Coexisting Kienböck's and Preiser's Disease of the Wrist: Experience with Proximal Row Carpectomy with Dorsal Capsular Interposition Technique.

BACKGROUND: Idiopathic avascular necrosis of the lunate is known as Kienböck's disease and that of the scaphoid is known as Preiser's disease. Because the prevalence of coexisting Kienböck's and Preiser's diseases is very low, standardized stages of disease and treatments are not established. CASE PRESENTATION: We report coexisting avascular necrosis of the scaphoid and lunate in a 68-year-old woman with no history of steroids or other risk factors. We treated her with proximal row carpectomy with capsular interposition technique. A distal-based dorsal capsular flap was prepared and repaired the palmar capsule. At the last follow-up, she had no pain and had gained improved range of wrist motion. There was no arthritic change at the newly formed radiocapitate joint. CONCLUSIONS: In the case of collapsed lunate and scaphoid with avascular necrosis, the proximal row carpectomy procedure has an advantage. Proximal row carpectomy with dorsal capsular interposition can be performed when the lunate or scaphoid cannot be saved. Arthritic changes of the capitate head and distal radius lunate facet can be covered with the dorsal capsule.

A Novel Surgical Technique for Neglected Volar Dislocation of the Lunate: Cases Report and Literature Review.

BACKGROUND: Treatments for chronic perilunate or lunate dislocations are very difficult and associated with poor prognoses. There is no established treatment method and are still many controversies. CASE PRESENTATION: We reported three cases of chronic neglected lunate volar dislocation treated with a novel surgical technique. All three cases were males with wrist pain and tingling sensation. Radiographs confirmed chronic volar dislocation of the lunate. Open reduction was performed by combined volar and dorsal approaches. After anatomical reduction, scapholunate and lunotriquetral interosseous ligament reconstructions were performed with the palmaris longus tendon and synthetic tape. The patients had an uneventful postoperative period with satisfactory functional outcomes at the last follow-up. CONCLUSIONS: We believe that open reduction and interosseous ligament reconstruction using the autogenous tendon and synthetic tape may be a valuable option for treating chronic volar dislocation of the lunate.

Pyoderma Gangrenosum of the Hand: Unique Experience and Literature Review.

BACKGROUND: Pyoderma gangrenosum (PG) is a reactive, noninfectious, neutrophilic dermatosis. Diagnosis of PG is based on exclusion, due to lack of availability of a confirmatory test. PG is not caused by infection or gangrene. Misdiagnosis or delayed diagnosis of PG can lead to devastating results. CASE PRESENTATION: In this report, we present a patient with a delayed diagnosis of PG lesion on right hand. Despite initial surgical treatment, the wound was aggravated, and amputation was considered; however, it was eventually treated successfully with an autologous split thickness skin graft. CONCLUSIONS: Knowledge of the PG is essential to actively consider PG in early stage to help facilitate immediate treatment and avoid unnecessary interventions that may worsen the outcome.

Intraosseous Lipoma of the Carpus: A Report of 2 Cases and a Review of the Literature.

ABSTRACT: Intraosseous lipoma is a very rare benign lipoma, accounting for less than 0.1% of primary bone tumors. Incidentally found in most cases, it frequently involves the metaphysis of the long bones of the lower extremity or calcaneus but rarely occurs in the upper extremity. Intraosseous lipoma of the carpal bones, especially, has yet to be reported, except for 3 cases of scaphoid and capitate involvement. Herein, we report 2 cases of intraosseous lipoma in the capitate and hamate bones with a literature review. Two patients complained of wrist discomfort despite conservative treatment and were diagnosed by computed tomography, magnetic resonance imaging, and surgical biopsy. They were treated with intralesional curettage and autologous bone graft, and their symptoms improved and showed no evidence of recurrence, both clinically and radiologically.

Scapholunate and lunotriquetral interosseous ligament augmentation with internal bracing in perilunate dislocation: Case reports.

