Intertrochanteric Region Research Articles

Hot Topics in Biomechanically Directed Fracture Fixation

The evolution of locking plates and modern nail constructs provides the orthopaedic trauma surgeon with a myriad of options with regard to implant selection for common fractures. There is a significant amount of biomechanical literature comparing modern constructs with those conventionally used. A basic understanding of this literature is required to make informed decisions with regard to implant selection in the management of these injuries. This article reviews the most recent biomechanical literature regarding implant selection and application for a variety of commonly treated injuries, including fractures of the clavicle, proximal humerus, distal humerus, intertrochanteric hip region, distal femur, and bicondylar tibial plateau.

Hook leverage technique for reduction of intertrochanteric fracture

An intramedullary nail has become the implant of choice for today’s orthopaedic surgeon for intertrochanteric fractures [1,2]. Fixation failure or severe complications such as cut-out and cutthrough result if accurate anatomical reduction is not achieved during surgery (Fig. 1) [3]. Although longitudinal traction and internal rotation of the fractured extremity will result in acceptable closed reduction of most intertrochanteric fractures, specific patterns of intertrochanteric fractures need percutaneous procedures, and some may even need open reduction [4–6]. Carr [4] defined a fracture pattern that needed a percutaneous procedure to achieve anatomical reduction. In this fracture pattern, the distal femoral shaft piece shortens and falls into external rotation, the proximal head and neck piece is displaced into a varus deformity and commonly translates posteriorly into the comminuted intertrochanteric region, and this fragment is engaged into the distal shaft piece. Accurate reduction of this particular fracture pattern is achieved with ease on the anteroposterior (AP) view during closed reduction, but there is a persistent disruption of the anterior cortex on the lateral view, which has to be manipulated into position (Fig. 2). Here we propose an ingenious way to overcome this problem and achieve anatomical reduction through a hook leverage technique as explained below.

RETRACTED ARTICLE] Fixation of basicervical and related fractures using DHS with DRS

Background: Basicervical fracture is a fracture through the base of femoral neck at its junction with the intertrochanteric region. Due to this location, it represents an intermediate form between femoral neck, usually fixed with multiple cancellous screws, and the intertrochanteric fracture, fixed with a sliding screw device. Previous studies recommended treating basicervical fractures as intertrochanteric fractures with the dynamic hip screw (DHS). However, because basicervical fractures have greater instability than stable intertrochanteric fractures, poor functional outcome may be expected when the DHS used alone. Aims & Objective: To evaluate the outcome of fixation of basicervical and related fractures using DHS with DRS. Materials and Methods: We prospectively studied 42 patients in order to identify a group of proximal femoral fractures having liability for axial and rotational instability, and to present results of their fixation using the dynamic hip screw (DHS) with derotation screw (DRS). Results: At 12 months postoperatively, patients were functionally evaluated and the radiological outcome was analysed. All fractures united within an average period of 11.5 weeks. The mean sliding distance was 5.5 mm and mean shortening of the limbs was 2 mm. According to the criteria of Kyle et al. (J Bone Joint Surg [Am] 61-A:216–221), 39 patients obtained excellent results, two good and one fair. Conclusion: We conclude that the AO types B2.1, A1.1, A2.1, A2.2 and A2.3 have a common instability denominator and therefore should be treated alike. The sliding component of the DHS allows solid fixation of the two major fragments in two planes and the DRS in the third plane.

Relations between Birth Weight and Hip Bone Strength Indices in a Group of Adolescent Girls

The aim of this study was to explore the relations between birth weight and hip bone strength indices in a group of adolescent girls. This study included 26 adolescent girls (153 +/- 2.9 years old). Weight and height were measured and body mass index (BMI) was calculated. Birth weights were obtained from obstetric records. Body composition and BMD were assessed by dual-energy X-ray absorptiometry (DXA). To evaluate bone geometry, DXA scans were analyzed at the femoral neck (FN), the intertrochanteric (IT) region and the femoral shaft (FS) by the Hip Structure Analysis (HSA) program. Cross sectional area (CSA), an index of axial compression strength, cross sectional moment of inertia (CSMI), an index of structural rigidity and section modulus (Z), an index of bending strength, were measured from bone mass profiles. Birth weight was positively correlated to CSA, CSMI and Z of the three sites (FN, IT and FS). However, the positive associations between birth weight and HSA variables disappeared after controlling for body weight. In this population, the positive associations between birth weight and hip bone strength indices disappear after controlling for body weight.

