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.

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Randomized comparative study to evaluate the role of proximal femoral nail and dynamic hip screw in unstable trochanteric fractures

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20162618 ◽

2016 ◽

Vol 2 (3) ◽

pp. 75

Author(s):

Shivanand C Mayi ◽

Sachin Shah ◽

Sadashiv R Jidgekar ◽

Arunkumar Kulkarni

Keyword(s):

Comparative Study ◽

Functional Outcome ◽

Trochanteric Fracture ◽

Dynamic Hip Screw ◽

Proximal Femoral Nail ◽

Trochanteric Fractures ◽

Stable Fixation ◽

Femoral Nail ◽

Duration Of Surgery ◽

Hip Screw

Background: Treatment of unstable trochanteric fracture is much more challenging than stable fracture. These fractures require stable fixation to minimize the fracture and implant related complications. Need of this study is to assess the suitable implant for stable fixation of unstable trochanteric fracture with less intra and postoperative complications and good functional outcome.Methods: In this prospective randomized comparative study, 64 patients were distributed into two groups. Group A consisted of patients treated by proximal femoral nail (PFN) (n=32) and group B treated by dynamic hip screw (DHS) (n=32). All the patients were evaluated preoperatively and surgery was done according to the group they were allotted. Post-operative follow up was done at 6 weeks, 3, 6 and 12 months.Results: Average age of the patients in this study was 51.26±10.24 year. In this study patients were followed up for an average of 10.87±2.61 month. The duration of surgery was shorter in PFN group. Weight bearing was earlier in PFN group than DHS group. Mean functional ability score was better in PFN group with significant gain in function earlier as compared to DHS group.Conclusions: PFN is a better implant for internal fixation of unstable trochanteric fractures which allows early mobilization and has got better functional outcome score in early postoperative period than DHS

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Dynamic Hip Screw (DHS) versus Proximal Femoral Nail Anti-rotation (PFNA) Fixation for Unstable (Evans-Jensen II and III) Inter-trochanteric Fractures of Femur in Elderly

Journal of College of Medical Sciences-Nepal ◽

10.3126/jcmsn.v15i3.25554 ◽

2019 ◽

Vol 15 (3) ◽

pp. 222-225

Author(s):

Manoj Kandel ◽

Robin Shrestha ◽

Krishna Prasad Poudel ◽

Shrawan Thapa ◽

Sushil Thapa ◽

...

Keyword(s):

Average Length ◽

Trochanteric Fracture ◽

Operation Time ◽

Healing Time ◽

Dynamic Hip Screw ◽

Proximal Femoral Nail ◽

Trochanteric Fractures ◽

Femoral Nail ◽

Fixation Group ◽

Hip Screw

Background: Dynamic hip screw (DHS) and proximal femoral nail anti-rotation (PFNA) are the two most commonly used fixation devices for inter-trochanteric fracture of femur. However, many clinical studies have shown lack of differences in the clinical outcome consistently with between these two fixation techniques. The main objective of this study is to compare the results of dynamic hip screw (DHS) and proximal femoral nail anti-rotation (PFNA) fixation in elderly patients with unstable inter-trochanteric fractures of femur. Methods: We retrospectively reviewed patients who underwent operative management for inter- trochanteric fractures of femur in our hospital between February 2013 and September 2017. Elderly patients (Age >60yrs) with unstable inter-trochanteric fracture of femur treated either with DHS fixation or with PFNA fixation were included and divided into two groups: DHS fixation group and PFNA fixation group. The comparative statistical analysis was done between two group using following parameters: average length of the incision, operation time, blood loss, fracture healing time, and degree of postoperative functional recovery. Results: The mean follow-up period, in DHS fixation group was 16 month (range 12 to 24 months) and in PFNA fixation group was 14 months (range 12 to 18 months). The differences between two groups regarding average length of the incision, operation time, and blood loss were statistically significant (p<0.05) and better in PFNA group whereas the differences between two groups regarding fracture healing time and the degree of postoperative functional recovery were not statistically significant (p >0.05). Conclusions: PFNA fixation may be better than DHS fixation for the treatment of unstable inter-trochanteric fractures of the femur in the elderly. However, the application and usage of DHS fixation could not be neglected and the choice of treatment depends upon the systemic condition and socioeconomic status of the patient, patient’s preferences, surgeon’s experience and availability of treatment facility.

