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Background Early postoperative mortality remains a major challenge in elderly patients with intertrochanteric hip fractures. Identifying simple and reliable preoperative biomarkers is essential for short-term risk stratification. The blood urea nitrogen-to-albumin ratio (BAR) integrates metabolic stress, renal perfusion, and nutritional status; however, its prognostic value in orthopedic trauma has not been fully clarified. Methods This retrospective cohort study included 514 patients aged ≥ 65 years who underwent surgical treatment for intertrochanteric femur fractures. Preoperative BAR and other inflammatory biomarkers—including CRP-to-albumin ratio (CAR), fibrinogen-to-albumin ratio (FAR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR)—were analyzed. Thirty-day mortality was evaluated using receiver operating characteristic (ROC) analysis and multivariable logistic regression. Results Thirty-day mortality occurred in 54 patients (10.5%). Non-survivors had significantly higher inflammatory and metabolic biomarker levels and lower albumin levels compared with survivors (all p  < 0.05). BAR demonstrated the highest discriminative ability for predicting 30-day mortality ( AUC = 0.82), with an optimal cut-off value of 9.0 (sensitivity 79%, specificity 72%). In multivariable analysis, BAR ≥ 9.0 remained the only independent predictor of mortality (adjusted OR 2.68; 95% CI 1.34–5.34; p  = 0.006). Conclusions Preoperative BAR is an independent biomarker for predicting early mortality in elderly patients with intertrochanteric hip fractures. Its simplicity and routine clinical availability support its potential use in preoperative risk stratification. Prospective multicenter studies are needed to confirm these findings.

Background This study aimed to evaluate the association between AO/OTA subclassification and treatment selection in intertrochanteric femur fractures and to determine how closely real-world clinical decisions align with classification-based recommendations. Methods A retrospective analysis was performed on 474 patients treated for intertrochanteric femur fractures between 2015 and 2020. Fractures were subclassified according to AO/OTA 31-A classification using standard radiographs. Chi-square tests with Cramer’s V were used to assess the relationship between fracture groups and treatment modalities. Multinomial logistic regression evaluated predictors of treatment choice, while guideline adherence was analyzed using binary logistic regression. A p value < 0.05 was considered statistically significant. Results PFN was the most frequently applied treatment (74.1%), followed by conservative management (13.5%) and DHS (5.7%). Treatment distribution differed significantly among AO/OTA groups (χ 2 = 40.408, p  < 0.001; Cramer’s V = 0.206). AO/OTA group independently predicted treatment selection ( p  = 0.002), whereas age ( p  = 0.179) and sex ( p  = 0.579) did not independently predict treatment selection. The regression model explained 8–10% of treatment variance (Nagelkerke R 2 = 0.097). Guideline adherence was 79.3%, with no independent predictors of non-adherence. Additionally, the 95% confidence intervals for regression coefficients crossed 1 for all variables (age: 0.947–1.016; sex: 0.570–1.483; AO group: 0.592–1.199), confirming that none independently predicted adherence. Conservative treatment was relatively frequent due to the cohort’s advanced age and comorbidity burden. Revision surgery occurred in 3.8% of cases. Conclusions Although AO/OTA subclassification significantly influences treatment choice, fracture morphology alone is insufficient for determining management. PFN remains preferred across fracture types, while non-operative care is suitable for high-risk patients. Future models should integrate frailty, bone quality, and functional status.

