Management of proximal femur malunion and distal femur nonunion via proximal femoral nailing and free fibular graft: A case report

INTRODUCTION AND IMPORTANCE: Concurrent ipsilateral femoral malunion and nonunion present substantial clinical challenges requiring comprehensive surgical interventions. We describe a unique case of a 65-year-old male with these complications who was treated with a proximal femoral osteotomy, radical sequestrectomy, and free fibula graft. CASE PRESENTATION: The patient underwent over 10 years of multiple surgical interventions, including hardware removal, local debridement, antibiotic-loaded cement spacer placement, autologous bone grafting, and external fixator applications, yet infectious non-union persisted. Additionally, a periprosthetic subtrochanteric fracture led to malunion due to his lack of consent for surgery. Despite attempted distraction osteogenesis, limited patient cooperation hindered success. Subsequent Free fibula grafting ultimately achieved satisfactory union, enabling full weight-bearing and according to the Short Form-36 (SF-36), the patient's physical function score increased from 30 % to 65 %. CLINICAL DISCUSSION: In the field of orthopedic surgery, addressing infectious non-union in long bones presents a notable clinical challenge. Radical debridement is fundamental to its management, a procedure that, in severe and resistant cases, may give rise to critical-sized bone defects. To address these defects, a spectrum of biological reconstruction techniques has evolved over time. The selection of the most appropriate strategy necessitates individualization based on the patient and the specific nonunion characteristics. CONCLUSION: This case underscores the importance of radical debridement for infectious non-union. It emphasizes the consideration of biological reconstruction for critical-sized defects, particularly when concurrent deformities are present. Patient compliance is pivotal for treatment success, necessitating alternative approaches when cooperation is compromised.