{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T03:16:49Z","timestamp":1792639009209,"version":"4.5.0"},"reference-count":40,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2023,4,9]],"date-time":"2023-04-09T00:00:00Z","timestamp":1680998400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Chungnam National University"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and objectives: Iatrogenic fractures are potential complications during intramedullary (IM) nailing for atypical femoral fractures (AFFs). The risk factors associated with iatrogenic fractures remain unclear, although excessive femoral bowing and osteoporosis are hypothesized to be contributing factors. The present study aimed to determine the risk factors for the occurrence of iatrogenic fractures during IM nailing in patients with AFFs. Materials and Methods: This retrospective cross-sectional study evaluated 95 patients with AFF (all female; age range: 49\u201387 years) who underwent IM nailing between June 2008 and December 2017. The patients were divided into two groups: Group I (with iatrogenic fracture: n = 20) and Group II (without iatrogenic fracture: n = 75). Background characteristics were retrieved from medical records and radiographic measurements were obtained. Univariate and multivariate logistic regression analyses were performed to identify risk factors for the occurrence of intraoperative iatrogenic fractures. Receiver operating curve (ROC) analysis was conducted to determine a cut-off value for the prediction of iatrogenic fracture occurrence. Results: Iatrogenic fractures occurred in 20 (21.1%) patients. The two groups exhibited no significant differences regarding age and other background characteristics. Group I exhibited significantly lower mean femoral bone mineral density (BMD) and significantly greater mean lateral and anterior femoral bowing angles than Group II (all p &lt; 0.05). There were no significant differences in AFF location, nonunion, and IM nail diameter, length, or nail entry point between the two groups. In the univariate analysis, femoral BMD and lateral bowing of the femur differed significantly between the two groups. On multivariate analysis, only lateral bowing of the femur remained significantly associated with iatrogenic fracture occurrence. The ROC analysis determined a cut-off value of 9.3\u00b0 in lateral bowing of the femur for prediction of iatrogenic fracture occurrence during IM nailing for AFF treatment. Conclusions: The lateral bowing angle of the femur is an important predictive factor for intraoperative iatrogenic fracture occurrence in patients undergoing IM nailing for AFF treatment.<\/jats:p>","DOI":"10.3390\/medicina59040735","type":"journal-article","created":{"date-parts":[[2023,4,10]],"date-time":"2023-04-10T03:49:29Z","timestamp":1681098569000},"page":"735","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Risk Factors Associated with Intraoperative Iatrogenic Fracture in Patients Undergoing Intramedullary Nailing for Atypical Femoral Fractures with Marked Anterior and Lateral Bowing"],"prefix":"10.3390","volume":"59","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4130-7431","authenticated-orcid":false,"given":"Yong Bum","family":"Joo","sequence":"first","affiliation":[{"name":"Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoo Sun","family":"Jeon","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Korea Worker\u2019s Compensation & Welfare Service Daejeon Hospital, 637, Gyejok-ro, Daedeok-gu, Daejeon 34384, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Woo Yong","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hyung Jin","family":"Chung","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong 30099, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,4,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/jbmr.1998","article-title":"Atypical Subtrochanteric and Diaphyseal Femoral Fractures: Second Report of a Task Force of the American Society for Bone and Mineral Research","volume":"29","author":"Shane","year":"2013","journal-title":"J. Bone Miner. Res."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1978","DOI":"10.2106\/JBJS.15.01422","article-title":"Factors Associated with Increased Healing Time in Complete Femoral Fractures After Long-Term Bisphosphonate Therapy","volume":"98","author":"Lim","year":"2016","journal-title":"J. Bone Jt. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"127","DOI":"10.5371\/hp.2017.29.2.127","article-title":"Lateral Femoral Bowing and the Location of Atypical Femoral Fractures","volume":"29","author":"Yoo","year":"2017","journal-title":"Hip Pelvis"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1289","DOI":"10.1302\/0301-620X.93B10.26924","article-title":"Long-term bisphosphonate usage and subtrochanteric insufficiency fractures: A cause for concern?","volume":"93","author":"Yoon","year":"2011","journal-title":"J. Bone Jt. