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Results of proximal femoral nail in intertrochanteric fractures of the hip with compromised lateral femoral wall: a clinical outcome study
INTRODUCTION
Results of proximal femoral nail in intertrochanteric fractures of the hip with compromised lateral femoral wall: a clinical outcome study
Intertrochanteric hip fractures account for approximately half of the hip fractures in the elderly and pose a number of management dilemmas depending on the fracture configuration and status of the bones.1,2 The operative procedures for the reduction and fixation of intertrochanteric fractures are technically challenging. Re-operation rates of 4–12% have been reported following the gold standard technique of fixation with dynamic hip screw.3–5 The re-operation rates are particularly high in patients with unstable fractures. Re-operations are usually performed for medialization of the femoral shaft following mobilization of the patients.3–6 The importance of integrity of the lateral femoral wall in intertrochanteric fractures has come up during the last decade. Intertrochanteric fractures associated with fracture of lateral femoral wall are now considered as a special group and integrity of lateral femoral wall is considered to be an important indicator of stability and prognosis.3,4 It has been suggested that the presence of an intact lateral femoral wall on the pre-operative radiograph should be a major factor in determining the internal fixation device used for fracture stabilization.3 Gotrified in retrospective analysis of 24 intertrochanteric fractures fixed with dynamic hip screw found that fractured lateral femoral wall was the cause of re-operations.4 The ideal method of fixation of unstable fractures associated with the fracture of lateral femoral wall and those fractures type which are vulnerable for fracture of lateral femoral during surgery is still not clearly defined. Although reports are available in the literature demonstrating inferior outcomes with dynamic hip screw in this subgroup of intertrochanteric fractures, the ideal fixation device is a matter of debate and the current trend is towards using an intramedullary device to fix these fractures. The aim of the present study is to evaluate the outcome of proximal femoral nail in unstable intertrochanteric fractures in terms of low rates of complications and re-operation rate.
V Kochar, MBBS A Pankaj, MS DNB MRCS (Ed) M Chadha, MS S Arora, MS DNB
Abstract The ideal method of fixation of intertrochanteric fractures of femur associated with compromised lateral femoral wall is still not clearly defined. The aim of the present study is to evaluate the outcome of proximal femoral nail in unstable intertrochanteric fractures with compromised lateral femoral wall in terms of low rate of complications and re-operation. Twenty-four consecutive patients who had sustained an unstable intertrochanteric fracture according to AO/OTA classification were operated with proximal femoral nail under image intensifier by a single surgeon within a week of sustaining trauma and were followed clinically and radiologically for at least 6 months. Twenty-three patients were available for follow-up after 24 weeks. One patient died due to effects of prolonged immobilization 2 months postoperative as the patient wasn’t able to bear weight on affected extremity due to screw cut-out and subsequent varus collapse in immediate postoperative period. There was a mean limb length shortening of 4.29 mm. In 19 of 23 (approx 83%) patients the shortening was less than 10 mm. Four of 24 patients (16%) had developed postoperative complications but none of the patients were re-operated during the subsequent follow-up of 6 months. Proximal femoral nail provides a good outcome in intertrochanteric fractures of the hip with fractured or compromised lateral femoral wall with an acceptable rate of technical difficulties and complications.
MATERIALS AND METHODS Twenty-four consecutive patients who had sustained an unstable intertrochanteric fracture according to AO/OTA classification7 (Figure 1) were selected for the study and informed consent obtained from all. All cases were operated within the first week of sustaining trauma after stabilizing the patient and obtaining pre-anesthetic clearance. All cases were operated by a single surgeon (AP). Proximal femoral nail (SSEPL, Vadodara, India), in stainless steel and for left and right use, 240 mm long, the distal part of which is available in 10, 11 or 12 mm diameter was used. There is a valgus of 6° about 11 cm below the nail and 2 screws of 8 mm diameter can be inserted into the femoral neck. Distally the tip is shaped to reduce stress concentration. Distal locking can be done in static and dynamic modes with 5 mm locking bolt (Figure 2). Prophylactic intravenous antibiotics (ceftriaxone and amikacin) were given just before induction of anesthesia, followed
Keywords Intertrochanteric fracture, lateral femoral wall, proximal femoral nail
Department of Orthopedics, University College of Medical Sciences and GTB Hospital, Delhi, India. Correspondence: Dr. Amite Pankaj, Associate Professor, Department of Orthopedics, University College of Medical Sciences and GTB Hospital, Delhi, India. Ph: +011-22692520. E-mail: [email protected] JCOT Vol 1 No 2
99
Kochar, et al
A1
.1
.2
.3
A2
.1
.2
.3
A3
.1
.2
.3
Figure 1 AO/OTA classification for intertrochanteric fractures. AO fractures A1.1–A2.1 are commonly described as stable, and fractures A2.2–A3.3 usually are unstable and have fractured or compromised lateral femoral wall.
