"Kissing Nail Technique" for the exchange of intramedullary implants in adjacent peri-implant fractures

One third of the people aged 65 years and over fall every year, and 1-5% of these falls result in a fracture. For these people, history of fracture and surgery become a risk factor for recurrent falls. In osteoporotic patients, repeated fractures often require several osteosynthetic procedures within a short time frame. Despite the lack of biomechanical studies, clinical experience suggests that additional fractures adjacent to implants occur because of the difference in stiffness between the metallic implant and the osteoporotic bone. This requires customized fixation techniques to ensure stability. The technique was first performed in an 81-year old female patient presenting with a dislocated proximal femoral fracture at the tip of a previously implanted distal femoral nail (DFN), and non-union of the old fracture. For this technique, the DFN was advanced until it passed the proximal fracture, thereby reducing both fractures, while a lateral femoral nail (LFN), extra-long and 3 mm thicker than the DFN, was introduced and advanced distally. The LFN was implanted in a "kissing nail technique," meaning the tips of the two nails were touching each other, and all fracture fragments were held in functional reduction. The DFN was slowly pulled backwards and fragment stability was maintained, while both nails passed the distal non-union. The Kissing Nail Technique allows simple, safe and fast reduction of all instable fragments, precise and easy positioning of the proximal entry point by the retrograde guide wire, a minimally invasive procedure, and stable fixation of a periprosthetic fracture. We found this new customized procedure accommodating to the unique anatomical features of a single patient, that can be applied as a strategy especially for osteoporotic patients with periprosthetic fractures.