Locally manufactured versus imported proximal femoral nails: inverse probability of treatment weighting: adjusted comparison of costs and complications in intertrochanteric femur fractures

Objective: To compare domestic and imported proximal femoral nails (PFNs) in the treatment of intertrochanteric femoral fractures with respect to implant cost trends and complication rates.

Methods: This retrospective cohort study included adults aged 65 years and older who underwent proximal femoral nailing for intertrochanteric femoral fractures. Fractures were identified using ICD-10 code S72.1 and AO/OTA types 31A1 and 31A2. All patients were treated between January 2019 and June 2024 at a tertiary academic trauma center. Patients with pathological fractures, prior ipsilateral hip surgery, death within 1 year, or insufficient follow-up were excluded. The primary outcomes were implant cost, reported in Turkish lira (TRY) and US dollars (USD), and complication rates. Secondary outcomes included length of hospital stay, total treatment cost, and PFN design (single- vs double-blade). Reduction quality was assessed using the Baumgaertner criteria, and the tip apex distance was measured on postoperative radiographs. In addition, data regarding the operating surgeon were recorded. Inverse probability of treatment weighting (IPTW) based on propensity scores was applied to adjust for baseline differences.

Results: A total of 307 patients (mean age 82.8 Å} 7.8 years; 70% women) were included and overall complication rates were 5.2%. Domestic implants were used in approximately two-thirds of cases. After IPTW adjustment, complication rates were comparable between domestic and imported PFNs (7.1% vs. 4.0%, P = .299), and most events were mechanical. From 2019 to 2021, domestic implants were cheaper in TRY but not in USD; from 2022 onward, implant costs showed an increasing trend. In 2024, when only domestic PFNs were available, the median implant cost reached its highest level ($677.28). Double-blade PFNs were more expensive than single-blade devices (P < .001), whereas differences in complication rates should be interpreted cautiously due to limited covariate overlap. Length of stay showed a strong correlation with total cost (ρ = 0.41-0.47, P < .001).

Conclusion: After adjustment for baseline differences, implant origin was not independently associated with complication risk in geriatric patients with intertrochanteric femoral fractures; however, this finding should be interpreted cautiously given the limited number of events. Implant-related costs varied substantially over time and were mainly driven by exchange-rate volatility and market conditions. Reduction quality was the strongest determinant of complications, emphasizing that implant selection should prioritize surgical technique alongside cost and availability considerations.

Cite this article as: Selçuk E, Mercan O, Pakyildiz E, Erem M, Yildirım S. Locally manufactured versus imported proximal femoral nails: inverse probability of treatment weighting: adjusted comparison of costs and complications in intertrochanteric femur fractures. Acta Orthop Traumatol Turc.2026; 60(5), 0772, doi: 10.5152/j.aott.2026.25772.