RATIONALE: The goals of surgical treatment of the perilunate dislocation (PLD) are confirmation of reduction, ligament repair, and supplemental fixation of the bony architecture. Open reduction and direct repair of the torn ligament are recommended for acute PLD. However, repair of the scapholunate interosseous ligament (SLIL) and lunotriquetral interosseous ligament (LTIL) is often unreliable, and secure repair is challenging. Internal bracing (IB) is an augmentation method that uses high-strength non-absorbable tape and enhances strength and support during the critical period of ligamentous healing. However, there is a paucity of data on the application of IB for PLD in the wrist. We report 3 cases of PLD that were augmented with IB after SLIL and LTIL repair. PATIENT CONCERNS: All 3 cases were men who visited our emergency department with wrist after falling off a ladder. DIAGNOSES: Initial radiographs revealed a dorsal PLD. INTERVENTIONS: Surgically, complete rupture of the SLIL and LTIL were confirmed. K-wires were placed into the scaphoid and lunate and used as joysticks to correct the intercalated segment instability pattern. This usually requires correcting scaphoid flexion and lunate extension and closing the scapholunate interval. Prior to SLIL and LTIL repair, temporary intercarpal fixation was performed with K-wires to maintain the carpal relationship. The dorsal SLIL and LTIL were carefully repaired using suture anchors. However, ligament repair was unreliable, and insecure. In view of the likelihood of insufficient repair, we performed IB augmentation using synthetic tape. OUTCOMES: At the last follow-up, all cases were pain-free and had returned to all activities. The last follow-up radiographs showed good alignment of the carpal bones and no arthritic changes. LESSONS: IB augmentation can reduce the period of K-wire fixation and cast immobilization and can enable early joint motion. We believe that interosseous ligament augmentation using IB is a reasonable treatment option for PLD.

Posterior Interosseous Fascicular Constriction Within the Radial Nerve in a Diabetic Patient With Bilateral Neuralgic Amyotrophy: A Case Report.

Background: Neuralgic amyotrophy (NA) is an acute, monophasic, painful inflammatory dysimmune focal, or multifocal mononeuropathy. The lesion in NA is not always restricted to the brachial plexus but also involves individual nerves or branches. The prognosis of NA is less favorable than previously assumed, but the reasons for poor recovery remain unknown. Nerve constriction may be one of the causes of poor prognosis in NA. Case Presentation: Herein, we described a 54-year-old male with a history of type 2 diabetes in whom bilateral neuralgic amyotrophy developed with constriction of the posterior interosseous fascicle within the radial nerve. The patient experienced sudden-onset severe pain in both shoulders followed, 2 days later, by weakness in bilateral shoulders and the left forearm extensors over the subsequent month. The left forearm extensors were more severely affected than both shoulder girdle muscles. He noted a 7-kg weight loss for 1 month before pain onset. After diagnosing diabetic NA based on the clinical symptoms, imaging, and electrophysiological studies, treatment with systemic steroids improved pain and weakness in both shoulder muscles. Weakness in the left forearm extensors persisted after 1 month of steroid treatment. Follow-up ultrasound revealed constriction of the posterior interosseous fascicle within the main trunk of the left radial nerve at the elbow. Surgical exploration at 6 months after onset identified fascicle constriction, for which neurolysis was performed. Weakness in the extensors of the wrist and fingers did not improve during the 16-month follow-up. Conclusion: A single constriction of the fascicle within a peripheral nerve may often be under-recognized if NA presents with variable degrees of weakness in bilateral upper limbs. Furthermore, fascicular constriction without edema of the parent nerve may be easily missed on the initial ultrasound. A lack of early recognition of nerve constriction and delay in surgical intervention can result in unfavorable outcomes. The physician should consider the possibility of the fascicular constriction when evaluating patients suspected of brachial NA with significant weakness in the distal upper limb compared to the proximal weakness or weakness of the distal upper limb that does not improve over time.

Importance of detection of capitellar cartilage injuries concomitant with isolated radial head fractures: A retrospective clinical study.

