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Objectives: To evaluate the radiographic and clinical outcomes of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions previously treated with an intramedullary nail., Design: Retrospective cohort., Setting: Tertiary referral center., Patients: Fifty aseptic femoral nonunions in 49 patients who presented with an intramedullary nail in situ an average of 25 months after the initial fracture nailing were evaluated., Intervention: Our systematic approach includes inserting an exchange nail at least 2 mm larger in diameter than the in situ nail, using a different manufacturer's nail, static interlocking, correction of any metabolic and endocrine abnormalities, and secondary nail dynamization in cases showing slow progression toward healing., Main Outcomes Measurements: The outcome measures were radiographic and clinical evidence of nonunion healing and time to union., Results: All 50 femoral nonunions (100%) healed after this systematic approach to exchange nailing. The average time to achieve union was 7 months (range, 3-26 months)., Conclusions: Utilization of this systematic approach of exchange nailing for the treatment of aseptic femoral nonunions resulted in a 100% healing rate., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion., Design: Retrospective cohort., Setting: Tertiary referral center., Patients: Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral and 4 segmental) who presented with an intramedullary nail on an average of 16 months after the initial treatment were presented in this study., Intervention: Insertion of an exchange nail of at least >2-mm diameter than the prior nail using a different manufacturer's nail, static interlocking, partial fibulectomy in a select group of patients, and correction of underlying metabolic and endocrine abnormalities., Main Outcome Measurements: Union rate, time to union., Results: Forty-five of 46 tibial nonunion sites (98%) healed at an average of 4.8 months., Conclusions: Patient selection criteria and a systematic approach to exchange nailing for tibial nonunion is highly successful., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.