Injury, Int. J. Care Injured 44 (2013) S1, S76–S81
Subtrochanteric fracture non-unions with implant failure managed with the
Peter V. Giannoudisa,*, Mudussar A. Ahmadb, Giuseppe V. Mineoc, Theodoros I. Tosounidisb,
Giorgio M. Caloric, Nikolaos K. Kanakarisb
aAcademic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
bDepartment of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, UK
cUniversity Department of Orthopaedics, Orthopaedic Institute Gaetano Pini, University of Milan, Milan, Italy
A R T I C L EI N F OA B S T R A C T
Background: Subtrochanteric femoral non-unions in the setting of failed metalwork pose a challenging clin-
ical problem. This study assessed the clinical outcome of patients treated according to the principles of the
Methods: Between 2007 and 2011 all patients presented with a subtrochanteric atrophic aseptic non-union
in the setting of metalwork failure (broken cephalomedullary reconstructionnail), and treated in a single ter-
tiary referral unit were included to this study. The hypertrophic and the non-unions of pathologic fractures
were excluded. The revision strategy was based on the “Diamond concept”; optimisation of the mechani-
cal and the biological environment (implantation of growth factor (rhBMP-7),scaffold (RIA bone graft from
contralateral femur) and concentrated mesenchymal stem cells (MSCs) harvested from the iliac crest). The
minimum follow up was 26 months (16–48).
Results: Fourteen patients met the inclusion criteria. A specific sequence of metalwork failure was noted with
initialbreakageof thedistallockingscrewsfollowedbynailbreakageatthelagscrewlevel.The intraoperative
examination of the removed nails revealed no gross structural damage indicative of inappropriate drilling at
the time of the initial intramedullary nailing. Varus mal-alignment was present in the majority of the cases,
with an average of 5.2 degrees (0–11). The average time to distal locking screwfailurewas 4.4 months (2–8.5)
and nail failure was 6.5 months (4–10). The time to union after the revision surgery was 6.8 months (5–12).
Complications included two deaths in elderly patients (due to unrelated causes), one pulmonary embolism,
one myocardial infarction, one below the knee deep vein thrombosis and one bladeplate failurethat required
further revision with double plating and grafting.
Conclusion: Varus mal-alignment must be avoided in the initial stabilisation of subtrochanteric fractures.Dis-
tal locking screw failure is predictive of future fracture non-union and nail breakage. In the absence of sepsis,
a single stage procedure based on the “Diamond concept” that simultaneously optimizes the mechanical and
biological environment is a successful method for managing complex subtrochanteric atrophic non-unions
with failed metalwork.
© 2013 Elsevier Ltd. All rights reserved.
Subtrochanteric fractures account for 10–34% of all hip frac-
tures.1,2The incidence of subtrochanteric femoral shaft fractures
has a bimodal age distribution, affecting young patients following
high-energy trauma (resulting in significant fracture comminu-
tion) and older patients after low velocity trauma secondary to
osteoporosis or metastatic pathological lesions.3,4
The subtrochanteric region extends distally from the lesser
* Corresponding author: Professor Peter V. Giannoudis, BSc, MD, FRCS, Academic
Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon wing,
Level A, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK. Tel.: +44 (0) 113
39 22750; fax: +44 (0) 113 39 23290.
E-mail address: email@example.com (P.V. Giannoudis).
0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
trochanter for a distance of 5 cm2. It is an area with predominantly
cortical bone with poor vascularity that accounts for longer healing
time after a fracture. Biomechanical features are also unique to
the subtrochanteric region. The concentration of stresses, has been
estimated to be up to 1200 lb/sq inch, the highest of the human
skeleton.5,6The medial side is subject to high compressive stresses,
whilst high tensile stresses are exerted on the lateral side.7,8
The region of the proximal femur 3–10 cm below the lesser
trochanter is eccentrically loaded and the compressive medial
forces are considerably greater than the lateral tensile forces.9Thus,
any internal fixation device is subject to significant concentrated
bending stresses, leading to implant fatigue and fixation failure if
the fracture does not unite on a timely manner.
