Treatment of Unstable Intertrochanteric Fractureswith Proximal Femoral Nail Antirotation II: Our Experience in Indian Patients§

Introduction:Unstable intertrochanteric fractures are difficult to manage and the choice of implant is critical for fracture fixation. The purpose of this study was to evaluate the functional and radiological outcome of proximal femoral nail antirotationII (PFNA II) in the treatment of unstable intertrochanteric fractures.Materials and Methods:We reviewed 45 patients of unstable intertrochanteric fractures, who were treated with the PFNA II between 2011 and 2013. Of which, 3 patients were died within 6 months of follow up. Hence, 42 patients were available for the study including 26 men and 16 women. The mean age was 61 years (range, 35 -90). Clinical evaluation was done using Harris hip score. The position of the blade in the femoral head was evaluated using Cleveland zones and tip apex distance. The fracture reduction was assessed using the Garden Alignment Index and postoperative fracture gap (mm) measurement.Results:The mean follow up period was 15.3 months (range, 9-27). Excellent to good results were accounted for 78% of cases according to Harris hip score. No cases of cut out or breakage of the implant noted. Implant removal was done in 2 patients due to persistent anterior thigh pain.Conclusion:We recommend PFNA II for fixation of unstable intertrochanteric fractures with less operative time and low complication rate. However, proper operative technique is important for achieving fracture stability and to avoid major complications.

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OUTCOME ANALYSIS OF PROXIMAL FEMORAL NAIL IN MANAGEMENT OF UNSTABLE INTERTROCHANTERIC FRACTURES

10.36106/ijsr/8522907 ◽

2021 ◽

pp. 55-56

Author(s):

Anshul Khare ◽

Shailandra Pandey ◽

Aman Agrahari ◽

Abhishek Pathak ◽

Sanjiv Gaur

Keyword(s):

Proximal Femoral Nail ◽

Harris Hip Score ◽

Outcome Analysis ◽

Intertrochanteric Fractures ◽

Average Hospital ◽

Incision Length ◽

Femoral Nail ◽

The Mean ◽

Mean Time

There is no perfect implant for intertrochanteric fractures. Nowadays Proximal Femoral Nail (PFN) is getting popular in these fractures. In this study we tried to nd and analyse the outcome of using PFN in 20 cases of unstable intertrochanteric fractures which were operated at our centre and completed the follow up till 6 months. These patients were analysed on various intra-operative and post-operative parameters. Functional assessment was done using Harris Hip Score. The mean age of patients in our study was 64 years. Average incision length was around 6.5cm and mean blood loss was 97ml. Average surgery duration was 71 minutes while average hospital stay was 18.1 days. Mean time to union was 14.9 weeks. All cases have achieved union. Varus malalignment was observed in one case. Harris Hip Score showed excellent results in 60% cases and good results in 30% cases. Our study indicates that PFN is a good implant for xation of unstable intertrochanteric fractures. However it superiority over other implants can only be conrmed with larger comparative studies.

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Osteoporotic Intertrochanteric Fractures in the Elderly Managed with Proximal Femoral Nail Antirotation-The Functional Outcome

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/42425.14499 ◽

2021 ◽

Author(s):

SPS Gill ◽

Ankit Mittal ◽

Manish Raj ◽

Satosh Singh ◽

Ajay Rajpoot ◽

...

Keyword(s):

Blood Loss ◽

Operative Time ◽

Proximal Femoral Nail ◽

Harris Hip Score ◽

Functional Evaluation ◽

Intertrochanteric Fractures ◽

Radiological Outcome ◽

Femoral Nail ◽

The Mean ◽

Proximal Femoral Nail Antirotation

Introduction: Despite recent evolution in the operating techniques and surgical implants, debate continues around the choice of implant for the management of intertrochanteric fractures of femur bone. There is a paucity of clinical data on the results with Proximal Femoral Nail Antirotation (PFNA). Aim: To evaluate the functional and radiological outcome of reduction and fixation of these fractures with PFNA. Materials and Methods: This prospective interventional study was conducted from december 2015 to november 2018. A total of 62 patients of more than 50 years of age with intertrochanteric fracture were managed with internal fixation using PFNA. All the pateints were evaluated with respect to the mean operative time, blood loss. Fluoroscopy exposure, time to union and development of any complication. The statistical analysis involved calculation of the mean and Standard Deviations (SD) of above parameters which was done using the Microsoft excel chart sheet. Functional evaluation was done using the Harris Hip Score (HHS). Results: A total of 62 patients with age ranging from 54 to 94 years (mean 78.2, SD 09.11) were evaluated. The mean duration of follow-up was 14.3 months. The average operative time, the mean blood loss and the average fluoroscopy time were 61.4 (range 45-90 minutes, SD 11.6) minutes, 103.9 (range 60-200 mL, SD 36.4) mL and 74.0 (range 41 to 98, SD 13.5) seconds respectively. About 100% union rate with the average time to union being 16.1 (SD 3.3) weeks and ranging from 12 weeks to 24 weeks was reported. Varus collapse and limb shortening >1 cm were observed in 3 patients. The average HHS at the end of study showed a mean value of 82.8 (SD 8.6) and ranged from 65 to 94 with 46 (74.2%) patients having excellent to good outcome. Conclusion: Owing to easy insertion, reduced operative time and blood loss, stable fixation, less complications and good functional and radiological outcome, PFNA can prove to be an implant of choice for the management of intertrochantric fractures of the femur.