OBJECTIVE: This study aimed to analyze the injury pattern and clinical importance of concomitant capitellar cartilage defects (CCDs) among patients treated surgically for radial head fracture (RHF). METHODS: A total of 74 patients who were treated surgically for isolated RHFs were retrospectively reviewed. Of these, 12 patients with CCDs (16.2%) were classified as Group I (10 men; mean age, 41.3±12.8 years) and the remaining 62 patients without CCD as Group II (control group) (48 men; mean age, 50.8±13 years). The mean follow-up was 21.3±3.2 months in Group I and 18.7±6.4 in Group II. In Group I, 11 patients underwent open reduction and internal fixation, whereas 1 patient was treated by radial head resection. The preoperative range of motion (ROM) was recorded; the severity of RHF was assessed using the Mason classification. The location, size, and thickness of CCD injuries at the time of surgery were also documented. At the final follow-up, radiological assessment was performed to determine the bone union, and clinical measurements, including ROM and the Mayo elbow performance score (MEPS), were performed. The clinical features of the 2 groups were statistically analyzed. RESULTS: In Group I, 10 patients showed limited forearm rotation. CCD was located posterolaterally in 11 patients and anterolaterally in 1 patient. At the final follow-up, 11 patients from Group I who underwent open reduction and internal fixation showed complete union of RHF and full recovery of pronation and supination. According to the MEPS, 9 patients exhibited excellent results, and 3 patients exhibited good results. In Group I, RHFs were classified as Mason type II in 7 patients (58.3%) and type III in 4 patients (58.3%). In Group II, RHFs were type II in 45 patients (72.6%) and type III in 17 patients (27.4%). In comparative analyses, there was a significant difference in age (41.3±12.8 versus 50.8±13.0, p=0.041) between the 2 groups. Preoperative pronation/supination was higher in Group II (131.7±36.2) than in Group I (106.3±31.6) (p=0.021). There were no significant differences in sex (p=0.097), follow-up period (p=0.326), Mason type (p=0.482), preoperative extension/flexion (102.3±43.3 [Group I] versus 107.6±44.9 [Group II]) (p=0.584), final follow-up extension/flexion (133.3±10.7 [Group I] versus 126.9±21.2 [Group II]) (p=0.384), pronation/supination (151.2±9.1 [Group I] versus 151.2±13.3 [Group II]) (p=0.558), and the MEPSs (92.9±6.6 [Group I] versus 93.3±7.5 [Group II]) (p=0.701). CONCLUSION: If a thorough physical examination of a patient with RHF reveals limited forearm rotation, effort must be made to identify the cause, and the possibility of CCD must be considered. Moreover, there is a need for careful observation during RHF surgery for not only fracture reduction or fixation but also possible CCD. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Treatment of purely ligamentous dorsoulnar radiocarpal dislocation with ulnar translation of the carpus: A case report.

RATIONALE: Radiocarpal fracture-dislocations are extremely infrequent injuries caused by high-energy trauma and involve significant osseous and ligamentous injuries. If not treated properly, it can lead to serious complications such as ulnar translation of the carpus, multidirectional instability, loss of motion, and post-traumatic arthritis. Purely ligamentous injuries are rarer than fracture-dislocation injuries. Because previous studies have reported small patient cohorts, there has been no standardized treatment strategy for purely ligamentous radiocarpal dislocation. PATIENT CONCERNS: A 24-year-old man suffered a left wrist injury in a motorcycle accident. Plain radiographs revealed dorso-ulnar radiocarpal dislocation without radial fracture and Carpal-ulnar distance ratio (CUDR) was 0.16. MRI scans showed the disruption of the dorsal ligaments and capsules and avulsed from the proximal insertion of the volar radiocarpal ligaments. DIAGNOSIS: Dorsoulnar radiocarpal dislocation with purely ligamentous injury. INTERVENTION: We removed the interposing chondral fragment from the radiocarpal joint and repaired the radioscaphocapitate (RSC) and radiolunate (RL) ligaments with the Jugger Knot Soft Anchor Suture (Biomet, Inc, Warsaw, IN) and applied additional radiocarpal K-wires and an external fixator to maintain reduction and optimal ligament tension. OUTCOMES: The patient showed good clinical results although ulnar translation of the carpus recurred in radiological follow-up. LESSONS: Aggressive surgical management is needed earlier in the treatment of purely ligamentous radiocarpal dislocation, especially if the ulnar translation of the carpus was observed in the initial radiographs.

Reverse turnover pedicled latissimus dorsi muscle flap for lower back reconstruction: Two case reports.

