Femoral shaft fractures represent a significant burden in orthopaedic trauma, commonly resulting from high-energy mechanisms such as motor vehicle collisions and disproportionately affecting young, active adults [1]. These injuries are a major cause of morbidity due to substantial pain, functional impairment, and the potential for systemic complications [2]. Historically, various methods for managing femoral shaft fractures have been employed, but intramedullary nailing has emerged as the gold-standard surgical intervention for diaphyseal femoral fractures [3]. This preference is attributed to several advantages, including minimal incision, reduced soft tissue dissection, lower rates of infection, non-union, and malunion, as well as shorter hospital stays and rehabilitation periods [4]. The technique also offers excellent union rates, rotational stability, length maintenance, rapid recovery, and early weight-bearing capabilities [4]. Antegrade intramedullary nailing, specifically, is a widely adopted method for treating femoral shaft fractures, demonstrating superior outcomes over other fixation methods in terms of union rates, alignment control, and early mobilization [1,5,6]. It involves inserting a nail into the medullary canal of the femur from a proximal entry point, typically the piriformis fossa [7]. This method is particularly effective for various fracture patterns of the femoral shaft, including those classified by Winquist-Hansen types [5]. Studies have consistently shown high union rates exceeding 95% with contemporary reamed nailing and early weight-bearing protocols, with mean time to radiological union often ranging between 14–18 weeks [2,4,5]. Despite the established efficacy of antegrade intramedullary nailing, attention has increasingly shifted towards evaluating functional outcomes beyond mere bony union. Functional recovery encompasses the restoration of gait mechanics, knee range of motion, limb-length symmetry, and the patient's ability to return to pre-injury activity levels [8]. The assessment of functional outcomes often utilizes validated scoring systems such as the Thoresen score, which integrates objective radiographic parameters (e.g., malalignment, shortening) with patient-reported metrics (pain, range of motion, ambulation) [2]. This comprehensive approach allows for a thorough evaluation of the patient's recovery and the effectiveness of the treatment. For open femoral shaft fractures, particularly Gustilo-Anderson type I and II, closed intramedullary interlocking nailing has shown favourable functional outcomes [9]. Given the evidence, this prospective observational study aimed to evaluate the functional outcomes of femoral shaft fractures managed with antegrade intramedullary interlocking nailing in adult patients. This study provides contemporary data on union rates, limb alignment, and knee function following antegrade intramedullary nailing in an Indian tertiary‐care setting.

Study Design: This study was a prospective observational study conducted to evaluate the functional outcomes of fracture shaft of femur managed with antegrade intramedullary interlocking nailing. Study Duration: The study was carried out over a period of 18 months, with regular postoperative follow-up at 6 weeks, 12 weeks, 24 weeks, and subsequently at 3-month intervals. Study Area: The study was carried out at AIMS & RC hospital, Rajasthan, including patients admitted to the Orthopaedic ward with fracture shaft of femur undergoing surgical management. Study Population: The study population comprised patients presenting with fracture shaft of femur to the inpatient department of the Department of Orthopaedics. Inclusion Criteria: • Adults aged ≥18 years of either sex • Closed fractures and Gustilo-Anderson type I and II open fractures • Patients willing for surgery and providing written informed consent Exclusion Criteria: • Pathological fractures • Fractures not amenable to intramedullary nailing • Associated neurovascular injury or head injury • Previous hip/knee pathology or previous femoral fracture • Delayed union, malunion, or non-union cases • Paediatric and adolescent patients • Gustilo-Anderson type III fractures Sample Size: A total of 56 patients were enrolled in the study. Sampling Methodology: Simple random sampling