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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 74-77

Results of proximal femoral nailing in subtrochanteric fracture of femur in adults


Department Of Orthopaedics, NHL Medical College, Ahmedabad, Gujarat, India

Date of Submission10-Jan-2022
Date of Decision20-Jan-2022
Date of Acceptance21-Jan-2022
Date of Web Publication28-May-2022

Correspondence Address:
Ishani Patel
Assistant Professor, Department of Orthopaedics, SMT. NHL Medical College, Ahmedabad - 380 007, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_4_22

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  Abstract 


Introduction: Subtrochanteric fractures occur in a zone extending from the lesser trochanter to 5 cm distal to the lesser trochanter, however, extension into the intertrochanteric region is common. The deforming forces on both the proximal and distal segments are difficult to control due to peculiar muscle insertion to the proximal and distal fragments. This study aims to assess the effectiveness of Proximal Femoral Nailing (PFN) for the treatment of subtrochanteric fractures of femur. Materials and Methods: This is a prospective study of evaluation of results of 32 patients who sustained subtrochanteric femur fracture treated with PFN at our institute from June 2018 to May 2020. All the patients in this study were above 18 years of age including both genders. All closed fractures and open Grade 1 and 2 fractures according to Gustilo–Anderson classification were included. Results: In this study of 32 patients, the mean age was around 3rd and 4th decade of life and Road traffic accidents was the major cause of injury (high-velocity trauma). The average radiological union time was 15.9 weeks. In 2 (6.24%) patients, there was postoperative infection and 3 (9.36%) patients had broken implant and 1 (3.12%) patient had nonunion. According to Harris hip score, 29 (90.6%) patients showed excellent-to-good results. Conclusion: PFN is a closed intramedullary nailing procedure which achieves biological fracture fixation with minimal blood loss, preserving the fracture hematoma and thus aiding in healing of the fractures. It provides good axial as well as rotational stability.

Keywords: Peritrochanteric, proximal femoral nailing, proximal femur, subtrochanteric


How to cite this article:
Patel I, Amin TK, Kachhad KH, Patel KM, Senta A, Modi DR, Kodiyatar AK. Results of proximal femoral nailing in subtrochanteric fracture of femur in adults. J Orthop Dis Traumatol 2022;5:74-7

How to cite this URL:
Patel I, Amin TK, Kachhad KH, Patel KM, Senta A, Modi DR, Kodiyatar AK. Results of proximal femoral nailing in subtrochanteric fracture of femur in adults. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Jul 3];5:74-7. Available from: https://jodt.org/text.asp?2022/5/2/74/346215




  Introduction Top


Subtrochanteric fractures occur in a zone extending from the lesser trochanter to 5 cm distal,[1] however extension into the intertrochanteric region is common. They account for approximately 10%–30% of peri-trochanteric fracture.[2],[3] The mechanical stresses at this level are very high, as they occur at the junction between the trabecular and cortical zone and also because of the deforming forces due to peculiar muscle insertion to the proximal and distal fragments. These factors have made subtrochanteric fractures a special consideration in orthopedic trauma because defective union of this fracture can lead to high disability for an individual.

The management of this fracture is difficult because this zone of the femur is subjected to maximum amount of mechanical stress. The proximal fragment is deformed by hip flexors and abductors making reduction of the fracture difficult. In spite of great advances made in the field of trauma in the last 50 years, the management of this fracture has always remained a subject of debate. There are several internal fixation options for managing these fractures that generally fall into two categories: One in the form of intramedullary fixation and others are extramedullary fixation.

Orthopedic fraternity is always on the lookout for an effective and suitable method to treat the upper femoral fractures in the best possible way. In this process, surgical management of these fractures and the surgical implants used have also gone through an array of changes in their procedures and designs. Various upper femoral devices such as dynamic condylar screw and dynamic hip screw with barrel plate are being used by various centers and each center claims reasonably satisfactory results with each type of device but no single technique has proved to give excellent results. The evolution of Proximal Femoral Nail by AO-ASIF in 1997, for various types of upper femoral fractures, claims to give superior results then other techniques.[4]

The aim of this study was to assess the effectiveness of Proximal Femoral Nailing (PFN) for the treatment of subtrochanteric fractures of femur, especially in the Indian scenario.


  Materials and Methods Top


This was a prospective study of evaluation of results of 32 patients who sustained subtrochanteric femur fracture treated with proximal femoral nail at our institute from June 2018 to May 2020.

Patients above 18 years of age having closed fracture and open Grade 1 or 2 included in this study. Patients <18 years of age with open fractures Grade 3, pathological fracture and fractures with vascular injury were excluded from this study.

As per ATLS guidelines, hemodynamic stabilization of all patients was carried out and injury to head, chest, or abdomen was ruled out and treated accordingly. After stabilization, anteroposterior and lateral radiograph of the affected part were done [Figure 1]a. Subtrochanteric fractures were classified in the current study according to Seinsheimer's classification. Skin traction with counter traction was given.
Figure 1: (a) Preoperative X-ray (b) Postoperative X-ray (c) Three months' follow-up

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Patients were posted for surgery after all routine investigations and anesthetic clearance under regional or general anesthesia. The patient was placed on a radiolucent fracture table in supine position with perineal post in place. Closed reduction was achieved by traction and internal rotation primarily or external rotation and adduction or abduction as required. Reduction was checked under the image intensifier with AP and lateral view.

