Hip biomechanics, health-related quality of life and walking ability after intramedullary fixation in intertrochanteric fracture: a prospective cohort study.

Abstract

Objectives: Altered hip biomechanics following intertrochanteric fracture fixation can result in impaired mobility, decreased functional outcomes, and a reduced quality of life. Despite achieving optimal reduction and fixation, patients often fail to regain their pre-injury activity levels. This study aims to evaluate how changes in hip biomechanics after intertrochanteric fracture fixation using a proximal femoral nail impact the quality of life.

Methods: This prospective cohort study, conducted from July 1, 2020, to June 30, 2022, included individuals aged 18 years and older with isolated intertrochanteric fractures managed using the Proximal Femur Nail Antirotation 2 (PFNA2). Clinical assessments included range of motion, pain levels, abductor strength, the modified Harris Hip Score (HHS), and the Parker and Palmer Mobility Score (PPMS) at 6 weeks, 3 months, and 6 months' post-surgery. Hip biomechanics were evaluated radiographically through parameters such as telescoping, tip-apex distance (TAD), neck-shaft angle, and femoral offset. These findings were correlated with functional scores and health-related quality of life (EQ5D-EuroQol 5 Dimension) score.

Results: Out of 47 eligible patients, only 30 could be followed up for six months due to the COVID-19 pandemic, and three patients died in the postoperative period. 25 of 33 patients were over 60 years old. Twenty-nine patients had unstable fractures. All patients had hypovitaminosis D, and 92% of patients had osteoporosis. Fracture union occurred in all cases, with a mean union time of 2.9 ± 0.8 months. Radiographic evaluation showed minimal changes in tip-apex distance and other hip biomechanical parameters (femoral offset, neck shaft angle, telescopy). Functional scores, including modified Harris Hip score and health-related quality of life (HRQOL) measures, improved significantly after surgery. However, at six months, these scores were lower than pre-injury levels. Walking ability varied considerably between age groups (< 60 years' vs > 60 years) at 6 weeks, but abductor strength did not differ significantly in subsequent follow-ups.

Conclusion: Poor bone quality, characterized by osteomalacia and osteoporosis, is significantly associated with intertrochanteric fractures in Indian populations. The PFNA 2 nailing system effectively maintains reduction and prevents varus collapse. Functional outcomes and HRQOL improve over time with intramedullary fixation, yet patients seldom return to pre-injury levels, potentially influenced by recall bias.