Bone Grafting in the Management of Femoral Nonunion: Principles, Graft Options, and Contemporary Reconstructive Strategies

Abstract

Background: Femoral nonunion remains one of the most challenging complications following fracture fixation because successful healing requires restoration of both mechanical stability and biological activity. Bone grafting plays an essential role in the management of bone defects, delayed union, and nonunion by providing biological and mechanical support for fracture healing. Autologous bone graft remains the gold standard because of its osteogenic, osteoinductive, and osteoconductive properties. Different graft sources and substitutes, including iliac crest bone graft, Reamer-Irrigator-Aspirator graft, allografts, synthetic grafts, demineralized bone matrix, bone morphogenetic proteins, and bone marrow aspirate concentrate, may be used according to the characteristics of the nonunion and bone defect. In atrophic nonunion, stable fixation combined with autologous bone grafting is essential to restore the biological environment, whereas large segmental defects may require advanced reconstructive procedures such as the Masquelet technique, vascularized fibular grafting, or bone transport. Despite emerging technologies, autologous grafting continues to provide the most comprehensive biological properties for complex femoral nonunion. Appropriate graft selection, meticulous debridement, stable fixation, and adequate biological augmentation remain fundamental principles for achieving successful union while minimizing complications and donor-site morbidity.