Increased Risk of Pulmonary Complications with Long Cephalomedullary Nails in Geriatric Intertrochanteric Femur Fractures: A Retrospective Review of 881 Patients.

Background: Despite extensive literature comparing short and long cephalomedullary nails (CMNs), the impact of CMN length on pulmonary complications in geriatric patients with intertrochanteric (IT) fractures is not well established. This study compared postoperative pulmonary complications in geriatric patients with IT fractures treated with short (<235 mm) or intermediate (235-240 mm) CMNs (SINs) versus long (≥300 mm) CMNs (LNs).

Methods: Patients aged ≥65 years with AO Foundation/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 fractures treated with SINs or LNs between 2008 and 2020 were retrospectively identified at a single Level 1 Trauma center. The primary outcome was inpatient postoperative pulmonary complications. Secondary outcomes included mortality, surgical duration, and other inpatient postoperative complications. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated using logistic regression to adjust for comorbidities (i.e., diabetes, hypertension, chronic) obstructive pulmonary disease, smoking status, age, AO/OTA classification, ASA ≥3, time to surgery, and surgical duration.

Results: Overall, 881 patients were treated with either an SIN (n = 327) or an LN (n = 554). The SIN group was older (80.7 ± 9.1 years vs. 79.3 ± 8.4 years, p = 0.016), had a higher proportion of AO/OTA 31A1 fractures (p < 0.001), and included more patients with ASA ≥3 (89% vs. 84%, p = 0.035). In the SIN group, the median surgical duration was shorter (60 [interquartile range (IQR): 47-79] vs. 81 minutes [IQR: 62-106], p < 0.001), and rates of postoperative anemia (74% vs. 81%, p = 0.017) and transfusion (43% vs. 54%, p = 0.001) were lower. After adjusting for covariates, multivariable analysis demonstrated increased odds of postoperative pneumonia (AOR: 2.09, 95% CI: 1.01-4.71, p = 0.048), pulmonary embolism (AOR: 4.38, 95% CI: 1.09-29.5, p = 0.036), and transfusion (AOR: 1.38, 95% CI: 1.02-1.85, p = 0.034) in the LN group. There were no differences in mortality or other postoperative complications (p > 0.05).

Conclusions: Geriatric patients with IT fractures treated with LNs had increased odds of inpatient postoperative pneumonia, pulmonary embolism, and transfusion. However, mortality and other postoperative complications were similar.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.