Proximal Femoral Nail Antirotation Research Articles

Outcomes of Intertrochanteric Fractures in Patients Managed with Proximal Femoral Nail Antirotation

Background: The older population is quite susceptible to intertrochanteric fractures. These fractures generally affect elderly patients with several medical conditions and eventually result in the patient losing their functional independence. Different treatment modalities are used for the management of proximal femoral fractures.s Objective: Outcomes of intertrochanteric fractures in patients managed with Proximal Femoral Nail Antirotation Methodology: The current study was descriptive study carried out at the orthopedic department, Qazi Hussain Ahmad Medical College, Nowshera from June 2021 to June 2022. All the enrolled patients were operated under an image intensifier by Proximal Femoral Nail Antirotation. Consultations after surgery were planned every two weeks for the first month, and then every month for the next six months. Radiographs were used to evaluate the radiological union at each visit. The functional outcome was determined with Harris Hip Score. SPSS version 23 was used to enter and analyze all of the data. Results: In the current study, totally 40 patients with intertrochanteric fractures were enrolled. The male participants in this study were 12 (30%) while female patients were 28 (70%). In all of our enrolled patients, radiological union occurs in a mean (SD) duration of 14.9 (2) weeks. The functional outcome in our study, based on Harris Hip Score was excellent in 12 (30%) patients, good in 18 (45%), fair in 8 (20%) patients and poor in 2 (5%) patients. Conclusion: Our study concludes that management of intertrochanteric fractures with proximal femoral nail antirotation is an effective procedure for excellent and good functional outcomes and less post-operative complication. Keywords: intertrochanteric fractures; Proximal Femoral Nail Antirotation; functional outcomes

Treatment of intertrochanteric femur fracture in elderly patients with the proximal femoral nail antirotation: evaluation in terms of union and functional outcome

<p><strong>Background: </strong>Trochanteric fractures almost invariably occur as a result of a trivial fall involving both direct and indirect forces. Fixation in the geriatric population generally consists of weakened, osteoporotic bone; intramedullary devices (PFNA) carry an advantage over other load sharing devices by not having to depend on plate fixation with bone screws purchasing a compromised lateral cortex. The purpose of the present study is to verify the theoretical advantages of the proximal femoral nail in elderly osteoporotic patients and eventually functional outcome of the patient.</p><p><strong>Method: </strong>A total of 30 patients with age >60 years with intertrochanteric femur fractures managed with proximal femoral nail anti-rotation for prospective study. Harris hip score had been used in our study for regular follow up and evaluation at each and every follow up visit.</p><p><strong>Results: </strong>Average Harris hip score at the end of study showed mean value of 87, ranged from 65 to 94 with almost 73% patients showing excellent or good outcome. And 100% fractures got united with a good component position and average time to bone healing was 14 weeks.</p><p><strong>Conclusions: </strong>PFNA are now favored in western countries and there are multiple studies coming from that region to support this. Due to advantages of high union rate, early postoperative mobilization, and short operation time, PFNA osteosynthesis is the method of choice for surgical treatment of stable and unstable osteoporotic intertrochanteric femoral fractures.</p>

Ortopedik Cerrahi Geçiren Geriatrik Hastalarda Postoperatif Kognitif Disfonksiyon ve Serebral Oksimetri Korelasyonu

Aim: The purpose of this study was comparing the type of anesthesia in geriatric patients undergoing orthopedic surgery with cerebral tissue oxygen saturation values and Mini Mental Test (MMT) scores. The relationship between cerebral tissue oxygen saturation values and MMT scores was also evaluated. Material and methods: A total of 40 patients over the age of 65 and above who were scheduled for Proximal Femoral Nail Antirotation (PFN-A) operation were included in our study. Cases were divided into 2 groups as general anesthesia (Group I) and spinal anesthesia (Group II). Cerebral tissue oxygen saturation right and left values and hemodynamic data were measured at regular intervals in the preoperative period until the postoperative 48th hour. MMT scores at the preoperative and 48th postoperative hours were evaluated. The relationship between cerebral oxygen saturation values and MMT scores were evaluated. Results: Although there was decreased in the MMT scores performed at 48th postoperative hours compared with the preoperative period, no statistically significant difference was observed between the groups (p>0.05). When the cerebral tissue oxygen saturation right and left values in the perioperative period were compared, there was no statistically significant difference between the groups, although there was a decrease in the cerebral tissue oxygen saturation values (p>0.05). When the relationship between perioperative cerebral tissue oxygen saturation right and left values and the MMT scores were examined, no statistically significant relationship was found (CI%95:0.318-35.364) (p>0.05). Conclusion: In elderly patients who undergo minimally invasive orthopedic surgery, a decrease in cerebral tissue oxygen saturation values and MMT scores can be seen in the perioperative period in both spinal anesthesia and general anesthesia. However, there was no relationship between cerebral tissue oxygen saturation values and MMT scores.

