1016 - Nailed It: Motorized Intramedullary Transport for a Chronic Femoral Nonunion

A 31-year-old man with obesity, hypertension, vitamin D deficiency, and prior provoked deep-vein thrombosis sustained a right femoral shaft fracture in a motorcycle crash, initially repaired overseas with an intramedullary nail. Exchange nailing with autograft later failed, leaving chronic nonunion and 12 cm shortening. He underwent staged reconstruction. Stage one removed hardware, debrided the canal with a reamer–irrigator–aspirator, and placed a vancomycin and tobramycin–loaded polymethylmethacrylate spacer. Stage two performed femoral osteotomy with autograft and inserted an Orthofix Fitbone motorized transport nail with subcutaneous receiver and antibiotic beads. Postoperatively he developed rhabdomyolysis with acute kidney injury, pulmonary insufficiency, tachycardia, and transfusion-requiring anemia, which resolved. During rehabilitation he showed functional gains: ten-meter walk speed rose from 0.28 to 0.88 m/s and sit-to-stand fell from 18.9 to 12.2 s. He progressed from moderate assistance to near independence in self-care and remains highly motivated to return to soccer.

Discussions:

Chronic femoral nonunion with major bone loss and severe shortening is uncommon and difficult to manage. External fixators permit transport but carry pain, pin-tract infection, and mobility limitations. Motorized intramedullary transport nails provide a fully internal method of distraction osteogenesis that improves comfort, cosmesis, and rehabilitation participation, though U.S. experience is limited and long-term outcomes remain under study. This case shows feasibility of staged internal reconstruction after infection risk, obesity, and failed fixations. Despite complications and receiver revision, the patient achieved meaningful functional gains, highlighting the importance of early physiatry involvement, structured therapy, and objective measures in guiding recovery and supporting return to sport.

Conclusions: Motorized intramedullary transport nails are a promising option for complex femoral nonunion with severe shortening. Success depends on meticulous surgical planning and coordinated interdisciplinary rehabilitation.