Unitized Nail-Plate Construct (NPC) for Atypical Femur Fracture Fixation: A Retrospective Study on Clinical Outcomes

Atypical femoral fractures (AFFs) are an uncommon yet serious complication associated with long-term bisphosphonate use for osteoporosis treatment. Despite their rising incidence, the optimal management strategy for AFFs is still a work in progress. Intramedullary nailing has traditionally been the preferred treatment; however, literature reports surprisingly high complication rates. This study evaluates the clinical outcomes of unitized nail-plate construct (NPC)-"Linking the nail with the plate with locking bolts through the plate and nail, proximal and distal to the fracture site"-as a primary fixation method for AFFs.

A retrospective review of 17 AFF cases was conducted from 2019 to 2023. After applying inclusion criteria defined by the 2013 American Society of Bone and Mineral Research (ASBMR) task force document, 14 AFFs (13 patients: 12 unilateral AFFs and 1 bilateral AFF) treated with unitized NPC were included in the study. Outcomes were assessed based on time to fracture union, independent mobilization, and return to activities of daily living (ADL).

The cohort consisted entirely of female patients with a mean age of 70.1 years (range: 56-84) and an average bisphosphonate therapy duration of 5.1 years (range: 1.5-11.5) prior to fracture. The group included 3 subtrochanteric and 11 diaphyseal fractures. The mean follow-up duration was 22 months (range: 14-58 months), with an average hospital stay of 7.2 days (range: 4-13 days) and a mean surgical time of 72 min (range 58-96 min). All 14 fractures healed without complications, with a mean time to union of 17.5 weeks (range: 12-23 weeks). There were no cases of non-union, implant failure, delayed union, or need for secondary procedures. The mean time to independent mobilization was 14 weeks (range: 9-23 weeks), and 12 patients were able to resume ADL independently by the 1-year follow-up.

While unitized NPC requires additional surgical time and expertise, its superior outcomes in AFFs suggest it may be a viable primary fixation strategy, especially in these notorious fractures where failure rates have been historically high.