High risks of failure observed for A1 trochanteric femoral fractures treated with a DHS compared to the PFNA in a prospective observational cohort study

Max P L Van Der Sijp,Arthur H P Niggebrugge,Karel J Du Pré,Marianne De Groot,Sander M Verhage,Sven A Meylaerts,Inger B Schipper

doi:10.1007/s00402-021-03824-0

Max P L Van Der Sijp, Arthur H P Niggebrugge + Show 5 more

Open Access

https://doi.org/10.1007/s00402-021-03824-0

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Abstract

IntroductionBoth the DHS and the PFNA are common and well-studied treatment options for stable trochanteric fractures. The aim of the current study was to compare the implant failure rates of these two implants in 31A1 type trochanteric femoral fractures.Materials and methodsA single-centre observational cohort study was conducted in the Hip Fracture Unit of a multicentre level 1 trauma teaching hospital between December 2016 and October 2018. Patients with an AO/OTA type 31A1 fracture were included. Pathological fractures, bilateral fractures, high-energy traumas and patients younger than 18 years of age were excluded. Surgery was performed using either a DHS or PFNA. Both were used routinely for stable trochanteric fractures, and allocation was decided by the surgeon performing the operation. The primary outcome of this study was the implant failure rate in the first postoperative year. Secondary outcomes included the reoperation rate, functional recovery, pain and morphine use.ResultsData were available from 126 patients treated with a DHS (n = 32, 25.4%) or PFNA (n = 95, 74.6%). Minor differences were observed in the patient characteristics including the prevalence of cognitive impairment (18.8% vs 40.2%; P = 0.028), prefracture independence in activities of daily living (87.1% vs 67.4%; P = 0.034) and prefracture mobility (independently without aides: 61.3% vs 40.4%; P = 0.033). Fractures treated with a DHS showed 25% implant failures, compared to 1.1% for fractures treated with a PFNA (P = 0.004). No differences were observed in any of the secondary outcomes.ConclusionsSignificantly more implant failures were observed for the DHS compared the PFNA within 1 year after surgery. Despite the fact that this did not result in differences in revision surgery, we conclude that the PFNA, considering the minimal number of implant-related fractures is a viable implant for A1 type trochanteric fractures.

Highlights

Both the dynamic hip screw (DHS) and the proximal femoral nail antirotation (PFNA) are common and well-studied treatment options for stable trochanteric fractures
Between December 21st, 2016 and October 1st, 2018, a total of 126 patients with an AO/OTA type 31A1 proximal femoral fracture were surgically treated with a DHS (N = 32, 25.4%, of which 2 (1.6%) with a 4-hole compression plate) or PFNA (N = 95, 74.6%)
An inadequate tip-apex distance (TAD) was observed in 13.3% for the DHS and 15.2% for the PFNA (P = 1.0)

Summary

Introduction

Both the DHS and the PFNA are common and well-studied treatment options for stable trochanteric fractures. Many studies comparing intramedullary nails and extramedullary implants in trochanteric fractures find only minor differences in implant failure rates These range between 0 and 6% for the DHS and between 0 and 3% for the PFNA [1, 4, 5, 20, 30]. Few studies focus on treatment of stable trochanteric fractures, and most of these observed no differences in implant failure and reoperation rates between the PFNA and DHS [5, 20, 30, 31]. Some studies indicated that the PFNA might be favourable in stable trochanteric fractures due to a shorter operation time [5], less blood loss [5, 20], less postoperative pain, faster weight bearing [20] and a better functional recovery in the often frail older hip fracture patient [5, 20, 31]

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