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Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures
G Model
JINJ-6405; No. of Pages 5 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures Daoud Makki a, Hosam E. Matar a,*, Nebu Jacob b, Stephen Lipscombe c, Ravindra Gudena c a
Speciality Registrar Trauma & Orthopaedics, Department of Trauma & Orthopaedics, St Helens &Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot, L35 5DR Clinical Fellow, Department of Trauma & Orthopaedics, St Helens &Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot, L35 5DR c Consultant Trauma & Orthopaedic Surgeon, St Helens &Knowsley, Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot, L35 5DR b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 July 2015 Received in revised form 13 September 2015 Accepted 29 September 2015
Reverse oblique intertrochanteric fractures have unique mechanical characteristics and are often treated with intramedullary implants. We compared the outcomes of the reconstruction trochanteric antegrade nail (TAN) with the proximal femoral nail antirotation (PFNA). Between July 2008 and February 2014, we reviewed all patients with reverse oblique intertrochanteric fractures treated at our hospital. Patients with pathological fractures and those who were treated with other than TAN and PFNA nailing systems were excluded. Preoperative assessment included the Abbreviated mental test score (AMT), the ASA grade, pre-injury mobility and place of residence. Postoperative outcome measures included the type of implant used, time to fracture union, failures of fixation and revision surgeries. Fifty-eight patients were included and divided into two groups based on the treatment: 22 patients treated with TAN and 36 patients treated with PFNA systems. The two groups were well matched with regards to demographics and fracture type. The overall union rate was similar in both groups but the time to union was shorter in the TAN group. There were 8 implant failures in the PFNA (22.2%) group compare to none in the TAN group. Implant failure was associated with the severity of fracture (AO 31.A3.3) but was not related to fracture malreduction or screw position (Tip-apex-distance). Our study suggests that the use of reconstruction system with two screws such as TAN may be more suitable implant for reverse oblique intertrochanteric hip fractures. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Intertrochanteric hip fractures Reverse oblique Proximal Femoral Nail Antirotation (PFNA) Trochanteric Antigrade Nail (TAN) Elderly patients
Introduction Reverse oblique intertrochanteric fractures account for 2–23% of all trochanteric fractures [1–5]. These are classified by the AO classification as (AO31A3) [6]. There is an increasing body of clinical evidence in the literature supporting the use of an intramedullary device for reverse oblique fractures. Large national registry data for Norway recently recommended the use of intramedullary devices compared with sliding hip screws [5]. Although the evidence supports the use of intramedullary devices, the availability of different designs in the market with different
* Corresponding author. Tel.: +44 7826692764; fax: +44 87488384. E-mail addresses: [email protected] (D. Makki), [email protected] (H.E. Matar), [email protected] (N. Jacob), [email protected] (S. Lipscombe), [email protected] (R. Gudena).
theoretical biomechanical properties and little comparative trials to support its effectiveness adds to the complexity of managing reverse oblique fractures. Examples of these implants include: Gamma 3 (Stryker), TriGen/TrigenIntertan (Smith & Nephew), Intramedullary Hip Screw (IMHS, Smith & Nephew), Proximal Femoral Nail Antirotation (PFNA, Synthes), and the Lateral Femoral Nail (LFN, Synthes). In our institution, we use the PFNA (Synthes) nail and the Trochanteric Antigrade Nail (TAN, Smith & Nephew) nail. Both designs have similar indications but are biomechanically different. The PFNA nail offers a sliding hip screw called a blade, which is designed to offer better hold in osteoporotic bone compared to the lag screw design. The TAN nail, on the other hand, has two parallel reconstruction screws into the femoral head that lock with the nail and do not allow compression at the screw-nail interface. Our aim was to compare the clinical outcomes of the reconstruction trochanteric antigrade nail (TAN) with the proximal
http://dx.doi.org/10.1016/j.injury.2015.09.038 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
G Model
JINJ-6405; No. of Pages 5 D. Makki et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures.
fully mobile. Patients were mobilised bed to chair on the second or third postoperative day whenever possible and supervised weightbearing was allowed as tolerated.