A 5 cm incision was made approximately 5–8 cm proximal from the tip of the greater trochanter. A parallel incision in the fasciae of the gluteus medius was made and the gluteus medius was split in line with the fibers. For patients requiring encirclage with stainless steel (SS) wire, a 2 cm incision was made and SS wire was inserted. Entry was taken with an awl/guide pin over a protector sleeve slightly medial through the pyriformis fossa. A 2.8 mm guidewire was inserted across the fracture site through the cannulated awl. Its position was checked in the C-arm and the entry was widened with the proximal reamer. Reaming of the shaft was done in younger patients.

Appropriate size long proximal femoral nail was fixed with a jig and inserted manually as far as possible with twisting movements or hammered down the canal. The position of the holes for the hip screws was checked in the C-arm for the depth of the nail insertion. Guidewires for the screws were inserted through the jig with the help of a drill sleeve. The ideal position of the guide wires is parallel and in the lower half of the neck in AP views and the center of the neck in the lateral views. The guide pins were inserted up to 5 mm from the articular surface of the femoral head and size of the lag screw determined. Reaming for the lag screw and anti-rotation screw was done and appropriate size screws inserted approximately 5 mm away from the subchondral bone. Distal locking was performed with two locking bolts with freehand technique under IITV guidance.

Postoperatively, a radiograph was done [Figure 1]b. Quadriceps exercises with knee and ankle mobilization were started from 2nd postoperative day. Injectable antibiotics were given till the 4th postoperative day. After that oral antibiotics were given till suture removal. Local wound care and dressing were done regularly and sutures were removed between 12th to 14th postoperative day. Patients were advised nonweight bearing walker walking after suture removal. Partial weight-bearing walker walking was started around 6–10 weeks and full-weight-bearing walker walking was allowed usually between 10 and 14 weeks after assessing for radiological and clinical union [Figure 1]c. The evaluation of the results was done with the help of Harris hip score.


  Results Top


This is a prospective study of evaluation of results of 32 patients who sustained subtrochanteric femur fracture and treated with PFN at our institute from June 2018 to May 2020. All the patients in this study were above 18 years of age. The youngest patient was 19 years old and the oldest patient was 85 years old. The mean age was 41.1 years. Out of 32 patients, 22 (68.75%) were male and 10 (31.25%) were female.

In our study, 18 (56.25%) patients had road traffic accident whereas, 7 (21.87%) patients were injured following a fall from height and 7 (21.87%) patients were injured following domestic fall. This suggests that the majority of patients had subtrochateric fracture as a result of high-velocity trauma. In this study, the most common type of fracture was Seinsheimer Type-4 11 (34.37%). In our study, out of 32 patients, PFN with encirclage with SS wire was done in 8 (25%) patients due to a long spiral oblique fracture pattern. However, 24 (75%) patients required PFN only.

The average operative time for surgery was 66.4 min (21 patients) with minimum operative time being 50 min (eight patients) and maximum time being 100 min (three patients). Most of the patients were advised partial weight-bearing in the form of walker walking between 6 and 10 weeks with average time around 9 weeks. Patients were advised full weight-bearing walking with walker between 10 and 14 weeks with average time around 12 weeks. The average radiological union time for subtrochanteric fracture was 15.9 weeks with the earliest union was seen at 12 weeks.

In our study, out of 32 patients, six patients had postoperative complications. One (3.12%) patient had non-union. Two (6.24%) patients had postoperative infection within 2 weeks.

Three (9.36%) patients had broken implant in the form of broken distal locking screws of proximal femoral nail, the fracture united in these patients.

In our series, the average Hip Harris score is 90.4 (Ranging from 68 to 100) [Table 1]. Twenty-nine (90.6%) patients showed excellent-to-good results which suggest that intramedullary fixation of subtrochanteric femur fracture treated with PFN provides good results [Figure 2].
Table 1: Results according to Harris hip score

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Figure 2: (a) Range of motion hip flexion (b) Hip External Rotation (c) Squatting position

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  Discussion Top


PFN is an effective intramedullary load-sharing device. It incorporates the principles and theoretical advantages of the Zickel–Nail, Dynamic hip screw, and locked intramedullary nail. The advantages of PFN are minimal blood loss, shorter operative time, and early weight-bearing. In comparison with intertrochanteric fractures, subtrochanteric fractures are generally associated with slightly higher failure rates.

We have studied 32 cases of subtrochanteric fracture of femur treated with proximal femur nailing. In our series, high-velocity trauma was observed in 25 (87.12%) patients which is comparable with Indian series by Sangwan et al.[5] which had 75% of patients with high-velocity motor vehicle accidents.

