Search Results (109)

Lateral femoral neck and peritrochanteric fractures are common and clinically challenging injuries, particularly in the elderly population, with significant implications for morbidity, mortality, and functional recovery. Traditional classification systems are widely used to guide treatment, yet their reproducibility and clinical applicability remain debated. Increasing attention has been directed toward trabecular architecture and its role in fracture behavior and reduction strategies. This review aims to summarize current evidence on classification systems, trabecular-based fracture patterns, pre-operative reduction techniques, and fixation strategies. A narrative review was conducted using PubMed/MEDLINE, Embase, and Scopus databases up to May 2026. Original studies, reviews, and biomechanical investigations focusing on proximal femur fracture classification, reliability, trabecular alignment, reduction techniques, and fixation methods were included. Data were qualitatively analyzed, with emphasis on interobserver reliability, biomechanical implications, and clinical outcomes. Conventional classification systems, including anatomical, Evans–Jensen, and AO/OTA frameworks, demonstrated variable and generally moderate reproducibility, with reported interobserver agreement ranging from approximately κ = 0.30 to 0.60. Emerging evidence highlights the importance of trabecular architecture, distinguishing intradigital fractures—confined within trabecular pathways and relatively stable—from extradigital fractures, which disrupt load-bearing structures and are associated with increased mechanical instability and higher failure rates. Biomechanical and clinical studies indicate that inadequate reduction with trabecular misalignment significantly increases the risk of varus collapse and implant cut-out. Reduction strategies tailored to fracture pattern, such as internal rotation for intradigital fractures and external or combined maneuvers for extradigital patterns, improve alignment and load transfer. In terms of fixation, dynamic hip screws remain effective in stable fractures, whereas cephalomedullary nails demonstrate superior performance in unstable patterns, with lower reoperation rates reported (approximately 5–8% vs. 10–15%). Management of lateral femoral neck and peritrochanteric fractures should extend beyond traditional classification systems to incorporate trabecular biomechanics. Restoration of trabecular alignment, alongside established parameters such as neck–shaft angle and tip–apex distance, is critical for optimizing outcomes. Further prospective studies are needed to validate trabecular-based classifications and standardize reduction strategies. Full article

Background: Vitamin K2 (menaquinone) has been studied as a molecule with important effects on bone metabolism and has been proposed as a potential adjuvant in fracture healing, particularly under osteoporotic conditions. However, its functional impact on osteoporotic fracture healing remains largely undefined. The aim of this study was to evaluate the effects of vitamin K2 supplementation, in the form of menaquinone-4 (MK-4) and menaquinone-7 (MK-7), on fracture healing in an ovariectomized rat model of osteoporosis. Methods: Forty Wistar rats were included in this study and allocated to four equal groups: Sham control, ovariectomized control, MK-4, and MK-7. Osteoporosis was induced by bilateral ovariectomy, and 12 weeks after ovariectomy, a femoral fracture was produced and fixed by intramedullary nailing. Starting on postoperative day 2, the MK-4 group received 5 mg/kg/day of MK-4, while the MK-7 group received MK-7 at a dose of 0.05 mg/kg/day. Fracture healing was assessed primarily by biomechanical testing using a three-point bending test and was further analyzed by histological and biochemical parameters, including CTXI, PINP, ucOC, BALP, and ALT. Results: Vitamin K2 supplementation did not improve functional fracture healing. In both treatment groups, fractures showed nonunion-like mechanical behavior, precluding meaningful quantitative biomechanical comparison. Although histological and biochemical findings, particularly in the MK-4 group, showed some degree of biological activity, these changes did not translate into mechanically competent bone union. Both treatment groups showed a tendency toward impaired healing, with progression toward nonunion-like behavior under the present experimental conditions. No significant hepatic toxicity was observed. Conclusions: In this ovariectomized rat femoral fracture model, vitamin K2 supplementation with either MK-4 or MK-7 did not enhance functional fracture healing despite evidence of biological activity of the treatment. These findings suggest a discrepancy between molecular or histological effects and biomechanical outcomes, indicating that, under the conditions tested, vitamin K2 is insufficient to overcome impaired healing in osteoporotic bone and may adversely influence fracture repair under these experimental conditions, although the mechanism remains uncertain. Full article