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Functional and Radiological Outcome of Unstable Intertrochanteric Fracture in Old Age Treated with Proximal Femoral Nail Antirotation-2

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/47653.14751 ◽

2021 ◽

Author(s):

OP Jamshad ◽

Jacob Mathew ◽

Raju Karuppal

Keyword(s):

Proximal Femoral Nail ◽

Harris Hip Score ◽

Intertrochanteric Fractures ◽

Biological Reduction ◽

Neck Shaft Angle ◽

Femoral Nail ◽

Unstable Intertrochanteric Fracture ◽

Shaft Angle ◽

The Mean ◽

Proximal Femoral Nail Antirotation

Introduction: Intertrochanteric fractures are prevalent in the elderly, which leave patients with functional restrictions. Proximal Femoral Nail Antirotation-2 (PFNA) was developed to achieve better fixation strength, particularly in the presence of osteoporotic unstable intertrochanteric fractures. Aim: To evaluate the role and result of PFNA-2 in the treatment of unstable intertrochanteric fractures in geriatric patients. Materials and Methods: A prospective analytical study was conducted in 35 patients with unstable intertrochanteric fractures. They were followed-up clinically and radiologically for one year. The quality of fixation was assessed, by neck-shaft angle and Tip Apex Distance (TAD). A functional assessment was done with the Harris Hip Score (HHS). Results: The mean follow-up period was 13 months (range, 12-14). The mean age of patients was 65.6 years and the majority were female patients (62.85%). Functional results according to modified HHS were found to be excellent in 6 (17.1%) patients, good in 14 (40%) patients, fair in 12 (34.3%) patients and poor in 3 (8.6%) patients. The average HHS in this study was 81.6. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 16.0. Conclusion: PFNA-2 helps in achieving biological reduction and good stability which enables early mobilisation and prevention of excessive collapse. A good functional outcome could be achieved when the radiological parameters are restored, i.e., TAD <25 mm and neck-shaft angle difference <5° (compared to the opposite side).

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The Results of Unstable Intertrochanteric Femur Fracture Treated with Proximal Femoral Nail Antirotation-2 with respect to Different Greater Trochanteric Entry Points

Advances in Orthopedics ◽

10.1155/2020/2834816 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Sharan Mallya ◽

Surendra U. Kamath ◽

Rajendra Annappa ◽

Nithin Elliot Nazareth ◽

Krithika Kamath ◽

...

Keyword(s):

Entry Point ◽

Proximal Femoral Nail ◽

Harris Hip Score ◽

Care Hospital ◽

Femoral Nail ◽

Tip Apex Distance ◽

Proximal Femoral Nail Antirotation ◽

Modified Harris Hip Score

Background. Proximal femoral nail antirotation-2 (PFNA-2) has been widely used to treat intertrochanteric fractures with varied outcomes in the previous studies. The entry point of the nail plays an important role in achieving acceptable reduction, stable fixation, and avoiding implant related complications. This study was proposed to determine the optimal greater trochanteric entry point for PFNA-2 in unstable intertrochanteric femur fractures. Methods. We conducted an observational study on 40 patients with unstable intertrochanteric fracture treated with PFNA-2 implant in a tertiary care hospital. The patients were grouped into two based on the entry point: group L for lateral and group M for medial entry. Randomization was carried out by assigning the patients to the group by alternate allocation. The quality of reduction, tip apex distance, Cleveland index, and all the complications were noted. The final follow-up was conducted at six months. The functional outcome was evaluated using modified Harris hip score. The data analysis was performed using Student’s t-test, chi square test, and Mann–Whitney test. A P value below 0.05 was considered significant. Results. Forty patients with 20 patients treated with medial entry point were included in group M and 20 patients in group L with lateral entry point. The group L had an average tip apex distance of 20.53 and group M had 20.02 (P=0.8). The complication of screw back out was seen in 3 out of 4 patients with poor reduction in group L. As per the Cleveland index, 6 patients in each group had suboptimal position and 4 out of 6 patients in group L with suboptimal position had screw back out. The lateral cortex impingement was seen in 14 patients of group L and 6 patients in group M with significant comparison (P=0.01). Three patients in group L had varus collapse with screw back out. Also, none in group M (0.05). The average modified Harris hip score in group L at six months follow-up was 71.94 and 76.8 in group M (P=0.84). Conclusion. Overall, to achieve good quality of fixation and reducing damage to gluteus medius entry point for PFNA-2 should be 5 mm medial to the greater trochanter tip.

