International Orthopaedics

https://doi.org/10.1007/s00264-022-05490-2

ORIGINAL PAPER

Fractures after cephalomedullary nailing of the femur

Systematization of surgical fixation based on the analysis of a single-center retrospective

cohort

Inca Vilar‑Sastre1 · Sebastián Corró2 · Jordi Tomàs‑Hernández1,3 · Jordi Teixidor‑Serra1,3 · Jordi Selga‑Marsà1,3 ·

Carlos‑Alberto Piedra‑Calle1,3 · Vicente Molero‑García1,3 · Yaiza García‑Sánchez3 · José‑Vicente Andrés‑Peiró1,3 

Received: 5 April 2022 / Accepted: 16 June 2022

© The Author(s) under exclusive licence to SICOT aisbl 2022

Abstract
Purposes  Femoral implant related fractures (IRF) are a growing pathology in an increasingly elderly and frail population.
A series of IRF after cephalomedullary nail (CMN) fixation of a femoral fracture is analyzed and an algorithm described to
guide the management of such fractures.
Methods  All eligible patients operated on for IRF fixation after CMN were reviewed regarding their demographics, comor-
bidities, injury pattern, and treatment. Primary outcomes were mortality and local complications. Secondary outcomes were
time to consolidation, time to weight-bearing initiation, length of hospitalization, and discharge destination.
Results  The incidence of IRF requiring fixation was 1.3% after 3401 CMN implantation procedures. Elderly women with
comorbidities and plate fixation predominated. One-year mortality was 18.6%, being higher for patients presenting with
infection and those unable to walk at the end of follow-up. Local complications occurred in 25.6%. Median time to weight-
bearing was 9.1 weeks, but longer for patients with plate fixation or complications. Patients presenting with an infection and
those discharged to nursing facilities had more comorbidity.
Conclusions  Following an algorithm presented here, patients were treated either with nail exchange or lateral locking plate
fixation, permitting straightforward evaluations and acceptable results in a very high-risk population.

Keywords  Implant-related fracture · Non-prosthetic peri-implant fracture · Cephalomedullary nail · Lateral plate · Nail
exchange · Treatment algorithm

Introduction modifies the elasticity of specific bone segments, generating

Implant related fractures (IRF) have become increasingly
common in the field of orthopaedic trauma. These injuries,
which occur around an implant used to treat a previous frac-
ture, create added technical difficulty during the manage-
ment of fragility fractures. The mere presence of an implant
* José‑Vicente Andrés‑Peiró
jose.andres@vhebron.net
1
Department of Orthopaedic Surgery and Traumatology,
Hospital Universitari Vall d’Hebron, Barcelona, Spain
2
Department of Orthopaedic Surgery and Traumatology,
Hospital de Manacor, Manacor, Spain
3
Department of Orthopaedic Surgery and Traumatology, Vall
d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
transition zones which are at increased risk of IRF [1, 2].
Moreover, the rapidly growing and aging global population
are leading to an increase in fracture-related procedures,
increasing the number of patients at risk of suffering an IRF
[1]. To increase knowledge and improve IRF outcomes, a
variety of classifications have been proposed [3–6]. Such a
complication is of particular concern when considering fem-
oral fractures in the frail population, patients who already
present with considerable loss of function and greater mor-
tality risk following primary femoral fractures [2].
In the present paper, we report the incidence, character-
istics, management, and outcomes of a single-center case
series of IRF associated with cephalomedullary nail (CMN)
implants placed after a femoral fracture. Concurrently,
a treatment algorithm developed for such fractures at our
institution is presented.

