Category Archives: Vol 11 | Issue 2 | July-December 2025
Comparable Functional and Radiological Outcomes of Cemented and Uncemented Hemiarthroplasty in Elderly Intracapsular Femoral Neck Fractures: A Hypothesis for Patient-Specific Implant Selection
Vol 11 | Issue 2 | July-December 2025 | page: 7-9 | Asjad Patel, Rajeev Joshi, Mahavir Dugad, Parag Sancheti, Darshan Sonawane, Ashok Shyam
https://doi.org/10.13107/jmt.2025.v11.i02.260
Author: Asjad Patel [1], Rajeev Joshi [1], Mahavir Dugad [1], Parag Sancheti [1], Darshan Sonawane [1], Ashok Shyam [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivaji- nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr Asjad Patel
Department of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Email: asjadp55@gmail.com
Abstract
Background: Elderly patients with intracapsular femoral neck fractures face high morbidity and mortality. Partial hip replacement (PHR) is the standard of care, but the optimal choice between cemented and uncemented implants remains controversial.
Hypothesis: Both cemented and uncemented PHR yield comparable functional and radiological outcomes at 12 months, provided implants are selected based on bone quality and patient factors.
Clinical Importance: Demonstrating equivalence would encourage individualized, evidence-based selection of implant type, reduce unnecessary risks and support best practices in geriatric fracture care.
Future Research Direction: Prospective, randomized, multicentre trials are needed to validate these findings across diverse patient populations and assess long-term outcomes, cost-effectiveness, and patient satisfaction.
Keywords: Femoral neck fracture, Hemiarthroplasty, Elderly, Cemented, uncemented, Functional outcome, Implant selection.
Background
Fragility fractures of the proximal femur are a growing burden in aging societies, causing significant morbidity, functional decline, and healthcare costs [1, 2]. Intracapsular femoral neck fractures constitute nearly half of all hip fractures in the elderly, with displaced fractures prevalent among postmenopausal women with osteoporosis [1, 3]. Due to poor healing potential and high risk of avascular necrosis, surgical intervention—most commonly partial hip replacement (hemiarthroplasty)—is preferred to restore mobility and reduce immobilization complications [4, 5].
Debate persists over implant fixation method. Cemented stems offer initial stability and lower periprosthetic fracture rates, but risk cement implantation syndrome [6, 7]. Uncemented stems may reduce operative time but can have higher rates of subsidence and thigh pain, especially in osteoporotic bone [6, 8, 9]. Indian studies directly comparing these approaches remain limited, particularly in prospective settings [6, 14, 20].
Hypothesis
We hypothesize that both cemented and uncemented partial hip replacements provide equivalent functional and radiological outcomes at 12 months, provided that:
• Cemented stems are used for patients with poor bone quality (Dorr Type C).
• Uncemented stems are reserved for patients with good bone stock (Dorr Type A/B)[6,9,11].
A patient-specific approach—rather than routine use of one implant type—is optimal for this population.
Supporting Evidence:
• In a prospective cohort of 194 elderly patients, both cemented and uncemented groups showed significant improvement in Harris Hip Score, SF-36, and VAS, with no statistical difference at any follow-up point[6,9,11,16].
• Radiological assessment showed all stems stable, with limb length discrepancy and migration comparable between groups[4,14,25].
• Complication rates (infection, DVT, dislocation, death) did not differ significantly by implant type[9,11,19].
Contrary Evidence:
• Some meta-analyses suggest cemented stems provide better early pain relief or lower revision rates, but these advantages diminish with careful patient selection[11,17,19].
• Uncemented stems may underperform in patients with poor bone quality or significant comorbidities[8,9,11,17].
Discussion
The equivalence of cemented and uncemented hemiarthroplasty in selected elderly patients challenges the traditional preference for one approach. Recent meta-analyses and large registry studies indicate no significant differences in medium-term functional and radiological outcomes when patient selection is individualized[6,9,11,17,19,22,25].
This approach allows surgeons to minimize risks associated with cement (e.g., cardiopulmonary events) in suitable candidates while maintaining excellent implant stability and function. In osteoporotic patients, cemented fixation remains advantageous. Our study found no excess in perioperative complications, death, or implant migration in either group, provided selection criteria were applied[9,11,12,14,20].
Clinical importance: This strategy promotes faster recovery, cost-effectiveness, and aligns with global trends towards tailored orthopaedic care[6,8,10,14,20].
Clinical Importance
Adopting a patient-specific implant selection strategy may:
• Reduce surgical risk by minimizing unnecessary cement use[9,11,12].
• Optimize outcomes in both high- and low-risk patients[9,16,17,19].
• Facilitate early mobilization, reduce complications, and improve quality of life[6,8,14,25].
• Encourage evidence-based practice in resource-limited settings[20,22,25].
Future Research Directions
Future work should:
• Test this hypothesis in large, multicentre, randomized controlled trials with longer-term follow-up[8,10,19,20].
• Evaluate cost-effectiveness, patient-reported satisfaction, and rare complications[17,19,20].
• Explore the role of enhanced rehabilitation and home safety modifications in maximizing outcomes across implant types[20,22,25].
References
1. Bezwada HP, Shah AR, Harding SH, Baker J, Johanson NA, Mont MA. Cementless bipolar hemiarthroplasty for displaced femoral neck fractures in the elderly. J Arthroplasty. 2004;19(3):295-301.
2. D’Angelo F, Murena L, Zatti G, Cherubino P. Hip fractures in elderly patients treated with bipolar hemiarthroplasty: a survival analysis. Arch Orthop Trauma Surg. 2005;125(7):538-541.
3. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. J Bone Joint Surg Am. 2006;88(2):249-260.
4. Schneider L, Leixnering M, et al. Radiological outcomes after bipolar hemiarthroplasty via direct anterior approach. J Orthop Surg Res. 2005;12(1):112-119.
5. Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur. Injury. 2000;31(10):793-797.
6. Singh V, Sahoo MM, Padhan P, et al. Partial hip replacement for femoral neck fractures in elderly. Indian J Orthop. 2006;40(1):6-9.
7. Marya SKS, Thukral R, Singh C, et al. Cementless bipolar hemiarthroplasty in the very elderly: a prospective study. Arch Orthop Trauma Surg. 2011;131(8):1113-1117.
8. Choi YJ, Lee JH, Kim JK, et al. Results of partial hip arthroplasty in displaced femoral neck fractures. Hip Int. 2008;18(2):104-110.
9. Aytekin MN, Uzkeser H, Karakurt L, et al. Partial hip arthroplasty in the elderly: analysis of 82 cases. Acta Orthop Traumatol Turc. 2011;45(2):109-115.
10. Miller MD, Thompson SR, Hart JA. Review of Orthopaedics. 6th Edition. Elsevier Saunders; 2012.
11. Veldman HD, Heyligers IC, et al. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: a systematic review and meta-analysis of randomized controlled trials. Int Orthop. 2017;41(11):2209-2219.
12. Bhandar MS, Sathe N, Pande K. Outcomes of partial hip replacement in elderly patients with femoral neck fractures. J Clin Orthop Trauma. 2018;9(3):254-259.
13. Squires B, Bannister GC. Displaced intracapsular hip fractures in the elderly: the role of primary hemiarthroplasty. J Bone Joint Surg Br. 1999;81(3):440-444.
14. Frenken M, Greb A, et al. Cemented versus uncemented hemiarthroplasty for femoral neck fractures. Injury. 2018;49(7):1438-1443.
15. Robertson GAJ, Wood AM. Hip hemiarthroplasty for fracture: the surgical approach and the use of cement. Bone Joint J. 2018;100-B(10):1271-1273.
16. Lin FF, Clyburn TA, et al. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: a meta-analysis. J Orthop Surg Res. 2019;14:250.
17. Kristensen TB, Dybvik E, et al. Cemented compared with uncemented hemiarthroplasty for displaced femoral neck fractures: data from the Norwegian Hip Fracture Register. J Bone Joint Surg Am. 2019;101(8):708-714.
18. Song K, Jang S, Lee SH, et al. Cemented versus uncemented hemiarthroplasty for femoral neck fractures in the elderly. Geriatr Orthop Surg Rehabil. 2019;10:1-8.
19. Imam MA, Alrashidi Y, et al. Cemented versus uncemented hemiarthroplasty for femoral neck fractures: a systematic review and meta-analysis of randomized controlled trials. J Orthop Trauma. 2019;33(4):166-175.
20. Bajaria RS, Garg B, et al. THA vs BHA for displaced femoral neck fractures in the active elderly: a prospective study. J Clin Orthop Trauma. 2024;38:102003.
21. Papavasiliou KA, et al. Bipolar vs unipolar hemiarthroplasty for displaced femoral neck fractures in the elderly: a systematic review and meta-analysis. J Arthroplasty. 2023;38(2):285-294.
22. Okike K, Chan PH, et al. Cemented versus uncemented fixation in hip fracture hemiarthroplasty. J Bone Joint Surg Am. 2020;102(16):1420-1427.
23. DeRogatis MJ, Eskander MS, et al. Cemented vs uncemented hemiarthroplasty for femoral neck fracture in elderly: meta-analysis. Geriatr Orthop Surg Rehabil. 2020;11:1-7.
24. Sharma R, et al. Validation of Sharma Risk Assessment Score for arthroplasty selection in elderly hip fracture. Indian J Orthop. 2024;58(1):54-60.
25. Kumar A, et al. Cemented vs uncemented hemiarthroplasty for intracapsular femoral neck fractures: a meta-analysis. J Orthop Surg (Hong Kong). 2020;28(3):1-10.
| How to Cite this Article: Patel A, Joshi R, Dugad M, Sancheti P, Sonawane D, Ashok Shyam A. Comparable Functional and Radiological Outcomes of Cemented and Uncemented Hemiarthroplasty in Elderly Intracapsular Femoral Neck Fractures: A Hypothesis for Patient-Specific Implant Selection. Journal of Medical Thesis. 2025 July-December; 11(2): 7-9. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2019
Full Text PDF | Full Text HTML
Non-Instrumented Posterior Decompression: Correlation between Radiological parameters and functional outcomes.
Vol 11 | Issue 2 | July-December 2025 | page: 22-25 | Rahul Jaiswal, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2025.v11.i02.268
Author: Rahul Jaiswal [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivaji- nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Rahul Jaiswal,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivajinagar, Pune, Maharashtra, India.
E-mail: rj199116@gmail.com
Abstract
Background: Degenerative lumbar canal stenosis causes neurogenic claudication, radicular pain and reduced walking capacity. When conservative care fails or neurological deficits progress, surgical decompression is commonly offered. This prospective study evaluated pain, disability and health-related quality of life after posterior lumbar decompression and examined changes in spinopelvic parameters.
Methods: Consecutive patients undergoing 1–4 level decompression were assessed preoperatively and at 18 months using Visual Analogue Scale for back and leg pain, Oswestry Disability Index and Short Form-36. Standing lateral radiographs including femoral heads were used to measure pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis. Standardized perioperative care and structured physiotherapy were applied.
