Is Distal Locking Necessary? A Biomechanical Investigation of Intramedullary Nailing Constructs for Intertrochanteric Fractures

Objectives: Unstable intertrochanteric fractures in the elderly occur frequently. Several studies have evaluated the biomechanical impact of distally locking long cephalomedullary nails under axial loading; however, the impact of torsional loading has not been investigated. The purpose of this study is to determine the rotational load to failure of unstable intertrochanteric fractures treated with long cephalomedullary nails, with and without distal interlocking. Methods: Eleven paired cadaveric femora treated with long cephalomedullary nails were randomized into 2 groups. Group 1 was left unlocked, whereas group 2 was distally locked. Osteotomies were completed to create unstable 4-part fractures. The femora were anatomically fixed proximally and distally and secured to the biomechanical testing machine to undergo internal rotation. Torque and rotational angle were measured until failure. Results: The locked group had a mean maximal torsional load of 57.9 +/- 19.0 N center dot m and a mean rotational stiffness of 119.4 +/- 35.7 N center dot m/rad. The femora treated with unlocked nails had a mean maximal torsional load of 29.1 +/- 12.2 N center dot m and a mean rotational stiffness of 77.2 +/- 31.3 N center dot m/rad. Distal locking resulted in a significant increase in maximal rotational load (P = 0.001) and rotational stiffness (P = 0.004) before failure. No significant difference was found in mean rotational angle at failure between groups (26.0 +/- 9.6 degrees, P = 0.263). Conclusions: Maximal torsional load to failure for the unlocked group is within the functional range of rotational loads experienced at the hip for an average adult. The results show that distal locking significantly increases rotational load to failure. The authors highly recommend routine use of distal interlocking screws during cephalomedullary nail placement in unstable intertrochanteric fractures.