Clin Orthop Surg.  2020 Mar;12(1):29-36. 10.4055/cios.2020.12.1.29.

Risk Factors Associated with Failure of Cephalomedullary Nail Fixation in the Treatment of Trochanteric Hip Fractures

  • 1Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea.
  • 2Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwasung, Korea.
  • 3Department of Orthopaedic Surgery, Hallym University Gangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.


Intramedullary (IM) nailing is widely performed in elderly patients with trochanteric fractures. Thus, it is important to identify causative factors associated with fixation failure. We investigated fixation failures after IM nailing in elderly patients with trochanteric fractures and compared the failure group with nonfailure group to identify risk factors of fixation failure.
A total of 396 patients aged 65 years or older underwent IM nailing for trochanteric fractures between January 2012 and August 2016 at our institution. Of those, 194 patients who were followed up for more than 12 months were enrolled in this study; 202 patients were excluded due to death during follow-up, bedridden status before injury, and loss to follow-up. All patients underwent plain radiography and preoperative computed tomography (CT).
Fixation failure occurred in 11 patients (5.7%). Seven patients had stable fractures (AO/OTA); eight patients had basicervical fractures (confirmed by CT). Five patients had comminution in the greater trochanter (confirmed by CT). Regarding fracture reduction, eight patients showed discontinuity in the anterior cortex. The position of the lag screw on the lateral view was in the center in six patients and in a posterior area in the other five patients. On the basis of comparison with the 183 patients without fixation failure, risk factors of fixation failure were higher body mass index (BMI; p = 0.003), basicervical type of fracture (p = 0.037), posterior placement of the lag screw on the lateral view (p < 0.001), and inaccurate reduction of the anterior cortex (p = 0.011).
Among the risk factors of fixation failure after IM nailing in elderly patients with trochanteric fractures, discontinuity of the anterior cortex and posterior position of the lag screw are modifiable surgeon factors, whereas higher BMI and basicervical type of fracture are nonmodifiable patient factors. Therefore, care should be taken to avoid fixation failure in IM nailing for patients with a basicervical type of fracture or higher BMI or both.


Fixation failure; Intramedullary nailing; Basicervical fracture type; Trochanteric fracture

MeSH Terms

Body Mass Index
Follow-Up Studies
Fracture Fixation, Intramedullary
Hip Fractures*
Risk Factors*


  • Fig. 1 Flowchart of patient inclusion and exclusion.

  • Fig. 2 Illustration of basicervical type of fracture on a computed tomographic scan. The continuous white line represents the area of typical trochanteric fractures and two interuppted gray lines represent the area of basicervical type of fractures.

  • Fig. 3 (A) An 88-year-old woman showed basicervical type of fracture with varus angulation before surgery. (B) The fracture was OTA A12 type fracture with greater trochanter comminution. (C) Surgery was performed by using Zimmer natural nail. (D) The lag screw was pulled out at 2 weeks after surgery. (E) The lag screw was cut out of the femoral head at 6 weeks after surgery.

  • Fig. 4 (A) An 81-year-old woman fell on the ground. The proximal fragment was short and varus angulated before surgery. (B) The three-dimensional computed tomographic scan shows the OTA-A21 fracture. (C) The fracture was reduced by the Proximal Femoral Nail Anti-rotation. (D) The lag screw was cutting through at 3 months after surgery. (E) Conversion to hemiarthroplasty with wiring was performed.


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