Exchange nailing has proven to be a reliable surgical technique for the management of aseptic femoral shaft nonunions. Similar to primary intramedullary nail fixation for femur fractures, exchange nailing for aseptic hypertrophic nonunions of the femur relies on successful navigation of the starting point and proper nail trajectory to minimize coronal and sagittal plane deformities. Compared with the supine position, the lateral decubitus position has the advantage of allowing gravity to displace the soft tissue around the piriformis start site to facilitate nail entry. In addition, the C-arm position and access to the affected limb from both sides by the surgeon and surgical assistant facilitate visualization of existing deformities and the ability to perform correction maneuvers. The purpose of this review is to highlight technical pearls associated with exchange nailing in a lateral decubitus position. Although other techniques are available, and should be used when indicated, exchange nailing provides patients with the opportunity to an early return to activity, improvement in pain and disability, and ultimate bony union.