was used to include all eligible patients during the study period. Data Collection and Procedure: • All patients underwent detailed history taking and clinical evaluation, including assessment of the mechanism of injury and pre-injury functional status. General and local examination was performed to assess deformity, swelling, shortening, neurovascular status, and associated injuries. Radiological evaluation included anteroposterior and lateral X-rays of the entire femur, including the hip and knee joints, along with routine preoperative investigations. • All patients were managed surgically with antegrade intramedullary interlocking nailing under spinal anaesthesia. Patients were positioned supine on a fracture table, and the entry point was made at the piriform fossa under C-arm guidance. Guidewire insertion, fracture reduction, sequential reaming, and nail insertion were performed, followed by distal locking using the freehand technique and proximal locking with a jig. The wound was then closed in layers. • Postoperatively, limbs were elevated and patients received antibiotic therapy. Early mobilization was initiated with ankle and quadriceps exercises, followed by gradual progression from non-weight bearing to partial and full weight bearing. Regular wound care was provided, and sutures were removed on the 12th postoperative day. • Patients were followed up clinically and radiologically at regular intervals. Fracture union was assessed by the presence of bridging callus formation. Functional outcomes were evaluated using the Thoresen et al. [10] classification (Annexure 1), considering parameters such as alignment, limb length discrepancy, range of motion of the knee, and pain or swelling. Data Analysis: • Data were recorded systematically and analysed. • Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables were presented as frequencies and percentages. Ethical Considerations: • Ethical approval was obtained from the Institutional Ethics Committee before the commencement of the study, which followed the Declaration of Helsinki. • Patient confidentiality was strictly maintained by anonymising personal data and securely storing medical information. • Written informed consent was obtained from all patients before inclusion in the study. All surgical interventions followed standard safety protocols, with anaesthesia coverage and post-surgical monitoring provided as per institutional guidelines.

In the present study, a total of 56 patients with fracture shaft of femur were evaluated. The age of patients ranged from 18 to 60 years, with a mean age of 31.54 years. The majority of patients were in the 18–30 years age group (28 patients, 50%), followed by 31–40 years (20 patients, 35.7%), 41–50 years (6 patients, 10.7%), and 51–60 years (2 patients, 3.5%). There was a male predominance, with 37 patients (66.07%) being male and 19 patients (33.92%) female. Road traffic accidents were the most common mode of injury, accounting for 53 cases (94.64%), while falls constituted 3 cases (5.35%). The right side was more frequently involved (39 cases, 69.64%) compared to the left side (17 cases, 30.35%). Winquist-Hansen classification showed that type III fractures were the most common, followed by type II and type I fractures, while type IV fractures were the least common. The majority of patients had a hospital stay of moderate duration, with fewer patients having shorter or prolonged stays. Most patients achieved partial weight bearing within the early postoperative period, and full weight bearing was generally achieved within the subsequent weeks, with only a few requiring longer durations. Radiological union was most commonly observed within the intermediate follow-up period, while delayed union was seen in a small number of cases. Associated injuries included patella fractures, tibial shaft fractures, head injuries, contralateral fractures, and metacarpal fractures, with head injuries being relatively more frequent. The majority of patients achieved full range of motion at the knee, while a smaller proportion had some restriction. Malunion was observed in a few cases, predominantly as valgus deformity followed by varus deformity, with no rotational deformities noted. Most patients had no limb length discrepancy, with only minimal shortening