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INTRODUCTION Intramedullary nailing is a common treatment for proximal femoral fractures. Fracture of the nail is a rare but devastating complication that exposes often frail patients to complex revision surgery. We investigated which risk factors predict nail failure. METHODS We reviewed all cases of nail breakage seen over a 10-year period in a single busy trauma unit; 22 nail fractures were seen in 19 patients. Comparison was made with a group of 209 consecutive patients who underwent intramedullary fixation of a proximal femur fracture with no nail breakage over a 2-year period. RESULTS In the fractured nail group, mean age was 70.4 years (range 55-88 years).The mean time to fracture was 10 months (range 2.5-23 months). Logistical regression was used to show that low American Society of Anesthesiologists (ASA) score, subtrochanteric fracture and pathological fracture were independent risk factors for nail fracture. CONCLUSIONS Young patients with a low ASA score are at highest risk of nail breakage. We advise close follow-up of patients with these risk factors until bony union has been achieved. In addition, there may be merit in considering other treatment options, such as proximal femoral replacement, especially for those with pathological fracture with a good prognosis.

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Background: Anterior vertebral body tethering (AVBT) offers a dynamic fusion less correction option for children with adolescent idiopathic scoliosis (AIS). Few existing clinical studies evaluating novel AVBT in skeletally immature children have questioned the midterm efficacy with concerns of overcorrection and curve progression with remaining growth. The current study investigates the effect of this technique in skeletally mature children (Risser ! 4 and Sanders ! 7) with AIS with limited remaining growth potential.Methods: We evaluated skeletally mature children with AIS who underwent the AVBT technique for a single structural major curve between 408 and 808 with !50% flexibility on dynamic radiographs and a minimum of 1 year of follow-up. Pertinent clinical and radiographic data collected include skeletal maturity, curve type, Cobb angle, sagittal parameters, and a patient-reported outcome measure Scoliosis Research Society-22 (SRS-22) questionnaire.Results: All 10 children were female with a mean age of 14.9 6 2.7 years at the time of surgery. The mean followup was 24.1 6 3.6 months. The mean Risser and Sanders scores were 4.2 6 0.6 and 7.2 6 0.6, respectively. Three patients had major thoracic curves, and 7 patients had thoracolumbar/lumbar curves. Cranial and caudal instrumented levels were T5 and L4. Mean preoperative Cobb's angle was 52.08 6 11.68 and was corrected to 15.98 6 6.88 on the first erect postoperative radiograph, with stabilization of corrected curve at the 1-year follow-up (mean Cobb's angle of 15.38 6 8.78). Mean preoperative and postoperative SRS-22 scores were 78.0 6 3.2 and 92.5 6 3.1, respectively (P , .01). No complications were noted until the last follow-up.Conclusion: Our preliminary experience with this novel AVBT as an alternative technique to fusion to stabilize progressive idiopathic scoliosis in skeletally mature children is promising.