When femoral fracture fixation fails

Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies.

Conversion Hemiarthroplasty and Valgus Osteotomy After Failed ORIF of Hip Intertrochanteric Fractures

Hip arthroplasty after open reduction and internal fixation of the proximal femur presents a challenge to reconstructive surgeons. Bony defects, fracture malunion, and non-union increase the risk of complications, including intraoperative fracture, unrecognized perforation, and trochanteric non-union. The authors describe a novel surgical technique using conversion hemiarthroplasty and valgus osteotomy for failed open reduction and internal fixation of intertrochanteric hip fractures. The described surgical technique resulted in trochanteric advancement and preservation of the bone stock in the intertrochanteric region. This technique was successful in eliminating pain and restoring ambulation and abductor function and resulted in stable ingrowth and healing in these patients.

Structural patterns of the proximal femur in relation to age and hip fracture risk in women

Fractures of the proximal femur are the most devastating outcome of osteoporosis. It is generally understood that age-related changes in hip structure confer increased risk, but there have been few explicit comparisons of such changes in healthy subjects to those with hip fracture. In this study, we used quantitative computed tomography and tensor-based morphometry (TBM) to identify three-dimensional internal structural patterns of the proximal femur associated with age and with incident hip fracture. A population-based cohort of 349 women representing a broad age range (21–97years) was included in this study, along with a cohort of 222 older women (mean age 79±7years) with (n=74) and without (n=148) incident hip fracture. Images were spatially normalized to a standardized space, and age- and fracture-specific morphometric features were identified based on statistical maps of shape features described as local changes of bone volume. Morphometric features were visualized as maps of local contractions and expansions, and significance was displayed as Student's t-test statistical maps. Significant age-related changes included local expansions of regions low in volumetric bone mineral density (vBMD) and local contractions of regions high in vBMD. Some significant fracture-related features resembled an accentuated aging process, including local expansion of the superior aspect of the trabecular bone compartment in the femoral neck, with contraction of the adjoining cortical bone. However, other features were observed only in the comparison of hip fracture subjects with age-matched controls including focal contractions of the cortical bone at the superior aspect of the femoral neck, the lateral cortical bone just inferior to the greater trochanter, and the anterior intertrochanteric region. Results of this study support the idea that the spatial distribution of morphometric features is relevant to age-related changes in bone and independent to fracture risk. In women, the identification by TBM of fracture-specific morphometric alterations of the proximal femur, in conjunction with vBMD and clinical risk factors, may improve hip fracture prediction.

Is the Mean Platelet Volume Predictive of Hip Fractures in the Elderly?

Erkan Cure, M.D., Mehmet Sabri Balik, M.D., Medine Cumhur Cure, M.D., Yilmaz Guvercin, M.D., Adem Erkut, M.D., Suleyman Yuce, M.D., and Davut Keskin, M.D.. Ann Lab Med 2013;33:367-70. https://doi.org/10.3343/alm.2013.33.5.367

Traumatic Posterior Hip Dislocation with an Ipsilateral Comminuted Femoral Intertrochanteric Fracture: A Case Report

Traumatic Posterior Hip Dislocation with an Ipsilateral Comminuted Femoral Intertrochanteric Fracture: A Case Report

Hip structural analysis: a comparison of DXA with CT in postmenopausal Japanese women

Geometry of the proximal femur is one determinant of fracture risk, and can be analyzed by a simple method using dual-energy X-ray absorptiometry (DXA). The aim of the present study was to investigate the accuracy of hip structural analysis (HSA) using clinical data in postmenopausal Japanese women. A total of 184 postmenopausal women aged 51–88 years (mean, 70.5 ± 8.7 years) who underwent artificial joint replacement surgery for osteoarthrosis of the hip or knee joint were included. Computed tomography (CT) data from preoperative assessment were utilized for analysis of proximal femoral geometry (CT-HSA) using QCTPro Software (Mindways Software Inc., Austin, TX) and compared with HSA results based on DXA (DXA-HSA). The results of femoral geometry were further compared with a CT-based finite-element method (CT/FEM). There was moderate to high correlation between DXA-HSA and CT-HSA (r=0.60-0.90, p<0.001), except for the buckling ratio in the intertrochanteric region. Moreover, the correlation of HSA with CT/FEM was similar between DXA-HSA and CT-HSA. The present results suggest that the geometry of proximal femoral cross sections can be reasonably well characterized using DXA.

