Critical analysis of factors determining mechanical failures in proximal femoral nailing


  • Karthik Ramachandran Department of Orthopaedic Surgery, PSG IMSR, Coimbatore Thiruvannamalai, Tamil Nadu, India
  • K. K. Arvind Manoj Department of Orthopaedic Surgery, Govt Sivagangai Medical College, Sivagangai, Thiruvannamalai, Tamil Nadu, India
  • A. Vishnu Sankar Department of Orthopaedic Surgery, Govt Thiruvannamalai Medical College, Thiruvannamalai, Tamil Nadu, India



Intertrochanteric fracture, Proximal femoral nail, TAD difference, Lag screw centre, Positive medial cortical support


Background: Intertrochanteric fractures are one of the commonest fractures encountered in elderly population. Though there are various implants, proximal femoral nail has been the standard choice for management of unstable fractures. Inspite of its biomechanical advantages, various complications like screw cut out, Z effect, reverse Z effect does occur in proximal femoral nailing. The aim of the study is to analyse various factors determining the mechanical failures in patients operated with proximal femoral nail.

Methods: This is a prospective study conducted in our institution from June 2014 to May 2018. The study included 72 patients with unstable intertrochanteric fractures treated with proximal femoral nail. All patients were followed for average period of 2 years. Functional outcome was assessed using Harris Hip score.

Results: Among the patients 33% had excellent outcome. 42% had good and 14% had fair outcome. 11% of cases ended with poor outcome. Mechanical failure rate was less in patients with positive medial cortical support (PMCS) and in patients with tip apex distance difference between antirotation screw and lag screw (TADAR -TADLS) more than 15 mm. Whereas the difference in the position of lag screw centre had no significant influence in the mechanical failure rate in our study.

Conclusions: From our study we like to conclude that the fracture reduction with positive medial cortical support and the TAD difference play a major role in determining the incidence of mechanical failure in proximal femoral nailing.


Herman A, Landau Y, Gutman G, Ougortsin V, Chechick A, Shazar N. Radiological evaluation of intertrochanteric fracture fixation by the proximal femoral nail. Injury. 2012;43(6):856–63.

Kulkarni GS, Limaye R, Kulkarni M, Kulkarni S. Intertrochanteric fractures. Indian J Orthop. 2006;40:16–23.

Gundle R, Gargan M.F, Simpson HRW. How to minimize failure of fixation of unstable intertrochanteric fractures. Injury. 1995;26(9):611-4.

Simpson AH, Varty K, Dodd CA. Sliding hip screws: modes of failure. Injury. 1989;20(4):227– 31.

Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res. 1998;348:87–94.

Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate:a prospective, randomized study. J Bone Joint Surg. Am. 2002;84(3):372–81.

Park SR, Kang JS, Kim HS, Lee WH, Kim YH. Treatment of intertrochanteric fracture with the gamma AP locking nail or by a compression hip screw-a randomised prospective trial. Int Orthop. 1998;22(3):157–60.

Gadegone WG and Salphale YS. Short proximal femoral nail fixation for trochanteric fractures. J Orthop Surg (Hong Kong). 2010;18(1):39-44.

Chang S-M, Zhang Y-Q, Ma Z, Li Q, Dargel J et al. Fracture reduction with positive medial cortical support:a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg. 2015;135(6):811-8.

Mainds CC, Newman RJ. Implant failures in patients with proximal fractures of the femur treated with a sliding screw device. Injury. 1989;20(2):98–109.

Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2008;3:CD93.

Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF- proximal femoral nail (PFN):a new device for the treatment of unstable proximal femur fractures. Injury. 1990;30(5):327–32.

Rethnam U, Cordell-Smith J, Kumar TM, Simha A. Complex proximal femoral fractures in the elderly managed by reconstruction nailing–complications and outcomes:a retrospective analysis. J Trauma Manag Outcomes. 2007;1(7):1–7.

Fogagnolo F, Kfuri M Jr, Paccola C. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg. 2004;124:31–7.

Uzun M, Erturer E, Ozturk I, Akman S, Seckin F, Ozcelik IB. Long term radiographic complications following treatment of unstable intertrochanteric femoral fractures with the proximal femoral nail and effects on functional results. Acta Orthop Traumatol Turc. 2009;43(6):457–63.

Gotfried Y. The Gotfried (nonanatomic, closed) reduction of unstable subcapital femoral fractures. Tech Orthop. 2012;27(4):259–61.

Gotfried Y, Kovalenko S, Fuchs D. Nonanatomical reduction of displaced subcapital femoral fractures (gotfried reduction). J Orthop Trauma. 2013;27(11):254–9.

Kuzyk et al Femoral Head Lag Screw Position for Cephalomedullary Nails: A Biomechanical Analysis. J Orthop Trauma. 2012;26:414–21.

Aithala JP, Rao S. Proximal Femoral Nailing: Technical Difficulties and Results in Trochanteric Fractures. Open J Orthop. 2013;3(5):234-42.

Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extra medullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res. 1998;348:87–94.

Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The Value of the Tip-Apex Distance in Predicting Failure of Fixation of Peritrochanteric Fractures of the Hip. J Bone Joint Surg Am. 1995;77(7):1058-64.

Kashigar A, Vincent A, Gunton MJ, Backstein D, Safir O, Kuzyk PR. Predictors of failure for cephalomedullary nailing of proximal femoral fractures. Bone Joint J. 2014;96(8):1029–34.

Morihara T, Arai Y, Tokugawa S, Fujita S, Chatani K, Kubo T. Proximal femoral nail for treatment of trochanteric femoral fractures. J Orthop Surg (Hong Kong). 2007;15:273–7.






Original Research Articles