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A Comparison of Proximal Femoral Nail Antirotation and Dynamic Hip Screw Devices in Trochanteric Fractures

Journal of International Medical Research ◽

10.1177/147323000903700410 ◽

2009 ◽

Vol 37 (4) ◽

pp. 1057-1064 ◽

Cited By ~ 48

Author(s):

J Zou ◽

Y Xu ◽

H Yang

Keyword(s):

Functional Outcome ◽

Trochanteric Fracture ◽

Dynamic Hip Screw ◽

Proximal Femoral Nail ◽

Trochanteric Fractures ◽

Femoral Nail ◽

Operation Rate ◽

Significant Difference ◽

Hip Screw ◽

Proximal Femoral Nail Antirotation

This prospective, randomized study compared the functional outcome and complications associated with a proximal femoral nail antirotation (PFNA) device with those of a traditional extramedullary device, the dynamic hip screw (DHS), in patients with trochanteric fracture. A total of 121 patients were randomized to the PFNA group ( n = 58) or the DHS group ( n = 63). Perioperative information and complications were recorded, and assessments of functional outcome were made. The DHS group required a longer operative time and was associated with greater blood loss than the PFNA group. The re-operation rate was lower in the PFNA group compared with the DHS group, especially in patients with unstable fractures, although there was no statistically significant difference in the overall complication rate between the two groups. There were no significant differences in functional outcome between the PFNA and the DHS groups. In conclusion, the PFNA device is useful in the treatment of trochanteric fractures.

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A study to assess proximal femoral nailing versus dynamic hip screw device in surgical management of intertrochanteric fractures: a comparative study

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20184719 ◽

2018 ◽

Vol 5 (1) ◽

pp. 23

Author(s):

E. S. Radhe Shyam ◽

K. Ashwin

Keyword(s):

Functional Outcome ◽

Intertrochanteric Fracture ◽

Trochanteric Fracture ◽

Dynamic Hip Screw ◽

Proximal Femoral Nail ◽

Technical Failure ◽

Intertrochanteric Fractures ◽

Femoral Nail ◽

Fracture Management ◽

Hip Screw

Background: The incidence of inter trochanteric fracture is expected to have doubled by 2040. Inter trochanteric fractures account for about 45% to 50% of all hip fractures in the elderly populationand out of these, near about 50% to 60% are classified as unstable intertrochanteric fractures. The goal of treatment is restoring mobility safely and efficiently, while minimizing the risk of medical complications and technical failure. This study as performed to assess functional outcome with dynamic hip screw and proximal femoral nail in intertrochanteric fracture management.Methods: It was prospective observational study done for a period of 1year from January 2016-January 2017 among patients who attended OPD or emergency department with intertrochanteric fracture. Two different implants were used dynamic hip screw (DHS) and proximal femoral nail (PFN).Results: Excellent results in functional outcome was more in case of PFN (66.6%) compared to DHS (50%). The type of trauma in DHS group was road traffic accident in 38.8%, domestic fall in 50% and others such as assault was in 11.1% while in PFN group intertrochanteric fracture was seen in 61.1% due to domestic fall.Conclusions: The functional outcome was more better with proximal femoral nail (PFN) compared to dynamic hip screw (DHS). Therefore, proximal femoral nail (PFN) should be preferred for management of intertrochanteric fractures.

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A comparison study of proximal femoral nail and dynamic hip screw devices in unstable trochanteric fractures

Benha Medical Journal ◽

10.4103/bmfj.bmfj_81_18 ◽

2018 ◽

Vol 35 (3) ◽

pp. 413

Author(s):

MohamedA Mostafa ◽

HassanH Ahmed ◽

HaniA.M Bassiooni ◽

ElsayedM Mohamady

Keyword(s):

Dynamic Hip Screw ◽

Proximal Femoral Nail ◽

Comparison Study ◽

Trochanteric Fractures ◽

Femoral Nail ◽

Hip Screw

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A Prospective Randomized Control Trial Comparing Proximal Femoral Nail and Sliding Hip Screw in The Management of Trochanteric Fracture of The Femur

Health Renaissance ◽

10.3126/hren.v9i1.4354 ◽

1970 ◽

Vol 9 (1) ◽

pp. 7-11

Author(s):

NK Kam ◽

Ashis Jain ◽

P Nepal ◽

Mahi Pal Singh ◽

N Das

Keyword(s):

