Intertrochanteric fractures in elderly is very challenging and accounts for global incidence of about 2 million each year which might rise to 6 million in the coming year by 2050. For hip fracture, treatment aims are basically trying the patient to provide relief from pain and even trying to restore function with lowest possible morbidity and mortality. Treatment of intertrochanteric fracture using extramedullary implants (e.g. DHS) or intramedullary implant (e.g. PFN) remain controversial. Some author recommended the use of a DHS in all patient; other recommended the use of PFN in all but most of authors (the third group) recommended that either device can be used. In spite of all the controversies, intramedullary implants have recently been used most commonly for the treatment of IT fracture world wise. There are variety of intramedullary implants / nails and Halifax nail [Figure 1a] is one such implant being used for IT fractures in elderly [Figure 1b]. This is modification of Gamma nail, available in only short versions (180 mm). There are 4 modifications in Gamma nail which are (i) head screw having provision of inserting tri wires that increase the tortional stability of head screw three times (ii) a top screw to lock the slotted screw with nail (iii) cap to cover the tri wire base which prevent outward migration of head screw and (iv) distal slot in dynamic or static mode as per surgeon preference.
Although variety of nails are available even though no data is available that proves the superiority of one nail over other. Every nail have its own advantage and disadvantages. Aim of our study is to find out the initial result Halifax nail in intertrochanteric fractures of elderly population.
MATERIALS AND METHODS
In this pilot study 15 elderly patients with IT fracture between August 2017 to January 2019 were recruited. Out of 15 elderly patients (age between 60 to 100 years), females outnumbered males (5 males and 10 females). All patients were operated by Halifax nail (modified gamma nail) between 2 to 3 days after admission depending on pre anesthetic checkup and fitness.
Technique are similar as with other nailing system except insertion of tri-wire. The steps of surgical technique are as follows:
- Reduction and Provisional fixation: Reduction is the first most important factor in intertrochanteric fracture. Second most important factor is provisional fixation of unstable fracture before making entry point and nail negotiation, otherwise achieved reduction may be lost. Open reduction seldom required in some cases to push the neck fragment down and lift up the shaft with Hohman retractor. We always do nailing over a fracture table.
- Entry Point: Our preferred entry point is medial border of greater trochanter but one may go through the tip of greater trochanter (GT) also. In many cases GT is not intact so difficult to find the right entry point. Many times entry occur through fracture and after nail negotiation neck may go into the varus. This can be minimized by entry through medial wall of greater trochanter.
- Guide wire passing, Reaming and Nail insertion: Pass the non-beaded guide wire, open the proximal canal with hand reamer, access the canal size and do mechanical reaming (if needed, who have tight canal and good bone quality otherwise hand reaming is sufficient). In most cases 10 mm diameter of nail is sufficient (length is fixed 180 mm).
- Screw and Tri-wire insertion: Best position of screw is central-central, following standard tip apex distance (TAD) value. Measurement of screw is little bit different compare to PFN Screw measurement. Suppose depth gauge shows 100 mm length then in standard technique 90 mm screw will be chosen but in this system we will chose 95 mm screw as because 5 mm of screw will be kept outside the bone to facilitate the introduction of tri-wire. Special feature of this nail system is insertion of tri-wire through head screw by plunger technique which is very easy. Precise instrumentation are available for loading of tri-wire, insertion of tri-wire (by hammering) and also removal of tri-wire (by pulling it out). General rule is length of screw similar to length of tri-wire so for 95 mm screw one has to use 95 mm tri-wire. In some cases, 5 mm shorter tri wire can be chosen (if C-arm shows tri-wire piercing neck or head). Zig is having both options for locking (static and dynamic locking) but we preferred dynamic locking. Complete surgical technique is shown in [Figure 2].
Post operative Protocol and Follow-up
We consider operation day as day one. We started mobilization over bed like sitting on bed, leg dangling down, quadriceps and foot exercise from 2nd day. 3rd day onwards, we encourage patient to stand with support at bed side and if tolerated then weight bearing also but most elderly do not cooperate in early post operative period. Stich removal around 14th day. Due to poor body control, we advise patient to use bed pan till 3rd week then encouraged to use commode pan with walking aid like walking frame. Follow-up done at 4 week interval till 12 week. After union patient allowed aided or unaided walking as per patient preference and comfort then 3 monthly follow up. No routine implant removal.
