Proximal Femoral Nail Antirotation Group Research Articles

Bipolar Hemiarthroplasty should not be selected as the primary option for intertrochanteric fractures in elderly patients

Intertrochanteric fractures (ITFs) in the elderly are still a big challenge for clinical doctors. Although proximal femoral nail antirotation (PFNA) and bipolar hemiarthroplasty (BPH) are selected by most of the orthopaedic surgeons for elderly ITFs patients, there is still no consensus on the superiority of PFNA and BPH for ITFs in elderly. In this study, we hypothesized that BPH should not be selected as the primary option for ITFs in elderly patients, and analyzed clinical data of 202 elderly ITFs patients aged 80 years or more treated with PFNA (Group A) and BPH (Group B) to compare the early outcome of PFNA and BPH for ITFs in elderly patients aged 80 years or more. We found that operation time and blood loss during surgery in group A are less than in Group B. Time of weight bearing after operation in Group A is longer than in Group B. Incidence of complications 2 weeks after operation in Group A is 9.29% less than 25.81% in Group B (χ2 = 9.539, p = 0.002). Mortality rates 12 months after operation in Group A is 11.43% similar with 19.35% in Group B (χ2 = 2.261, p = 0.133). Harris Hip Score 12 months after operation in Group A is 68.00 ± 29.11 points similar with 65.73 ± 33.29 points in Group B (t = 0.490, p = 0.625). Therefore, for elderly ITFs patients aged 80 years or more, BPH should not be selected as the primary option for ITFs in elderly patients.

Blade type nails cause more varus collapse than screw type nails in the treatment of elderly trochanteric fractures

Aim: Blade and screw type nail designs are widely used in the treatment of trochanteric fractures. Although, blade designs were put as last generation nails on the market, it remains unclear which design has better clinical and radiographic outcomes. The purposes of our study were to compare two cephalo medullary nail designs as helical blade and lag screw type for trochanteric fractures (AO/OTA 31-A type fractures), to analyse and compare clinical and functional outcomes, complication rates. Material and Methods: This study comprised 101 patients with trochanteric fractures treated with either proximal femoral nail antirotation (PFNA) as blade type nail, or Peritrochanteric nail (PTN) as screw type nail for a minimum of 6 months. We assessed comorbidities, fracture type pre-operatively, operation time, blood loss, reduction quality, tip apex distance intra and post operatively, medical and mechanical complications, partial, full weight bearing time, Harris hip scores and Short form 36 scores and mortality during follow up period. Results: There was no significant difference in the operation time, blood loss, total mechanical or medical complications, partial, full weight bearing time, mortality rate, and Harris Hip scores of PTN or PFNA groups. Lateral migration and varus collapse rates of patients treated with PFNA were significantly higher than patients treated with PTN. However particular SF 36 scores of PFNA group were significantly higher than PTN group. Conclusion: Blade type nail designs caused more varus collapse than screw type nails in the treatment of elderly trochanteric fractures, however these radiographic complications didn’t influence on clinical outcomes of patients.

Effects of Proximal Femoral Nail Anti-Rotation (PFNA-II) and Artificial Total Hip Arthroplasty (THA) on Unstable Intertrochanteric Femoral Fracture Combined with Severe Osteoporosis

The current study was conducted to compare the therapeutic effects of proximal femoral nail antirotation (PFNA-II) and artificial total hip arthroplasty (THA) on elderly Chinese patients with unstable intertrochanteric femoral fracture combined with severe osteoporosis. There were 60 people in each group. The duration of surgery, blood loss, and weight-bearing period when standing on the floor were compared between the two groups (P > 0.05). Harries function scores of both groups increased over time. Scores of THA group were significantly higher than those of PFNA-II group during six- and twelve-months follow-up visit (P < 0.05). In addition, excellent and good rates of hip joint function in THA group were higher than those of PFNA-II group during twelve-month follow-up visit (P < 0.05). The occurrence rates of follow-up complications in both groups showed no statistical significance (P > 0.05). Thus, both PFNA-II and THA have good effects on Chinese elderly patients with unstable intertrochanteric femoral fracture combined with severe osteoporosis.

Outcomes of U-Blade Lag Screw for Cephalomedullary Fixation of Unstable Trochanteric Femur Fractures: A Case Control Study.