seen in a few cases (Table 1). Table 1: Clinical and Radiological Outcomes Parameter Category n (%) Winquist-Hansen Classification Type I 11 (19.64%) Type II 13 (23.2%) Type III 26 (46.4%) Type IV 6 (10.7%) Duration of Hospital Stay 1–9 days 13 (23.2%) 10–15 days 30 (53.57%) 16–20 days 11 (19.64%) 21–30 days 2 (3.57%) Weight Bearing Partial weight bearing ≤12 weeks 40 (71.4%) Partial weight bearing 13–16 weeks 16 (28.6%) Full weight bearing 13–16 weeks 40 (71.4%) Full weight bearing 17–20 weeks 16 (28.6%) Radiological Union 12–16 weeks 19 (33.9%) 17–20 weeks 22 (39.2%) 21–24 weeks 11 (19.6%) >24 weeks 4 (7.1%) Associated Injuries Ipsilateral patella fracture 3 (5.35%) Ipsilateral tibial shaft fracture 3 (5.35%) Head injury 5 (8.92%) Contralateral IT + proximal tibia fracture 3 (5.35%) Right 3rd metacarpal fracture 3 (5.35%) Knee Range of Motion Full range 39 (69.6%) 0–120° 11 (19.64%) 0–90° 6 (10.71%) Malunion Valgus 4 (7.14%) Varus 2 (3.57%) Rotational deformity 0 (0%) Limb Length Discrepancy None 52 (92.8%) 1 cm 2 (3.57%) 2 cm 2 (3.57%) Associated injuries were managed appropriately with additional surgical interventions. Three patients with ipsilateral patella fractures were treated with tension band wiring. Three patients with ipsilateral tibial shaft fractures underwent intramedullary interlocking nailing. Three patients with right third metacarpal fractures were managed with closed reduction and K-wire fixation. Additionally, three patients with contralateral intertrochanteric femur fractures and proximal tibial fractures were treated with trochanteric femoral nailing and cancellous screw fixation, respectively. There were no cases of non-union observed in the present study. However, delayed union was noted in 2 patients, with fracture union achieved at 32 weeks. One patient developed a superficial infection, which resolved with appropriate antibiotic therapy, and no cases of deep infection were reported. There were no instances of implant failure, including nail or locking bolt breakage. Regarding postoperative symptoms, 3 patients reported sporadic knee pain, while 3 patients experienced significant knee pain following fracture union. The majority of patients had excellent functional outcomes, followed by good results, while a smaller proportion showed fair outcomes. No patients had poor functional outcomes (Table 2). Table 2: Functional Outcome (Thoresen Score) Outcome n (%) Excellent 39 (69.64%) Good 11 (19.64%) Fair 6 (10.71%) Poor 0 (0%) Representative Images: Case 1 – Fig. 1: (A) Preoperative radiograph showing fracture shaft of femur. (B) Immediate postoperative radiograph demonstrating fixation with intramedullary interlocking nail. (C) Follow-up radiograph showing maintained alignment. (D) Radiograph showing fracture union with callus formation. Fig. 2: (A) Clinical photograph showing hip flexion and knee extension. (B) Clinical photograph showing hip and knee extension. (C) Patient in cross-legged sitting position. (D) Patient performing squatting. (E) Patient walking with full weight bearing. Case 2 – Fig. 3: (A) Preoperative radiograph showing fracture shaft of femur. (B) Immediate postoperative radiograph demonstrating fixation with intramedullary interlocking nail. (C) Follow-up radiograph showing maintained alignment. (D) Radiograph showing fracture union. Fig. 4: (A) Clinical photograph showing hip flexion and knee extension. (B) Clinical photograph showing hip and knee extension. (C) Patient in cross-legged sitting position. (D) Patient walking with full weight bearing. Annexure 1: Functional Outcome Scoring • Functional outcomes were graded based on the following parameters and Excellent, Good, Fair, and Poor outcomes are assigned based on combined clinical and radiological assessment. Parameter Excellent Good Fair Poor Malalignment (degrees) Varus/Valgus ≤5° ≤5° ≤10° >10° Antecurvatum/Recurvatum ≤5° ≤10° ≤15° >15° Internal Rotation ≤5° ≤10° ≤15° >15° External Rotation ≤10° ≤15° ≤20° >20° Shortening of Femur ≤1 cm ≤2 cm ≤3 cm >3 cm Range of Motion of Knee Flexion >120° 120° 90° <90° Extension Deficit ≤5° ≤10° ≤15° >15° Pain/Swelling None Mild/Sporadic Significant Severe