All 15 patients were elderly with age between 60 to 95 years (average 82.4 years) out of which 5 males (33.33%) and 10 females (66.66%). 8 patients (53.33%) had Right sided IT fracture and 7 patients (46.66%) had left sided. Detailed demographic profile of all patients are shown in table [Table 1]. Out of 15 patients 2 patient lost in follow up due to natural death (one was female after 2 follow up of 8 week and other was male patient after 15th day). Rest 13 (n = 13) patient followed for 18 – 24 months. The average time of union was 14 weeks. There is no nonunion or implant failure in this study. Commonest complication of screw, that is superior migration or lateral back out did not occur with this implant in any cases. The phenomenon of controlled collapse is well tolerated by this implant. 5 patient walking without support. 5 patient with tripod stand, 3 patient with walking frame, all are using toilet independently. The functional outcome was evaluated by Harris Hip Score, according to which out of 13 patients (n = 13), 7 patients (53.85%) had excellent, 5 patients (38.45%) had good and 1 patient (7.7%) had poor results [Table 2].
Intertrochanteric fracture fixation can be done by using extramedullary implants or intramedullary implant. Operative option for extramedullary implants are Dynamic Hip Screw (DHS), Dynamic Compression Screw (DCS), Proximal femoral plate, Reverse distal femoral plate etc. Intramedullary options are mainly Proximal Femoral Nails (PFN). These nails are categorized in single screw system (e.g. helical blade or gamma nail) or two screw system (e.g. Recon nail, TFN etc.). Now newer concept of augmentation of nail with plate-screw-wire or combination besides nail become popular. Still nonunion/implant failure rate is 10% and there is no consensus regarding optimum method of operative management weather plate or nail.
Conceptually, the decision of plate or nail is depending on type of IT fracture. Based on AO classification of IT fracture, type A1.1 and A1.2 (being stable fracture) can be treated with extramedullary implants however type A1.3 onwards (being unstable fracture) can be best treated by intramedullary implants. Earlier DHS was one of the most commonly used implant for operative management of all types of IT fracture but over the time its indication became restricted to stable fracture where lesser trochanter is intact or sufficient lateral wall available. It is because the high failure rate of DHS (mainly screw cut out) in unstable fracture, comminuted fracture, osteoporotic fracture. In our experience, DHS failure can be categorized in 3 way. 1st due to uncontrolled collapsed of unstable fracture, 2nd when DHS placed in fracture having coronal split or lateral wall comminution and 3rd due to iatrogenic lateral wall fracture during triple reaming or barrel insertion.
To overcome all above complication of extramedullary implants (DHS), nailing is now a days most acceptable method of surgical treatment in unstable fracture but which nail is suitable still debatable. It is well documented in literature that Two screw nail system is associated with Z and reverse Z effect and Helical screw system associated with superior –medial –posterior perforation and lateral back out. Nonunion rate is also higher in Helical blade due to poor ability to collapse during union process.
So now a days a newer concept of augmentation of nail with Stainless Steel (SS) Wire- Plate- screw is emerging for comminuted IT fracture. If augmentation of nail with wire-plate –screw done, it is no longer a minimally invasive procedure and one has to open the fracture which increase blood loss and operating time.
Our pilot study on Halifax nail which is basically a Gamma nail internally augmented by a externally introduced tri-wire. This tri-wire increase the stiffness mainly rotational stability three times. So in this system stability is better than any other system. Another concern is controlled collapse of fracture during union and this system allow femoral head-screw-tri wire collapse simultaneously without implant failure. Middle portion of nail is not round but squarish hence better metaphyseal fit also add the stability. There is lock for head screw through nail which prevent lateral migration of screw. Tri-wire also prevent superior migration of screw that’s why suitable for poor bone quality patient also. With this improved biomechanics we have not noted any implant failure in in 13 out of 15 patients. It may be noted that wo patients lost to follow-up due to death (one died in early post operative period before 1st follow up and 2nd died after 2nd follow-up) and we have not considered them as mortality due to surgery. Female outnumbered males in this series which is comparable to other study. The functional outcome was evaluated by Harris Hip Scoring system and the results are comparable to other study.
The main limitation of our study was a pilot study on a small sample size. Prospective randomized controlled trail with large sample size are necessary to verify the therapeutic effect of this procedure. However according to our present result we are optimistic that this new nail may lead to a successful outcome in treatment of unstable intertrochanteric fracture.
Results of Halifax nail for IT fractures in elderly was found to be highly encouraging. All patients had early union and none had implant failure. Early mobilization and negligible mortality and morbidity were other added advantages. The main limitation of our study was small sample size however prospective randomized controlled trail with large sample size are necessary to verify the therapeutic effect of this procedure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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