Figure 2 Proximal femoral nail.
observer (VK). Walking ability was analyzed using Parkar and Palmar mobility score8 (Table 1). Radiological assessment of the hip was done at 6, 12, and 24 weeks to look for fracture union, neck shaft angle and any signs of implant failure.
A1: Simple (2-fragment) pertrochanteric area fractures A1.1. Fractures along the intertrochanteric line A1.2. Fractures through the greater trochanter A1.3. Fractures below the lesser trochanter
RESULTS
A2: Multifragmentary pertrochanteric fractures A2.1. With one intermediate fragment (lesser trochanter detachment) A2.2. With 2 intermediate fragments A2.3. With more than 2 intermediate fragments
The average age of the study group was 54.7 years (range 22–79 years). The male to female ratio was found to be 1.5:1. The mechanism of injury was a low-impact injury in 67% cases. Fractures were classified as 31 A2.2 and A2.3 (approximately 71%) patients and A3 type in rest of patients. The pre-operative mean Parkar and Palmar mobility score was 8.47 ± 0.46. The mean duration of surgery was 65.1 minutes (range 45–98 minutes) and mean blood loss during surgery was 152 ml. Intra-operative technical problems were encountered in one patient. There was difficulty in the insertion of the proximal screw with only one screw in the head and neck fragment. Median length of lag screw was 100 mm. In 87.5% cases the tip of lag screw was central or inferior in AP view and central in lateral view (Figure 4). Twenty-three patients were available for follow-up at 24 weeks. One patient died due to effects of prolonged immobilization at 2 months postoperative as the patient wasn’t able to bear weight on affected extremity due to screw cutout and subsequent varus collapse in immediate postoperative period (Figure 5). There was a mean limb length shortening of 4.29 mm. In 19 of 23 (approx 83%) patients the shortening was less than 10 mm. The mean Parkar and Palmar score at 24 weeks was 8.05 (95% of pre-operative score) which shows that at 6 months most of the patients had regained their pre-trauma status. Four of 24 patients (16%) had developed postoperative complications but none of the patient was re-operated during the subsequent follow-up of 6 months. One case had superficial infection of proximal locking site at 4 months post-surgery which was managed with incision and drainage under local anesthesia and oral antibiotics. One case had screw cut through leading
A3: Intertrochanteric fractures A3.1. Simple, oblique A3.2. Simple, transverse A3.3. With a medial fragment
by two doses in postoperative period. The fracture was reduced under image intensifier with the patient on fracture table. The entry point was made with a guide pin (Figure 3) and confirmed on anteroposterior and lateral projections. The entry hole was enlarged with a powered reamer and a ball tip guide wire was inserted. Sequential reaming was done either with hand or power reamers. Nail was inserted and proximal and distal locking was done. Anteroposterior and lateral views of the operated hip were done on the first postoperative day. The patient was allowed to sit up in bed the day after surgery, and active exercises of the operated hip and knee were begun. Patients were observed for presence of deep vein thrombosis (DVT) and any other medical complications. Supportive medical treatment was instituted as per requirements of the patient. Patients were encouraged to walk with support as soon as the pain was tolerable and weight bearing was tolerable. Sutures were removed on the 14th postoperative day. All the patients were followed for a minimum duration of 6 months and evaluated by a standard protocol by a single JCOT Vol 1 No 2
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Results of proximal femoral nail in intertrochanteric fractures of the hip with compromised lateral femoral wall: a clinical outcome study
Figure 3 Images taken during surgery.