In the present series of 56 femoral shaft fractures treated with antegrade intramedullary interlocking nailing, the demographic profile and injury characteristics closely mirror those reported in contemporary literature. The mean patient age was 31.54 years (range 18–60), with 50% of patients in the 18–30 age group and a male predominance of 66.07%. This distribution reflects the typical involvement of young, active individuals in high-energy trauma. Similar findings have been reported by Ali et al. [11], who observed a mean age of 36.9 years with approximately 74% males, while global epidemiological data also demonstrate peak incidence among young adults, particularly males [12]. Comparable mean ages were reported by Jatin et al. [1] (35.7 years) and Patel and Pethapara [13] (33.7 years), while Mert et al. [14] documented a higher male predominance of 79.5%. This consistent demographic pattern underscores the vulnerability of the working-age population to high-velocity injuries. Road traffic accidents were the predominant mode of injury in 94.64% of cases, highlighting the major contribution of high-speed vehicular trauma in developing regions. This finding is comparable to the 95.3% road traffic accidents incidence reported by Ali et al. [11] and higher than the 73.3% reported by Jatin et al. [1], reinforcing the dominance of road traffic accidents as the causative mechanism. The side distribution (69.6% right, 30.4% left) also aligns with findings by Meena et al. [15]. Overall, our cohort characteristics are consistent with other reports from similar settings [11,16], emphasizing the role of high-energy trauma in femoral shaft fractures. In terms of fracture morphology, 46.4% of patients had Winquist-Hansen Type III fractures, indicating a high proportion of comminuted injuries and significant energy transfer at the time of trauma. Despite the inherent challenges in maintaining alignment and length in such fractures, the interlocking mechanism of intramedullary nails provided adequate stability, reflected in the overall favourable outcomes. The duration of hospital stay in our study was moderate, with 53.57% of patients hospitalized for 10–15 days and only 23.2% discharged within 9 days, yielding an average of approximately 12–13 days. This is slightly longer than the weighted mean of 9.3 days reported by Ryan-Coker et al. [16], possibly due to differences in healthcare infrastructure, rehabilitation protocols, and injury severity. Mobilization protocols in our study were cautious yet progressive; 71.4% of patients achieved partial weight-bearing by 12 weeks and full weight-bearing by 13–16 weeks, with the remainder progressing by 17–20 weeks. While pooled literature suggests a mean time to full weight-bearing of 9.4 weeks [16], our findings are comparable to Ali et al. [11], who reported full weight-bearing at 14.2 ± 1.2 weeks. This suggests that rehabilitation timelines may vary depending on fracture complexity and institutional practices. Radiological outcomes in our study were highly satisfactory. By 24 weeks, 92.9% of fractures had united, with only 7.1% demonstrating delayed union. A substantial proportion (39.2%) achieved union between 17–20 weeks, consistent with expected healing timelines. These findings compare favourably with the mean union time of 15.4 weeks and union rate of 88.1% reported in a systematic review [16], as well as with Tiwari et al. [17], who observed a mean union time of 16.87 ± 3.09 weeks. Higher union rates have also been reported by Ali et al. [11] (95.3%) and Burç et al. [18] (90.9%). Notably, no cases of non-union were observed in our series, underscoring the effectiveness of antegrade nailing. Alignment-related complications were minimal. Malunion was observed in 10.7% of cases, slightly higher than the 4.8% reported in pooled data [16], but within acceptable limits given the high proportion of comminuted fractures. Specifically, valgus deformity was seen in 7.14% and varus in 3.57%, with no cases of rotational malalignment. This contrasts with Gadhe and Ghorpade [19], who reported 12.5% rotational deformity with no coronal malalignment, suggesting effective intraoperative rotational control in our series. Limb length discrepancy was minimal, with 92.8% showing no discrepancy and only 7.1% having 1–2 cm shortening. This is slightly higher than the 3.5% reported in pooled analyses [16], but lower than the 20% reported by Meena et