Fixation Of Unstable Intertrochanteric Fractures Research Articles

Functional Outcomes of Primary Hemiarthroplasty for Unstable Intertrochanteric Fractures in the Elderly: A Prospective Observational Study.

Background and objective Intertrochanteric fractures pose a growing healthcare challenge among the elderly, demanding effective management strategies. This study addressed the rising incidence of hip fractures, emphasizing the complications associated with traditional nonsurgical approaches. It aimed to explore postoperative functional outcomes and complications associated withprimary hemiarthroplasty as an alternative to internal fixation for unstable intertrochanteric fractures in the elderly. Materials and methods This study included 20 elderly patients undergoing hemiarthroplasty for unstable intertrochanteric fractures. It evaluated key variables such as patient demographics, comorbidities, fracture characteristics, surgical approach, and postoperative metrics. To perform hemiarthroplasty, weutilized a nonmodular bipolar prosthesis with cement. Postoperative follow-up included an assessment of clinical and radiological parameters, focusing on outcomes and complications. Results The mean age of the participants was 71.65 years; it was found that a significant segment of the participants (n=9, 45%) did not have any comorbidities. The surgical outcomes were characterized by minimal blood loss (275 ± 57.35 ml), short hospital stays (6.55± 1.95 days), and satisfactory operative durations (80.25 ± 10.19 minutes). Additionally, 14 (70%) patients did not require blood transfusions. After the surgery, complications were minimal, and there were no cases of deep wound complications, prosthesis dislocations, or deep vein thrombosis. The Harris Hip Scores reflected favorable outcomes in 14 cases (72.7%), with good or excellent hip scores. Conclusions Our findings revealed that primary hemiarthroplasty is a reliable and effective strategy for managing unstable intertrochanteric fractures in the elderly, providing stable joints and acceptable complication rates. Early mobilization, facilitated by hemiarthroplasty, mitigates postoperative complications, making it a viable alternative for elderly patients.

Intramedullary Nailing versus Dynamic Screw and Plate for Treatment of Trochanteric Fractures of the Femur

Background Trochanteric and intertrochanteric femur fractures are extracapsular fractures of the proximal femur at the level of the greater and lesser trochanter. Trochanteric fractures in adults mostly affect elderly subjects. Frequency is increasing with population aging despite the development of treatments for osteoporosis. The two most widely used types of internal fixation are intramedullary nailing and screw-plate fixation, often performed by trainee surgeons due to their frequency and reputed simplicity. Aim of the Work The aim of the study is to conduct a systematic review of literature and metaanalysis comparing between intramedullary nailing and dynamic plate and screw in treatment of trochanteric fractures of the femur according to: Length of mean operation time, time of radiation exposure (fluoroscopy time), Intraoperative blood loss, reoperation rate, fracture non-union and postoperative wound infection wither superficial or deep infection. Patients and Methods We followed the PRISMA statement guidelines during this study preparation and performed all steps according to the Cochrane handbook of systematic reviews of intervention. We searched PubMed, Scopus, Cochrane, and Web of Science, Embase, and Science Direct in June 2021 and updated the search in July 2021 using relevant Keywords. The eligibility inclusion criteria for studies inclusion were the following: (1) Adult patients above 18 years old (2) Double arm designs (3) Studies designs are limited to randomized control trial (RCT) (4) English studies (5) Any outcome is acceptable. The risk of bias was evaluated by the Cochrane handbook of systematic reviews of interventions 5.1.0. Regarding the data extraction, we obtained data from text, tables, figures (using graph grabber version 2.0), and supplementary data. We conducted this metaanalysis by using Review Manager software (RevMan version 5.4). Results Compared to the control group (Dynamic hip screw and plate technique), Intramedullary nailing (IMN) showed a significant improvement in length of operation time (MD = −9.27; 95% CI: [-18.07, -0.47]; P = 0.04) and perioperative blood loss(MD = -120; 95% CI: [-164.05, -77.89]; P < 0.00001) than dynamic hip screw with plate fixation technique. However, in the term of intraoperative radiation exposure time (Fluoroscopy time), dynamic hip screw (DHS) with plate fixation showed a significant lesser fluoroscopy time than IMN(MD = 0.61; 95% CI: [0.23, 0.99]; P = 0.002). Regarding the postoperative patient satisfaction (assessed by visual analogue scale), postoperative Fracture non-union, perioperative wound infection, femur shaft fracture, and hip prosthetic instability, they showed no significant difference between IMN and dynamic hip screw with plate fixation. Reoperation rate also showed no significant difference between IMN and DHS with plate fixation. Conclusion DHS with plate is not the preferred implant for stable intertrochanteric femur fractures. IMN showed a better result than DHS. We believe that the IMN is biologically superior to DHS for fixation of unstable inter-trochanteric fractures as it provides stable intramedullary fixation resistant to varus collapse and fixation failure, with relatively less operation time, and blood loss.

