Abstract
BACKGROUND: Peri-implant femoral fractures occurring around an intramedullary nail ("around the nail" fractures) represent a complex challenge in orthopedic trauma. These fractures have been increasingly reported over the last two decades, and studies from 2001 to 2025 were selected to capture contemporary surgical techniques and implant designs. Management remains controversial due to both mechanical issues (implant loosening, malposition, nail breakage, and fracture at stress risers) and systemic complications (infections, thromboembolic events, and medical comorbidities). MATERIALS AND METHODS: A systematic review was conducted following PRISMA guidelines. PubMed, Scopus, and Google Scholar were searched for studies published between 2001 and 2025. Inclusion criteria comprised studies on adult patients undergoing surgical treatment for peri-implant femoral fractures after anterograde nailing. Data on demographics, fracture patterns, implant characteristics, surgical strategies, and outcomes were extracted. Methodological quality was assessed using the MINORS score. RESULTS: The study included 315 patients with a mean age of 82.3 years, predominantly female (2:1 ratio). Most fractures were treated with anterograde intramedullary nails, mainly short nails. A total of 211 peri-implant fractures were analyzed, with the majority occurring around the nail (58.8%). Fractures were more common within 12 months post-surgery. Surgical treatment involved reinforcement with long nails or lateral plating. The union rate was 93.7%, with a mean healing time of 23.96 weeks. Complications included infections (19 cases), systemic issues, and mechanical problems (implant loosening, breakage, or malposition), leading to additional surgeries in some cases. Infection was linked to higher mortality rates (44.4% vs. 11.8%). CONCLUSION: There is no definitive consensus on the optimal surgical treatment of "around the nail" femoral fractures. Treatment choice is influenced by fracture location, implant stability, and patient comorbidities. Plating, nail revision, and prosthetic replacement each carry specific risks and benefits. The high complication and mortality rates, along with variability in outcomes, highlight the need for standardized classification systems and high-quality comparative studies to guide treatment in this challenging clinical scenario.