Background:Unstable trochanteric femur fractures in elderly patients with osteoporosis are still challenging. Gamma3 nail with the U-blade lag screw (U-blade gamma nail) has been developed to improve mechanical stability of proximal femoral fragment. This study aimed to compare the clinical and radiologic outcomes of U-blade gamma nail to proximal femoral nail antirotation (PFNA), and standard Gamma3 nail (gamma nail) for unstable trochanteric femur fractures.Methods:A retrospective matched-pair case study was performed with U-blade gamma nail, PFNA, and gamma nail. During 2012-2018, 970 patients with unstable trochanteric femur fractures were reviewed. Matching criteria were set as follows: 1) sex; 2) age (± 3 years); 3) body mass index (± 2 kg/m2); 4) bone mineral density (± 1 T-score in femur neck). Finally, a total of 159 patients were enrolled. We assessed the tip-apex distance (TAD), neck shaft angle, and hip screw sliding distance using plain radiographs. Also, we evaluated the clinical outcomes with Koval’s grade and fixation failure during 2 years.Results:The mean postoperative TAD was not significantly different among the 3 groups (p = 0.519). However, the change in the TAD at 1 year (p = 0.027) and 2 years (p = 0.008) after surgery was significantly smaller in U-blade gamma nail group compared with PFNA and gamma nail group. The hip screw sliding distance at 1 year (p = 0.004) and 2 years (p = 0.001) after surgery was significantly smaller in U-blade gamma nail group compared with PFNA and gamma nail group. However, there was no significant difference of Koval’s grade and fixation failure among the 3 groups (p = 0.535).Conclusion:U-blade gamma nail showed favorable radiologic results in terms of the change in the hip screw position. However, U-blade gamma nail was not superior to PFNA and gamma nail in clinical outcomes.

Therapeutic Effect of Artificial Femoral Head Replacement and Proximal Femoral Nail Antirotation on Elderly Unstable Intertrochanteric Fractures

Objective: To compare the clinical efficacy of artificial femoral head replacement and Proximal femoral nail antirotation (PFNA) in the treatment of unstable femoral intertrochanteric fractures in the elderly. Methods: This study retrospectively analyzed 60 elderly patients with unstable intertrochanteric fractures treated with PFNA and artificial femoral head replacement from 2015.06 to 2018.06, of which 34 were in the PFNA group (Group A) and 26 in the artificial femoral head replacement group (Group B). Statistical analysis of relevant surgical indicators such as surgical time, intraoperative blood loss, postoperative blood transfusion, postoperative time to landing, postoperative infection rate, hospital stay, number of secondary operations, postoperative VAS score, and postoperative Hip function score comparison. Results: All 60 patients were followed up for 1 - 24 months. Compared with the artificial femoral head replacement group, the operation time of PFNA group was shorter, the blood loss during operation was less, and the difference was statistically significant (P 0.05). Conclusion: The hip joint function and pain scores of the artificial femoral head replacement group in the early and follow-up periods are better than those of the PFNA group. The artificial femoral head replacement is more suitable for the treatment of elderly unstable intertrochanteric fractures.

Proximal femoral nail anti-rotation versus cementless bipolar hemiarthroplasty for unstable femoral intertrochanteric fracture in the elderly: a retrospective study

BackgroundThe treatment for unstable intertrochanteric fractures in the elderly has always been a controversial issue. The aim in this study was to compare the curative effects of proximal femoral nail anti-rotation (PFNA) and cementless bipolar hemiarthroplasty (CPH) on femoral intertrochanteric fracture in the elderly.MethodsFrom March 2008 to December 2012, 108 elderly patients with femoral intertrochanteric fractures were treated by PFNA or CPH. There were 63 males and 45 females, aged 75.3–99.1 years [(83.7 ± 5.6) years]. The patients’ bone mineral density was routinely measured, and the fractures were classified according to Evans-Jensen. The patients were divided into CPH group and PFNA group. The differences in operation time, intraoperative bleeding, immobilization duration, hospitalization time, Harris scores and postoperative complications including deep venous thrombosis, lung and urinary infection were analyzed.ResultsAll patients were followed for 12.5–36.2 months [(28.0 ± 6.3) months)]. The operation time was (53.7 ± 15.2) min and (77.5 ± 16.8) min in PFNA group and CPH group, respectively (P < 0.05); intraoperative bleeding was (132.5 ± 33.2) mL and (286.3 ± 43.2) mL, respectively (P < 0.05); immobilization duration was (28.2 ± 3.7) days and (3.1 ± 1.2) days, respectively (P < 0.05); hospitalization time was (7.6 ± 1.8) days and (6.9 ± 2.2) days, respectively (P > 0.05); and the Harris scores after 1 year were (87.7 ± 7.9) points and (88.3 ± 9.2) points, respectively (P > 0.05). There was no significant difference in postoperative complications between the two groups (P > 0.05).ConclusionBoth PFNA and CPH are safe and effective treatments for femoral intertrochanteric fracture in elderly patients. Nonetheless, CPH allows faster mobilization and recovery.Trial registrationRegistration Number: ChiCTR1900022846.Reg Date:2019-04-26 00:27:33Retrospective registration

Computed Tomographic Image Analysis of Proximal Femoral Nail Antirotation and Dynamic Hip Screw in the Treatment of Intertrochanteric Fractures