In addition, the anatomical features of the subtrochanteric re-
gion, with the deforming forces of flexion and external rotation
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 44 (2013) S76–S81
from the iliopsoas, abduction from the gluteal medius, adduction
and shortening of the shaft from the hamstrings and adductors,
as well as the degree of the comminution of the medial cortical
buttress at the level of the fracture constitute a surgical challenge
for the orthopaedic surgeon.8,10,11Intramedullary fixation devices
are favoured over the extra-medullary fixation, due to the shorter
lever arm of the fixation, the better load sharing and less bending
movement across the fracture site and implant.4,12,13The overall
incidence of non-union or delayed union of subtrochanteric frac-
tures, and subsequent failure for any type of fixation varies from 7%
Over the last years a specific framework of preoperative assess-
ment and subsequently management strategy of non-unions in gen-
eral has been introduced under the name “Diamond concept”.16–18
The optimisation of the mechanical environment (revision of fixa-
tion) along with the enhancement of the multidimensional biologi-
cal pathways of bone healing has been proposed as the framework
of a single stage surgical revision for the recalcitrant or atrophic
non-unions with implant failure.
The aim of this study was to evaluate the characteristics and the
outcome of a cohort of patients with subtrochanteric non-unions
and metalwork failure that were treated according to the diamond
concept after an index procedure of a trochanteric entry point
locked cephalomedullary nailing.
Patients and methods
Between June 2007 and June 2011, a retrospective cohort
study (institutional board approval was obtained) conducted at our
institution investigated a series of skeletally mature patients, with
subtrochanteric femoral non-unions and failed metalwork following
initial locked intramedullary nailing (Gamma 3 IM nailing system;
Stryker Biotech). Institutional departmental board approval was
obtained for the study.
Non-union was defined as the absence of radiographic progres-
sion of healing 6 months post-surgery or hardware failure more
than 5 months post-surgery. All the atrophic aseptic subtrochanteric
non-unions with failure of metalwork presented to our institution
were included in this study. The exclusion criteria were hyper-
trophic non-unions, pathologic fractures, and non-unions stabilised
with implants other than intramedullary nails.
The collected data included demographics, initial fracture pat-
tern, method of stabilisation, quality of fracture reduction at index
surgical procedure, mode and pattern of failure of the intra-
medullary nail, time to revision of fixation, details of revision
procedure, complications, and time to final union.
The preoperative evaluation after history taking, clinical exam-
ination and blood inflammatory markers excluded the presence
of infection in all cases. Imaging studies included plain radio-
graphs of the pelvis, hip and femur, and a CT scan of the affected
hip. The revision procedure in all cases was based on the “Dia-
mond concept”16–18(revision of the failed implant together with
the application of an osteoinductive factor [recombinant human
bone morphogenetic protein-7 (Osigraft®Olympus)], of an os-
teoconductive scaffold [autologous reaming debris obtained via
the Reamer-Irrigator-Aspirator from the contralateral femur (RIA,
DePuy Synthes, North America, Inc., West Chester, PA, USA)], and
osteoprogenitor cells (MSCs) s [nucleated cell concentrate har-
vested from the iliac crest (MarrowStim Concentration System,
Biomet Biologics Inc., Warsaw, IN)].
The single stage revision surgery consisted of the following
standardized surgical steps in each case:
1. The patient was positioned supine on a fracture table.
2. Harvesting from the contralateral femur using the RIA system
and collection of the filtered reaming aspirate as previously
3. Aspiration of 60 ml of bone marrow from the iliac crests, which
was then concentrated to 7mls of nucleated cells using the
4. Removal of the broken hardware from the non-union site (use of
the conical extraction rod and extraction hook from the Implant
Extraction Set – Stryker®).
5. Debridement of the non-union site, removal of fibrous tissue,
and collection of deep samples that were sent for microbiol-
ogy analysis to definitely exclude the presence of low grade
6. Prophylactic antibiotics (single dose flucloxacillin and gentam-
icin) was administered after collection of the samples as per our
7. The proximal femur was fixed with an appropriately sized 95
degree blade plate (DePuy-Synthes) or the Affixus®Hip Fracture
nail (Biomet). Standard operative techniques for both types of
implant were utilised.
8. Implantation of the composite graft at the debrided non-union
9. Watertight closure was performed in layers without the use of
drains for the containment of the graft material.
The post-operative mobilisation scheme included toe-touch
weight bearing using two crutches or a zimmer frame for 4–6
weeks, followed by progressive increase to full weight bearing
at 3 months. Thromboprophylaxis (low molecular weight heparin
subcutaneously (Tinzaparin 4.500 IU)) was administered for the six
weeks of the postoperative period of the restricted weight bearing.
Outpatient follow-up with clinical and radiographic assessment was
carried out at 6 weeks, 3, 4, 5, 6, 8, 12 and 18 months or until
radiographic union (Figs. 1–3).