RATIONALE: Large soft tissue defects on the lower back represent a treatment challenge. Among a variety of reconstructive procedures, the latissimus dorsi (LD) muscle or musculocutaneous flap is one of most frequently used pedicled flaps. However, the pedicled LD flap carries a bulky pivot point and a short arc of rotation. If a pedicled LD muscle flap is transferred using a reverse turnover pattern, theses drawbacks can be avoided. PATIENT CONCERNS: The first patient was a 56-year-old man with hepatocellular carcinoma and multiple bone metastases involving D11-L4 vertebral bodies. A chronic ulcer was developed on his lower back area after palliative radiation therapy for bone metastases. The second patient was a 41-year-old man with a soft tissue mass on his lower back, which was diagnosed as dermatofibrosarcoma protuberans via previous incisional biopsy. A large soft tissue defect was developed on his lower back as a result of a wide resection. DIAGNOSIS: Both patients were referred to our department for the treatment of a large soft tissue defect on lower back. INTERVENTIONS: They underwent the reverse turnover pedicled LD muscle flap and split-thickness skin graft. OUTCOMES: At postoperative 6-month follow-up, both patients remained free of wound problem. LESSONS: The reverse turnover pedicled LD muscle flap is quite straightforward. Even if a soft tissue defect in the lower back is large or complicated by infection or radiation therapy, perfusion of LD by posterior intercostal arteries is likely to be preserved. We recommend the reverse turnover pedicled LD muscle flap as an effective alternative for reconstruction of soft tissue defects involving the lower back.

Cubital Tunnel Syndrome Caused by Anconeus Epitrochlearis Muscle.

OBJECTIVE: We evaluated the clinical manifestation and surgical results following operative treatment of cubital tunnel syndrome (CuTS) caused by anconeus epitrochlearis (AE) muscle. METHODS: Among 142 patients who underwent surgery for CuTS from November 2007 to October 2015, 12 were assigned to the AE group based on discovery of AE muscle; 130 patients were assigned to the other group. We analyzed retrospectively; age, sex, dominant hand, symptom duration, and weakness in hand. Severity of the disease was evaluated using the Dellon classification and postoperative symptom were evaluated using disability of arm shoulder and hand (DASH) and visual analogue scale (VAS) scores. Surgery consisted of subfascial anterior transposition following excision of AE muscle. RESULTS: AE muscle was present in 8.5% of all patients, and was more common in patients who were younger and with involvement of their dominant hand; the duration of symptom was shorter in patients with AE muscle. All patients showed postoperative improvement in symptoms according to DASH and VAS scores. CONCLUSION: The possibility of CuTS caused by AE muscle should be considered when younger patients have rapidly aggravated and activity-related cubital tunnel symptoms with a palpable mass in the cubital tunnel area. Excision of AE muscle and anterior ulnar nerve transposition may be considered effective surgical treatment.

Surgical Treatment of Piriformis Syndrome.

BACKGROUND: Piriformis syndrome (PS) is an uncommon disease characterized by symptoms resulting from compression/irritation of the sciatic nerve by the piriformis muscle. Uncertainty and controversy remain regarding the proper diagnosis and most effective form of treatment for PS. This study analyzes the diagnostic methods and efficacy of conservative and surgical treatments for PS. METHODS: From March 2006 to February 2013, we retrospectively reviewed 239 patients who were diagnosed with PS and screened them for eligibility according to our inclusion/exclusion criteria. All patients underwent various conservative treatments initially including activity modification, medications, physical therapy, local steroid injections into the piriformis muscle, and extracorporeal shock wave therapy for at least 3 months. We resected the piriformis muscle with/without neurolysis of the sciatic nerve in 12 patients who had intractable sciatica despite conservative treatment at least for 3 months. The average age of the patients (4 males and 8 females) was 61 years (range, 45 to 71 years). The average duration of symptoms before surgery was 22.1 months (range, 4 to 72 months), and the mean follow-up period was 22.7 months (range, 12 to 43 months). We evaluated the degree of pain and recorded the responses using a visual analog scale (VAS) preoperatively and 3 days and 12 months postoperatively. RESULTS: Buttock pain was more improved than sciatica with various conservative treatments. Compared with preoperatively, the VAS score was significantly decreased after the operation. Overall, satisfactory results were obtained in 10 patients (83%) after surgery. CONCLUSIONS: PS is thought to be an exclusively clinical diagnosis, and if the diagnosis is performed correctly, surgery can be a good treatment option in patients with refractory sciatica despite appropriate conservative treatments.

Treatment of Kienböck's disease using a fourth extensor compartmental artery as a vascularized pedicle bone graft.