IntroductionWe aimed to investigate secondary fracture and mortality rates, and risk factors in patients with proximal femoral fractures.Materials and MethodsWe conducted a multicenter prospective cohort study on female patients with proximal femoral fractures who underwent surgical treatment between April 2020 and March 2021. Postoperative follow-ups were performed at 6-, 12-, 18-, and 24-month intervals to determine the secondary fracture and mortality rates, and the risk factors and its influence were examined.ResultsOf the 279 registered patients, 144 patients (51.6%) were diagnosed with very high fracture risk osteoporosis. The postoperative osteoporosis rate exceeded 96%; however, osteoanabolic agents were used sparingly. The risk factor of both secondary fracture and mortality was very high fracture risk osteoporosis, and secondary fractures within 12 months were markedly occurred. Secondary fracture rates increased as the number of matched very high fracture risk osteoporosis criteria increased. Notably, secondary fractures and mortality were recorded in 21.4% and 23.5% of the patients who met all criteria, respectively.ConclusionOver half of the female patients with proximal femoral fractures had very high fracture risk osteoporosis. Although, very high fracture risk osteoporosis demonstrated a notably increased risk of secondary fractures, particularly at 12 months post-surgery, the use of osteoanabolic agents was substantially low. Collectively, our findings highlight the need to consider the risk of very high fracture risk osteoporosis, expand the use of medications to include osteoanabolic agents, and reconsider the current healthcare approach for proximal femoral fractures.

Objectives The purpose of this study was to compare the surgical outcomes, perioperative and after-discharge structural and functional recovery of proximal femoral nail anti-rotation (PFNA) combined with and without cable cerclage for intertrochanteric femoral fractures with vulnerable lateral wall. Methods In this retrospective analysis, 80 patients of intertrochanteric femoral fractures with vulnerable lateral wall were divided into two groups according to internal fixation: 60 in the PFNA group (group P) and 20 in the PFNA combined with cable cerclage group (group PCC). Postoperative complications and functional outcomes were assessed. Results The mean follow-up was 23.34 ± 2.85 months in the P group versus 24.85 ± 3.42 ones in PCC group without statistical significance. The PCC group exhibited significantly longer surgical time, fluoroscopy time, shorter fracture union, partial weight-bearing time and less neck-shaft angle change than those in the P group (p value < 0.05). Harris Hip Score (HHS) at 3, 6 months was higher in the PCC group (p value < 0.001). However, no significant differences were observed between the two groups regarding blood loss, Visual Analogue Scale (VAS) score, tip-apex distance (TAD), HHS at 12, 18 months and full weight-bearing time (p value > 0.05). Furthermore, no significant differences were noted in postoperative complications. Conclusion The PFNA with and without cable cerclage both demonstrated similar and satisfactory functional outcomes and relatively-low complication rates in patients with vulnerable lateral wall in intertrochanteric femoral fractures. The PCC group was superior in accelerating bone union, minimizing hip deformity and promoting early rehabilitation.

Purpose This study was conducted to develop a finite element analysis (FEA) model for proximal femoral nail antirotation (PFNA) fixation for intertrochanteric femoral fractures, aiming to analyze the effects of varying proximal femur trabecular bone CT values on stress distribution and device stability, as well as to determine their relationships. Methods We established a three-dimensional model for PFNA fixation of intertrochanteric femoral fractures based on computed tomography images. Different elastic moduli were assigned to the trabecular bone according to varying proximal femur CT values, enabling an analysis of the differences in stress distribution and maximum displacement of the model under the same loading conditions. Results Under the same stress loading conditions, as the CT values of the proximal femoral trabecular bone decreased from 160 to 120, 80, 40, and 0 HU, the von Mises stress values around the trabecular bone decreased. Moreover, the stress values near the cortical bone, intramedullary nail, screw tip, and junction between the screws and the main nail increased. Additionally, the maximum displacement of the entire model also increased. This finding indicates that as the proximal femur CT values decreased, the load on the cortical bone and internal fixation increased, leading to greater instability of the model and a higher risk of internal fixation failure. Conclusion As the CT value of the proximal femoral trabecular bone decreases, the stability of the PFNA fixation device diminishes, leading to increased stress on both the cortical bone and the intramedullary nail, thereby increasing the risk of PFNA fixation failure.

