Cephalomedullary Screws as the Standard Proximal Locking Screws for Nailing Femoral Shaft Fractures

Objectives: In 2004, we modified our technique for the stabilization of femoral shaft fractures so that all fractures were stabilized using a reconstruction nail with proximal locking screws oriented into the femoral head. The rationale for this was twofold: first, potentially "missed" associated femoral neck fractures would be stabilized. Second, hip fractures that might occur later in life above the intramedullary nail might be avoided. The purpose of this study therefore was to determine whether there were any risks to patients treated for femoral shaft fractures with antegrade nails using cephalomedullary proximal locking screws. Design: Retrospective. Setting: Two regional trauma centers. Patients/Participants: Eighty-seven consecutive patients were treated for a femoral shaft fracture treated with antegrade femoral nailing with a cephalomedullary locked nail. Intervention: Reamed, trochanteric insertion of an intramedullary nail with proximal locking screws placed in a cephalomedullary direction. Main Outcome Measurement: Patient and injury data, radiographic analyses, and complications of treatment were assessed at a minimum of 12 months. Results: Sixty-one of 87 patients (70%) were available at a mean of 19.8 months (range, 12-44 months). Sixty of 61 fractures united after the index procedure. Complications included one delayed union successfully treated with exchange nailing, one distal locking screw fracture (allowing dynamization and completion of fracture healing), two patients with postoperative deformity that required a derotation procedure, and two drill bits that broke intraoperatively and were retained. There were no major complications at the hip, no migration or failure of proximal locking screws, and no screws required removal. Conclusions: Using a reconstruction nail and cephalomedullary proximal locking screws for antegrade femoral nailing of femoral shaft fractures was not associated with major complications in this series. This modification of standard femoral nailing offers potential advantages, including fixation of any "missed" associated femoral neck fractures and prevention of late hip fractures that might occur above the nail.