Short cephalomedullary nail toggle: a closer examination.

OBJECTIVES: In patients with wide femoral canals, an undersized short nail may not provide adequate stability, leading to toggling of the nail around the distal interlocking screw and subsequent loss of reduction. The purpose of this study was to identify risk factors associated with nail toggle and to examine whether increased nail toggle is associated with increased varus collapse. DESIGN: Retrospective cohort study. SETTING: Level 1 and level 3 trauma center. PATIENTS/PARTICIPANTS: Seventy-one patients with intertrochanteric femur fractures treated with short cephalomedullary nails (CMN) from October 2013 to December 2017. INTERVENTION: Short CMN. MAIN OUTCOME MEASUREMENTS: Nail toggle and varus collapse were measured on intraoperative and final follow-up radiographs. Risk factors for nail toggle including demographics, fracture classification, quality of reduction, Dorr type, nail/canal diameter ratio, lag screw engaging the lateral cortex, and tip-apex distance (TAD) were recorded. RESULTS: On multivariate regression analysis, shorter TAD (P = .005) and smaller nail/canal ratio (P < .001) were associated with increased nail toggle. Seven patients (10%) sustained nail toggle >4 degrees. They had a smaller nail/canal ratio (0.54 vs 0.74, P < .001), more commonly Dorr C (57% vs 14%, P = .025), lower incidence of lag screw engaging the lateral cortex (29% vs 73%, P = .026), shorter TAD (13.4 mm vs 18.5 mm, P = .042), and greater varus collapse (6.2 degrees vs 1.3 degrees, P < .001) compared to patients with nail toggle < 4 degrees. CONCLUSIONS: Lower percentage nail fill of the canal and shorter TAD are risk factors for increased nail toggle in short CMNs. Increased nail toggle is associated with increased varus collapse.Level of evidence: Therapeutic Level III.

Plate fixation of femoral nonunions over an intramedullary nail with autogenous bone grafting.

OBJECTIVE: To describe a novel approach for the treatment of nonunions of diaphyseal femur fractures. DESIGN: Retrospective review. SETTING: University hospital. PATIENTS: Seven patients (six men, one woman, average age 42.5 years) with diaphyseal femoral fracture nonunions treated between November 2006 and November 2007 were reviewed. The injuries included two open and five closed fractures. All were treated initially with intramedullary nail fixation (two antegrade, five retrograde) and went on to develop a symptomatic nonunion by radiographic and clinical criteria. INTERVENTION: Nonunions were treated with operative débridement of the nonunion with plate fixation and autogenous bone grafting without removal or exchange of the intramedullary nail. MAIN OUTCOME MEASURES: Clinical criteria of decreased pain and return to function as well as radiographic evidence of fracture consolidation. RESULTS: All patients demonstrated radiographic evidence of fracture consolidation with an average follow-up time of 17.9 months (range 12-26 months). All were allowed immediate weightbearing and reported decreased pain with improved function. Six patients reported absolutely no pain with ambulation as related to the fracture site, whereas one noted discomfort about the distal femoral compression plate. Independent ambulation was observed in six subjects. None of the patients required additional operations for implant removal or bone grafting procedures. CONCLUSION: Treatment of diaphyseal femoral fracture nonunion after intramedullary nail fixation with large fragmentary compression plating and bone grafting is a reasonable option, especially for complex fractures about the metadiaphyseal region. The procedure appears to be successful in reducing pain, improving function, and predictably leads to radiographic consolidation of the nonunion.