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Methods
Study design and participants
The present study was approved by our institutional review
board (reference number PR(ATR)121/2021) and its writ-
ing adapted to the STROBE statement. Ours is a retro-
spective case series (level of evidence IV) of patients who
underwent surgery at a single public university hospital
over the period from January 2010 to January 2020. All
patients were operated upon by surgeons with recognized
expertise in the treatment of implant-related fractures.
The following case-inclusion criteria were applied:
• Skeletally mature patient (age ≥ 18 years).
• CMN used to stabilize a previous femur fracture.
• Current femur fracture around the nail distal to the
intersection of the intramedullary and cephalic com-
ponents of the device.
• Surgical treatment of the implant-related fracture by
means of internal fixation.
• Minimum post-operative follow-up of one year.
The following exclusion criteria also were applied:
• Implant failure with an unconsolidated fracture.
• Cut-out failure of fixation.
• Records indicating tumoral or infectious disease in the
femur.
• Some bone metabolism disorder other than osteoporo-
sis.
Data collection and statistical analysis
Medical records were obtained from an institutional data-
base in SAP format (SAP SE, Germany). For radiological
evaluation, RAIM Viewer software (Corporació Sanitària
Parc Taulí, Spain) was used. Fractures were classified
based on the fracture line’s location relative to the locking
screws. Demographic data, comorbidities, injury charac-
teristics, and their treatment and evolution were collected
in an anonymized Microsoft Excel database. Primary out-
comes were mortality and local postoperative complica-
tions. Secondary outcomes were time to consolidation,
time to weight-bearing initiation, length of hospitalization,
and discharge destination.
Statistical analysis was performed, and charts cre-
ated using Stata 14.2 (StataCorp, USA). Descriptive and
inferential statistics were calculated. Continuous vari-
ables are summarized here as means and standard devia-
tions (SD) or medians and interquartile ranges (IQRs), as
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International Orthopaedics
appropriate. Categorical variables are reported as counts
and percentages. Pearson's Chi-square analysis was used
to examine for differences between categorical variables.
To identify differences between continuous variables, the
nonparametric Wilcoxon–Mann–Whitney test was used.
The Kaplan–Meier estimator and its associated graphical
representation were used during survival analysis.
Interventions
All patients were admitted through our emergency depart-
ment with the diagnosis of a CMN-related fracture. Proper
analgesics were administered, and the limb was immobilized
with a skin traction system. Low-molecular-weight heparin
deep vein thrombosis prophylaxis was initiated. In the case
of prior anticoagulation or antiplatelet therapy, appropri-
ate treatment adjustments were made. Once admitted to the
ward, patients were managed by a multidisciplinary ortho-
geriatric team. Surgeries were scheduled once the patients
were in good condition and surgical procedures had been
planned appropriately. They included overlapping plate
fixation and intramedullary nail exchange. To decide which
treatment was best adapted to each case, many criteria were
considered: nail length (short for a locking screw above the
femoral isthmus and long for below), location and mor-
phology of the fracture line, and the potential for previous
implant removal (Fig. 1).
In the operating room, antibiotic prophylaxis was admin-
istered, according to hospital guidelines. Patients were posi-
tioned on a fracture table in a lateral decubitus or supine
position, depending on the needs for exposure and surgeon's
preference. Revision fixation included both intramedullary
long nails and lateral locking plates. For nailing, complete
previous implant removal was necessary. For plate fixation,
only the locking screws that interfered with plate applica-
tion were removed. When considered necessary, an open
reduction was performed via a lateral sub-vastus approach
and cerclages were used. Irrigation, layered closure, and the
application of sterile dressings were performed at the end
of the procedure.
Patients were discharged only after good local and gen-
eral health evolution was guaranteed. After discharge, all
patients were followed-up with periodic radiological and
clinical evaluations.
Results
A total of 3401 CMN were implanted over the study period.
Of these, 2023 were short nails and 1378 long. We identi-
fied 43 IRF fractures related to CMN managed by revision
internal fixation, with a short nail previously used in 30 and
a long nail in 13 instances. The resulting incidence rate,
International Orthopaedics

We propose the use of a periprosthetic proximal plate for fractures above the locking screw of a short CMN plate when implant
removal is not possible. Some cases may benefit from a salvage hip replacement. Since this is an algorithm about fixation,
we did not include this option. Unfortunately, no fracture in this series exemplifies this situation.

Fig. 1  Treatment algorithm for fixation of implant-related fractures after femoral cephallomedulary nails

