Impact of reduction quality during intramedullary nailing of intertrochanteric femur fractures on outcomes of elderly patients:imaging characteristics analysis

Chen Wenlong; Zeng Xianghong; Luo Jingsheng

doi:10.3969/j.issn.1009-4237.2025.04.005

Abstract：Objective To investigate the predictive value of postoperative 1-d imaging findings for different reduction quality on clinical outcomes in elderly patients with intertrochanteric fractures treated with proximal femo-ral nail anti-rotation(PFNA).Methods This retrospective analysis was performed on elderly patients with inter-trochteric fractures who received PFNA fixation in our hospital from Jan.2018 to Dec.2022.A total of 71 patients with neutral alignment of the medial cortex on anteroposterior X-ray films on the first day after surgery were screened and included in this study,with 30 males and 41 females aged 70-92(mean 76.8)years.Among them,there were 30 cases of falls,31 road traffic injuries,and 10 others.According to the postoperative 1-d 3D-CT images,the ana-tomic support between the anteromedial cortex of the head and neck bone fragments and the anteromedial cortex of the femoral shaft were evaluated and patients were classified into positive,neutral,and negative support groups.There were 12 cases in the positive support group,22 in the neutral support group,and 37 in the negative support group.Gender,age,ASA grade,comorbidities,preoperative time,operation time,and intraoperative blood loss were recorded.The neck-shaft angle,femoral neck length,nail-removal distance,weight-bearing time at postoperative 1 d and 3 months on X-ray films,as well as hip Harris score at 12 months after surgery were analyzed.Results Pa-tients were followed up for 12-15(mean 13.0)months.All patients achieved bone healing.No statistically signifi-cant differences were found in terms of age,sex,ASA grade,comorbidities,operation time,and intraoperative blood loss among the three groups.The neck-shaft angle and femoral neck length showed no obvious difference at postoper-ative 1 d,but they were significantly larger in the positive,and neutral support groups than in the negative support group at postoperative 3 months(neck-shaft angle:133.5°±2.4° and 129.9°±3.1° vs.120.1°±1.1°;femoral neck length:mm,45.5±2.8 and 43.8±1.9 vs.37.6±2.9;all P＜0.05),but comparison between the positive,and neutral support groups revealed no significant difference(both P＞0.05).Moreover,the negative support group was more easily to lose neck-shaft angle(10.3°±0.9° vs.1.7°±0.3° and 1.8°±0.5°)and femoral neck length(mm,6.9±0.5 vs.1.2±0.1 and 1.3±0.2)at 3 months,with much longer nail-removal distance(mm,8.2±0.6 vs.1.5±0.2 and 1.6±0.3)at 3 months,delayed off-bed weight-bearing activities(d,62.5±3.5 vs.42.5±3.1 and 46.5±3.4),and much lower postoperative 12-month hip Harris scores(70.5±3.5 vs.86.5±3.2 and 88.1±2.8)(all P＜0.05 com-pared with positive and neutral support groups).Differences between the positive and neutral support groups were insignificant for all the results(all P＞0.05).Conclusion Negative support of the anteromedial cortex after PFNA fixation of intertrochanteric fractures presents a high risk of neck-shaft angle and femoral neck length loss,whereas the positive and neutral support can provide mechanical stability for fracture healing.