BACKGROUND: Vascularized bone grafts for the treatment of Kienböck's disease may facilitate revascularization and remodeling of the avascular lunate. The aim of this study was to evaluate the radiological and clinical results obtained when a fourth extensor compartmental artery (ECA) bone graft was used to treat Kienböck's disease. METHODS: Between May 2009 and June 2012, 13 patients (6 men, 7 women) with Kienböck's disease were treated with placement of fourth ECA vascularized bone grafts. The mean patient age was 39.2 (20-58) years, and the mean follow-up period was 32.5 (12-72) months. At the time of surgery, One patient had Lichtman's stage II Kienböck's disease, 11 stage IIIA disease, and one stage IIIB disease. We measured the pre- and post-operative ranges of motion, pain, grip strength, and radiological parameters, including the carpal height ratio and the radioscaphoid angle. RESULTS: At the last follow-up, pain was significantly reduced, and grip strength had improved from 60.5% to 87.8% relative to that of the contralateral side. The mean range of motion for flexion had improved from 39° to 53° while that of wrist joint extension improved from 41° to 56°. There were little or no changes in either the carpal height ratio or the radioscaphoid angle (both p values > 0.05). CONCLUSIONS: Placing of a fourth ECA vascularized bone graft is a reliable alternative to other revascularization procedures for treatment of Kienböck's disease. Such grafting is effective, minimally invasive, and associated with a low risk of pedicle kinking. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic/IV.

Multiple etiologies of trigger wrist.

BACKGROUND: Trigger wrist, a relatively unusual condition, is a triggering at the wrist produced by wrist or finger motion. The clinical manifestations and surgical results of trigger wrist with multiple etiologies were evaluated. METHODS: From October 2008 to December 2012, this study retrospectively reviewed 15 patients diagnosed with trigger wrist. The patients comprised six men and nine women with a mean age of 44.8 years (range, 29-86 years). The mean follow-up period was 16.2 months (range, 11-30 months). RESULTS: The causes of trigger wrist were an anomalous muscle belly of the flexor digitorum superficialis (n = 5), severe tenosynovitis of the flexor tendon (n = 4), fibroma around the flexor tendon sheath (n = 2), a rheumatoid nodule (n = 1), both anomalous muscle belly and tenosynovitis (n = 1), a ganglion (n = 1), and pigmented villonodular synovitis (n = 1). Mild-to-moderate symptoms of median neuropathy without thenar muscle atrophy were present in all patients. Postoperatively, all patients recovered well with resolution of median nerve symptoms, and the wrist triggering was absent. CONCLUSIONS: Trigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic/IV.

An intraosseous epidermal cyst developing in a metacarpal bone after K-wire fixation: a case report.

Intraosseous epidermal cysts (IECs) are rare benign lesions caused by the proliferation of epidermal cells within the bone. The pathogenesis of IEC remains unclear; however, trauma-triggered infiltration of the bone by epidermal elements has been suggested. Here, we present a case of an IEC in the metacarpal bone of the little finger associated with K-wire fixation for treatment of a fifth metacarpal fracture.

Anthropometric study of the proximal radius: does radial head implant fit in all cases?

PURPOSE: The purpose of this study was to evaluate anthropometry of the radial head and neck and compare the results with radial head prosthesis in current use. METHODS: A total of 144 cases were analysed that underwent antero-posterior (AP) elbow radiographs in full supination and extension position between January 2013 and April 2013. Mean age was 54.3 years (range, 21-79). The distance between the articular surface and the radial tuberosity, the height of the radial head, the diameter of the radial head, and the width of the proximal radioulnar joint were measured. The specifications of 13 products from nine companies were compared with the parameters. RESULTS: The mean distance between the articular surface and the radial tuberosity was 19.6 mm. Mean height, diameter, and width of the proximal radioulnar joint were 10.6, 22.0, and 8.9 mm, respectively. A violation of the distal biceps insertion will occur in up to 87.5 % of the cases when some of the bipolar implants were used. The height of some of the implant heads was larger than the height of head in our study. Although the height and diameter of the radial head were similar to those of previous reports, the distance between the articular surface of the head and radial tuberosity was different. CONCLUSION: The anatomical parameters of the proximal radius of the cases, especially the distance between the articular surface of the head and the radial tuberosity, and the radial head implant specifications should be assessed when selecting a radial head implant.

Bone regeneration potential of allogeneic or autogeneic mesenchymal stem cells loaded onto cancellous bone granules in a rabbit radial defect model.

