Intertrochanteric fractures constitute a major orthopedic challenge worldwide and predominantly affect the elderly osteoporotic population. These fractures are associated with significant morbidity, mortality, and socioeconomic burden due to prolonged immobilization and functional dependency ^[1]. Early surgical fixation enabling stable reduction and mobilization remains the cornerstone of management. Cephalomedullary nailing has become the preferred treatment modality for intertrochanteric fractures due to its superior biomechanical properties, including improved load sharing, shorter lever arm, and reduced bending moment compared with extramedullary implants ^[2,3]. However, the role of medullary canal reaming during proximal femoral nailing (PFN) continues to be debated. Advocates of reaming emphasize that sequential canal preparation permits insertion of a larger diameter nail, thereby improving implant-canal congruence and enhancing axial as well as rotational stability ^[4]. Adequate canal filling ratio (CFR) reduces distal nail toggling and the “pendulum effect,” both of which are implicated in varus collapse and secondary loss of reduction ^[5]. Reaming may also contribute biologically by depositing autologous osteogenic debris at the fracture site, potentially enhancing fracture healing ^[6]. Despite these advantages, concerns regarding reaming in elderly osteoporotic patients persist due to the risks of increased intramedullary pressure, fat embolism, thermal necrosis, cortical perforation, prolonged operative time, and increased blood loss ^[7,8]. Consequently, short PFN is frequently performed without reaming in this age group due to the relatively wider medullary canal. Nevertheless, elderly patients often exhibit substantial femoral canal widening and increased anterior femoral bowing, factors that may compromise nail fit and predispose to mechanical instability. Literature evaluating the impact of controlled reaming on maintenance of reduction in intertrochanteric fractures remains limited, and most available evidence is extrapolated from femoral shaft fracture studies ^[9]. Despite widespread use of PFNs, limited evidence exists regarding the optimal CFR required to minimize post-operative reduction loss, particularly in osteoporotic elderly patients undergoing reamed short PFN. The present study was therefore undertaken to evaluate the radiological outcomes of reamed short PFN in patients aged 50 years and above with intertrochanteric fractures, with particular emphasis on maintenance of reduction and biomechanical factors associated with reduction loss.

Study design and setting: 

This prospective observational study was conducted in the Department of Orthopaedics at Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, from July 2024 to December 2025 after obtaining approval from the Institutional Ethics Committee (SGRD/IEC/2024–343).

Study population: 

Thirty patients aged 50 years and above presenting with intertrochanteric femur fractures classified according to the AO/OTA classification and treated with reamed short PFN were included in the study. Subgroup analysis according to AO/OTA fracture classification was not performed due to the limited sample size, although fracture morphology may influence post-operative stability.

Inclusion criteria: 

Age ≥50 years, intertrochanteric femur fractures, patients managed with reamed short PFN, and availability for follow-up.

Exclusion criteria: 

Pathological fractures, fractures with subtrochanteric extension requiring long nails, previous ipsilateral hip or femoral surgery, and abnormal contralateral hip anatomy. Written informed consent was obtained from all participants before enrolment.

Surgical technique: 

All procedures were performed on a radiolucent traction table by two senior orthopedic surgeons using a standardized operative technique. Therefore, the results may not be directly reproducible in centers with different levels of surgical expertise. Closed reduction was attempted initially in all cases. Mini-open or percutaneous reduction techniques were employed where satisfactory alignment could not be achieved by closed methods. Temporary fixation with Kirschner wires was performed outside the intended nail trajectory. A proximal incision of approximately 5 cm was made, and the entry point was established slightly medial to the tip of the greater trochanter under fluoroscopic guidance. Sequential flexible reaming of the medullary canal was then performed while maintaining fracture reduction. Definitive fixation was achieved using a short PFN with either a helical blade or lag screw.

Radiological assessment: 

Standardized calibrated anteroposterior (AP) pelvis radiographs with 15° internal rotation and lateral radiographs were obtained preoperatively, immediately postoperatively, and at 1 and 3 months’ follow-up. Radiological measurements were performed using Digimizer software version 5.7.0. The following parameters were assessed:

1. Femoral neck-shaft angle (NSA): Angle formed between the longitudinal axes of the femoral neck and shaft
2. Horizontal femoral offset: Perpendicular distance from the femoral shaft axis to the center of the femoral head
3. Cortical reduction quality: Classified as positive, neutral, or negative cortical support on AP radiographs
4. CFR: Ratio of nail diameter to intramedullary canal diameter measured at the diaphyseal level on both AP and lateral views
5. Anterior femoral bowing angle: Angle between the proximal femoral axis and the femoral shaft axis at the distal nail tip on lateral radiographs
6. Radiological union: Defined as bridging callus formation across at least three cortices on two orthogonal views, accompanied by painless full weight-bearing.

Loss of reduction was defined by the presence of any one of the following:

• ≥5° decrease in NSA
• ≥4 mm increase in horizontal femoral offset
• Deterioration in cortical reduction quality.

Functional outcome measures such as the Harris Hip Score, Oxford Hip Score, and quality-of-life assessments were not included, preventing direct correlation between radiological healing and patient function. Radiological measurements were based on standardized plain radiographs rather than computed tomography (CT) imaging. Although CT provides a more precise three-dimensional assessment, routine post-operative CT was not justified for these emergency trauma patients due to additional radiation exposure, cost, and limited clinical indication.