Objective: Based on the observation of Computed Tomography (CT) image analysis technique, the efficacy of Proximal Femoral Nail Antirotation (PFNA) and Dynamic hip screw (DHS) in the treatment of intertrochanteric fractures in the elderly was analyzed. Methods: Thirty-nine elderly patients with unstable intertrochanteric fractures were randomly divided into two groups: 19 patients in the DHS internal fixation group and 20 patients in the PFNA group. They were treated with DHS and PFNA internal fixation, and were observed based on CT image analysis techniques. The patient performs follow-up testing of the procedure before and after surgery. Results: There was a statistically significant difference in mean operative time and intraoperative blood loss between the groups (P &lt; 0.01). The incidence of intraoperative and postoperative complications was statistically different between the two groups (P &lt; 0.05). The incidence of postoperative and postoperative complications in the PFNA group was lower than that in the DHS group. The excellent and good rates of DHS group and PFNA group were 89.47% and 95.00%, respectively. There was no significant difference between the two groups (P &gt; 0.05). There was a significant difference in fracture healing time between the PFNA group and the DHS group (P &lt; 0.01). Discussion: Compared with DHS, PFNA has the advantages of short operation time, low bleeding volume and short hospital stay. There were 7 cases of internal fixation failure or non-union in the DHS group and 1 case of delayed healing in the PFNA group. Conclusion: DHS and PFNA were used to treat intertrochanteric fractures in the elderly. After observation by CT image analysis technique, there was no significant difference in efficacy. The average operative time of PFNA was the shortest, the intraoperative blood loss was the least, the incidence of intraoperative and postoperative complications was low, and the fracture healing time was short. PFNA has a lesser effect on the blood circulation and bone destruction at the fracture end, and it is more secure. It is a reasonable surgical method for the treatment of senile osteoporotic intertrochanteric fractures.

Dynamic Hip Screw (DHS) versus Proximal Femoral Nail Anti-rotation (PFNA) Fixation for Unstable (Evans-Jensen II and III) Inter-trochanteric Fractures of Femur in Elderly

Background: Dynamic hip screw (DHS) and proximal femoral nail anti-rotation (PFNA) are the two most commonly used fixation devices for inter-trochanteric fracture of femur. However, many clinical studies have shown lack of differences in the clinical outcome consistently with between these two fixation techniques. The main objective of this study is to compare the results of dynamic hip screw (DHS) and proximal femoral nail anti-rotation (PFNA) fixation in elderly patients with unstable inter-trochanteric fractures of femur.&#x0D; Methods: We retrospectively reviewed patients who underwent operative management for inter- trochanteric fractures of femur in our hospital between February 2013 and September 2017. Elderly patients (Age &gt;60yrs) with unstable inter-trochanteric fracture of femur treated either with DHS fixation or with PFNA fixation were included and divided into two groups: DHS fixation group and PFNA fixation group. The comparative statistical analysis was done between two group using following parameters: average length of the incision, operation time, blood loss, fracture healing time, and degree of postoperative functional recovery.&#x0D; Results: The mean follow-up period, in DHS fixation group was 16 month (range 12 to 24 months) and in PFNA fixation group was 14 months (range 12 to 18 months). The differences between two groups regarding average length of the incision, operation time, and blood loss were statistically significant (p&lt;0.05) and better in PFNA group whereas the differences between two groups regarding fracture healing time and the degree of postoperative functional recovery were not statistically significant (p &gt;0.05).&#x0D; Conclusions: PFNA fixation may be better than DHS fixation for the treatment of unstable inter-trochanteric fractures of the femur in the elderly. However, the application and usage of DHS fixation could not be neglected and the choice of treatment depends upon the systemic condition and socioeconomic status of the patient, patient’s preferences, surgeon’s experience and availability of treatment facility.

Comparison of the effects of two cephalomedullary nails (zimmer natural nail and proximal femoral nail antirotation) in treatment of elderly intertrochan teric fractures