During the pre-specified time frame, 50 femoral non-unions
were managed at our institution (tertiary referral centre). Fourteen
14/50 (28%) cases met the inclusion criteria. The mean patient age
was 65 years (range 33–92). There were 8 males and 6 females
A specific pattern of metalwork failure was observed; initial
breakage of the distal locking screws, was followed by fracture
of the nail at the level of the lag screw insertion area through
the metaphyseal part of the nail (Figs. 1a,b, 2a–c and 3a–d). At
this critical region of the neck of the nail, where the forces are
transmitted from the femoral neck to the diaphysis, the cross
sectional area of the nail is reduced by approximately 70%. Analysis
of the nails intra-operatively after extraction revealed no structural
damage to the nail from previous passage of the drill bit or the lag
screw itself into the femoral head during the index operation. An
analysis of three of the broken nails under an electron microscope
was also performed and did not reveal any structural deficiencies.
Varus mal-reduction was present in 11/14 cases, with an average
of 5.2 degrees (range 0–11). The average time to distal locking screw
failure was 4.4 months (2–8.5 months) and nail failure at the critical
region was 6.4 months (5–10) post the index surgery.
Eleven of the 14 cases were revised to a 95 degree angle blade
plate and three to an Affixus®Hip Fracture nail. The average time
to final clinical and radiological union was 6.8 months (range 5–12).
All patients returned to the their pre-injury mobility status. During
an average follow-up period of 26 months (range 16–48 months)
the observed complications included two deaths (both of them due
to unrelated causes), one pulmonary embolism, one below the knee
deep vein thrombosis, and one blade plate failure 4 months after
the first revision surgery. This case had further revision surgery
with a double-plate construct (95 degree blade plate and an anterior
femoral plate) and graft (BMP-7, MSCs and RIA Graft) and before
progressing to union after 6 months (Fig. 2).
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 44 (2013) S76–S81
Fig. 1. a) AP radiograph of right hip demonstrating a subtrochanteric fracture non-union with a broken nail in situ 5 months after fixation. b) AP radiograph of right distal
femur illustrating the presence of broken distal locking screws. c), d) AP and lateral radiographs of the right proximal femur showing the union of the fracture following
the application of the diamond concept (revision of fixation to a blade plate and implantation of composite graft).
The basic characteristics of the presented cohort of patients.
Fracture classification Varus mal-
Time to metalwork
Comminuted Subtroch #
Reverse oblique +
Died after 6/12 – unrelated
Died after 9/12 – unrelated
Below knee deep vein thrombosis
Breakage of blade plate – second
revision to double plate construct
Post-op MI fully recovered
N/A, Not applicable.
*Denotes that nail was revised to blade plate.
aDenotes that nail was revised to nail again.
The treatment of subtrochanteric fractures is a challenging and
a technically demanding endeavour for surgeons. The fracture dis-
placement and comminution, the high concentration of stresses in
this area, the poor bone quality in the elderly and the slow pace of
bone healing of some of the affected patients result to high num-
bers of non-union and implant failures.11The management of these
cases of subtrochanteric non-union in the context of metalwork
failure constitutes a difficult clinical scenario even for the experi-
enced trauma surgeon. This study represents a cohort analysis of
such cases treated in a single referral centre over a period of 4 years.
This is retrospective study and its inherent limitations should
be taken into account. No comparative analysis could be performed
due to absence of a control group of patients managed with a
different protocol, or in between the subgroups of this cohort due
to its relatively small numbers. Over a period of 4 years this cohort
consists of only 14 cases, a fact that can be explained by the rarity
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 44 (2013) S76–S81
Fig. 2. a) AP radiograph of the right hip demonstrating a subtrochanteric non-union with a broken nail in situ 6 months following the original fixation of the fracture.
b) Lateral radiograph of the right hip illustrating subtrochanteric non-union with a broken nail in situ. c) AP radiograph distal femur showing the broken distal locking
screws. d) Intraoperative picture illustrating stabilisation of the non-union following removal of the broken nail with a blade plate and the composite graft to be implanted
(BMP-7, concentrated bone marrow aspirate and RIA graft). e) Intra-operative picture demonstrating the application of a second plate anteriorly following the implantation
of the graft at the non-union site. f), g) AP and lateral radiographs illustrating union of the fracture.
of these complex cases with simultaneous mechanical failure and
atrophic non-union, even in a large tertiary referral centre covering
a population of more than 3 million people. This fact could also
be an indication of a high-level surgical management of acute
subtrochanteric fractures provided in a regional level. However, the
true incidence of this serious complication could not be determined
accurately since the precise number of subtrochanteric fractures
that have been treated remains unknown.