Superior Table 1 Parker and Palmer mobility score. Walking ability
No Alone with With help difficulty an assistive from another device person Able to walk inside house 3 2 1 Able to walk outside house 3 2 1 Able to go shopping, 3 2 1 to a restaurant, or to visit family
Not at all 0 0 0
Anterior
1
1
1
21
Posterior
The values are given as the number of points assigned for that answer. The maximum possible score is 9 points.
Inferior Figure 4 Position of the lag screw in the femoral head.
A
B
C
Figure 5 (A) 70-year-old female with AO type 31 A2.2 fracture of right femur. (B), (C)—postoperative X-rays showing screw cut-out and varus collapse.
time and with minimal complications. The operative treatment of intertrochanteric fractures has been a matter of debate and a number of fixation devices have been used with varying degrees of success. A Dynamic Hip Screw is the most commonly used implant for intertrochanteric fractures.9–11 Load bearing in the proximal femur is predominantly through calcar femorale, the lever arm of laterally placed plate is increased so there is a risk of implant cutout1,12 (Figure 7). Biomechanically compared to a laterally fixed side plate, an intramedullary device decreases the bending force of the
to varus collapse immediately after surgery and the patient died at 2 months postoperatively. Two patients had delayed union which united without intervention at 8 months post-surgery (Figure 6).
DISCUSSION Intertrochanteric fracture of femur has always been recognized as a major challenge not only for achieving fracture union, but also for restoration of optimal function in the shortest possible JCOT Vol 1 No 2
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A
B
C
Figure 6 (A) 48-year-old male with AO type 31 A2.2 fracture of right femur. (B), (C)—fracture union and maintained neck shaft angle at 6 months follow-up.
hip joint on implant by 25–30%. This has advantages especially in elderly patients, in whom the primary treatment goal is immediate full-weight bearing mobilization. So, now the intramedullary screw devices are gaining popularity for stabilizing intertrochanteric fractures.13 A search of the review groups of the Cochrane library for the ideal implant in intertrochanteric fractures still favors the use of sliding hip screw over intramedullary implants.14,15 Also reviews of various other meta-analysis also were in favor of sliding hip screw.13,16,17 This was predominantly due to risk of femoral shaft fracture associated with earlier version of gamma nail9,10 and complications due to steep learning curve associated with the implant. But, with the advent of proximal femoral nail the complications associated with gamma nail have been reduced and results of proximal femoral nail in treatment of intertrochanteric fractures are comparable or even better than dynamic hip screw especially in unstable intertrochanteric fractures.18,19 Traditionally it was the posteromedial comminution which was considered the most important factor in determining the severity of fracture. The importance of the integrity of the lateral femoral wall has been documented recently.3,4,6 The lateral wall is the proximal extension of the femoral shaft. This lateral wall is extremely thin in unstable 31 A2 type fracture.3,4 The lateral wall in patients treated with dynamic hip screw provides a lateral buttress for the controlled fracture impaction and preventing collapse. Palm et al3 found that there was an eight times higher risk of re-operation due to technical failure with the gold standard technique of dynamic hip screw in patients with fracture of the lateral femoral wall. This has been attributed to the fact that when the lateral femoral wall is fractured, the fracture line is parallel to the sliding vector of the sliding hip screw, which, as in the reverse oblique intertrochanteric fracture, allows the trochanteric and femoral head and neck fragments to slide laterally and the shaft to slide medially. The fracture complex subsequently disintegrates, with a high risk of failure including cut-out of the screw into the hip joint. Another fact is that most of the fractures of the lateral femoral wall occur intra-operatively with the gold standard technique when the large diameter hole is drilled into the lateral femoral wall, thereby converting a 31 A2 type to 31 A3 type. Gotfried4 in JCOT Vol 1 No 2
D d
D>d
Figure 7 Decreased lever arm of intramedullary nail.
