1 Introduction

A proximal femur fracture remains the most common reason for an adult to be admitted to orthopaedic ward., but the total count of hip fractures continue to increase as life expectation continues to increase. nearly half of these hip fractures will be extracapsular, that is, the fracture is substantially confined to the area of bone between the femur capsular attachments to a position of 5 cm distal to the lower border of the lower trochanter. Extracapsular fractures can also be further divided into trochanteric and subtrochanteric fractures.

Primary idea is to estimate union of the fracture.

Secondary idea is to estimate and compare the hips joint function

justification of Study: displaced fractures need to be fixed for mobility and assessed regularly.

2 Materials & methods

1.Study Design This study is a prospective analysis of cases above 40 yrs who underwent cephalomedullary nail surgery for proximal femur fractures at our institution.2.Case Selection criteria:age 40 and above both gender/displaced fracture/extracapsular fracture (Fig. 1 and 2

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Fig. 1 STUDY CASE PATTERN

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Fig. 2 Sample case

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3 Analysis of results

Follow up:from surgery every 2 weeks till 6 weeks followed by xray hip.

Then once in a month for 6 months with xray hip.

Withdrawal from study:any period of study as per patient willingness.

Documentation, storage and archival of study documents:one year.

Statistical analysis: hip scores (Fig. 3).

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Fig. 3 Harris HIP Score

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4 Discussion

Trochanteric fractures constitute nearly half of total hip fractures caused by a low-energy injury, like a fall from standing height.⁸ These hip fractures occur in a population with threat factors including senior age, women, osteoporosis, history of trauma. these fractures are not common in young age and are caused by high velocity injuries or from a pathological process. therefore, secondary injuries or malignancy must be ruled out. Surgery is generally the recommended treatment as the morbidity and mortality associated with non-operative treatment has been high. diagnosis is confirmed by plain radiographs in the AP and side views. Traction with internal rotation radiograph view is helpful in assessing significant fracture displacement. The antero-posterior and side X-ray views of the whole femur are needed for long anatomical PFN fixation. The treatment of proximal femoral fractures with cephalomedullary is widely accepted.In intramedullary fixation there's minimum soft tissue damage, lower blood loss, a lower chance of infection, and smaller crack complications than extramedullary procedure, which has favoured PFN in these fractures. At present, PFN is a favourable minimally invasive fashion for treating proximal femur fractures, especially where unrestricted reduction is attainable. nevertheless, proximal screw cut, Z-effect, reverse Z-effect, peri implant femur fracture at the tip of nail or at the point of distal screw insertion, hip pain as a result of iliotibial tract inflammation or cortical hypertrophy and difficulty in insertion of distal interlocking screw are among the probable complications that can occur. At our institute, we've been using long anatomical PFNs. We routinely use long PFN with two proximal interlocks that maintain IT fracture reduction in good valgus position and give excellent rotational control of the proximal femur.Hardware or fixation failure is not related to the type of nail, implant material or AO/OTA classification, but a neck shaft angle of <125° leads to a significant increase in chance of fixation failure. The influence of varus malreduction for trochanteric fractures is associated with a higher cut-out rate after sliding hip screw fixation. An increased valgus reduction is beneficial for screw positioning resulting in stable fixation of the femoral head and neck.¹³

The pattern of the fracture had a significant effect on the distal interlocking of the nail. In stable IT fractures (31-A1 and 31-A2), the lateral cortex of the femur is unaffected. After anatomical reduction when the proximal locks are inserted from the lateral wall of the distal fracture part into the femoral head and the IM nail is matched well to the medullary canal, then varus deformity of the hip joint and rotational instability are controlled by the nail-proximal lock structure. In stable IT fractures, good cortical connection is established after acceptable reduction, and most of the compressive forces on the fracture site are borne by the bony cortex along the axis of neck of femur after surgery. Thus, performing distal interlocking of the nail was found to be unnecessary.

In unstable IT fractures (31-A3), the lateral cortex of the femur is fractured. This includes reverse oblique and transverse fracture patterns with particular anatomical and mechanical properties. Weight bearing on the affected limb gives rise to shearing movement at the fracture site that results in telescoping of the implant. When IM nailing of this unstable fracture pattern was done without distal interlocking screws, neither longitudinal nor rotational stability was attained. Thus, this fracture is not fixed firmly without a distal interlocking screw. However, we concluded that distal interlocking screws⁶ are needed for unstable IT fractures (31-A3), particularly those with subtrochanteric extension of the fracture or those with wide IM canals.

On the basis of these findings,… A typical case where PFN with distal locking was performed. In the immediate postoperative period, the proximal femoral neck shaft angle was maintained. In the healing phase, there was collapse of the fracture site, but the proximal femoral neck shaft angle was not maintained. There was loss of parallelism of the screw in the screw hole of the nail due to failure of downward migration of the nail because of distal locking. The whole construct works as a bottle opener or hammer claw, that leads to a windshield wiper effect around the purchase area of the screw in the head resulting in forward migration of the proximal lag screw and back-out of the distal lag screw. Due to this loss of parallelism, there can be screw back-out, screw cut-through from the femoral head, Z-effect, reverse Z-effect, and screw breakage.

5 Conclusion

The functional outcome of extracapsular proximal femur fracture fixation by a cephalo medullary system is generally good (Fig. 4).This type of fixation allows for early weight-bearing and mobilization, which can help prevent complications such as muscle weakness, joint stiffness, and pressure sores.

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Fig. 4 Results as bar CHART

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Overall, the use of a Cephalomedullary system for extracapsular proximal femur fracture fixation is associated with a high rate of successful fracture healing and restoration of function, allowing patients to return to their pre-injury level of activity.

CRediT authorship contribution statement

R. Ramaraj: Conceptualization, Writing – review & editing, Writing – original draft, Supervision. P. Balasubramaniyan: Visualization, Investigation, Methodology, Software. Umasanker: Data curation, Software, Validation.

Ethical statement

Ethical approval was obtained from the Institutional Ethics Committee of Government Medical College, Kallakurichi.

Informed consent

I, [Patient's Name], understand that my healthcare provider has recommended proximal cephalomedullary nail surgery to treat my condition. I have been provided with information about the procedure, its risks, benefits, and alternatives. I have had the opportunity to ask questions and have those questions answered to my satisfaction. I understand that the decision to undergo this surgery and post surgical study is voluntary, and I have the right to refuse or withdraw consent at any time.

I understand that proximal cephalomedullary nail surgery involves the insertion of a metal nail into the femur bone to stabilize and support a fracture or other condition. The procedure will be performed under anesthesia, and there are risks associated with any surgical procedure, including but not limited to infection, bleeding, nerve damage, and blood clots.

I understand that there is no guarantee that the surgery will be successful in treating my condition, and there may be complications that require additional treatment or surgery. I understand that the recovery process may be lengthy and require physical therapy to regain strength and function in my leg.

I understand that my healthcare provider will provide me with post-operative instructions and follow-up care to monitor my progress and address any concerns or complications that may arise. I understand that it is important to follow these instructions and attend all follow-up appointments to ensure the best possible outcome.

I understand that I have the right to ask questions, seek a second opinion, or request more information at any time. I have been given the opportunity to discuss the risks and benefits of the surgery with my healthcare provider and have made an informed decision to proceed with proximal cephalomedullary nail surgery.

I hereby consent to undergo proximal cephalomedullary nail surgery and acknowledge that I have read, understood, and agree to the information provided in this consent form.

Funding statement

On behalf of all authors I would like to give statement there is no internal or external funds received for this study.