A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-II) in the fixation of stable intertrochanteric fractures

PurposeLong proximal femoral nail anti-rotation (PFNA-II) is a preferred implant in recent years for fixation of pertrochanteric fractures, especially in osteoporotic patients. The purpose of this study is to prospectively investigate the effect of distal locking in long PFNA-II fixation of stable intertrochanteric fractures. MethodsA total of 58 patients with isolated stable intertrochanteric fractures and treated in our hospital during the study period of 2017–2019 by distal locked or unlocked long PFNA-II fixation were included in this study. Patients who had multiple injuries or open fractures were excluded. There were 40 female and 18 male patients, with 33 affecting the left side and 25 the right side. Of them, 31 belonged to the distal locked group (group A) and 27 to the unlocked group (group B). Surgical procedures and implants used in both groups were similar except for the distal locking of the nails. General data (age, gender, fracture side, etc.) showed no significant difference between two groups (all p > 0.05). The intraoperative parameters like operative time, radiation exposure and follow-up parameters like functional and radiological outcomes were recorded and compared. Statistical tests like the independent samples t-test Fischer's exact and Chi-square test were used to analyze association. ResultsThe distribution of the fractures according to AO/OTA classification and 31A1.2 type of intertrochanteric fractures were most common in our study. All the included fractures united and the average functional outcome in both groups were good and comparable at the end of one year. The operative time (mL, 107.1 ± 12.6 vs. 77.0 ± 12.0, p < 0.001) and radiation exposure (s, 78.6 ± 11.0 vs. 40.3 ± 9.3, p < 0.001) were significantly less among the patients in group B. Fracture consolidation, three months after the operative procedures, was seen in a significantly greater proportion of patients in group B (92.6% vs. 67.7%, p = 0.025). Hardware irritation because of distal locking bolt was exclusively seen in group A, however this was not statistically significant (p = 0.241). ConclusionWe conclude that, in fixation of stable intertrochanteric fractures by long PFNA-II nail, distal locking not only increases the operative time and radiation exposure but also delays the fracture consolidation and increases the chances of hardware irritation, and hence is not required.

A comparison of functional and radiological outcome of combine compression antegrade intertrochanteric nail (InterTan) and proximal femoral nail anti-rotation II (PFNA-II) in elderly patients with intertrochanteric fractures.

To compare the functional and radiological outcome of combine compression interlocking intramedullary nail (InterTan) and proximal femoral nail anti-rotation II (PFNA-II) in the treatment of elderly patients with intertrochanteric fractures. As a retrospective cohort study, records of 88 patients with intertrochanteric fractures treated in our hospital from January 1st, 2019 to July 31st, 2021 were retrospectively reviewed. According to treatment records, it included 45 patients treated with InterTan (Group-A) and 43 patients treated with PFNA-II (Group-B). The operation safety and functional rehabilitation of the two groups were compared and analyzed. This study included 88 patients with intertrochanteric fractures (mean [SD] age, 68.72 [0.10] years at baseline), of whom 52 (59.09%) were males and 36 (40.91%) were females. Operation time and intraoperative blood loss in Group-B were less than Group-A, while fracture healing time was shorter in Group-A. The fracture separation distance was measured four weeks after the operation. The widening rate of the fracture line in Group-A was lower than Group-B (4.4% vs.18.6%; P<0.05). The incidence of complications in Group-A was lower than Group-B (4.4% vs.18.6%; P<0.05). At three, six and twelve months after the operation, the Harris hip score of the two groups was higher than at discharge (P<0.05), with no significant difference between groups (P>0.05). We found no significant difference in the functional outcome in elderly patients with intertrochanteric fractures treated with InterTan and PFNA-II. Early fracture healing and reduced complication rate however has been noted with InterTan.

