Background/Objectives: Anterior redisplacement, defined as a postoperative anterior shift of the distal fragment despite intraoperative reduction, is occasionally observed after cephalomedullary nailing for trochanteric femoral fractures. However, its incidence and associated risk factors remain unclear. This study aimed to determine the incidence of anterior redisplacement following intramedullary nail fixation in geriatric trochanteric fractures, and to identify independent risk factors. Methods: This study retrospectively reviewed data from 598 consecutive hips in 577 patients (aged ≥65 years) who underwent intramedullary nail fixation for trochanteric fractures at a single center (2012–2023). Sagittal reduction on the lateral radiographic view was classified as posterior, anatomical, or anterior according to the position of the distal fragment, and was recorded preoperatively and postoperatively. Anterior redisplacement, the primary outcome, was defined as a change in alignment from a posterior or anatomical position postoperatively to an anterior position on any subsequent follow-up radiograph. Independent risk factors were identified by logistic regression. Results: Among the 543 hips reduced posteriorly (n = 204) or anatomically (n = 339), anterior redisplacement occurred in 73 (13.4%). The incidence of anterior redisplacement was significantly higher following anatomical compared to posterior reduction (19.5% vs. 3.4%; p < 0.001), and also higher in fractures that were anteriorly aligned preoperatively (18.0%) compared to anatomical (8.5%; p < 0.01) and posterior (6.2%; p < 0.01) alignment. Multivariate analysis revealed two independent predictors: preoperative anterior alignment (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.24–2.81; p = 0.003) and postoperative anatomical (vs. posterior) reduction (OR 6.49, 95% CI 2.92–14.44; p < 0.001). Age, sex, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification, Evans–Jensen classification, nail length, and canal-filling ratio were not associated with redisplacement. No lag-screw cutout occurred during the follow-up. Conclusions: Anterior redisplacement occurred in one of seven geriatric trochanteric fractures despite apparently satisfactory fixation. An anatomical sagittal reduction—traditionally considered “ideal”—increases the risk more than sixfold, whereas a deliberate posterior-buttress is protective. Unlike patient-related risk factors, sagittal reduction is under the surgeon’s control. The study findings provide evidence that choosing a slight posterior bias can significantly improve stability.

Background: Although adequate intraoperative imaging is routinely performed during cephalomedullary nailing for trochanteric femoral fractures, an anterior shift of the distal fragment—referred to as anterior redisplacement—is occasionally observed postoperatively. However, the incidence of this dynamic malalignment and its underlying mechanisms remain unclear. Methods: This study retrospectively reviewed data from 598 consecutive hips in 577 patients (aged ≥65 years) who underwent intramedullary nail fixation for trochanteric fractures at a single center (2012–2023). Sagittal reduction on the lateral radiographic view was classified as posterior, anatomical, or anterior according to the position of the distal fragment, and was recorded both preoperatively and postoperatively. Anterior redisplacement, the primary outcome, was defined as a change in alignment from a posterior or anatomical position postoperatively to an anterior position on any subsequent follow-up radiograph. Independent risk factors were identified by logistic regression. Results: Among the 543 hips reduced posteriorly (n = 204) or anatomically (n = 339), anterior redisplacement occurred in 73 (13.4%). The incidence of anterior redisplacement was significantly higher following anatomical than posterior reduction (19.5% vs 3.4%; p <0.001) and also higher in fractures that were anteriorly aligned preoperatively (18.0%) than in anatomical (8.5%; p <0.01) and posterior (6.2%; p <0.01) alignment. Multivariate analysis revealed two independent predictors: preoperative anterior alignment (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.24–2.81; p = 0.003) and postoperative anatomical (vs posterior) reduction (OR 6.49, 95% CI 2.92–14.44; p <0.001). Age, sex, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification, Jensen classification, nail length, and canal-filling ratio were not associated with redisplacement. No lag-screw cutout occurred during the follow-up. Conclusions: Anterior redisplacement occurred in one of seven geriatric trochanteric fractures despite apparently satisfactory fixation. An anatomical sagittal reduction—traditionally considered “ideal”—increases the risk more than sixfold, whereas a deliberate posterior-buttress is protective. Unlike patient-related risk factors, sagittal reduction is under the surgeon’s control. The study findings provide evidence that choosing a slight posterior bias can significantly improve stability.

Background: Tibial shaft fractures are frequently treated with intramedullary nailing; however, malalignment remains a concern, particularly in proximal metaphyseal fractures. The surgical approach influenced the nail entry point; however, the three-dimensional (3D) geometric characteristics of the entry point among different approaches remain unclear. Methods: This single-center retrospective study included 68 patients with acute tibial shaft fractures (AO/OTA type 42) treated with reamed and locked intramedullary nails from January 2014 to June 2024. The surgical techniques employed included lateral parapatellar (LPA, n = 31), infrapatellar (IPA, n = 27), and suprapatellar (SPA, n = 10) approaches. Postoperative computed tomography (CT) data were reconstructed into standardized 3D images. The mediolateral insertion ratio was calculated as the percentage distance from the lateral tibial plateau edge to the nail entry point relative to the plateau’s width in the coronal plane. The shortest distance from the tibial articular surface to the nail (r) was measured in the sagittal plane. The Kruskal–Wallis test and Dunn’s post hoc comparisons were used to analyze group differences. Results: Baseline patient and fracture characteristics did not significantly differ among the groups. The mediolateral insertion ratio significantly differed (p < 0.0001), with a more lateral entry for the LPA (44.0% [43.0–47.0]) than for the IPA (51.0% [49.0–53.0], post hoc p < 0.0001) and SPA (49.0% [47.0–51.3], post hoc p = 0.0034). Further, the sagittal distance r significantly differed (p < 0.0001), with a more distal entry for the LPA (14.8 [12.8–20.1] mm) than for the IPA (9.7 [7.0–11.8] mm, post hoc p < 0.0001) and SPA (10.5 [5.5–12.9] mm, post hoc p = 0.0008). No statistically significant difference was observed between the IPA and SPA. Conclusions: The LPA generates a significantly more lateral and distal tibial nail entry point than the IPA and SPA. No statistically significant differences were detected between the IPA and SPA in either plane. These 3D-CT findings may warrant attention during approach selection and guidewire placement, particularly for fractures extending into the proximal metaphysis.