One of the most consistent findings in this cohort of patients
was the varus mal-alignment of the fixed acute fractures. This
is a well-recognised risk factor for failure and non-union of
these fractures.20–22The unique biomechanical features of the
subtrochanteric region, the great bending stresses developing at the
medial cortex along with the deficiency/comminution of the medial
buttress can explain the mode of failure especially in the presence
of varus mal-reduction.3,4,23The importance of optimal fracture
reduction in this anatomic region is highlighted in this series and
is emphasized by the findings of other clinical and biomechanical
The second consistent finding in this study was the mode of the
implant failure. The “self-dynamisation” of the initial reconstruction
nail, as defined by the breakage of the distal locking screws
indicates the instability of the overall mechanical construct. Over
a period of a few weeks this was followed by the breakage of the
nail itself at its junction with the lag screw. This has also been
previous described and represents the standard mode of failure
of cephalomedullary nails.24,27–29The metalwork failure should be
considered the consequence rather than the cause of the non-union.
The early identification of the breakage of the distal locking screws
in a patient who is still symptomatic at the fracture level should be
utilised as a predictor of a pending failure, and should initiate action
by the treating surgeon towards either restriction of weight bearing
or revision surgery performed in an institution with experience in
the management of these non-unions.
Until recently, the approach to impaired fracture healing and
non-union was based on the triangular concept, which placed
more emphasis on bone regeneration, utilisation of growth factors,
scaffolds and mesenchymal stem cells.18The addition of mechanical
stability to these three dimensions of biological enhancement of
bone healing, transformed the above traditional approach into the
“Diamond” concept and highlighted the important role of stability
in fracture healing.
The gold standard augmentation in the treatment of fracture
non-unions has been autologous bone graft harvested from the iliac
crest.30Iliac crest bone harvesting is associated with significant
donor site morbidity and can also result in limited graft availabil-
ity.31More over in the elderly population the underlying osteopenia
and the replacement of red marrow to yellow marrow precludes
the harvesting of autologous graft from the pelvis. Contemporary
autologous bone harvesting has evolved lately with the introduc-
tion of the RIA system. The high volume of the harvested bone
graft along with the limited associated morbidity has made the
RIA harvesting the method of choice in our unit.32,33The filtered
reaming debris possess proven osteogenic properties, whilst at the
same time offers a large volume of morselised scaffold covering the
bony defect/non-union area.34,35
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 44 (2013) S76–S81
Fig. 3. a) AP radiograph of the right hip 3 months after stabilisation of the sub trochanteric fracture with a cephalomedullary nail. b) AP pelvic radiograph illustrating
broken metal work at 6 months follow up. c) Lateral radiograph illustrating broken metal work at 6 months follow up. d) AP radiograph of distal femur illustrating the
broken distal locking screws. e), f) AP and lateral radiograph of the right hip illustrating union of the sub-trochanteric fracture which was stabilised with a lag screw and a
blade plate and implantation of the composite bone graft.
The utilisation of composite bone grafts in recalcitrant non-
unions, with the combination of potent osteoinductive proteins (in
the form of rhBMP-736) and cells with osteogenic potential (in
the form of concentrated osteoprogenitor cells37) has been also
advocated with excellent results.38The complexity of these cases,
the proven limited healing potential of atrophic non-union sites,
and the high risk of implant failure due to the biomechanical
characteristics of the subtrochanteric region, provide the grounds
for using the full spectrum of fracture healing optimization options.
Additionally, a comprehensive cost/efficacy analysis, including
direct and indirect medical costs as previously defined,39further
strengthens the argument of performing this type of complex single
stage surgery, optimising the rates of eventual healing, avoiding
prolonged follow up and most importantly the need for additional
The number of studies commenting on the outcomes of sub-
trochanteric fracture non-unions is limited.15,40–45The present
cohort reflects the practice of a large referral centre in the treat-
ment of subtrochanteric non-unions, according to the principles
of the “Diamond” concept. Preoperative evaluation on a case-by-
case basis, exclusion of infection and planning according to this
conceptual framework, results in a safe and efficient management
in a single stage revision surgery. The use of a full spectrum of
biological and mechanical enhancement is proposed as a successful,
time and cost-saving approach for the management of the atrophic
subtrochanteric non-unions with implant failure.