Results: Significant and sustained reductions in back and leg pain were observed with large falls in VAS and ODI, and marked gains in SF-36 domains at final follow up. Radiographically, lumbar lordosis increased modestly and PI–LL mismatch decreased on average, but these changes did not reliably predict functional improvement.
Conclusion: Posterior decompression provides meaningful, durable symptomatic and functional benefit in well selected patients with degenerative lumbar canal stenosis; modest radiographic alignment changes may occur but are not required for clinical recovery. These findings support decompression as a safe, effective option when nonoperative care fails. Periodically monitored.
Keywords: Lumbar canal stenosis, Posterior decompression, Neurogenic claudication, Oswestry Disability Index, Lumbar lordosis, PI–LL mismatch.
Introduction
Lumbar canal stenosis is a degenerative narrowing of the lumbar spinal canal and foramina that commonly presents with neurogenic claudication—leg pain, numbness or weakness precipitated by walking and relieved by sitting or flexion. Patients frequently report axial low back pain combined with limited walking distance and reduced quality of life. Nonoperative management, including activity modification, analgesics, supervised physiotherapy and selective injections, is often effective initially, but progressive or refractory symptoms and objective neurological decline are accepted indications for surgical decompression [14]. The surgical goal is to relieve neural compression, restore walking capacity and reduce pain while minimizing morbidity and preserving segmental stability. Approaches range from open laminectomy to minimally invasive unilateral laminotomy with bilateral decompression; technique selection depends on the distribution of pathology, the presence of instability and surgeon preference [15]. Outcome evaluation relies on validated patient-reported measures—Visual Analogue Scale for pain, Oswestry Disability Index for function and Short Form-36 for general health—and standardized radiographic assessment of sagittal alignment, including pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis. Pelvic incidence is an anatomic constant that determines the lumbar lordosis needed for an upright balanced posture, while pelvic tilt and sacral slope are compensatory and may change with pain-avoidant posture. Restoration of pain-free posture after decompression may allow increased lordosis and decreased PI–LL mismatch in some patients, but the extent and clinical relevance of such changes remain debated. By measuring preoperative and 18-month postoperative PROMs and standing radiographs that include femoral heads for accurate pelvic parameter measurement, we sought to quantify the magnitude and durability of symptom relief and to test whether radiographic alignment changes correlate with clinically meaningful improvements. Findings aim to guide patient counselling and surgical planning. Specifically.
Aims and objectives
This prospective study aimed to evaluate the clinical effectiveness of posterior lumbar decompression in patients with degenerative lumbar canal stenosis and to relate clinical recovery to radiographic spinopelvic measures. Primary objectives were to quantify pain reduction using the Visual Analogue Scale for back and leg pain and to measure improvement in disability using the Oswestry Disability Index and health-related quality of life using the Short Form-36. Secondary objectives included calculating pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis on standardized standing lateral radiographs before and after surgery and exploring correlations between radiographic change, including PI–LL mismatch, and patient-reported outcomes. The intent was to determine whether radiographic restoration of sagittal relationships parallels meaningful clinical recovery after decompression. We also sought to record perioperative complications, level-wise decompression details and the need for further intervention, to inform patient selection and counselling for decompression without routine fusion across enrolled patients to 18 months.
Materials and methods
This single-centre prospective study enrolled consecutive patients between October 2019 and December 2021 who met predefined inclusion criteria: age 40 years or older, symptomatic degenerative lumbar canal stenosis and planned posterior decompression at one to four levels. Exclusion criteria included grade ≥2 spondylolisthesis, prior lumbar fusion, infection, tumor, traumatic stenosis and inability to complete outcome scoring. Institutional ethical clearance and informed consent were obtained. Baseline assessment comprised a structured history, neurological examination and patient-reported outcome measures—Visual Analogue Scale for back and leg pain, Oswestry Disability Index and Short Form-36. Imaging included standing anteroposterior and lateral lumbar radiographs that included the femoral heads for accurate pelvic parameter measurement and MRI to localise levels of neural compression. Spinopelvic angles were measured using standard geometric definitions (PI = PT + SS; lumbar lordosis by Cobb angle from L1 to S1). Surgical procedures—open laminectomy, laminotomy or unilateral over-the-top bilateral decompression—were selected according to pathology and surgeon judgement with the aim of adequate neural decompression while preserving posterior supporting structures when feasible [16,17]. Perioperative care consisted of routine antibiotic prophylaxis, thromboprophylaxis where indicated, early ambulation and a structured physiotherapy pathway. Complications were recorded prospectively. Follow-up assessments, including PROMs and repeat standing radiographs, were performed at 18 months. Level-wise decompression, operative time, estimated blood loss and perioperative complications were documented. Missing data were handled and sensitivity analyses evaluated their effect on primary outcomes. Statistical comparisons used paired tests for preoperative and postoperative measures and Spearman correlation to explore relationships between radiographic change and patient-reported outcomes.
Review of literature
Lumbar canal stenosis is a common degenerative spinal disorder whose prevalence rises with age and that represents a frequent cause of chronic low back pain and walking limitation in older adults [1]. Pathology commonly reflects a combination of intervertebral disc height loss, facet joint arthropathy, osteophyte formation and ligamentum flavum hypertrophy that together narrow the central canal, lateral recesses and foramina producing neurogenic claudication and radicular symptoms [2, 3]. Historical descriptions linked nerve compression to leg symptoms and surgical pioneers developed decompressive operations aimed at relieving neural compromise while attempting to preserve spinal stability [4]. Contemporary surgical options range from wide open laminectomy to targeted laminotomy, unilateral over-the-top decompression and minimally invasive fenestration, with muscle-sparing approaches advocated to reduce soft-tissue trauma and accelerate recovery [5, 6]. Randomized and cohort studies generally show significant and durable symptom relief after decompression, though perioperative morbidity and recovery profiles vary by technique and patient factors. Less invasive techniques tend to reduce blood loss and hospital stay while producing comparable short-term patient-reported outcome measure gains. Systematic reviews emphasise that decompression reliably lessens pain and disability, but controversies persist about when to add fusion—particularly in the presence of low-grade spondylolisthesis [7].
Biomechanical models and clinical series highlight spinopelvic morphology as an important aspect of adult spinal mechanics. Pelvic incidence is a fixed anatomical parameter that influences the magnitude of lumbar lordosis required for balanced posture, while pelvic tilt and sacral slope reflect compensatory pelvic rotation [8]. Observational reports indicate that pain-driven flexed posture may partially reverse after decompression, allowing modest increases in lumbar lordosis and reductions in PI–LL mismatch when preoperative flexion is dynamic rather than structural [9,10]. Other studies caution that degenerative loss of lordosis due to disc collapse and chronic muscular atrophy may be less amenable to change without instrumented realignment, emphasising the need to distinguish reversible pain-adaptive postures from fixed deformity when planning surgery [11]. Outcome assessment has moved toward validated patient-reported outcome measures—Visual Analogue Scale, Oswestry Disability Index and Short Form-36—which capture pain, function and general health and facilitate comparison across series [12]. Finally, reported complications of decompression are well described and include dural tear, infection and rare progression to instability; most series report low rates manageable with standard techniques and targeted rehabilitation [13].
Results
One hundred and forty consecutive patients were included (86 males, 54 females) with a mean age of 57.7 years (range 28–81) and mean BMI 26.4 kg/m². Distribution of decompressed levels was single level 43.6%, two levels 33.6%, three levels 18.6% and four levels 4.3%. Mean symptom duration was 17.9 months, and 70.4% of patients reported claudication within 100 metres of walking. Comorbidities included hypertension and diabetes in a substantial subset.
Functional outcomes improved markedly. Median preoperative VAS was 7 for back pain and 9 for leg pain; median VAS fell to 4 immediately postoperatively and to 1 at 18 months for both domains. Mean ODI decreased from 58.1 preoperatively to 36.5 early after surgery and to 20.9 at final follow up. SF-36 domain scores rose across physical function, pain and general health, with the overall median SF-36 rising from 42.1 to 78.1 (p < 0.001).
Radiographic analysis available for 112 patients showed a modest increase in lumbar lordosis (median 44.31° pre-op to 48.06° at 18 months) and a reduction in PI–LL mismatch (median 1.81° to –0.07°, p = 0.008). Complications included six intraoperative dural tears and one spondylodiscitis requiring reoperation; most complications were managed without long-term adverse effect. No deaths.
Discussion
This prospective cohort demonstrates that posterior decompression reliably reduces leg and back pain and improves function in patients with degenerative lumbar canal stenosis. Most patients had marked early benefits that were sustained at 18 months, reflected in large falls in VAS and ODI and gains in SF-36 [5, 7, and 18]. On imaging we found modest but consistent increases in lumbar lordosis and reductions in PI–LL mismatch at the group level. This pattern likely reflects reversal of a pain-avoidant, flexed posture rather than true structural realignment, since many patients assume a guarded stance to lessen neural tension. Relief of neural compression removes nociceptive drivers and allows functional gains even in the absence of large radiographic shifts [9, 11].
Several reports of non-instrumented decompression describe clinical benefit with only modest alignment change, underscoring that sagittal parameters are one piece of a multifactorial outcome picture [4, 6]. We included patients treated with varied decompression techniques, including chimney sublaminar approaches described by Lin and colleagues, which can achieve neural release while conserving posterior elements [19]. Complications were uncommon; dural tears were repaired intraoperatively and one deep infection required reoperation, but most adverse events were managed without lasting functional loss. These results highlight the importance of meticulous technique, prompt recognition and treatment of complications, and a structured rehabilitation pathway to consolidate gains [13, 20].
Limitations temper the strength of our conclusions. This single-centre series used heterogeneous operative approaches and experienced some loss to follow up, which may introduce selection effects and limit generalizability. Only a subset had complete radiographic datasets, reducing power for subgroup analyses and making it difficult to define which baseline spinopelvic profiles predict radiographic or clinical trajectories. Future studies stratifying PI, spondylolisthesis and preoperative lordosis will better guide fusion decisions [8, 20].
Conclusion
Posterior lumbar decompression in patients with degenerative lumbar canal stenosis produces substantial and sustained reductions in back and leg pain and meaningful improvements in disability and overall health-related quality of life. Modest group-level increases in lumbar lordosis and reductions in PI–LL mismatch may occur after surgery, but these radiographic shifts did not reliably predict the extent of symptomatic recovery in this cohort. Therefore, while spinopelvic assessment offers valuable anatomical context for surgical planning, restoration of sagittal parameters should not be viewed as a prerequisite for clinical benefit following neural decompression. Emphasis should remain on careful patient selection, meticulous decompressive technique, standardised perioperative care and structured rehabilitation to optimize outcomes. Longer-term and subgroup analyses are needed to determine whether particular patients derive additional advantage from alignment restoration or fusion procedures. Shared decision-making that explains expected symptomatic improvement and the uncertain role of radiographic change will aid personalized care planning over time.
References
1. Ferguson SA, Merryweather A, Thiese MS, Hegmann KT, Lu ML, Kapellusch JM, et al. Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States. BMC Musculoskelet Disord. 2019; 20(1):1–8.