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Functional and radiological outcome of osteosynthesis using proximal femoral nail antirotation II system in intertrochanteric femoral fractures

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20210619 ◽

2021 ◽

Vol 7 (2) ◽

pp. 267

Author(s):

Wajahat Ahmad Mir ◽

Mohmad Nawaz Rather ◽

Rasiq Rashid

Keyword(s):

Morbidity And Mortality ◽

Proximal Femoral Nail ◽

Harris Hip Score ◽

Common Source ◽

Intertrochanteric Fractures ◽

College Hospital ◽

Femur Fractures ◽

Femoral Nail ◽

Proximal Femoral Nail Antirotation

Background: Intertrochanteric fractures are relatively common injuries in adults and a common source of morbidity and mortality among the elderly. Incidence of fractures is increasing because the general life expectancy of the population has increased significantly during the past few decades. Stable fixation and early mobilization is needed in these fractures to reduce the morbidity and mortality. Extra-medullary implants are biomechanically inferior in these cases. The proximal femoral nail antirotation-II (PFNA-II) is an intra-medullary nail system designed for such fractures. The purpose of this study was to assess the results and complications of PFNA-II in intertrochanteric femur fractures.Methods: After seeking approval from institutional Ethical committee, this study was conducted on 30 patients attending our emergency department with intertrochanteric femur fractures at SKIMS Medical College Hospital Bemina, Srinagar from February 2018 to June 2019. The patients were treated with proximal femoral nail antirotation-II. Follow up was done at 2, 6, 12 and 24 weeks. The functional outcome was assessed at 6 months follow up using the Harris Hip Score.Results: Based on the Harris hip score, 18 (60%) patients had excellent results, 10 (33%) had good results and 2 (7%) had Fair results. None of the patients had poor result. Average time to union was 12.27 weeks.Conclusions: This study found the PFNA-II to be a versatile, easy to use and dependable implant for stable as well as unstable intertrochanteric fractures. PFNA II is distinct advance over the previous methods of treatment, though it has an initial learning curve.

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Comparison of clinical outcomes with proximal femoral nail anti-rotation versus InterTAN nail for intertrochanteric femoral fractures: A meta-analysis

10.21203/rs.3.rs-21889/v1 ◽

2020 ◽

Author(s):

Wei Liu ◽

Guangrong Ji ◽

Jie Liu

Keyword(s):

Observational Studies ◽

Femoral Shaft Fracture ◽

Femoral Shaft ◽

Shaft Fracture ◽

Proximal Femoral Nail ◽

Harris Hip Score ◽

Intertrochanteric Fractures ◽

Femoral Nail ◽

Tip Apex Distance ◽

Intertan Nail

Abstract Objective: To access the efficacy and safety of proximal femoral nail anti-rotation (PFNA) and InterTAN nail for intertrochanteric femoral fractures.Methods: According to the Cochrane systemic analysis method, randomized control trials (RCTs) and retrospective comparative observational studies which were related to the comparison of PFNA and InterTAN nail in the treatment of the elderly with intertrochanteric fractures were retrieved. Data were independently extracted from the included studies by two reviewers and analyzed using RevMan 5.3 , and the quality of the studies was assessed.Results: Two RCTs and seven observational studies were recruited, which consisted of 681 patients with PFNA and 651 patients with InterTAN nail. The meta-analyses showed no significant differences between the two approaches on Harris Hip Score, operation time, blood loss, time to union, mean hospital stay, union problems, intraoperative complications, hematoma, infection, other complication in both RCTs and observational studies. In terms of other outcomes, for the RCTs, results showed that there were shorter tip–apex distance, reduced pain at thigh or hip in InterTAN nail than in PFNA; however, InterTAN nail was not superior to PFNA in cutout, reoperation, and femoral shaft fracture; for observational studies, the risk of the screw migration (RR=5.13, 95%CI: [1.33,19.75], P=0.02), cutout (RR=3.26, 95%CI: [1.64,6.47], P=0.0008), the varus collapse of the femoral head (RR=7.19, 95%CI: [2.18,23.76], P=0.001), femoral shaft fracture (RR=5.73, 95%CI: [2.24,14.65], P=0.0003) treated by InterTAN nail were significantly decreased, compared with those by PFNA; however, no significant differences was observed in the aspects of tip–apex distance and pain at thigh or hip between these two groups.Conclusion: Analysis of a large number of relevant clinical indicators available shows that InterTAN nail has better clinical manifestation than PFNA in treating unstable femoral intertrochanteric fractures.

