Background: Femoral interlocking intramedullary (IM) nailing fixation is an effective method for the treatment of femoral shaft fractures. Aseptic nonunion of femoral shaft fracture after IM nailing is uncommon. Currently, the treatment for aseptic femoral shaft nonunion is controversial. The aim of this study was to investigate the clinical effect of augmentative antirotational plating plus decortication and autogenic bone grafting for aseptic femoral shaft nonunion after IM nailing failure.Methods: A retrospective study was conducted on 25 cases of aseptic femoral shaft fracture nonunion treated with IM nailing from January 2015 to August 2019. All patients were treated by leaving the nail in situ, debridement of nonunion sites, decortication, autogenous iliac bone grafting, and augmentative antirotational plating fixation. The time to fracture union and complications were recorded.Results: All patients were followed up for 12-18 months. The union rate after revision surgery was 100%. The average union time was 5.5 months (range, 4-10). Subjective pain symptoms had disappeared in all patients. There were no incision infections or internal fixator fatigue fractures. Average scores of the physical function and bodily pain components of the SF-36 were 95.5 (range, 91-98) and 94.1 (range, 90-97), respectively. No other obvious complications occurred postoperatively. Conclusion:Augmentative antirotational plating plus decortication and autogenic bone grafting is an excellent choice for treating femoral shaft fracture nonunion after IM nailing; this approach has an overall high union rate and few complications.