Impact of Post Operative Tip Apex Distance, Cortical reduction, lateral wall integrity on radiological outcome in unstable trochanteric fractures managed by cephallomedullary nail in elderly

Background: The global elderly population is steadily increasing, and among the fractures commonly observed in this age group, trochanteric hip fractures are particularly prevalent. Over time, various implant designs have been developed to manage these fractures, with the proximal femoral nail (PFN) emerging as the preferred choice for treating unstable trochanteric fractures due to its biomechanical advantages. However, despite its benefits, the application of PFN is not without challenges. Complications such as screw cut-out, Z-effect, reverse Z-effect, and suboptimal functional outcomes have been reported in some cases. This study aims to evaluate the individual and combined effects of key factors—tip-apex distance (TAD), lateral wall integrity, and the type of cortical reduction observed in immediate postoperative images—on the final radiological outcomes in elderly patients with unstable intertrochanteric fractures managed using PFN. Methods: This study is a retrospective observational study conducted in our institution from June 2021 to December 2023. After fulfilling the inclusion & exclusion criteria of our study, we had 100 patients; 35 males & 65 females with mean age of about 71 years with unstable intertrochanteric fractures managed with proximal femoral nail. All patients were followed for at least a minimum period of 6 months. Regular Antero posterior and lateral view X rays of the operated femur were taken when patient came for follow up and were analysed for signs of radiological union and any mechanical failure. Results: Patients with all 3 parameters in acceptable range (i.e.TAD < 25mm, positive cortical reduction in anteroposterior & lateral views and maintained/restored integrity of the lateral cortical wall showed comparatively better radiological outcome with fracture union & less number of mechanical failures. Conclusions: We would like to conclude from this study that intertrochanteric fractures fixed using proximal femoral nail with positive cortical support, maintained or restored functional integrity of lateral wall & TAD <25 in the immediate postoperative radiographs had better radiological outcome & lesser incidence of mechanical failure compared to cases where one or more of these criteria were not met intraoperatively.