therefore, was 1.3 fractures for every 100 trochanteric nails
implanted in one year: 1.5 for short nails and 0.9 for long
nails (p = 0.22).
Among the 43 with fractures were five men and 38
women, of mean age 87.3 years. According to the American
Society of Anesthesiologists (ASA) physical status classifi-
cation system [7] and age-adjusted Charlson’s Comorbidity
Index (CCI) [8], all patients had at least one relevant comor-
bidity, with 15 suffering from dementia and 21 previously
living in a nursing facility.
Intertrochanteric fractures predominated over all other
CMN indications. The median time from nailing to the
implant-related fracture was 1.8 years, with 25.6% of the ini-
tial fractures not consolidated at that time. Open reduction,
the use of cerclages, and stabilization with a locking lateral
plate predominated over other constructs. Open reduction
was more common with plate than nail fixations (90.3 vs.
50.0%; p < 0.01). Table 1 summarizes the most relevant
patient characteristics, as well as their injuries and treatment.
Most fracture lines were located distal to the locking
screw. Only 13.3% of the fractures were proximal after short
nailing, compared to 53.9% after long nailing (p < 0.01). A
nail exchange was the treatment for 100% of the proximal
fractures after short nailing versus 23.1% for the distal ones
(p < 0.01). Consequently, 12.5% of all proximal fractures
surrounded open reduction versus 87.5% of distal fractures
(p = 0.02). Figure  2 shows the distribution of treatment
modalities based on the algorithm. Fracture location had no
impact upon the time to union, time to weight-bearing, or
incidence of complications.
One-year mortality was 18.6% (eight patients). Figure 3
depicts the results of survival analysis for that period. Mean
follow-up for the surviving patients was 22.4 months (IQR
12.2 to 28.6). There was a higher mortality rate in patients
presenting with an infection (44.4 vs. 11.8%; p = 0.03) and
in those unable versus able to walk at the end of follow-up
(65.7 vs. 12.5%; p < 0.01). Eleven patients (25.6%) presented
with a local post-operative complication, including nine

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 International Orthopaedics

Table 1  Features of patients,
injuries, and treatments
Baseline characteristics of patients
• Sex 5 men, 38 women
• Age (years) Mean = 87.3; range 63 to 97
• ­ASA1 II = 16, III = 27
• ­CCI2 Mean = 6.8; SD = 1.9
• Residence place 22 own home, 21 nursing facility
Previous fracture diagnosis and treatment (cephalomedullary nailing)
• AO/OTA classification 31A = 34, 31B = 2, 32*a = 7
• Nail ­length3 30 shorts, 13 longs
• Consolidation status 32 consolidated, 11 non-consolidated
• Fracture malunion 6 cases
• Hardware ­failure4 1 case
Current fracture diagnosis and treatment (implant-related)
• Fracture location 11 above and 32 below the locking screw
• Time between fractures (years) Median = 1.8; IQR 0.7 to 3.5
• Previous implant removal 16 none, 16 locking screws, 11 complete
• Fracture reduction 9 closed, 34 open
• Implant used for fixation 33 lateral locking plates, 10 intramedullary nails
• Cerclages Used in 26 out of 43 fixations (60.47%)
• Plate overlapping (cortices) Mean = 5.48; range 1 to 12
• Plate and nail interlocking Used in 8 out of 31 plates (25.81%)
• Operative time (minutes) 135.5 min (ranging 50 to 366)
1
 American Society of Anesthesiologists physical status classification[7]
2
 Age-adjusted Charlson’s Comorbidity Index[8]
3
 Short for interlocking screw above the femoral isthmus; long for below
4
 Not related to the current injury; consolidated fracture

Fig. 2  Distribution of patients
according to the algorithm

infections and two mechanical failures (failure of fixation
and nonunion requiring salvage procedures). Patients pre-
senting with an infection had a higher mean ASA score pre-
operatively than those without (mean 3.0 vs. 2.5; p < 0.01).
The median number of hospitalization days was 18 (IQR
13 to 25). Thirty-eight patients (88.4%) required admission
to a nursing home upon discharge versus just 21 (48.8%)
having lived in such a facility before the IRF. The patients
referred to nursing homes had a higher pre-operative CCI
(mean 7.0 vs. 5.0; p = 0.02). The median time from surgery
to weight-bearing initiation was 9.1 weeks (IQR 4.4 to 13.7),
and this duration was longer in patients who underwent plate
than nail fixation (12.4 vs. 3.3 week; p < 0.01) and in those
presenting with versus without a local complication (13.2 vs.
7.4 weeks; p = 0.04). Almost half (43.2%) of the patients did
not recover the ability to walk over the course of follow-up.