Materials and methods Outcome measures Study design This was a retrospective consecutive study. The study protocol was approved by the local review board of research and clinical effectiveness department. Patients The data of all patients with intertrochanteric fractures presented to our hospital between July 2008 and February 2013 were evaluated. Radiological data were reviewed to identify the reverse oblique fractures based on the AO classification [6]. Patients with open fractures, metastatic pathological fractures and those treated with implants other than TAN/PFNA were excluded. Preoperative assessment All patients underwent routine preoperative assessment including routine blood tests, electrocardiograms and anaesthetic assessments. Evaluation of the pre-injury functional level was based on two simple components that included the mobility prior to injury (independent, use of walking stick or frame) and the place of residence (own home, sheltered accommodation or nursing home). Cognitive assessment was carried out using the Abbreviated Mental Test Score (AMTS) [7]. Choice of implant In our department, at time of study, we had nine trauma and orthopaedic consultants who operated on trauma cases routinely. Both PFNA and TAN systems were available concurrently and given that there was no clear evidence to support the use of one system over the other, the choice of implant was based entirely on surgeon’s preference. Operative technique The procedure was carried out under fluoroscopy control. Patients were positioned supine on a radiolucent fracture table. Close reduction was achieved with longitudinal traction applied in line with the axis of femur. Following routine skin preparation and draping, percutaneous trochanteric entry point used, a long guide wire is passed through the femoral canal, proximal femur opened with an entry reamer, occasionally a reducer was used to aid fracture reduction. Nails were selected based on preoperative planning and were also checked intraoperatively to provide translational fill of the intramedullary canal in mid-diaphysis. The nail implants were then inserted; rotational position of the extremity was checked to prevent malalignment. The proximal interlocking screws (2 screws for TAN and Blade for PFNA) were inserted using the attached targeting device through stab incisions. In two patients of the PFNA group, an additional cerclage wire was applied to help reduce the abducted proximal fragment. All nails used were long and distal locking was performed using freehand technique through mini-incision. Postoperative management All patients received antibiotic prophylaxis as per local guidelines. For thromboprophylaxis, low molecular weight heparin (LMWH) was administered subcutaneously until the patients were
When successfully discharged from hospital, patients were reviewed clinically and radiologically at 6 weeks initially then at variable intervals until satisfactory fracture union. Time from surgery to union or failure, complications and further procedures if needed, were reviewed. Patients were evaluated postoperatively with regards to mobility and place of residence. The Tip Apex Distance (reference) was measured in patients treated with the PFNA nail as it uses a single screw. Statistical analysis The values of all parameters are presented as the mean standard deviation. Fischer exact test and t-test considered significant for p < 0.5. SPSS 16.0 software (SPSS Inc., Chicago, IL, USA) was used for descriptive statistical analysis. Results In total, 441 consecutive extra-capsular femoral neck fractures were treated at our institution in the period between July 2008 and February 2014. Eighty-two patients (18.6%) had AO-31.A3 reverse oblique fractures. However, 24 patients were excluded because of metastatic fractures, and those treated with other implants. Fiftyeight patients with reverse oblique (AO-31.A3) were included in the final analysis, 36 (62%) treated with PFNA and 22 (38%) treated with TAN (Table 1). Demographic data of both groups were similar with regards to age, sex and fracture pattern (Table 2). Time to fracture union Radiological union was achieved in 25 fractures in the PFNA group (70%) and in 20 fractures in the TAN group (90%). This difference in the overall union rate between the two implants was not statistically significant (Fisher’s exact test, P = 0.1). However time to union was shorter in the TAN group compared to the PFNA group [18/22 (81.8%) TAN group versus 17/36 (47.2%) PFNA group united within 6 months from surgery; P = 0.01, Fisher’s exact test]. For union between 6 and 12 months, there were 6 fractures in the Table 1 Patients demographics, preoperative mobility, place of residence and fracture classification based on the AO classification system.
Mean age (SD) Male/female Laterality: Right/Left Mean AMT (SD) Mean ASA Grade (SD) Preoperative Mobility Independent Walking tick Walking Frame Place of residence Own home Sheltered home Nursing home AO classification A3.1 A3.2 A3.3
PFNA Group (n = 36)
TAN Group (n = 22)
P value
80 (11.75) 7/29 19/17 5.1(2.8) 2.7(0.87)
78(10.44) 9/13 8/14 5.3(2.4) 2.5(0.9)
0.51a 0.12$ 0.28$ 0.78a 0.40a
13 17 6
10 8 4
0.58$ 0.58$ 0.99$
19 12 5
12 8 2
0.99$ 0.99$ 0.69$
14 3 19
6 1 15
0.4$ 0.99$ 0.28$
$ Fisher’s exact test a t-test.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
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JINJ-6405; No. of Pages 5 D. Makki et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx Table 2 Summary of clinical and radiological outcomes, mobility status at final follow up, place of residence and mortality.