Objective To explore the effect of cephalomedullary nails for elderly intertrochanteric fractures: proximal femoral nail antirotation (PFNA) versus zimmer natural nail (ZNN) to provide the data support for clinical perioperative management. Methods A retrospective study was used to analyze the clinical data of elderly intertrochanteric fractures cases which were treated with PFNA or ZNN fixation from May 2016 to May 2017. In the study, 59 cases were followed up completely, in which 28 cases accepted PFNA, and the other 31 cases accepted ZNN. The operation time, amount of bleeding, fracture healing time, postoperative complication, postoperative radiographic measurement (tip apex distance, TAD) and the last follow-up of hip function score were analyzed. Results The patients were followed up for 6 to 19 months, with an average (10.8±4.0) months. In PFNA group, the operation time was (62.7±14.2) min, the amount of bleeding was (56.8±20.6) mL, the fracture healing time was (4.6±0.8) months, the postoperative complication was 3.6%, the TAD was (17.7±5.5) mm, and the last follow-up hip function score was 91.8±3.6. In ZNN group, the operation time was (73.6±18.3) min, the amount of bleeding was (68.7±31.6) mL, the fracture healing time was (4.5±0.7) months, the postoperative complication was 3.2%, the TAD was (16.5±4.7) mm, and the last follow-up hip function score was 92.2±3.8. The two groups of comparative experiments were carried out, the operation time of the PFNA group was less than that of the ZNN group (P 0.05). Conclusion Although group ZNN had significant longer operation time than group PFNA, both implants were useful tools in the treatment of elderly intertrochanteric fractures. The operation of PFNA was simpler,while the design of the anterior bow of ZNN might be more suitable for the patients with a large femoral anterior bow.

Medial sustainable nail versus proximal femoral nail antirotation in treating AO/OTA 31-A2.3 fractures: Finite element analysis and biomechanical evaluation

ObjectivesUsing finite element analysis and biomechanical tests, the biomechanical behaviors of Medial Sustainable Nail (MSN) and Proximal Femoral Nail Antirotation (PFNA) were compared for the fixation of fracture type of AO/OTA 31-A2.3. MethodsFinite element software Abaqus 6.14 was used to conduct axial loading of 2100 N and we analyzed the von Mises stress distribution and the model displacement of two implant models. Biomechanical tests were separately conducted in the axial stiffness test and axial cyclical loading test on a mechanical testing machine. ResultsThe results indicate that von Mises stress of MSN was lower than that of PFNA, and the model displacement in the MSN group was lower than that in the PFNA group. In the axial stiffness tests, MSN group was stiffer than PFNA construct. With respect to the axial load to ultimate failure, the PFNA construct exhibited higher loads exceeding 4000 N while the MSN construct withstood 3313.8 ± 92.8 N. Specifically, F10mm was 2178.6 ± 133.2 N of the MSN group and 1822.6 ± 93.1 N of the PFNA group (P = 0.001). Additionally, X2100N was 9.8 ± 0.5 mm of the MSN group and 11.7 ± 0.7 mm of the PFNA group (P = 0.002). The MSN group exhibited superior performances in terms of the mean value of the vertical displacement, frontal rotation angle, and lateral rotation angle. ConclusionsThe results indicated that the MSN construct might exhibit a better biomechanical performance when compared with that of the PFNA in reducing displacement and anti-varus in fracture type of AO/OTA 31-A2.3.

Examining implant superiority in the treatment of simple pertrochanteric fractures of the proximal femur in elderly patients.

The aim of this study was to compare the clinical and radiological results of the proximal femoral nail antirotation (PFNA) with those of the dynamic hip screw (DHS) and percutaneous compression plate (PCCP) in the treatment of simple pertrochanteric fractures. A total of 203 patients were included in the study. PFNA fixations were performed in 73 patients (PFNA group), DHS in 68 patients (DHS group), and PCCP in 62 patients (PCCP group). The main outcome measurements were perioperative properties, the Harris hip score, changes in the neck-shaft angle, and loss of the abductor muscle strength. Data were compared between the groups. The mean estimated total blood loss and the number of patients receiving the blood transfusion rate in the PFNA group were statistically significantly lower. The mean operation and fluoroscopy times in the PCCP group were statistically significantly higher. The mean loss of the abductor muscle strength and changes in the neck-shaft angle in the PFNA group were statistically significantly higher. The mean Harris hip scores were similar. Our findings demonstrated that although PFNA was superior with regard to the perioperative data, DHS and PCCP were superior in maintaining the reduction and the abductor muscle strenght. All three implants were similar and had satisfactory functional outcomes.

Efficacy and safety of proximal femoral anatomical locking compression plate and proximal femoral nail antirotation for long-segment comminuted subtrochanteric fractures of the femur: a non-randomized controlled trial