Bony impingement depends on the bone morphology of the hip after total hip arthroplasty

The purpose of this study was to evaluate whether the bone morphology of the hip affects the range of motion (ROM) in total hip arthroplasty (THA). Using the CT data of 63 patients who underwent THA, we calculated the ROM of flexion (Flex), internal rotation (Int-R) and external rotation (Ext-R) using 3D dynamic analysis software. We measured the distance between the anterior surface of the stem and anterior aspect of the greater trochanter (GTa length) at the cutting point and between the tip of the antero-inferior iliac spine (AIIS) and coronal plane of both femoral heads (AIIS length), as a parameter of the femur and pelvis, respectively. The relationship between the ROM, bone anatomy and impingement site was evaluated. We found a significant decrease in the ROM of Flex and the Int-R to be inversely proportional to the GTa and AIIS length. In Flex and Int-R, the anterior intertrochanteric region often impinges on the AIIS in patients with larger bone anatomy. We demonstrated that the bone morphology of the hip substantially affects the ROM of Flex and Int-R, especially in patients with large bone anatomy. For these patients we should consider bony impingement in THA.

Effect of vitamin D replacement on hip structural geometry in adolescents: A randomized controlled trial

BackgroundWe have shown in a randomized controlled trial that vitamin D increases bone mass, lean mass and bone area in adolescent girls, but not boys. These increments may translate into improvements in bone geometry and therefore bone strength. This study investigated the impact of vitamin D on hip geometric dimensions from DXA-derived hip structural analyses in adolescents who participated in the trial. Methods167 girls (mean age 13.1years) and 171 boys (mean age 12.7years) were randomly assigned to receive weekly placebo oil or vitamin D3, at doses of 1400IU or 14,000IU, in a double blind placebo-controlled 1-year trial. DXA images were obtained at baseline and one year, and hip images were analyzed using the hip structural analysis (HSA) software to derive parameters of bone geometry. These include outer diameter (OD), cross sectional area (CSA), section modulus (Z), and buckling ratio (BR) at the narrow neck (NN), intertrochanteric (IT), and shaft (S) regions. Analysis of Covariance (ANCOVA) was used to examine group differences for changes of bone structural parameters. ResultsIn the overall group of girls, vitamin D supplementation increased aBMD (7.9% and 6.8% in low and high doses, versus 4.2% in placebo) and reduced the BR of NN (6.1% and 2.4% in low and high doses, versus 1.9% in placebo). It also improved aBMD (7.9% and 5.2% versus 3.6%) and CSA (7.5% and 5.1% versus 4.1%) of the IT and OD of the S (2.4% and 2.5% versus 0.8% respectively). Significant changes in the OD and BR of the NN, in the overall group of girls remained, after adjusting for lean mass, and were unaffected with further adjustments for lifestyle, pubertal status, and height measures. Conversely, boys did not exhibit any significant changes in any parameters of interest. A dose effect was not detected and subgroup analyses revealed no beneficial effect of vitamin D by pubertal stage. ConclusionsVitamin D supplementation improved bone mass and several DXA-derived structural bone parameters, in adolescent girls, but not boys. This occurred at a critical site, the femoral neck, and if maintained through adulthood could improve bone strength and lower the risk of hip fractures.

Three-dimensional structural analysis of the proximal femur in an age-stratified sample of women

IntroductionAging is associated with worsening bone structure and increasing risk of hip fracture. However, the commonly used clinical tool, dual-energy x-ray absorptiometry, does not provide information on changes with age or disease separately in trabecular versus cortical bone or in bone geometry. Here we used 3D quantitative computed tomography (QCT) to analyze age-related changes in femoral volumetric bone mineral density (vBMD) and structure in a well characterized, population-based cohort of Rochester, Minnesota women. MethodsMIAF-Femur (MIAF: medical image analysis framework) was used for the analysis of CT datasets from 358 women age 20 to 97years. Integral, “apparent” cortical (rather than true cortical vBMD, due to volume averaging effects) and trabecular vBMD, volume, and bone mineral content (BMC) as well as cortical thickness of the femur head, neck, trochanter, inter-trochanteric, and proximal shaft volumes of interest (VOIs) were measured. In addition, changes in vBMD in the superior, inferior, posterior and anterior quadrants of the femur neck were assessed. ResultsCross-sectional percent decreases in vBMD across life were 2- to 5-fold higher in trabecular versus cortical bone at all sites in the femur, although absolute changes in the trabecular and cortical bone were fairly similar. In addition, the slopes of the relationships of trabecular vBMD with age were generally similar in pre- and postmenopausal women, whereas apparent cortical vBMD in the femur neck, trochanter, inter-trochanteric region, and proximal shaft remained relatively stable in premenopausal women but decreased significantly with age following the menopause. Bone volume increased at all sites, more so in pre- compared to postmenopausal women. Age-related BMC changes were not significant in premenopausal women, but BMC losses were highly significant in postmenopausal women. Detailed analyses of femur neck cortical bone showed that percent apparent vBMD decreases in the superior quadrants were 2- to 3-fold greater than in the inferior quadrants; changes in absolute values were most different (~2-fold) between the superior-posterior and inferior-posterior quadrants. ConclusionsThese data demonstrate that patterns of changes with age within the femur differ in the trabecular versus cortical bone. In the cortical compartment which, due to limitations in spatial resolution, contains some subcortical bone and should be regarded as an “apparent” cortical VOI, the superior quadrants in the femur neck undergo the greatest decreases. These findings may have important implications for understanding the structural basis for increased hip fracture risk with aging.