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2211","DOI":"10.1007\/s00198-010-1384-1","article-title":"Atypical femoral stress fractures in bisphosphonate-free patients","volume":"22","author":"Tan","year":"2011","journal-title":"Osteoporos. Int."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1020","DOI":"10.1007\/s11999-013-3352-5","article-title":"Are Race and Sex Associated With the Occurrence of Atypical Femoral Fractures?","volume":"472","author":"Marcano","year":"2013","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"502","DOI":"10.1007\/s00276-005-0019-2","article-title":"The comparison of femoral curves and curves of contemporary intramedullary nails","volume":"27","author":"Harma","year":"2005","journal-title":"Surg. Radiol. Anat."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1097\/BOT.0b013e31829ff3c9","article-title":"Variation in the Femoral Bow: A novel high-throughput analysis of 3922 femurs on cross-sectional imaging","volume":"28","author":"Maratt","year":"2014","journal-title":"J. Orthop. Trauma"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1570","DOI":"10.1016\/j.injury.2017.05.033","article-title":"Factors affecting fracture location in atypical femoral fractures: A cross-sectional study with 147 patients","volume":"48","author":"Kim","year":"2017","journal-title":"Injury"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1007\/s00774-012-0358-0","article-title":"Low-energy diaphyseal femoral fractures associated with bisphosphonate use and severe curved femur: A case series","volume":"30","author":"Sasaki","year":"2012","journal-title":"J. Bone Miner. Metab."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e8.1","DOI":"10.2106\/JBJS.L.00568","article-title":"Atypical Femoral Fractures: What Do We Know about Them? AAOS Exhibit Selection","volume":"95","author":"Unnanuntana","year":"2013","journal-title":"J. Bone Jt. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"701","DOI":"10.1016\/S0020-1383(02)00158-4","article-title":"Antegrade femoral nailing: An anatomical determination of the correct entry point","volume":"33","author":"Gausepohl","year":"2002","journal-title":"Injury"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1097\/00003086-199602000-00006","article-title":"Geometric Mismatch of the Gamma Nail to the Chinese Femur","volume":"323","author":"Leung","year":"1996","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"410","DOI":"10.1097\/00005131-200408000-00003","article-title":"Mismatch of Current Intramedullary Nails With the Anterior Bow of the Femur","volume":"18","author":"Egol","year":"2004","journal-title":"J. Orthop. Trauma"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1318","DOI":"10.1016\/j.injury.2016.02.026","article-title":"Surgical tips of intramedullary nailing in severely bowed femurs in atypical femur fractures: Simulation with 3D printed model","volume":"47","author":"Park","year":"2016","journal-title":"Injury"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"202","DOI":"10.5371\/hp.2018.30.4.202","article-title":"Surgical Treatment of the Atypical Femoral Fracture: Overcoming Femoral Bowing","volume":"30","author":"Lee","year":"2018","journal-title":"Hip Pelvis"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2295","DOI":"10.1007\/s11999-012-2412-6","article-title":"Bisphosphonate-associated Femur Fractures Have High Complication Rates with Operative Fixation","volume":"470","author":"Prasarn","year":"2012","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"726","DOI":"10.2106\/JBJS.16.00760","article-title":"Intramedullary Nailing for Atypical Femoral Fracture with Excessive Anterolateral Bowing","volume":"99","author":"Park","year":"2017","journal-title":"J. Bone Jt. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"479","DOI":"10.1007\/s00068-009-8151-z","article-title":"Iatrogenic femoral neck fracture during closed nailing of the femoral shaft fracture","volume":"35","author":"Castellanos","year":"2009","journal-title":"Eur. J. Trauma Emerg. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","article-title":"A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation","volume":"40","author":"Charlson","year":"1987","journal-title":"J. Chronic Dis."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1097\/00000542-197810000-00003","article-title":"ASA Physical Status Classifications: A study of consistency of ratings","volume":"49","author":"Owens","year":"1978","journal-title":"Anesthesiology"},{"key":"ref_22","first-page":"9553531","article-title":"Functional outcome after hip fracture. Effect of general versus regional anesthesia","volume":"37\u201341","author":"Koval","year":"1998","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1936","DOI":"10.1007\/s00167-014-3006-5","article-title":"Femoral shaft bowing in the coronal plane has more significant effect on the coronal alignment of TKA than proximal or distal variations of femoral shape","volume":"23","author":"Kim","year":"2014","journal-title":"Knee Surg. Sport. Traumatol. Arthrosc."