{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T15:07:19Z","timestamp":1788793639734,"version":"build-2803163510"},"reference-count":43,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2025,6,4]],"date-time":"2025-06-04T00:00:00Z","timestamp":1748995200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Toggling of the short cephalomedullary nail is an understudied phenomenon characterized by a change in the longitudinal axis of the nail in relation to the longitudinal axis of the femoral medullary canal, with subsequent potential loss of reduction. This retrospective study aims to examine the incidence and impact of toggling of short cephalomedullary nails in cases with wide femoral canals. Methods: One thousand two hundred fifty-six (1256) cases that received short proximal femoral nails for intertrochanteric fractures were reviewed. Of them, 101 cases that had wide femoral canals (\u226515 mm) and a minimum radiographic follow-up of 6 weeks were included in this study. Outcome measures included nail toggling, varus malunion and revision surgery. Results: After a mean radiographic follow-up of 53.5 weeks, sixteen cases (15.8%) showed significant nail toggling of more than 4 degrees and had subsequent varus displacement of the fracture. In all 16 cases, there was deficient proximal nail fixation, in the form of either a lag device not engaging the lateral wall (2 cases), lateral proximal femoral wall fracture\/incompetency (7 cases), or a combination of the two factors (7 cases). Despite this, all sixteen cases achieved fracture union. Five additional cases had complications related to poor initial reduction (four cases) or femoral head avascular necrosis (one case). The other 80 cases had minimal (0\u20134 degrees) nail toggling and healed without varus malunion, and none of them required revision surgery. Conclusions: Short cephalomedullary nails may toggle in patients with wide femoral canals. The effect of femoral canal width on nail movement and subsequent varus malunion may be abolished when the lag device engages the lateral proximal femoral cortex, and the lateral cortical bone is intact. In patients with wide femoral medullary canals or cases with proximal lateral femoral cortical fracture, the utilization of long or intermediate length cephalomedullary nails may be a more viable option.<\/jats:p>","DOI":"10.3390\/jcm14113961","type":"journal-article","created":{"date-parts":[[2025,6,4]],"date-time":"2025-06-04T08:51:04Z","timestamp":1749027064000},"page":"3961","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Incidence, Impact, and Complications of Short Cephalomedullary Nail Toggling in Patients with Wide Femoral Medullary Canal"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5869-133X","authenticated-orcid":false,"given":"Ahmed Nageeb","family":"Mahmoud","sequence":"first","affiliation":[{"name":"Geisinger Medical Center, Danville, PA 17821, USA"},{"name":"Faculty of Medicine, Ain Shams University, Cairo 11455, Egypt"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria F.","family":"Echeverry-Martinez","sequence":"additional","affiliation":[{"name":"Geisinger Medical Center, Danville, PA 17821, USA"},{"name":"School of Medicine and Health Sciences, University of Rosario, Bogot\u00e1 111221, Colombia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-2047-4460","authenticated-orcid":false,"given":"Catherine Mary","family":"Doyle","sequence":"additional","affiliation":[{"name":"Geisinger Medical Center, Danville, PA 17821, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7627-3668","authenticated-orcid":false,"given":"Juan David","family":"Bernate","sequence":"additional","affiliation":[{"name":"Geisinger Medical Center, Danville, PA 17821, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Suk","sequence":"additional","affiliation":[{"name":"Geisinger Medical Center, Danville, PA 17821, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel Scott","family":"Horwitz","sequence":"additional","affiliation":[{"name":"Geisinger Medical Center, Danville, PA 17821, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1097\/BOT.0000000000001063","article-title":"Fracture and Dislocation Classification Compendium\u20142018","volume":"32","author":"Meinberg","year":"2018","journal-title":"J. Orthop. Trauma"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"270","DOI":"10.5301\/hipint.5000216","article-title":"Trends in the management of intertrochanteric femur fractures in the United States 2005\u20132011","volume":"25","author":"Werner","year":"2015","journal-title":"Hip Int."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e50","DOI":"10.5435\/JAAOS-D-15-00325","article-title":"Nail length in the management of intertrochanteric fracture of the femur","volume":"24","author":"Horwitz","year":"2016","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_4","first-page":"CD000093","article-title":"Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults","volume":"1","author":"Lewis","year":"2022","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1186\/s13018-022-03189-z","article-title":"Comparative effectiveness research on proximal femoral nail versus dynamic hip screw in patients with trochanteric fractures: A systematic review and meta-analysis of randomized trials","volume":"17","author":"Xu","year":"2022","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1016\/j.injury.2012.12.010","article-title":"Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures: A study of 2716 patients in the Norwegian Hip Fracture Register","volume":"44","author":"Matre","year":"2013","journal-title":"Injury"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e779","DOI":"10.5435\/JAAOS-D-21-00657","article-title":"Comparison of extramedullary and intramedullary implants for stable intertrochanteric fractures: Have we swung the pendulum too far the other way?","volume":"30","author":"Darbandi","year":"2022","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_8","first-page":"142","article-title":"Unstable trochanteric femoral fractures: Extramedullary or intramedullary fixation","volume":"35","author":"Schipper","year":"2004","journal-title":"Rev. Lit. Inj."