Smith and Nephew. George J. Haidukewych, M.D., receives
royalties and consultant fees Biomet and Depuy and consultant
fees from Synthes and Smith and Nephew. The authors have
no conflicts of interest in addition to those mentioned above.

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