2. Magras I, Athanasiou A, Magra V. Lumbar spinal stenosis. Spine Surg A Case-Based Approach. 2019; 77–80.
3. Botwin KP, Gruber RD. Lumbar spinal stenosis: Anatomy and pathogenesis. Phys Med Rehabil Clin N Am. 2003; 14(1):1–15.
4. Divi SN, Goyal DKC, Bowles DR, Mujica VE, Guzek R, Kaye ID, et al. How do spinopelvic parameters influence patient-reported outcome measurements after lumbar decompression? Spine J. 2020; 20(10):1610–7.
5. Hatakka J, Pernaa K, Rantakokko J, Laaksonen I, Saltychev M. Effect of lumbar laminectomy on spinal sagittal alignment: a systematic review. Eur Spine J. 2021; 30(9):2413–26.
6. Shin EK, Kim CH, Chung CK, Choi Y, Yim D, Jung W, et al. Sagittal imbalance in patients with lumbar spinal stenosis and outcomes after simple decompression surgery. Spine J. 2017; 17(2):175–82.
7. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical evaluation and self-assessment by patients after decompression surgery for degenerative lumbar canal stenosis. Spine J. 2008; 8(2):380–4.
8. Ghobrial GM, Al-Saiegh F, Heller J. Spinopelvic Balance. Oper Tech Spine Surg. 2018; 2(8):281–7.
9. Anna I, Gemma V-C, David C, Augusto C, Enric C, Ana Garcia DF, et al. Lumbar lordosis in patients undergoing non-instrumented spinal stenosis. Int J Spine Res. 2021; 3:004–10.
10. Liang C, Sun J, Cui X, Jiang Z, Zhang W, Li T. Spinal sagittal imbalance in patients with lumbar disc herniation: Its spinopelvic characteristics, strength changes of the spinal musculature and natural history after lumbar discectomy. BMC Musculoskelet Disord. 2016; 17(1):1–8.
11. Jeon CH, Lee HD, Lee YS, Seo HS, Chung NS. Change in Sagittal Profiles after Decompressive Laminectomy in Patients with Lumbar Spinal Canal Stenosis: A 2-Year Preliminary Report. Spine. 2015; 40(5):E279–85.
12. Kirkaldy-Willis C. The three-joint complex and degeneration. (Referenced in thesis). 1961/1978.
13. Ashley P. Of Neurosurgery. 1986; 3–36.
14. Genevay S, Atlas SJ. Lumbar Spinal Stenosis. Best Pract Res Clin Rheumatol. 2010; 24(2):253–65.
15. Postacchini F. Management of lumbar spinal stenosis. J Bone Joint Surg Br. 1996; 78(1):154–64.
16. Shenouda EF, Gill SS, Laing R, Johnston R. Laminal fenestration for the treatment of lumbar nerve root foraminal stenosis. Br J Neurosurg. 2002; 16(5):494–6.
17. Sengupta DK, Herkowitz HN. Lumbar spinal stenosis: Treatment strategies and indications for surgery. Orthop Clin North Am. 2003; 34(2):281–95.
18. Watanabe K, Hosoya T, Shiraishi T, Matsumoto M, Chiba K, Toyama Y. Lumbar spinous process-splitting laminectomy for lumbar canal stenosis. J Neurosurg Spine. 2005; 3(5):405–8.
19. Lin SM, Tseng SH, Yang JC, Tu CC. Chimney sublaminar decompression for degenerative lumbar spinal stenosis. J Neurosurg Spine. 2006; 4(5):359–64.
20. Benz RJ, Garfin SR. Current techniques of decompression of the lumbar spine. Clin Orthop Relat Res. 2001; 384:75–81.
| How to Cite this Article: Jaiswal R, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P. Non-Instrumented Posterior Decompression: Correlation between Radiological parameters and functional outcomes. Journal of Medical Thesis. 2025 July-December; 11(2):22-25. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022
Full Text PDF | Full Text HTML
The Spinopelvic Alignment Hypothesis: Does Optimal PI–LL and PT Restoration Drive Better Patient-Reported Outcomes after Laminectomy?
Vol 11 | Issue 2 | July-December 2025 | page: 3-6 | Rahul Jaiswal, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2025.v11.i02.258
Author: Rahul Jaiswal [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivaji- nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Rahul Jaiswal,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivajinagar, Pune, Maharashtra, India.
E-mail: rj199116@gmail.com
Abstract
Background: Lumbar canal stenosis commonly causes leg pain, numbness and reduced walking distance in middle-aged and older adults. Degenerative loss of disc height, enlargement of facet joints and thickening of the ligamentum flavum narrow the spinal canal, compressing nerve roots and producing neurogenic claudication and disability. Conservative care—physiotherapy, medications and epidural injections—helps many patients, yet persistent symptomatic stenosis often requires surgical decompression to relieve nerve compression and restore walking tolerance and independence.
Hypothesis: The study proposes that decompression alone, applied to patients with degenerative lumbar canal stenosis and Grade I spondylolisthesis without clear instability, will yield meaningful and sustained reductions in leg and back pain and substantial improvement in daily function and overall health. It further proposes that measurable restoration of lumbar lordosis and pelvic alignment will be modest for most patients, and that symptomatic recovery will depend chiefly on relief of neural compression and reversal of pain-driven antalgic posture rather than on large radiographic corrections.
Clinical importance: If these expectations are met, a decompression-first strategy supports a less invasive pathway for most patients who lack objective instability, avoiding the additional morbidity of fusion while delivering reliable symptom relief. Emphasis on validated patient-reported outcomes—pain scores, the Oswestry Disability Index and general health measures—keeps decision-making focused on what matters to patients: reduced pain, improved mobility and better quality of life. Counseling should set realistic expectations about likely functional gains and the limited degree of radiographic change to be expected after decompression alone.
Future research: Randomized, multicentre trials comparing decompression alone with decompression plus fusion in patients who have borderline sagittal parameters are needed to define radiographic thresholds that justify fusion. Longer follow-up and objective measures—quantitative assessment of paraspinal muscle quality and gait analysis—will help predict who benefits most from fusion versus decompression alone. This study reports prospective medium-term outcomes using validated measures and standardized standing radiographs to examine the link between symptom relief and sagittal alignment. Findings aim to guide practical surgical decisions for everyday spine care. Durable outcomes.
Keywords: Lumbar canal stenosis, Decompression, Lumbar lordosis, Spinopelvic parameters, Oswestry Disability Index, Neurogenic claudication
Background
Lumbar canal stenosis is a common degenerative condition of the lower spine that produces leg pain, numbness and progressive difficulty with walking. Over time, loss of disc height, enlargement of the facet joints, osteophyte formation and thickening of the ligamentum flavum narrow the spinal canal and compress nerve roots. Patients typically report leg symptoms that worsen with standing and walking and ease with sitting or forward flexion; back pain often coexists but the dominant complaint is usually reduced walking tolerance and functional decline. [1–4]
Initial care is conservative: physiotherapy, analgesics, activity modification and epidural injections can relieve symptoms for many patients. When symptoms persist or progressive neurological deficit develops despite nonoperative care, surgery is considered. The surgical aim is straightforward — remove the compressive elements to free the nerves, reduce pain, and restore walking ability and day-to-day function. Traditional open laminectomy achieves reliable decompression but may injure paraspinal muscles or destabilize the posterior elements in some patients. Over the years, muscle-sparing laminotomies and other less invasive decompressive techniques have been developed to lower soft-tissue trauma while preserving the neural benefit. [5–9]
Beyond nerve decompression, modern practice considers spinal balance. Spinopelvic parameters — pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis — describe how the spine and pelvis align in the sagittal plane and influence load distribution and long-term mechanical pain. In degenerative disease, patients commonly adopt a flexed, antalgic posture; relief of pain may permit a more erect stance and a measurable increase in lumbar lordosis. However, true structural correction depends on reversing degenerative disc collapse, facet arthropathy and muscle degeneration — changes that often cannot be corrected solely by decompression. Reported effects of decompression on sagittal metrics therefore vary: some series show modest improvement in lordosis, whereas others find little change. [10–13]
This uncertainty has important clinical consequences. For patients with clear instability or marked deformity, fusion with realignment may be necessary. For the majority with symptomatic stenosis and at most low-grade spondylolisthesis, the question is whether decompression alone will deliver the functional recovery they need without the added morbidity of fusion. Large cohort studies and randomized trials have demonstrated that decompression reliably reduces leg pain and improves disability and quality of life for many such patients, though a subset will later require fusion for mechanical symptoms or progression. [14, 15, 21]
Measuring both patient-reported outcomes (pain scores, Oswestry Disability Index, general health measures such as SF-36) and standing spinopelvic radiographs before and after surgery provides practical information. It shows whether symptom relief aligns with measurable changes in sagittal balance, and it helps surgeons decide when radiographic findings should push them toward fusion rather than decompression alone. The present work reports a prospective series that tracked validated clinical scores and standardized standing radiographs in patients undergoing lumbar decompression, with the aim of clarifying the relationship between symptomatic recovery and radiographic alignment. [16–20]
Hypothesis
Two linked hypotheses guided the study.