Complete radiological union Time to union (number of patients) <6 months 6–12 months >12 months Failures Other secondary procedures Mobility at final follow up Independent Walking tick Walking Frame Discharge destination Own home Sheltered home Nursing home Deaths
P valuea
PFNA Group
TAN Group
(n = 36)
(n = 22)
25
20
0.1
17 6 2 8 2
18 1 1 0 1
0.01 0.23 0.99 0.01 0.99
3 14 13
5 8 7
0.23 0.77 0.76
10 10 10 6
8 7 4 3
0.55 0.99 0.51 0.99
$ Fisher’s exact test a t-test.
PFNA group and one in the TAN group but this difference was not statistically significant (p = 0.23) (Fig. 1). Similarly, 2 fractures in the PFNA group and one in the TAN group united beyond 12 months from surgery. In these cases, secondary procedures such as dynamisation of the implant by removing distal screws were performed. Radiological union was not achieved in the remaining 11 patients in the PFNA group (3 deaths and 8 implant failures) and in 2 patients in the TAN group due to death.
3
Failures There were 8 (22.2%) implant failures in the PFNA group (Figs. 1 and 2) and none in the TAN group (Fig. 3), this difference was statistically significant (P = 0.01, Fisher’s exact test). Failures occurred within two weeks (6 fractures) and between 2 to 4 weeks (2 fractures). None of the failures was secondary to infection or recurrent injury. Intraoperative and postoperative radiographs of failed cases showed satisfactory fracture reduction (Garden alignment index) and screw position (tip apex distance) when compared to other fractures treated with same implant and did not fail (mean TAD). The pattern of implant failure was identical in all cases whereby the femoral neck fragment abducts and tilts into varus followed by lag screw cutting out. Measurement of tip apex distance (TAD) The mean TAD amongst the failed 8 patients was 19.24 mm (SD 6.13) whereas the mean TAD of the cases that did not fail in the PFNA group was 20.23 mm (SD 3.58). This difference in TAD was not statistically significant (p = 0.66, unpaired t-test). Revision surgery 7/8 patients with failed PFNA underwent revision surgery while one patient was medically unfit and died. Revision procedures included conversion to complex total hip replacement (3 patients), revision of fixation using trochanteric locking plate (3 patients) and removal of the cut out screw in a patient with poor mobility and was medically unfit for a reconstructive procedure.
Fig. 1. (a–g): plain radiographs demonstrating right reverse oblique fracture fixed with PFNA nail with adequate reduction, subsequent follow up radiographs at 8 months demonstrating delayed union.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
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JINJ-6405; No. of Pages 5 D. Makki et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
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Fig. 2. (a–f): plain radiographs demonstrating right reverse oblique fracture fixed with PFNA nail with adequate reduction, subsequent follow up radiographs demonstrate the proximal fragment sliding into varus and the blade backing out with implant failure.
Other secondary procedures Two patients of the PFNA group and one patient in the TAN group underwent dynamisation of the nail to promote fracture healing which was then achieved within 6 months. Other complications Two patients in the PFNA group and 2 patients in the TAN group developed wound infection. However, none of these patients had delayed union or implant failure. One patient in the PFNA group was treated successfully with antibiotics and one with surgical debridement and retention of metalwork. In the TAN group both patients required surgical debridement but with retention of implants. Mortality The overall mortality rate in our series was (15.5%). In the PFN group, there were 6 deaths in total and all were of unrelated causes.
