Intertrochanteric femur fractures represent a significant proportion of hip fractures, frequently occurring in elderly individuals with osteoporotic bone following low-energy trauma, as well as in younger adults following high-energy impacts [1, 2]. These fractures pose a major clinical challenge due to the high risks of morbidity, prolonged immobilization, and potential loss of independence [3].The primary clinical problem associated with intertrochanteric fractures is achieving stable surgical fixation that can withstand physiological loads, thereby allowing early mobilization while minimizing the risk of complications such as varus collapse, implant cut-out, and non-union. While extramedullary devices like the Dynamic Hip Screw (DHS) have historically been standard, intramedullary devices such as the Trochanteric Femoral Nail (TFN) have gained prominence [4]. Intramedullary nails offer a shorter lever arm and better load-sharing biomechanics, making them particularly advantageous for unstable fracture patterns [5, 6].The objective of this study was to evaluate the clinical outcomes, the time to bone union, and the longitudinal progression of radiographic stability—quantified via a customized Fixation Stability Score (FSS)—in patients with intertrochanteric femur fractures treated with a TFN.

Study Design and Setting This ambispective cross-sectional study was conducted at the Department of Orthopaedics, Sri Aurobindo Medical College and Postgraduate Institute, a tertiary care center located in Indore (M.P.), India. The study was carried out over a 18-month period. Ethical approval was obtained from the Institutional Ethics Committee, and written informed consent was procured from all participating patients or their legally acceptable representatives. Participants A total of 30 patients were enrolled in the study based on specific eligibility criteria. • Inclusion Criteria: Patients aged 18 years and above of either sex presenting with an intertrochanteric femur fracture who provided voluntary written informed consent. • Exclusion Criteria: Patients presenting more than three weeks post-injury, those with pathological fractures or subtrochanteric extension, and those refusing consent. Preoperative Evaluation Following admission, a comprehensive clinical assessment was conducted for all patients. Standard preoperative anteroposterior (AP) radiographs of the pelvis with both hips, along with lateral views of the affected hip, were obtained. Fractures were classified utilizing the Evans [7] and Kyle’s [8] classification systems. Standard pre-anesthesia assessments were completed to determine surgical fitness. Surgical Technique All procedures were performed using a Trochanteric Femoral Nail (TFN) following standard AO/ASIF protocols. The TFN utilized was 180 mm in length with a diameter of either 10 mm or 11 mm. Depending on the patient's anatomy, a 130° or 135° angled nail was selected, accompanied by a 6 mm de-rotation screw and an 8 mm compression screw.Patients were positioned supine on a radiolucent fracture table, and closed reduction was achieved under continuous fluoroscopic guidance (image intensifier). Following the administration of appropriate anesthesia, a 3 cm lateral incision was made approximately 2 cm proximal to the greater trochanter. The entry point was established at the tip of the greater trochanter (2 mm medial to the tip in the AP view and centrally in the lateral view). In cases of severe comminution, the entry was made directly at the fracture site.The medullary canal was opened with an awl, and a guide wire was advanced into the femoral canal. After subsequent reaming (or unreamed insertion, based on canal size), the appropriate nail was seated. Guide wires for the proximal screws were passed into the femoral head and neck under fluoroscopic guidance. The de-rotation screw was fixed first, followed by the compression screw, which was advanced approximately 10 mm past the de-rotation screw tip into the subchondral bone. Finally, distal locking bolts were secured using a targeted zig technique. Postoperative radiographs were taken immediately to confirm reduction and implant position. Postoperative Protocol and Rehabilitation Intravenous antibiotics were administered for three days post-surgery, followed by a seven-day course of oral antibiotics. Sutures were removed on the 13th postoperative day. Rehabilitation commenced on postoperative day two with static quadriceps exercises, progressing to passive range of motion. Patients were initially mobilized with a walker utilizing touch-down weight-bearing, with strict instructions to avoid full weight-bearing on the affected limb for three months. Clinical and radiographic follow-ups were scheduled at 3, 6, 12, and 24 weeks. Clinical and Radiographic Evaluation Postoperative fixation stability was evaluated using a customized Fixation Stability Score System based on immediate postoperative AP and lateral radiographs. The system evaluates six primary parameters targeting anatomical reduction and stable fixation: 1. Bony contact/alignment of the posteromedial cortex in the trochanteric region. 2. Degree of angulation. 3. Presence and amount of distraction. 4. Tip-apex distance (TAD) [9]. 5. Accuracy of the intramedullary nail insertion point. 6. Placement of the lag screw tip in the femoral head (assessed via the Cleveland Index [10], which divides the head into nine zones). A maximum stability score of 7 denotes optimal radiographic alignment and fixation placement. Statistical Analysis Data were recorded using a standardized proforma and inputted into Microsoft Excel. Statistical analysis was performed using appropriate statistical software. Descriptive statistics were presented as frequencies, percentages, and numerical values. Within-group mean comparisons were analyzed using the Paired t-test. A p-value of < 0.05 was considered statistically significant.