The most common type was Seinsheimer's Type IV accounting for 11 (34.37%) followed by Type III accounting for 9 (28.12%) which is comparable with a study by Zhou, et al.[6]

Our study shows that surgery time with PFN takes a shorter time (mean duration of 66.4 min) compared to extramedullary implants such as Dynamic hip screw, Dynamic condylar screw, and blade plates described in studies by Sadowski et al.,[7] Rahme et al.[8]

The average union time in our study was 15.9 weeks, which is in comparable to Boldin et al.[9]

As compared to extramedullary fixation the amount of blood loss during PFN was less because it is essentially a close procedure and even when open reduction is done, the soft tissue dissection is much less than extramedullary fixation.[10] This decreases the morbidity and preserves the biology thus improving the union chances and decreasing the rate of complications.

We had 2 cases of postoperative infection which were cured by antibiotics and dressing. Chances of postoperative infection in PFN are much less owing to small incisions and less surgical dissection.

There was 1 nonunion (3.12%) in our study. Nonunion rate of 28% (Rahme et al.[8]), 10% (Yolmaz et al.[11]) for Angled plate have been reported.

PFN is essentially a close intramedullary fixation with proximal and distal locking with resultant small incision and good stability resulting in better patient compliance during postoperative rehabilitation. Longer immobilization and nonweight bearing were seen with the use of other implants.

The benefits of early knee and hip mobilization include – reduction of hip stiffness and improved cartilage and soft tissue healing (regeneration). However, these benefits are to be cautiously balanced by risks, including loss of fracture reduction, failure of internal fixation, and compromised ligament and soft tissue healing.

Seinsheimer[12] stated that the prognosis is given by the degree of displacement, type of fracture, method of treatment, and quality of postoperative care. In our study, we achieved 90.6% excellent-to-good results and 9.3% fair-to-poor result with our standard surgical care using proximal femoral nail. Zhou, et al.[6] have reported 96.05% excellent-to-good result and 3.95% patients have fair-to-poor results. Our results are comparable with other series.

The limitations of this study were less number of patients and no alternative treatment to compare this study.


  Conclusion Top


PFN is a closed nailing procedure which achieves biological fracture fixation with minimal blood loss, preserving the fracture hematoma and thus aiding in healing of the fractures. As compared to other modalities, there is a low infection rate, as well as fewer postoperative complications. Proximal and distal bolts passed through femoral nail gives good axial and rotational stability and prevent shortening and malunion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rockwood C A, Green D P, and Bucholz R W. Subtrochanteric femur fractures Rockwood and Green's fractures in adults (8th ed.). Philadelphia: Lippincott Williams and Wilkins 2015,Vol. 1. Ch. 54  Back to cited text no. 1
    
2.
Burstein AH. Fracture classification systems: Do they work and are they useful? J Bone Joint Surg Am 1993;75:1743-4.  Back to cited text no. 2
    
3.
Nieves JW, Bilezikian JP, Lane JM, Einhorn TA, Wang Y, Steinbuch M, et al. Fragility fractures of the hip and femur: Incidence and patient characteristics. Osteoporos Int 2010;21:399-408.  Back to cited text no. 3
    
4.
Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): A new device for the treatment of unstable proximal femoral fractures. Injury 1999;30:327-32.  Back to cited text no. 4
    
5.
Sangwan SS, Kundu ZS, Siwach RC, Marya KM, Yadav V, Devgan A. Role of modified kuntscher's nail in management of subtrochanteric fractures of femur. Indian J Orthop 2004;38:100-3.  Back to cited text no. 5
  [Full text]  
6.
Zhou ZB, Chen S, Gao YS, Sun YQ, Zhang CQ, Jiang Y. Subtrochanteric femur fracture treated by intramedullary fixation. Chin J Traumatol 2015;18:336-41.  Back to cited text no. 6
    
7.
Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: A prospective, randomized study. J Bone Joint Surg Am 2002;84:372-81.  Back to cited text no. 7
    
8.
Rahme DM, Harris IA. Intramedullary nailing versus fixed angle blade plating for subtrochanteric femoral fractures: A prospective randomised controlled trial. J Orthop Surg (Hong Kong) 2007;15:278-81.  Back to cited text no. 8
    
9.
Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R. The proximal femoral nail (PFN) – A minimal invasive treatment of unstable proximal femoral fractures: A prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand 2003;74:53-8.  Back to cited text no. 9
    
10.
Schipper IB, Steyerberg EW, Castelein RM, van der Heijden FH, den Hoed PT, Kerver AJ, et al. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg Br 2004;86:86-94.  Back to cited text no. 10
    
11.
Yolmaz E, Karakurt L, Güzel H, Serin E. Evaluation of treatment results with the 95-degree AO/ASIF angular plate in subtrochanteric femur fractures. Joint Dis Relat Surg 2005;16:42-8.  Back to cited text no. 11
    
12.
Seinsheimer F. Subtrochanteric fractures of femur. J Bone Joint Surg Am 1978;60:300-6.  Back to cited text no. 12
    


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