Four deaths occurred during same hospital admission and 2 following discharge. In the TAN group, 3 deaths occurred and all were during same hospital admission. Discussion The largest published series on reverse oblique trochanteric and subtrochanteric fractures is from the Norwegian hip fracture registry [5]. Patients with transverse/reverse oblique trochanteric and subtrochanteric fractures operated with a Sliding Hip Screws (1792 patients) had a significantly higher reoperation rate compared to those treated with an intramedullary nails (924 patients; PFNA 54, TAN 129). However, there were no direct comparisons of outcomes between different intramedullary devices. Our patients in both groups were similar at baseline. The overall mortality rate of our patients was 15.5%; this is comparable with published literature. The reported 1-year postoperative mortality in patients treated surgically for trochanteric fractures ranges from
Fig. 3. (a–d): plain radiographs demonstrating right reverse oblique fracture fixed with TAN nail with adequate reduction, follow up radiographs at 4.5 months demonstrating bony union.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
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JINJ-6405; No. of Pages 5 D. Makki et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
15% to 26%, as compared with a mortality of 9% in the age-matched general population [8]. The failure rate was statistically significant in our PFNA group compared to the TAN group and the time to radiological union was shorter in the TAN group with the majority of our patients achieving union within 6 months. Modes of failure of sliding hip screws fixation of reverse oblique fractures are predictable and reported in the literature as high as 56% [9]. Although, intramedullary nails can more reliably resist the relatively high forces across the medial calcar that are typically borne by the implant in an unstable fracture, the sliding blade of PFNA does not seem to prevents femoral shaft medialisation. The failures noted in our series all had the same pattern associated with excessive sliding of the femoral neck screw leading to the femoral neck fragment to abduct and tilt into varus. The radiological analyses of intraoperative images suggest that the PFNA blade was positioned in the centre of the femoral head with the mean tip-apex distance 19.24 mm (SD 6.13). In addition, failure in the PFNA group occurred within 6 weeks of surgery, with infection ruled out biochemically and at revision surgery. It is likely, therefore, that the biomechanical failure observed in our patients relates to the excessive sliding and toggling of the neck screw exaggerated by the osteoporotic bone of proximal femur leading to its failure. Similar modes of implant failure of PFNA have been reported in small published series [2,10]. In a recent randomised controlled trial, Vaquero et al. [11], comparing PFNA with Gamma-3 nail for unstable trochanteric fractures, both implants were similar with complications rate of 45% and 40% respectively. At the 6-month and 1-year follow-up evaluations, there were no significant differences in terms of range of motion, clinical scores and radiological outcomes. In another similar Chinese series [12], authors compared InterTan nail with PFNA for unstable trochanteric fractures. There were 11 (A3) patients PFNA versus 12 (A3) patients InterTan group, there were no statistically significant differences between the two groups in complications, walking ability, Harris Hip Scores, or hip range of motion at final follow-up. Our study is limited by its retrospective nature and its susceptibility to associated risks of bias. Further, the choice of implant was based on surgeon’s preference. However, the two groups were well matched and this allowed us to conclude that the differences observed between the two implants were not related to patients’ demographics or the severity of fracture.
5
Conclusion We conclude that, in our experience, PFNA is perhaps less effective than TAN in treating reverse obliquity intertrochanteric hip fractures as it allows excessive movement at the fracture site and can lead to delayed union or failure. Conflict of Interests None to be declared by any of the authors. References [1] Park SY, Yang KH, Yoo JH, Park HW. The treatment of reverse obliquity intertrochanteric fractures with the intramedullary hip nail. J Trauma 2008;65:852–7. [2] Min WK, Kim SY, Kim TK, Lee KB, Cho MR, Ha YC, et al. Proximal femoral nail for the treatment of reverse obliquity intertrochanteric fractures compared with gamma nail. J Trauma 2007;63:1054–60. [3] Brammar TJ, Kendrew J, Khan RJ, Parker MJ. Reverse obliquity and transverse fractures of the trochanteric region of the femur: a review of 101 cases. Injury 2005;36:851–7. [4] Haidukewych G, Israel A, Berry D. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643–50. [5] Matre K, Havelin LI, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury 2013;44(6 (June)):735–42. DOI 101016/jinjury201212010. Epub 2013 Jan 8. [6] Muller ME. The principle of the classification. In: Muller ME, Allgower M, Schneider R, et al., editors. Manual of Internal Fixation: Techniques Recommended by the AO-ASIF Group. New York: Springer-Verlag; 1991. [7] Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233–8. [8] Bentler SE, Liu L, Obrizan M, Cook EA, Wright KB, Geweke JF, et al. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol 2009;170:1290–9. [9] Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83–A(5 (May)):643–50. [10] Wang W, Yang T, Fang Y, Wang G, Pu J, Liu L. Treatment of reverse oblique fractures of intertrochanteric region of femur with proximal femoral nail antirotation. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009;23(11 (November)):1306–10. [11] Vaquero J, Munoz J, Prat S, Ramirez C, Aguado HJ, Moreno E, et al. Proximal Femoral Nail Antirotation versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. A randomised comparative study. Injury 2012;43(Suppl 2 (December)):S47–54. DOI 101016/S0020-1383(13)70179-7. [12] Zhang S, Zhang K, Jia Y, Yu B, Feng W. InterTan nail versus Proximal Femoral Nail Antirotation-Asia in the treatment of unstable trochanteric fractures. Orthopedics 2013;36(3 (March)):e288–94. DOI 103928/0147744720130222-16.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
