Smoking and injury severity score predict major complications after surgical treatment of ipsilateral proximal and shaft femoral fractures.

INTRODUCTION

Ipsilateral proximal and shaft femoral fractures are rare, high-energy injuries associated with substantial morbidity. Evidence on predictors of adverse outcomes after surgical treatment remains limited.

METHODS

We conducted a retrospective cohort study at a tertiary trauma center including all skeletally mature patients who underwent surgical treatment for ipsilateral proximal femoral fractures (femoral neck or trochanteric region) associated with femoral shaft fractures between January 2019 and December 2024. The primary outcome was a composite of major complications, including deep surgical site infection, delayed union, nonunion, symptomatic pulmonary embolism, or all-cause mortality. Bivariable analyses were performed to compare patients with and without major complications, followed by multivariable logistic regression to identify independent predictors.

RESULTS

Fifty-two patients were included, with a mean age of 41.8 years and a mean Injury Severity Score (ISS) of 23.1. Major complications occurred in 17 patients (32.7%). The most frequent major complications were all-cause mortality (13.5%) and deep surgical site infection (11.5%). In bivariable analysis, smoking, longer time to definitive treatment, and higher ISS were associated with major complications. In the multivariable model, smoking (adjusted odds ratio [OR] 19.24, 95% confidence interval [CI] 2.78-133.04; p = 0.003) and higher ISS (adjusted OR per point 1.10, 95% CI 1.01-1.19; p = 0.027) remained independently associated with the primary outcome, whereas time to definitive treatment and age did not.

CONCLUSION

Major complications were frequent after surgical treatment of ipsilateral proximal and shaft femoral fractures, affecting nearly one-third of patients. Smoking and greater trauma severity, as measured by ISS, were the main independent predictors of adverse outcomes. These findings highlight the importance of perioperative risk stratification and support smoking as a relevant modifiable risk factor in this setting.