Intertrochanteric fractures occur commonly in elderly patients. Cummings et al stated four possible factors for prevalence of intertrochanteric fractures in elderly (i) Inadequate local shock absorbers such as muscles and fats (ii) Osteoporosis and reduced bone quality (iii) Slowing down of protective reflexes and (iv) Orientation of the fall over the hip. Most intertrochanteric femoral fractures occur in elderly individuals as a result of low energy trauma like a simple fall due to osteoporotic bones while in younger patients these fractures usually result from high-energy trauma. Incidence of these fractures has increased primarily due to increase in life span and sedentary life style. Intertrochanteric fractures account for 5% of all hip fractures and 35–40% of these fractures are unstable three or four part fractures.
Due to difficulty in obtaining anatomical reduction, management of the unstable intertrochanteric fractures in elderly patients is challenging and controversial. Osteoporosis and instability are the most important factors preventing early weight bearing and leading to unsatisfactory results in these cases.
Operative treatment is the best option in most of the trochanteric fractures. Conventional extramedullary implants like dynamic hip screw (DHS) or angular blade plates can be used for the successful treatment of stable intertrochanteric femoral fractures. However the use of intramedullary devices e.g. PFN may allow a faster restoration of postoperative walking ability, when compared with extramedullary sliding devices.
This study was aimed to investigate the efficacy of short and long proximal femur nail (PFN) by comparing blood loss, operation time, postoperative complications, periprosthetic fracture and patient outcomes.
MATERIALS AND METHODS
A prospective randomized study was conducted in the department of orthopaedics of our institute between April 2019 to April 2022 after seeking approval from Institutional Ethical Committee (IEC). The study included 41 cases of unstable peri-trochanteric fractures (intertrochanteric fractures with maximum of 3 cm extension below lesser trochanter) divided into two groups. Patients of Group-I were operated with Short PFN and Group-II were operated with Long PFN by standard technique. Intraoperative parameters, post-operative data and events were noted. Patients were selected as per inclusion / exclusion criteria and randomization was done by Double blind method.
(i) All unstable intertrochanteric fractures based on AO / OTA system of classification (ii) All patients above 50 years of age.
(i) All patients with any pathological cause for the fracture (ii) All young patients (iii) All patients with multiple limb fractures and (iv) Patients with any contraindications for operative management.
The patients were assessed in immediate post operative day, 12 days, 1 month, 3 months, 6 months, 1 year and at 2 years. During follow-ups, patients were assessed by clinico-radiological evaluation and Harris hip score. Clinically the findings noted were: Deformity, Complaints of pain (if any), Range of Hip and knee movements, Shortening, whether the patient resumes his occupation to pre injury state, ability to sit cross legged and squat, walking ability with or without support. Radiological assessment for progression and time of union, fracture alignment and implant related complications were analyzed.
Total of 41 patients of peri-trochanteric fracture have been included in study out of which 24 belonged to Group-I and were operated with short PFN and rest 17 were of Group-II operated with long PFN. The patient characteristics of both groups was not significantly different. Majority of patients in both the groups were above the age of 50 and sustained injury due to low energy trauma. Average age of the patient treated with short PFN was 70.5 years (ranging from 54 – 84 years) while that with long PFN was 65.3 years (ranging from 51 – 80 years). Females outnumbered the males in both the groups. 9 (37.5%) patients were male and 15 (62.5%) patients were females in Group-I while 7 (41.2%) patients were male and 15 (58.8%) patients were females in Group-II.
As per AO /OTA Classification the A1 and A2 types were most common fractures in both groups. Out of 24 patients in Group-I, 7 (29%) cases were A1 type, 13 (54%) were A2 and 4 (17%) patients were A3 type. In Group-II, out of 17 patients, 7 (41%) were A1 type, 8 (47%) cases were A2 and only 2 (12%) cases were A3 type.
The average blood loss during the surgical procedure of short PFN was 100 ml while that in long PFN was 150 ml. In short PFN group, patients had operative time (from incision to closure) of 30–50 minutes with average of 43.6 minutes whereas in long PFN operative time was 45–90 minutes with average of 64.3 minutes.
In post-operative period there was no significant difference. 2 cases of short PFN and 1 case of long PFN had serous discharge and soakage which eventually resolved with change of antibiotics. Later both the groups were evaluated in post operative period and at 3rd and 6 month to compare the outcome. The radiological signs of union were present in almost all the patients at 2–4 months. The Harris hip score was calculated for both the groups and mean HHS for short PFN was 76.63 and 82.33 whereas for long PFN average score was 79.87 and 85.43 at 3 and 6 months respectively. Few patients also complained of thigh pain which included 7 patients (13%) of short PFN and 2 patients (4.5%) of long PFN. During 3 months of follow up, implant related complication was seen in one patient of short PFN (infected implant with loosening of proximal screw) and 1 patient of long PFN group (lag screw cut out). The HHS and Thigh pain were compared with similar study and was comparable [Table 1]. Over-all result in patients of both the groups were good [Figures 1 and 2].
The goal of treatment of any fracture fixation is restoration of the patient to his or her pre-injury condition as soon as possible and same is true for peri-trochanteric fracture also. Intramedullary implants like the PFN have an advantage in such fractures as their placement allows the implant to lie closer to the mechanical axis of the extremity, which decreases the lever arm and bending moment on the implant. Intramedullary nailing, with less operative time and less operative blood loss allow early weight bearing with less resultant shortening on long term follow up.
Patients who underwent short PFN procedures in the current study had lesser bleeding as compared to the long PFN group. Proximal reaming and insertion of a longer nail leading to opening of the medullary canal leads to increased blood loss. Most of the time, such a blood loss is concealed. The ethnic background of the patient should be borne in mind while operating, especially the Asian population. An excessive anterior bow in a relatively shorter femur should be paid special attention. The nail entry point has to be precise. Longer nails are recommended in elderly patients with significant osteoarthritis. In an anticipated extension of sub-trochanteric fracture, looking like a normal intertrochanteric fracture forced us to use Long PFN instead of risking with short PFN. In our study we preferred a longer nail and results are comparable to study done by Shyamkumar et al. (2018).
In our short term results, it was evident that the use of Long PFN has advantages over short PFN in terms of the less postoperative complications, less mean time of union and better lower extremity functional scores. Our sample size reflects the routine patient inflow in our hospital. A study with a larger sample size would have made a better assessment of this surgical intervention. As our study was time bound the patients were followed up for a minimum of 3 months and a maximum of 2 years. Therefore the long-term effects of this intervention remains unknown in our study. A longer follow up would have made a complete assessment of this surgical intervention.
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Conflicts of interest
There are no conflicts of interest.
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