First, in patients with degenerative lumbar canal stenosis — including those with Grade I spondylolisthesis but without clear mechanical instability — decompression alone will produce substantial and sustained reductions in leg and back pain, plus meaningful improvement in disability and overall health. Relief of direct neural compression reduces ongoing nociception and venous congestion of the nerve roots, allowing functional recovery and improved walking tolerance. Previous prospective studies support the expectation that decompression yields clinically important gains on VAS, ODI and general health measures. [7, 14, 15]
Second, measurable restoration of sagittal alignment after decompression will be modest for most patients and will not be essential for clinical recovery. Pain-driven forward-flexed posture and posterior pelvic tilt commonly accompany stenosis; when pain subsides, a degree of postural correction may occur, producing small increases in lumbar lordosis. Yet long-standing structural degeneration — disc height loss, facet arthropathy and fatty change of the paraspinal musculature — limits large or durable radiographic correction without reconstructive measures. Several reports document inconsistent changes in pelvic parameters after decompression, suggesting that functional recovery often occurs even in the absence of major alignment change. [10–13, 16–18]
To test these hypotheses, the study enrolled consecutive, eligible patients who met predefined inclusion criteria (symptomatic degenerative lumbar canal stenosis, age threshold, instability up to Grade I) and excluded those with higher-grade slips, prior fusion, infection or tumour. Each patient underwent decompression appropriate to the pathology (laminotomy, laminectomy or muscle-preserving techniques). Outcome assessment combined validated PROMs — VAS for back and leg pain, ODI for disability, and SF-36 for health-related quality of life — with standardized standing lateral radiographs that included the femoral heads to permit accurate measurement of pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis. [20–22]
Follow-up extended to the medium term and compared baseline and postoperative PROMs and radiographic metrics. The core analytic questions were: how large are the clinical gains after decompression, do spinopelvic parameters change meaningfully, and are radiographic changes correlated with improvements in pain and function? The practical intent was to determine whether decompression-first remains the sound initial strategy for most patients without objective instability, reserving fusion for those with evidence of structural deformity or persistent mechanical symptoms. [21–25]
Discussion
The study observed consistent and clinically meaningful improvement in symptoms and function after lumbar decompression. Patients reported substantial drops in leg and back pain and marked reduction in disability scores; general health measures improved in parallel, reflecting greater mobility and daily independence. These clinical gains mirror those found in prior prospective cohorts and randomized studies that established decompression as the primary surgical treatment for symptomatic stenosis when instability is absent. [7, 14, 23]
On radiographs, changes in lumbar lordosis and pelvic parameters were generally modest. Some patients regained a measure of lordosis as pain relieved and antalgic posture resolved, but the cohort did not show large, uniform corrections of sagittal alignment. Importantly, the magnitude of radiographic change did not consistently predict the degree of functional recovery: many patients with little or no radiographic change experienced large symptomatic benefit, and conversely, radiographic improvement did not guarantee superior clinical outcomes. This dissociation underscores that relief of neural compression — not radiographic perfection — chiefly drives early to medium-term recovery after decompression. [10–12, 16–18]
Several considerations explain why radiographs and symptoms diverge. Decompression directly treats the proximate cause of neurogenic claudication, allowing nerve roots to recover function; this process improves pain and walking even when underlying degenerative deformity remains. Structural features such as disc collapse, facet joint arthropathy and paraspinal muscle atrophy restrict the scope for radiographic correction unless reconstructive procedures are performed. Measurement variability, heterogeneity in the number of levels decompressed, and patient factors (obesity, sarcopenia, and hip or knee compensation) further blur any simple relationship between angle changes and patient function. [11, 21, 22]
Clinically, the findings support a pragmatic approach. For patients whose principal problem is neurologic — leg pain and neurogenic claudication — and who lack clear dynamic instability or marked sagittal deformity, decompression alone is an appropriate initial strategy. It reduces operative morbidity compared with fusion while delivering predictable symptomatic relief. For patients whose predominant complaint is mechanical back pain linked to fixed sagittal imbalance, or those with high pelvic incidence–lumbar lordosis mismatch, fusion and alignment-restoring surgery should be considered to address the structural driver of pain and to prevent late progression. Thus, selection should integrate symptoms, objective instability assessment, radiographic measures and the patient’s functional goals. [23–25]
Limitations include single-centre design, potential selection bias, variability of surgical technique and medium-term rather than long-term follow-up. Radiographic measurement error and absence of quantitative paraspinal muscle assessment are additional constraints. Nonetheless, the results add to the body of evidence demonstrating that decompression alone provides meaningful symptom relief for the majority of appropriately selected patients and that substantial radiographic correction is not a necessary precondition for clinical benefit.
Clinical importance
Decompression without fusion reliably reduces leg pain, improves walking capacity and enhances quality of life in patients with degenerative lumbar canal stenosis and Grade I or absent spondylolisthesis when objective instability is not present. Prioritizing symptom-driven indications and validated patient-reported outcomes keeps decision-making focused on what matters to patients: less pain and better function. Fusion remains important for those with fixed deformity, progressive slip or predominant mechanical back pain, but for many patients a decompression-first pathway minimizes surgical risk while achieving the desired clinical goals. [21–24]
Future direction
Randomized, multicentre trials comparing decompression alone with decompression plus fusion in patients with borderline sagittal parameters are needed to define thresholds that justify adding fusion. Longer follow-up with objective measures — quantitative MRI of paraspinal muscles, gait analysis and standardized PROMs — will improve the ability to predict who will regain upright posture after decompression and who will progress to mechanical failure, enabling more precise, individualized surgical planning. [23–25]
References
1. Ferguson SA, Merryweather A, Thiese MS, Hegmann KT, Lu ML, Kapellusch JM, et al. Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States. BMC Musculoskelet Disord. 2019; 20(1):1–8.
2. Magras I, Athanasiou A, Magra V. Lumbar spinal stenosis. Spine Surg A Case-Based Approach. 2019; 77–80.
3. Botwin KP, Gruber RD. Lumbar spinal stenosis: Anatomy and pathogenesis. Phys Med Rehabil Clin N Am. 2003; 14(1):1–15.
4. Divi SN, Goyal DKC, Bowles DR, Mujica VE, Guzek R, Kaye ID, et al. How do spinopelvic parameters influence patient-reported outcome measurements after lumbar decompression? Spine J. 2020; 20(10):1610–7.
5. Hatakka J, Pernaa K, Rantakokko J, Laaksonen I, Saltychev M. Effect of lumbar laminectomy on spinal sagittal alignment: a systematic review. Eur Spine J. 2021; 30(9):2413–26.
6. Shin EK, Kim CH, Chung CK, Choi Y, Yim D, Jung W, et al. Sagittal imbalance in patients with lumbar spinal stenosis and outcomes after simple decompression surgery. Spine J. 2017; 17(2):175–82.
7. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical evaluation and self-assessment by patients after decompression surgery for degenerative lumbar canal stenosis. Spine J. 2008; 8(2):380–4.
8. Ghobrial GM, Al-Saiegh F, Heller J. Spinopelvic Balance. Oper Tech Spine Surg. 2018; 2(8):281–7.
9. Anna I, Gemma V-C, David C, Augusto C, Enric C, Ana Garcia DF, et al. Lumbar lordosis in patients undergoing non-instrumented spinal stenosis. Int J Spine Res. 2021; 3:004–10.
10. Liang C, Sun J, Cui X, Jiang Z, Zhang W, Li T. Spinal sagittal imbalance in patients with lumbar disc herniation: Its spinopelvic characteristics, strength changes of the spinal musculature and natural history after lumbar discectomy. BMC Musculoskelet Disord. 2016; 17(1):1–8.
11. Jeon CH, Lee HD, Lee YS, Seo HS, Chung NS. Change in Sagittal Profiles after Decompressive Laminectomy in Patients with Lumbar Spinal Canal Stenosis: A 2-Year Preliminary Report. Spine. 2015; 40(5):E279–85.
12. Kirkaldy-Willis WH. The three-joint complex and the pathogenesis of backache. J Bone Joint Surg Br. 1982; 64-B: 178–86.
13. Ashley P. Historical perspectives in spinal surgery. J Neurosurg. 1985; 62:394–8.
14. Genevay S, Atlas SJ. Lumbar Spinal Stenosis. Best Pract Res Clin Rheumatol. 2010; 24(2):253–65.
15. Postacchini F. Management of lumbar spinal stenosis. J Bone Joint Surg Br. 1996; 78(1):154–64.
16. Shenouda EF, Gill SS, Laing R, Johnston R. Laminal fenestration for the treatment of lumbar nerve root foraminal stenosis. Br J Neurosurg. 2002; 16(5):494–6.
17. Sengupta DK, Herkowitz HN. Lumbar spinal stenosis: Treatment strategies and indications for surgery. Orthop Clin North Am. 2003; 34(2):281–95.
18. Watanabe K, Hosoya T, Shiraishi T, Matsumoto M, Chiba K, Toyama Y. Lumbar spinous process-splitting laminectomy for lumbar canal stenosis. J Neurosurg Spine. 2005; 3(5):405–8.
19. Lin SM, Tseng SH, Yang JC, Tu CC. Chimney sublaminar decompression for degenerative lumbar spinal stenosis. J Neurosurg Spine. 2006; 4(5):359–64.
20. Benz RJ, Garfin SR. Current techniques of decompression of the lumbar spine. Clin Orthop Relat Res. 2001; 384:75–81.
21. Elder BD, Witham TF. Low Back Pain and Spondylosis. Semin Neurol. 2016; 36(5):456–61.
22. Ills A W, Olivieri S. Aging and musculoskeletal function. Aging Ment Health. 1998; 2:344–8.
23. Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE. Surgical and nonsurgical management of lumbar spinal stenosis: Four-year outcomes from the Maine lumbar spine study. Spine. 2000; 25(5):556–62.
24. Thomé C, Zevgaridis D, Leheta O, Bäzner H, Pöckler-Schöniger C, Wöhrle J, et al. Outcome after less-invasive decompression of lumbar spinal stenosis: a randomized comparison of unilateral laminotomy, bilateral laminotomy, and laminectomy. J Neurosurg Spine. 2005; 3(2):129–41.
25. Hatta Y, Shiraishi T, Sakamoto A, Yato Y, Harada T, Mikami Y, et al. Muscle-preserving interlaminar decompression for the lumbar spine: A minimally invasive new procedure for lumbar spinal canal stenosis. Spine. 2009; 34(8):276–80.
| How to Cite this Article: Jaiswal R, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P. The Spinopelvic Alignment Hypothesis: Does Optimal PI–LL and PT Restoration Drive Better Patient-Reported Outcomes after Laminectomy?. Journal of Medical Thesis. 2025 July-December; 11(2):3-6. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022
Full Text PDF | Full Text HTML
Predictors of Early Mortality Following Proximal Femoral Nailing for Intertrochanteric Hip Fractures in Patients Aged ≥65 Years
Vol 11 | Issue 2 | July-December 2025 | page: 26-29 | Prithviraj Patil, Ashok Shyam, Rajeev Joshi, Sahil Sanghavi, Mahavir Dugad, Darshan Sonawane, Parag Sancheti
https://doi.org/10.13107/jmt.2025.v11.i02.270
Author: Prithviraj Patil [1], Ashok Shyam [1], Rajeev Joshi [1], Sahil Sanghavi [1], Mahavir Dugad [1], Darshan Sonawane [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivaji- nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Prithviraj Patil,
Sancheti Institute for Orthopaedics and Rehabilitation PG College, 16, Shivajinagar, Pune -411005, Maharashtra, India.
E-mail: prithvipatil777@gmail.com
Abstract
Background: Hip fractures in older adults cause high morbidity and mortality and demand coordinated care.
Methods: We analyzed a cohort of consecutive patients aged 65 years and older with intertrochanteric femur fractures treated with proximal femoral nail at a tertiary care center between 2017 and 2020. Demographics, comorbidities, pre-injury mobility, perioperative details and early complications were prospectively recorded. Patients were followed at six weeks, three months, six months and twelve months. Primary outcome was mortality at 12 months; secondary outcomes included Harris Hip Score, SF-36, VAS pain and ambulatory status.
Results: Among 284 patients (median age 75 years), overall one-year mortality was 15% with most deaths occurring in the first three months. Advanced age, presence of medical comorbidity—particularly diabetes—reduced pre-injury mobility and longer hospital stay were associated with higher mortality. Delirium and cardiorespiratory complications were frequent early events.
Conclusion: Early identification of high-risk patients, timely surgery when appropriate, focused medical optimization especially for cardiorespiratory disease and diabetes, delirium prevention, and early structured rehabilitation are practical targets to reduce early mortality and improve function after intertrochanteric fracture treated with proximal femoral nail.
Keywords: Hip fracture, Proximal femoral nail, Geriatric orthopedics, Mortality, Functional outcome, Orthogeriatric care.