Background and objective: The proximal femoral anatomical locking compression plate and proximal femoral nail antirotation device are commonly used in the treatment of long-segment comminuted subtrochanteric fractures of the femur. However, few studies have evaluated the difference in efficacy and safety between these two implants. The present study is being performed to compare the efficacy and safety of the proximal femoral anatomical locking compression plate versus proximal femoral nail antirotation in the treatment of long-segment comminuted subtrochanteric fractures of the femur. The results will be used to identify the optimal implant treatment plan. Participants and methods: This prospective, single-center, non-randomized controlled clinical trial will include 180 patients with long-segment comminuted subtrochanteric fractures of the femur from Sanya Traditional Chinese Medicine Hospital, China. The patients will be equally divided into a locking compression plate group and a proximal femoral nail antirotation group. All patients will be followed up at 2 and 10 months postoperatively. Patient recruitment and data collection will begin on June 30, 2019 and end on June 30, 2020. Analysis of the results will be performed from 1 to 30 July 2020. This study will be scheduled to end on August 1, 2022. This study was approved by the Medical Ethics Committee of Sanya Traditional Chinese Medicine Hospital in China in March 2013 (approval No. (2013) (02)). Study protocol version is 1.0. This study will be performed in strict accordance with the Declaration of Helsinki formulated by the World Medical Association. Written informed consent regarding the study protocol and surgery procedure will be obtained from the participants. Results: The primary outcome measure is the rate of excellent and good Harris hip scores at 10 months postoperatively; this rate will be used to evaluate the recovery of hip function after repair. The secondary outcome measures are the rate of excellent and good Harris hip scores preoperatively and 2 months postoperatively, intraoperative blood loss, operation time, incision length, hospital stay, fracture healing time, hip morphology on radiographs preoperatively and 2 months postoperatively, and incidence of adverse events 2 and 10 months postoperatively. Our pilot study involved 80 patients with long-segment comminuted subtrochanteric fractures of the femur from February 2013 to February 2016 (locking compression plate group, n = 40; proximal femoral nail antirotation group, n = 40). The 10-month follow-up results showed that the intraoperative blood loss, operation time, incision length, hospital stay, and fracture healing time were lower in the proximal femoral nail antirotation group than in the locking compression plate group (P 0.05). These pilot study results verified higher efficacy and safety of proximal femoral nail antirotation than locking compression plate fixation in the treatment of long-segment comminuted subtrochanteric fractures of the femur. Conclusion: The results of the present study will provide evidence indicating whether proximal femoral nail antirotation in the treatment of long-segment comminuted subtrochanteric fractures of the femur can facilitate better recovery of hip function and higher safety than anatomical locking compression plate fixation. Trial registration: This study was registered with the Chinese Clinical Trial Registry on February 3, 2019 (registration number: ChiCTR1900021251).

Effectiveness comparison between proximal femoral nail anti-rotation and proximal femoral locking compression plate for intertrochanteric fracture in elderly patients combined with hemiplegia due to cerebral infarction

To investigate the difference in the effectiveness between proximal femoral nail anti-rotation (PFNA) and proximal femoral locking compression plate (PFLCP) for intertrochanteric fracture in elderly patients combined with hemiplegia due to cerebral infarction. The clinical data of 67 cases of intertrochanteric femoral fractures combined with hemiplegia due to cerebral infarction between October 2013 and January 2017 were retrospectively analyzed. Among them, 32 cases were treated with PFNA internal fixation (PFNA group), and 35 cases were treated with PFLCP internal fixation (PFLCP group). There was no significant difference in gender, age, injury side, modified Evans classification of fracture, preoperative medical disease, and interval from injury to operation between 2 groups ( P>0.05). The operation time, intraoperative blood loss, postoperative bed time, incidence of perioperative complications, time of fracture healing, and hip Harris score at 6 months and 1 year after operation were recorded and compared. Both groups were followed up 12-24 months with an average of 14 months. Compared with the PFLCP group, the PFNA group had shorter operation time, less intraoperative blood loss, and shorter bed time, and the differences were significant ( P<0.05). X-ray films showed that the fractures healed in both groups. The fracture healing time of the PFNA group was shorter than that of the PFLCP group, but the difference was not significant ( t=0.743, P=0.460). During hospitalization, there were 3 cases of pulmonary infection, 2 cases of deep venous thrombosis of lower limbs, and 1 case of urinary tract infection in the PFNA group; and the incidence of perioperative complications was 18.8% (6/32). There were 4 cases of pulmonary infection, 6 cases of deep venous thrombosis of lower limbs, 1 case of recurrent cerebral infarction, and 1 case of stress ulcer in the PFLCP group; and the incidence of perioperative complications was 34.3% (12/35). There was no significant difference in the incidence of perioperative complications between 2 groups ( χ2=2.053, P=0.152). At 6 months after operation, the Harris total score and individual scores in the PFNA group were higher than those in the PFLCP group ( P<0.05). At 1 year after operation, there was no significant difference in the Harris total score and pain score, life ability score, and walking ability score between the PFNA group and the PFLCP group ( P>0.05); However, the joint deformity and activity score of the PFNA group was significantly better than that of the PFLCP group ( t=4.112, P=0.000). For intertrochanteric fracture in elderly patients with cerebral infarction hemiplegia, the PFNA has shorter operative time, less intraoperative blood loss, shorter bed time after operation, and better short-term hip function when compared with the PFLCP.