Intertrochanteric fracture PFN vs DHS

Background: DHS fixation has remained a well-established gold standard in intertrochanteric fractures of femur for a long time. 1 However, it has shortcomings and pitfalls. In inter-trochanteric fractures of femur, DHS fixation has shown higher failure rates. PFN is a new fixation device proposed for fixation of unstable intertrochanteric fractures. 1 Being intramedullary, it is a biomechanically advantageous device which should allow better fixation of unstable intertrochanteric translating into lesser failure rates of fixation and also permitting early mobilization and faster rehabilitation especially in elderly patients. We present a study comparing outcomes of managing unstable intertrochanteric fractures with PFN and DHS. Materials and Methods: We evaluated 30 (PFN: 15; DHS: 15) cases of intertrochanteric fractures of femur out of which 26 were unstable and 4 stable type, from January 2017 to December 2018, with minimum 12 months follow up period. Mean age was 60 years for both PFN and DHS group. We studied the surgical complications in both groups and also compared functional and radiographic results of both groups. Results: There was significantly more clinical shortening in DHS group than in PFN group (average 1- 1.9 cm versus 0.5-0.9 cm). There were 3 cases of superficial and 2 cases of deep infection in the DHS group while there was one case of infection in PFN group. There was no case of implant failure in the DHS group compared to one case in PFN group (due to screw breakage). Harris hip score at follow up was fair to excellent in PFN as compared to DHS. This difference was statistically significant. Discussion: DHS despite remaining a gold standard for fixation of intertrochanteric fractures of femur for a long time, it may not be suitable for certain fracture patterns and in older age groups with more medical co-morbidities and osteoporosis. PFN is a biomechanically sound device for fixation of comminuted intertrochanteric fractures of femur2 which has lesser surgical morbidity and should be especially beneficial in elderly, osteoporotic and medically compromised patients. Its load sharing capability provides a more stable fixation allowing early mobilization and rehabilitation.Conclusion: PFN is unequivocally a better choice of implant for fixation of unstable intertrochanteric fractures of femur, especially in osteoporotic and medically compromised patients as compared to DHS fixation device.

Salvage procedure for cut-through after surgical fixation of trochanteric fractures with TFN.

Closed reduction and fixation using a cephalomedullary nail represents the accepted management of unstable intertrochanteric fractures. Cut-through has been described as a complication associated with the treatment. Although a hip arthroplasty may be the most predictable revision method, a non-prosthetic option can lead to similar results. The objective is to describe a non-prosthetic revision procedure in cases of cut-through. We performed a retrospective analysis of our Institutional Registry for Hip Fractures in elderly patients (RIAFC) from January 2010 to June 2018 searching for cut-through as a failure after unstable intertrochanteric fracture treatment. REVISION PROCEDURE: (A) Helical blade removal, introduction of structural bone graft (autologous or allograft) as a plug to obliterate the communication to the joint and a new blade insertion. (B) Same as in A but augmenting the blade/head purchase with poly(methyl methacrylate) (PMMA). Before the cement insertion, a radio-opaque solution was instilled to assure lack of joint leakage. We evaluated 1616 patients. Sixteen of them presented a cut-through complication (1%). Ten of them were females with an average age for all of 84years. One patient denied an implant revision and opted for a total joint replacement. In four of the patients, the procedure A was done, 2 of them had a new failure, and an joint arthroplasty was performed. In the B group, only one patient needed a revision to a total hip. The other 10 patients healed uneventfully and did not need any further intervention. Cut-through revision after fixation of unstable intertrochanteric fractures treated with cephalomedullary nail by blocking of the joint communication and augmenting the head blade purchase with PMMA is a safe and minimal invasive procedure, generates low blood loss and rate of complications and allows bone healing preserving the native joint. Nil.