Introduction
Hip fractures have become a major public health problem as population’s age, producing substantial mortality, loss of independence, rising healthcare costs and a heavy burden on caregivers. Most hip fractures in older adults follow low-energy domestic falls, with the intertrochanteric pattern being particularly common. Intramedullary fixation using a proximal femoral nail aims to obtain stable fixation and permit early mobilization, but patient outcomes vary widely depending on baseline health and the perioperative course. Observational series and registry analyses have repeatedly shown that advanced age, Multimorbidity, cognitive impairment and limited pre-injury mobility are among the strongest determinants of short- and long-term outcome after hip fracture [1][2][3]. System factors matter too: delays to definitive surgery and prolonged hospitalization worsen outcomes in many series and are often addressable through process improvement [4] [5].
Recognizing which patients are at highest risk at the time of admission allows teams to prioritize medical optimization, geriatric input and early rehabilitation. Simple bedside assessments of function and comorbidity burden can guide allocation of scarce resources and inform realistic conversations with families about expected recovery. Using the institutional dataset from the attached thesis, this manuscript examines patient and perioperative factors associated with one-year mortality after proximal femoral nailing for intertrochanteric fractures. Our goal is practical: to identify modifiable targets and triage indicators that clinicians and care systems can act upon immediately to reduce early complications and preserve independence in this vulnerable population.
Review of literature
Studies across regions consistently identify age, comorbidity burden and baseline mobility as the dominant predictors of mortality after hip fracture [4] [5] [6]. Many observational analyses have explored whether reducing time to surgery lowers mortality and complications; the majority report benefits when surgery occurs early—often within 24–48 hours—though randomized data remain limited and confounding is possible [7][8]. Specific chronic conditions, particularly cardiorespiratory disease, renal impairment and active malignancy, are linked to higher perioperative and one-year mortality [9] [10]. Delirium is a common, prognostically important postoperative complication; it extends hospital stay, impairs participation in rehabilitation and is associated with increased mortality, making prevention and early management a priority [11] [12]. Pre-injury function, most simply measured by the ability to ambulate outside the home, is a strong, reproducible predictor of recovery and survival and serves as an efficient triage tool on admission [13] [14]. Integrated orthogeriatric models—where geriatricians and orthopedic teams co-manage patients—have shown promise in observational program evaluations, reducing delays, minimizing complications and improving functional outcomes when implemented effectively [5][15]. While regional variation in outcomes exists and many prognostic scores require broader validation, the literature supports focusing on perioperative processes (timely surgery, delirium prevention, early mobilization) and tailored management of key comorbidities to improve survival and function after hip fracture. Local, center-specific data therefore remain valuable to adapt these general principles to available resources and patient profiles.
Materials & Methods
This retrospective analysis used prospectively collected records from a tertiary referral centre. Patients aged 65 years and older admitted with traumatic intertrochanteric femur fractures and treated with proximal femoral nail between 2017 and 2020 were eligible. Exclusion criteria were intracapsular femoral neck fractures, pathological fractures, polytrauma and prior ipsilateral hip implants. Data extracted included age, sex, body mass index, comorbidities (including diabetes, ischemic heart disease, chronic lung disease and renal impairment), medication use, pre-injury ambulatory status (household versus social), laboratory results and radiographic classification.
Preoperative management focused on correcting reversible medical issues and obtaining anesthetic clearance. Operations used a standardized intramedullary nailing technique under fluoroscopic guidance with cephalomedullary fixation and distal locking; anesthesia was spinal or general per clinical indication. Postoperative care emphasized early physiotherapy, thromboembolism prophylaxis where appropriate, standardized wound checks and routine clinical review at six weeks, three months, six months and twelve months. Outcomes recorded were mortality at three, six and twelve months, Harris Hip Score, SF-36 domains, visual analogue pain score and ambulatory status. Complications such as delirium, infection, anemia requiring transfusion and cardiopulmonary events were recorded.
Descriptive statistics summarized baseline characteristics. Kaplan–Meier methods described survival over the first year and Cox proportional hazards models explored independent predictors of mortality. The study used only material from the attached thesis dataset and was carried out under the institutional approvals reported in that document.
Results
From 2017 to 2020, 284 patients met inclusion criteria. Median age was 75 years (IQR 70–83); sex distribution was essentially equal (143 male, 141 female). All injuries followed low-energy domestic falls. Median hospital stay was six days (IQR 5–8). Overall one-year mortality was 15% (41 of 284), with 14 deaths by three months and 25 by six months. One or more comorbidities were present in 160 patients (56%); diabetes was present in 49 patients and contributed disproportionately to deaths. Pre-injury ambulatory status was household-only in 182 patients and social in 102; mortality was notably higher among household ambulators. Complications occurred in 82 patients (28%), with delirium, anemia requiring transfusion and cardiorespiratory events being most common. Survivors demonstrated a decline in function early after injury with partial recovery by twelve months, but a subset did not return to baseline mobility. (No references cited in Results.)
Discussion
This single-center series confirms that one-year mortality after proximal femoral nailing for intertrochanteric fracture remains clinically important — 15% in our cohort — and that the risk is concentrated in the early postoperative months. The clustering of deaths in the first three months mirrors many prior analyses and reflects an interplay of limited physiologic reserve, acute medical complications and inability to participate effectively in rehabilitation [16][17]. Advanced age was strongly associated with higher mortality; older patients have less physiologic resilience and a higher prevalence of Multimorbidity, both of which increase vulnerability to perioperative decompensation.
Pre-injury mobility emerged as one of the clearest prognostic indicators. Patients restricted to household ambulation before injury experienced substantially worse survival than social ambulators. This simple clinical observation is valuable: a brief functional screen at admission identifies those most likely to benefit from early geriatric input, aggressive medical optimization and prioritized rehabilitation resources. In practical terms, admitting teams should flag household-only ambulators for immediate multidisciplinary review.
Comorbidity burden — particularly diabetes and cardiorespiratory disease — was a major driver of early mortality in this cohort. The disproportionate number of deaths among patients with diabetes suggests that tighter perioperative metabolic control and attention to glycemic variability may be actionable targets. Likewise, proactive cardiopulmonary optimization, perioperative monitoring and low threshold for specialist input are prudent for patients with known heart or lung disease. These approaches align with the literature that highlights specific chronic conditions as strong predictors of adverse outcomes after hip fracture [9][10].
Delirium was common and frequently preceded clinical deterioration. Prevention strategies (orientation protocols, sleep hygiene, minimizing deliriogenic medications), early recognition and multidisciplinary management are low-cost, high-yield interventions that reduce length of stay and may improve survival and function [11][12]. Early mobilization — even assisted bedside activity on the first postoperative day when feasible — reduces the cascade of complications that lead to decline; programs that emphasize immediate physiotherapy have been associated with lower short-term mortality and improved functional recovery [17][18].
Longer hospital stay was associated with higher mortality in our data. Although causality is complex — complications both extend admission and reflect underlying severity — streamlining pathways so that lower-risk patients proceed promptly through perioperative care and rehabilitation may reduce exposure to nosocomial risks and accelerate return to community supports. Time-to-surgery is a modifiable process metric; where delays are system-driven rather than clinically necessary, reducing time to definitive fixation should be a quality priority [7][8].
Orthogeriatric co-management programs provide a model for implementing these principles at scale. Combining geriatric assessment, proactive management of comorbidities, delirium prevention, nutritional support and structured early rehabilitation shortens delays and reduces complications in many program evaluations [5][15]. Implementing such a model locally requires leadership, clear protocols, staff training, and measurement of key process indicators — for example, median time-to-surgery, early mobilization rates and incidence of postoperative delirium. Continuous audit and iterative improvement help teams identify bottlenecks and test targeted interventions.
This study has limitations. Its single-center, observational design limits causal inference and generalizability. Cause-of-death data were incomplete in a subset of patients, constraining precise attribution. The cohort reflects care where intramedullary nailing is the predominant modality for intertrochanteric fractures; outcomes may differ where arthroplasty is used more widely for unstable patterns or in selected patients. Strengths include prospective data collection within the thesis database, standardized operative technique, and systematic one-year follow up.
Future pragmatic research should evaluate bundled interventions — metabolic optimization, delirium prevention and early mobilization within orthogeriatric frameworks — using stepped-wedge or multicenter designs to assess effectiveness across systems and populations [19] [20]. Economic evaluation will be important to guide resource allocation, since even modest reductions in early mortality and disability translate into meaningful savings and improved quality of life at a population level. In the meantime, clinicians can act now: prioritize geriatric screening on admission, expedite evaluation and surgery when appropriate, manage comorbidities proactively and start rehabilitation early to support recovery.
Conclusion
In this cohort of 284 geriatric patients with intertrochanteric fractures treated by proximal femoral nailing, one-year mortality was 15% and concentrated in the early postoperative months. Advanced age, comorbidity (particularly diabetes), lower baseline mobility and longer hospital stays were associated with higher risk. Practical, immediately actionable steps include routine geriatric screening at admission, prioritized optimization for patients with major comorbidities, strict delirium prevention and early structured rehabilitation aimed at restoring mobility. Adoption of orthogeriatric co-management pathways and measurement of process metrics such as time-to-surgery and early mobilization rates are reasonable institutional priorities. Further pragmatic multicenter evaluations of bundled perioperative interventions are warranted to confirm the best approaches to reduce early mortality and preserve function in older hip fracture patients.
References
1. Scott Braithwaite R, et al. Estimating Hip Fracture Morbidity, Mortality and Costs. J Am Geriatr Soc. 2003; 51:364–370.
2. Downey C, et al. Changing trends in the mortality rate at 1-year post hip fracture – a systematic review. World J Orthop. 2019; DOI:10.5312/wjo.v10.i3.166.
3. Colais P, et al. The effect of early surgery after hip fracture on 1-year mortality. BMC Geriatr. 2015; 15:141. DOI: 10.1186/s12877-015-0140-y.
4. Cenzer IS, Tang V, Boscardin WJ, Smith AK, Ritchie C, Wallhagen MI, et al. One-year mortality after hip fracture: Development and validation of a prognostic index. J Am Geriatr Soc. 2016; 64:1863–1868.
5. Folbert EC, Hegeman JH, Vermeer M, Regtuijt EM, van der Velde D, Ten Duis HJ, et al. Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment. Osteoporos Int. 2017; 28:269–277.
6. Geiger F, Zimmermann-Stenzel M, Heisel C, Lehner B, Daecke W. Trochanteric fractures in the elderly: The influence of primary hip arthroplasty on 1-year mortality. Arch Orthop Trauma Surg. 2007; 127:959.
7. Jiang HX, Majumdar SR, Dick DA, Moreau M, Raso J, Otto DD, et al. Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures. J Bone Miner Res. 2005; 20:494–500.
8. Bass E, French DD, Bradham DD, Rubenstein LZ. Risk-adjusted mortality rates of elderly veterans with hip fractures. Ann Epidemiol. 2007; 17:514–519.
9. Forsen L, Sogaard AJ, Meyer HE, Edna T, Kopjar B. Survival after hip fracture: Short- and long-term excess mortality according to age and gender. Osteoporos Int. 1999; 10:73–78.
10. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop Relat Res. 1984:45–56.
11. Beringer TR, Clarke J, Elliott JR, Marsh DR, Heyburn G, Steele IC. Outcome following proximal femoral fracture in Northern Ireland. Ulster Med J. 2006; 75:200–206.
12. Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: Prospective observational cohort study. BMJ. 2005; 331:1374.
13. Hip fracture outcomes in people age 50 and over—background paper (OTA-BPH-120). U.S. Congress, Office of Technology Assessment. Washington, DC: U.S. Government Printing Office; 1994.
14. Schneider EL, Guralnik JM. The aging of America: Impact on health care costs. JAMA. 1990; 263:2335–2340.
15. Banks E, Reeves GK, Beral V, Balkwill A, Liu B, Roddam A, et al. Hip Fracture Incidence in Relation to Age, Menopausal Status, and Age at Menopause: Prospective Analysis. PLoS Med. 2009; DOI:10.1371/journal.pmed.1000181.
16. Gökhan Karademir Y, Bilgin Y, Erşen A, Polat G, Buğet M, Demirel M, Balcı HI. Hip fractures in patients older than 75 years old: Retrospective analysis for prognostic factors. Int J Surg. 2016; DOI:10.1016/j.ijsu.2015.11.009.
17. Foss NB, Kristensen MT, Kehlet H. Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: the cumulated ambulation score. Clin Rehabil. 2006; 20(8):701–708. Doi: 10.1191/0269215506cre987oa.
18. Heiden JJ, Goodin SR, Mormino MA, Siebler JC, Putnam SM, Lyden ER, Tao MA. Early Ambulation After Hip Fracture Surgery Is Associated With Decreased 30-Day Mortality. J Am Acad Orthop Surg. 2021; 29(5):e238–e242. Doi: 10.5435/JAAOS-D-20-00554.
19. Panula J, Pihlajamäki H, Mattila VM, Jaatinen P, Vahlberg T, Aarnio P, Kivelä SL. Mortality and cause of death in hip fracture patients aged 65 or older: a population-based study. BMC Musculoskelet Disord. 2011; 12:105. Doi: 10.1186/1471-2474-12-105.
20. Flikweert ER, Wendt KW, Diercks RL, Izaks GJ, Landsheer D, Stevens M, Reininga IHF. Complications after hip fracture surgery: are they preventable? Eur J Trauma Emerg Surg. 2018; 44(4):573–580. Doi: 10.1007/s00068-017-0826-2.
| How to Cite this Article: Patil P, Shyam A, Joshi R, Sanghavi S, Dugad M, Sonawane D, Sancheti P. Predictors of Early Mortality Following Proximal Femoral Nailing for Intertrochanteric Hip Fractures in Patients Aged ≥65 Years. Journal of Medical Thesis. 2025 July-December; 11(2):26-29. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022
Full Text PDF | Full Text HTML
Functional and Radiological Outcomes of Surgical Management in Radial Head Fractures: A Prospective Cohort Study
Vol 11 | Issue 2 | July-December 2025 | page: 18-21 | Pandurang Magar, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2025.v11.i02.266
Author: Pandurang Magar [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivaji- nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Pandurang Magar,
Sancheti Institute of Orthopaedics and Rehabilitation PG College,Shivaji Nagar, Pune, Maharashtra, India.
E-mail: dr.magarpandurang@gmail.com
Abstract
Background: Radial head fractures impair elbow stability and function when displaced or comminuted. Treatment options—open reduction and internal fixation (ORIF), excision, and radial head arthroplasty—are chosen based on fracture pattern, associated ligament injury and patient demands.
Methods: We reviewed adults with modified Mason II–IV radial head and neck fractures treated surgically at a single centre from 2019–2022. Reconstructible fractures underwent headless screw or low-profile plate fixation; unreconstructible comminuted heads received modular metallic radial head arthroplasty; isolated fragment excision was reserved for low-demand patients. All followed a routine standard rehabilitation protocol and were assessed to at least 12 months. Outcomes included Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score and arcs of motion; radiographs monitored implant position and heterotopic ossification.
Results: Forty patients met inclusion. Arthroplasty showed the most consistent recovery, with lower median DASH scores and reliable restoration of the flexion-extension arc. ORIF produced excellent results when stable anatomic fixation was achieved. Excision yielded more variable outcomes and higher symptom burden.
Conclusion: Preserve the native radial head when stable reconstruction is feasible. If reconstruction cannot restore anatomy and stability, radial head arthroplasty offers predictable functional recovery.
Keywords: Radial head fracture, ORIF, Arthroplasty, Excision, MEPS, DASH.
Introduction
Fractures of the radial head and neck are frequent around the elbow and usually result from a fall onto an outstretched hand. The radial head contributes importantly to elbow stability by resisting valgus and axial loads, and by sharing load transmission through the radiocapitellar joint. When collateral ligaments or the coronoid are injured, the radial head becomes even more critical as a secondary stabilizer. Early approaches sometimes favored excision for badly comminuted fragments, but biomechanical and clinical studies revealed that removing the radial head can permit proximal radial migration, increase valgus instability, and contribute to late pain or distal radioulnar symptoms. For these reasons modern treatment emphasizes preserving the native head when anatomic reduction and stable fixation are achievable, using headless screws or low-profile plates placed within a safe zone to avoid articular impingement. When the radial head is too comminuted to reconstruct or when ligamentous injury cannot be reliably addressed, radial head arthroplasty restores columnar support, maintains radial height and allows early rehabilitation. The decision between fixation and replacement requires careful assessment of fracture pattern, bone quality and associated lesions, as well as patient age and activity expectations. This study reports a single-centre experience comparing outcomes following ORIF, arthroplasty and limited excision for modified Mason II–IV injuries, with the aim of clarifying indications and functional tradeoffs for each strategy. The analysis focuses on MEPS and DASH scores, motion arcs, radiographic findings and complication profiles to provide practical guidance for tailoring treatment to fracture morphology and soft-tissue status [1–4].
Literature review
Mason’s original classification and its later modifications remain a practical foundation for treating radial head fractures because they capture displacement, comminution and the presence of associated injuries such as elbow dislocation or coronoid fractures. Non-displaced injuries generally do well with nonoperative care and early motion, whereas displaced two-part and multi-fragment fractures raise questions about fixation versus resection or replacement [5,6].
Biomechanical work underlines the radial head’s contribution to valgus and axial stability. Experimental studies demonstrate that loss of radial height or excision increases valgus laxity and shifts load to other elbow articulations, which can accelerate degenerative changes. These findings have moved the field away from routine excision toward preservation or reconstruction of the radial column whenever feasible [4,7].
Fixation techniques have improved with the advent of headless compression screws and low-profile plating. Headless screws used across the articular surface in the safe zone provide interfragmentary compression while minimizing prominence in the radiocapitellar articulation. Numerous series report well to excellent outcomes when anatomic reduction and stable fixation are obtained, particularly for two-part fractures and select three-part patterns in younger patients with good bone quality [8–11]. Technical considerations include accurate fragment reduction, avoiding articular screw prominence, and ensuring the implant does not impinge during forearm rotation.
When comminution precludes reliable fixation, radial head arthroplasty is an effective alternative. Modern modular metallic prostheses aim to restore radial length and permit early range of motion. Multicentre and single-centre reports demonstrate that arthroplasty often provides more predictable pain relief and elbow stability than excision for unreconstructible fractures, with acceptable complication rates when implants are correctly sized and soft tissues repaired [12–15]. Implant-specific risks include oversizing (which may cause capitellar overload and restricted motion), metaphyseal mismatch and radiolucent lines around stems, and heterotopic ossification that can limit motion. Careful intraoperative sizing, assessment of radial height and attention to ligament repair reduce these problems [13, 14].
Contemporary practice therefore favors a staged algorithm: attempt fixation when fracture morphology permits interfragmentary compression and secure implant placement; if reconstruction cannot restore radial height and stability, proceed to arthroplasty; reserve excision for isolated, low-demand situations [10, 12, 16–18].
Outcome measures such as MEPS and DASH alongside objective motion arcs provide a useful, reproducible means of comparing strategies. Across reported series, appropriate matching of treatment to fracture type produces well to excellent outcomes for most patients; conversely, mismatched treatment—especially resection in patients with ligamentous compromise—predicts persistent dysfunction and secondary procedures [15–17].
Materials and methods
This mixed retrospective–prospective study included adult patients (age >18 years) with modified Mason type II–IV radial head and neck fractures treated surgically at a single tertiary centre between January 2019 and December 2022. Exclusion criteria were pathological fractures, active infection, and congenital elbow deformity and isolated non-displaced (Mason I) injuries. Institutional ethics approval and written informed consent were obtained.
Preoperative evaluation used standard anteroposterior and lateral elbow radiographs; CT scans were obtained selectively for complex, multi-fragment injuries to assist surgical planning. Routine preoperative laboratory screening and baseline fitness assessments were completed.
Surgical strategy followed an algorithm: reconstructible fractures with two or three fragments permitting compression were treated with headless compression screws or small plates placed in the safe zone; severely comminuted heads or fractures that could not be restored to stable radial height underwent modular metallic radial head arthroplasty; isolated fragment excision was reserved for rare, low-demand patients. Repair of collateral ligaments or coronoid fractures was performed when indicated. Postoperative rehabilitation emphasized early controlled motion, with passive and active-assisted range of motion beginning within two weeks and progressive strengthening as tolerated.
Patients were followed at 6 weeks, 3 months, 6 months and 12 months. Primary outcomes were MEPS and DASH at final follow-up; secondary outcomes included flexion-extension arc and forearm rotation. Radiographs assessed implant position, fracture union and heterotopic ossification. Complications and reoperations were recorded. Data were described using medians and ranges; clinical interpretation focused on functional outcome and complication patterns across ORIF, arthroplasty and excision groups [2, 8, and 15].
Results
Forty patients met inclusion criteria and completed at least 12 months of follow-up. Treatment distribution was 29 radial head arthroplasties, 9 ORIFs (headless screws or small plates) and 2 isolated excisions. Mechanisms were predominantly falls on an outstretched hand. At final review the arthroplasty group showed the most consistent functional recovery: most patients were graded excellent or good by MEPS and the median DASH score was lowest in this group. Median DASH values were approximately 6 for arthroplasty, 11 for fixation and 22 for excision. Mean flexion-extension arcs were about 130° for arthroplasty and fixation groups and approximately 118° for the excision group. Forearm pronation and supination were better preserved after arthroplasty and ORIF than after excision. Radiographs demonstrated occasional radiolucent lines around stems and limited heterotopic ossification in a subset of patients; there were no prosthetic revisions within the first year. Complications were few: one patient in the arthroplasty group reported persistent pain, two patients in the fixation group had symptomatic hardware or restricted motion, and one excision patient remained symptomatic. No neurovascular deficits were recorded at final follow-up.
Discussion
This series supports a morphology-driven approach to radial head fractures. ORIF remains the preferred option when the fracture pattern allows anatomic reduction and stable fixation: appropriately performed fixation preserves the native joint and often results in excellent motion and low disability, echoing multiple series that report good outcomes with headless screw or low-profile plate techniques [8–11]. However, attempting fixation in extensively comminuted fractures risks loss of fixation, symptomatic hardware and persistent instability if interfragmentary compression cannot be reliably obtained.
