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1. Letter to the Editor
Letter to the editor concerning “The learning
curve with a new cephalomedullary femoral
nail”
Dear Editor,
We read the article by Fine et al., entitled “The learning curve
with a new cephalomedullary femoral nail” with great interest [1].
We congratulate the authors on highlighting the factors that affect
implant failure after treatment of femoral fractures with cepha-
lomedullary nailing. Nevertheless, we would like to draw attention
to some points related to factors which could affect the learning
curve for the application of these new cephalomedullary nails
(CMN).
In a biomechanical study it was reported that encircling with an
additional cerclage cable provided significant posteromedial sup-
port and could reduce the risk of osteosynthesis failure in complex
fractures[2]. Ban etal.[3] appliedcerclage cableadditionalto nailing
in 35 reverse fractures and reported that mobilisation was
accelerated and reduction quality was increased in 75% of the
patients. In several studies in literature, the application of cerclage
wire around CMN as support has been reported to give better
functional results in trochanteric region fractures [3–5]. Therefore,
the contribution to the learning curve of open surgery or the use of
cable in these patients cannot be ignored.
Early weight-bearing after CMN in femoral fractures which
could change the loading on the implant increases the risk of
mechanical failure. This risk can be reduced with the application of
the mobilisation protocol according to fracture type, reduction
stability and bone quality[6]. Therefore, the authors should have
stated the physical therapy protocol applied and the follow-up
intervals of the patients. If static locking is applied in cases with
delayed union in follow-up, it would be useful to state whether
dynamisation was planned or not. Moreover, in cases of early
weight-bearing, it is important to provide weight transfer with
aligned bone fragments to protect the reduction and reduce
complication rates.
Although the authors included patients applied with nailing as
prophylactic implants for imminent pathological fractures togeth-
er with patients with pathological fractures, these patient rates
were not given [6]. Separate evaluation of these patients as a
homogenous patient group is important and the contribution to
the learning curve could be more strongly evaluated.
In Table 1, it is stated that 3 patients in Group A and 19 in Group
B were using biphosphonate at the time of hospital admission,
whereas in paragraph 6 of the Results section it is written that 28
patients were using biphosphonate preoperatively. Providing some
correlation between these results is important to eliminate the
confusion. At the same time, it is recommended that the use of the
medication is stopped because of delayed union or non-union after
nailing treatment caused by biphosphonate use seen in patients
with atypical fractures associated with the long-term use of
biphosphonate [7].
Atypical femoral fractures are often seen associated with long-
term biphosphonate use [8], particularly AO 32-A1 and 31-A2
fracture types [9]. As there were 19 patients with this type of
fracture in the study, it would be useful to have an explanation of
how many of these were diagnosed as atypical fracture related to
long-term biphosphonate. In a series of 48 patients with atypical
subtrochanteric femur fracture, Cho et al. [10] reported that
delayed union and non-union developed in 13 (27%) patients. We
firmly believe that the complication of nail breakage as a result of
biphosphonate-related delayed union affected the study results.
In the Results section, the authors have stated that 107 patients
started biphophonate treatment after evaluation in the postoper-
ative period. If this evaluation was made by measuring bone
mineral density, the results of a comparison of the T-scores of
Group A and Group B patients would be more important in terms of
evaluation of the results. If there was any cut-out complication in
the patients treated with the consideration that they were
osteoporotic, that could make a significant contribution to the
learning curve. That the choice of short or long nails was at the
surgeon’s discretion could have been stated as a limitation. We
would like to know the authors view on the various queries we
have had after reading their article.
Conflict of interest
None.
References
[1] Fine NF, Sexton SA, Williams DH. The learning curve with a new
cephalomedullary femoral nail. Injury 2017;48(7):1575–8.
[2] Muller T, Topp T, Kühne CA, Gebhart G, Ruchholtz S, Zettl R. The benefit of wire
cerclage stabilisation of the medial hinge in intramedullary nailing for the
treatment of subtrochanteric femoral fractures: a biomechanical study. Int
Orthop 2011;35(8):1237–43.
[3] Ban I, Birkelund L, Palm H, Brix M, Troelsen A. Circumferential wires as a
supplement to intramedullary nailing in unstable trochanteric hip fractures: 4
reoperations in 60 patients followed for 1 year. Acta Orthop 2012;83(3):240–3.
[4] Hoskins W, Bingham R, Joseph S, Liew D, Love D, Bucknill A, et al.
Subtrochanteric fracture: the effect of cerclage wire on fracture reduction
and outcome. Injury 2015;46(10):1992–5.
https://doi.org/10.1016/j.injury.2017.10.017
0020-1383/© 2017 Elsevier Ltd. All rights reserved.
Injury, Int. J. Care Injured xxx (2017) xxx–xxx
G Model
JINJ 7450 No. of Pages 2
Please cite this article in press as: A. Imerci, N.H. Aydogan, Letter to the editor concerning “The learning curve with a new cephalomedullary
femoral nail”, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.017
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury

2. [5] Tomás J, Teixidor J, Batalla L, Pacha D, Cortina J. Subtrochanteric fractures:
treatment with cerclage wire and long intramedullary nail. J Orthop Trauma
2013;27(7):e157–60.
[6] Tosounidis TH, Castillo R, Kanakaris NK, Giannoudis PV. Common
complications in hip fracture surgery: Tips/tricks and solutions to avoid
them. Injury 2015;46(Suppl. 5):S3–11.
[7] Bogdan Y, Tornetta 3rd P, Einhorn TA, Guy P, Leveille L, Robinson J, et al. Healing
time and complications in operatively treated atypical femur fractures
associated with bisphosphonate use: a multicenter retrospective cohort. J
Orthop Trauma 2016;30(4):177–81.
[8] Lee KJ, Yoo JJ, Oh KJ, Yoo JH, Rhyu KH, Nam KW, et al. Surgical outcome of
intramedullary nailing in patients with complete atypical femoral fracture: a
multicenter retrospective study. Injury 2017;48(April (4)):941–5.
[9] Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA, Brown TD, et al. Atypical
subtrochanteric and diaphyseal femoral fractures: report of a task force of the
American Society for Bone and Mineral Research. J Bone Miner Res 2010;25
(11):2267–94.
[10] Cho JW, Oh CW, Leung F, Park KC, Wong MK, Kwek E, et al. Healing of atypical
subtrochanteric femur fractures after cephalomedullary nailing: which factors
predict union? J Orthop Trauma 2017;31(3):138–45.
Ahmet Imerci*
Nevres Hurriyet Aydogan
Mugla Sitki Kocman University, Faculty of Medicine, Department of
Orthopaedics and Traumatology, Mugla, Turkey
* Corresponding author at: Karamehmet Mah, 19 sokak No: 10 A
blok daire: 9 Mentese/Mugla, Turkey.
E-mail addresses: ahmetimerci@hotmail.com (A. Imerci),
nevreshaydogan@gmail.com (N. Aydogan).
Received 10 September 2017
2 Letter to the Editor / Injury, Int. J. Care Injured xxx (2017) xxx–xxx
G Model
JINJ 7450 No. of Pages 2
Please cite this article in press as: A. Imerci, N.H. Aydogan, Letter to the editor concerning “The learning curve with a new cephalomedullary
femoral nail”, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.017