Malunion after Fixation of Intertrochanteeic Fracture by Proximal Cephalomedullry Nail Fixation

• Ayman Bargaya Moktar Raslan

  Department of Orthopedic Surgery, Faculty of Medicine, Tobruk University, Libya

  Author

• Idris M.Tajoury

  Department of Orthopedic Surgery, Faculty of Medicine, Tobruk University, Libya

  Author

• Mounir. R.ATIA FARAG

  Department of Orthopedic Surgery, Faculty of Medicine, Tobruk University, Libya

  Author

Background: Intertrochanteric fractures (ITFs) of the proximal femur are common in the elderly, causing high morbidity, mortality, and healthcare costs. Proximal cephalomedullary nail (CMN) fixation is preferred for its biomechanical benefits and early mobilization, though malunion and nonunion can impair outcomes. Aim: This study aimed to assess the incidence and predictors of malunion following fixation of intertrochanteric fractures with proximal cephalomedullary nail fixation. Methods: A retrospective study was conducted on 80 patients with intertrochanteric fractures treated by CMN fixation at Tobruk Medical Centre. Patients were evaluated clinically and radiologically, with outcomes assessed using the Harris Hip Score (HHS), tip–apex distance (TAD), and neck–shaft angle (NSA). Healing is classified as anatomical union, malunion, delayed union, or nonunion. Logistic regression identified predictors. Results: The mean patient age was 58.6±7.9 years, with 61.3% males and 38.7% females. According to AO/OTA classification, 36.3% had type A1 and 63.7% type A2 fractures. Radiographic union was achieved in 96.3% of patients: 75.0% anatomical unions, 13.8% malunions, 7.5% delayed unions, and 3.7% nonunions. The mean union time was 16.8±5.4 weeks. The mean TAD was 21.2±2.4 mm in anatomically united cases versus 29.1±3.1 mm in malunion or nonunion cases (p<0.001). Functional outcomes improved significantly, with the mean HHS increasing from 68.2±9.8 at three months to 76.4±10.1 at six months (p<0.001). Multivariate regression identified higher ASA score, diabetes mellitus, road traffic accident (RTA) trauma, longer operative time, A2 fracture pattern, osteoporosis, and increased TAD as independent predictors of malunion and nonunion, with TAD being the most significant determinant. Conclusion: CMN yields high union rates for ITFs with low complications. Malunion/nonunion is linked to poor function. Optimise reduction, TAD ≤25 mm, technique, comorbidities, and unstable fractures for better recovery.

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