Radial head arthroplasty provided predictable restoration of columnar support and allowed early mobilization, with lower median DASH scores in our cohort. This aligns with broader literature indicating that arthroplasty is a dependable strategy for unreconstructible fractures and for cases with associated ligamentous injury that would otherwise leave the elbow unstable [12–15]. Implant-related problems—oversizing, capitellar wear, radiolucencies—were uncommon but present; meticulous intraoperative sizing and robust soft-tissue repair reduce these risks [13, 14].
Excision produced the least favorable functional profile in this group, consistent with biomechanical and clinical work warning that simple resection can permit proximal migration and valgus instability, especially if ligamentous injury is not addressed [7,16]. Thus, excision should be restricted to rare, well-selected low-demand patients.
Taken together, our findings support a staged algorithm: attempt ORIF when stable reconstruction can be achieved; if reconstruction cannot restore radial height or elbow stability, proceed to arthroplasty; reserve excision for exceptional situations. Individual patient factors — age, activity level and expectations — must guide final decisions [1, 3, 17–19].
Conclusion
Good management of radial head fractures starts with matching the operation to the fracture pattern and the patient. When the head can be anatomically reduced and fixed securely, ORIF preserves the native joint, allows early movement and most often restores excellent function. For severely comminuted fractures or when ligament injury leaves the elbow unstable, modern radial head prostheses reliably re-establish radial height and stability and permit predictable recovery with early rehabilitation. Simple excision should be reserved for rare, low-demand cases because it can permit proximal radial migration and lead to later instability or pain. Careful intraoperative assessment, correct implant sizing and repair of associated soft-tissue injuries, together with a structured physiotherapy plan, are essential for good results. Shared decision-making with the patient improves satisfaction and adherence postoperatively.
References
1. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954; 42(172):123–32.
2. Pike JM, Athwal GS, Faber KJ, King GJ. Radial head fractures—an update. J Hand Surg Am. 2009; 34(3):557–65.
3. Rosenblatt Y, Athwal GS, Faber KJ. Current recommendations for the treatment of radial head fractures. Orthop Clin North Am. 2008; 39(2):173–85.
4. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983; 11(5):315–9.
5. Johnston GW. A follow-up of one hundred cases of fracture of the head of the radius. Ulster Med J. 1962; 31(1):51–5.
6. Davidson PA, Moseley JB Jr, Tullos HS. Radial head fracture: a potentially complex injury. Clin Orthop Relat Res. 1993 ;( 297):224–30.
7. Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation. J Bone Joint Surg Br. 1951; 33(2):244–7.
8. Demiroglu M, Ozturk K, Baydar M, et al. Results of screw fixation in Mason type II radial head fractures. SpringerPlus. 2016; 5:1–7.
9. Hotchkiss RN. Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg. 1997; 5(1):1–10.
10. Duckworth AD, Watson BS, Will EM, et al. Radial head and neck fractures: functional results and predictors of outcome. J Trauma Acute Care Surg. 2011; 71(3):643–8.
11. Åkesson T, Herbertsson P, Josefsson PO, et al. Primary nonoperative treatment of moderately displaced two-part fractures of the radial head. J Bone Joint Surg Am. 2006; 88(9):1909–14.
12. Duckworth AD, McQueen MM. Surgical options and outcomes in comminuted radial head fractures. J Shoulder Elbow Surg. 2014; 23(1):S50–7.
13. Zarattini G, Galli S, Marchese M, et al. Surgical treatment of isolated Mason type 2 radial head fractures: resection versus ORIF. J Orthop Trauma. 2012; 26(4):229–35.
14. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987 ;( 216):109–19.
15. Morrey BF. The elbow and its disorders. 3rd ed. Philadelphia: WB Saunders; 2000.
16. Essex-Lopresti P. (relevant biomechanical observations and clinical implications). J Bone Joint Surg Br. 1951; 33(2):244–7.
17. Serrano KD, Rebella GS, Sansone JM, Kim MK. Posterior interosseous nerve palsy associated with radial head fracture: a rare case. J Emerg Med. 2012; 43(2):e115–7.
18. Schatzker J. The rationale of operative fracture care. 2nd ed. Springer; 1996.
19. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984; 66(1):114–23.
| How to Cite this Article: Magar P, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P. Functional and Radiological Outcomes of Surgical Management in Radial Head Fractures: A Prospective Cohort Study. Journal of Medical Thesis. 2025 July-December; 11(2):18-21. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022
Full Text PDF | Full Text HTML
Clinical and Radiological Outcomes of Open Reduction and Plate Fixation for Displaced Midshaft Clavicle Fractures: A Single-Centre Series
Vol 11 | Issue 2 | July-December 2025 | page: 10-13 | Akhil Chauhan, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2025.v11.i02.262
Author: Akhil Chauhan [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivajinagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Akhil Chauhan
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivajinagar, Pune, Maharashtra, India.
E-mail: akhilchauhan94@gmail.com
Abstract
Background: Displaced midshaft clavicle fractures often heal poorly with conservative care and may result in malunion, nonunion or persistent shoulder dysfunction. This study reports outcomes after open reduction and plate fixation.
Methods: Thirty adults with displaced midshaft clavicle fractures treated between July 2019 and December 2021 underwent plate osteosynthesis via an anterosuperior approach. A standardized rehabilitation protocol was followed. Patients were reviewed at 6 weeks, 3, 6 and 12 months with radiographs, VAS pain scoring and validated functional measures (Constant, UCLA, and SF-36). Intraoperative details and complications were recorded.
Results: All patients united radiologically by final follow-up. Median age was 32 years. Functional scores improved steadily, with median Constant scores around 80–85 and UCLA scores in the mid-30s at one year. Median VAS pain scores fell to low values. No deep infections, implant failures or nonunion occurred. Two patients experienced symptomatic implant prominence managed without immediate surgery. Median operative time was approximately 50 minutes with minimal blood loss recorded.
Conclusion: Plate fixation reliably restored clavicular length and alignment in selected displaced midshaft fractures, produced predictable union and satisfactory shoulder function, and allowed early mobilization. Preoperative counselling about possible implant irritation remains essential.
Keywords: Clavicle fracture, Midshaft, Plate fixation, Union, Functional outcome
Introduction
Clavicle fractures are a frequent injury in orthopaedic practice, most commonly affecting the middle third of the bone. The clavicle’s curved shape and its superficial position beneath the skin make it particularly prone to displacement after direct shoulder impact or high-energy trauma. In many cases, minor fractures heal well without surgery, but when the midshaft fragment is significantly displaced, shortened or comminuted, conservative treatment has been shown to produce disappointing outcomes in a notable proportion of patients. These outcomes include symptomatic malunion, nonunion and persistent shoulder dysfunction, especially in active adults and those with high functional demands. [1–6]
Surgical fixation aims to restore the clavicle’s length, alignment and rotation so that shoulder mechanics are re-established and pain and disability resolve more predictably. The two main operative approaches are plate osteosynthesis and intramedullary fixation. Plating provides strong cortical purchase and excellent control of rotation and length, making it preferable in comminuted or segmental fractures; however, plates sit directly under thin soft tissue and can be prominent or bothersome. Intramedullary nails or elastic devices require smaller incisions and preserve more soft tissue, offering cosmetic and early comfort advantages in suitable patterns, but they may provide less rotational stability in complex fracture configurations and occasionally migrate. [7–12]
Recent comparative studies and reviews suggest that, for markedly displaced midshaft fractures, operative fixation reduces the risk of nonunion and often speeds functional recovery compared with nonoperative management, albeit at the expense of implant-related complaints in some patients. Given these trade-offs, modern practice tends to be selective: nonoperative care for minimally displaced, stable fractures, and operative fixation—commonly plate fixation—for displaced, shortened or comminuted midshaft injuries in active patients who want a reliable, timely return to function. This series reports outcomes after open reduction and plate fixation, focusing on union, functional recovery, pain and complications to inform shared decision making. [13–16]
Review of literature
Epidemiological studies show the midshaft as the most commonly fractured segment of the clavicle; mechanisms include direct blows to the shoulder and road-traffic or sports injuries. Early outcome reports noted low absolute nonunion rates after conservative care, but closer analysis revealed that completely displaced or significantly shortened midshaft fractures were at increased risk of symptomatic malunion and functional deficit. Those observations prompted randomized trials and cohort studies that compared nonoperative management with surgical fixation. [1–5]
Classification systems remain useful clinical tools. Simple schemes that group fractures by location are practical for routine care, while more detailed systems help identify fracture patterns less likely to do well without fixation. This aids prognostication and helps surgeons choose between conservative and operative approaches. [2,3]
Plating restores length and resists bending and torsional forces; it is especially valuable in comminuted or segmental fractures where maintaining reduction is otherwise difficult. Modern precontoured and locking plates aim to lower prominence and mechanical failure, but hardware irritation under thin soft tissue remains a real concern. Intramedullary fixation preserves periosteal blood supply and soft tissue, often using smaller incisions and producing early comfort in simple transverse fractures; however, nails give less rotational control in multifragmentary patterns and carry a small risk of migration. [7–12]
Systematic reviews and meta-analyses that pool randomized and observational trials indicate that surgery—especially plating—for displaced midshaft fractures reduces nonunion risk and can speed early functional recovery, though implant-related problems and subsequent operations for hardware removal are commonly reported. Taken together, the literature advocates a tailored approach: conservative care for stable, minimally displaced fractures and operative fixation for displaced, shortened or comminuted midshaft fractures in active patients willing to accept implant-related trade-offs. [13–19]
Materials and Methods
This single-centre series combined prospective and retrospective data from thirty adult patients treated with open reduction and plate fixation for displaced midshaft clavicle fractures between July 2019 and December 2021. Patients were included if they were over 18 years old and had displacement or shortening greater than 20 mm, marked comminution, segmental fracture patterns, floating shoulder or evident scapular malposition. Exclusions were presenting neurovascular injury, local infection, or inability to comply with postoperative follow-up.
All patients underwent clinical assessment and standard radiographs prior to surgery. Routine blood tests and anaesthesia fitness were confirmed. Procedures were performed under general anaesthesia with the patient in the beach-chair position. An anterosuperior transverse approach centred over the fracture was used in most cases. Careful soft-tissue dissection preserved the clavipectoral fascia and supraclavicular nerve branches when possible. Reduction was achieved with pointed bone clamps and provisional fixation (small fragment screws) where helpful. A contoured reconstruction or anatomically precontoured locking plate was applied to restore length and control rotation; cortical or locking screws were used as indicated and screw lengths checked under fluoroscopy to avoid joint penetration and minimise prominence.
Postoperative care included short sling immobilisation with early pendulum and passive range-of-motion exercises, followed by a graduated physiotherapy programme. Follow-up visits were at 6 weeks, 3 months, 6 months and 12 months with serial radiographs and assessments of shoulder range of motion, pain by visual analogue scale (VAS) and validated functional instruments (Constant and UCLA scores; SF-36 for general health). Intraoperative data (operative time, estimated blood loss) and any complications were prospectively recorded. Institutional ethics approval and informed consent were obtained for all patients.