Conflict of interest
All authors declare that they have not received anything of value
relating to the preparation of this manuscript.
1. Yli-Kyyny TT, Sund R, Juntunen M, Salo JJ, Kroger HP. Extra- and in-
tramedullary implants for the treatment of pertrochanteric fractures – Re-
sults from a Finnish National Database Study of 14,915 patients. Injury
2. Loizou CL, McNamara I, Ahmed K, Pryor GA, Parker MJ. Classification of
subtrochanteric femoral fractures. Injury 2010;41:739–45.
3. Kennedy MT, Mitra A, Hierlihy TG, Harty JA, Reidy D, Dolan M. Sub-
trochanteric hip fractures treated with cerclage cables and long cephalo-
medullary nails: a review of 17 consecutive cases over 2 years. Injury 2011;
4. Kuzyk PR, Bhandari M, McKee MD, Russell TA, Schemitsch EH. Intramedullary
versus extramedullary fixation for subtrochanteric femur fractures. J Orthop
5. Melis GC, Chiarolini B, Tolu S. Surgical treatment of subtrochanteric fractures
of the femur: biomechanical aspects. Ital J Orthop Traumatol 1979;5:163–86.
6. Maquet P, Pelzer-Bawin G. Mechanical analysis of inter- and subtrochanteric
fractures of the femur. Acta Orthop Belg 1980;46:823–8.
7. Muller T, Topp T, Kuhne CA, Gebhart G, Ruchholtz S, Zettl R. The benefit of
wire cerclage stabilisation of the medial hinge in intramedullary nailing for
the treatment of subtrochanteric femoral fractures: a biomechanical study. Int
8. Fielding JW. Subtrochanteric fractures. Clin Orthop Relat Res 1973;86–99.
9. Rybicki EF, Simonen FA, Weis EB, Jr. On the mathematical analysis of stress in
the human femur. J Biomech 1972;5:203–15.
10. Heiple KG, Brooks DB, Samson BL, Burstein AH. A fluted intramedullary rod
for subtrochanteric fractures. J Bone Joint Surg Am 1979;61:730–7.
11. SimsSH. Subtrochantericfemur
12. Forward DP, Doro CJ, O’Toole RV, Kim H, Floyd JC, Sciadini MF, et al. A
biomechanical comparison of a locking plate, a nail, and a 95 degrees angled
blade plate for fixation of subtrochanteric femoral fractures. J Orthop Trauma
13. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary
nails versus extramedullary implants for extracapsular hip fractures in adults.
Cochrane Database Syst Rev 2008;3:CD000093.
14. Craig NJ, Sivaji C, Maffulli N. Subtrochanteric fractures. A review of treatment
options. Bull Hosp Jt Dis 2001;60:35–46.
P.V. Giannoudis et al. / Injury, Int. J. Care Injured 44 (2013) S76–S81 Download full-text
15. de Vries JS, Kloen P, Borens O, Marti RK, Helfet DL. Treatment of sub-
trochanteric nonunions. Injury 2006;37:203–11.
16. Calori GM, Giannoudis PV. Enhancement of fracture healing with the diamond
concept: the role of the biological chamber. Injury 2011;42:1191–3.
17. Giannoudis PV, Einhorn TA, Schmidmaier G, Marsh D. The diamond concept –
open questions. Injury 2008;39(Suppl 2):S5–8.
18. Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept.
Injury 2007;38(Suppl 4):S3–6.
19. Giannoudis PV, Tzioupis C, Green J. Surgical techniques: how I do it? The
Reamer/Irrigator/Aspirator (RIA) system. Injury 2009;40:231–6.
20. Waddell JP. Subtrochanteric fractures of the femur: a review of 130 patients.
J Trauma 1979;19:582–92.
21. Davis TR, Sher JL, Horsman A, Simpson M, Porter BB, Checketts RG. In-
tertrochanteric femoral fractures. Mechanical failure after internal fixation. J
Bone Joint Surg Br 1990;72:26–31.
22. Shukla S, Johnston P, Ahmad MA, Wynn-Jones H, Patel AD, Walton NP.
Outcome of traumatic subtrochanteric femoral fractures fixed using cephalo-
medullary nails. Injury 2007;38:1286–93.
23. Park J, Yang KH. Correction of malalignment in proximal femoral nailing –
Reduction technique of displaced proximal fragment. Injury 2010;41:634–8.
