Medial Displacement Osteotomy Research Articles

Der erworbene Plattfuß: mittelfristige Ergebnisse der medialisierenden Kalkaneusosteotomie mit Flexor digitorum longus-Sehnentransfer

The present retrospective study investigates the mid-term results after medial displacement calcaneal osteotomy combined with flexor digitorum longus transfer for the treatment of acquired flatfoot deformity due to posterior tibial tendon insufficiency at stage II (Johnson and Strom Classification). 30 feet in 29 patients (6 male, 23 female) with an average age of 58 years (from 43 to 68 years) had surgery between 1995 and 2001. All feet were examined at an average follow-up of 58.5 months (range 35-97 months) and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score. The average AOFAS-Score was 88.8+/-10.7 points (range 48 to 100) at final follow-up. The AOFAS-pain-subscale score was 34+/-6.2 points. At the latest follow-up were 14 feet (47%) painfree, 14 feet (47%) noted mild pain and 2 feet (6%) had daily pain. One foot (3%) had pain due to subluxation of the musculus flexor digitorum longus tendon, in another one pain was caused by a contract Chopart joint (3%). Further complications were painful prominent hardware (17%) and neuralgia of the sural nerve (7%). The authors conclude that the combination of the medial calcaneal displacement osteotomy with flexor digitorum longus transfer may provide optimal results in patients with adult acquired flatfoot deformity and posterior tibialis tendon dysfunction.

Variations in the origin of the medial and inferior calcaneal nerves

Entrapment of the medial heel region nerves is often mentioned as a possible cause of heel pain. Some authors have suggested that the medial and inferior calcaneal nerves may be involved in such heel pain, including plantar fasciitis, heel pain syndrome and fat pad disorders. The aim of this study was to give a detailed description of the medial heel that would determine the variability and pattern of the medial and inferior calcaneal nerves, as well as to relate these findings to the currently used incision line for tarsal tunnel, fixations of fractures with external nailing, medial displacement osteotomy and nerve blocks in podiatric medicine. The origin, relationship, distribution, variability and innervation of medial and inferior calcaneal nerves were studied with the use of a 3.5 power loupe magnification for dissection of 25 adult male feet of formalin-fixed cadavers. The medial heel was found to be innervated by just one medial calcaneal nerve in 38% of the feet, by two medial calcaneal nerves in 46%, by three medial calcaneal nerves in 12% and by four medial calcaneal nerves in 4%. An origin for a medial calcaneal nerve from the medial plantar nerve was found in 46% of the feet. This nerve most often innervates the skin of the posteromedial arch. In our dissection, the rate of occurrence of the medial and inferior calcaneal nerves in medial heel region was 100%. When compared with the inferior calcaneal nerve, the medial calcaneal nerve was posterior, superior and thicker. The inferior calcaneal nerve supplies deeper structures. In the majority of the cases, inferior calcaneal nerve aroused from the lateral plantar nerve, but it may also arise from the tibial nerve, sometimes in a common origin with the medial calcaneal nerve. Knowledge of fine anatomy of the calcaneal nerves is necessary to ensure safe surgical intervention in the medial heel region.

Lesser-Metatarsal Medial Displacement Osteotomy for the Treatment of Digital Transverse Plane Deformities

We sought to evaluate the clinical and radiographic outcomes in patients treated with a medial displacement transverse osteotomy of the second metatarsal to correct transverse hammer toe deformities. Eighteen patients underwent 20 procedures in 3 years. Each patient had a transverse plane deformity of the second metatarsophalangeal joint. Evaluation consisted of clinical examination, radiographic examination, and self-reported pain and function parameters. Mean +/- SD follow-up was 2.5 +/- 1.0 years. Radiographic joint congruence improved from 20% before surgery to 95% after surgery. Clinical examination revealed a rectus digit in 85% of cases, a transverse plane deviation in 10%, and a residual hammer toe deformity in 5%. At follow-up, the mean +/- SD visual analog scale score for pain with activity was 2.2 +/- 2.8 and for pain at rest was 0.6 +/- 1.4. Ninety-five percent of the patients said that they would undergo the procedure again. Medial displacement osteotomy for transverse plane deformity of the second metatarsophalangeal joint is a reliable procedure, with substantial improvement in joint congruence and self-reported pain.