a retrospective analysis of 24 patients with documented postoperative fracture collapse and their findings showed unequivocally that in all patients, this complication followed fracture of the lateral wall and resulted in protracted period of disability until fracture healing. The importance of the integrity of the lateral wall for event-free fracture healing clearly is indicated, and fracture of the lateral wall should be avoided in any fixation procedure. Palm et al3 have recommended dividing the fractures into two categories: A1–A2.1 & A2.2–A3, and not just into A1, A2, and A3 fracture types as has been reported in most studies taking into account the integrity of lateral femoral wall. This has implication on treatment guideline that the dynamic hip screw is not a good implant in patients falling into the second category. In the series by Gotfried,4 lateral wall fracture occurred in one third of the hips with the most vulnerable lateral femoral wall i.e., in those with an AO/OTA A2.2 or A2.3 fracture, which lacks buttress support of the greater trochanter. Intramedullary nails are associated with less shortening and less sliding of the lag screw. This is due to the fact that intramedullary nail stops the telescoping displacement of the proximal aspect of the femur.20 In fact, the proximal part of the nail blocks 102
Results of proximal femoral nail in intertrochanteric fractures of the hip with compromised lateral femoral wall: a clinical outcome study
the head-and-neck fragment, preventing its complete impaction. Hardy et al,20 in a randomized study of 100 patients with an intertrochanteric fracture, found less limb shortening in the group treated with an intramedullary hip screw than in those treated with a dynamic hip-screw, especially in unstable intertrochanteric fracture. In unstable fractures with compromised femoral wall, a modification of dynamic hip screw with trochanteric stabilizing plate has been used in order to provide lateral buttress and limit excessive collapse of the trochanter and head and neck fragment but still achieving controlled impaction of the fragment. But the disadvantages are that it adds to surgical time, blood loss, and amount of dissection needed.21 Another implant which is used in intertrochanteric fractures is 95° dynamic condylar screw. Haidukewych et al5 in a retrospective analysis of 47 patients with reverse oblique type of intertrochanteric fractures concluded that 95° fixed-angle internal fixation devices performed significantly better than did dynamic hip screws. Dynamic condylar screw in intertrochanteric fractures doesn’t cause any sliding of the lag screw and it is used like a neutralization plate. But Sadowski et al22 in a randomized, prospective study comparing proximal femoral nail (PFN) with dynamic condylar screw (DCS) in treatment of the reverse oblique and transverse intertrochanteric fractures supported the use of an intramedullary nail rather than a 95° screw-plate for the fixation of reverse oblique and transverse intertrochanteric fractures in elderly patients. The results of our study regarding fixation of intertrochanteric fractures with lateral cortical breech (31 A3 type fracture) and those with extremely thin lateral cortex (31 A2.2 and A2.3) are highly encouraging with shortening of less than 1 cm in (approximately 75%) patients and close to 95% return of pre-injury mobility. The role of proximal femoral locking plate in intertrochanteric fractures is also coming up with fixation of fractures by minimally invasive techniques. We agree with Palm et al3 that while awaiting larger randomized studies of other implants, we recommend treating simple intertrochanteric fractures (A1–A2.1) with a sliding hip screw fixed to a side-plate and treating more complex intertrochanteric fractures (A2.2–A3) with a sliding hip screw fixed to an intramedullary nail. The results of fixation of intertrochanteric fractures with compromised lateral femoral wall with the gold standard dynamic hip screw are associated with high rates of complications. Newer implants such as proximal femoral nail, trochanteric stabilizing plate, and proximal femoral locking plates are being investigated with increasing frequency whether they can provide superior biomechanical stability and clinical outcome. Although a large randomly controlled trial with adequate statistical power is desirable to substantiate/negate the superiority of one implant over the other, our clinical series has validated the fact that proximal femoral nail is a suitable implant for these type of fractures where lateral femoral wall is compromised with good clinical outcome and an acceptable rate of technical complications. JCOT Vol 1 No 2
We affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript. There is no conflict of interest. ♦
REFERENCES 1.
Koval KJ, Cantu RV. Intertrochantreric fractures. In: Rockwood & Green’s Fractures in Adults, 6th edn, Bucholz RW, Heckman JD, Court-Brown C, eds, Philadelphia: Lippincot Williams and Wilkins 2006:1793–825.
2.
Lavelle DG. Fractures and dislocation of hip. In: Campbell’s Operative Orthopedics, 11th edn, Canale ST, Beaty JH, eds, Philadelphia: Mosby Elsevier 2008:3237–70.
3.
Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a re-operation. J Bone Joint Surg Am 2007;89:470–5.
4.
Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop 2004; 425:82–6.
5.
Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83: 643–50.
6.
Im G, Shin YW, Song YJ. Potentially unstable intertrochanteric frac-
7.
Muller ME, Allgower M, Schneider R. In: The Comprehensive Classifi-
tures. J Orthop Trauma 2005;19:5–9. cation of Fractures of Long Bones, 3rd edn, New York: Springer-Verlag 1990:118. 8.
Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J Bone Joint Surg Br 1993;75-B:797–8.
9.
Radford PJ, Needoff M, Webb JK. A prospective randomized comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br 1993;75-B:789–93.
10. O’Brien PJ, Meek RN, Blachut PA, Broekhuyse HM, Sabharwal S. Fixation of intertrochanteric hip fractures: gamma nail versus dynamic hip screw: a randomized, prospective study. Can J Surg 1995;38:516–20. 11. Osnes EK, Lofthus CM, Falch JA, Meyer HE, et al. More postoperative femoral fractures with the gamma nail than the sliding screw plate in the treatment of trochanteric fractures. Acta Orthop Scand 2001;72:252–6. 12. Banan H, Al-Sabti A, Jimulia T, Hart AJ. The treatment of unstable, extracapsular hip fractures with the AO/ASIF proximal femoral nail—our first 60 cases. Injury 2002;33:401–5. 13. Anglen JO, Weinstein JN. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopedic Surgery Database. J Bone Joint Surg Am 2008;90-A: 700–7. 14. Parker MJ, Handoll HHG. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults (review). The Cochrane Library 2008;3. 15. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database Syst Rev 2004. 16. Jones HW, Johnston P, Parkar M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures. Int Orthop 2006;30:69–78. 17. Jiang SD, Jiang LS, Zhao CQ, Dai LY. No advantages of gamma nail over sliding hip screw in the management of peritrochanteric hip 103
Kochar, et al fractures: a meta-analysis of randomized controlled trials. Disability & Rehabilitation 2008;30:493–7. 18. Menezes DFA, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures. Clin Orthop 2005;439:221–7. 19. Morihara T, Arai Y, Tokugawa S, Fujita S, Chatani K, Kubo T. Proximal femoral nail for treatment of trochanteric femoral fractures. J Orthop Surg 2007;15:273–7. 20. Hardy DCR, Descamps P, Krallis P, Fabeck L, et al. Use of an intramedullary hip screw compared with a compression hip screw with a plate
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for intertrochanteric femoral fractures. J Bone Joint Surg Am 1998;80: 618–30. 21. Nuber S, Schonweiss T, Ruter A. Stabilization of unstable trochanteric femoral fractures: dynamic hip screw (DHS) with trochanteric stabilization plate vs. proximal femur nail (PFN). Unfallchirurg 2003;106: 39–47. 22. Sadowski C, Lubbeke 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° screw-plate: a prospective, randomized study. J Bone Joint Surg Am 2002;84-A:372–81.
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Results of proximal femoral nail in intertrochanteric fractures of the hip with compromised lateral femoral wall: a clinical outcome study
Intertrochanteric hip fractures account for approximately half of the hip fractures in the elderly and pose a number of management dilemmas depending on the fracture configuration and status of the bones.1,2 The operative procedures for the reduction and fixation of intertrochanteric fractures are technically challenging. Re-operation rates of 4–12% have been reported following the gold standard technique of fixation with dynamic hip screw.3–5 The re-operation rates are particularly high in patients with unstable fractures. Re-operations are usually performed for medialization of the femoral shaft following mobilization of the patients.3–6 The importance of integrity of the lateral femoral wall in intertrochanteric fractures has come up during the last decade. Intertrochanteric fractures associated with fracture of lateral femoral wall are now considered as a special group and integrity of lateral femoral wall is considered to be an important indicator of stability and prognosis.3,4 It has been suggested that the presence of an intact lateral femoral wall on the pre-operative radiograph should be a major factor in determining the internal fixation device used for fracture stabilization.3 Gotrified in retrospective analysis of 24 intertrochanteric fractures fixed with dynamic hip screw found that fractured lateral femoral wall was the cause of re-operations.4 The ideal method of fixation of unstable fractures associated with the fracture of lateral femoral wall and those fractures type which are vulnerable for fracture of lateral femoral during surgery is still not clearly defined. Although reports are available in the literature demonstrating inferior outcomes with dynamic hip screw in this subgroup of intertrochanteric fractures, the ideal fixation device is a matter of debate and the current trend is towards using an intramedullary device to fix these fractures. The aim of the present study is to evaluate the outcome of proximal femoral nail in unstable intertrochanteric fractures in terms of low rates of complications and re-operation rate.