Safety aspects in surgical treatment of pathological fractures of the proximal femur – modular endoprosthetic replacement vs. intramedullary nailing

BackgroundPathologic fractures of the femoral intertrochanteric and subtrochanteric region require special consideration in terms of biomechanically stable fixation and durability of the implant. In addition, the type of surgery might also influence patient survival. We conducted this retrospective study to evaluate the safety of modular proximal femur replacement compared to intramedullary nailing with patient survival being the primary and complications the secondary endpoint.MethodsWe retrospectively studied the records of 20 consecutive patients with actual pathologic fracture due to bone metastasis in the intertrochanteric and subtrochanteric part of the femur. The pathologic fractures were stabilized with a locked cephalomedullary nail in 12 patients and treated with en-bloc resection and modular proximal femur replacement in eight patients.ResultsIn the tumor prosthesis group median patient survival was more than twice as high (4.5 months, IQR 2.3 – 16.5) than in the osteosynthesis group (2.0 months, IQR 0.3 – 20.5), but did not reach significance (p = 0.58). Besides, a significantly better preoperative general health status in patients with endoprosthetic reconstruction puts better survival into perspective. Median implant survivorship did not differ between groups with 2.5 (IQR 1.0 – 7.5) months for endoprothesis and 3.0 (IQR 0.3 – 11.0) months for osteosynthesis (p = 0.93). Complication rates were comparable with 25% in each group.ConclusionPatient survival was not influenced by type of surgery or choice of implant. Preoperative general health condition and ambulatory capacity may aid in decision for type of surgery and improve patient safety, respectively.

A new technique of endoprosthetic replacement for osteosarcoma of proximal femur with intra-articular extension

INTRODUCTIONOsteosarcoma is the most common primary malignant tumour of bone and commonly involved sites are the distal femur, proximal tibia, and humerus. Osteosarcoma of proximal femur usually arises at the metaphysis and articular cartilage acts as a relative barrier to tumour spread, with extension into the hip joint being extremely rare. PRESENTATION OF CASEA previously fit and well sixteen-year-old male presented with a 2month history of right hip pain and a limp. Plain radiographs and magnetic resonance imaging (MRI) showed an expansile lesion in the right femoral neck, extending 16cm distally from the proximal femoral articular surface through the intertrochanteric region into the upper right femoral shaft. There was also clear evidence of intra-articular extension into the acetabulum. DISCUSSIONEndoprosthetic replacement following resection is a good treatment option for proximal femoral tumours due to the low complication rate and achievement of good postoperative function. However, treatment of a proximal femoral lesion with intra-articular involvement by prosthetic reconstruction is challenging. We report a patient who presented with osteosarcoma of the proximal femur extending into the hip joint and describe the technique of en-bloc extra-articular resection of the acetabulum and proximal femur with reconstruction using a custom made prosthesis. CONCLUSIONWe conclude that extra-articular resection and endoprosthetic reconstruction using a coned hemi-pelvic implant with fluted stem and a modular femoral implant is a useful treatment option in the management of a proximal femoral lesion involving the hip-joint. It allows adequate tumour clearance and stable reconstruction for rapid post-operative recovery with early mobilisation.

