Factors influencing implant failure in cephalomedullary nails for proximal femoral fractures: A retrospective review.

Abstract

The use of cephalomedullary nailing (CMN) to treat extracapsular hip fractures is a well-established fixation method. Nationally, the use of CMN has increased from 67.7% in 2012 to 90.9% in 2025 for subtrochanteric fractures (National Hip Fracture Database). Although rare, implant failure is a recognised complication which poses risk to patients who are otherwise already burdened with high morbidity and mortality. The purpose of this study is to review the outcomes of CMN fixations for proximal femoral fractures, with particular focus on implant failure. We analysed patient demographics, surgical factors, and fracture patterns to identify factors associated with rate of implant failure. This was a retrospective longitudinal cohort study of CMN fixations at a district general hospital between January 2020 and October 2024. All adult proximal femoral fractures treated with long CMN were included. Data collection was obtained from clinical records and relevant imaging. Measurement of radiological parameters was performed to evaluate quality of reduction. Multivariable logistic regression modelling was performed to analyse results. Long CMN was used for 208 cases. Of these, the majority were female (74.5%) with a mean age 82 years. Open reduction and augmentation with cerclage wires was used in 27.4% of cases (n = 57). An overall implant failure rate of 4.3% (n = 9) was identified. Implant failure occurred more frequently following open reduction with cerclage wire augmentation compared with closed reduction alone (10.5% vs 2.0%, p = 0.006). This association remained significant following multivariable adjustment for potential confounders. Outcomes of CMN fixation in this cohort were comparable to those reported in the literature. After adjustment for the measured reduction parameters, open reduction with cerclage wire augmentation was associated with increased odds of implant failure. However, given the retrospective design and small number of failure events, causal inference cannot be established, and these findings should be interpreted cautiously. Patients requiring open reduction and cerclage wire augmentation likely represent more complex fracture patterns and may benefit from closer postoperative surveillance until fracture union.