al. [15]. Delayed union and LLD rates (3.5% and 7.1%, respectively) were also lower than those reported by Meena et al. [15], likely reflecting the advantages of closed nailing techniques in preserving periosteal blood supply. Comparable LLD rates have been reported by Sahu and Pandey [20] (5.75%). Associated injuries were present in 28.6% of patients, with head injuries being the most common (8.9%). This reflects the polytrauma nature of high-energy femoral fractures and supports the principle of prioritizing life-threatening conditions. Similar patterns have been described by Yoon et al. [21], where femoral fractures frequently indicate systemic trauma. While these associated injuries did not significantly impact union rates, they influenced rehabilitation and delayed weight-bearing in some cases. Postoperative complications were minimal, with no deep infections observed, compared to an average infection rate of 4.8% reported in the literature [16]. Knee range of motion was excellent in 69.6% of patients, while 30.4% had mild restriction. Although this is higher than the average knee stiffness rate of 8% reported in pooled analyses (range 0–33%) [16], it remains within the reported spectrum and may be attributed to stricter assessment criteria and the higher incidence of complex fractures. Functional outcomes assessed by Thoresen’s criteria were favourable, with 69.64% excellent, 19.64% good, and 10.71% fair outcomes, and no poor results. The combined excellent/good rate of approximately 89% compares well with the weighted average of 74.6% excellent outcomes reported in the literature [16]. Although Ali et al. [11] reported a higher excellent rate of 93%, differences in patient demographics and scoring methods may account for this variation. Lower outcomes were reported by Burç et al. [18], with 50% excellent and 13.6% good results, possibly due to differences in surgical approach. Importantly, the absence of poor outcomes in our study aligns with literature reporting 0–5% poor results [11,16]. Functional outcomes correlated closely with radiological and clinical parameters, with patients experiencing malunion or knee stiffness more likely to have fair outcomes. Overall, this study confirms that antegrade reamed intramedullary interlocking nailing is an effective treatment for femoral shaft fractures, demonstrating high union rates, good alignment, low complications, and favourable functional outcomes consistent with global literature. Union time and functional recovery were within accepted standards, and despite minor variations such as occasional malunion or knee stiffness, the absence of non-union and poor outcomes highlights the reliability of this technique.

This study demonstrates that antegrade interlocking intramedullary nailing is an effective and reliable modality for the management of femoral shaft fractures, yielding high union rates, favourable functional outcomes, and low complication rates. While the findings are encouraging, the single-centre design and limited sample size may affect generalisability, and the lack of advanced imaging may underestimate subtle malalignment. Future multicentre, prospective studies with standardized outcome measures and comparisons with alternative techniques are needed to further refine treatment strategies and optimise patient outcomes.

[1] Jatin S, Rasik D, Harsh P. Operative outcomes of antegrade intramedullary ineterlock nailing in femoral shaft fracture: A study of 30 cases. International Journal of Orthopaedics Sciences 2021;7:154–6. https://doi.org/10.22271/ortho.2021.v7.i1c.2474. [2] Sarukte V, Kumar Rai A, Shrinivas Pandurang L, Kumar Shukla A, Bansal D, Sarukte V. Functional outcome following fixation of diaphyseal fracture of femur with closed intramedullary interlocking nail in adults: A prospective study. International Journal of Orthopaedics Sciences 2022;8:202–5. https://doi.org/10.22271/ortho.2022.v8.i2c.3138. [3] Hasan MH, Alam MS, Azad MAK, Ahsanuzzaman M. Evaluation of the Results of Closed Antegrade Interlocking Intramedulary Nail for Proximal and Mid Shaft Femur Fracture. TAJ: Journal of Teachers Association 2019;32:27–35. https://doi.org/10.3329/taj.v32i2.44877. [4] Sah SK, Gyawali M, Kandel PR. Functional outcome of intramedullary nailing of the femoral shaft fracture. Janaki Medical College Journal of Medical Science 2023;11:40–52. https://doi.org/10.3126/jmcjms.v11i2.58027. [5] Pal DrSK, Mishra DrD, Nanda DrSN. Prospective study on functional outcome of fracture shaft of femur (Winquest Hansen type 1, 2 and 3) treated with intramedullary interlocking nail. International Journal of Orthopaedics Sciences 2021;7:162–9. https://doi.org/10.22271/ortho.2021.v7.i1c.2476. [6] Helmy N, Jando VT, Lu T, Chan H, O’Brien PJ. Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures. J Orthop Trauma 2008;22:10–5. https://doi.org/10.1097/BOT.0b013e31815f5357. [7] Pasion M, Abrahan L, Bonifacio L, Flavier M. Closed Antegrade Intramedullary Nailing of Femoral Shaft Fracture on a Radioluscent Table Using X-ray or Image Intensifier in a Delayed Setting. Philipp J Surg Spec 2012;67:81–6. https://doi.org/10.61662/pcs_oamh9686. [8] El Moumni M, Voogd EH, Ten Duis HJ, Wendt KW. Long-term functional outcome following intramedullary nailing of femoral shaft fractures. Injury 2012;43:1154–8. https://doi.org/10.1016/j.injury.2012.03.011. [9] Bhasale A, Joshi S. Functional Outcome of Closed Intramedullary Interlocking Nailing in Gustillo-Anderson Type I and II Compound Fractures of Femoral Shaft. MVP Journal of Medical Sciences 2016;3:110–4. https://doi.org/10.18311/mvpjms/2016/v3i2/745. [10] Thoresen BO, Alho A, Ekeland A, Strømsøe K, Follerås G, Haukebø A. Interlocking intramedullary nailing in femoral shaft fractures. A report of forty-eight cases. The Journal of Bone and Joint Surgery American 1985;67:1313–20. https://doi.org/10.2106/00004623-198567090-00002. [11] Ali DrMdE, Islam DrMdS, Rahman DrMdM, Rahman DrMdM. Functional Outcome of Closed Locked Intramedullary Nailing of The Femoral Shaft Fracture. Asia Pacific Journal of Surgical Advances 2024;1:4–14. https://doi.org/10.70818/apjsa.2024.v01i01.02. [12] Xiong R, Mai QG, Yang CL, Ye SX, Zhang X, Fan SC. Intramedullary nailing for femoral shaft fractures in adults. Cochrane Database Syst Rev 2018;2018:CD010524. https://doi.org/10.1002/14651858.CD010524.pub2. [13] Patel SD, Pethapara VM. A prospective study on functional outcome of fracture shaft of femur stabilised with reamed intramedullary nail. National Journal of Clinical Orthopaedics 2020;4:95–9. https://doi.org/10.33545/orthor.2020.v4.i1b.206. [14] Mert A, Bozgeyik B, Tekin SB. Which is Superior in the Treatment of Femoral Shaft Fracture? A Comparison of Talon Intramedullary Nailing and Conventional Locked Intramedullary Nailing . Medical Journal of Bakırköy 2022;18:384–90. https://doi.org/10.4274/BMJ.galenos.2022.2021.10-3. [15] Meena A, Meena DS, Saini N, Meena P. A Study on Fracture of Femur Shaft Treatment with Intramedullary Interlocking Nailing. Int J Med Biomed Stud 2021;5:37–8. https://doi.org/10.32553/ijmbs.v5i12.2333. [16] Ryan-Coker MFD, Batura R, Kubai H, Forde MYE, Perdomo-Lizarraga JC, Marenah K, et al. Outcomes of intramedullary nailing for traumatic adult femoral shaft fractures in low-and-middle-income countries; a systematic review. OTA International 2025;8:e434. https://doi.org/10.1097/OI9.0000000000000434. [17] Tiwari A, Kohli SS, Kokne M. Study of management of diaphyseal fracture shaft femur by intramedullary interlocking nail. Int J Res Orthop 2019;5:588. https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20192109. [18] Burç H, Atay T, Demirci D, Baykal YB, Kirdemir V, Yorgancigil H. The Intramedullary Nailing of Adult Femoral Shaft Fracture by the Way of Open Reduction is a Disadvantage or Not? Indian J Surg 2013;77:583. https://doi.org/10.1007/s12262-013-0931-3. [19] Gadhe S, Ghorpade NA. Section: Orthopaedics Treatment of Unstable Diaphyseal Fracture Femur with Femur Intramedullary Interlocking Nailing. International Journal of Contemporary Medical Research 2020;7:A7–11. https://doi.org/10.21276/ijcmr.2020.7.1.14. [20] Sahu DrSK, Pandey DA. Short Proximal Femoral Nail A2 Vs Long Proximal Femoral Nail A2 For The Management of Intertrochanteric Fractures in Elderly. European Journal of Molecular & Clinical Medicine 2020;7:1144–9. [21] Yoon YC, Song HK, Han JS, Lee KC. Antegrade nailing in femoral shaft fracture patients - comparison of outcomes of isolated fractures, multiple fractures and severely injured patients. Injury 2021;52:3068–74. https://doi.org/10.1016/j.injury.2021.01.044.