V Kochar, MBBS A Pankaj, MS DNB MRCS (Ed) M Chadha, MS S Arora, MS DNB
Abstract The ideal method of fixation of intertrochanteric fractures of femur associated with compromised lateral femoral wall is still not clearly defined. The aim of the present study is to evaluate the outcome of proximal femoral nail in unstable intertrochanteric fractures with compromised lateral femoral wall in terms of low rate of complications and re-operation. Twenty-four consecutive patients who had sustained an unstable intertrochanteric fracture according to AO/OTA classification were operated with proximal femoral nail under image intensifier by a single surgeon within a week of sustaining trauma and were followed clinically and radiologically for at least 6 months. Twenty-three patients were available for follow-up after 24 weeks. One patient died due to effects of prolonged immobilization 2 months postoperative as the patient wasn’t able to bear weight on affected extremity due to screw cut-out and subsequent varus collapse in immediate postoperative period. There was a mean limb length shortening of 4.29 mm. In 19 of 23 (approx 83%) patients the shortening was less than 10 mm. Four of 24 patients (16%) had developed postoperative complications but none of the patients were re-operated during the subsequent follow-up of 6 months. Proximal femoral nail provides a good outcome in intertrochanteric fractures of the hip with fractured or compromised lateral femoral wall with an acceptable rate of technical difficulties and complications.
MATERIALS AND METHODS Twenty-four consecutive patients who had sustained an unstable intertrochanteric fracture according to AO/OTA classification7 (Figure 1) were selected for the study and informed consent obtained from all. All cases were operated within the first week of sustaining trauma after stabilizing the patient and obtaining pre-anesthetic clearance. All cases were operated by a single surgeon (AP). Proximal femoral nail (SSEPL, Vadodara, India), in stainless steel and for left and right use, 240 mm long, the distal part of which is available in 10, 11 or 12 mm diameter was used. There is a valgus of 6° about 11 cm below the nail and 2 screws of 8 mm diameter can be inserted into the femoral neck. Distally the tip is shaped to reduce stress concentration. Distal locking can be done in static and dynamic modes with 5 mm locking bolt (Figure 2). Prophylactic intravenous antibiotics (ceftriaxone and amikacin) were given just before induction of anesthesia, followed
Keywords Intertrochanteric fracture, lateral femoral wall, proximal femoral nail
Department of Orthopedics, University College of Medical Sciences and GTB Hospital, Delhi, India. Correspondence: Dr. Amite Pankaj, Associate Professor, Department of Orthopedics, University College of Medical Sciences and GTB Hospital, Delhi, India. Ph: +011-22692520. E-mail: [email protected] JCOT Vol 1 No 2
99
Kochar, et al
A1
.1
.2
.3
A2
.1
.2
.3
A3
.1
.2
.3
Figure 1 AO/OTA classification for intertrochanteric fractures. AO fractures A1.1–A2.1 are commonly described as stable, and fractures A2.2–A3.3 usually are unstable and have fractured or compromised lateral femoral wall.
Figure 2 Proximal femoral nail.
observer (VK). Walking ability was analyzed using Parkar and Palmar mobility score8 (Table 1). Radiological assessment of the hip was done at 6, 12, and 24 weeks to look for fracture union, neck shaft angle and any signs of implant failure.
