Cephalomedullary Nailing of Intertrochanteric Femoral Fractures

Overview

Intramedullary fixation of trochanteric fractures places the implant closer to the mechanical axis, giving a shorter lever arm than a screw–side plate (Campbell). The first widely used cephalomedullary nail for these fractures was the gamma nail of the 1980s; many designs followed, with different lengths and diameters, static or dynamic locking, and single- or dual-axis proximal fixation (Rockwood). Early designs had higher complication rates, especially femoral shaft fractures, but contemporary nails give results similar to the sliding hip screw (Rockwood).

Classification (AO/OTA 31A)

Indications

• Unstable trochanteric fractures (31A3 and probably many 31A2) are best treated with an intramedullary implant (Campbell). AO recommends an intramedullary nail with static distal locking for unstable A2 and A3 fractures.

• Theoretical advantages: Better biomechanics, less blood loss, smaller incisions and less femoral neck shortening (Campbell). Operative time and blood loss are lower than with plating (AO).

• Evidence:

  • Cochrane: functional outcomes are similar to screw–side plate devices; superiority of nails for A1/A2 fractures has not been shown, and revision rates were higher with nails (Campbell; AO).

  • Two recent meta-analyses found no significant overall difference in primary or secondary outcomes between nails and SHS across fracture types; several randomized trials of minimally invasive nails reported slightly better mobility with nails, possibly due to less collapse and medialization (Rockwood).

  • Return to preinjury walking at 4 months: 76% with nails vs 54% with screw–side plates; mean neck shortening 1.3 mm vs 6.1 mm. In A2/A3 fractures, medialization at 1 year was greater with screw–side plates, and more than 50% medialization was associated with worse pain and mobility (Campbell).

  • Norwegian Hip Fracture Register (17,341 patients): lower reoperation rates with nails for unstable A2/A3 fractures, lower 1-year mortality for all trochanteric fractures and better patient-reported outcomes in unstable fractures. A US propensity-matched study (17,000 patients) found no difference in mortality, reoperation or major complications (Rockwood).

• Rockwood authors' algorithm: A2 → cephalomedullary nail preferred; A3 and oblique fractures → cephalomedullary nail.

• Subtrochanteric extension: Treat as a subtrochanteric fracture (Rockwood; AO).

Preoperative Planning

• Standard AP pelvis and lateral hip views; look for lateral wall lines and coronal fragments (AO).

• Contralateral hip image: Store it for varus/valgus templating, because neck–shaft malreduction is associated with fixation failure (Campbell).

• Nail angle: Campbell generally uses a 130° nail. Nails with an angle smaller than the native neck–shaft angle have been associated with varus malreduction (Campbell).

• Nail diameter: Campbell usually uses a 10 mm nail. A larger nail rarely helps and may increase the risk of anterior cortical perforation; nail diameter has not been shown to affect outcome (Campbell).

• Nail length:

  • Results are the same for short and long nails when the fracture extends no more than 3 cm below the trochanteric region, so a short nail (about 200 mm) is generally recommended; longer nails are needed only if the fracture extends below the lesser trochanter (Rockwood).

  • In a review of 1,276 patients, refracture was 1.6% with short vs 0.95% with long nails (not significant), while operative time, blood loss, transfusion and cost were all lower with short nails (Rockwood).

  • Long nails: operative time 13–19 min longer, 37–39 mL more blood loss, higher transfusion rates; peri-implant fracture rates did not differ significantly (< 2% overall) (Campbell).

• Obese patients: Some adduction may be needed to reach the greater trochanter (Rockwood); the lateral position can help in morbid obesity and some fracture patterns (Campbell).

Surgical Technique

Positioning and Reduction

1. Supine on a fracture table with a perineal post (Campbell; Rockwood).

2. Scissor the legs, with the injured hip extended relative to the other side (Campbell).

3. Shift the upper trunk away from the fracture (adduct the torso) and secure the ipsilateral arm across the chest on a holder (Campbell; Rockwood).

4. Reduce with traction under AP and lateral fluoroscopy (Rockwood). Place the C-arm on the contralateral side and confirm imaging before draping (Campbell). Consider a sterile transparent isolation drape (Rockwood).

5. Reduction targets (Rockwood): Anatomic or slight valgus on AP; never varus. Garden alignment index 160–175° on AP and 180° on the lateral, with head, neck and shaft in a straight line.

6. Avoid varus, posterior sag and excessive internal rotation (Campbell). Campbell is particularly critical of anterior malreduction on the lateral or oblique lateral view, because it is associated with cut-out.

7. Correct any malreduction before reaming (Campbell).

Entry Portal

1. Incision: About 3 cm, starting proximal to the tip of the greater trochanter and extending proximally (Campbell); Rockwood describes a 3 cm incision about 5 cm proximal to the greater trochanter. Lengthen according to body habitus.

2. Divide the fascia lata / gluteus maximus aponeurosis and split the muscle down to the tip of the trochanter (Campbell; Rockwood).

3. Guide pin position (critical):

   • AP view: Just lateral to the medial aspect of the greater trochanter on a true AP of the proximal femur (Rockwood); Campbell uses a modified medial trochanteric portal on the medial aspect of the greater trochanter along the trochanteric ridge.

   • Lateral view: In line with the femoral shaft (Campbell), at the center or slightly posterior to the center of the neck and head (Rockwood).