Statistical analysis: 

Statistical analysis was performed using IBM Statistical Package for the Social Sciences Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Quantitative variables were expressed as mean ± standard deviation, whereas categorical variables were presented as frequencies and percentages. A paired t-test was used for intragroup comparisons and an independent Student’s t-test for intergroup comparisons. A P < 0.05 was considered statistically significant.

The study included 30 patients, of whom 17 (56.7%) were aged ≥65 years and 17 (56.7%) were female. Two patients were lost to follow-up, leaving 28 patients available for final radiological assessment (Fig. 1).

Figure 1: Flow diagram of patient enrolment and follow-up.

Two patients were lost during follow-up, introducing the possibility of attrition bias despite the relatively small proportion of missing data. Radiological union at 3 months was achieved in 28 patients (93.3%). Stable reduction was maintained in 23 patients (82.1%), whereas 5 patients (17.9%) demonstrated significant loss of reduction characterized by varus collapse and increased femoral offset (Table 1).

Table 1: Patient demographics and overall radiological outcomes at 3 months

The mean femoral NSA decreased significantly from 130.04° ± 4.61° immediately postoperatively to 128.64° ± 4.79° at 3 months’ follow-up (P = 0.005). Horizontal femoral offset showed a statistically significant increase from 38.18 ± 6.07 mm to 38.96 ± 6.03 mm, P = 0.040 (Table 2).

Table 2: Radiological alignment and cortical reduction (immediate post operative versus 3 months)

Patients with loss of reduction exhibited significantly lower CFRs in both AP and lateral planes compared with those maintaining stable reduction. The mean AP CFR was 0.65 ± 0.04 in the loss-of-reduction group versus 0.82 ± 0.04 in the maintained-reduction group (P < 0.001). Similarly, lateral CFR was significantly lower in the loss group (0.55 ± 0.03 vs. 0.74 ± 0.05; P < 0.001). The mean anterior bowing angle was also significantly greater in patients with reduction loss (7.10° ± 0.60° vs. 3.80° ± 0.49°; P < 0.001). Despite these radiological differences, all evaluable patients achieved fracture union at final follow-up (Table 3). The CFR values identified in this study should be considered exploratory and require external validation in larger prospective studies before routine clinical application.

Table 3: Group stratification and associated biomechanical factors

Intertrochanteric fractures in elderly individuals continue to pose significant therapeutic challenges due to osteoporosis, widened femoral canals, and altered femoral anatomy ^[10]. Cephalomedullary nailing has emerged as the preferred fixation method because it permits stable fixation and early mobilization with favorable biomechanical characteristics ^[11]. The present study demonstrated a high radiological union rate of 93.3% at 3 months following reamed short PFN. Furthermore, stable reduction was maintained in more than 80% of patients, supporting the effectiveness of controlled reaming in achieving satisfactory implant stability. A major finding of the present study was the strong association between inadequate CFR and reduction loss. Patients demonstrating loss of reduction had significantly lower CFR values in both AP and lateral planes. Poor implant-canal congruence permits nail toggling within the widened osteoporotic femoral canal, thereby predisposing to progressive varus collapse and medialization ^[12]. Another important observation was the influence of anterior femoral bowing. Increased femoral curvature was significantly associated with reduction loss, likely due to a mismatch between the straight intramedullary implant and the bowed femoral canal. Similar findings have been reported by Xue et al., who highlighted the biomechanical consequences of implant-bone mismatch in Asian femoral morphology ^[13]. Although reaming has traditionally been avoided in elderly patients due to concerns regarding fat embolism, increased blood loss, and thermal necrosis, no major reaming-related complications were encountered in the present study ^[7,8]. Controlled and judicious reaming allowed insertion of a larger diameter nail and improved mechanical fixation without increasing perioperative morbidity. Despite mild radiological deterioration in a subset of patients, fracture union was achieved in all cases available for follow-up, suggesting that loss of reduction may primarily represent a mechanical issue rather than impaired biological healing. However, persistent alteration in the NSA and femoral offset may adversely affect long-term hip biomechanics and gait. This study has several limitations. Its single-center design, relatively small sample size, and short follow-up period may limit the generalizability of the findings and preclude assessment of long-term radiological and functional outcomes. As a prospective observational study without randomization or a control group, the possibility of selection bias cannot be excluded. Functional outcome measures, objective bone quality assessment, and detailed perioperative variables were not evaluated, while radiological assessment relied on plain radiographs without CT confirmation. In addition, subgroup analyses by fracture type were limited by sample size, and the standardized surgical technique performed by experienced surgeons may restrict the external applicability of the results. Larger multicenter studies with longer follow-up, comprehensive functional assessment, and advanced imaging are warranted to validate these findings.

Reamed short PFN provides satisfactory early radiological union and maintenance of reduction in elderly patients with intertrochanteric fractures. However, inadequate CFR, particularly in the lateral plane, and increased anterior femoral bowing were associated with post-operative reduction loss. Careful preoperative planning, assessment of femoral morphology, and optimization of implant-canal congruence are essential to minimize mechanical failure and preserve fracture alignment.

Adequate canal filling and assessment of femoral bowing are critical determinants of mechanical stability during short proximal femoral nailing in elderly intertrochanteric fractures. Controlled reaming may improve implant fit and reduce the risk of post-operative loss of reduction.