Background/Objectives: Due to the inherent rotational instability of the proximal fragment in unstable basicervical intertrochanteric (IT) fractures, the biomechanical effect of lag screw position may differ from that observed in typical unstable IT fractures. This study aimed to evaluate the influence of lag screw positioning on proximal fragment displacement and stress distribution after cephalomedullary nailing (CMN) in unstable basicervical IT fractures using finite element analysis. Methods: Twelve finite element models of unstable basicervical IT fractures fixed with a CM nail were constructed with lag screws placed in four anteroposterior (AP) positions (superior 5 mm, center, inferior 5 mm, and inferior 10 mm) and three axial positions (anterior, center, and posterior). The positional change of the proximal fragment and stress concentration on the nail construct were measured. Results: In this computational model, proximal fragment displacement and stress concentration, including peak von Mises stress and mean stress over a region of interest, increased as the lag screw was positioned more inferiorly on the AP view and more posteriorly on the axial view. Conversely, a relatively superior-anterior lag screw position was associated with the lowest proximal fragment displacement and reduced stress concentration on the nail construct and around the lag screw tip. Conclusions: Within the limitations of this finite element analysis using a single femoral model and axial loading condition, a relatively superior-anterior lag screw position was associated with more favorable biomechanical behavior compared with more inferior or posterior positions. These findings should be interpreted as hypothesis-generating biomechanical observations rather than direct clinical guidance. Full article

Background: With the rising volume of knee arthroplasty and increasing adoption of robotic- and computer-assisted systems, the routine use of tracker pins has introduced procedure-specific risks. This systematic review aimed to characterize the types and incidence of pin-site complications associated with robotic-assisted and computer-navigated primary knee arthroplasty and to describe the timing, management strategies, and reported outcomes. Methods: A PRISMA-guided search of PubMed/MEDLINE was performed using terms related to pin-related complications, robotic assistance, computer navigation, total and unicompartmental knee arthroplasty procedures. Clinical studies (RCTs, cohorts, case series, and case reports) that explicitly documented pin-related complications in robotic- or computer-assisted knee arthroplasty in English were included. Two independent reviewers performed study selection and data extraction; the methodological quality of non-randomized studies was assessed with the MINORS instrument. Extracted variables encompassed study design, patient demographics, pin characteristics, type and timing of complications, treatments, and outcomes. Descriptive statistics and means were used where appropriate. Results: From 1231 initial records, 28 studies met the inclusion criteria, comprising 15,004 cases in cohort/series analyses. The aggregate pin-related complication incidence in non-case-report series was 0.95% (142 events). Of these, 13.4% were intraoperative and 86.6% postoperative. The most common postoperative events were pin-site wound issues and infections (each ≈35.7% of complications); pin-site fractures accounted for 0.16% in cohort/series data. Case reports (n = 17 patients) showed fractures chiefly at femoral pin sites, arising on average 8.5 weeks postoperatively; management ranged from protected weight-bearing to intramedullary nailing or ORIF. Potential risk factors suggested in the literature include higher BMI, bicortical or transcortical fixation, metaphyseal pin placement, and larger pin diameter, but findings were inconsistent. Conclusions: Pin-related complications after robotic- and computer-assisted knee arthroplasty are uncommon but clinically significant (≈0.95%). There is insufficient evidence to define optimal pin-placement strategies or fixation configurations. Surgeons should include pin-related risks in informed consent discussions. Further prospective research is required to identify patient- and technique-specific risk factors and to establish evidence-based pin-placement guidelines. Full article