Favorable revision-free survivorship of cemented arthroplasty following failed proximal femoral nail antirotation: a case series with a median follow-up of 10 years

BackgroundGiven the ever-increasing rate of failure related to proximal femoral nail antirotation (PFNA), it is expected that an increasing number of PFNA individuals will undergo conversion to total hip arthroplasty (THA). The long-term survivorship of conversion of the initial PFNA to cemented THA is still debated. The aim of this retrospective study was to assess the long-term revision-free survivorship of cemented THAs after initial failures of PFNA in geriatric individuals.MethodsConsecutive geriatric individuals who underwent secondary cemented THA after initial PFNA fixation from July 2005 to July 2018, were retrospectively identified from three medical centres. The primary outcome was revision-free survivorship estimated using the Kaplan–Meier method and Cox proportional hazards regression with revision for any reason as the endpoint; secondary outcomes were functional outcomes and key THA-related complications. Follow-ups occurred at 3 months, 6 months, 12 months and then every 12 months after conversion.ResultsIn total, 186 consecutive patients (186 hips) were available for study inclusion. The median follow-up was 120.7 months (60–180 months) in the cohort. Kaplan–Meier survivorship with revision for any reason as the end point showed that the 10-year revision-free survival rate was 0.852 (95% confidence interval [CI], 0.771–0.890). Good functional outcomes were seen, and the HHS decreased markedly over the 24th month to the final follow-up interval from 92.2 to 75.1 (each p < 0.05). The overall rate of key THA-related complications was 16.1% (30/186).ConclusionCemented THA executed following initial PFNA failure may yield satisfactory revision-free survival and, at least for the initial 10 years after conversion, good functional outcomes and a 16.1% complication rate of key THA-related complications, which supports the trend towards increased use of cemented THA.

Clinical analysis of extended PFNA combined with MIPPO plate for reconstruction of lateral wall in treatment of AO-A3.3 intertrochanteric fracture

To compare the clinical efficacy of lengthened proximal femoral nail anti-rotation(PFNA) combined with minimally invasive percutaneous plate osteosynthesis(MIPPO) and common PFNA in the treatment of AO-A3.3 intertrochanteric fracture. The clinical data of 58 patients with AO-A3.3 intertrochanteric fracture treated from January 2015 to April 2020 were retrospectively analyzed. Among them, 27 patients were treated with extended PFNA + MIPPO plate to reconstruct the lateral wall (group A), and 31 patients were treated with closed reduction and PFNA fixation (group B). The bleeding volume, operation time, femoral neck length and tip apex distance(TAD), fracture healing time and postoperative complications were observed and compared between two groups. Harris score was used to evaluate hip joint function 10 months after operation. All patients were followed up for 12 to 28 months. The incision healed well after operation. The bleeding volume and operation time of group A were significantly more than that of group B (P<0.05), and the fracture healing time of group A was significantly less than that of group B(P<0.05). There was no significant difference in the length of femoral neck between two groups at 2 days after operation(P>0.05). The length of femoral neck at 6 months after operation in each group was shorter than that at 2 days after operation(P<0.05), and the shortening of femoral neck at 6 months after operation in group B was significantly shorter than that in group A(P<0.05). There was no significant difference in TAD values between two groups at the same time point(P>0.05) at 2 days and 6 months after operation. There was no significant difference in TAD values between 2 days and 6 months after operation(P>0.05). The incidence of complications in group B was significantly higher than that in group A(P<0.05). The Harris scores of hip joint function in group A were higher than those in group B 10 months after operation (P<0.05). Compared with the treatment of AO-A3 femoral intertrochanteric fracture with closed reduction and PFNA fixation, the lengthened PFNA combined with MIPPO small plate for reconstruction and fixation of the lateral wall can promote the fracture healing, improve the patient's functional recovery, and significantly reduce the complications.

Comparison of Helical Blade Systems for Osteoporotic Intertrochanteric Fractures Using Biomechanical Analysis and Clinical Assessments.