JINJ-6405; No. of Pages 5 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures Daoud Makki a, Hosam E. Matar a,*, Nebu Jacob b, Stephen Lipscombe c, Ravindra Gudena c a
Speciality Registrar Trauma & Orthopaedics, Department of Trauma & Orthopaedics, St Helens &Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot, L35 5DR Clinical Fellow, Department of Trauma & Orthopaedics, St Helens &Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot, L35 5DR c Consultant Trauma & Orthopaedic Surgeon, St Helens &Knowsley, Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot, L35 5DR b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 July 2015 Received in revised form 13 September 2015 Accepted 29 September 2015
Reverse oblique intertrochanteric fractures have unique mechanical characteristics and are often treated with intramedullary implants. We compared the outcomes of the reconstruction trochanteric antegrade nail (TAN) with the proximal femoral nail antirotation (PFNA). Between July 2008 and February 2014, we reviewed all patients with reverse oblique intertrochanteric fractures treated at our hospital. Patients with pathological fractures and those who were treated with other than TAN and PFNA nailing systems were excluded. Preoperative assessment included the Abbreviated mental test score (AMT), the ASA grade, pre-injury mobility and place of residence. Postoperative outcome measures included the type of implant used, time to fracture union, failures of fixation and revision surgeries. Fifty-eight patients were included and divided into two groups based on the treatment: 22 patients treated with TAN and 36 patients treated with PFNA systems. The two groups were well matched with regards to demographics and fracture type. The overall union rate was similar in both groups but the time to union was shorter in the TAN group. There were 8 implant failures in the PFNA (22.2%) group compare to none in the TAN group. Implant failure was associated with the severity of fracture (AO 31.A3.3) but was not related to fracture malreduction or screw position (Tip-apex-distance). Our study suggests that the use of reconstruction system with two screws such as TAN may be more suitable implant for reverse oblique intertrochanteric hip fractures. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Intertrochanteric hip fractures Reverse oblique Proximal Femoral Nail Antirotation (PFNA) Trochanteric Antigrade Nail (TAN) Elderly patients
Introduction Reverse oblique intertrochanteric fractures account for 2–23% of all trochanteric fractures [1–5]. These are classified by the AO classification as (AO31A3) [6]. There is an increasing body of clinical evidence in the literature supporting the use of an intramedullary device for reverse oblique fractures. Large national registry data for Norway recently recommended the use of intramedullary devices compared with sliding hip screws [5]. Although the evidence supports the use of intramedullary devices, the availability of different designs in the market with different
* Corresponding author. Tel.: +44 7826692764; fax: +44 87488384. E-mail addresses: [email protected] (D. Makki), [email protected] (H.E. Matar), [email protected] (N. Jacob), [email protected] (S. Lipscombe), [email protected] (R. Gudena).
theoretical biomechanical properties and little comparative trials to support its effectiveness adds to the complexity of managing reverse oblique fractures. Examples of these implants include: Gamma 3 (Stryker), TriGen/TrigenIntertan (Smith & Nephew), Intramedullary Hip Screw (IMHS, Smith & Nephew), Proximal Femoral Nail Antirotation (PFNA, Synthes), and the Lateral Femoral Nail (LFN, Synthes). In our institution, we use the PFNA (Synthes) nail and the Trochanteric Antigrade Nail (TAN, Smith & Nephew) nail. Both designs have similar indications but are biomechanically different. The PFNA nail offers a sliding hip screw called a blade, which is designed to offer better hold in osteoporotic bone compared to the lag screw design. The TAN nail, on the other hand, has two parallel reconstruction screws into the femoral head that lock with the nail and do not allow compression at the screw-nail interface. Our aim was to compare the clinical outcomes of the reconstruction trochanteric antigrade nail (TAN) with the proximal
http://dx.doi.org/10.1016/j.injury.2015.09.038 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
G Model
JINJ-6405; No. of Pages 5 D. Makki et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
2
femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures.
fully mobile. Patients were mobilised bed to chair on the second or third postoperative day whenever possible and supervised weightbearing was allowed as tolerated.