The demographic profile of the cohort (n=30) demonstrated an average age of 60.60 ± 16.06 years, with the majority of patients (50%) falling into the 41-60 age group. There was a male predominance, comprising 60% of the study population (Table 1). Table 1: Demographic Profile of the Study Population Demographic Variable Number (n = 30) Percentage (%) Age Group (in years) 21-40 4 13.3 41-60 15 50.0 61-80 9 30.0 >80 2 6.7 Mean Age ± SD 60.60 ± 16.06 years Sex Male 18 60.0 Female 12 40.0 Right-sided involvement was more common (60%). Most patients presented and were managed promptly, with 80% treated within 2 to 3 days of injury. According to the Evans Classification, Type 1B fractures were the most prevalent, representing 53.3% of the cases (Table 2). Table 2: Baseline Clinical and Injury Characteristics Clinical Variable Number (n = 30) Percentage (%) Side Involved Right 18 60.0 Left 12 40.0 Time Interval from Injury 1 day 4 13.3 2 days 13 43.3 3 days 11 36.7 >3 days 2 6.7 Mean Time Interval ± SD 2.43 ± 1.00 days Evans Classification of Fracture Type 1A 1 3.3 Type 1B 16 53.3 Type 1C 11 36.7 Type 1D 2 6.7 Postoperative outcomes were highly favorable. Bone union was achieved in all cases with a mean time of 2.90 ± 0.61 months. The majority of patients (63.3%) achieved union at the 3-month mark. Complications were extremely low, with only one patient (3.3%) experiencing implant failure and one (3.3%) developing a superficial infection, leaving 93.3% of the cohort complication-free (Table 3). Table 3: Postoperative Clinical Outcomes and Complications Outcome Variable Number (n = 30) Percentage (%) Complications None 28 93.3 Implant failure 1 3.3 Superficial infection 1 3.3 Time Taken for Bone Union 2 months 7 23.3 3 months 19 63.3 4 months 4 13.3 Mean Time for Union ± SD 2.90 ± 0.61 months A progressive and statistically significant improvement in the Fixation Stability Score (FSS) was observed over the 6-month follow-up period. The mean FSS increased from 5.36 ± 0.61 at 3 weeks to 6.89 ± 0.31 at 6 months. Paired interval comparisons (3 vs. 6 weeks, 6 weeks vs. 3 months, and 3 vs. 6 months) all yielded highly significant p-values (Table 4), indicating steady bony consolidation and sustained implant stability over time. Table 4: Progression of Fixation Stability Score (FSS) Over Time Comparison Interval Number Mean FSS ± SD 't' value, df P-value 3 weeks vs. 6 weeks At 3 weeks 30 5.36 ± 0.61 -5.767, df=29 0.001* At 6 weeks 30 6.20 ± 0.66 6 weeks vs. 3 months At 6 weeks 29 6.24 ± 0.64 -4.770, df=28 0.001* At 3 months 29 6.69 ± 0.60 3 months vs. 6 months At 3 months 29 6.69 ± 0.60 -2.703, df=28 0.012* At 6 months 29 6.89 ± 0.31

The management of intertrochanteric fractures aims to restore mobility safely and rapidly while minimizing surgical and long-term complications. In our study, intramedullary fixation using the TFN yielded excellent clinical and radiological outcomes.The demographic distribution in our study revealed a mean age of 60.60 years with a male predominance. This differs slightly from standard Western epidemiological data, which often shows a strong female predominance due to postmenopausal osteoporosis, but it is highly consistent with epidemiological studies from the Indian subcontinent, such as those by Sharma et al. [11], which note a higher incidence of high-energy trauma among middle-aged males.Achieving reliable bone union is the ultimate metric of successful internal fixation. Our cohort demonstrated a mean time to union of 2.90 months. This is firmly in line with findings by Gadegone et al. [12], who reported fracture consolidation within 12 to 14 weeks utilizing proximal femoral nails. The excellent union rates can be attributed to the closed reduction technique, which preserves the fracture hematoma, and the biomechanically superior load-sharing design of intramedullary nails.Complication rates in our study were minimal (6.6% overall, comprising one implant failure and one superficial infection). Historically, extramedullary devices have been associated with higher rates of varus collapse and screw cut-out in unstable fractures. However, our findings closely match the 5-8% overall complication rate reported for intramedullary nails by Boldin et al. [13], reaffirming the safety profile of the TFN.The most notable finding of our study is the statistically significant, longitudinal progression of the Fixation Stability Score (FSS). By assessing parameters like the tip-apex distance (TAD) and medial cortical alignment, the FSS provides a robust quantifiable measure of structural integrity. The improvement in FSS from 5.36 at 3 weeks to nearly optimal levels (6.89) at 6 months validates the biomechanical superiority of the TFN. This aligns with the biomechanical analyses presented by Pajarinen et al. [14], which demonstrated that intramedullary devices effectively limit postoperative sliding and maintain the neck-shaft angle during the critical healing phases.

The Trochanteric Femoral Nail (TFN) is a highly effective, minimally invasive implant for the treatment of intertrochanteric femur fractures. It provides excellent anatomical reduction, stable longitudinal fixation, and predictable bone union (mean 2.9 months) with a remarkably low complication rate. The progressive improvement in objective fixation stability allows for confident, early patient rehabilitation, ultimately reducing the morbidity associated with prolonged bed rest.

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