Background and Objectives: This study aimed to compare the biomechanical properties and outcomes of osteoporotic intertrochanteric fractures treated with two different helical blade systems, the trochanteric fixation nail-advanced (TFNA) and proximal femoral nail antirotation II (PFNA), to evaluate the efficacy and safety of the newly introduced TFNA system. Materials and Methods: A biomechanical comparison of the two helical blades was performed using uniaxial compression tests on polyurethane foam blocks of different densities. The peak resistance (PR) and accumulated resistance (AR) were measured during the 20 mm advancement through the test block. For clinical comparison, 63 osteoporotic intertrochanteric fractures treated with TFNA were identified and compared with the same number of fractures treated with PFNA using propensity score matching. Ambulatory status, medial migration, lateral sliding, fixation failure, and patient-reported outcomes were compared between the two groups over a minimum of 1 year's follow up. Results: The uniaxial compression test showed that a slightly, but significantly lower resistance was required to advance the TFNA through the test block compared with the PFNA (20 PCF, p = 0.017 and p = 0.026; 30 PCF, p = 0.007 and p = 0.001 for PR and AR, respectively). Clinically, the two groups showed no significant differences in post-operative ambulatory status and patient-reported outcomes. However, in TFNA groups, significantly more medial migration (TFNA, 0.75 mm; PFNA, 0.40 mm; p = 0.0028) and also, lateral sliding was noted (TFNA, 3.99 mm; PFNA, 1.80 mm; p = 0.004). Surgical failure occurred in four and two fractures treated with the TFNA and PFNA, respectively. Conclusions: The results of our study suggest that the newly introduced TFNA provides clinical outcomes comparable with those of the PFNA. However, inferior resistance to medial migration in the TFNA raises concerns regarding potential fixation failures.

An innovative scoring system for predicting an excellent Harris hip score after proximal femoral nail anti-rotation in elderly patients with intertrochanteric fracture

Typically, intramedullary and extramedullary devices are used to treat elderly with intertrochanteric fractures. The majority of previous research has focused on the association between surgical factors and mechanical failure after internal fixation. There is, however, limited evidence to demonstrate the association between functional outcomes after proximal femoral nail anti-rotation (PFNA) fixation and the non-surgical factors such as patient’s comorbidities. The aim of this study is to determine the predictive factors associated with excellent outcome, as well as to develop an integrated scoring system to predict the outcome after PFNA fixation in elderly patients with an intertrochanteric fracture. A retrospective study was conducted between January 2012 and December 2018. Elderly patients with low-energy intertrochanteric fractures who underwent PFNA fixation and at least a year of follow-up were recruited. Demographics, comorbidities, cognitive status, time to operation, and surgical parameters of the patients were all identified. Excellent and non-excellent outcomes were assessed by Harris Hip Score (HHS) after a one-year follow up. Regression analysis was used to determine the predictors for an excellent functional outcome. A new integrated scoring system (ISSI; Integrate Scoring System in elderly patients with Intertrochanteric fracture) was developed and validated. 450 elderly patients were randomly divided into two cohorts: a development (N = 225) and validation cohorts (N = 225). In this study, age < 85 years, normal weight/overweight, Charlson comorbidity index (CCI) < 6, no cognitive impairment, a modified AO/OTA 31A1.3, time to operation < 6 days, and Tip Apex Distance between 20 and 30 mm were significantly associated with an excellent outcome after PFNA fixation. The range of ISSI score was between 0 to 16 and the cut-off score of 13 was found to have the highest discriminatory power to determine the excellent functional outcome where the area of ROC was 0.85. In regards to the validation cohort, the sensitivity and specificity of ISSI score was 69% and 87%, respectively, and the AUC was 0.81. The ISSI score is effortless and practical for orthopedic surgeons for predicting an outcome after PFNA fixation in elderly patients with an intertrochanteric fracture.

Offset nail fixation for intertrochanteric fractures improves reduction and lag screw position.

Surgery for intertrochanteric fractures using intramedullary hip nails (IHNs) is among the most common surgical procedures in the orthopedic field. Although IHNs provide good overall outcomes, they sometimes cause complications, such as loss of reduction and cut-out. Here, we investigated the usefulness of IHNs with an anterior offset (Best Fit Nail® [BFN]) in maintaining fragment reduction and ensuring proper lag screw position compared with conventional non-offset nails (Proximal Femoral Nail Antirotation® [PFNA]), using postoperative computed tomography (CT). Fifty consecutive patients with intertrochanteric fractures who underwent surgery with BFNs (BFN group) and 50 patients who underwent surgery with PFNAs (PFNA group) were retrospectively analyzed. Indices evaluated by postoperative CT were displacement distance of proximal fragment relative to distal fragment, reduction status (intramedullary, anatomical, and extramedullary types), lag screw direction, and angle between lag screw and femoral neck axis (deviation angle). Median [interquartile range] displacement distance was significantly smaller in the BFN group (0 [0, 0] mm) compared with the PFNA group (5.2 [3.6, 7.1] mm) (p<0.001). Reduction status was significantly better in the BFN group (anatomical type, 40 cases; intramedullary type, in 9 cases, and extramedullary type in 1 case) than in the PFNA group (anatomical type, 6 cases; intramedullary type, 43 cases; extramedullary type, 1 case) (p<0.001). Deviation of lag screw direction was observed in significantly fewer cases in the BFN group (20 cases; 40%) compared with the PFNA group (36 cases; 72%). Lag screw deviation angle was significantly smaller in the BFN group (-0.71°±4.0°) compared with the PFNA group (6.9°±7.1°). No adverse events related to surgery were observed in either group. Intertrochanteric fracture surgery using offset BFNs exhibited significantly smaller displacement distance, better reduction status, and higher frequency of no deviation with central lag screw position, compared with surgery using non-offset PFNAs.

