Should nails be locked dynamically or statically in atypical femoral fractures? – A radiological analysis of time to union and reoperations in 236 displaced fractures with 4 years average follow-up

• Published in: Injury 2023-08, Vol.54 (8), p.110909-110909, Article 110909
• Main Authors: Fang, Christian, Shen, Wan Yiu, Wong, Janus Siu Him, Yee, Dennis King-Hang, Yung, Colin Shing-Yat, Fang, Evan, Lai, Yuen Shan, Woo, Siu Bon, Cheung, Jake, Chau, Jackie Yee-Man, Ip, Ka Chun, Li, Wilson, Leung, Frankie
• Format: Article
• Language: English
• Subjects: Atypical femoral fracture; Bisphosphonate; Bone Nails; Dynamic locking; Dynamisation; Femoral Fractures - diagnostic imaging; Femoral Fractures - surgery; Follow-Up Studies; Fracture Fixation, Intramedullary; Humans; Intramedullary nail; Reoperation; Reproducibility of Results; Retrospective Studies; Treatment Outcome
• ISSN: 0020-1383; 1879-0267
• DOI: 10.1016/j.injury.2023.110909

•Dynamization of intramedullary nails for treating atypical femoral significantly reduces time-to-union and is associated with lower rates of non-union and treatment failure.•Static locking and varus reduction are independent risk factors for reoperation and treatment failure. Atypical femoral fractures (AFFs) are associated with delayed union and higher reoperation rates. Axial dynamization of intramedullary nails is hypothesized to reduce time-to-union (TTU) and fixation failure as compared to static locking. Consecutive acutely displaced AFFs fixed with long intramedullary nails across five centres between 2006 and 2021 with a minimum postoperative follow-up of three months were retrospectively reviewed. The primary outcome was TTU, compared between AFFs treated with dynamically or statically locked intramedullary nails. Fracture union was defined as a modified Radiographic Union Score for Tibial fractures score of 13 or greater. Secondary outcomes involved revision surgery and treatment failure, defined as non-union beyond 18 months or revision internal fixation for mechanical reasons. A total of 236 AFFs (127 dynamically locked and 109 statically locked) were analysed with good interobserver reliability of fracture union assessment (intraclass correlation coefficient = 0.89; 95% CI = 0.82–0.98). AFFs treated with dynamized nails had significantly shorter median TTU (10.1 months; 95% CI = 9.24–10.96 vs 13.0 months; 95% CI = 10.60–15.40) (log-rank test, p = 0.019). Multivariate Cox regression revealed that dynamic locking was independently associated with greater likelihood of fracture union within 24 months (p = 0.009). Reoperations were less frequent in the dynamic locking group (18.9% vs 28.4%), although the difference was not statistically significant (p = 0.084). Static locking was an independent risk factor for reoperation (p = 0.049), as were varus reduction and lack of teriparatide use within three months of surgery. Static locking also demonstrated a higher frequency of treatment failure (39.4% vs 22.8%, p = 0.006) and was an independent predictor of treatment failure in logistic regression (p = 0.018). Other factors associated with treatment failure included varus reduction and open reduction. Dynamic locking of intramedullary nails in AFFs is associated with faster time to union, lower rate of non-union, and fewer treatment failures.