Introduction Proximal femoral fractures are critically associated with increased risk of mortality and secondary fractures. Identifying prognosis predictors related to sagittal imbalance that are known to have negative impact on fracture risk and mortality is crucial. This study aimed to explore the relationship between various sagittal imbalance parameters and the prognosis of proximal femoral fractures to identify the most important prognostic indicators. Materials and methods This multi-center prospective cohort study included patients with proximal femoral fractures treated surgically from April 2020 to March 2021. Spinal standing radiographs were obtained to measure various sagittal spine parameters. Postoperative follow-ups were conducted at 6, 12, 18, 24, and 36 months to assess mortality and secondary fracture rates and examine the predictors and their effects. Results Among the 137 patients who underwent spinal standing radiographs, 22 died and 23 developed secondary fractures. Multivariate analyses identified the number of previous vertebral fractures and thoracolumbar kyphosis (TLK) as significant risk factors for mortality and secondary fractures. Survival analysis revealed that patients with TLK < 20° had significantly higher survival rates than those with TLK ≥ 20° ( P  = 0.002 and P  < 0.001 for mortality and secondary fractures, respectively). In addition, serum albumin was associated with mortality, and the intake of sleeping pills and antidepressants was associated with secondary fractures. Conclusion TLK after surgery and the number of previous vertebral fractures affected both mortality and secondary fractures. When each risk factor, such as low serum albumin levels, intake of sleeping pills and antidepressants, was also considered, it was found that comprehensive postoperative care is essential.

Introduction The primary aim of this study was to evaluate the clinical and radiological outcomes after surgical treatment of proximal femoral fractures utilizing the Proximal Femoral Nail Antirotation (PFNA), with the main focus on complications and reoperations. The secondary aim was to compare the outcomes of patients with and without cement augmentation of the cephalomedullary nails. Materials and methods All patients with an acute proximal femoral fracture consequently treated with a PFNA between January 2011 and Dezember  2018 were evaluated. Clinical and radiological data were assessed for intra- and postoperative complications, including treatment failure. In addition, intra- and postoperative radiographs were used to determine the position of the implant, and any migration, via Tip-Apex-Distance (TAD) and the caput-collum-diaphyseal angle (CCD). The accuracy of the fracture reduction was rated according to Baumgaertners criteria. Results Two hundred sixty-four consecutive patients (mean age 78.8 ± 12.0; 73.1% female) were included. The predominant OTA/AO fracture classification was 31A1 (153 cases, 58.0%). The average duration of surgery was 63.1 ± 28.0 min and showed no significant differences between PFNA and PFNA with augmentation. The implant positioning was rated as good in 222 cases (84.1%). Two hundred sixty-three patients (99.6%) showed evidence of healing within the time frame of three months postoperatively, one case of delayed union healed after secondary dynamization. During the observational period, 18 patients (6.8%) required a total of 23 additional surgeries. Overall, a lower reoperation rate was observed following the use of the augmentation option (2/86 patients (2.3%) vs. 16/178 patients (9.0%), p  = 0.04). In particular, there were no cases of cut-out or cut-through among patients who underwent augmentation as part of osteosynthesis. Conclusions Overall reoperation rate after surgical treatment of proximal femoral fractures utilizing the Proximal Femoral Nail Antirotation (PFNA) was 6.8%, with 23 additional surgeries performed in 18 patients. The usage of the PFNA with augmentation showed equally good implant positioning, excellent healing rates and fewer postoperative complications compared to the PFNA implant alone with a similar overall duration of surgery.