Conversion Hip Arthroplasty Using Standard and Long Stems after Failed Internal Fixation of Intertrochanteric Fractures.

Failed internal fixation of intertrochanteric fractures (FIF-ITF) is often treated by conversion hip arthroplasty (CHA). This study aimed to evaluate the results and complications of using standard and long femoral stems in this operation. This retrospective, multi-center study enrolled 31 total hip arthroplasty (THA) and 23 hemiarthroplasties (HA) cases (30 women, 24 men; mean age 76 years) after FIF-ITF between 2012 and 2019, divided into two groups: standard stem group (n=20) and long stem group (n=34). The initial internal fixation includes 38 cases of proximal femoral nail anti-rotation (PFNA), eight cases of the dynamic hip screw (DHS), and eight cases of locking proximal femoral plate (LPFP). The indications for CHA included 38 cases of failure of fixation, seven cases of nonunion, and nine cases of avascular necrosis or posttraumatic osteoarthritis. Perioperative data and complications related to fracture and operation were collected, and preoperative and postoperative clinical and radiological data were analyzed. Clinical outcomes were assessed using Harris hip score (HHS) and 36-item Short Form survey (SF-36: including physical function (PF) score and body pain (BP) score). Statistical analyses were performed using the chi-square or Fisher's exact test, and the 2-sample t-test or Wilcoxon rank sum test. At an average of 5.6 years with a minimum of 2 years follow-up. A significant overall surgeon-related complication rate was detected (27.8% [15/54]), five cases had an intraoperative femur fracture, one case had a late periprosthetic femoral fracture, two cases had a stem penetration, one case had a cement leakage, and two patients had an early postoperative dislocation, one infection and three cases of stem loosening or subsidence. Long stems had an increased risk of complication (13/34) compared to standard stems (2/20) (P=0.031). The operation time and blood loss in the long stem group were higher than those in the standard stem group (P=0.002; 0.017). HHS and SF-36 significantly improved in both groups from preoperative to the final follow-up and did not present significant differences at the final follow-up (P > 0.05). CHA following FIF-ITF showed a successful mid-term clinical result, long stem arthroplasty should be approached with caution for the risks of higher complication rate, especially intraoperative femoral fractures.

Predictors of and predictive nomogram for cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures.

This study determined independent predictors and developed a predictive nomogram for failed correction of intertrochanteric fractures due to cut-out of the proximal femur nail anti-rotation (PFNA) device. Demographic and radiological data of 592 adult patients with intertrochanteric fractures (AO 31A) treated by PFNA were collected retrospectively. Independent predictors of cut-out were obtained through univariate and multivariate analyses, and a predictive nomogram was established. The discrimination, calibration, and clinical utility of the nomogram were based on receiver operating characteristic curve (AUC), concordance index (C-index), calibration curve, and decision curve analysis, respectively. Overall, 18 (3.04%) cases of cut-out occurred. Independent predictors according to the multivariate analysis were body mass index (BMI), poor-to-acceptable quality of reduction, PFNA blade position, and tip-apex distance (TAD). AUC of the nomogram was 0.849, and C-index was 0.849 (95% CI [0.844-0.854]). Bootstrapping yielded a corrected C-index of 0.849. The calibration and decision curves indicated good agreement and clinical benefit of the nomogram. A reliable predictive nomogram was developed for cut-out of the PFNA in intertrochanteric fractures, based on BMI, quality of reduction, blade position, and TAD.