Background: Implant-related infection following femoral fracture surgery is a severe complication in elderly patients and is associated with high morbidity and mortality. Most available evidence on periprosthetic joint infection (PJI) derives from elective arthroplasty populations, which differ substantially from patients undergoing surgery for femoral fractures. This study aimed to investigate the microbiological profile and clinical characteristics of implant-related infections after proximal femoral fracture surgery. Materials and Methods: A retrospective observational study was conducted on 20 patients aged ≥70 years who developed implant-related infection after surgical treatment of proximal femoral fractures between 2020 and 2025 at a referral trauma center. Surgical procedures included intramedullary nailing, hemiarthroplasty, and total hip arthroplasty. Only patients with Charlson Comorbidity Index ≥ 4 and infection occurring within one year of the index surgery were included. Clinical, surgical, microbiological, and antibiotic therapy data were retrospectively reviewed. Results: The cohort had a mean age of 82.4 years and a high comorbidity burden (mean Charlson index 4.8). The most frequently isolated pathogen was Staphylococcus aureus (25.9%), with 85% methicillin-resistant strains. Other pathogens included Enterococcus faecalis, Klebsiella pneumoniae, and Escherichia coli. Polymicrobial infections were observed in 25% of patients. One-year mortality was 25%. Conclusions: Implant-related infections after femoral fracture surgery represent a distinct clinical entity compared with elective PJI, characterized by frail patients and a higher prevalence of multidrug-resistant organisms. These findings highlight the need for tailored preventive and therapeutic strategies in this high-risk population. Full article

Background: Long-bone non-unions complicated by osteomyelitis remain a major reconstructive and healthcare challenge, particularly in resource-limited settings with a high prevalence of multidrug-resistant (MDR) pathogens. Conventional staged management is associated with a prolonged treatment burden, repeated procedures, and delayed functional recovery. This study evaluated the clinical, radiological, functional, and short-term safety outcomes of a single-stage approach using custom-threaded antibiotic-coated locking nails (TACLNs) in a high-resistance cohort. Methods: This prospective single-center cohort study enrolled 30 adults with osteomyelitis-associated femoral or tibial nonunion at a tertiary hospital in Peshawar, Pakistan. All patients underwent radical debridement and single-stage stabilization with a chest tube mold TACLN loaded with vancomycin and gentamicin, with culture-directed adjunctive antibiotics for resistant organisms. Outcomes were assessed at baseline, Weeks 3 and 6, and Month 6 using inflammatory markers, RUST score, VAS pain, EQ-5D-5L, ASAMI criteria, and return to work or usual activity. No formal sample size calculation was performed, and this study was exploratory in nature. Results: The cohort (mean age 44.9 ± 9.9 years) had a challenging microbiological profile, with 40.0% MDR and 13.3% extensively drug-resistant (XDR) infections. By Month 6, short-term infection control was achieved in 96.7% of patients, with significant reductions in ESR and CRP (both p < 0.001). Radiographic union was achieved in 90.0% of cases at a mean of 18.6 weeks, and the mean RUST score improved from 4.87 to 10.43 at the final follow-up. The VAS pain decreased from 5.23 at week 3 to 0.73 at month 6, EQ-5D-5L improved from 0.39 to 0.84, and 90.0% returned to work or usual activity by month 6. No cement debonding, implant failure, or nephrotoxicity was noted. Conclusions: In this single-arm exploratory cohort, TACLNs were associated with favorable short-term infection control, radiographic union, and functional recovery in osteomyelitis-associated long-bone nonunion, including in an MDR/XDR setting. The independent contribution of the threaded core design cannot be established. Larger multicenter comparative studies with longer follow-ups are needed to confirm the durability and implementation feasibility. Full article

