Closed reduction and intramedullary nailing of atypical femur fractures results in high rates of fracture union
Injury. 2026 Feb 28;57(4):113144. doi: 10.1016/j.injury.2026.113144. Online ahead of print.
ABSTRACT
OBJECTIVES: To evaluate outcomes of a series of consecutive, atypical femur fractures (AFFs) treated exclusively with closed reduction and reamed, statically locked intramedullary nailing.
METHODS: Design: Retrospective review.
SETTING: Single North American Level I trauma center. Patient Selection Criteria: All skeletally mature patients treated between 2012 and 2024 with closed reduction and reamed, statically locked IMN of a complete AFFs (OTA/AO 32) with > 6 months follow-up were eligible. Radiographic inclusion required fractures distal to the lesser trochanter and proximal to the supracondylar flare that met ≥4 of 5 American Society for Bone and Mineral Research (ASBMR) major criteria Outcome Measures and Comparisons: Primary outcome was radiographic and clinical union. Secondary measures included time to union, alignment quality, implant failure, and the relationship of neck-shaft angle (NSA) restoration with union.
RESULTS: There was a total of 52 AFFs with a mean age of 68 years (52-89 years). Overall, 46 (88%) patients were female and 6 (12%) were male. The mean BMI was 25.6 ± 4.51 kg/m2 and 52 (100%) patients reported bisphosphonate use. The mean follow-up was 21 months (range, 6-102). Thirty-nine (75%) were subtrochanteric and 13 (25%) were diaphyseal femur fractures. Overall, fracture union occurred in 49 AFFs (94%) at a mean of 6 months (range, 3-14). Three fractures (6%) progressed to nonunion. Notably, 7 AFFs were incompletely healed at 6 months, but 6 of 7 united by 12 months. Reduction quality was excellent in 98% of cases. Restoration of native NSA was significantly associated with union; nonunion cases demonstrated greater deviation from the contralateral NSA (p = 0.034). Implant-related variables (nail type, diameter, interlocking configuration) were not associated with union. Complications were limited to two cases of broken distal interlocking screws and one superficial surgical site infection.
CONCLUSIONS: Treatment of atypical femur fractures with solely closed reduction and reamed, statically locked intramedullary nailing provides reliable healing, with a 94% union rate.
PMID:41795353 | DOI:10.1016/j.injury.2026.113144












