title: Breakage of cephalomedullary nailing in operative treatment of trochanteric and subtrochanteric femoral fractures.
abstract: BACKGROUND
  Mechanical breakage of cephalomedullary nail osteosynthesis is a rare complication attributed to delayed fracture union or nonunion. This study presents a series of cases of breakage and secondary lag screw dislocation after cephalomedullary nailing. The aim of this study was to identify factors that contribute to cephalomedullary nail breakage.
  
  
  METHODS
  In a retrospective case series review between 02/2005 and 12/2013, we analyzed 453 patients with trochanteric and subtrochanteric fracture who had been treated by cephalomedullary nailing. Fractures were classified according to AO/OTA classification. 13 patients with cephalomedullary nail breakage were included (failure rate 2.9 %).
  
  
  RESULTS
  Seven patients were women, and six men with a mean age of 72 years (range 35-94). Implant breakage occurred 6 months postoperatively (range 1-19 months). In ten cases, breakage was secondary to delayed or nonunion, which was thought to be mainly due to insufficient reduction of the fracture, and in two cases due to loss of the lag screw because of missing set screw. In one case, breakage was apparent during elective metal removal following complete fracture healing. Short-term outcome was evaluated 6 months after operative revision using Harris hip score in 11 out of 13 patients showing a mean score of 84 %. Complete radiological fracture healing has been found in 11 patients available for follow-up within 6 months after revision surgery.
  
  
  CONCLUSIONS
  Breakage of cephalomedullary nail osteosynthesis of trochanteric fractures is a severe complication. The results of our study demonstrate that revision surgery provides good clinical and radiological short-term results. Predominately, failures of trochanteric fractures are related to lack of surgeon performance. Therefore, application of the implant requires accurate preoperative planning, advanced surgical experience to evaluate the patient and the fracture classification, and precise surgical technique including attention to detail and anatomical reduction of the fracture fragments.
authors.affiliation: Department of Trauma Surgery, Trauma Center Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Germany. christian.vonrueden@bgu-murnau.de.
authors.forename: Christian
authors.initials: C
authors.lastname: von Rüden
authors.affiliation: Department of Trauma Surgery, Trauma Center Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Germany.
authors.forename: Sven
authors.initials: S
authors.lastname: Hungerer
authors.affiliation: Institute of Biomechanics, Trauma Center Murnau, Murnau, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Augat
authors.affiliation: Department of Trauma Surgery, Trauma Center Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Germany.|Institute of Biomechanics, Trauma Center Murnau, Murnau, Germany.
authors.forename: Oliver
authors.initials: O
authors.lastname: Trapp
authors.affiliation: Department of Trauma Surgery, Trauma Center Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Germany.
authors.forename: Volker
authors.initials: V
authors.lastname: Bühren
authors.affiliation: Department of Trauma Surgery, Trauma Center Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Hierholzer
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001858:Bone Nails / Q000009:adverse effects; D001863:Bone Screws / Q000009:adverse effects; D005260:Female; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects* / Q000295:instrumentation; D017102:Fracture Healing; D017759:Fractures, Malunited / Q000209:etiology / Q000601:surgery; D005599:Fractures, Ununited / Q000209:etiology / Q000601:surgery; D006620:Hip Fractures / Q000150:complications / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies