Decortication in the Surgical Management of Complete Atypical Femoral Fractures: A Strategy to Accelerate Fracture Healing.

Background/Objectives: Surgical management of atypical femoral fractures (AFFs) stabilized with intramedullary (IM) nailing is frequently challenged by delayed union or nonunion due to the severely suppressed bone turnover characteristic of bisphosphonate-related bone pathology, often leading to a hypertrophic nonunion-like state at the fracture site. This consecutive case series aimed to evaluate the effectiveness of intraoperative percutaneous decortication at the hypertrophic cortex in promoting rapid bone healing in complete AFFs. Methods: This was a single-center consecutive case series of patients with complete atypical femoral fractures (AFFs) treated with intramedullary nailing and adjunctive percutaneous decortication since February 2021. The standardized surgical protocol-including percutaneous decortication performed through a small anterolateral incision using an osteotome to create bone chips and stimulate the sclerotic cortex-was applied prospectively to all consecutive patients from February 2021. Of the 20 patients who underwent surgery during this period, 14 with sufficient radiographic follow-up were included in the final retrospective analysis. Data collected included patient demographics, duration of bisphosphonate use, fracture location (diaphyseal vs. subtrochanteric), operative details (including iatrogenic fracture), and radiographic bone union time. Bone union was assessed on serial radiographs by two independent observers. Results: All 14 patients were female, with a median age of 75 years (IQR 67-79 years). Thirteen patients (92.9%) had prior bisphosphonate exposure for a median of 4.5 years (IQR 3-10 years). Six fractures were subtrochanteric fractures, and six were complicated by iatrogenic fracture during nail insertion. Postoperative teriparatide was administered to six patients. Radiographic bone union was achieved in all 14 patients at a median of 19 weeks (IQR 16-22 weeks; range 16-24 weeks). No major complications (infection, implant failure, nonunion, or neurovascular injury) occurred during follow-up. Conclusions: Percutaneous decortication is a simple, safe, and biologically plausible adjunct to intramedullary nailing. In this series of 14 elderly women with long-term bisphosphonate exposure (median 4.5 years), the technique was associated with 100% radiographic union at a median of 19 weeks without major complications, suggesting a promising strategy that warrants validation in larger, controlled trials.