Evaluation of Dynamic Hip Screw with Trochanteric Stabilization Plate in management of Unstable Inter-Trochanteric Fractures

The goal of this study is to gauge the radiological results and therefore the functional outcomes consistent with Parker mobility score of the patients after using of Dynamic hip screw with trochanteric stabilizing plate in fixation of unstable trochanteric fractures and assess the complication. Twenty patients (ages ranged from 51 to 70 with an average age of 64.20 ± 6.338 years, 12 of them (60%) were females and 8 (40%) were males) with unstable trochanteric fracture were treated with Dynamic Hip Screw with Trochanteric Stabilization Plate between first of September 2019 to end of March 2020 at Beni-Suef University Hospital. Most of the operations were done in the first week 16 (80%) and only 4 (20%) patients had intraoperative complication and the same percent had post-operative complications. Parkers score was higher in non-diabetic patients p value (p value 0.041).The ASIA score was higher in patients with good bone quality and without intraoperative complication and this difference was statistically significant significantly (p-value, 0.011). DHS with TSP fixation of unstable intertrochanteric fractures of femur is an effective technique and has excellent functional and radiological outcomes with minimal complications and early rehabilitations rates.

Zimmer Natural Nails in the Treatment of Unstable Intertrochanteric Fractures: A Longitudinal Study

Introduction:Cephalomedullary nails are preferred over intramedullary nails for internal fixation of unstable intertrochanteric fractures; however, they are associated with complications as they do not match the anatomy of the proximal femur to a great extent. Aim: To investigate functional and radiological results of Zimmer natural nails in the management of unstable intertrochanteric fractures. Materials and Methods: A longitudinal prospective study of 99 patients with unstable intertrochanteric fractures was carried out. All patients underwent closed reduction and internal fixation with 180 mm short Zimmer natural nails. Follow-up visits were scheduled for six weeks, three months, and six months for radiological healing and mobility measurements using RUSH and Parker scores, respectively. Statistical analysis was performed using Chi-square and ANOVA. Results: Mean age of patients was 69.77±11.47 years with a male to female ratio of 1:1. A majority of patients had co-morbidities like diabetes mellitus and hypertension. Average duration of surgery was 58.38 minutes with no statistically significant difference among the different categories of unstable intertrochanteric fractures. Fixation of fractures with Zimmer natural nails increased Parker score and RUSH score consistently with each follow-up visit (p<0.05). There were no postoperative complications in 93.94% cases. Conclusion: This study emphasised good functional and radiological results of Zimmer natural nails in the treatment of unstable intertrochanteric fractures.

Effect of screw blade position on proximal femoral nail anti-rotation internal fixation for unstable intertrochanteric fractures in the elderly

To investigate the effect of the screw blade position on the effectiveness of proximal femoral nail anti-rotation (PFNA) internal fixation for unstable intertrochanteric fractures in the elderly. A clinical data of 131 elderly patients with unstable intertrochanteric fractures who were treated with PFNA internal fixation between January 2010 and January 2017 was retrospectively analyzed. According to the anteroposterior X-ray films, the screw blades were placed in the middle of the femoral neck in 72 patients (group A) and at one-third of the femoral neck in 59 patients (group B). There was no significant difference between the two groups ( P>0.05) in the gender, age, bone density, classification of fractures, other medical diseases, and the time between injury and operation. Multiple treatment indexes were analyzed, including complications, hip Harris score, the healing status of fracture, tip-apex distance (TAD), and the height of the tail nail. All patients were followed up 11-14 months, with an average of 12.1 months. All incisions healed by first intention with no complications. All fractures healed and no significant difference in bone healing time between the two groups ( Z=-0.190, P=0.849). At 6 months after operation, TAD was (2.23±0.07) cm in group A and (2.85±0.12) cm in group B, showing significant difference ( t=-47.643, P=0.000); and the height of the tail nail was (1.72±0.14) cm in group A and (0.53±0.26) cm in group B, showing significant difference ( t=31.031, P=0.000). According to the Harris score, the hip functions were rated as excellent in 48 cases, good in 15 cases, and poor in 9 cases in group A, while as excellent in 38 cases, good in 16 cases, and poor in 5 cases in group B, with no significant difference between the two groups ( Z=-0.075, P=0.941). For the unstable intertrochanteric fracture in the elderly, the PFNA internal fixation with appropriated TAD and the screw blades placed in the middle or at one-third of the femoral neck can obtain good effectiveness.

A clinical study to evaluate the effectiveness of the short proximal femoral nail in the management of unstable intertrochanteric fractures

<p class="abstract"><strong>Background:</strong> The objective was to study the effectiveness and drawbacks of short proximal femoral nail in the management of unstable intertrochanteric fractures.</p><p class="abstract"><strong>Methods:</strong> This prospective study was conducted in the department of orthopaedics Al-Ameen medical college, Vijayapura, Karnataka, India from July 2010 to June 2017. Total 175 patients (130 males and 45 females) aged between 41 to 80 years with unstable Intertrochantreric fracture (155 had type IV and 20 had type III according to Boyd and Griffin classification). All patients were operated using Short proximal femoral nail and followed at least for a minimum period of 6 months and were evaluated radiologically and clinically by Kyle’s Criteria.<strong></strong></p><p class="abstract"><strong>Results:</strong> Anatomical reduction was achieved in 125 patients, 105 (60%) had no complications post operatively. Complications included 5 cases of avascular necrosis and screw cut out, 5 cases of delayed union, 5 cases of Z-effect, 20 cases of varus malunion, 10 cases of antirotation screw breakage, 5 cases of distal bolt breakage and 15 cases with lateral thigh discomfort. 125 patients had No shortening and the average shortening was 0.34 cm, average time of union was 19.26 weeks (15-30 weeks) in 170 cases. At the end of 6 months, good to excellent results were seen in 71.5% of cases, 57% patients returned to their pre injury functional level.</p><p class="abstract"><strong>Conclusions:</strong> Short proximal femoral nail provides good fixation for unstable intertrochanteric fractures, if proper pre-operative planning, good reduction and surgical techniques are followed leading to high rate of bone union and minimal soft tissues damage especially for Asian patients with relatively small femora.</p>

Study of clinical and functional outcomes of unstable intertrochanteric femur fractures treated with long proximal femoral nail

Introduction: The following study was conducted to examine the long term clinical, radiological and functional results of unstable intertrochanteric femur fractures treated with long Proximal Femoral Nail. Materials and Methods: This was a prospective, non-randomized study of 50 cases of intertrochanteric fractures of unstable variety treated by long Proximal Femoral Nail at the Department of Orthopedics, B J Medical College and Civil Hospital, Ahmedabad, between 2014 to 2016. Patients were undergoing primary surgery, with unstable types of fracture pattern AO/OTA type 31A2.2 to 31A3.3. Pathological fractures and patients with previous surgery on proximal femur were excluded. Results: The sample consisted fifty patients, 33 were males and 17 females. The patients’ ages ranged from 18 - 90 years with mean of 68.2 years. Majority (86%) of the intertrochanteric fractures occurred following trivial trauma usually a domestic accident like fall in bathroom or fall from stairs. Associated bony injuries were present in 3 cases (6%). Most common associated injury was fracture lower end radius (in all 3 cases). 29(58%) patients had an osteoporosis Grade 5 while 17 (34%) had Grade 4. AO/OTA Type A2.3 type of fractures were most common in 31 (62%) patients, followed by A2.2, A3.1 and A3.3. Functional Outcome was assessed with modified Harris Hip Score in which 70% of the patients had good to excellent functional results on final follow up at 1 year. Conclusion: The proximal femoral nail, is an optimum implant for the internal fixation of unstable intertrochanteric fractures with advantages of stable fixation, perfect reduction, early weight bearing and ambulation, shortened hospital stay and improved rate of union with early resumption of independent life style.