   • A cadaver study found no damage to the gluteus medius tendon with the modified medial portal, which may mean less abductor weakness (Campbell).

   • Advance the pin 2–3 cm and check both views. A two-pin technique with a honeycomb guide saves fluoroscopy time (Campbell).

4. Open the proximal femur with a cannulated reamer over the pin, about the proximal 5 cm (Rockwood) or to just below the lesser trochanter (Campbell).

Canal Preparation

1. Pass a ball-tipped guide wire to the physeal scar and measure for nail length (Campbell).

2. Ream if required by the nail design: about 1.5 mm larger than the nail, or 2 mm larger to allow for the anterior bow (Campbell). Appropriate reaming prevents intraoperative shaft fracture during nail insertion (Rockwood).

Nail Insertion

1. Insert the nail with the jig facing anteriorly, rotating it laterally about halfway down the canal; watch the lateral view to avoid anterior cortical perforation (Campbell).

2. Seat the nail at a depth that allows a center–center (or inferocentral) lag screw position (Campbell; Rockwood).

3. Version check: On the lateral view, nail, jig, femoral neck and head should be aligned (Campbell).

Lag Screw or Blade

1. Through a small lateral stab incision, seat the drill sleeve on the lateral cortex (Campbell).

2. Advance the guide wire:

   • Center–center (Campbell) or inferocentral on AP and central on lateral (Rockwood); peripheral placement is never acceptable (Rockwood).

   • Tip within about 5 mm of subchondral bone (Campbell; Rockwood).

3. Tip–apex distance (TAD) ≤ 25 mm (Campbell; AO; Rockwood); a TAD of about twice the lag screw diameter is a useful intraoperative check (Rockwood). With helical blades, medial migration has been reported at TADs below 20 mm (Campbell).

4. Measure, ream, and tap if the bone is not osteoporotic (Campbell). Insert the lag screw 5–7 mm from the joint line (Rockwood).

5. Compression: Apply after traction is released, per the manufacturer's technique; it helps create a more stable construct through bone-to-bone contact (Rockwood; Campbell).

6. Lag screw length and dynamization: Leave the lateral end of the screw outside the cortex so that sliding and dynamic compression at the fracture remain possible; if it sits inside the cortex, later dynamization by removing the distal locking screw may not work (Rockwood).

7. A trochanteric-entry nail should always be used with a sliding lag screw and the option of distal locking (Rockwood).

Distal Locking

1. All short nails should be locked (Rockwood). Distal locking is currently recommended for all unstable fractures (Rockwood; AO uses static distal locking for A2/A3).

2. Two observational studies of long nails reported fewer complications with distal locking. There is no evidence that static or dynamic locking is better; dynamic locking may be preferred for a transverse fracture to allow longitudinal compression (Rockwood).

3. Close the fascia lata and skin (absorbable subcuticular suture), apply a pressure dressing, and move the patient to a pressure-relieving mattress as soon as possible (Rockwood).

Implant Design Notes

• Proximal fixation may be single-axis, dual-axis (integrated two-screw) or a blade. Dual-axis designs may add rotational stability and allow an inferior screw in the head, but clinical evidence of benefit is lacking (Rockwood).

• Integrated two-screw nails (e.g., InterTAN): In the first series (n = 100; 48 followed for 1 year), there were no malunions or nonunions, 73% had no shortening, and 58% returned to preinjury function. Fractures distal to the nail tip have been reported, mainly with short nails (Campbell).

• Helical blade vs screw: Clinical studies found them equally effective (Rockwood).

Postoperative Care

• Weight bearing as tolerated in most cases (Campbell); full weight bearing from day 1 in the elderly (AO).

• Healing within about 3 months; secondary osteoporosis prevention for all fragility fractures (AO).

Complications

• Cut-out: Usually from varus reduction, a high TAD or peripheral screw position; anterior malreduction and an incorrect neck–shaft angle are further predictors (Campbell; Rockwood). Refixation is difficult; revision arthroplasty is an option (Rockwood).

• Fracture at the nail tip: 0.7–1.7% with modern designs, from stress concentration at the tip; mid-thigh pain may precede it in short nails (Rockwood).

  • Contributing factors (Rockwood): Stiff large-diameter nail; blunt (rather than tapered or fluted) tip; large-diameter distal locking screw; distal locking screw close to the tip; overtightening of the distal locking screw; a nail that is too short for a fracture with subtrochanteric extension.

  • Treatment: Exchange to a longer nail for a fracture below a short nail; for a fracture above the knee around a long nail, a distal locking plate around the nail (Rockwood).

• Nonunion (1–3%): Initial treatment may be dynamization at 3–6 months depending on callus; if ineffective, revision nailing with reaming and a larger nail, or extramedullary fixation; bone graft is rarely needed (Rockwood).

• Anterior cortical perforation of the distal femur during insertion (Campbell).

References

1. Weinlein JC. Fractures and dislocations of the hip. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 60, Technique 60.5.

2. Simmermacher RKJ. Femur, proximal. In: Buckley RE, Moran CG, Apivatthakakul T, eds. AO Principles of Fracture Management. 3rd ed. Stuttgart: Thieme; 2017. Chapter 6.6.1. (Turkish edition: AO Kırık Tedavisinin Prensipleri.)

3. Heetveld MJ, Flikweert ER. Trochanteric hip fractures. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 54. (Turkish edition: Erişkin Kırıkları.)