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International Orthopaedics
One-year mortality was 18.6% (8 patients). Five patients died within the 3
postoperative months. Surgical site infection and deteriorated function at the end of
follow-up were related with a higher mortality.
Fig. 3  Kaplan–Meier estimator curve on first postoperative year mor-
tality
Five patients died before fracture healing and two had a non-
union, so data on time to consolidation were unavailable.
All the remaining healed over a median of 7.7 months (IQR
3.9 to 11.1). This period was longer in patients with a local
complication (13.2 vs. 7.7 weeks; p = 0.04).
Discussion
Overall, IRF fixation revision after CMN fixation of a fem-
oral fracture occurred in roughly 1.3% of the 3401 CMN
used at our institution. Elderly female patients with a previ-
ous intertrochanteric fracture and significant comorbidities
were more usually affected. Fixation revision with a lateral
locking plate clearly predominated over nailing techniques.
Post-operatively, most patients who underwent IRF fixation
required prolonged hospitalization and nursing care facilities
at discharge. One in four (25.6%) patients developed some
local post-operative complication, while 18.6% died within
the first post-operative year.
Management of femoral fractures, especially proximal
segment fractures, by means of CMN fixation has increased
in recent decades [9]. First-generation nails have been
acknowledged to result in more IRF than prior implants,
particularly the dynamic hip screw [10–12]. However, the
optimization of nail designs has led to the homogeniza-
tion of such differential IRF incidence rates [11, 13–15],
refocusing the issue on nail length. Short nails have been
associated with shorter surgical times and less blood loss
[16, 17], while probably improving procedural cost-effec-
tiveness [18, 19]. On the other hand, long nails provide
improved stability in the setting of unstable intertrochanteric
fractures, subtrochanteric or diaphyseal femoral fractures,
pathologic tumor-related fractures, and severe osteoporosis
[20]. Previous reports provide discrepant results regarding
IRF incidence when considering nail length [13, 17, 21–23].
In our case series, IRF incidence was not associated with
nail length. However, distinct fracture patterns have been
identified for each of these implants [24]. Typically, frac-
tures around short CMN exhibit diaphyseal patterns while
long nails are associated with periarticular and distal femo-
ral fractures. In our series, only 13.3% of the IRF around
short nails progressed proximally to distal locking screws.
Meanwhile, 53.9% of the IRF associated with long nails pro-
gressed proximally. Diaphyseal patterns were more com-
monly found around short nails, with periarticular and distal
femoral fractures associated with long nail fixation. The inci-
dence of IRF has been shown to largely be related to implant
and technical issues, such as anterior impingement of the
CMN tip in the femoral canal, large distal locking screws
use, rigid distal-end nail design, cranial placement of the
lag screw, and single proximal screw nail use [13, 25, 26].
When facing such a challenging complication, surgical
management is usually advised. It should procure a prompt
and safe functional performance restoration while protecting
and spanning the entire femoral segment by the means of
the least surgically aggressive procedure [27, 28]. Although
some cases with a very short proximal fragment could ben-
efit from a salvage arthroplasty, fixation revision is usually
indicated, including nail exchange and lateral plating proce-
dures. While CMN exchange allows for immediate weight
bearing, it also generally results in greater blood loss, higher
transfusion rates, and an increased incidence of complica-
tions [24]. On the other hand, newly designed lateral locking
plates may allow for early weight bearing while reducing the
incidence of the previously mentioned complications [29,
30]. Nail exchange could be beneficial in cases where the
proximal segment is too short to obtain sufficient proximal
fixation with a plate or those fracture patterns in which the
mechanical performance of a lateral plate is more limited,
like transverse or comminuted fractures. Nail exchange will
be conditioned by the feasibility of removing the previous
implants. Alternatively, we believe that all cases with a suf-
ficient proximal segment and spiral or oblique fracture pat-
terns could be managed with a lateral locking plate.
Multiple classification systems have been proposed over
the years to better categorize IRF. Both bone-specific and
non-specific classification systems have been published, con-
sidering factors like fracture location in the bone segment,
fracture location relative to the implant, healing status of
the previous fracture, and implant type and location [3–6].
Although helpful categorizing IRF, available classification
systems can be difficult to apply and fail to provide treat-
ment guidelines. To address this issue, we propose a treat-
ment algorithm for IRF around a previous femoral CMN
(Fig. 1). The present algorithm does not pretend to classify
13