Flexible intramedullary nails (FINs) are commonly used in children and adolescents to treat long bone fractures, but few studies exist in animals. This study aimed to evaluate the biomechanical performance of FINS for the stabilization of transverse femoral fractures in cats. Fifteen bones were kept intact, while in another 15 bones, a mid-diaphyseal transverse fracture was induced and stabilized with two steel FINs of equal diameter, advanced divergently toward the greater trochanter and femoral neck, with end caps applied to the free ends. Five constructs and five intact bones were subjected to axial compression, four-point bending, and torsion tests. In axial compression, intact bones showed higher mean maximum force (1090.51 N vs. 608.43 N) and stiffness (845.98 vs. 298.86 N/m) than constructs. In bending, intact bones reached a maximum force of 1384.75 N, whereas a distinct maximum force could not be determined for the constructs; stiffness was also greater (1580.92 vs. 13.32 N/m). In torsion, intact bones demonstrated substantially higher mean maximum force (6.764 vs. 0.166 Nm) and stiffness (32.11 vs. 1.04 Nm/rad) than constructs. In conclusion, FINs with end caps demonstrate low construct stiffness, particularly under torsional loads, when used to stabilize mid-diaphyseal transverse femoral fractures in cats. Full article

Background and Objectives: The management of periprosthetic tibial fractures distal to revision Total Knee Arthroplasty (TKA) presents a biomechanical challenge, often requiring extramedullary locking plates when long stems preclude nailing. While in femoral fractures the gap between the stem and plate is a well-documented stress riser, requiring implant overlap to prevent an inter-implant fracture, this specific biomechanical scenario has not been studied in the tibia, and it remains unclear if the femoral dogma of mandatory overlap applies to the straight, centrically loaded tibial anatomy. This study utilized Finite Element Analysis (FEA) to evaluate stress distribution in the tibial inter-implant gap. Materials and Methods: A comparative FEA was performed using a validated standardized tibia model simulating a healed distal fracture. Two cemented revision TKA constructs (50 mm and 80 mm stems) were modeled. These were paired with medial locking plates of varying lengths (10, 12, and 14 holes) to create different inter-implant distances. Eight distinct configurations, including non-plated controls, were subjected to physiological axial compression and three-point bending. Outcome measures included von Mises stress and total displacement. Results: The analysis revealed no significant stress concentration in the bone within the inter-implant zone across all plated models, regardless of the gap size. Instead, the addition of plates universally reduced bone stress compared to controls, effectively transferring load to the fixation hardware. Peak stresses were consistently observed in the proximal locking screws rather than the bone gap. The longest plates (14 holes) offered superior construct rigidity and stress distribution. Conclusions: Under the conditions evaluated in this preclinical finite element model, the tibia does not exhibit a biomechanical requirement for implant overlap to prevent stress risers. Our findings suggest that extramedullary fixation with the longest available anatomical locking plate represents a biomechanically plausible strategy for these fractures, even if an inter-implant gap remains. Full article

This first part of a two-part review examines how Computed Tomography(CT)-based, additively manufactured (AM) porous implants are used to reconstruct large segmental defects of the femur and tibia. We focus on lightweight patient-specific lattice implants, architected cages, and modular porous constructs that incorporate engineered porosity into the load-bearing structure and are deployed with plate-, nail-, or external-fixator-based stabilization. We show how defects are described and classified by size, morphology, and anatomical subsegment; how these descriptors influence fixation choice and the resulting mechanical environment; and where along the femur and tibia porous implants have been applied in clinical and preclinical settings. Across the literature, outcomes appear to depend most strongly on defect morphology and local biology, while fixation feasibility and construct behavior vary by subregional anatomy. Most reported constructs use Ti6Al4V porous architectures intended to share load with fixation, reduce stress shielding, and provide a regenerative space for graft and tissue ingrowth. Finite element analyses (FEA) and bench-top studies consistently indicate that lattice architecture, relative density (RD), and fixation concept jointly control stiffness, micromotion, and fatigue-sensitive regions, whereas early animal and human reports describe promising incorporation and functional recovery in selected cases. However, defect descriptors, fixation reporting, boundary conditions, and outcome metrics remain diverse, and explicit quantitative validation of simulations against mechanical or in vivo measurements is uncommon. Most published work relies on simulation and bench testing, with limited reporting of biological endpoints, leaving a validation gap that prevents direct translation. We emphasize the need for standardized defect and fixation descriptors, harmonized mechanical and modeling protocols, and defect-centered datasets that integrate anatomy, mechanics, and longitudinal outcomes. Across the 27 included studies (may be counted in more than one group), simulation and mechanical testing are reported in 19/27 (70%) and 15/27 (56%), respectively, while in vivo studies (preclinical or clinical) account for 9/27 (33%), highlighting a validation gap that limits translation. Part 2 (under review); of these two series review paper; Patient-Specific Lattice Implants for Segmental Femoral and Tibial Reconstruction (Part 2): CT-Based Personalization, Design Workflows, and Validation-A Review; extends this work by detailing CT-to-implant workflows, lattice design strategies, and methodological validation. Full article