Pioglitazone increases bone marrow fat in type 2 diabetes: results from a randomized controlled trial

To determine the effect of pioglitazone on bone marrow fat in humans. Twenty participants in a double-blind, randomized, placebo-controlled trial of the skeletal effects of pioglitazone 30 mg daily in type 2 diabetes mellitus (T2DM) entered a 6-month substudy evaluating bone marrow fat. Main outcome measures were bone marrow fat in lumbar spine (L4) and proximal femur (intertrochanteric region), measured using magnetic resonance (MR) imaging, and bone mineral density (BMD), measured using dual-energy X-ray absorptiometry. after 6 months, change in the fourth lumbar vertebra (l4) bone marrow lipid fraction, assessed using two different methods, was greater in the pioglitazone group than in the placebo group (dixon method: mean (95% CI) change from baseline pioglitazone 1.3% (-0.3, 2.9), placebo -0.2% (-0.8, 0.4), P=0.06; MR spectroscopy: pioglitazone 2.5% (0.4, 4.7), placebo -1.1% (-3.7, 1.4), P=0.02). Similarly, the change in lipid fraction in the intertrochanteric region was greater in the pioglitazone group (Dixon method: mean (95% CI) change from baseline pioglitazone 1.3% (0.6, 1.9), placebo -0.8% (-1.8, 0.2), P=0.001). Within the pioglitazone group, there was no evidence of a significant relationship between change in marrow lipid fraction and BMD. Short-term treatment with pioglitazone increases bone marrow fat in patients with T2DM.

Comment on Stern et al.: Prospective randomised study comparing screw versus helical blade in the treatment of low-energy trochanteric fractures

We admire the work of Richard Stern et al. on the cephalic implant to be used in the treatment of low-energy trochanteric fractures [1]. The authors have conducted a randomised controlled trial and concluded that both screw and a blade perform equally well with a SHS or IM nail for the treatment of trochanteric fractures in the elderly age group. The primary idea of treatment of a trochanteric fracture with a DHS or an IM nail is procurement of controlled fracture impaction by the cephalic implant in femoral head with plate or a nail acting as a lateral tension band. This allows unimpeded healing in a cancellous environment of the extracapsular intertrochanteric region. Thus, there is a constant race between the fracture healing by collapse and tendency for implant failure typified by cephalic implant cut-out. Most trochanteric fractures heal uneventfully with good clinical and radiological outcome. However, some of them, especially the unstable ones and those with delayed union, may end up in varus malunion due to the combined effects of fracture collapse, lack of posteromedial buttress and poor anchorage of the cephalic implant resulting in suboptimal clinical and radiological outcome. Rarely, the tendency for implant cut-out may win the race over fracture healing, resulting in implant failure and worse clinical result. Before moving into a discussion of the article by Stern et al., we describe the proposed advantages of a helical blade. The helical blade allows for compaction of the bone during insertion, an advantage in osteoporotic bone. Improved rotational stability along with better anchorage in a cancellous environment is supposed to reduce the risk of screw cut-out, delayed union and varus malunion. The higher resistance of helical blade to heavy loads and reduced chance of screw cut-out has been made evident by various anatomical and biomechanical studies [2–5]. However the proposed benefits of helical blade have not been construed by any clinical studies to demand a change in the conventional practice. There are a few issues which need to be addressed in the article by Stern et al.: The quality of reduction has been shown to affect the outcome in trochanteric fractures [6]. Only the tip apex distance (TAD) and position of the implant in the femoral head in the immediate postoperative radiographs have been compared between the two groups including cases of implant cut-out. Appended information about the quality of reduction in these radiographs in cases that healed uneventfully and ones with screw cut-out would have added more enlightenment into the quandary. As discussed above the helical blade is supposed to reduce the risk of cut-out, varus malunion and delayed union. Thus, clinical validation of helical blade in the management of a trochanteric fracture should be based on implant position in the femoral head, incidence of varus malunion, re-operation rates and implant failure and include time of healing complemented by clinical outcome. The authors have considered only the re-operation rates along with incidence of cephalic implant cut-out and these cases constitute only the tip of the iceberg. Although the limitation of lack of complete evaluation of patients at one-year follow up was addressed, such a prime study with randomisation and good number of subjects should have thrown light on the incidence of varus malunion, time of fracture healing and clinical outcome by appropriate radiological and clinical evaluation. These would have made the article more edifying and denouements of such a unique clinical study would have more impact in clinical decision making.