such fractures, but does guide its management based on the
previous CMN type, fracture pattern, and implant removal
feasibility. Considering the previous conditions and the
issues previously stated, nail exchange or lateral locking
plate fixation is recommended. Figure 4 shows examples of
fractures managed using this algorithm.
The management of femoral nail-related IRF is not an
issue of minor concern, as such fractures tend to occur
in the frailest population. In our series, mean patient age
was 87.3 years and all patients had relevant comorbidi-
ties (ASA ≥ II), while 63.6% were classified as ASA ≥ III.
Female patients were more frequently affected than males,
reflecting the influence of bone fragility in the incidence
of both the initial and implant-related fractures. Certainly,
these patients consumed significant healthcare resources.
In fact, 48.8% lived in nursing facilities before admis-
sion, their median hospitalization length was 18 days, and
88.4% were discharged to convalescence facilities. Consid-
ering these parameters, it is not surprising that local com-
plications occurred in as many as 25.6% of the patients and
one-year mortality was 18.6%, especially common in those
who presented with an implant-related infection (p = 0.03)
and those who remained unable to walk (p < 0.01). Other
case series reports have documented high complication
and mortality rates linked to patient profiles. An average
hospital stay of 27.1 days and complication rate of 21.5%
were reported by Lang et al. [31]. Meanwhile, 66.7% of
patients in the series reported by Müller et al. required
an assisted-living facility at discharge [10]. Overall, pre-
viously reported one-year mortality rates have ranged
Fig. 4  Internal fixation of IRF following the proposed algorithm. A.
The fracture line only progresses below the level of the interlocking
screw around the short nail. There is enough room proximal to the
fracture to attach a lateral plate, so removal of the proximal nail is not
necessary. It is a spiroid pattern, so it benefited from open reduction
and cerclage and plate fixation. B. The fracture line does not progress
proximal to the interlocking screw around the short nail. However,
it is a transverse fracture. The mechanical behavior of lateral plates
is poor in such scenario, so we recommend replacing the nail with a
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International Orthopaedics
between 23.1% and 36.3% [10, 24, 31]. Considering the
frailty of these patients, incidence of complications, pro-
longed hospitalizations, and the extended care required
after discharge, IRF after CMN of femoral fractures poses
high economic and social burdens for any healthcare sys-
tem. Hence, concerted effort should be focused on fracture
prevention, pre-operative optimization, precise fracture
management, and post-operative care.
There are obvious limitations to our study. First, we
acknowledge all the biases inherent to retrospective data
collection. Although of considerable size, our study sample
also fails to provide enough femoral IRF cases after CMN
to accept our findings with full confidence. The lack of an
internationally accepted classification and treatment proto-
col for the analyzed fractures is another obvious drawback,
both for our own and all previous studies in this field. On
the other hand, the homogeneity of our sample is one of
our study’s strengths. The homogeneity implied by use of
a single implant resulted in a single complication that was
treated by expert Orthopedic Trauma surgeons following
a well-established protocol.
Although the incidence of IRF after CMN fixation of
femoral fractures is low, the issue should nonetheless be con-
sidered seriously, given the general fragility of most affected
patients. Using the algorithm presented here, patients were
treated either with nail exchange or lateral locking plate fixa-
tion. This algorithm allowed for straightforward evaluations
and acceptable results in patients at very high risk of poor
outcomes, due to their advanced age and physical frailty.
longer one. C. The fracture progresses proximal to the interlocking
around the short nail. Proximal fixation will be poor using a plate, as
the proximal fragment is too short. The fracture is not yet consoli-
dated, but it is a relatively stable pattern. Consequently, it is safe and
advisable to exchange the nail. D & E. Fractures around long nails
can always be managed with lateral locking plates, regardless of their
location with respect to the interlocking and whether an open reduc-
tion (D) or a minimally invasive technique (E) is performed
International Orthopaedics
Authors contributions  All authors contributed to the study concep-
tion and design. Material preparation, data collection, and analysis
were performed by Inca Vilar Sastre, Sebastián Corró Ramis, and José
Vicente Andrés Peiró. The first draft of the manuscript was written by
José Vicente Andrés Peiró and Sebastián Corró Ramis, and all authors
commented on previous versions of the manuscript. All authors read
and approved the final manuscript.
Data availability  The data that support the findings of this study are
available from the corresponding author, José Vicente Andrés Peiró,
upon reasonable request.
Declarations  cations of Gamma nailing: A prospective study of 554 trochanteric
Ethical approval  This study was approved by our institutional review
board (reference number PR(ATR)121/2021).
Consent to participate and publish  This is a retrospective study. Its
realization did not imply any risk for the participants and all the col-
lected data were de-identified. Therefore, IRB approved a full waiver
of informed consent.
Competing interests  The authors have financial conflicts of interest
to declare with Smith & Nephew, Zimmer-Biomet, Stryker, and MBA
Surgical Empowerment.
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