Materials and methods Outcome measures Study design This was a retrospective consecutive study. The study protocol was approved by the local review board of research and clinical effectiveness department. Patients The data of all patients with intertrochanteric fractures presented to our hospital between July 2008 and February 2013 were evaluated. Radiological data were reviewed to identify the reverse oblique fractures based on the AO classification [6]. Patients with open fractures, metastatic pathological fractures and those treated with implants other than TAN/PFNA were excluded. Preoperative assessment All patients underwent routine preoperative assessment including routine blood tests, electrocardiograms and anaesthetic assessments. Evaluation of the pre-injury functional level was based on two simple components that included the mobility prior to injury (independent, use of walking stick or frame) and the place of residence (own home, sheltered accommodation or nursing home). Cognitive assessment was carried out using the Abbreviated Mental Test Score (AMTS) [7]. Choice of implant In our department, at time of study, we had nine trauma and orthopaedic consultants who operated on trauma cases routinely. Both PFNA and TAN systems were available concurrently and given that there was no clear evidence to support the use of one system over the other, the choice of implant was based entirely on surgeon’s preference. Operative technique The procedure was carried out under fluoroscopy control. Patients were positioned supine on a radiolucent fracture table. Close reduction was achieved with longitudinal traction applied in line with the axis of femur. Following routine skin preparation and draping, percutaneous trochanteric entry point used, a long guide wire is passed through the femoral canal, proximal femur opened with an entry reamer, occasionally a reducer was used to aid fracture reduction. Nails were selected based on preoperative planning and were also checked intraoperatively to provide translational fill of the intramedullary canal in mid-diaphysis. The nail implants were then inserted; rotational position of the extremity was checked to prevent malalignment. The proximal interlocking screws (2 screws for TAN and Blade for PFNA) were inserted using the attached targeting device through stab incisions. In two patients of the PFNA group, an additional cerclage wire was applied to help reduce the abducted proximal fragment. All nails used were long and distal locking was performed using freehand technique through mini-incision. Postoperative management All patients received antibiotic prophylaxis as per local guidelines. For thromboprophylaxis, low molecular weight heparin (LMWH) was administered subcutaneously until the patients were
When successfully discharged from hospital, patients were reviewed clinically and radiologically at 6 weeks initially then at variable intervals until satisfactory fracture union. Time from surgery to union or failure, complications and further procedures if needed, were reviewed. Patients were evaluated postoperatively with regards to mobility and place of residence. The Tip Apex Distance (reference) was measured in patients treated with the PFNA nail as it uses a single screw. Statistical analysis The values of all parameters are presented as the mean standard deviation. Fischer exact test and t-test considered significant for p < 0.5. SPSS 16.0 software (SPSS Inc., Chicago, IL, USA) was used for descriptive statistical analysis. Results In total, 441 consecutive extra-capsular femoral neck fractures were treated at our institution in the period between July 2008 and February 2014. Eighty-two patients (18.6%) had AO-31.A3 reverse oblique fractures. However, 24 patients were excluded because of metastatic fractures, and those treated with other implants. Fiftyeight patients with reverse oblique (AO-31.A3) were included in the final analysis, 36 (62%) treated with PFNA and 22 (38%) treated with TAN (Table 1). Demographic data of both groups were similar with regards to age, sex and fracture pattern (Table 2). Time to fracture union Radiological union was achieved in 25 fractures in the PFNA group (70%) and in 20 fractures in the TAN group (90%). This difference in the overall union rate between the two implants was not statistically significant (Fisher’s exact test, P = 0.1). However time to union was shorter in the TAN group compared to the PFNA group [18/22 (81.8%) TAN group versus 17/36 (47.2%) PFNA group united within 6 months from surgery; P = 0.01, Fisher’s exact test]. For union between 6 and 12 months, there were 6 fractures in the Table 1 Patients demographics, preoperative mobility, place of residence and fracture classification based on the AO classification system.
Mean age (SD) Male/female Laterality: Right/Left Mean AMT (SD) Mean ASA Grade (SD) Preoperative Mobility Independent Walking tick Walking Frame Place of residence Own home Sheltered home Nursing home AO classification A3.1 A3.2 A3.3
PFNA Group (n = 36)
TAN Group (n = 22)
P value
80 (11.75) 7/29 19/17 5.1(2.8) 2.7(0.87)
78(10.44) 9/13 8/14 5.3(2.4) 2.5(0.9)
0.51a 0.12$ 0.28$ 0.78a 0.40a
13 17 6
10 8 4
0.58$ 0.58$ 0.99$
19 12 5
12 8 2
0.99$ 0.99$ 0.69$
14 3 19
6 1 15
0.4$ 0.99$ 0.28$
$ Fisher’s exact test a t-test.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
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JINJ-6405; No. of Pages 5 D. Makki et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx Table 2 Summary of clinical and radiological outcomes, mobility status at final follow up, place of residence and mortality.