Comparison of the clinical effects of proximal femoral anti-rotation nail and dynamic hip screw internal fixation in the treatment of elderly patients with intertrochanteric fracture

Objective To compare the effects of proximal femoral nail anti-rotation (PFNA) and dynamic hip screw (DHS) internal fixation in treating senile intertrochanteric fractures. Methods From January 2014 to March 2016, 100 elderly patients with intertrochanteric fracture in the Second People's Hospital of Yaodu District were selected and randomly divided into two groups according to the digital table, with 50 patients in each group.The PFNA group and DHS group were treated with PFNA and DHS internal fixation, respectively.The curative effect, fracture healing, complications and hip function scores were compared between the two groups. Results The treatment excellent rate of the PFNA group (92%) was significantly higher than 76% of the DHS group (χ2=4.762, P<0.05). The fracture healing time of the PFNA group was (15.37±6.29)weeks, which was significantly shorter than (23.64±8.17)weeks of the DHS group (t=5.671, P<0.05). The incidence rate of complications of the PFNA group (6%) was significantly lower than 22% of the DHS group ( χ2=5.316, P<0.05); .After surgery, the Harri hip scores of the PFNA group and DHS group were significantly higher than those before surgery (t=11.330, 5.788, all P<0.05), and the Harri hip score of the PFNA group after surgery was higher than that of the DHS group (t=5.147, P<0.05). Conclusion Compared with DHS, the clinical effect of PFNA internal fixation in the treatment of elderly patients with femoral intertrochanteric fractures is more significant. Key words: Femoral fractures; Fracture fixation, intramedullary; Internal fixators; Bone nails; Aged

Comparison of efficacy, complications and TGF-β2 expression between DHS and PFNA in elderly patients with osteoporotic femoral intertrochanteric fracture.

The aim of the present study was to compare the efficacy and complications of two fixation techniques, namely dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA), in the treatment of osteoporotic femoral intertrochanteric fracture in elderly patients, and to detect changes in transforming growth factor β2 (TGF-β2) expression in the two groups. A total of 100 elderly patients with femoral intertrochanteric fracture were randomly divided into two groups that were treated with either DHS or PFNA. Peri-operative complications were observed in the patients and ELISA was used to detect TGF-β2 expression levels at 1, 7, 15 and 30 days after surgical treatment. The clinical efficacy and the incidence rate of complications at 3 months after the operation were compared. In comparison with the DHS group, the PFNA group had a shorter operation time, a lower bleeding volume and a shorter post-operative weight-bearing time. The contents of TGF-β2 in the two groups at 7 days after the operation were higher than those at 1 day, reached a peak at 15 days and had gradually decreased again at 30 days after the operation. The contents of TGF-β2 at 1, 7 and 15 days in the PFNA group were higher than those at the identical time-points in the DHS group (P<0.01). Regarding the clinical efficacy in the two groups at 3 months of post-surgery, the rate of excellent/good efficacy in the PFNA fixation group (90.0%) was higher than that in the DHS fixation group (74.0%). Of note, PFNA fixation had a higher clinical efficacy, a shorter operation time, less intra-operative trauma, a relatively faster fracture healing process and fewer complications in comparison with DHS fixation, and is therefore more suitable for treating osteoporotic femoral intertrochanteric fracture in the elderly. PFNA fixation is superior to DHS fixation, which may be associated with the higher level of TGF-β2 expression in comparison with that in the DHS group.

Comparison of fixations with dynamic hip screw, percutaneous compression plate and proximal femoral nail anti-rotation for intertrochanteric femoral fractures with paries medialis defect

Objective To compare the effects of fixations with dynamic hip screw (DHS), percutaneous compression plate (PCCP) and proximal femoral nail anti-rotation (PFNA) for treatment of intertrochanteric femoral fractures with paries medialis defect. Methods We reviewed the 82 patients with femoral intertrochanteric fracture and paries medialis defect who had been treated at our department from January 2011 to July 2016. They were 42 men and 40 women, aged from 27 to 91 years (average, 73.0 years). According to the AO classification, 72 cases belonged to type 31-A2.2, 10 to type 31-A2.3. Of them, 9 cases were treated with DHS, 17 cases with PCCP and 56 cases with PFNA-Ⅱ. The 3 groups were compared in terms of intraoperative blood loss, blood infusion, fluid infusion, operation duration, time for fracture union, postoperative complications and Functional Recovery Score (FRS) of the hip 12 months after operation. Results The fluid infusion [1,100 (850, 1,100) mL] and intraoperative blood loss [60 (5, 100) mL] in the PCCP group were significantly less than in the PFNA group [1,100 (1,000, 1,700) mL and 150 (50, 300) mL] and the operation duration (91.4±29.2 min) in the former was significantly shorter than in the latter [121 (85, 185) min] (P 0.05). Of the patients, 57 (8 DHS, 12 PCCP and 37 PFNA ones) were followed up for an average of 47 months (from 15 to 85 months). There were no statistically significant differences between the 3 groups in time for fracture union, complications, or average FRS score of the hip 12 months after operation (P>0.05). Conclusions For unstable intertrochanteric fractures with paries medialis defect, it is not clear that intramedullary nails are superior to extramedullary fixation. Intramedullary nails like PFNA may be suggested for patients with better preoperative conditions while extramedullary fixation like PCCP suggested for those with poor general conditions. Key words: Hip fractures; Fracture fixation, internal; Bone plates; Bone nails

