SummaryThe acute treatment of femoral shaft fractures with reamed intramedullary nailing results in high union rates and low morbidity. Unfortunately, treatment failures do occur and can be devastating to the patient. Fixation failure can result from technical errors, severe injuries, systemic morbidity, and local biologic damage. In many cases, successful treatment is complicated by associated injuries, functional and psychologic disability incurred as a result of the initial trauma, infection, and broken hardware. Strategies to salvage failed femoral fixation must begin with careful elucidation of causes to not repeat initial errors or exacerbate existing complications. While exchange reamed nailing is a familiar procedure for delayed or hypertrophic nonunion, a variety of methods including biologic plating, bone grafting, distraction osteogenesis, and vascularized fibular transplantation may be required in specific cases. The goal of the surgeon should be to develop a logical framework for diagnosis and treatment decision-making and to have access to the complete armamentarium of reconstructive techniques.