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e17010","DOI":"10.1097\/MD.0000000000017010","article-title":"A meta-analysis comparing intramedullary with extramedullary fixations for unstable femoral intertrochanteric fractures","volume":"98","author":"Sun","year":"2019","journal-title":"Medicine"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2768","DOI":"10.1007\/s11999-013-2948-0","article-title":"Which implant is better for treating reverse obliquity fractures of the proximal femur: A standard or long nail?","volume":"471","author":"Okcu","year":"2013","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"111420","DOI":"10.1016\/j.injury.2024.111420","article-title":"Comparing short vs. intermediate and long nails in elderly patients with unstable multifragmental femoral trochanteric fractures (AO type A2): Multicenter (TRON group) retrospective study","volume":"55","author":"Tsugeno","year":"2024","journal-title":"Injury"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"661","DOI":"10.1016\/j.injury.2022.11.037","article-title":"Complications of standard versus long cephalomedullary nails in the treatment of unstable extracapsular proximal femoral fractures: A randomized controlled trial","volume":"54","author":"Pellejero","year":"2023","journal-title":"Injury"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1097\/BOT.0000000000000036","article-title":"Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years","volume":"28","author":"Kleweno","year":"2014","journal-title":"J. Orthop. Trauma"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1097\/BOT.0000000000000521","article-title":"Costs and complications of short versus long cephalomedullary nailing of OTA 31-A2 proximal femur fractures in U.S. veterans","volume":"30","author":"Krigbaum","year":"2016","journal-title":"J. Orthop. Trauma"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"83","DOI":"10.3928\/01477447-20161116-01","article-title":"Short versus long cephalomedullary nails for pertrochanteric hip fracture","volume":"40","author":"Frisch","year":"2017","journal-title":"Orthopedics"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.ocl.2019.11.011","article-title":"Intertrochanteric femur fracture treatment in Asia: What we know and what the world can learn","volume":"51","author":"Chang","year":"2020","journal-title":"Orthop. Clin. N. Am."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e185","DOI":"10.1097\/OI9.0000000000000185","article-title":"Short cephalomedullary nail toggle: A closer examination","volume":"5","author":"George","year":"2022","journal-title":"OTA Int."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1016\/8756-3282(93)90146-2","article-title":"Structural and cellular assessment of bone quality of proximal femur","volume":"14","author":"Dorr","year":"1993","journal-title":"Bone"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"3204","DOI":"10.1016\/j.arth.2020.05.066","article-title":"The relationship between canal diameter and the Dorr classification","volume":"35","author":"Karayiannis","year":"2020","journal-title":"J. Arthroplast."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.2106\/00004623-199507000-00012","article-title":"The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip","volume":"77","author":"Baumgaertner","year":"1995","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1097\/BOT.0000000000001096","article-title":"Does the angle of the nail matter for pertrochanteric fracture reduction? Matching nail angle and native neck shaft angle","volume":"32","author":"Parry","year":"2018","journal-title":"J. Orthop. Trauma"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1016\/j.clinbiomech.2019.11.006","article-title":"The early failure of the gamma nail and the dynamic hip screw in femurs with a wide medullary canal. A biomechanical study of intertrochanteric fractures","volume":"71","author":"Ceynowa","year":"2020","journal-title":"Clin. Biomech."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"414","DOI":"10.1016\/j.injury.2021.02.007","article-title":"Distal locking of short cephalomedullary nails decreases varus collapse in unstable intertrochanteric fractures\u2014A biomechanical analysis","volume":"52","author":"Tisherman","year":"2021","journal-title":"Injury"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1016\/j.jcot.2014.06.001","article-title":"Is distal locking of long nails for intertrochanteric fractures necessary? A clinical study","volume":"5","author":"Vopat","year":"2014","journal-title":"J. Clin. Orthop. Trauma"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1302\/0301-620X.95B6.31018","article-title":"Inadequate \u2018three-point\u2019 proximal fixation predicts failure of the Gamma nail","volume":"95-B","author":"Abram","year":"2013","journal-title":"Bone Jt. J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1097\/BOT.0000000000000165","article-title":"A biomechanical comparison of locked and