Cement augmentation of the Proximal Femoral Nail Antirotation (PFNA) – A multicentre randomized controlled trial

IntroductionNew implant designs like the Proximal Femoral Nail Antirotation (PFNA) were developed to reduce failure rates in unstable pertrochanteric fractures in the elderly. Standardized implant augmentation with up to 6 mL of polymethylmethacrylate (PMMA) cement has been introduced to enhance implant anchorage by increasing the implant-bone interface in osteoporotic bone conditions. Biomechanically, loads to failure were significantly higher with augmentation. The primary objective of this study was to compare the mobility of patients with closed unstable trochanteric fractures treated by PFNA either with or without cement augmentation. Patients and methodsA prospective multicentre, randomized, patient-blinded trial was conducted with ambulatory patients aged 75 or older who sustained a closed, unstable trochanteric fracture. Surgical fixation had to be performed within 72 h after admission. Outcomes were evaluated at baseline, during surgery, 3 to 14 days after surgery, 3 months, 6 months, and 12 months after surgery. To evaluate the primary objective, patients’ walking speed was assessed by the Timed Up and Go (TUG) test. Secondary objectives included the analysis of implant migration assessed on radiographs, quality of life measured by the Barthel Index, mobility measured by the Parker Mobility Score, and complications. ResultsOf 253 randomized patients, 223 patients were eligible: 105 patients were allocated to the PFNA Augmentation group and 118 to PFNA group. At 3 to 14 days after surgery, there was no statistical significant difference in mean walking speed between the treatment groups. For the secondary objectives, also no statistical significant differences were found. However, no patient in the PFNA Augmentation group had a reoperation due to mechanical failure or symptomatic implant migration compared to 6 patients in the PFNA group. ConclusionsAugmentation of the PFNA blade did not improve patients’ walking ability compared to the use of a non-augmented PFNA but might have the potential to prevent reoperations by strengthening the osteosynthesis construct.

Comparative study of proximal femoral shortening after the third generation of Gamma nail versus proximal femoral nail anti-rotation in treatment of intertrochanteric fracture

To explore the difference of the proximal femoral shortening (PFS) between the third generation of Gamma nail (TGN) and the proximal femoral nail anti-rotation (PFNA) in treating intertrochanteric fracture of femur. The clinical data of 158 patients with intertrochanteric fracture of femur who were treated with TGN internal fixation or PFNA internal fixation between January 2014 and December 2015 were retrospectively analysed. The patients were divided into TGN group (69 cases) and PFNA group (89 cases) according to surgical operation. There was no significant difference in gender, age, bone mineral density, causes of injury, AO/Association for the Study of Internal Fixation (AO/ASIF) classification, accompanied disease, and the time from injury to operation between 2 groups ( P>0.05). The result of fracture reduction was divided into 3 types: positive medial cortex support, neutral position cortex support, and negative medial cortex support according to the method of Chang et al. At 18 months postoperatively, bilateral hip anteroposterior X-ray films were taken to measure horizontal PFS values (marked as X), vertical PFS values (marked as Y), and calculate the total PFS values (marked as Z). The PFS values were divided into 4 grades according to the criteria (≤1.0 mm, 1.0-4.9 mm, 5.0-9.9 mm, and ≥10.0 mm), and the constituent ratio was calculated and compared between 2 groups. The X, Y, and Z values and the collodiaphyseal angles of 2 groups at 18 months postoperatively were compared. The X, Y, and Z values of 2 groups of patients with failed fixation and normal healing within 18 months after operation were recorded and compared. The X, Y, and Z values of 2 groups of the patients with different cortex support types were also compared. There were 34 cases of positive medial cortex support, 30 cases of neutral position cortex support, and 5 cases of negative medial cortex support in TGN group, and there were 45, 33, and 11 cases in PFNA group respectively, showing no significant difference between 2 groups ( Z=-1.06, P=0.29). All patients were followed up 18 months after operation. At 18 months after operation, the constituent ratios of PFS values (X, Y, Z) had significant differences between 2 groups ( P<0.05). The patients of shortening of 1.0-4.9 mm and 5.0-9.9 mm were obviously more in TGN group than in PFNA group; the patients of shortening of ≥10.0 mm were obviously more in PFNA group than in TGN group. There were significant differences in X, Y, and Z values between 2 groups ( P<0.05), but no significant difference of the collodiaphysial angle was found between 2 groups ( t=0.47, P=0.64). Six cases of internal fixation failed in TGN group and PFNA group respectively within 3 months after operation, and there was no significant difference of X, Y, and Z values between failed fixation and normal healing patients within 2 groups ( P>0.05). When the reposition effect was the positive medial cortex support, the X, Y, and Z values were significantly lower in TGN group than in PFNA group ( P<0.05); but no significant difference was found between 2 groups when the reposition effect was the neutral position cortex support or negative medial cortex support ( P>0.05). At 18 months after operation, the X, Y, and Z values of the negative medial cortex support patients were significantly higher than those of the positive medial cortex support or the neutral position cortex support patients within 2 groups ( P<0.05). PFS is a common complication of the intertrochanteric fracture of the femur after internal fixation. During operation, the selection of internal fixation should be based on the results of intraoperative reduction. TGN should be applied to reduce PFS if positive medial cortex support happened.

