Incidence of Complications in Proximal Femoral Nailing for Comminuted Intertrochanteric Femur Fractures in a Rural Population: A Retrospective Analysis

Background: Unstable intertrochanteric fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) 31-A2 and 31-A3) are technically demanding. In rural care pathways, delays to presentation and surgery, limited implant/operating resources, and restricted access to structured rehabilitation and follow-up may increase the risk of mechanical failure, wound complications, and delayed functional recovery. Methods: We retrospectively screened consecutive adults treated with proximal femoral nailing (PFN) for intertrochanteric femur fractures between January 2024 and December 2025. Stable AO/OTA 31-A1 patterns were excluded by design; only unstable AO/OTA 31-A2 and 31-A3 fractures with ≥6 months follow-up were included. Data were extracted from records and radiographs. The primary outcome was the Modified Harris Hip Score (MHHS) at final follow-up, and the secondary outcomes included time to radiological union and postoperative complications. Results: A total of 128 patients were included, with a mean age of 72.6 ± 9.4 years (55.5% were female, and 67.2% had at least one comorbidity). Fractures were 31-A2 in 78 (60.9%) and 31-A3 in 50 (39.1%). Radiological union was achieved in 120 patients (93.8%), with a mean union time of 12.1 ± 2.9 weeks; delayed union occurred in six (4.7%) and non-union in two (1.6%). Mean follow-up was 15.6 ± 4.9 months. The MHHS at final follow-up was 89.4 ± 8.7 for AO/OTA 31-A2 fractures and 84.8 ± 11.2 for AO/OTA 31-A3 fractures (unadjusted). Excellent or good outcomes were achieved in 103 patients (80.4%). Mechanical complications included Z effect in five (3.9%), screw cutout in seven (5.5%), and varus collapse greater than 5° in nine (7.0%). Surgical site infection occurred in eight (6.3%), and limb length discrepancy greater than 1 cm in 10 (7.8%). Outcomes and complication rates were less favorable in 31-A3 fractures compared with 31-A2 fractures. Conclusion: PFN achieved high union rates and satisfactory functional outcomes in unstable intertrochanteric fractures treated in a rural setting, although mechanical complications and wound issues were observed, particularly in AO/OTA 31-A3 patterns.