Acetabular Medial Wall Displacement Osteotomy in Total Hip Arthroplasty: A Technique to Optimize the Acetabular Reconstruction in Acetabular Dysplasia

Twenty-six patients (30 hips) who had acetabular dysplasia were operated on by circumferential acetabular medial wall displacement osteotomy to reconstruct the acetabulum during total hip arthroplasty. All patients had cementless acetabular components implanted. The average acetabular component size was 50 mm (range, 44-56 mm). Only 2 hips needed structural bone graft. The mean follow-up period was 22 months (range, 6-32 months). Harris hip score had changed from 47.31 (range, 19-69 points) to 94.69 (range, 85-100 points) postoperatively ( P < .01). Using the Ranawat acetabular triangle to determine the optimal hip center of rotation, the postoperative hip biomechanical environment had been improved. Our short-term follow-up suggests this technique is reliable and reproducible and generally avoids the use of bone graft and graft site morbidity. In addition, it allows the use of standard modular cementless components in patients with acetabular dysplasia.

The Kirby view: A radiographic view for flatfoot evaluation

The authors reintroduce the anterior axial projection of the foot as described by Kirby et al (1) and how it can be used to better evaluate a flatfoot deformity when a medial calcaneal displacement osteotomy is contemplated. Over the years, although flatfoot surgery has become more sophisticated in both procedures and the selection of these procedures, many decisions are being made by the surgeon based on clinical examination and previous experiences without relying on a specific test to definitively determine the need for a specific surgical procedure. The use of the Kirby view when evaluating a flatfoot deformity will provide the surgeon with specific knowledge about location of the calcaneus relative to the tibiotalar joint (2–4). If a calcaneal osteotomy is needed, this radiographic view will allow the surgeon to determine, by the use of a preoperative template, how much medial displacement should be performed at the time of surgery.

Percutaneous displacement calcaneal osteotomy

Gleich (1) first described in 1893 the calcaneal osteotomy as a plantar-medial wedge resection to increase the calcaneal inclination angle. Later, Dwyer (2) and Silver (3) each described closingand opening-wedge osteotomies for calcaneal realignment with promising results. Koutsogiannis (4) popularized the medial displacement osteotomy in 1971. It has been shown that the medial displacement osteotomy addresses the flatfoot deformity in all 3 planes (5). The calcaneal displacement osteotomy (CDO) can also be used to reposition the heel in all 3 cardinal body planes. The tuberosity can be rotated to accommodate a frontal-plane deformity. It can be translocated medially and laterally or in the sagittal plane (6). Several authors suggest that the complication rate for medial displacement osteotomies is low (7, 8). Wound complications, especially in immunocompromised individuals, may pose a threat to the outcome of the procedure. Furthermore, the relationships of the soft tissues on the medial side of the calcaneus must be understood to minimize trauma to this area. A recent study by Greene et al (9) analyzed the topography of the medial neuro vascular supply and its relationship to the site of the open CDO. They surveyed the medial plantar nerve, lateral plantar nerve, posterior tibial artery, and their branches. Neither the medial plantar nerve nor its branches crossed the osteotomy site in any of the 22 specimens. The lateral plantar nerve crossed the site in only 1 specimen; however, its calcaneal branch crossed the site 86% of the time. This intersection occurred at approximately 20% of the distance from the proximal portion of the calcaneus. Additionally, the second lateral plantar nerve branch crossed in 95% of the specimens at two-thirds from the proximal point. The posterior tibial artery crossed the osteotomy site in 2 specimens. Branches crossed in 77% of the cases at the midsection of the osteotomy. They concluded that, when performing the CDO, the

Anatomic study of the medial neurovascular structures in relation to calcaneal osteotomy.