Background and Objectives: This biomechanical study aimed to compare the fixation stability of proximal fragments and assess the mechanical properties in models of unstable basicervical intertrochanteric fractures. Materials and Methods: Thirty-six synthetic femur models were utilized. After cephalomedullary nail insertion, unstable basicervical intertrochanteric fractures were created using an engraving machine. Specimens were divided into three groups based on the femoral head fixation method: Group 1 (n = 12, single 100 mm lag screw); Group 2 (n = 12, lag screw + 75 mm anti-rotation screw); and Group 3 (n = 12, lag screw + 95 mm anti-rotation screw). The anti-rotation screws were full-threaded locking screws positioned just below the lag screw. After applying 10,000 vertical cyclic loads, stereophotogrammetry was used to evaluate the proximal fragment rotation in three planes (coronal, sagittal, and axial), and screw-tip displacement was measured radiographically. Vertical load was then applied at a 10 mm/min rate until structural failure. Results: Rotational change in the sagittal plane was least in Group 3 (Group 1 = 1.7 ± 1.3°, Group 2 = 1.0 ± 0.8°, Group 3 = 0.6 ± 0.6°, p = 0.038). Varus (coronal plane) and retroversion (axial plane) collapse did not differ significantly among the three groups. While cranial migration showed no difference, axial migration was the significantly lowest in Group 3 (Group 1 = 1.07 ± 0.62 mm, Group 2 = 0.60 ± 0.57 mm, Group 3 = 0.50 ± 0.43 mm, p = 0.040). Failure load was slightly higher in Groups 2 and 3 than in Group 1, but without statistical significance. No significant differences were observed between Group 2 and Group 3 in any biomechanical outcomes. Conclusions: The novel cephalomedullary nail with a long inferior anti-rotation screw significantly reduced rotational instability and axial migration compared to a single-lag screw. There was no significant difference in the rotational stability between the 75 mm and 95 mm anti-rotation screw groups. This novel nail demonstrates superior biomechanical properties in this experimental model and warrants clinical evaluation for treating unstable basicervical intertrochanteric fractures. Full article

Background/Objectives: Surgical management of atypical femoral fractures (AFFs) stabilized with intramedullary (IM) nailing is frequently challenged by delayed union or nonunion due to the severely suppressed bone turnover characteristic of bisphosphonate-related bone pathology, often leading to a hypertrophic nonunion-like state at the fracture site. This consecutive case series aimed to evaluate the effectiveness of intraoperative percutaneous decortication at the hypertrophic cortex in promoting rapid bone healing in complete AFFs. Methods: This was a single-center consecutive case series of patients with complete atypical femoral fractures (AFFs) treated with intramedullary nailing and adjunctive percutaneous decortication since February 2021. The standardized surgical protocol—including percutaneous decortication performed through a small anterolateral incision using an osteotome to create bone chips and stimulate the sclerotic cortex—was applied prospectively to all consecutive patients from February 2021. Of the 20 patients who underwent surgery during this period, 14 with sufficient radiographic follow-up were included in the final retrospective analysis. Data collected included patient demographics, duration of bisphosphonate use, fracture location (diaphyseal vs. subtrochanteric), operative details (including iatrogenic fracture), and radiographic bone union time. Bone union was assessed on serial radiographs by two independent observers. Results: All 14 patients were female, with a median age of 75 years (IQR 67–79 years). Thirteen patients (92.9%) had prior bisphosphonate exposure for a median of 4.5 years (IQR 3–10 years). Six fractures were subtrochanteric fractures, and six were complicated by iatrogenic fracture during nail insertion. Postoperative teriparatide was administered to six patients. Radiographic bone union was achieved in all 14 patients at a median of 19 weeks (IQR 16–22 weeks; range 16–24 weeks). No major complications (infection, implant failure, nonunion, or neurovascular injury) occurred during follow-up. Conclusions: Percutaneous decortication is a simple, safe, and biologically plausible adjunct to intramedullary nailing. In this series of 14 elderly women with long-term bisphosphonate exposure (median 4.5 years), the technique was associated with 100% radiographic union at a median of 19 weeks without major complications, suggesting a promising strategy that warrants validation in larger, controlled trials. Full article