Hip Cortical Thickness Assessment in Postmenopausal Women With Osteoporosis and Strontium Ranelate Effect on Hip Geometry

The aims of this study were to assess the relationship between hip geometry and the 5-yr risk of hip fractures in postmenopausal osteoporotic women and the effects of strontium ranelate on these parameters. Using the 5-yr data of a randomized placebo-controlled trial of strontium ranelate (Treatment of Peripheral Osteoporosis Study [TROPOS]), we reanalyzed the hip dual-energy X-ray absorptiometry scans to determine the role of hip geometry in the risk of hip fractures (placebo group, n=636) and to analyze the effects of strontium ranelate (n=483). The outcomes included the hip structure analysis (HSA) parameters: cross-sectional area (CSA), section modulus, cortical thickness, and buckling ratio, measured at femoral neck, intertrochanteric (IT) region, and proximal shaft. The geometric parameters associated with an increased risk of hip fracture over 5yr were IT CSA and femoral shaft cortical thickness independent of age and total-hip bone mineral density (BMD). Using Bonferroni adjustment, IT cortical thickness was associated with the risk of hip fracture. Over 5yr, significant decreases in some femoral dimensions of the placebo group contrast with significant increases in strontium ranelate group after adjustment for age and BMD. Using Bonferroni adjustment, differences between placebo and strontium ranelate groups were no longer significant after adjustment on 5-yr BMD changes. Some HSA parameters have predictive value for hip fracture risk in postmenopausal osteoporotic women. Strontium ranelate improves some HSA parameters, through the BMD increase.

Cortical Osteoid Osteomas of the Calcaneus Managed by En Bloc Resection and Autogenous Iliac Bone Grafting

Osteoid osteoma was firstly described by Bergstrand [1] as a benign osteoblastic tumor in 1930, then followed by Jaffe [2] in 1935 who described it and he was the first one to recognize it as a unique entity. The most common sites of osteoid osteomas are the femur, especially the intertrochanteric or intracapsular regions of the hip, which are affected in two thirds of cases [2,3] the other common sites are the diaphyseal parts of the tibia and the humerus. This osteoid osteoma is not common in the foot and its incidence ranges from 4% to 16%, the preferred locations in the foot are the talus which ranges from 31% to 59% followed by the calcaneus which ranges from 12.5% to 22% of all osteoid osteomas of the foot [3-5]. There are frequent difficulties in the diagnosis and the localization of osteoid osteomas in the foot and also difficulties for the standard x-ray films to detect the tumor especially if there are extensive sclerosis in cortical lesion or arthrititic changes in subarticular regions in the small tarsal bone [3-6]. In this study we evaluated the results of six rare cases of cortical osteoid osteomas of the calcaneus managed by en bloc resection of osteoid osteomas with autogenous iliac bone grafting.

Primary nonunion of intertrochanteric fractures of femur: An analysis of results of valgization and bone grafting

Background:Nonunion of intertrochanteric fractures is uncommon because there is excellent blood supply and good cancellous bone in the intertrochanteric region of the femur. A diagnosis of primary intertrochanteric nonunion is made when at least 15 weeks after the fracture there is radiological evidence of a fracture line, with either no callus (atrophic) or with callus that does not bridge the fracture site (hypertrophic). There is only one published series that exclusively describes seven primary nonunions of intertrochanteric fractures. The aim of the present study was to analyze the results of internal fixation, valgization with 135° dynamic hip screw (DHS), and bone grafting in patients with primary nonunion of intertrochanteric fractures.Materials and Methods:Eighteen patients with primary intertrochanteric nonunion were included in the study; 16 were male and 2 were female. The age range was 30–70 years (mean: 46.9 years). The mean duration since index injury was 8.5 months (range: 4–18 months). As per the AO classification, the fractures were 31A 1.1 (n=1), 1.2 (n=1), 2.2 (n=3), 2.3 (n=9), and 3.3 (n=4). Three patients had hypermobile nonunion and 15 had stiff nonunion. The surgical principle was excision of pseudarthrosis, if present (n=3); freshening of the bone ends; stable fixation with 135° DHS, with good proximal purchase; bone grafting; and valgization.Results:Union was achieved in all patients at an average of 5.62 months (range: 4–7 months). The Harris hip score improved from 38 points preoperatively to 86 postoperatively at healing. The average limb shortening improved by 2 cm (range: 1.5 cm–3 cm). There was no infection and pain at the hip at final follow-up in any of the cases. All patients were subjectively satisfied with the outcome. All were capable of full weight bearing on their affected limb.Conclusion:Union in primary nonunion of intertrochanteric fractures in physiologically young patients with a well-preserved femoral head and good bone stock can be achieved with internal fixation, valgization, and grafting procedures.