For developing a clinically effective bone regeneration strategy, we compare the bone regeneration potential of cultured allogeneic bone marrow-derived mesenchymal stem cells (BM-MSCs) and of autologous BM-MSCs loaded onto allogeneic cancellous bone granule scaffolds. A critical-sized segmental bone defect was made at the mid-shaft of both radiuses in 19 New Zealand White rabbits (NWRs). In the experimental group, allogeneic BM-MSCs loaded onto small-sized allogeneic cancellous bone granules (300~700 um in diameter) were implanted in one side of a bone defect. In the control group, autologous BM-MSCs loaded onto allogeneic cancellous granules were grafted in the other side. Bone regeneration was assessed by radiographic evaluation at 4, 8, 12 and 16 weeks post-implantation and by micro-computed tomography (micro-CT) and histological evaluation at 8 and 16 weeks. The experimental groups showed lower bone quantity indices (BQIs) than the control groups at 12 and 16 weeks (p < 0.05), although no significant difference was observed at 4 and 8 weeks (p > 0.05). Micro-CT analysis revealed that both groups had similar mean total bone volume and other parameters including trabecular thickness, number and separation at either 8 or 16 weeks. Only bone surface area revealed less area in the experimental group at 16 weeks. Histological evaluation of 8-week and 16-week specimens showed similar biologic processes of new bone formation and maturation. There was no inflammatory reaction indicating an adverse immune response in both allogeneic and autologous MSC groups. In conclusion, allogeneic BM-MSCs loaded onto allogeneic cancellous bone granules had comparable bone regeneration potential to autologous BM-MSCs in a rabbit radial defect model.

A Comparative Study of CG CryoDerm and AlloDerm in Direct-to-Implant Immediate Breast Reconstruction.

BACKGROUND: To date, various types of acellular dermal matrix (ADM) have been developed for clinical use. AlloDerm is the most familiar type of ADM to most surgeons in breast reconstruction. It is prepared by freeze-drying. CG CryoDerm is the first form of ADM that requires no drying process. Therefore, theoretically, it has a higher degree of preservation of the dermal structures than AlloDerm. We conducted this study to compare the clinical course and postoperative outcomes of patients who underwent direct-to-implant breast reconstructions using AlloDerm and those who did using CG CryoDerm. METHODS: We performed a retrospective analysis of the medical records in a consecutive series of 50 patients who underwent direct-to-implant breast reconstruction using AlloDerm (n=31) or CryoDerm (n=19). We then compared the clinical course and postoperative outcomes of the two groups based on the overall incidence of complications and the duration of drainage. RESULTS: The mean follow-up period was 16 months. There were no significant differences in the overall incidence of complications (seroma, infection, skin flap necrosis, capsular contracture, and implant loss) between the two groups. Nor was there any significant difference in the duration of drainage. CONCLUSIONS: CG CryoDerm has the merits of short preparation time and easy handling during surgery. Our results indicate that CG CryoDerm might be an alternative allograft material to AlloDerm in direct-to-implant breast reconstruction.

Treatment of subtrochanteric nonunion of the femur: whether to leave or to exchange the previous hardware.

OBJECTIVE: Our aim was to compare the clinical results of two different methods for treatment of subtrochanteric nonunion: an additional fixation to the previous hardware, and exchange of previous hardware. METHODS: We retrospectively analyzed 19 cases of subtrochanteric nonunion, and compared clinical results from 10 cases (Group 1) with exchange of the previous hardware, and 9 cases (Group 2) with retained previous hardware and an additional fixation. Autogenous bone grafting were performed for all cases. The mean age of the patients was 49.1 years in Group 1, and 48.2 years in Group 2. The mean follow-up period was 19.3 months. RESULTS: The union rate was 100% in Group 1, and 77.8% in Group 2 (p<0.05). The average time of union was 7.6 months in Group 1, and 6.9 months in Group 2. The mean preoperative leg length discrepancy (LLD) was 8.3 mm in Group 1, 10.0 mm in Group 2; and the mean final LLD was 13.9 mm in Group 1, and 11.2 mm in Group 2. The mean length of hospital stay was 23.8±3.3 days in Group 1, and 18.2±2.7 days in Group 2; the mean amount of blood transfusion was 960 ml in Group 1, and 647 ml in Group 2; and the mean operative time was 3.7±0.8 hrs in Group 1, and 2.7±0.6 hrs in Group 2 (p<0.05). CONCLUSION: The union rate in patients with exchange of the previous hardware was better than in those with retained hardware in the treatment of subtrochanteric nonunion by complete removal of the interposed fibrous tissue and meticulous bone grafting leading to a biological environment to achieve bony union.