Management of Subtrochanteric Fracture Femur- by ProximalFemoralNailing

Background: Numerous variations of intramedullary nailing have been evolved over the years for stable fixation and early mobilisation of subtrochanteric fracture, out of which one is proximal femoral nail. Aims and objectives –We conducted this study with an objective to evaluate the results of internal fixation of subtrochanteric fractures of the femur with proximal femoral nail – AO type Design.Methods:This was a prospective study carried out at our tertiary care institute on 30 patients who had suffered subtrochanteric fracture and were subsequently treated with a proximal femoral nail (PFN). Proximal femoral nail was inserted through the tip of greater trochanter. All patients were followed up for a period of one year; at an interval of 3 months and during each follow-up visit for the functional outcome by modified Harris Hip Score, was assessed in the form of walking, squatting, sitting and rising from chair.Results:Modified Harris hip score was used for the evaluation of results in our study which showed excellent result in 21 patients (70%), good results in 3 cases(10%), fair results in 3 patient (10%) and poor results in 3 cases(10%). The mean Harris hip score in our study was 90.6.Conclusion:PFN is an intramedullary load sharing implant. Reduction and management of subtrochanteric fractures is challenging in traumatology. Proximal femoral nailing spanning whole femur with proximal and distal locking appears to be a satisfactory implant in management of fractures of subtrochanteric femur.

Increased failure rates after the introduction of the TFNA proximal femoral nail for trochanteric fractures: implant related or learning curve effect?

Background and purpose — Trochanteric fractures are often treated using intramedullary fixation. In our institution, the TFN-Advanced Proximal Femoral Nailing System (TFNA) was introduced as replacement for the Gamma Trochanteric Nail (GTN3) for the treatment of these fractures as a result of a hospital-driven change of trauma implant supplier. We compared trochanteric fracture fixation failure rate between these 2 intramedullary nails. Patients and methods — All trochanteric fractures treated surgically from 2011 to 2019 were retrospectively reviewed for fixation failure. From 2016 only the TFNA was used. Fixation failure was defined as implant cut-out, implant breakage, non-union, malpositioning of the screw/blade requiring reoperation, new fracture around the nail, or miscellaneous. Propensity score matching was used to balance distribution of covariates and to compare failure rates between TFNA and GTN3 groups. Learning curve analyseswere performed. Results — After exclusion, 797 GTN3s (779 patients) and 542 (536 patients) TFNAs were available for analysis. A higher risk of fixation failure was found in the TFNA group (14%) compared with the GTN3 group (7.0%) (hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.2–3.5). This was mainly attributed to a higher risk of cut-out (HR 2.2; CI 0.9–5.7), malpositioning (HR 4.7; CI 0.7–34), and new fracturearound the nail (HR 4.0; CI 1.0–16). Learning curve analyses indicated no clear learning curve effect. Interpretation — Failure of fixation increased after a switch from the GTN3 to the TFNA proximal femoral nail for the treatment of trochanteric fractures. Cut-out and malpositioning of the calcar screw or blade appeared to be the most dominant failure mechanisms. Modifications in implant design may have played a role in this increased risk of failure of fixation. In our institution a new implant device was introduced without solid clinical evidence behind it. This study may help to underline the need for medical doctors with acritical and scientific background to be involved in implant choices.

A comparative study of Dynamic Hip Screw and Proximal Femoral Nail in the management of Intertrochanteric Fractures of the Femur

Introduction: Intertrochanteric fractures account for approximately half of the hip fractures in the elderly because of the osteoporotic nature of the bone. There are various modalities to treat these fractures. The objective of this study was to compare and evaluate the clinical and radiological outcome of intertrochanteric femur fracture treated with Dynamic hip screw (DHS) and proximal femoral nail (PFN). Methods: This study was conducted at Nepalgunj medical college, Department of orthopedics Nepalgunj over a time span of two years. A total of 52 patients were included and randomized into Dynamic hip screw (n=26) and Proximal femoral nail (n=26) group. Patient’s demographic details, perioperative findings, radiological findings and follow up findings were recorded. The results were evaluated and compared. Results: The mean age in our study was 57.63 years. Trivial fall was the most common mode of injury. There was significantly higher intraoperative blood loss in the DHS group. Radiological union and functional outcomes were similar overall, but in case of unstable fracture functional outcome was clinically better in PFN group. Conclusion: From our study we concluded that PFN has better outcome in case of unstable intertrochanteric fractures, however in stable fracture also it has distinct advantage over DHS.

