Background
The role of traction radiographs in the preoperative evaluation of intertrochanteric femur fractures remains controversial, with inconsistent evidence regarding their impact on fracture classification, stability assessment, and surgical decision-making. This nationwide simulation-based study aimed to investigate how orthopedic trauma surgeons use and interpret traction radiographs and to determine their influence on surgical planning across varying levels of clinical experience.

Methods
A nationwide, cross-sectional simulation-based study was conducted among actively practicing orthopedic and trauma surgeons between October 14 and November 15, 2025 using a structured questionnaire containing simulated cases. The questionnaire included demographic characteristics, clinical experience, perceptions of traction radiographs, and case-based assessments of 15 AO/OTA-classified intertrochanteric fractures (31-A1, A2, A3). A total of 133 surgeons participated, yielding 1995 individual case evaluations. Surgical decision changes before and after traction radiographs were analyzed using McNemar tests, while independent predictors were identified using Generalized Estimating Equations (GEE).

Results
Traction radiographs were requested in 59.5% of all assessments, with significantly higher request rates in unstable patterns (31-A2: 75%; 31-A3: 68.2%) compared with 31-A1 fractures (30%). Overall, traction imaging resulted in a 12.4% change in surgical planning, rising to 21% among cases where traction radiographs were obtained. Decision changes were most common in 31-A2.3 (14.9%) and 31-A3.3 (16.9%) patterns. The most frequent implant transition was from short to long PFN (40.8%), followed by conversion to arthroplasty (18.8%). GEE analysis demonstrated that both fracture type and requesting traction radiographs were independent predictors of surgical plan modification (OR=1.55–2.40 for unstable fracture types; OR=1.60 for traction radiograph request; p<0.05 for all). Surgeon title, institutional setting, years of experience, and case volume were not associated with decision change.

Conclusion
Traction radiographs provide clearer visualization of fragment configuration and medial/lateral wall integrity, leading to improved recognition of fracture instability and a measurable shift toward more durable fixation strategies. Their impact on surgical planning is most pronounced in complex or borderline-unstable fracture patterns and remains consistent across experience levels. As a low-cost, readily accessible adjunct, traction radiography represents a valuable tool in the preoperative assessment of intertrochanteric fractures. Routine use is recommended, particularly when instability is suspected or standard radiographs provide insufficient clarity.

Keywords: Intertrochanteric femur fracture, Traction radiograph, Fracture stability, Surgical decision-making, AO/OTA classification

Traksiyon Grafileri Kompleks Ýntertrokanterik Kýrýklarýn Deðerlendirilmesini Ýyileþtirir: Cerrah Deneyiminden Baðýmsýz Etkiler Gösteren Ulusal Ölçekli Simülasyon Temelli Çalýþma

Amaç
Traksiyon grafilerinin intertrokanterik femur kýrýklarýnýn preoperatif deðerlendirilmesindeki yeri halen tartýþmalýdýr. Literatürde kýrýk sýnýflandýrmasý, stabilite deðerlendirmesi ve cerrahi planlama üzerindeki etkisine iliþkin bulgular kesinleþmemiþtir. Bu ulusal ölçekli çalýþma, ortopedi ve travmatoloji uzmanlarýnýn traksiyon grafisi kullanýmýna yönelik yaklaþýmlarýný ve bu görüntülemenin cerrahi karar verme sürecine etkisini, klinik deneyimden baðýmsýz olarak deðerlendirmeyi amaçlamýþtýr.

Gereç ve Yöntem
14 Ekim–15 Kasým 2025 tarihleri arasýnda aktif olarak çalýþan ortopedi ve travmatoloji hekimlerine çevrimiçi vaka temelli bir deðerlendirme uygulanmýþtýr. Bu deðerlendirme; demografik bilgiler, klinik deneyim, traksiyon grafisine yönelik algý ve 15 AO/OTA sýnýflandýrýlmýþ intertrokanterik kýrýk vakasýna (31-A1, A2, A3) iliþkin vaka temelli sorularý içermiþtir. Toplam 133 katýlýmcýdan 1995 gözlem elde edilmiþtir. Cerrahi karar deðiþiklikleri McNemar testi ile analiz edilmiþ, baðýmsýz belirleyiciler Genelleþtirilmiþ Tahmin Denklemleri (GEE) ile deðerlendirilmiþtir.

Bulgular
Traksiyon grafisi istem oraný tüm deðerlendirmelerin %59.5’ini oluþturmuþ olup, bu oran instabil kýrýk tiplerinde anlamlý biçimde yükselmiþtir (31-A2: %75; 31-A3: %68.2; 31-A1: %30). Traksiyon grafisi sonrasý genel cerrahi plan deðiþikliði oraný %12.4, traksiyon grafisi istenen olgularda ise %21 olarak bulunmuþtur. Karar deðiþikliði özellikle 31-A2.3 (%14.9) ve 31-A3.3 (%16.9) kýrýklarýnda belirginleþmiþtir. En sýk implant geçiþi kýsa PFN’den uzun PFN’ye (%40.8), ardýndan artroplastiye geçiþ (%18.8) þeklinde olmuþtur. GEE analizinde kýrýk tipi ve traksiyon grafisi istemi cerrahi karar deðiþikliðinin baðýmsýz belirleyicileri olarak saptanmýþtýr (OR=1.55–2.40 ve OR=1.60; p<0.05). Katýlýmcýnýn unvaný, kurum tipi, deneyim yýlý ve vaka hacminin karar deðiþikliði üzerinde anlamlý etkisi bulunmamýþtýr.

Sonuç
Traksiyon grafileri fragman konfigürasyonunun ve medial/lateral duvar bütünlüðünün daha net deðerlendirilmesine olanak saðlayarak kýrýk instabilitesinin daha doðru tanýnmasýna ve daha dayanýklý implant tercihlerine yönelimde artýþa neden olmaktadýr. Bu etkinin özellikle kompleks veya sýnýrda instabil kýrýklarda belirgin olduðu ve cerrah deneyiminden baðýmsýz olarak korunduðu gösterilmiþtir. Traksiyon grafisinin düþük maliyetli, uygulanabilir ve klinik karar sürecine anlamlý katký saðlayan bir yöntem olarak intertrokanterik kýrýklarýn preoperatif deðerlendirilmesinde rutin kullanýmýnýn, özellikle instabiliteden þüphelenilen durumlarda, faydalý olabileceði düþünülmektedir.

Anahtar Kelimeler: Ýntertrokanterik femur kýrýðý, Traksiyon grafisi, Kýrýk stabilitesi, Cerrahi karar verme, AO/OTA sýnýflandýrmasý