Intramedullary nails are a well accepted method of fixing fractures of the femur, however there are several potential complications associated with femoral nail insertion. One under-reported complication is perforation of the anterior cortex of the distal femur. Cortical perforation is well documented in immature bone however there is little evidence of perforation in skeletally mature adults.

We present a 5 year retrospective clinical audit into correct positioning of the TriGen™ intramedullary nail system (Smith & Nephew Inc.), with respect to determining the anterior cortex perforation rate. Cases were identified using searches of the electronic operation notes, followed by manual cross checking of the reference numbers of the implants used. The radiographs for each case were then checked to identify cases of distal anterior cortex perforation. 138 femoral nails were inserted over the 5 years 2005–2010 at our institution. 79 cases met the inclusion criteria, of which 8 were deemed to show radiological evidence of cortical perforation on lateral view, this represents a perforation rate of 10.1% in this population. There was also a significant difference in the mean age of the perforated vs non-perforated groups (80.1 vs 62.1 yrs respectively). These results are at odds with the current literature which reports few or no cases of cortical perforation. As a result of this audit we have made various recommendations for future practice. This study highlights a need for larger scale randomised trials to be carried out in the future.