Medial displacement osteotomy of the calcaneous is commonly performed for stage II posterior tibial tendon insufficiency in an effort to improve the valgus deformity of the hindfoot. We performed an anatomic study examining the medial neurovascular anatomy and its relation to the osteotomy in an attempt to determine which structures may be at risk during the procedure. Calcaneal osteotomies were performed through a lateral approach on 22 fresh-frozen cadaver below-knee specimens. Dissection was then performed medially to identify the Medial Plantar Nerve (MPN), the Lateral Plantar Nerve (LPN), the Posterior Tibial Artery (PTA), and their respective branches. Measurements determined either 1) where the structure crossed the osteotomy or 2) if the structure did not cross, the closest perpendicular distance from the osteotomy and at which point along its length this occurred. Perpendicular distances were recorded in millimeters and position along the osteotomy as a percentage of the total length from the posterosuperior aspect. An average of four neurovascular structures crossed each osteotomy site (range 2 to 6), most of which were branches of the LPN or the PTA. The MPN did not cross in any of the specimens studied, the LPN crossed in one specimen, and the PTA crossed in two specimens. The MPN distributed no crossing branches. The calcaneal sensory branch of the LPN was identified and crossed in 86% of the cadavers at 19% (+/- 15%) along the osteotomy length. A more distal second branch of the LPN (Baxter's nerve) was identified and crossed in 95% of the specimens at 61% (+/ 20%) along the osteotomy length. A third crossing branch existed in one specimen. Each PTA distributed from zero to three branches which variably crossed the osteotomy at a point from 2% to 100% along its length. The PTA bifurcated in 77% of the specimens at 49% (+/- 9%) along the osteotomy length. A consistent finding in every specimen was the presence of two veins accompanying the PTA with one on either side. A number of medial neurovascular structures may be at risk when perfoming a calcaneal osteotomy through a lateral approach. A minimum of two structures crossed the osteotomy site at variable positions in this study, although most of these structures represented branches off of the LPN or the PTA, with the LPN and the PTA themselves crossing only infrequently. The authors recommend that the completion of the osteotomy through the medial calcaneal cortex be performed in a carefully controlled manner to reduce the risk of post-operative complications including pain, numbness, and hematoma formation.

The contribution of the medial calcaneal osteotomy to the correction of flatfoot deformities.

The success of the medial displacement calcaneal osteotomy in correcting flatfoot deformities is likely to be the result of a shift of the Achilles tendon forces on the hindfoot. The purpose of this study was twofold: 1) to define the contribution of the Achilles tendon to the flatfoot deformity, and 2) to define the effect of a calcaneal medial displacement osteotomy. We used six different experimental dynamic stages: 1) intact foot without Achilles loading; 2) intact foot with Achilles loading; 3) flatfoot without medial calcaneal displacement osteotomy and without Achilles loading; 4) flatfoot without medial calcaneal displacement osteotomy but with Achilles loading; 5) flatfoot with medial calcaneal displacement osteotomy but without Achilles loading; and 6) flatfoot with medial calcaneal displacement osteotomy and with Achilles loading. The experimental flaffoot was developed by releasing the posterior tibial tendon, spring ligament, and plantar fascia and applying 7,000 cycles of axial fatigue load (range, 700 to 1,400 N; 1-Hz frequency). To simulate the phase of midstance, the peroneus longus, peroneus brevis, flexor digitorum longus, and flexor hallucis longus tendons were grasped by clamps, connected to pneumatic actuators, and loaded with precalculated forces. Anteroposterior and lateral radiographs were obtained for each stage on which the following measurements were made: talonavicular coverage angle, talar-first metatarsal angle, talocalcaneal angle, and height of the medial cuneiform. These measurements were compared with a one-way ANOVA. Between stages 1 and 2, all measurements were statistically insignificant. Between stages 3 and 4, for all measurements, Achilles tendon loading aggravated the flatfoot deformity (p < 0.05). After medial calcaneal osteotomy (stages 5 and 6), the Achilles tendon contributed less to the arch-flattening. We found that the medial displacement osteotomy plays an important role in reducing and/or delaying the progress of flatfoot deformity. In the flatfoot, loading of the Achilles tendon increases the deformity. Medial calcaneal osteotomy significantly decreases the arch-flattening effect of this tendon and therefore limits the potential increase of the deformity.

Surgical Treatment of Severe Hindfoot Valgus by Medial Displacement Osteotomy of the Os Calcis in Children with Myelomeningocele

This is a retrospective review of 27 patients with severe hindfoot valgus who were treated with a medial sliding osteotomy of the os calcis. The group consisted of 38 feet in 27 patients with myelomeningocele, ranging in age from 7 to 17 years. Follow-up averaged >5 years. The amount of hindfoot deformity, problems with brace and shoe wear, and overall patient satisfaction were analyzed. Eighty-two percent of the patients were completely satisfied. Most had complete correction of the hindfoot deformity. There was one superficial pin site infection and no nonunions.

