Intertrochanteric femur fractures with compromised proximal fixation may have nail toggle
Click Here to Manage Email Alerts
Key takeaways:
- Intertrochanteric fractures with a wide medullary canal may lead to nail toggle without intact lateral wall and compression screw engagement.
- These results may provide evidence for the use of intermediate nails.
Results presented at the Orthopaedic Trauma Association Annual Meeting showed short proximal femoral nails may toggle secondary to a proximal fixation defect if used for intertrochanteric fractures in patients with wide medullary canals.
“[These results] should encourage [surgeons] to be extra critical of the position of the compression device so that it engages the lateral wall, and to carefully evaluated the competency of the lateral wall itself,” Catherine M. Doyle, MD, of Geisinger Medical Center, told Healio. “We do not always have advanced imaging, and if there is any question or doubt about the lateral wall’s competency, then we should consider that using an intermediate nail may be a more suitable option to prevent toggling in patients with wide medullary canals.”
Doyle, Daniel S. Horwitz, MD, and colleagues retrospectively reviewed data from nearly 3,000 intertrochanteric femur fractures treated with short proximal femoral nails between 2007 and 2023.
“Our inclusion criteria consisted of any Dorr C-[type] femurs, any Dorr B-[type] femurs with a medullary canal of at least 15 mm, a minimum 6-week postoperative follow-up and follow-up radiographs, including the immediate postoperative radiograph,” Doyle said.
According to Doyle, out of 101 cases that met the inclusion criteria, 16 cases had significant nail toggle, defined as 4° or more of varus collapse. She added all cases with significant nail toggle had a proximal fixation defect, including lateral wall incompetency, a lag device that did not engage the lateral cortex or a combination of the two. Doyle said cases with significant nail toggle had no significant differences in nail-to-canal ratio or tip-apex distance.
Horwitz said these results provide a good argument for the use of intermediate nails, which have evolved during the past decade.
“[With] the new, modern intermediate nails, the interlock site is exactly the same as a short nail. It is a short nail that has an extra 6 [cm] to 8 cm of nail that extends distally,” Horwitz, of Geisinger Medical Center, told Healio. “If you use an intermediate nail, it does not matter whether the lateral wall is intact in terms of toggling. The results of this study have already significantly changed my practice. I now treat patients with intertrochanteric femur fractures with wide medullary canals with intermediate nails to avoid any risk of toggling with a possible incompetent lateral wall.”
Collapse
Mahmoud AN, et al. Paper 73. Presented at: Orthopaedic Trauma Association Annual Meeting; Oct. 23-26, 2024; Montreal, Québec, Canada.
Read more about
Click Here to Manage Email Alerts