COMPARATIVE STUDY OF HEMIREPLACEMENT ARTHROPLASTY WITH BIPOLAR PROSTHETIC AND PROXIMAL FEMORAL NAIL (PFN) IN UNSTABLE INTERTROCHANTERIC FRACTURE OF FEMURE: INTERVENTIONAL PROSPECTIVE RANDOMIZED STUDY

Background: Intertrochanteric femur fracture incidence has increased due to increased life expectancy and osteoporosis. Methods- The present study was prospectively carried out in 60 consecutive patients of Fracture Intertrochanter Femur and treated with Hemiarthroplasty with Cemented Bipolar Prosthesis and Proximal Femoral Nail. Results: The age of the patients in present study was in range of 60 - 80 years. There was a preponderance of female in present study in both groups. The mean duratioin of surgery in the Bipolar group (91.24±9.21Minutes) was much More That In PFN (53.12 ±6.02Minutes) Group. All patients of Bipolar group was discharged between 4 to 9 days and in PFN group 4 to 12 days after surgery. The average harris hip score in PFN group is 87.32±4.13 and in Bipolar group is 85.02±7.92. Final functional outcome were better in PFN group (P value 0.01) than by Bipolar group and significant. Conclusion: The outcomes of the stable fractures treated with either Bipolar or PFN were similar. Unstable comminuted fractures treated with Bipolar showed significantly better outcomes with all patients having good results. Keywords: Hip Arthroplasty, PFN, Complication

EVALUATION FUNCTIONAL OUTCOME OF HELICAL FIXATION PFN A2 IN PROXIMAL FEMUR FRACTURE IN ELDERLY

Background: Intertrochantric fractures are the most frequently operated fractures and has the highest mortality and morbidity rates. Evaluation functional outcome of helical fixation pfn a2 in proximal femur fracture in elderly Methods: Hospital based prospective randomized comparative study conducted on 30 patients with Close stable &unstable intertrochanteric femur fracture. Results: As per HHS, we have found that 76.67% cases (23) under excellent category and 20.00% (6) good and 3.33% (1) fair of HHS. Conclusion: We can conclude that the PROXIMAL FEMORAL NAIL ANTIROTATION2 is after proper training and technique a safe and easy implant option for treatment of complex peritertrochanteric fractures. Keywords: HHS, Femur, fracture

Dynamic Hip Screw in Comparison with Proximal Femoral Nail Technique in Intertrochanteric Femur Fracture Patients

Background: Hip bone fractures are the main cause of concern on a worldwide level. The main two operative techniques involve dynamic hip screw and proximal femoral nail technique. Aim: To compare the dynamic hip screw with proximal femoral nail technique in intertrochanteric femur fracture patients. Study design: Retrospective study Place and duration of study: Department of Orthopaedics, Khyber Teaching Hospital, Peshawar from 1-7-2019 to 30-12- 2021. Methodology: Seventy patients were enrolled and they were divided in two groups; Group 1 patients were operated with dynamic hip screw (DHS) while group 2 patients were operated by proximal femoral nail (PFN) technique. The detailed pre and post-operative clinical information including blood loss, incision size, Harris hip score and rate of complication was documented. Results: The mean age of patients was 58.62±6.71 year with more male patients than females. The Harris hip score of proximal femoral nail technique was better than distal hip screw. The incision length of distal hip screw cases was 7.61±0.89 in comparison to 4.72±0.73 in proximal femoral nail technique cases with a longer duration of surgery and inter-operative blood loss in case of distal hip screw cases. Conclusion: Proximal femoral nail technique is comparatively better than the distal hip screw procedure. Keywords: Proximal femoral nail technique, distal hip screw, Hip fracture

Kết quả nắn kín và kết hợp xương bên trong sử dụng đinh nội tủy đầu trên xương đùi trong điều trị gãy liên mấu chuyển xương đùi