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1862","DOI":"10.2106\/JBJS.G.01580","article-title":"Variability in the Assessment of Fracture-Healing in Orthopaedic Trauma Studies","volume":"90","author":"Corrales","year":"2008","journal-title":"J. Bone Jt. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jcm.2016.02.012","article-title":"A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research","volume":"15","author":"Koo","year":"2016","journal-title":"J. Chiropr. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2556","DOI":"10.2106\/JBJS.H.01774","article-title":"Bilateral Low-Energy Simultaneous or Sequential Femoral Fractures in Patients on Long-Term Alendronate Therapy","volume":"91","author":"Capeci","year":"2009","journal-title":"J. Bone Jt. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"954","DOI":"10.2214\/AJR.10.6262","article-title":"Bisphosphonate-Related Complete Atypical Subtrochanteric Femoral Fractures: Diagnostic Utility of Radiography","volume":"197","author":"Rosenberg","year":"2011","journal-title":"Am. J. Roentgenol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2267","DOI":"10.1002\/jbmr.253","article-title":"Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research","volume":"25","author":"Shane","year":"2010","journal-title":"J. Bone Miner. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"930","DOI":"10.1001\/archinternmed.2012.1796","article-title":"Increasing Occurrence of Atypical Femoral Fractures Associated with Bisphosphonate Use","volume":"172","author":"Meier","year":"2012","journal-title":"Arch. Intern. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"100","DOI":"10.3109\/17453674.2015.1004149","article-title":"Risk of atypical femoral fracture during and after bisphosphonate use","volume":"86","author":"Schilcher","year":"2015","journal-title":"Acta Orthop."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1097\/00003086-199611000-00014","article-title":"Outcome of Femoral Shaft Fractures in the Elderly","volume":"332","author":"Bouchard","year":"1996","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"5258","DOI":"10.1210\/jc.2010-1571","article-title":"Cumulative Alendronate Dose and the Long-Term Absolute Risk of Subtrochanteric and Diaphyseal Femur Fractures: A Register-Based National Cohort Analysis","volume":"95","author":"Abrahamsen","year":"2010","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_33","first-page":"29","article-title":"Femoral shaft bowing with age: A digital radiological study of Anatolian Caucasian adults","volume":"14","author":"Harma","year":"2008","journal-title":"Diagn. Interv. Radiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2893","DOI":"10.1007\/s00198-012-2173-9","article-title":"Atypical fractures do not have a thicker cortex","volume":"23","author":"Koeppen","year":"2012","journal-title":"Osteoporos. Int."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1016\/j.bone.2014.06.008","article-title":"The fracture sites of atypical femoral fractures are associated with the weight-bearing lower limb alignment","volume":"66","author":"Saita","year":"2014","journal-title":"Bone"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1016\/j.injury.2020.10.012","article-title":"Outcome of intramedullary nail for fixation of osteoporotic femoral shaft fractures in the elderly above 60","volume":"52","author":"Elbarbary","year":"2021","journal-title":"Injury"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"743","DOI":"10.2106\/JBJS.I.00919","article-title":"The Assessment of Fracture Risk","volume":"92","author":"Unnanuntana","year":"2010","journal-title":"J. Bone Jt. Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"721","DOI":"10.3928\/01477447-20090818-05","article-title":"Lateral Decubitus Positioning for Intramedullary Nailing of the Femur Without the Use of a Fracture Table","volume":"32","author":"Carr","year":"2009","journal-title":"Orthopedics"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"227","DOI":"10.12671\/jkfs.2010.23.2.227","article-title":"Bursting Fracture of the Proximal Femur during Insertion of Unreamed Femoral Nail for Femur Shaft Fracture\u2014A Case Report","volume":"23","author":"Kim","year":"2010","journal-title":"J. Korean Fract. Soc."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Moldovan, F., Gligor, A., and Bataga, T. (2021). Structured Integration and Alignment Algorithm: A Tool for Personalized Surgical Treatment of Tibial Plateau Fractures. J. Pers. Med., 11.","DOI":"10.3390\/jpm11030190"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/4\/735\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:12:42Z","timestamp":1760123562000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/59\/4\/735"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,4,9]]},"references-count":40,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2023,4]]}},"alternative-id":["medicina59040735"],"URL":"https:\/\/doi.org\/10.3390\/medicina59040735","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,4,9]]}}}