Background To investigate the reliability and threshold of five-factor modified frailty index (mFi-5) for predicting postoperative mortality in patients aged 80 years and older with intertrochanteric fractures (ITF). Methods This retrospective study included advanced-age ITF patients who underwent surgery between January 2016 and January 2020 at a single center, and the eligible patients were sequentially divided into six groups according to mFi-5 scores. The mortalities in in-hospital, 3-months and 1-year after surgery were defined as observed outcomes. Baseline characteristics, including age, gender, time to surgery, surgery time, length of hospital, anesthesia, anemia and hypoproteinemia at admission, were collected for logistic regression analysis. Then, Receiver-Operating Characteristic (ROC) was used to assess reliability, and decision curve analysis (DCA) was used to evaluate the clinical benefit of the mFi-5. Results 263 patients were included in the final analysis. The in-hospital, 3-month and 1-year all-cause mortalities of all patients were 4.2% (11/263), 14.1% (37/263) and 24.7% (65/263). Overall, the mortalities increased with mFi-5 score. There were no significant between-group differences of baseline characteristics between the groups. Multivariate regression analysis indicated only gender was an independent factor for in-hospital morality, gender, anemia and high mFi-score for 3-month mortality, and age, gender, anemia and high mFi-score for 1-year mortality. The ROC analysis shown that the areas under the curve of mFi-5 for predicting in-hospital, 3-month and 1-year morality were 0.862, 0.773 and 0.756, respectively P  < 0.01). DCA demonstrated that using an mFi-5 threshold of ≥ 3 provided a higher net benefit. Conclusions In conclusion, mFi-5 is a reliable prognostic predictor in the advanced-age ITF patients following surgery. Also, high risk of mortality is associated with a mFi-5 score no less than “three” especially in the much older male patient with anemia.

Purpose To evaluate the mortality rate, intensive care unit (ICU) referral, and Charlson comorbidity index (CCI) between different types of vaccinated and non-vaccinated patients operated on due to intertrochanteric femoral fracture (IFF) during the pandemic. Methods Ninety-six patients (43 males, 53 females) who had proximal femur nails (PFN) for the IFF during the pandemic were included in the study. The patients were divided into four subgroups; non-vaccinated, and different types of vaccinated. Mortality rates, ICU referrals, and CCI relations were evaluated. Results No significant difference was observed in terms of demographic data such as age, gender, side, CCI, and ICU referrals between the subgroups ( p  = 0.164, p  = 0.546, p  = 0.703, p  = 0.771, p  = 0.627 respectively). The mortality rate was significantly lower in the Sinovac + BioNTech subgroup ( p  = 0.044). Conclusion No relationship was found between mortality rate, ICU referral, and CCI in different types of vaccinated and non-vaccinated patient subgroups.

Aims The loss of medial and lateral wall support were the main risk factors of implant failure for proximal femoral fractures. A novel intramedullary nail, called proximal femoral universal nail system (PFUN), was proposed by our team to reconstruct the medial wall and lateral wall integrity and the biomechanical performance was evaluated in this study. Methods The synthetic femora were assigned to three groups randomly according to three different proximal femoral fracture types. For each group, the PFUN or PFNA were implanted separately and divided into PFUN subgroup and PFNA subgroup. Biomechanical tests were separately conducted in the axial compression test, torsional test, and fatigue test in sequence. The finite element analysis (FEA) was conducted by ANSYS 14.5 and we analyzed the von Mises stress distribution and the model displacement of two implant models in three different fracture types. Results For proximal femoral fractures with intact medial wall and lateral wall, our biomechanical results showed that the PFUN had a similar biomechanical property with the PFNA. Furthermore, the biomechanical results showed that the PFUN had a larger axial stiffness, higher torsional strength, and a similar failure load when compared with the PFNA for proximal femoral fracture with medial wall fracture. For proximal femoral fractures with broken medial wall and lateral wall, a larger axial stiffness, higher average torque and higher failure load were found in the PFUN when compared with the PFNA. The FEA results showed that the PFUN model had a higher stress concentration compared with the PFNA model, and the total displacement of the PFNA model increased by 11.63% when compared with the PFUN model in the proximal femoral fracture with broken medial wall and lateral wall. Conclusion Our results showed that PFUN had better biomechanical performance than PFNA, especially for complex proximal femoral fractures with medial wall fracture and lateral wall fracture, indicating that the PFUN had great potential as a new fixation strategy in future clinical applications.