Risk factors for intramedullary nail breakage in proximal femoral fractures: a 10-year retrospective review

Abstract

INTRODUCTION Intramedullary nailing is a common treatment for proximal femoral fractures. Fracture of the nail is a rare but devastating complication that exposes often frail patients to complex revision surgery. We investigated which risk factors predict nail failure. METHODS We reviewed all cases of nail breakage seen over a 10-year period in a single busy trauma unit; 22 nail fractures were seen in 19 patients. Comparison was made with a group of 209 consecutive patients who underwent intramedullary fixation of a proximal femur fracture with no nail breakage over a 2-year period. RESULTS In the fractured nail group, mean age was 70.4 years (range 55-88 years).The mean time to fracture was 10 months (range 2.5-23 months). Logistical regression was used to show that low American Society of Anesthesiologists (ASA) score, subtrochanteric fracture and pathological fracture were independent risk factors for nail fracture. CONCLUSIONS Young patients with a low ASA score are at highest risk of nail breakage. We advise close follow-up of patients with these risk factors until bony union has been achieved. In addition, there may be merit in considering other treatment options, such as proximal femoral replacement, especially for those with pathological fracture with a good prognosis.

Intramedullary Nail Breakage and Mechanical Displacement in Patients with Proximal Femoral Fractures: A Commercial and Medicare Supplemental Claims Database Analysis

“…In regard to the types of proximal femoral fractures more commonly associated with IMN breakage, the findings that subtrochanteric and pathological fractures were more commonly associated with IMN breakage observed in the current study are also consistent with Johnson et al 15 A higher rate of IMN breakage in pathologic fractures was also observed by Willeumier et al 27 who found that 8% of patients with femoral metastases experienced breakage between 2000 and 2015 at five centers in the Netherlands. Only 7.4% of the fractures treated with IMN in the database were subtrochanteric and only 9% were pathological.…”

“…Closer follow-up of patient subgroups who may be at increased risk of IMN breakage and mechanical displacement of proximal femoral fractures might be beneficial until bony union has been achieved. 15 Johnson et al also suggest that other treatment options such as proximal femoral replacement may be considered for higher risk patients (eg, pathological fracture). 15 …”

“…Implant device fracture is rare (range in published literature from 0.2% to 5.6% 16–18 ), however it is often a tragic event as revision is very complex and difficult in this typically vulnerable patient population. 15 …”

“…Implant breakage usually occurs at the level of the lag screw aperture, 15 although the nail itself may also break, usually at distal barrel taper or at the nail lag screw aperture. 15 , 19–21 Reasons for the breakage may be excessive premature weight bearing or prolonged cyclical loading (eg, with nonunion).…”

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

“…Johnson et al reported on 221 cases of 31 AO fractures with 22 nail breakages: 20 were Intramedullary Hip Screw® (IMHS) (Smith & Nephew™, Tennessee, USA) and 2 were Affixus® (AFF) (Zimmer Biomet™, Warsaw, Indiana, USA). All nails of this series were broken through the hole for the lag screw [ 26 ]. Therefore, there is no cephalomedullary nail reported in the literature not presenting the complication of nail breakage [ 13 – 16 ].…”