Salvage for intramedullary nailing breakage after operative treatment of trochanteric fractures Jordi Tomás-Hernández*, Jorge Núñez-Camarena, Jordi Teixidor-Serra, Ernesto Guerra-Farfan, Jordi Selga, Juan Antonio Porcel, José Vicente Andrés-Peiró, Vicente Molero Trauma Unit of the Department of Traumatology and Orthopaedic Surgery of Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona (UAB), Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain A R T I C L E I N F O Article history: Received 16 May 2018 Received in revised form 8 July 2018 Accepted 23 July 2018 Keywords: Trochanteric fracture Intramedullary nail breakage Mechanical failure Nonunion Revision surgery A B S T R A C T Background: Trochanteric fractures are one of the most common fractures in elderly people. The use of intramedullary nails is an option for their treatment, especially in unstable patterns. Nail breakage is a rarely reported complication. The aim of this study was to determine the prevalence of nail breakage in our center. Secondary objectives are to show the management of this complication in our institution as well as the technical problems, complications and final outcomes of these patients in our hands. Material and Methods: In a retrospective case series review between 2010 and 2015, we analyzed 1481 patients with trochanteric and subtrochanteric fractures who had been treated by cephalomedullary nailing in our centre. 13 patients with nail breakage were identified. Results: The percentage failure rate in our institution is 0.87%. 9 (69.2%) patients were women and 4 (3.8%) were men, with a mean age of 74.6 years (range 47–90). In all cases the mechanism of injury was a simple fall from standing height. Initial fracture types were: 1 case of AO/OTA 31A1, 6 cases of AO/OTA 31A2 and 6 cases of AO/OTA 31A3. Only 3 cases had a good overall reduction with a correct TAD, an optimal femoral neck-shaft angle and absence of fracture gaps >5 mm after surgery. The average time from the first surgery to the diagnosis of implant breakage was 333 days (range 70–1460), 11 months. Breakage occurred at the nail junction with the lag screw in 11 cases and in the distal nail aperture in 2 cases. Conclusions: An insufficient reduction with varus and fracture gaps >5 mm, the use of short nails in unstable patterns with subtrochanteric involvement and patients with certain comorbidities are facts observed that can contribute to the development of delayed or nonunion with subsequent nail breakage. Different salvage treatments, conversion to hip arthroplasty or revision osteosynthesis, may be considered but we think that prevention has to be the best treatment. © 2018 Elsevier Ltd. All rights reserved. Background Trochanteric fractures are one of the most common fractures in orthopaedic surgery with a high cost for the public health system in our country. They represent an important cause of hospitaliza- tion, morbidity and mortality for elderly patients [1]. Many devices have been developed to fix them, the most widely used being the dynamic hip screw (DHS) and the intramedullary nails [2]. In terms of load shearing, the biomechanical advantage of the nails with regard to the DHS is related to its position which is nearer to the weight-bearing axis. When the intramedullary system is compare with the extramedullary device, there is up to a 30% reduction of bending stresses [3]. A decrease in the operation time and surgery blood loss, the periostium preservation and the ability for an early weight-bearing due to its biomechanical properties are other advantages related to intramedullary nailing of trochanteric fractures. For the previous reasons, the use of intramedullary nails is increasing, and they are now the most commonly used fixation devices, especially in the treatment of unstable trochan- teric fractures [4]. Excellent results have been reported with the use of intra- medullary nails. However, a variety of complications have been reported [5] being the nail breakage an uncommon complication. The causes of breakage are usually related to variables depending on the surgery being a poor surgical technique and a malreduction the most common scenarios. Other causes are related to variables depending on the patient such as osteoporosis, tobacco use, corticoid treatments or alcoholism [6]. * Corresponding author. E-mail address: jotomas@vhebron.net (J. Tomás-Hernández). https://doi.org/10.1016/j.injury.2018.07.018 0020-1383/© 2018 Elsevier Ltd. All rights reserved. Injury, Int. J. Care Injured 49S (2018) S44–S50 Contents lists available at ScienceDirect Injury journa l home page : www.e lsevier.com/loca te/injury