A comparative study of intertan nail versus proximal femoral nail antirotation in the treatment of peritrochanteric fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Over the past decades the incidence of intertrochanteric fractures has increased and there is a universal agreement about the intramedullary nail being the preferred implant of fixation for these fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this study we have attempted to assess and compare the results and immediate as well as long term outcome of fractures managed by proximal femoral nail anti rotation and the intertan nail. We included 102 patients in our study, half in the group managed by proximal femoral nail anti rotation group and half in the group managed by intertan nail. Over a period of almost one and half years we evaluated the patients in immediate and late post op period for the union of the fracture, functional outcomes and the short- and long-term complications.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The results were evaluated in the terms of intraoperative variables like fluoroscopy time, mean blood loss and reduction achieved and postoperatively in terms of superficial wound infections and Harris hip score and mobility score of paper and palmer which were comparable for both groups of patients with slight differences in some variables.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; We concluded that the intertan nail is a good option for fracture fixation in patients with unstable intertrochanteric fractures and though associated with a steeper learning curve it has lesser complications and slightly better functional outcomes as compared to the proximal femoral nail anti rotation.&lt;/p&gt;

The analgesic efficacy of pericapsular nerve group block in patients with intertrochanteric femur fracture: A randomized controlled trial.

The aim of this study is to evaluate analgesic efficacy of pericapsular nerve group (PENG) block in patients with intertrochanteric femur fracture (IFF). This double-blinded randomized controlled trial in patients with IFF scheduled for proximal femoral nail antirotation (PFNA) between December 2020 and November 2021. The primary outcome was VAS scores during exercising at 6 h after surgery; secondary outcomes were pain during exercising and rest, intraoperative dose of remifentanil, cumulative dose of postoperative fentanyl, postoperative analgesia satisfaction scores, and ratio of quadriceps weakness. A total of 50 patients were randomly divided into PENG block group (n = 25) or fascia iliaca compartment block (FICB) group (n = 25). Exercising VAS scores at 6 h after surgery were significantly lower in PENG block group than that in FICB group (2 (2, 4) vs. 6 (4, 7), P < 0.001). The intraoperative dose of remifentanil and cumulative dose of postoperative fentanyl by patient-controlled intravenous analgesia within 24 h after surgery in PENG block group were significantly lower than in FICB group (both P < 0.001). Postoperative analgesia satisfaction scores in PENG block group were significantly higher than those in FICB group (P = 0.016). The ratio of quadriceps weakness at 6 h after surgery was significantly higher in FICB group than PENG block group (48% vs. 0%, P < 0.001). Compared to FICB, ultrasound-guided PENG block may provide better postoperative pain relief in patients with IFF, with less pronounced quadriceps weakness.

Does the Entry Point of Proximal Femoral Nail Antirotation Affect the Malalignment of Intertrochanteric Fracture? A Cadaveric Study

Purpose: Proximal femoral nailing (PFN) is a reliable and common procedure for treating intertrochanteric fractures. The optimal entry point is considered a critical step in avoiding malreduction. This study investigated the effects of various entry points on fracture displacement and force reduction. Methods: Twenty-four cadaveric femurs were randomly categorized into three groups: the greater trochanter (GT) tip, medial to the GT tip, and lateral to the GT tip. Each intact femur was provisionally stabilized using a ring external fixator. The entry point was identified and reamed to accommodate the nail insertion. After osteotomy was performed to simulate an A1-type fracture, the PFN was inserted. Digital calipers were used to measure horizontal fracture displacements. The force required to reduce displaced fractures to the anatomical position was measured using a digital force gauge. Fluoroscopic images were recorded to assess changes in the neck-shaft angle. Results: The lateral entry group showed significantly displaced fractures in the coronal plane, whereas the medial and tip entry groups were insignificant. Displacement in the sagittal plane was not significantly different between the groups. The lateral entry group showed significantly irreducible displaced fractures compared with the other groups. After nail insertion, the changes in the neck-shaft angle were 0.77° varus, 3.66° valgus, and 3.16° varus in the tip, medial, and lateral entry groups, respectively. The degree of neck-shaft angle change demonstrated significant differences between the groups. Conclusions: The lateral entry point of PFNA tends to displace reduced fractures, resulting in malalignment and irreducibility. Lateral entry points should be avoided to prevent surgery-related complications.

Cost-Effectiveness of Cement Augmentation Versus No Augmentation for the Fixation of Unstable Trochanteric Fractures.