Controlled Trial ◽

Trochanteric Fracture ◽

Proximal Femoral Nail ◽

Joint Disease ◽

Harris Hip Score ◽

Sliding Hip Screw ◽

Femoral Nail ◽

Number Of Patients ◽

Hip Screw ◽

Screw Group

Introduction: There are various implants designed for fixation of trochanteric fracture which can be extramedullary (Sliding hip screw) and intramedullary (Proximal Femoral Nail). A randomized controlled trial comparing these techniques was conducted at BP Koirala Institute of Health Sciences. Objective: To compare efficacy of proximal femoral nail and sliding hip screw in the management of trochanteric fractures. Methods: Patients in both groups were matched for age (mean 67 years, 50 to 100) and gender. We excluded all pathological fractures, patients presenting at more than one week, multiple fractures or any bone and joint disease interfering with rehabilitation. Results: The amount of blood loss and length of incision were significantly higher in the sliding hip screw group (p < 0.05). The time of union, range of movement and Western Ontario and McMasterUniversity knee scores were comparable at two years. The mean Harris hip score was better in proximal femoral group. Conclusion: The number of patients showing shortening, external malrotation and varus angulation was more in sliding hip screw group. There was one case of wound infection and a single case of breakage of implant in sliding hip screw group. Keywords: fracture trochanter; proximal femoral nail; sliding hip screw DOI: 10.3126/hren.v9i1.4354Health Renaissance, 2011: Vol.9 No.1:7-11

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Medial support nail and proximal femoral nail antirotation in the treatment of reverse obliquity inter-trochanteric fractures (Arbeitsgemeinschaft fur Osteosynthesfrogen/Orthopedic Trauma Association 31-A3.1): a finite-element analysis

Chinese Medical Journal ◽

10.1097/cm9.0000000000001031 ◽

2020 ◽

Vol 133 (22) ◽

pp. 2682-2687

Author(s):

Shao-Bo Nie ◽

Yan-Peng Zhao ◽

Jian-Tao Li ◽

Zhe Zhao ◽

Zhuo Zhang ◽

...

Keyword(s):

Finite Element Analysis ◽

Finite Element ◽

Proximal Femoral Nail ◽

Orthopedic Trauma ◽

Trochanteric Fractures ◽

Element Analysis ◽

Femoral Nail ◽

Medial Support ◽

Proximal Femoral Nail Antirotation

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Risk factors for intraoperative greater trochanteric fractures in hemiarthroplasty for intracapsular femoral neck fractures

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-020-01549-0 ◽

2020 ◽

Author(s):

Johannes Karl Maria Fakler ◽

Alexander Brand ◽

Christian Lycke ◽

Christina Pempe ◽

Mohamed Ghanem ◽

...

Keyword(s):

Risk Factors ◽

Femoral Neck ◽

Prothrombin Time ◽

Waiting Time ◽

Revision Surgery ◽

Trochanteric Fracture ◽

Trochanteric Fractures ◽

Increased Risk ◽

Neck Fracture ◽

Intracapsular Femoral Neck Fracture

Abstract Purpose Hemiarthroplasty is widely accepted as the treatment of choice in elderly patients with a displaced intracapsular femoral neck fracture. Intraoperative greater trochanteric fractures thwart this successful procedure, resulting in prolonged recovery, inferior outcome, and increased risk of revision surgery. Hence, this study analyzed factors potentially associated with an increased risk for intraoperative greater trochanteric fracture. Methods This retrospective study included 512 hemiarthroplasties in 496 patients with a geriatric intracapsular femoral neck fracture from July 2010 to March 2020. All patients received the same implant type of which 90.4% were cemented and 9.6% non-cemented. Intra- and postoperative radiographs and reports were reviewed and particularly screened for greater trochanteric fractures. Results Female patients accounted for 74% and mean age of the patients was 82.3 (± 8.7) years. 34 (6.6%) intraoperative greater trochanteric fractures were identified. In relation to patient-specific factors, only a shorter prothrombin time was found to be significantly associated with increased risk of intraoperative greater trochanteric fracture (median 96%, IQR 82–106% vs. median 86.5%, IQR 68.8–101.5%; p = 0.046). Other factors associated with greater trochanteric fracture were a shorter preoperative waiting time and changes in perioperative settings. Outcome of patients with greater trochanteric fracture was worse with significantly more surgical site infection requiring revision surgery (17.6% vs. 4.2%, p = 0.005). Conclusion Prolonged prothrombin time, a shorter preoperative waiting time, and implementing new procedural standards and surgeons may be associated with an increased risk of a greater trochanteric fracture. Addressing these risk factors may reduce early periprosthetic infection which is strongly related to greater trochanteric fractures.

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