Failure of intertrochanteric nailing due to distal nail jamming

Abstract

Nail impingement against the anterior femoral cortex during nail insertion, or anterior cortex penetration, has been described in the literature as a worrying complication. We describe a previously unreported surgical failure due to a compromised dynamic distal locking caused by distal jamming of the nail. An 80-year-old male suffered a closed right intertrochanteric femoral fracture. Due to the presence of a long medial fragment, a 240 mm long titanium trochanteric nail was chosen to stabilize the fracture. Dynamic distal locking was performed by placing the distal screw at the inferior rim of the elliptical locking hole to allow compression of the fracture site during weight-bearing. Six-month X-ray follow-up revealed a broken nail and nonunion of the fracture due to failed dynamization of the distal locking screw. The nail was removed and replaced by a total arthroplasty. Due to the femoral anterior bow of the shaft, anterior cortical impingement of the distal tip of a nail may result in the failure of the nail to slide within the diaphyseal canal when using a medium-length nail preventing compression of the fracture. Dynamic distal locking can be ineffective if the ability of the distal nail to slide within the diaphyseal canal is hindered. This type of scenario can represent an opportunity for anterior nail impingement. Distal jamming of the nail can thus compromise dynamic compression at the fracture site during loading, thus inducing nonunion of the fracture, and leading to breakage of the osteosynthesis device. For these reasons, caution is recommended when using medium-length trochanteric nails for unstable trochanteric fractures.

Breakage in Two Points of a Short and Undersized “Affixus” Cephalomedullary Nail in a Very Active Elderly Female: A Case Report and Review of the Literature

“…The risk of distal shaft fractures was not associated with the patient age, gender, fracture type, or cortical bone index [ 13 – 23 ]. Maniscalco et al presented a rare case of 31-A2 nonunion and breakage of an EndoViS® nail (Citieffe™, Calderara di Reno, Bologna, Italy), due to failure at the hole for the dynamic locking screw, caused by distal jamming of the tip of the nail against the anterior cortex [ 24 ]. A surgical failure due to distal jamming had never been described in the literature before [ 24 ].…”

“…Maniscalco et al presented a rare case of 31-A2 nonunion and breakage of an EndoViS® nail (Citieffe™, Calderara di Reno, Bologna, Italy), due to failure at the hole for the dynamic locking screw, caused by distal jamming of the tip of the nail against the anterior cortex [ 24 ]. A surgical failure due to distal jamming had never been described in the literature before [ 24 ]. Liu et al in a retrospective review of 341 intertrochanteric fractures treated with the TFN found two patients whose nails had failed at the junction of the helical blade and the nail.…”

Using Three‐Dimensional Computational Modeling to Compare the Geometrical Fitness of Two Kinds of Proximal Femoral Intramedullary Nail for Chinese Femur

“…Intramedullary fixation device has advantages from the biomechanical point of view and has become increasingly popular in treating unstable trochanteric fractures [1, 2], but serious implant-related complications have been reported, such as femoral shaft fracture [3], cutting out [4], lateral migration of the femoral neck screw [4, 5], and distal locking [6, 7]. In 2003, the AO/ASIF group developed the Proximal Femoral Nail Antirotation (PFNA) to improve the rotational and angular stability with a helical blade which can avoid bone loss that occurs during the drilling and insertion of a standard sliding hip screw [8].…”

Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm

“… 49 Anterior impingement has also been described in locked nails and although theoretically may be associated with nonunion and peri-implant fractures, it has not yet been proven. 50 , 51 , 52 …”

“… 38 Additional unstable fracture patterns that benefit from locked nailing include fractures with an incompetent lateral wall, severe dorsomedial comminution, subtrochanteric extension and a wide intramedullary canal. 6 , 52 , 54 …”