Complete radiological union Time to union (number of patients) <6 months 6–12 months >12 months Failures Other secondary procedures Mobility at final follow up Independent Walking tick Walking Frame Discharge destination Own home Sheltered home Nursing home Deaths
P valuea
PFNA Group
TAN Group
(n = 36)
(n = 22)
25
20
0.1
17 6 2 8 2
18 1 1 0 1
0.01 0.23 0.99 0.01 0.99
3 14 13
5 8 7
0.23 0.77 0.76
10 10 10 6
8 7 4 3
0.55 0.99 0.51 0.99
$ Fisher’s exact test a t-test.
PFNA group and one in the TAN group but this difference was not statistically significant (p = 0.23) (Fig. 1). Similarly, 2 fractures in the PFNA group and one in the TAN group united beyond 12 months from surgery. In these cases, secondary procedures such as dynamisation of the implant by removing distal screws were performed. Radiological union was not achieved in the remaining 11 patients in the PFNA group (3 deaths and 8 implant failures) and in 2 patients in the TAN group due to death.
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Failures There were 8 (22.2%) implant failures in the PFNA group (Figs. 1 and 2) and none in the TAN group (Fig. 3), this difference was statistically significant (P = 0.01, Fisher’s exact test). Failures occurred within two weeks (6 fractures) and between 2 to 4 weeks (2 fractures). None of the failures was secondary to infection or recurrent injury. Intraoperative and postoperative radiographs of failed cases showed satisfactory fracture reduction (Garden alignment index) and screw position (tip apex distance) when compared to other fractures treated with same implant and did not fail (mean TAD). The pattern of implant failure was identical in all cases whereby the femoral neck fragment abducts and tilts into varus followed by lag screw cutting out. Measurement of tip apex distance (TAD) The mean TAD amongst the failed 8 patients was 19.24 mm (SD 6.13) whereas the mean TAD of the cases that did not fail in the PFNA group was 20.23 mm (SD 3.58). This difference in TAD was not statistically significant (p = 0.66, unpaired t-test). Revision surgery 7/8 patients with failed PFNA underwent revision surgery while one patient was medically unfit and died. Revision procedures included conversion to complex total hip replacement (3 patients), revision of fixation using trochanteric locking plate (3 patients) and removal of the cut out screw in a patient with poor mobility and was medically unfit for a reconstructive procedure.
Fig. 1. (a–g): plain radiographs demonstrating right reverse oblique fracture fixed with PFNA nail with adequate reduction, subsequent follow up radiographs at 8 months demonstrating delayed union.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
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JINJ-6405; No. of Pages 5 D. Makki et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
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Fig. 2. (a–f): plain radiographs demonstrating right reverse oblique fracture fixed with PFNA nail with adequate reduction, subsequent follow up radiographs demonstrate the proximal fragment sliding into varus and the blade backing out with implant failure.
Other secondary procedures Two patients of the PFNA group and one patient in the TAN group underwent dynamisation of the nail to promote fracture healing which was then achieved within 6 months. Other complications Two patients in the PFNA group and 2 patients in the TAN group developed wound infection. However, none of these patients had delayed union or implant failure. One patient in the PFNA group was treated successfully with antibiotics and one with surgical debridement and retention of metalwork. In the TAN group both patients required surgical debridement but with retention of implants. Mortality The overall mortality rate in our series was (15.5%). In the PFN group, there were 6 deaths in total and all were of unrelated causes.