Analysis of outcome of unstable intertrochanteric fractures treated by proximal femoral nail- A prospective and retrospective study

Background: An analytical study was conducted on the outcome of unstable Intertrochanteric fractures treated by conventional proximal femoral nailing in a prospective and retrospective method. Materials and methods: During our study period, 130 patients, both males and females, aged between 50 years and 100 years who were suffering from unstable intertrochanteric fracture and who were treated with Proximal femoral Nailing were included in the study. Both prospective and retrospective studies were conducted to evaluate clinical and functional outcome of 130 patients. Modified Harris Hip score was used to evaluate clinical and functional outcome. Radiological assessment with hip anteroposterior and lateral views were taken.quality of reduction, malialignments, screw cut outs, bony union and implant related complications were noted. Results: In our study majority of the cases about 60% were in the age group of 61 to 80 years among the study group of 50 to 100 years. Females were slightly more affected (52.35%) as compared to males (47.65%).Average time for radiological union was about 16 weeks. Among 130 of our patients 1 cased died on 3rd posteoperative day for reason unrelated to the surgery. So Harris Hip Score was calculated for 129 patients. We had 53.9% of excellent and 36.1% of good results which together accounted to about 90% of the cases Conclusion: Based on our experience and results we conclude that proximal femoral nailing is an excellent judicious and rational method of fixation for unstable intertrochanteric fractures in elderly patients.

Comparison of the functional and radiological outcomes of unstable intertrochanteric fractures treated with dynamic hip screw and proximal femoral nail- A prospective randomized controlled study

The intertrochanteric fractures constitute 34% of all hip fractures1. 50% are unstable patterns. DHS and PFN are the two main options for treatment. A prospective randomized control study including 40 patients was carried out. The average blood loss, operating time and complications were significantly higher in the DHS group. PFN provides better fixation for unstable intertrochanteric fractures, if proper preoperative planning, good reduction and surgical technique are followed.

A Comparison of the Clinico-Radiological Outcomes with Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) in Fixation of Unstable Intertrochanteric Fractures.

Management of unstable intertrochanteric fractures poses challenges in terms of obtaining stable fixation and good postoperative outcomes. There is a paucity of clinical data comparing the commonly used Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) implants, especially in relation to osteoporosis. To assess comparative performance of PFN and PFNA in the setting of osteoporosis. Patients presenting with unstable intertrochanteric fractures (AO 31.A2 and 31.A3) were included and treated with either PFN or PFNA. Preoperative radiographs of normal side were used to grade osteoporosis by Singh's index. Grade 3 or less was considered significant. Postoperative radiographs were assessed for tip-apex distance, Cleveland index and quality of reduction. Patients were followed up for a minimum of nine months and any complications noted. Comparison of functional outcomes was done using the Harris Hip Score and Parker-Palmer mobility score at final follow up. Statistical analysis was done using the unpaired t-test/Mann-Whitney U test and Chi-square test/Fisher's-exact test. A p-value of < 0.05 was considered significant. The study included 48 patients with unstable intertrochanteric fractures, of which 23 were treated with PFN and 25 with PFNA. Average age of PFN group was 60.78 years and of PFNA group was 74.12 years. In PFN group 8 patients (38.09%) and in PFNA group 13 patients (54.1%) had Singh's osteoporotic index of ≤ 3. The average Harris Hip Score was 75.37 and 78.85 in PFN and PFNA groups (p=0.54) respectively. From PFN and PFNA groups, 35% and 32% patients respectively were able to return to pre-injury mobility status as assessed by the Parker-Palmer mobility score (p=0.83). Out of eight implant related complications; seven were in patients treated with PFN (p=0.02). Among patients with Singh's grade ≤ 3, 3 (37.5%) in PFN group suffered from implant failure whereas all 13 patients in PFNA group had successful outcome (p=0.04). Although functional outcomes achieved with both implants are similar (p=0.83), number of implant related complications were fewer with PFNA (p=0.02), even in osteoporotic group (p=0.04). We recommend use of the PFNA in unstable fractures, especially in the elderly osteoporotic population.

Early Rehabilitation in Elderly after Arthroplasty versus Internal Fixation for Unstable Intertrochanteric Fractures of Femur: Systematic Review and Meta-Analysis.

The purpose of this study was to compare the outcomes focusing on the functional outcome and clinical results of replacement arthroplasty (AP) vs. internal fixation (IF) for the treatment of unstable intertrochanteric femoral fracture in elderly. Systematic review and meta-analysis were performed on 10 available clinical studies (2 randomized controlled trials and 8 comparative studies). Subgroup analysis was performed by type of methodological quality. Partial weight bearing time in AP group was earlier than that in IF group (SMD = −0.86; 95% CI = −0.42, 1.29; P = 0.050). The overall outcomes such as mortality, reoperation rate, and complication showed no significant diffrence between the 2 groups (AP vs. IF). Therefore, this systematic review demonstrates that AP provides superior functional outcomes especially earlier mobilization, as compared to IF in elderly patients with an unstable intertrochanteric femoral fracture.