A previous randomized controlled trial (RCT) demonstrated a trend toward a reduced risk of implant-related revision surgery following fixation with use of a Proximal Femoral Nail Antirotation (PFNA) with TRAUMACEM V+ Injectable Bone Cement augmentation versus no augmentation in patients with unstable trochanteric fractures. To determine whether this reduced risk may result in long-term cost savings, the present study assessed the cost-effectiveness of TRAUMACEM V+ cement augmentation versus no augmentation for the fixation of unstable trochanteric fractures from the German health-care payer's perspective. The cost-effectiveness model comprised 2 stages: a decision tree simulating clinical events, costs, and utilities during the first year after the index procedure and a Markov model extrapolating clinical events, costs, and utilities over the patient's lifetime. Sources of model parameters included the previous RCT, current literature, and administrative claims data. Outcome measures were incremental costs (in 2020 Euros), incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model uncertainty was assessed with deterministic and probabilistic sensitivity analyses. The base-case analysis showed that fixation with cement augmentation was the dominant strategy as it was associated with cost savings (€50.3/patient) and QALY gains (0.01 QALY/patient). Major influential parameters for the ICER were the utility of revision, rates of revision surgery within the first year after fixation surgery, and the costs of augmentation and revision surgery. Probabilistic sensitivity analyses demonstrated that estimates of cost savings were more robust than those of increased QALYs (66.4% versus 52.7% of the simulations). For a range of willingness-to-pay thresholds from €0 to €50,000, the probability of fixation with cement augmentation being cost-effective versus no augmentation remained above 50%. Fixation with use of cement augmentation dominated fixation with no augmentation for unstable trochanteric fractures, resulting in cost savings and QALY gains. Given the input parameter uncertainties, future analyses are warranted when long-term costs and effectiveness data for cement augmentation are available. Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.

Analysis of clinical, radiological and functional outcome of proximal femoral nail antirotation II in the treatment of unstable inter-trochanteric fracture

Purpose: To study the clinical, radiological and functional outcome of patients with IT fractures treated with pfn AII methods - An Hospital based Observational study was done at A J Institute of Medical Sciences and Research Centre, Mangalore. During the period June 2019 to April 2021, on 36 patients who underwent PFN AII fixation for Intertrochanteric fracture. Patient had regular follow ups at 1, 3, 6 and 9 month. Clinico-radiological outcome was assessed at the end of 9 months. Functional outcome was assessed using Harris Hip Score. Results: Among 36 patients with Intertrochanteric fracture meeting Inclusion criteria, patients studied, the mean time of union is 10.88 weeks. 2 patients presented with minor complications such as superficial skin infection treated conservatively. All fractures United uneventfully, no patients underwent re-surgery. Conclusion: PFN A-II is a significant advancement in the treatment of trochanteric fractures which has the unique advantage of closed reduction, preservation of fracture hematoma, minimal soft tissue damage during surgery, early rehabilitation and early return to work.

Long-term survival of hybrid total hip replacement for prior failed proximal femoral nail antirotation: a retrospective study with a median 10-year follow-up

BackgroundHybrid total hip replacement (THR) is commonly used in the management of proximal femur fractures in elderly individuals. However, in the context of the revision, the literature on hybrid THR is limited, and differences in the long-term survival outcomes reported in the literature are obvious. This retrospective study aimed to evaluate the long-term survival of hybrid THR for failed proximal femoral nail antirotation (PFNA) in elderly individuals aged ≥ 75 years.MethodsAn observational cohort of 227 consecutive individuals aged ≥ 75 years who experienced hybrid THRs following prior primary PFNAs was retrospectively identified from the Joint Surgery Centre, the First Affiliated Hospital, Sun Yat-sen University. Implant survival was estimated using the Kaplan–Meier method. The primary end point was the implant survivorship calculated using the Kaplan–Meier method with revision for any reason as the end point; secondary end points were the function score measured using the modified Harris Hip Score (mHHS) and the incidence of main orthopaedic complications.ResultsIn total, 118 individuals (118 THRs) were assessed as available. The median follow-up was 10 (3–11) years. The 10-year survivorship with revision for any reason as the endpoint was 0.914 (95% confidence interval [CI], 0.843–0.960). The most common indication for revision was aseptic loosening (70.0%), followed by periprosthetic fracture (30.0%). At the final follow-up, the median functional score was 83.6 (79.0–94.0). Among the 118 patients included in this study, 16 experienced 26 implant-related complications. The overall incidence of key orthopaedic complications was 13.5% (16/118).ConclusionFor patients aged ≥ 75 years old with prior failed PFNAs, hybrid THR may yield satisfactory long-term survival, with good functional outcomes and a low rate of key orthopaedic complications.