Results
Thirty consecutive patients met the inclusion criteria and underwent open reduction with plate fixation. The cohort’s median age was 32 years (range 19–64); 22 were male and eight female. Road-traffic accidents were the predominant cause of injury. The median interval from injury to surgery was about 36 hours. Mean operative time averaged roughly 50 minutes and blood loss was minimal in most cases.
Radiographic callus formation was commonly visible between six and twelve weeks, and all patients achieved radiological union by final review. Functional recovery improved steadily: median Constant scores at one year were around 80–85 and UCLA scores clustered in the mid-30s. Pain scores fell sharply from preoperative levels, with median VAS near minimal values at 12 months. There were no deep infections, implant failures or nonunions recorded in this series. Two patients reported symptomatic implant prominence; both were managed conservatively without immediate return to the operating room. The majority returned to their previous daily activities and work and expressed satisfaction with the cosmetic and functional results.
Discussion
This series reinforces that plate fixation offers predictable restoration of clavicular length and alignment and leads to reliable union and satisfactory shoulder function in selected displaced midshaft fractures. The rigidity and rotational control conferred by plating are especially valuable in comminuted and segmental injuries, where maintaining accurate reduction is crucial for restoring shoulder mechanics and avoiding symptomatic malunion. [10–12] Intramedullary techniques remain useful for simple transverse fractures because they preserve soft tissues and often result in smaller wounds and early comfort, but their lesser rotational stability limits their role in complex patterns and raises concerns about potential migration. [8, 9]
Although operative fixation lowers nonunion risk and can accelerate early functional recovery for markedly displaced fractures, implant-related irritation and hardware prominence are the most frequent drawbacks. Low-profile and precontoured plates and careful intraoperative contouring reduce the incidence of symptomatic implants, but they do not eliminate it; patients should be counselled clearly about the possibility of later implant removal. [14–19]
The strengths of this work include consistent surgical technique, standardized follow-up and the use of validated outcome measures. Limitations include the single-centre setting, modest cohort size and mixed prospective/retrospective design, which may affect generalisability and introduce selection bias. Despite these limitations, the findings align with larger series and meta-analyses that support a selective surgical strategy—typically plating—for displaced midshaft clavicle fractures in active adults who prioritise a reliable, timely return of shoulder function and accept the trade-offs associated with implants. [13–16, 20]
Conclusion
Open reduction and plate fixation of displaced midshaft clavicle fractures produced consistent radiological union and satisfactory functional recovery in this series. Accurate restoration of length and rotation with stable fixation allowed early rehabilitation, significant pain relief and progressive restoration of shoulder motion. Implant prominence remained the principal postoperative nuisance but rarely necessitated immediate reoperation in this cohort. Careful patient selection, meticulous operative technique and frank preoperative counselling about the potential for hardware irritation and possible later removal are essential. Taken together, these results support a selective surgical policy for displaced, shortened or comminuted midshaft clavicle fractures in active adults who seek a predictable and timely return to shoulder function.
References
1. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007; 89:1–10.
2. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968; 58:29–42.
3. Neer CS II. Nonunion of the clavicle. J Am Med Assoc. 1960; 172:1006–1011.
4. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997; 79:537–539.
5. Nowak J, Holgersson M, Larsson S. Sequelae from clavicular fractures are common: a prospective study of 222 patients. Acta Orthop. 2005; 76:496–502.
6. McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006; 88:35–40.
7. McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012; 94:675–684.
8. van der Meijden OA, Houwert RM, Hulsmans M, et al. Operative treatment of dislocated midshaft clavicular fractures: plate or intramedullary nail fixation? A randomized controlled trial. J Bone Joint Surg Am. 2015; 97:613–619.
9. Andrade-Silva FB, Kojima KE, Joeris A, Santos Silva J, Mattar R Jr. Single, superiorly placed reconstruction plate compared with flexible intramedullary nailing for midshaft clavicular fractures: a prospective, randomized controlled trial. J Bone Joint Surg Am. 2015; 97:620–626.
10. Zeng L, Wei H, Liu Y, et al. Titanium elastic nail (TEN) versus reconstruction plate repair of midshaft clavicular fractures: a finite element study. PLoS One. 2015; 10:e0126131.
11. Wilson DJ, Scully WF, Min KS, Harmon TA, Eichinger JK, Arrington ED. Biomechanical analysis of intramedullary vs superior plate fixation of transverse midshaft clavicle fractures. J Shoulder Elbow Surg. 2016; 25:949–953.
12. Ni M, Niu W, Wong DW, Zeng W, Mei J, Zhang. Finite element analysis of locking plate and two types of intramedullary nails for treating midshaft clavicle fractures. Injury. 2016; 47:1618–1623.
13. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD; Evidence-Based Orthopaedic Trauma Working Group. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures. J Orthop Trauma. 2005; 19:504–507.
14. Leroux T, Wasserstein D, Henry P, et al. Rate of and risk factors for reoperations after open reduction and internal fixation of midshaft clavicle fractures: a population-based study. J Bone Joint Surg Am. 2014; 96:1119–1125.
15. VanBeek C, Boselli KJ, Cadet ER, Ahmad CS, Levine WN. Precontoured plating of clavicle fractures: decreased hardware-related complications? Clin Orthop Relat Res. 2011; 469:3337–3343.
16. Wijdicks FJ, Van der Meijden OA, Millett PJ, Verleisdonk EJ, Houwert RM. Systematic review of the complications of plate fixation of clavicle fractures. Arch Orthop Trauma Surg. 2012; 132:617–625.
17. Galdi B, Yoon RS, Choung EW, et al. Anteroinferior 2.7-mm versus 3.5-mm plating for AO/OTA type B clavicle fractures: a comparative cohort study. J Orthop Trauma. 2013; 27:121–125.
18. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures. J Orthop Trauma. 2005; 19:504–507.
19. McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. J Bone Joint Surg Am. 2012; 94:675–684.
20. Collinge C, Devinney S, Herscovici D, DiPasquale T, Sanders R. Anterior-inferior plate fixation of middle-third fractures and nonunions of the clavicle. J Orthop Trauma. 2006; 20:680–686.
| How to Cite this Article: Chauhan A, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P. Functional Outcome of Medial Collateral Ligament Reconstruction Using a SingleTendon Autograft and Suture Anchor: A Prospective Study. Journal of Medical Thesis. 2025 July-December; 11(2):10-13. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022
Full Text PDF | Full Text HTML
Navigating the Labyrinth: Key Considerations for Choosing Your Thesis Topic
Vol 11 | Issue 2 | July-December 2025 | page: 1-2 | Sachin Kale, Shivesh Datta, Ojasv Gehlot, Shweta Taji, Ashok Shyam
https://doi.org/10.13107/jmt.2025.v11.i02.256
Authors: Sachin Kale [1], Shivesh Datta [1], Ojasv Gehlot [1], Shweta Taji [1], Ashok Shyam [2]
[1] Department of Orthopaedics, D Y Patil Hospital, Navi Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Sachin Kale,
Department of Orthopaedics, D Y Patil Hospital, Navi Mumbai, Maharashtra, India.
E-mail:sachinkale@gmail.com
Editorial
The thesis, for many, is the magnum opus of their academic journey – a culmination of years of learning and a testament to intellectual rigor. Yet, before the first word is written or the first experiment conducted, there's a crucial, often daunting, initial step: selecting the topic. This isn't just about picking something that sounds interesting; it's about making a strategic decision that will shape your research experience, influence your academic trajectory, and define your contribution to your chosen field.
So, what are the vital signposts in this intellectual labyrinth?
Follow Your North Star: Passion and Personal Interest
Perhaps the most underestimated factor in thesis topic selection is genuine personal interest. You're about to embark on a marathon, not a sprint, and sustained motivation is your most valuable fuel. Choosing a topic that genuinely excites you, one that keeps you curious even when faced with obstacles, will make the arduous process significantly more bearable, and even enjoyable. Think about the courses that ignited your passion, the unanswered questions that linger in your mind, or the real-world problems you feel compelled to address. A thesis born of genuine curiosity is far more likely to be a successful and fulfilling endeavor.
The "So What?" Factor: Relevance and Significance
While personal interest is your internal compass, relevance and significance are your external validation. Your thesis shouldn't just be an academic exercise; it should aim to contribute meaningfully to your field. Ask yourself: "So what?" Will your research fill a gap in existing literature, challenge a prevailing assumption, offer a fresh perspective on an old problem, or provide new insights? A strong thesis topic addresses unanswered questions or offers novel solutions, ensuring your work resonates beyond the confines of your immediate academic circle.
Ground Control: Feasibility and Scope
Many aspiring researchers, brimming with grand ideas, often fall prey to the allure of overly ambitious topics. This is where feasibility becomes your intellectual anchor. A brilliant idea that cannot be executed is merely an idea.
Scope is paramount. Your topic must be narrow enough to be thoroughly investigated within the time and resources available to you. Resist the temptation to solve all the world's problems in one thesis. Instead, focus on a specific, well-defined research question.
Consider your resources: Can you access the necessary data, whether it's primary qualitative interviews, vast datasets, or specialized laboratory equipment? Is there sufficient existing literature to build upon, but not so much that your contribution becomes redundant? Assess your own expertise and be realistic about what you can learn and accomplish. Most importantly, identify a suitable advisor whose expertise aligns with your chosen area and who is available to provide guidance. Without their mentorship, even the most promising topic can falter.
The Path Forward: Researchability and Methodology
Your chosen topic must lend itself to rigorous researchability. Can you formulate clear, concise, and answerable research questions from it? Moreover, does it align with appropriate methodologies? Whether you're planning a quantitative statistical analysis, a qualitative thematic exploration, or a mixed-methods approach, ensure you have (or can acquire) the necessary skills to execute your chosen methodology effectively. A well-chosen topic naturally guides the methodological choices, ensuring a coherent and robust research design.
A Touch of the New: Originality
While true revolutionary discovery is rare, your thesis should aim for a degree of originality. This doesn't mean inventing a whole new field, but rather offering a novel contribution. Perhaps you're applying an existing theory to a new context, comparing variables not previously examined together, or re-evaluating historical data from a fresh perspective. Your originality is what will distinguish your work and establish your voice within the scholarly conversation.
Looking Ahead: Alignment with Career Goals
While not a strict requirement, considering how your thesis topic might align with your future career goals can be a strategic bonus. Could this research open doors to specific industries, enhance your profile for further academic pursuits, or contribute to a portfolio that showcases your expertise in a desired field? A well-aligned thesis can be a powerful stepping stone beyond graduation.
In essence, selecting a thesis topic is a delicate balance of passion and practicality. It requires introspection, thorough research, and candid conversations with your mentors. By carefully weighing personal interest, relevance, feasibility, researchability, originality, and future aspirations, you can transform this initial hurdle into a foundational stride towards a meaningful and impactful piece of scholarship. Choose wisely, and the journey itself will be as rewarding as the destination.
| How to Cite this Article: Kale S, Datta S, Gehlot O, Taji S, Shyam A. Navigating the Labyrinth: Key Considerations for Choosing Your Thesis Topic. Journal of Medical Thesis. 2025 July-December; 11(2):1-2. |
Full Text HTML | Full Text PDF