A prospective study to evaluate the radiological and functional outcome of unstable intertrochanteric fractures treated with proximal femoral nail

Background and Objectives: Intertrochanteric fracture is one of the most common fractures of the hip especially in the elderly. These fractures are three to four times more common in women and the mechanism of injury is usually due to low-energy trauma like a simple fall. More than 50% of intertrochanteric fractures are unstable. The surgical stabilization of unstable intertrochanteric fractures remains a persistent challenge. The purpose of this dissertation is to study the effectiveness and drawbacks of one such newer intramedullary device, the Proximal Femoral Nail in the management of unstable intertrochanteric fractures Methodology: This study is a prospective, time bound, hospital based study conducted at P.G.I of swasthiyog Pratishthan, Miraj, between March 2013 to Feb 2014. The study included 45 cases of unstable intertrochanteric fractures (AO classification 31A2 & 31A3) that were operated with the PFN which fitted into the inclusion criteria. All patients were informed about the study in all aspects and an informed consent was obtained. Follow up at 4, 8, 12, 18, 24 weeks for serial clinical and radiological evaluation was done and assessed clinically regarding pain, limp, hip movements, walking ability, deformity and shortening. Functional evaluation at end of 6 months was done by using Harris hip score. Results: The study included 45 cases of unstable intertrochanteric fractures (36 cases of 31A2 & 9 cases of 31A3) that were operated with the PFN. The average age was 64 years. The most common mode of injury was trivial fall in 30 cases. Good reduction was achieved in 39 patients (86.66%). Acceptable reduction was achieved in 6 patients. 3 intraoperative complications and 9 post-operative complications observed. The average time of union was 18.44 weeks. Maximum number of fractures united between 16-20 weeks. Good to excellent results were seen in 88.8% of the cases according to Harris hip score at end of 6 months.Conclusion: Hence we conclude that short Proximal Femoral Nail provides good fixation for unstable intertrochanteric fractures if proper preoperative planning, good reduction and surgical technique are followed, leading to high rate of bone union and minimal soft tissue damage especially for asian patients with relatively small femora.

Dynamic Hip Screw with Trochanteric Stablization Plate Fixation of Unstable Inter-Trochanteric Fractures: A Prospective Study of Functional and Radiological Outcomes.

Management of unstable intertrochanteric fractures have posed a unique challenge to orthopaedicians over years. Several surgical techniques and implants have been developed for the same. Fractures of the lateral wall have been considered as the major cause of femoral medialization after fixation by Dynamic Hip Screw (DHS). Studies have shown that supplementation of trochanteric stabilization plate reduces the incidence of femoral medialization. To assess the radiological union and hip function after fixation of unstable intertrochanteric fractures with DHS and Trochanteric Stabilization Plate (TSP). A prospective study was conducted with a total of 32 patients between age groups of 30-70 years with Evan Jensen unstable and very unstable type of intertrochanteric fractures, between August 2013 to March 2015 in the Department of Orthopaedics ARS Hospital, Tirupur, Tamil Nadu, India. They underwent open reduction and DHS and TSP fixation. They were started on full weight bearing mobilization on post op day three. They were reviewed at post-op weeks 3,6,12 and 24. Hip mobilization and rehabilitation exercises were instituted during course of reviews. Radiographs were taken to assess fracture union and hip function was evaluated during follow-ups. At the end of 24 weeks, degree of radiographic union was scored as per Radiological Union Score for Hip (RUSH). Hip function was scored with Harris hip score. Analyses were done using frequency and proportions. Chi-square tests were used to assess the test of association. Fifteen patients had RUSH scores between 10-20 and 17 patients had scores between 20-30 points. RUSH score had mean of 21.03+/- 2.132 points. 9 of 32 patients had excellent results as per Harris hip score, 10 had good, nine had fair and four had poor. On comparison of Harris hip score with RUSH score: Interval between 10-20 points, of 15 patients; two had excellent results, five had good, five had fair and three had poor. Of 17 patients between 20-30 points, seven had excellent, five had good, four had fair and one had poor results. DHS and TSP fixation of unstable intertrochanteric fractures is an effective technique with good radiological and functional outcome.