Reduction with Pre-Drilling Combined with a Finger Reduction Tool in Difficult-to-Reduce Intertrochanteric Fracture.

ObjectiveTo investigate the feasibility of pre‐drilling combined with a finger reduction tool for the reduction of difficult‐to‐reduce intertrochanteric fractures.MethodsPatients diagnosed with complicated intertrochanteric fractures during the period from July 2016 to May 2021 at the Affiliated Hospital of our College were enrolled in this study. All patients underwent reduction by pre‐drilling combined with a finger reduction tool followed by fixing with proximal femoral nail antirotation. The outcome of reduction was evaluated by intraoperative fluoroscopy. The operation time, intraoperative fluoroscopy frequency, and incidence of postoperative complications (including infection in the incision area, coxa vara, nail withdrawal, nail breakage, blade cut‐out, lower limb vein thrombosis, and pulmonary embolism) were recorded to evaluate the speed of the operation, the difficulty of the operation, and the prognosis of the patient, respectively. The Harris hip score at 9 months after surgery was used to evaluate the hip recovery.ResultsA total of 52 patients (17 men and 35 women), 61–88 (77.54 ± 7.40) years of age were included in the study. There were 14 patients with cardiovascular or cerebrovascular disease, ten patients with diabetes, three patients with Parkinson's disease, and three patients with respiratory diseases. The fractures included in the study were classified according to the Orthopedic Trauma Association 31 classification system as type A2.2 (n = 36) or type A2.3 (n = 16). The time from injury to surgery was 1–11 (3.35 ± 1.78) days, and the operation time ranged 31–101 (65.67 ± 14.17) min. The intraoperative blood loss ranged from 40 to 100 (67.69 ± 18.24) mL, and the number of intraoperative fluoroscopy images obtained was 12 to 32 (20.42 ± 5.27). The Harris hip score at 9 months after surgery ranged from 84 to 94 (90.06 ± 2.15). Patients were followed for 9–16 (10.63 ± 1.61) months. One patient died of acute myocardial infarction at 9 months after surgery. One patient suffered from nail withdrawal 5 months post‐operation and thus underwent hemiarthroplasty.ConclusionsSatisfactory reduction can be achieved using a pre‐drilling femoral trochanter combined with a finger reduction tool for the management of difficult‐to‐reduce complex intertrochanteric fractures. This technique does not increase surgical trauma and also reduces the dose of radiation administered to the patient.

Analysis of one-year postoperative mortality and risk factors of elderly patients with intertrochanteric fractures after PFNA.

Intertrochanteric fracture is very common in elderly patients, It is one of the main reasons for the elderly to be hospitalized, and is closely related to the mortality rate. With the speeding up of the population aging, the treatment of intertrochanteric fracture is becoming more and more significant. PFNA (Proximal femoral nail antirotation) is the most commonly used surgical method, although the surgical technique has improved a lot, the postoperative mortality rate after one year is still high. If we can take active and effective control measures against the high-risk factors affecting mortality in time, it will help to improve the prognosis. To study the 1-year postoperative mortality rate of elderly patients with intertrochanteric fractures after being treated with proximal femoral nail antirotation (PFNA) and its influencing factors. The data of patients with intertrochanteric fracture treated by PFNA in our hospital during the period from August 2016 to April 2020 were retrospectively studied, and the data of age, sex, type of fracture, preoperative comorbid diseases, American Society of Anesthesiology (ASA) score, the timing of the operation, duration of operation, preoperative and postoperative hemoglobin levels, albumin level, and postoperative complications were collected through medical records, and the survival rate of patients in 1 year after operation was investigated by telephone follow-up, and single-factor analysis was carried out to analyze related influencing factors. A total of 80 patients with complete data were followed up for 1-23 months (mean 12.5 months), and totally 22 patients died within 1 year, the mortality rate was 27.5%. Single analysis results suggested that the differences in factors such as age, number of preoperative combined diseases, ASA score, preoperative and postoperative albumin levels, and postoperative complications between the survival group and the death group were statistically significant (P < 0.05). The risk factors affecting long-term death in the treatment of intertrochanteric fractures in elderly patients with PFNA shall be taken into consideration fully, and the improvement of preoperative and postoperative health status will help to reduce the postoperative mortality and improve the efficacy of surgery.