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Functional and radiological outcomes of intertrochanteric fractures treated with proximal femoral nail

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20203721 ◽

2020 ◽

Vol 6 (5) ◽

pp. 1001

Author(s):

Mayur Chopra ◽

Sanjay Kumar Srivastava ◽

Sumit Kumar ◽

Deepak Kumar Mishra

Keyword(s):

Weight Bearing ◽

Proximal Femoral Nail ◽

Harris Hip Score ◽

Intertrochanteric Fractures ◽

Radiological Outcome ◽

Neck Length ◽

Neck Shaft Angle ◽

Femoral Nail ◽

Shaft Angle ◽

Tip Apex Distance

Background: Hip fracture is one of the most invalidating diseases affecting geriatric populations and in fall related fractures, they lead to most severe morbidity and mortality. Their surgical treatment allows stable fracture fixation which allows the early weight bearing. Many devices have been developed, yet mechanical failures still occur. The aim of this study was to assess the functional and radiological outcomes of intertrochanteric fractures treated with proximal femoral nail.Methods: 46 patients with intertrochanteric fractures fixed with proximal femoral nail were assessed. Functional outcome was measured by Harris hip score (HHS) and lower extremity functional scale (LEFS) and radiological outcome was measured by tip apex distance (TAD), any changes in neck shaft angle, neck length and the offset as compared to uninjured hip.Results: The tip apex distance on the postoperative X-ray was found to be 22.02±2.499 mm, change in the neck length as compared to the uninjured hip was found to be 1.507±1.1808 and change in the offset and neck shaft angle was 1.470±1.0126 and -1.602±1.5992 respectively. The LEFS was found to be 70.63±6.584 whereas the HHS was found to be 90.35±7.593Conclusions: With the increase in TAD the functional and radiological outcome worsens. It was also seen that the cutoff of 25 mm stands true in predicting the outcome of the patients with PFN in intertrochanteric fractures. Hence, the TAD should be routinely measured and if found more than 25 mm then proper precautions like delayed weight bearing may be advised.

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Critical analysis of factors determining mechanical failures in proximal femoral nailing

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20190504 ◽

2019 ◽

Vol 5 (2) ◽

pp. 275 ◽

Cited By ~ 1

Author(s):

Karthik Ramachandran ◽

K. K. Arvind Manoj ◽

A. Vishnu Sankar

Keyword(s):

Failure Rate ◽

Mechanical Failure ◽

Proximal Femoral Nail ◽

Harris Hip Score ◽

Intertrochanteric Fractures ◽

Excellent Outcome ◽

Lag Screw ◽

Femoral Nailing ◽

Femoral Nail ◽

Proximal Femoral Nailing

Background: Intertrochanteric fractures are one of the commonest fractures encountered in elderly population. Though there are various implants, proximal femoral nail has been the standard choice for management of unstable fractures. Inspite of its biomechanical advantages, various complications like screw cut out, Z effect, reverse Z effect does occur in proximal femoral nailing. The aim of the study is to analyse various factors determining the mechanical failures in patients operated with proximal femoral nail.Methods: This is a prospective study conducted in our institution from June 2014 to May 2018. The study included 72 patients with unstable intertrochanteric fractures treated with proximal femoral nail. All patients were followed for average period of 2 years. Functional outcome was assessed using Harris Hip score.Results: Among the patients 33% had excellent outcome. 42% had good and 14% had fair outcome. 11% of cases ended with poor outcome. Mechanical failure rate was less in patients with positive medial cortical support (PMCS) and in patients with tip apex distance difference between antirotation screw and lag screw (TADAR -TADLS) more than 15 mm. Whereas the difference in the position of lag screw centre had no significant influence in the mechanical failure rate in our study.Conclusions: From our study we like to conclude that the fracture reduction with positive medial cortical support and the TAD difference play a major role in determining the incidence of mechanical failure in proximal femoral nailing.

