Is distal locking with IMHN necessary in every pertrochanteric fracture?

Abstract

Two groups of patients were treated for pertrochanteric fractures (AO/ASIF 31A1+A2) with an intramedullary hip nail. In the first group of 44 patients distal dynamic locking was used, and in the second group of 74 patients the nail was not distally locked. Comparison of the two groups of patients did not show any difference in terms of the period of fracture healing, radiological and functional results or frequency of complications. In the group with a distally locked nail the surgery took 40.4 minutes, while in the group without distal locking only 34.4 minutes. In total, we recorded only seven complications, none of which were caused by absence of distal locking of the nail. This study has shown that distal locking of IMHN is unnecessary in most pertrochanteric fractures (AO/ASIF 31A1+2). The only exceptions are comminution of the lateral wall of the greater trochanter, secondary diaphyseal fracture line, large posteromedial fragment extended distally below the level of the lesser trochanter and broad intramedullary canal.

The benefit of wire cerclage stabilisation of the medial hinge in intramedullary nailing for the treatment of subtrochanteric femoral fractures: a biomechanical study

“…This was not tested in this study. Skála-Rosenbaum et al did not encounter any cases of cutout of screws after osteosynthesis of pertrochanteric fractures with two head screws [26]. In our samples with additional cerclage a fracture of the medial cortex was found in 70% of the cases without varus dislocation or a cutout, because the medial buttress remained (Fig.…”

Distal locking in short hip nails: Cause or prevention of peri-implant fractures?

“…Compression of the head fragment along the axis of the femoral neck can occur in these fractures, with rotational stability being provided via lag screws going through the intact lateral femoral cortex. In a previous study, we showed that unlocked nailing is not associated with increased complications and is actually associated with a significant reduction in operation and fluoroscopy time [14]. The authors mentioned above concur that distal locking is only indicated for unstable comminuted fractures, fractures with secondary subtrochanteric lines, and in those with wide medullary cavities.…”

“…When addressing the distal locking issue, some authors have stated that distal locking is not necessary for most pertrochanteric AO 31-A1 + 2 fractures [8,[11][12][13][14][15]; they then used their samples to confirm that unlocked nailing was safe and not associated with increased complications.…”

“…Based on the analysis of our sample, we identified specific fracture patterns in which distal locking is necessary for pertrochanteric AO 31-A1 + 2 fractures [14]. Given the recent increase in the number of peri-implant fractures, we assessed a group of patients who had been surgically managed with short nails in an effort to determine the potential impact of the distal locking technique on the emergence of peri-implant fractures.…”

Distal locked or unlocked nailing for stable intertrochanteric fractures? A meta‐analysis

“…Usually, intramedullary nails are designed with various distal fixation options to improve axial and rotational stability, which can also restrain the movement of distal tip of nail when a broad femoral medullary canal was encountered . Everything has two sides.…”