Patient & Study Details

• Patient: Yellamma, 85F
• Study: AP Pelvis radiograph
• Operative side: Right proximal femur with intramedullary fixation

Implant Present

• Intramedullary nail shaft running down the femoral diaphysis
• Two cephalic (lag/anti-rotation) screws passing from the nail into the femoral neck and head
• One distal cortical locking screw at the shaft level

Identified Defects and Complications

1. Varus Collapse (Most Significant Finding)

• Severe varus malalignment of the proximal femoral fragment relative to the shaft
• The neck-shaft angle is markedly reduced from normal (~130°), indicating the proximal fragment has collapsed into varus under load
• This is likely secondary to poor initial reduction or failure of the medial calcar to maintain support post-operatively

2. Cephalic Screw Cut-Out (Hardware Failure)

• Classic superior cut-out of the cephalic screws is visible - the screws are positioned superiorly within the femoral head and appear to be migrating through the femoral head cortex
• This is the most common and serious complication of proximal femoral nailing, especially in osteoporotic bone
• The Tip-Apex Distance (TAD) appears to be excessive (poorly positioned screws relative to the apex of the femoral head)

3. Non-Union / Delayed Union

• A persistent wide fracture gap is present at the medial cortex (calcar region) and subtrochanteric zone
• There is a complete lack of medial cortical contact - no calcar buttressing
• No visible callus bridging the fracture site, suggesting non-union or delayed union

4. Medial Calcar Defect / Loss of Medial Support

• Large void/gap at the medial femoral neck and calcar region
• Absence of calcar support is a major contributor to the varus collapse and is a known risk factor for implant failure in intertrochanteric fractures

5. Severe Osteoporosis

• Generalized marked osteopenia/osteoporosis of the entire pelvis and proximal femora bilaterally
• Thin, washed-out cortices
• This is expected in an 85-year-old woman but significantly compromises fixation purchase and healing potential
• Poor bone quality likely contributed to all of the above hardware complications

6. Limb Shortening

• Significant shortening of the right femoral neck and apparent limb length discrepancy as a consequence of the varus collapse and fracture non-union

Left Hip (Incidental)

• The left hip appears to show moderate joint space narrowing, consistent with osteoarthritis
• No acute fracture seen on the left

Summary of Defects

Clinical Implications

• Revision to longer cephalomedullary nail with better screw positioning
• Salvage total hip arthroplasty (THA) - often preferred in ambulatory elderly patients with failed hip fracture fixation
• Optimization of bone health (calcium, vitamin D, anti-resorptive therapy)

Disclaimer: This analysis is based on radiological image review and is intended to support, not replace, clinical assessment by a qualified orthopaedic surgeon. Always correlate with clinical findings and history.