unlocked long cephalomedullary nails in a stable intertrochanteric fracture model","volume":"28","author":"Kane","year":"2014","journal-title":"J. Orthop. Trauma"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e23.00118","DOI":"10.2106\/JBJS.OA.23.00118","article-title":"A Lateral Fracture Line Affects Femoral Trochanteric Fracture Instability and Swing Motion of the Intramedullary Nail: A Biomechanical Study","volume":"9","author":"Usami","year":"2024","journal-title":"JBJS Open Access"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Horwitz, D.S., Mahmoud, A.N., and Suk, M. (2025). Intermediate Length Cephalomedullary Nails in Proximal Femoral Fractures: Review of Indications and Outcomes. J. Am. Acad. Orthop. Surg.","DOI":"10.5435\/JAAOS-D-24-01018"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"70","DOI":"10.25259\/JMSR_382_2024","article-title":"Low trochanteric fractures in the presence of knee arthroplasty: The role of intermediate length cephalomedullary nail","volume":"9","author":"Mahmoud","year":"2025","journal-title":"J. Musculoskelet. Surg. Res."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2151459320936444","DOI":"10.1177\/2151459320936444","article-title":"Clinical outcome of mid-length proximal femoral nail for patients with trochanteric hip fractures: Preliminary investigation in a Japanese cohort of patients more than 70 years old","volume":"11","author":"Matsumura","year":"2020","journal-title":"Geriatr. Orthop. Surg. Rehabil."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/S0976-5662(11)60021-0","article-title":"Results of proximal femoral nail in intertrochanteric fractures of the hip with compromised lateral femoral wall: A clinical outcome study","volume":"1","author":"Kochar","year":"2010","journal-title":"J. Clin. Orthop. Trauma"},{"key":"ref_32","first-page":"e21.00322","article-title":"Comparison of short, intermediate, and long cephalomedullary nail length outcomes in elderly intertrochanteric femur fractures","volume":"6","author":"Womble","year":"2022","journal-title":"J. Am. Acad. Orthop. Surg. Glob. Res. Rev."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"706","DOI":"10.1007\/s00402-006-0117-6","article-title":"First results with the trochanter fixation nail (TFN): A report on 120 cases","volume":"126","author":"Lenich","year":"2006","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1097\/BOT.0000000000000652","article-title":"Controversies in intramedullary fixation for intertrochanteric hip fractures","volume":"30","author":"Baldwin","year":"2016","journal-title":"J. Orthop. Trauma"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"19.229","DOI":"10.7812\/TPP\/19.229","article-title":"Treatment of intertrochanteric femur fractures with long versus short cephalomedullary nails","volume":"24","author":"Sadeghi","year":"2020","journal-title":"Perm. J."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"85","DOI":"10.11622\/smedj.2016048","article-title":"The long and short of cephalomedullary nails in the treatment of osteoporotic pertrochanteric fracture","volume":"58","author":"Hong","year":"2017","journal-title":"Singapore Med. J."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1016\/j.injury.2021.11.064","article-title":"Biomechanical performance of short and long cephalomedullary nail constructs for stabilizing different levels of subtrochanteric fracture","volume":"53","author":"Chantarapanich","year":"2022","journal-title":"Injury"},{"key":"ref_38","first-page":"2217","article-title":"Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma","volume":"87","author":"Robinson","year":"2005","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1165","DOI":"10.1007\/s43465-023-00915-5","article-title":"Comparison of outcomes of long versus short cephalomedullary nails for the fixation of intertrochanteric femur fractures: A systematic review and meta-analysis of 14,547 patients","volume":"57","author":"Rajnish","year":"2023","journal-title":"Indian J. Orthop."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"926","DOI":"10.1016\/j.injury.2020.10.059","article-title":"Intertrochanteric fracture with distal extension: When is the short proximal femoral nail antirotation too short?","volume":"52","author":"Lee","year":"2021","journal-title":"Injury"},{"key":"ref_41","first-page":"e61363","article-title":"Factors Associated with Failure of Synthesis in the Treatment of Proximal Femur Fractures with Cephalomedullary Nails","volume":"16","author":"Longo","year":"2024","journal-title":"Cureus"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1186\/s13018-022-02921-z","article-title":"Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: A case control study","volume":"17","author":"Song","year":"2022","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1186\/s12891-023-06213-3","article-title":"Insufficient proximal medullary filling of cephalomedullary nails in intertrochanteric femur fractures predicts excessive postoperative sliding: A case-control study","volume":"24","author":"Li","year":"2023","journal-title":"BMC Musculoskelet. Disord."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/11\/3961\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:46:26Z","timestamp":1760031986000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/11\/3961"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,4]]},"references-count":43,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["jcm14113961"],"URL":"https:\/\/doi.org\/10.3390\/jcm14113961","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,4]]}}}