Peri-Implant Femoral Fractures Around Intramedullary Nails: A Multicenter Case Series

Background: Peri-implant fractures following intramedullary nailing of femoral fractures are an increasing concern in elderly orthopedic trauma patients. These fractures pose significant clinical challenges due to altered load transmission in osteoporotic bone, comorbidities and complex fracture patterns. Optimal management remains unclear and secondary prevention strategies such as osteoporosis treatment are underutilized. Materials and Methods: This retrospective multicenter study analyzed 11 patients who sustained peri-implant fractures after intramedullary femoral nailing between 2015 and 2022. Data collected included demographics, comorbidities, fracture characteristics, implant details, postoperative rehabilitation protocols, complications and functional outcomes measured by WOMAC and SF-12 scores. Results: The mean patient age was 85 years, with fractures most frequently occurring at the distal and proximal nail tips. Cardiovascular comorbidities were prevalent, with an mean Charlson Comorbidity Index of 4.27. Nearly half the fractures followed low-energy trauma such as falls. Complications affected 45.5% of patients and included infections, myocardial infarction, periprosthetic fracture and one death. Among available postoperative assessments, the mean WOMAC score was 49.0 (n = 10), and the mean SF-12 physical component score was 25.0 (n = 11). Functional outcomes were generally poor and only one patient was on anti-osteoporotic therapy. The small cohort does not allow reliable identification of implant-related risk factors. Conclusions: A personalized treatment framework integrating fracture morphology, implant stability, bone stock, comorbidity burden, joint status, and rehabilitation potential is clinically relevant, although this descriptive series cannot validate a decision algorithm. Peri-implant fractures in elderly, comorbid patients represent a complex clinical problem with high complication rates and poor functional recovery. The low rate of osteoporosis treatment highlights an important area for improvement. Management should be tailored to fracture morphology, existing fixation, bone stock, associated joint disease, and patient frailty. Larger prospective studies are needed to establish standardized treatment protocols and improve patient outcomes.