Comparative study of proximal femoral nail anti-rotation and dynamic hip screw in the unstable intertrochanteric fractures in the elderly

Objective: To compare the effect of proximal femoral nail anti-rotation and dynamic hip screw in treating the femoral intertrochanteric fractures in elderly patients. Methods: From June 2011 to June 2014, totally 158 elderly patients of femoral intertrochanteric fracture were treated by surgery, among whom 68 cases were treated with dynamic hip screws (DHS), and 90 patients were treated with proximal femoral nail anti-rotation (PFNA). The operative time, hospitalization time, weight-bearing time, fracture-healing time, blood loss and the hip function score after the operation were compared between the two groups by using the t test; and the incidence of the postoperative complication was compared between the two groups by using the Chi square test. Results: All the patients were followed-up for 6 to 18 months (12. 6 months on average). There was no statistic differences in the gender, age, the surgical time after injury and the fracture type between the two groups (χ(2)=0.025, t=1.461, 1.329, χ(2)=2.070, all P>0.05). While, the operative time, blood loss, hospitalization time and the weight-bearing time in the PFNA group were all significantly lower than those in the DHS group[(47±14) vs (114±20) min, (121±26) vs (281±44) ml, (10.2±3.3) vs (13.5±2.8) d, (29±8) vs (53±10) d, t=8.376, 6.669, 2.176, 2.664, all P<0.05]; and the Harris hip score of 6 months post operation in PFNA group was significantly higher than that in the DHS group (90±17 vs 87±15, t=2.337, P<0.05). However, no significant difference in fracture healing time was found between the two groups[(11.8±2.3) vs (12.2±2.7) weeks, t=1.114, P>0.05]. Moreover, the incidence of complications in the DHS group was 16.2% while it was 7.8% in the PFNA group, the latter was obviously lower (χ(2)=4.801, P<0.05). Conclusions: DHS is suitable for the patients with good physical condition or for the patients with stable fracture types. While, PFNA has the advantages of firmly fixation, less tissue damage, lower complications and wide indications. So, it is superior in the femoral intertrochanteric fractures.

A retrospective analysis of the InterTan nail and proximal femoral nail anti-rotation in the treatment of intertrochanteric fractures in elderly patients with osteoporosis: a minimum follow-up of 3\xa0years

BackgroundThe study aims to compare the long-term functional and radiographic outcomes of two devices for the treatment of primary intertrochanteric fractures (IFs, OTA 3.1A2.1–A2.3) in elderly patients with osteoporosis.MethodsBetween December 2010 and August 2014, 332 elderly osteoporosis patients with IFs (OTA 3.1A2.1–A2.3) fixed by an InterTAN nail (IT) or a proximal femoral nail anti-rotation (PFNA) device were retrospectively evaluated. Follow-up occurred 1, 3, 6, and 12 months postoperatively and every year thereafter. Mortality was recorded. Patient-related functional and radiographic outcomes were compared. The primary endpoint was the long-term radiographic outcomes. The secondary endpoint was the long-term functional outcomes.ResultsA total of 283 patients (283 hips) with osteoporosis (IT, n = 144; PFNA, n = 139) were evaluated with a mean follow-up period of 38.8 months (range, 36–43 months). No between-group significant differences were noted in the patient demographics, operation variables, and postoperative Harris Hip Score. More radiographic complications were noted in terms of screw cut-out, femoral shaft fracture distal or around the tip of the main nail, and varus collapse of the femoral head in the PFNA group compared with that in the IT group (P < 0.05).ConclusionFor osteoporotic IFs (OTA 3.1A2.1–A2.3) in elderly patients, the use of IT aids in decreasing radiographic complications, but the between-group functional outcomes showed no significant difference.