LONG VERSUS SHORT PROXIMAL FEMORAL NAIL IN THE MANAGEMENT OF UNSTABLE INTERTROCHANTERIC FRACTURES IN ELDERLY POPULATION

INTRODUCTION: Intertrochanteric fractures constitute a vast majority of geriatric orthopedic trauma having highest postoperative morbidity and mortality of surgically treated fractures. Use of cephalomedullary nails for treatment of highly unstable intertrochanteric fractures is now more common as plate xation is associated with higher risk of implant breakage and screw cutout. However, choice of length of these nails remains surgeon dependent. AIM: to compare the functional outcome and complications associated with the use of Long and Short PFN for the treatment of unstable intertrochanteric fractures (AO/OTAtype 31A1 and 31A2) in elderly population. METHOD: A prospective interventional study comprising of 58 patients distributed in two groups in which one group (n=25) was treated with long PFN while other group (n=33) was operated with short PFN. Parameters compared between these two groups included demographic data, intraoperative blood loss and surgical duration as well as analysis of radiological and clinical progression of union and postoperative complications in the form of hip pain, anterior thigh pain and failure rate. Functional assessment was done using Harris hip score. RESULT:This study included only AO/OTAtype 31A1 and 31A2 fracture types in elderly patients above 60 years of age. We found no statistically signicant difference with regard to age, sex as well as fracture type among two groups. Long PFN group had a shorter union time (11.4 weeks) and was associated with lesser postoperative complication and failure rate as compared to short PFN. Also, functional outcome evaluated using Harris hip score shown better scores in long PFN group. However, intraoperative blood loss and surgical duration was found to be signicantly lesser in short PFN group. CONCLUSION: use of cephalomedullary nails either short or long for xation of unstable intertrochanteric fractures particularly AO/OTA type 31A1 and 31A2 provides good results. However, longer nails should be preferred over short nails as these are associated with less postoperative complication such as hip pain or anterior thigh pain owing to excessive curvature of femur in Indian population with lesser union time and better functional outcome as compared to short PFN. Shorter nails may be used in cases of sick and polytrauma patients where shorter operative time with minimal blood loss is desirable

Biomechanics of subtrochanteric fracture fixation using short cephalomedullary nails: A finite element analysis

A finite element analysis was performed to evaluate the stresses around nails and cortical bones in subtrochanteric (ST) fracture models fixed using short cephalomedullary nails (CMNs). A total 96 finite element models (FEMs) were simulated on a transverse ST fracture at eight levels with three different fracture gaps and two different distal locking screw configurations in both normal and osteoporotic bone. All FEMs were fixed using CMNs 200 mm in length. Two distal locking screws showed a wider safe range than 1 distal screw in both normal and osteoporotic bone at fracture gaps ≤ 3 mm. In normal bone FEMs fixed even with two distal locking screws, peak von Mises stresses (PVMSs) in cortical bone and nail constructs reached or exceeded 90% of the yield strength at fracture levels 50 mm and 0 and 50 mm, respectively, at all fracture gaps. In osteoporotic bone FEMs, PVMSs in cortical bone and nail constructs reached or exceeded 90% of the yield strength at fracture levels 50 mm and 0 and 50 mm, respectively, at a 1-mm fracture gap. However, at fracture gaps ≥ 2 mm, PVMSs in cortical bone reached or exceeded 90% of the yield strength at fracture levels ≥ 35 mm. PVMSs in nail showed the same results as 1-mm fracture gaps. PVMSs increased and safe range reduced, as the fracture gap increased. Short CMNs (200 mm in length) with two distal screws may be considered suitable for the fixation of ST transverse fractures at fracture levels 10 to 40 mm below the lesser trochanter in normal bone and 10 to 30 mm in osteoporotic bone, respectively, under the assumptions of anatomical reduction at fracture gap ≤ 3 mm. However, the fracture gap should be shortened to the minimum to reduce the risk of refracture and fixation failure, especially in osteoporotic fractures.

264 Intertrochantic Hip Fracture Fixation at Musgrove Park Hospital

Background Hip fractures, the commonest fragility fracture in the UK, carry a 6.7% 30-day mortality. NICE-CG124 guide advises extramedullary implants for trochanteric (AO3.1A1/2) and intramedullary nails for subtrochanteric fractures. We carried out a retrospective study on the use of cephalomedullary nails (CMN) at MPH to determine compliance with CG124. Method National Hip Fracture Database (NHFD) from 2019 was reviewed. Trust records were used for fracture type, surgery, and reasons for deviation from CG124. Results 201 fractures were identified. NHFD revealed 38 A3 fractures of which 36 underwent CMN, one SHS and one non-operative management. Of 163 A1/A2 fractures, 33 received CMN and 130 CHS. Only 77% of the NHFD data was correct. Further analysis revealed 18 CMNs were used for AO1/2 injuries. All had justifiable reasons for deviation from CG124, although not documented. Conclusions There is scope to improve accuracy of NHFD data. Deviation from guidelines may be appropriate but reasons must be documented and, when appropriate, discussed with patient. Similar nationwide inaccuracy can have significant implications for research based upon NHFD data. To prevent input of incorrect data, our recommendations include: Consultant to confirm AO grade during trauma meetings Reason CMN used for AO1/2 fractures to be documented Monthly local NHFD data audit

How to Assess Proximal Femoral Shortening after Nailing of Proximal Femoral Fractures? A Short Review

Proximal femoral fractures (PFFs) are considered one of the most frequent situations faced by orthopaedic surgeons. Many lines of management had been described. Although management of PFFs with cephalomedullary nails (CMNs) is now considered the gold standard with many mechanical and biological advantages, this technique may have some disadvantages such as residual peritrochanteric pain, limping, limited walking distance, and difficulty with stairs. These complications may be attributed to fracture malreduction with shortening, which may result in either malunion or nonunion and ultimately implant failure. The resultant proximal femoral shortening (PFS) with alteration of the proximal femoral mechanics may affect both the hip abductor function and the daily patient activities. The purpose of this short review is to discuss the assessment and secondary effects of PFS after treating femoral fractures with CMNs.