Optimal fracture site compression of trochanteric region fracture managed with proximal femoral nailing at the time of surgery: Analysis of clinico-radiological and functional outcome

Abstract

Objectives: Proximal Femoral Nail (PFN) with dual cephalic screw configuration is now widely used for management of trochanteric region fracture. Good fracture reduction and intraoperative achievement of optimal fracture site compression are very important surgical steps of proximal femoral nailing. There is very limited information available in literature regarding trochanteric region fracture site compression while fixation by PFN with dual cephalic screws (lag and anti-rotation screws). We are practicing a technique of intraoperative compression of fracture site by alternate tightening of lag and anti-rotation screws of PFN. Aim of this study is to evaluate the clinico-radiological and functional outcome of trochanteric region fracture management by PFN with intraoperative adequate fracture site compression achieved by this method. Materials and Methods: Total 47 patients, who underwent PFN fixation for trochanteric region fractures during September 2017 to October 2019 with 12 months follow up period, were included in this prospective study. Fractures were classified according to the AO/OTA system; the most common fracture type 31A2 (n = 28), followed by 31A1 (n = 18) and 31A3 (n = 1). At the time of PFN fixation, fracture site compression was performed by combination of two surgical steps - 1) by giving firm manual pressure towards medial direction with the help of PFN Jig after nail insertion into medullary canal, maintaining this pressure till fixation of both lag and anti-rotation screws and 2) alternate tightening of the anti-rotation and lag screws till final sitting of both screws was achieved. Clinical and radiological parameters including quality of reduction, tip-apex distance (TAD), lateral slide of lag screw, length of both cephalic screws as well as complications were measured. Functional outcome was assessed using Harris Hip Score (HHS). Results: Good reduction was achieved in 89.4% cases. Mean TAD AP (anteroposterior) was 11.6 mm, mean TAD LAT (lateral) was 11.1 mm and mean TAD Total was 22.7 mm. Overall mean lateral slide was 3.2 mm and it was more in unstable 31A2fracture. The HHS at 12 months postoperatively was excellent in 20 (42.6%), good in 16 (34.0%), fair in 5 (10.6%), and poor in 6 patients (12.8%). Conclusion: Intraoperative fracture site compression achieved by alternate tightening of the anti-rotation and lag screws of PFN shows excellent to good results in the management of trochanteric region fractures and a low incidence of complications.