The Role of Osteoporosis and Fracture Comminution in the Outcome of Anatomically Reduced and Adequately Fixed Intertrochanteric Femoral Fractures

To assess the role of osteoporosis and fracture comminution in the migration of the tip of the sliding screw within the femoral head, as well as the fracture collapse in anatomically reduced and adequately fixed intertrochanteric fractures, 151 patients, whose intertrochanteric fractures had been treated surgically with anatomic reduction and a centrally placed Dynamic Hip Screw (Protek Synthes, Switzerland), were reviewed with an average follow-up of 6 months after the fracture had healed (mean 9 months after fracture fixation). Osteoporosis was determined using the Singh scale, whereas fracture comminution was classified using the Tronzo criteria. Vertical and horizontal screw migration as well as fracture collapse (screw retrolisthesis) were measured in immediate anterioposterior postoperative roentgenograms and in roentgenograms at the end of the treatment. Failure in osteosynthesis occurred in 2.65% of the cases. Osteoporosis is strongly related to vertical (P = 0.00001), and horizontal (P = 0.0125) migration of the tip of the screw within the femoral head and less so to fracture collapse. On the other hand, fracture comminution is strongly related to fracture collapse (P = 0.0124) but not to the migration of the screw within the femoral head. The successful outcome of treating patients with intertrochanteric fractures depends on both adequate biology (no severe osteoporosis) and adequate mechanics (proper implant and surgical technique). Anatomic reduction and central placement of the sliding screw must be performed as a routine. Modifications to decrease the loading of the fractured hip (medial displacement and valgus osteotomy) should only be considered in exceptional cases in the presence of significant osteoporosis, thus avoiding the expected severe vertical and horizontal migration of the tip of the screw as well as fracture collapse.

Effect of calcaneal osteotomy and lateral column lengthening on the plantar fascia: a biomechanical investigation.

Medial calcaneal displacement osteotomy or lateral column lengthening fusion has been advocated to augment tendon transfer in planovalgus foot deformity associated with chronic posterior tibial tendon insufficiency. It is hypothesized that plantar fascia tightening occurs with these procedures, helping to restore a more normal longitudinal arch. To investigate this further, nine fresh-frozen cadaver below-knee specimens were used. A flatfoot model was created by sectioning of the posterior tibial tendon, spring ligament, talonavicular capsule, and deltoid ligament. A liquid-metal strain gauge, calibrated to measure fractional changes in length, was sutured proximally to the origin and distally into the thickest portion of the medial band of the plantar fascia. Specimens were axially loaded to 400 N and plantar fascia strain was measured. Fractional length changes in the plantar fascia were then measured after a medial displacement calcaneal osteotomy and after a lateral column lengthening through the calcaneocuboid joint. Tightening of the plantar fascia did not occur with either medial calcaneal displacement or lateral column lengthening. The plantar fascia became significantly less taut with both medial displacement and lateral column lengthening. We found that lateral column lengthening produced significantly looser plantar fascia than did medial displacement of the calcaneal tuberosity.

Tendon Transfer Combined with Calcaneal Osteotomy for Treatment of Posterior Tibial Tendon Insufficiency: A Radiological Investigation

We present the radiographic results after flexor digitorum longus tendon transfer combined with a medial displacement calcaneal osteotomy for the treatment of posterior tibial tendon insufficiency. Eighteen patients with posterior tibial tendon insufficiency were reviewed from 12 to 26 months after surgery. The 15 women and 3 men had a mean age of 54 years (range, 38-72 years). The talar-first metatarsal and talonavicular coverage angles were measured before and after surgery on the anteroposterior weightbearing radiographs. The mean preoperative talar-first metatarsal and talonavicular coverage angles were 21 degrees (range, 3-45 degrees) and 34 degrees (range, 0-55 degrees), respectively. The mean postoperative values for these angles were 8.5 degrees (range, 0-35 degrees) and 21 degrees (range, -30-45 degrees), respectively. The mean talar-first metatarsal angle decreased from 21 degrees to 8.5 degrees, a mean improvement of 12.5 degrees, and the mean talonavicular coverage angle decreased from 34 degrees to 21 degrees, a mean improvement of 13 degrees. On the lateral weightbearing radiographs, the talar-first metatarsal angle and the distance from the medial cuneiform to the floor were measured before and after surgery. The mean preoperative values were -22 degrees (range, -10 to -40 degrees) and 9 mm (range, 1-19 mm), respectively. The mean postoperative values were -9 degrees (range, +5 to -25 degrees) and 16 mm (range, 10-28 mm), respectively. The mean talar-first metatarsal angle decreased from -22 to -9 degrees (a mean improvement of 13 degrees), and the distance from the medial cuneiform to the floor increased from 9 to 16 mm (a mean improvement of 7 mm). We conclude that the use of a combined medial displacement osteotomy of the calcaneus with a tendon transfer for treatment of posterior tibial tendon insufficiency may offset the inherent weakness of the flexor digitorum longus transfer by reducing the antagonistic deforming force of heel valgus.