Background/Objectives: Unstable intertrochanteric femur fractures (IFFs) in geriatric patients are associated with high rates of morbidity and mortality due to poor bone quality, multiple comorbidities, and limited functional capacity. This study aimed to compare the clinical outcomes of cementless bipolar hemiarthroplasty (BHA) performed via a transtrochanteric approach and proximal femoral nailing (PFN) in elderly patients with unstable IFFs. Methods: This retrospective comparative study included 131 patients aged ≥70 years who underwent surgery for AO/OTA 31-A2 and 31-A3 unstable fractures between January 2021 and July 2025 were retrospectively reviewed. 64 patients received cementless BHA and 67 underwent PFN. Eligible patients were ambulatory prior to fracture (independently or with a cane/walker); patients with pathological fractures/malignancy, alternative procedures (cemented or posterolateral BHA, total hip arthroplasty, tumor prosthesis, or other osteosynthesis methods), incomplete records, or <6 months of follow-up were excluded. Demographics, perioperative variables, mechanical complications, revision requirement, time to mobilization, and 1- and 6-month mortality rates were analyzed. Primary outcomes were mortality and perioperative clinical parameters. Results: The two groups were comparable in age, sex, ASA scores, and fracture patterns. Intraoperative blood loss and transfusion requirements were significantly higher in the BHA group (both p < 0.001). Mobilization was observed earlier in patients treated with BHA (1 [1,2] vs. 3 [2,3] days; p < 0.001). Mechanical complications were more frequently observed after PFN, which was associated with a higher revision requirement (17.9% vs. 4.7%; p = 0.018). Operative time, hospital stay, and 1- and 6-month mortality rates showed no significant differences between the groups. Conclusions: In geriatric patients with unstable IFFs, cementless BHA performed via a transtrochanteric approach may be considered a viable surgical option with appropriate patient selection, taking into account its association with earlier mobilization and the observed mechanical complication profile. PFN offers advantages of reduced blood loss and lower transfusion needs. Surgical decision-making should be individualized based on fracture morphology, bone quality, and the patient’s overall medical condition. Given the heterogeneity of unstable fractures within the AO/OTA classification and the retrospective nature of the present study, larger, multicenter prospective investigations incorporating functional outcomes are warranted to further clarify optimal treatment strategies. Full article

Background and Objectives: Screw cut-out is the most common mechanical complication after intertrochanteric fracture fixation with proximal femoral nails (PFNs). While the traditional tip–apex distance (TAD) is widely used, the calcar-referenced TAD (CalTAD) may better represent inferomedial cortical support. This study aimed to identify radiographic predictors of cut-out in dual-screw PFN fixations and establish a clinically relevant threshold for inferior-screw-based CalTAD. Materials and Methods: A retrospective cohort of patients treated with a dual cephalic screw PFN between 2017 and 2024 was analyzed. The implant uses two equal-diameter screws. Radiographic parameters included TAD, inferior-screw CalTAD, reduction quality, lateral wall thickness (LWT), collodiaphyseal angle (CDA), and Cleveland zone positioning. Logistic regression analyses were used to identify independent predictors of mechanical failure. Results: Both TAD and CalTAD values were significantly higher in patients who experienced screw cut-out. ROC analysis identified an inferior-screw-referenced CalTAD cutoff with strong predictive accuracy (AUC = 0.84). Optimal screw positioning, particularly avoiding superior placement on AP radiographs, was associated with reduced cut-out risk, while anterior positioning on the lateral view demonstrated only a borderline effect. Reduction quality showed borderline significance in univariate testing but remained independently predictive in multivariate modeling, while LWT and CDA were not significantly different between groups. Conclusions: Ensuring the inferior lag screw is positioned close to the calcar and achieving a low CalTAD, together with proper Cleveland zone alignment, appear to be key technical goals for minimizing mechanical cut-out in dual-screw PFN fixations. These findings support the use of inferior-screw–referenced CalTAD as a reliable and reproducible parameter for surgical optimization. Full article