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.

Le clou fémoral proximal antirotation Asia versus le clou fémoral proximal antirotation conventionnel dans les fractures instables de la région trochantérienne sur une population de patients chinois

BackgroundThe best options of internal fixation for unstable intertrochanteric fractures in elderly Chinese patients remain controversial. The Asia proximal femoral nail antirotation (PFNA-II) was specifically designed for Asian patients, which could be more effective than the regular proximal femoral nail antirotation (PFNA). Compared to PFNA, whether PFNA-II is associated with shorter operative time and lower rates of complications is unknown. HypothesisThe rate of complications using PFNA-II is lower than PFNA for the treatment of unstable intertrochanteric fractures in elderly Chinese patients, and the operation using PFNA-II is quicker. Materials and methodsBetween June 2008 and December 2011, 188 patients with unstable intertrochanteric fractures treated with the PFNA-II (n=118) or PFNA (n=70) were retrospectively evaluated. Follow-up evaluations were performed at 1, 3, 6, 9 and 12months, and every year thereafter. According to residual valgus-varus deformation, the quality of the fracture reduction was graded as poor (>10° deformation), acceptable (5 to 10° deformation), or good (<5° deformation). The operative time, intraoperative blood loss, overall time of fluoroscopy, blood transfusion volume, postoperative drainage, length of hospital stay and postoperative complications were recorded. ResultsThe mean operative time in the PFNA-II group was significantly shorter than that in the PFNA group (66.25±13.15 vs. 79.50±21.12minutes; P<0.05), intraoperative blood loss was smaller (131.86±69.16 vs. 162.14±66.18ml; P<0.05), and fewer local complications were observed (25% vs. 46%; P<0.05). There was no significant difference in the postoperative blood transfusions, overall time of fluoroscopy, postoperative drainage, length of hospital stay, fracture reduction, the position of the implant and tip apex distance between the two groups. At follow-up, no significant difference was found between the two groups in Harris hip score (HHS) (86.19±6.53 vs. 85.27±5.47; P>0.05), visual analogue scale (VAS) (0.87±0.85 vs. 0.97±0.87; P>0.05). DiscussionDue to its special design for the Asian population, PFNA-II offers a better match with the Chinese people's proximal femur anatomic structure. This study showed that the rate of complications using PFNA-II is lower than PFNA for the treatment of unstable intertrochanteric fractures in elderly Chinese patients, and the operation time is shorter. Level of evidenceLevel III case control study.

The Asia proximal femoral nail antirotation versus the standard proximal femoral antirotation nail for unstable intertrochanteric fractures in elderly Chinese patients

BackgroundThe best options of internal fixation for unstable intertrochanteric fractures in elderly Chinese patients remain controversial. The Asia proximal femoral nail antirotation (PFNA-II) was specifically designed for Asian patients, which could be more effective than the regular proximal femoral nail antirotation (PFNA). Compared to PFNA, whether PFNA-II is associated with shorter operative time and lower rates of complications is unknown. HypothesisThe rate of complications using PFNA-II is lower than PFNA for the treatment of unstable intertrochanteric fractures in elderly Chinese patients, and the operation using PFNA-II is quicker. Materials and methodsBetween June 2008 and December 2011, 188 patients with unstable intertrochanteric fractures treated with the PFNA-II (n=118) or PFNA (n=70) were retrospectively evaluated. Follow-up evaluations were performed at 1, 3, 6, 9 and 12 months, and every year thereafter. According to residual valgus-varus deformation, the quality of the fracture reduction was graded as poor (>10° deformation), acceptable (5° to 10° deformation), or good (<5° deformation). The operative time, intraoperative blood loss, overall time of fluoroscopy, blood transfusion volume, postoperative drainage, length of hospital stay and postoperative complications were recorded. ResultsThe mean operative time in the PFNA-II group was significantly shorter than that in the PFNA group (66.25±13.15 vs 79.50±21.12minutes; P<0.05), intraoperative blood loss was smaller (131.86±69.16 vs 162.14±66.18mL; P<0.05), and fewer local complications were observed (25% vs 46%; P<0.05). There was no significant difference in the postoperative blood transfusions, overall time of fluoroscopy, postoperative drainage, length of hospital stay, fracture reduction, the position of the implant and tip apex distance between the two groups. At follow-up, no significant difference was found between the two groups in Harris hip score (HHS) (86.19±6.53 vs 85.27±5.47; P>0.05), visual analogue scale (VAS) (0.87±0.85 vs 0.97±0.87; P>0.05). DiscussionDue to its special design for the Asian population, PFNA-II offers a better match with the Chinese people's proximal femur anatomic structure. This study showed that the rate of complications using PFNA-II is lower than PFNA for the treatment of unstable intertrochanteric fractures in elderly Chinese patients, and the operation time is shorter. Level of evidenceLevel III, case control study.

Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial

There is no consensus about the best option of internal fixation for unstable intertrochanteric fractures. The aim of the present study was to compare proximal femoral nail (PFN) with contralateral reverse distal femoral locking compression plate (reverse-DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall. In a randomized controlled study, from November 2011 to October 2012, 40 patients with unstable intertrochanteric fractures with compromised lateral wall (AO 31A 2.2 to 3.3) had osteosynthesis by PFN (n = 20) or reverse-DFLCP (n = 20). Intra-operative variables compared were duration of surgery, blood loss during surgery, fluoroscopy time and surgeons perception of the surgery. Patients were followed up clinically for a minimum of one year. Functional outcome was assessed by Parker Palmer mobility score (PPMS), Harris hip score (HHS), and Short Form-12. Failure was defined as any condition which would necessitate revision surgery with change of implant. Duration of surgery (p = 0.022), blood loss during surgery (p = 0.008) and fluoroscopy time (p = 0.0001) were significantly less in the PFN group than in the reverse-DFLCP group. No significant difference was found in type of reduction, difficulty in reduction and surgeon's perception of surgery. The PFN group had better functional outcome than the reverse-DFLCP group. HHS for the PFN group was 81.53 ± 13.21 and for the reverse-DFLCP group it was 68.43 ± 14.36 (p = 0.018). SF-12 physical (p = 0.002) and mental component (p = 0.007) scores in the PFN group was significantly better than in the reverse-DFLCP group. There was one failure in the PFN group as compared to six in the reverse-DFLCP group (p = 0.036). Due to favourable intra-operative variables, better functional outcome and lower failure rates, we conclude that PFN is a better implant than reverse-DFLCP for intertrochanteric fractures with compromised lateral wall.

Cephalomedullary Nail versus Sliding Hip Screw for Unstable Intertrochanteric Fractures in Elderly Patients

To compare the short-term ambulatory function of elderly patients after fixation of unstable intertrochanteric fractures with either the AO-ASIF proximal femoral nail anti-rotation (PFNA) device or the dynamic hip screw (DHS). 63 patients aged 60 years or older underwent fixation for unstable intertrochanteric fractures (AO types A2 and A3) using the PFNA (n=25) or DHS (n=38). The decision for the type of implant used was based on the lead surgeon's preference, according to perceived fracture stability and clinical experience. In patients having PFNA fixation, weight bearing ambulation and rehabilitation was commenced on day 2. The extent of weight bearing was decided by the lead surgeon based on the stability of the fracture. In patients having DHS fixation, non-weight bearing and ambulation with a walking aid was commenced on day 2. Ambulatory function before injury and after surgery was measured using the Parker Mobility Score (PMS). The 2 groups were compared in terms of the PMS, ambulatory independence, and environmental mobility. Respectively in PFNA and DHS patients, 32% and 13% (p=0.035) were ambulant with a walking frame at discharge; the remainder were wheelchair bound. Patients treated with PFNA had significantly higher median PMS at 6 months (4 vs. 2, p=0.002), median ambulatory independence score at 6 months (4 vs. 3, p=0.004) and at 12 months (5 vs. 4, p=0.001), and median environmental mobility score at 6 months (2 vs. 1, p=0.007). They also had significantly higher percentage of patients able to ambulate outdoor and in community at 6 months (64% vs. 29%, p=0.02) and able to walk independently or with a walking aid at 12 months (96% vs. 69%, p=0.01). There were 3 complications. Two patients treated with PFNA had blade cut-out, owing to poor fracture reduction. One patient treated with DHS had screw cut-out and subsequently developed avascular necrosis of the femoral head. Unstable intertrochanteric fractures in elderly patients with good pre-fracture ambulatory function stabilised with the PFNA resulted in better short-term ambulatory function.