24. Zafiropoulos G, Pratt DJ. Fractured Gamma nail. Injury 1994;25:331–6.
25. Tomas J, Teixidor J, Batalla L, Pacha D, Cortina J. Subtrochanteric Fractures:
Treatment with cerclage wire and long intramedullary nail. J Orthop Trauma
2012 Aug 28 [Epub ahead of print].
26. Archdeacon MT, Cannada LK, Herscovici D, Jr., Ostrum RF, Anglen JO. Pre-
vention of complications after treatment of proximal femoral fractures. Instr
Course Lect 2009;58:13–9.
27. Boriani S, De Iure F, Bettelli G, Specchia L, Bungaro P, Montanari G, et al. The
results of a multicenter Italian study on the use of the Gamma nail for the
treatment of pertrochanteric and subtrochanteric fractures: a review of 1181
cases. Chir Organi Mov 1994;79:193–203.
28. Bojan AJ, Beimel C, Speitling A, Taglang G, Ekholm C, Jonsson A. 3066
consecutive Gamma Nails. 12 years experience at a single centre. BMC
Musculoskelet Disord 2010;11:133.
29. Pervez H, Parker MJ. Results of the long Gamma nail for complex proximal
femoral fractures. Injury 2001;32:704–7.
30. Crowley DJ, Kanakaris NK, Giannoudis PV. Femoral diaphyseal aseptic non-
unions: is there an ideal method of treatment? Injury 2007;38(Suppl 2):S55–
31. Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA. Complications
of iliac crest bone graft harvesting. Clin Orthop Relat Res 1996;300–9.
32. Kanakaris NK, Morell D, Gudipati S, Britten S, Giannoudis PV. Reaming
Irrigator Aspirator system: early experience of its multipurpose use. Injury
33. Dimitriou R, Mataliotakis GI, Angoules AG, Kanakaris NK, Giannoudis PV.
Complications following autologous bone graft harvesting from the iliac crest
and using the RIA: a systematic review. Injury 2011; 42 Suppl 2 S3–15.
34. Giannoudis PV, Suk M, Pape HC. RIA: The journey just started but what the
future holds? Injury 2010;41(Suppl 2):S1–3.
35. Kobbe P, Tarkin IS, Frink M, Pape HC. [Voluminous bone graft harvest-
ing of the femoral marrow cavity for autologous transplantation. An in-
dication for the “Reamer-Irrigator-Aspirator-” (RIA-)technique]. Unfallchirurg
36. Kanakaris NK, Lasanianos N, Calori GM, Verdonk R, Blokhuis TJ, Cherubino P,
et al. Application of bone morphogenetic proteins to femoral non-unions: a
4-year multicentre experience. Injury 2009;40(Suppl 3):S54–61.
37. Ridgway J, Butcher A, Chen PS, Horner A, Curran S. Novel technology to
provide an enriched therapeutic cell concentrate from bone marrow aspirate.
Biotechnol Prog 2010;26:1741–8.
38. Giannoudis PV, Kanakaris NK, Dimitriou R, Gill I, Kolimarala V, Montgomery
RJ. The synergistic effect of autograft and BMP-7 in the treatment of atrophic
nonunions. Clin Orthop Relat Res 2009;467:3239–48.
39. Kanakaris NK, Giannoudis PV. The health economics of the treatment of
long-bone non-unions. Injury 2007;38(Suppl 2):S77–84.
40. Wu CC. Locked nailing for shortened subtrochanteric nonunions: a one-stage
treatment. Clin Orthop Relat Res 2009;467:254–9.
41. Pascarella R, Maresca A, Palumbi P, Boriani S. Subtrochanteric nonunion of
the femur. Chir Organi Mov 2004;89:1–6.
42. Barquet A, Mayora G, Fregeiro J, Lopez L, Rienzi D, Francescoli L. The
treatment of subtrochanteric nonunions with the long gamma nail: twenty-six
patients with a minimum 2-year follow-up. J Orthop Trauma 2004;18:346–53.
43. Haidukewych GJ, Berry DJ. Nonunion of fractures of the subtrochanteric
region of the femur. Clin Orthop Relat Res 2004;185–8.
44. Prosperi P, De Iure F, Beluzzi R, Verni E. Gamma nailing for the treatment of
subtrochanteric nonunion: two clinical cases. Chir Organi Mov 1996;81:213–6.
45. Charnley GJ, Ward AJ. Reconstruction femoral nailing for nonunion of sub-
trochanteric fracture: a revision technique following dynamic condylar screw
failure. Int Orthop 1996;20 55–7.