Background/Objectives: Cement augmentation of cephalomedullary head elements can improve the purchase of osteoporotic bone; however, it does not eliminate the need for accurate implant positioning or the preservation of sliding. We report the case of an 87-year-old woman who underwent intramedullary nailing with a cement-augmented helical blade for intertrochanteric fracture. Methods: This is a single-patient case report. Calibrated radiographic measurements—tip–apex distance (TAD), calcar-referenced TAD (CalTAD), neck–shaft angle (NSA), and telescoping—were obtained immediately postoperatively and at 4, 7, 12, and 15 months. CT was performed at postoperative week 1 and at failure, and MRI was performed for clinical deterioration. In addition, a targeted narrative review summarizes the evidence on the head-element position, sliding behavior, reduction alignment, and augmentation. Results: Immediate postoperative indices were within the accepted targets: TAD 22.6 mm, CalTAD 22.8 mm, NSA 134°, with the head element inferior on the anteroposterior view and central on the lateral view. Rehabilitation proceeded with full weight bearing as tolerated. Early telescoping was minimal (3.8–3.9 mm). Between 7 and 15 months, progressive varus with shortening of TAD/CalTAD and little additional telescoping was observed, radiographically consistent with relative proximal migration of the head–cement complex and a cleavage plane along the inferior cement mantle, culminating in a subcapital femoral neck fracture with the implant in situ. Emphasis should be placed on accurate implant positioning and preservation of sliding capacity, because cement augmentation alone may not prevent mechanical failure when the implant position or load transfer is suboptimal. Conclusions: Cement augmentation stiffens the interface and reduces micromotion but does not neutralize malposition-induced stresses. Accurate positioning, preservation of sliding, and timely conversion when sliding fails to progress are advisable; these findings are hypothesis-generating from a single case. We propose a position- and sliding-based decision guide to support clinical decision-making; its usefulness remains to be validated in larger studies. Full article

Background/Objectives: Femoral intertrochanteric fractures (ITFs) in older adults are associated with a substantial risk of mechanical failure after fixation, which can lead to persistent pain, delayed mobilization, and increased mortality. Injectable calcium composite bone substitute (ICCBS) augmentation has been proposed as a strategy to enhance construct stability and promote bone healing, but clinical evidence remains limited. The purpose of this study was to evaluate the efficacy of ICCBS in the management of osteoporotic ITFs. Methods: We conducted a multicenter, prospective, non-randomized controlled study of patients undergoing surgical fixation for osteoporotic ITFs using proximal femoral nails. Patients who consented to augmentation received ICCBS, while the control group underwent standard fixation alone. Demographic and injury-related variables were documented, and outcome data were prospectively collected. The primary outcome was time to radiographic bone union, while secondary outcomes included functional recovery (pain and ambulatory status) and complications, including fixation failure. Results: The mean time to radiographic bone union did not differ significantly between groups (p = 0.28). However, patients receiving ICCBS augmentation reported significantly lower postoperative pain scores up to 6 weeks and demonstrated reduced lag screw sliding and varus collapse at the time of bone union. There were no significant differences in complication rates, fixation failure, or ambulatory status at last follow-up between the two groups. Conclusions: ICCBS augmentation may improve early postoperative pain, construct stability, and functional recovery in patients with osteoporotic ITFs, although its effect on fracture healing and long-term outcomes remains uncertain. Further high-quality randomized trials are warranted to confirm these findings. Full article