Mục tiêu: Trước đây điều trị gãy liên mấu chuyển (LMC) xương đùi chủ yếu là nắn mở và kết hợp xương (KHX) bên trong bằng DHS, nẹp khóa … đòi hỏi sự bộc lộc rộng rãi và mở ổ gãy, sẽ dẫn đến tình trạng mất máu, đau, hạn chế vận động sau mổ và sẽ dẫn đến các biến chứng. Đối với những trường hợp gãy mất vững, tổn thương thành ngoài nhiều thì việc điều trị bằng DHS, nẹp khóa thường dẫn đến di lệch thứ phát và thất bại trong quá trình điều trị. Với sự ra đời của đinh nội tủy Gamma, PFNA, Reconstruction và thế hệ đinh mới nhất hiện nay InterTAN, với kỹ thuật mổ xâm nhập tối thiểu, không mở ổ gãy rút ngắn thời gian phẫu thuật và lượng máu mất, kết hợp xương vững về mặt cơ học, giúp bệnh nhân vận động sớm sau mổ giúp ngăn ngừa các biến chứng do nằm lâu. Báo cáo này nhằm đánh giá kết quả điều trị gãy liên mấu chuyển với kỹ thuật nắn kín trên bàn chỉnh hình và KHX bên trong bằng đinh nội tủy đầu trên xương đùi. Phương pháp: Chúng tôi thực hiện mổ nắn kín trên bàn chỉnh hình có sử dụng C arm, kỹ thuật mổ áp dụng theo AO trên 58 trường hợp gãy liên mấu chuyển xương đùi. Ghi nhận độ dài đường mổ, thời gian phẫu thuật, ước tính lượng máu mất, đánh giá thang điểm đau VAS, thời gian nằm viện, các biến chứng, kết quả điều trị, chức năng khớp háng theo thang điểm Harris ở thời điểm 3 tháng, 6 tháng và 12 tháng. Kết quả: Phương tiện đinh PFNA 41 trường hợp, đinh Gamma 5 trường hợp, đinh Reconstruction 12 trường hợp. Tuổi trung bình 78,86 ± 11,67 (38 - 97), nữ chiếm 72,4%. Thời gian mổ trung bình 70,34 ± 20,5 phút (45 - 135), kích thước vết mổ 6,70 ± 1,09 cm (5 - 10), ước tính lượng máu mất trung bình 257,1 ± 163,04 mL. Điểm đau VAS trước mổ và sau mổ trung bình lần lượt là 7,26 và 2,79. Thời gian nằm viện trung bình 13,37 ± 4,38 (5 - 24). Biến chứng trong phẫu thuật ghi nhân 1 trường hợp gãy rạn thân xương đùi và một trường hợp nắn kín thất bại. X quang liền xương ghi nhận ở tất cả trường hợp bệnh nhân tái khám, 4 trường hợp có can lệch. Điểm Harris ở thời điểm 3,6,12 tháng lần lượt là 76,42 ± 13,01, 85,96 ± 6,36, 90,25 ± 2,63. Kết luận: KHX bằng đinh nội tủy đầu trên xương đùi cho thấy kỹ thuật mổ xâm nhập tối thiểu giúp giảm mất máu, kích thước vết mổ nhỏ, bệnh nhân tỳ lực sớm và phục hồi sớm sau mổ. ABSTRACT THE RESULTS OF CLOSED REDUCTION AND INTERNAL FIXATION SINGPROXIMAL FEMORAL NAIL IN TREATMENT OF INTERTROCHANTERIC FEMUR FRACTURE Objective: In the past, treatment of intertrochanteric fractures was mainly to open reduction and internal fixation with DHS, locking plate … require extensive exposure, open fractures, will lead to blood loss, pain, and limited mobility postoperatively and lead to complications.In cases of unstable fractures with large external wall injuries treatment with DHS, locking plate often lead to secondary displacement and failure of treatment. With the introduction of intramedullary nails Gamma, PFNA, Reconstruction, and the latest generation of nails InterTAN, with minimally invasive surgical technique, without opening the fracture, shorter surgery time and blood loss, mechanically more stable, helping patients to move and weight bearing early after surgery and prevent complications due to prolonged lying down. This report aims to evaluate the results of treatmentintertrochanteric fractures with closed reduction technique on the orthopedic table and internal fixation with the proximal femoral nail. Material and method: We perform closed reduction on the orthopedic table using C Arm. And using surgical techniques applied according to AO on 58 cases of intertrochanteric fracture. Record the length of incision, surgery time, estimated blood loss, VAS pain score, hospital stay, complications, treatment results, hip function according to Harris scale. at 3 months, 6 months and 12 months. Results: The mean age was 78.86 ± 11.67 (38 - 97), female accounted for 72.4%. Means of nailing PFNA 41 cases, Gamma nails 5 cases, Reconstruction nails 12 cases. Average operative time 70.34 ± 20.5 minutes (45 - 135), incision size 6.70 ± 1.09 cm (5 - 10), estimated average blood loss 257.1 ± 163, 04 mL. The mean preoperative and postoperative VAS pain scores were 7.26 and 2.79, respectively. Average length of hospital stay was 13.37 ± 4.38 (5 - 24). Intraoperative complications recorded 1 case of femoral shaft fracture and 1 case of failure of closed manipulation. X-ray of bone healing was recorded in all patients at follow - up examination, 4 cases with fracture deformity. Harris score at 3,6,12 months is 76.42 ± 13.01, 85.96 ± 6.36, 90.25 ± 2.63, respectively. Conclusions: Treatment with a proximal femoral nail (PFN) showed that minimally invasive surgical technique, reduced blood loss, small incision size, allows early full weight bearing and postoperative recovery. Keywords: Proximal femoral nail, intertrochanteric femur fracture.