変形性股関節症に対する大腿骨転子間骨切り術とキアリー骨切り術の併用例の検討 キアリー骨盤骨切り術の効果

We performed Chiari's medial displacement osteotomy combined with transtrochanteric osteotomy for secondary osteoarthritis of the hip with dysplasia. We discussed the clinical effect of 13 joints performed Chiari's osteotomy combined with varus osteotomy and 12 joints performed Chiari's osteotomy with valgus osteotomy in over 3 years. Results are as follows.1. Clinical estimation is good for long term except 1 case.2. Fine new acetabulum is formed in the joint after Chiari's osteotomy at less than 6mm height from the edge of the acetabulum.3. The femoral head displaced medially by an average of 7.7mm.4. The acetabular bone cysts decreased in size or disappeared in 11 joints out of 13 joints, which may have occurred clue to dispersion of dynamic load and biological effect aquired by the osteotomy.

Medial Displacement Osteotomy for Unstable Intertrochanteric Fractures

Fifty-five unstable intertrochanteric fractures were treated with a sliding compression screw apparatus. Thirty-seven cases were treated by anatomic nailing and 18 cases were treated by primary medial displacement osteotomy (MDO) by the method of Dimon and Hughston. The mean age of these patients was 82.5 years. Women out-numbered men seven to one. The times to healing for fractures treated with MDO and anatomic nailing were the same. There were no nonunions. The rate of major complications was similar for both groups; however, trochanteric bursitis was more apparent in the anatomically nailed group. Eighty-nine percent of the fractures treated with anatomic nailing collapsed into a medially displaced position. Ninety-seven percent of anatomically nailed fractures in which the sliding compression screw was appropriately placed healed without complications. Satisfactory stability and healing occurred in both MDO and anatomic nailing groups. There was no demonstrated advantage of MDO over anatomic nailing using a sliding compression screw.

Total hip replacement after medial-displacement osteotomy of the proximal part of the femur.

Intertrochanteric osteotomy has been recommended as an alternative to total hip replacement for the treatment of osteoarthrosis of the hip in younger patients because of the higher risk of mechanical loosening after total hip replacement in this age-group. The results of 112 consecutive cemented total hip replacements that were performed after a medial-displacement intertrochanteric osteotomy had failed (the conversion group) were compared with the results of 262 consecutive primary total hip replacements with cement (the control group). The mean length of follow-up was fifty-six months for the first group and fifty-four months for the second. The mean time between the osteotomy and the total hip replacement was six years. Two hundred and four Müller prostheses and 170 Lubinus hip prostheses were used. Pain was satisfactorily relieved in 89 per cent of the group that had a conversion and in 91 per cent of the control group. There were only minor differences in the range of motion of the hip and in walking performance between the two groups. The femoral component was more frequently in a varus position in the control group (p less than 0.05). The radiographic findings, including migration of the stem and radiolucency around the stem, were not inferior in the group that had a conversion. The rate of intraoperative fracture was significantly greater in the group that had a conversion, and it was correlated with the amount of displacement of the osteotomy. There were four failures (1.5 per cent) in the control group and one (0.9 per cent) in the group that had a conversion.(ABSTRACT TRUNCATED AT 250 WORDS)

Sliding hip screws and medial displacement osteotomy.

The case notes and radiographs of 108 patients who had undergone compression screw fixation of trochanteric fractures of the femur were reviewed. Forty-seven patients had unstable comminuted fractures, and 20 of these had medial displacement osteotomies performed. In 40% of this group the operation was not a success in terms of extrusion of the screw through the femoral head, compared with 20% for the whole series of 108 patients. A number of parameters were studied in the search for a cause for the failure, and there was a correlation with a superior position of the screw initially, and a low serum albumin. Although the proximal fragment abutted the plate at the time of operation, the medial cortices of the proximal and distal fragments were often not in apposition, allowing the fracture to collapse into varus with resultant extrusion. Unless a stable configuration is achieved at the time of operation, reliance on the sliding component of these implants to allow for collapse at the fracture site will not necessarily produce this stability, and failure will ensue.

The intertrochanteric hip fracture. A retrospective analysis.