Four deaths occurred during same hospital admission and 2 following discharge. In the TAN group, 3 deaths occurred and all were during same hospital admission. Discussion The largest published series on reverse oblique trochanteric and subtrochanteric fractures is from the Norwegian hip fracture registry [5]. Patients with transverse/reverse oblique trochanteric and subtrochanteric fractures operated with a Sliding Hip Screws (1792 patients) had a significantly higher reoperation rate compared to those treated with an intramedullary nails (924 patients; PFNA 54, TAN 129). However, there were no direct comparisons of outcomes between different intramedullary devices. Our patients in both groups were similar at baseline. The overall mortality rate of our patients was 15.5%; this is comparable with published literature. The reported 1-year postoperative mortality in patients treated surgically for trochanteric fractures ranges from
Fig. 3. (a–d): plain radiographs demonstrating right reverse oblique fracture fixed with TAN nail with adequate reduction, follow up radiographs at 4.5 months demonstrating bony union.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038
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JINJ-6405; No. of Pages 5 D. Makki et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
15% to 26%, as compared with a mortality of 9% in the age-matched general population [8]. The failure rate was statistically significant in our PFNA group compared to the TAN group and the time to radiological union was shorter in the TAN group with the majority of our patients achieving union within 6 months. Modes of failure of sliding hip screws fixation of reverse oblique fractures are predictable and reported in the literature as high as 56% [9]. Although, intramedullary nails can more reliably resist the relatively high forces across the medial calcar that are typically borne by the implant in an unstable fracture, the sliding blade of PFNA does not seem to prevents femoral shaft medialisation. The failures noted in our series all had the same pattern associated with excessive sliding of the femoral neck screw leading to the femoral neck fragment to abduct and tilt into varus. The radiological analyses of intraoperative images suggest that the PFNA blade was positioned in the centre of the femoral head with the mean tip-apex distance 19.24 mm (SD 6.13). In addition, failure in the PFNA group occurred within 6 weeks of surgery, with infection ruled out biochemically and at revision surgery. It is likely, therefore, that the biomechanical failure observed in our patients relates to the excessive sliding and toggling of the neck screw exaggerated by the osteoporotic bone of proximal femur leading to its failure. Similar modes of implant failure of PFNA have been reported in small published series [2,10]. In a recent randomised controlled trial, Vaquero et al. [11], comparing PFNA with Gamma-3 nail for unstable trochanteric fractures, both implants were similar with complications rate of 45% and 40% respectively. At the 6-month and 1-year follow-up evaluations, there were no significant differences in terms of range of motion, clinical scores and radiological outcomes. In another similar Chinese series [12], authors compared InterTan nail with PFNA for unstable trochanteric fractures. There were 11 (A3) patients PFNA versus 12 (A3) patients InterTan group, there were no statistically significant differences between the two groups in complications, walking ability, Harris Hip Scores, or hip range of motion at final follow-up. Our study is limited by its retrospective nature and its susceptibility to associated risks of bias. Further, the choice of implant was based on surgeon’s preference. However, the two groups were well matched and this allowed us to conclude that the differences observed between the two implants were not related to patients’ demographics or the severity of fracture.
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Conclusion We conclude that, in our experience, PFNA is perhaps less effective than TAN in treating reverse obliquity intertrochanteric hip fractures as it allows excessive movement at the fracture site and can lead to delayed union or failure. Conflict of Interests None to be declared by any of the authors. References [1] Park SY, Yang KH, Yoo JH, Park HW. The treatment of reverse obliquity intertrochanteric fractures with the intramedullary hip nail. J Trauma 2008;65:852–7. [2] Min WK, Kim SY, Kim TK, Lee KB, Cho MR, Ha YC, et al. Proximal femoral nail for the treatment of reverse obliquity intertrochanteric fractures compared with gamma nail. J Trauma 2007;63:1054–60. [3] Brammar TJ, Kendrew J, Khan RJ, Parker MJ. Reverse obliquity and transverse fractures of the trochanteric region of the femur: a review of 101 cases. Injury 2005;36:851–7. [4] Haidukewych G, Israel A, Berry D. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643–50. [5] Matre K, Havelin LI, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury 2013;44(6 (June)):735–42. DOI 101016/jinjury201212010. Epub 2013 Jan 8. [6] Muller ME. The principle of the classification. In: Muller ME, Allgower M, Schneider R, et al., editors. Manual of Internal Fixation: Techniques Recommended by the AO-ASIF Group. New York: Springer-Verlag; 1991. [7] Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233–8. [8] Bentler SE, Liu L, Obrizan M, Cook EA, Wright KB, Geweke JF, et al. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol 2009;170:1290–9. [9] Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83–A(5 (May)):643–50. [10] Wang W, Yang T, Fang Y, Wang G, Pu J, Liu L. Treatment of reverse oblique fractures of intertrochanteric region of femur with proximal femoral nail antirotation. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009;23(11 (November)):1306–10. [11] Vaquero J, Munoz J, Prat S, Ramirez C, Aguado HJ, Moreno E, et al. Proximal Femoral Nail Antirotation versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. A randomised comparative study. Injury 2012;43(Suppl 2 (December)):S47–54. DOI 101016/S0020-1383(13)70179-7. [12] Zhang S, Zhang K, Jia Y, Yu B, Feng W. InterTan nail versus Proximal Femoral Nail Antirotation-Asia in the treatment of unstable trochanteric fractures. Orthopedics 2013;36(3 (March)):e288–94. DOI 103928/0147744720130222-16.
Please cite this article in press as: Makki D, et al. Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures. Injury (2015), http://dx.doi.org/ 10.1016/j.injury.2015.09.038