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Biomechanical comparison of medial sustainable nail and proximal femoral nail antirotation in the treatment of an unstable intertrochanteric fracture

Bone and Joint Research ◽

10.1302/2046-3758.912.bjr-2020-0284.r1 ◽

2020 ◽

Vol 9 (12) ◽

pp. 840-847

Author(s):

Shaobo Nie ◽

Ming Li ◽

Hui Ji ◽

Zhirui Li ◽

Wenwen Li ◽

...

Keyword(s):

Cyclic Loading ◽

Torsional Stiffness ◽

Proximal Femoral Nail ◽

Axial Stiffness ◽

Intertrochanteric Fractures ◽

Loading Test ◽

Cyclic Loading Test ◽

Femoral Nail ◽

Unstable Intertrochanteric Fracture ◽

The Mean

Aims Restoration of proximal medial femoral support is the keystone in the treatment of intertrochanteric fractures. None of the available implants are effective in constructing the medial femoral support. Medial sustainable nail (MSN-II) is a novel cephalomedullary nail designed for this. In this study, biomechanical difference between MSN-II and proximal femoral nail anti-rotation (PFNA-II) was compared to determine whether or not MSN-II can effectively reconstruct the medial femoral support. Methods A total of 36 synthetic femur models with simulated intertrochanteric fractures without medial support (AO/OTA 31-A2.3) were assigned to two groups with 18 specimens each for stabilization with MSN-II or PFNA-II. Each group was further divided into three subgroups of six specimens according to different experimental conditions respectively as follows: axial loading test; static torsional test; and cyclic loading test. Results The mean axial stiffness, vertical displacement, and maximum failure load of MSN-II were 258.47 N/mm (SD 42.27), 2.99 mm (SD 0.56), and 4,886 N (SD 525.31), respectively, while those of PFNA-II were 170.28 N/mm (SD 64.63), 4.86 mm (SD 1.66), and 3,870.87 N (SD 552.21), respectively. The mean torsional stiffness and failure torque of MSN-II were 1.72 N m/° (SD 0.61) and 16.54 N m (SD 7.06), respectively, while those of PFNA-II were 0.61 N m/° (SD 0.39) and 6.6 N m (SD 6.65), respectively. The displacement of MSN-II in each cycle point was less than that of PFNA-II in cyclic loading test. Significantly higher stiffness and less displacement were detected in the MSN-II group (p < 0.05). Conclusion The biomechanical performance of MSN-II was better than that of PFNA-II, suggesting that MSN-II may provide more effective mechanical support in the treatment of unstable intertrochanteric fractures. Cite this article: Bone Joint Res 2020;9(12):840–847.

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An outcome analysis of intertrochanteric fracture of femur managed with proximal femoral nail antirotation II

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20192687 ◽

2019 ◽

Vol 5 (4) ◽

pp. 699

Author(s):

Hemeshwar Harshwardhan ◽

Shubhanshu Jain ◽

Manish Sharma

Keyword(s):

Blood Loss ◽

Intramedullary Nailing ◽

Operative Time ◽

Weight Bearing ◽

Harris Hip Score ◽

Intertrochanteric Fractures ◽

Time Duration ◽

Early Weight Bearing ◽

Pull Out ◽

The Mean

Background: Intertrochanteric fractures are common osteoporotic fractures in adults above 60 years with high mortality and morbidity. Common techniques for fixation of these fractures are sliding hip screw and plate or intramedullary nailing. Intramedullary nailing has advantage of short incision, less operative time, rapid rehabilition & thus decreased medical complications. PFNA II is newer intramedullary implant developed to obtain better fixation strength in osteoporotic bones. Biomechanical studies has demonstrated that PFNA II blade has a significance of higher cut out resistance than other commonly used screw systems.Methods: Prospective follow up study carried out at J.L.N. Medical College Ajmer from 1 March 2017 to 31st October 2018. 30 patients with unstable intertrochanteric fractures were included and operated on fracture table in supine position with PFNA2. We measured operative time, duration of hospital stay, modified Harris hip score and complications.Results: The mean age of the patients was 70.83 years of age. The mean time in surgery was 38.2 minutes. The mean amount of blood loss in surgery was 110.8 ml. In implant related complications, 2 patients had cut out and 1 patient had pull - out of the implant. Functional results according to modified Harris hip scores was found to be excellent in 8 (30%) patients, good in 12 (40%) patients, fair in 7 (20%) patients and poor in 3 (10%) patients.Conclusions: Elderly patients treated with PFNA2 has good outcome as less operative time, minimal blood loss, early weight bearing, less union time and very few cases of medial penetration and back out of spiral blade.

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