One hundred intertrochanteric hip fractures were analyzed utilizing a computer-assisted digitization system to study the factors affecting postoperative stability. Fractures were evaluated by measuring shortening and angulation, collapse of telescoping device when utilized, and migration of the fixation device within the femoral head. Fractures were classified preoperatively according to their stability and postoperatively according to the type of operative reduction performed. The failure rate and postoperative stability were then compared according to the type of fracture, type of operative reduction, and internal fixation device utilized. Results indicate that the preoperative fracture classification is a strong and significant determinant of postoperative stability. Conversely, the type of operative reduction was not as significant a determinant of postoperative stability. In particular, medial displacement osteotomy had no advantage over anatomic reduction in the unstable fracture. The use of a fixed angle nail plate was associated with an increased failure rate.

Biomechanical Evaluation of Anatomic Reduction Versus Medial Displacement Osteotomy in Unstable Intertrochanteric Fractures

The biomechanical characteristics of anatomic reduction versus medial displacement osteotomy were compared for four-part intertrochanteric fractures experimentally produced in cadaver femurs. Eighteen pairs of femurs were assigned randomly to either the anatomic (A) or the medial displacement (MD) group and instrumented with multiple strain gauges. The femurs in the MD group were tested while intact and following four-part fracture with fixation. The femurs in the A group were first tested intact, followed by a stable two-part fracture with fixation, and then by a four-part fracture with fixation and perfect reduction of the posteromedial fragment (PMF) with a lag screw, partial reduction of the PMF, and with the PMF omitted. All fractures were fixed with a 135 degrees, four-hole, sliding hip screw. The strain distribution in the MD group changed significantly after fracture. The plate tensile strain increased by 360% while the compressive calcar strain decreased 85%. The plate tensile strain in the A group also increased significantly after four-part fracture when the PMF was perfectly reduced (160%), partially reduced (290%), or discarded (275%); the calcar compressive strains for these subgroups decreased approximately 50%. This laboratory study indicates that anatomic reduction of four-part intertrochanteric fractures with the sliding hip screw, regardless of the presence or position of the PMF, provides significantly higher compression across the calcar region and significantly lower tensile strain on the plate than fractures reduced by medial displacement osteotomy. The more physiologic strain distribution and the increased medial load transmission support the use of anatomic reduction for the treatment of unstable intertrochanteric fractures.

Treatment of unstable intertrochanteric fractures with sarmiento valgus osteotomy and acrylic cement augmentation

Seventy unstable intertrochanteric fractures (Kyle III) were treated by Sarmiento valgus osteotomy, fixation with a sliding hip-screw and plate, and augmentation of the posteromedial upper femoral defect with acrylic cement. Immediate full weight bearing walking was started after the operation. Forty-two patients were followed up for more than 1 year (average 21.4 months). Excellent or good results were obtained in 71.4 per cent. However, there was mechanical failure in which the hip screw cut out of the femoral head superolaterally in 8.6 per cent. Comparison was made between the results of the present technique and our previously reported technique which consisted of Dimon-Hughston medial displacement osteotomy, fixation with sliding hip screw and acrylic cement augmentation to the upper posteromedial femoral defect. It was found that the result of the latter technique is slightly better, probably because of the more rigid reduction.

Nonunion of Intertrochanteric Fractures of the Femur Following Open Reduction and Internal

A retrospective review was performed on 20 patients treated at the authors' hospital between 1961 and 1981 with noninfected nonunions following primary open reduction and internal fixation (ORIF) of intertrochanteric femoral fractures. All patients were available for follow-up examination. Each patient was interviewed at an average follow-up period of 6.6 (0.8-11.9) years. The group consisted of 15 women and five men with an average age at the time of fracture of 63 (36-86) years. Only one fracture was "stable" while 19 were "unstable" with loss of medial support. The initial fixation device was a sliding nail or screw in four patients, fixed nail plate in 11, Smith-Petersen in two, Deyerle pins in one, and was unrecorded in two. Of the 20 cases, it was possible to obtain the original postoperative roentgenograms in 12. Anatomic reduction had been achieved in four, medial displacement osteotomy had been used in two, varus positioning in one, and valgus positioning in five. Subsequent operative treatment for the nonunions consisted of three endoprostheses, six total hip arthroplasties, and 11 repeated attempts at ORIF. Of those treated with repeat ORIF, nine (82%) achieved radiographic union at an average time of six months. Of the remaining two who did not achieve union with the second ORIF, one achieved union following removal of internal fixation and bone grafting (five months) and one required a total hip arthroplasty. The postoperative functional results, as determined by a modified Harris hip score, were improved over the preoperative functional results for each treatment mode. Functional results were best in those patients who achieved union with a second surgical attempt.