A1: Simple (2-fragment) pertrochanteric area fractures A1.1. Fractures along the intertrochanteric line A1.2. Fractures through the greater trochanter A1.3. Fractures below the lesser trochanter
RESULTS
A2: Multifragmentary pertrochanteric fractures A2.1. With one intermediate fragment (lesser trochanter detachment) A2.2. With 2 intermediate fragments A2.3. With more than 2 intermediate fragments
The average age of the study group was 54.7 years (range 22–79 years). The male to female ratio was found to be 1.5:1. The mechanism of injury was a low-impact injury in 67% cases. Fractures were classified as 31 A2.2 and A2.3 (approximately 71%) patients and A3 type in rest of patients. The pre-operative mean Parkar and Palmar mobility score was 8.47 ± 0.46. The mean duration of surgery was 65.1 minutes (range 45–98 minutes) and mean blood loss during surgery was 152 ml. Intra-operative technical problems were encountered in one patient. There was difficulty in the insertion of the proximal screw with only one screw in the head and neck fragment. Median length of lag screw was 100 mm. In 87.5% cases the tip of lag screw was central or inferior in AP view and central in lateral view (Figure 4). Twenty-three patients were available for follow-up at 24 weeks. One patient died due to effects of prolonged immobilization at 2 months postoperative as the patient wasn’t able to bear weight on affected extremity due to screw cutout and subsequent varus collapse in immediate postoperative period (Figure 5). There was a mean limb length shortening of 4.29 mm. In 19 of 23 (approx 83%) patients the shortening was less than 10 mm. The mean Parkar and Palmar score at 24 weeks was 8.05 (95% of pre-operative score) which shows that at 6 months most of the patients had regained their pre-trauma status. Four of 24 patients (16%) had developed postoperative complications but none of the patient was re-operated during the subsequent follow-up of 6 months. One case had superficial infection of proximal locking site at 4 months post-surgery which was managed with incision and drainage under local anesthesia and oral antibiotics. One case had screw cut through leading
A3: Intertrochanteric fractures A3.1. Simple, oblique A3.2. Simple, transverse A3.3. With a medial fragment
by two doses in postoperative period. The fracture was reduced under image intensifier with the patient on fracture table. The entry point was made with a guide pin (Figure 3) and confirmed on anteroposterior and lateral projections. The entry hole was enlarged with a powered reamer and a ball tip guide wire was inserted. Sequential reaming was done either with hand or power reamers. Nail was inserted and proximal and distal locking was done. Anteroposterior and lateral views of the operated hip were done on the first postoperative day. The patient was allowed to sit up in bed the day after surgery, and active exercises of the operated hip and knee were begun. Patients were observed for presence of deep vein thrombosis (DVT) and any other medical complications. Supportive medical treatment was instituted as per requirements of the patient. Patients were encouraged to walk with support as soon as the pain was tolerable and weight bearing was tolerable. Sutures were removed on the 14th postoperative day. All the patients were followed for a minimum duration of 6 months and evaluated by a standard protocol by a single JCOT Vol 1 No 2
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Results of proximal femoral nail in intertrochanteric fractures of the hip with compromised lateral femoral wall: a clinical outcome study
Figure 3 Images taken during surgery.
Superior Table 1 Parker and Palmer mobility score. Walking ability
No Alone with With help difficulty an assistive from another device person Able to walk inside house 3 2 1 Able to walk outside house 3 2 1 Able to go shopping, 3 2 1 to a restaurant, or to visit family
Not at all 0 0 0
Anterior
1
1
1
21
Posterior
The values are given as the number of points assigned for that answer. The maximum possible score is 9 points.
Inferior Figure 4 Position of the lag screw in the femoral head.
A
B
C
Figure 5 (A) 70-year-old female with AO type 31 A2.2 fracture of right femur. (B), (C)—postoperative X-rays showing screw cut-out and varus collapse.
time and with minimal complications. The operative treatment of intertrochanteric fractures has been a matter of debate and a number of fixation devices have been used with varying degrees of success. A Dynamic Hip Screw is the most commonly used implant for intertrochanteric fractures.9–11 Load bearing in the proximal femur is predominantly through calcar femorale, the lever arm of laterally placed plate is increased so there is a risk of implant cutout1,12 (Figure 7). Biomechanically compared to a laterally fixed side plate, an intramedullary device decreases the bending force of the
to varus collapse immediately after surgery and the patient died at 2 months postoperatively. Two patients had delayed union which united without intervention at 8 months post-surgery (Figure 6).
DISCUSSION Intertrochanteric fracture of femur has always been recognized as a major challenge not only for achieving fracture union, but also for restoration of optimal function in the shortest possible JCOT Vol 1 No 2
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Kochar, et al
A
B
C
Figure 6 (A) 48-year-old male with AO type 31 A2.2 fracture of right femur. (B), (C)—fracture union and maintained neck shaft angle at 6 months follow-up.
hip joint on implant by 25–30%. This has advantages especially in elderly patients, in whom the primary treatment goal is immediate full-weight bearing mobilization. So, now the intramedullary screw devices are gaining popularity for stabilizing intertrochanteric fractures.13 A search of the review groups of the Cochrane library for the ideal implant in intertrochanteric fractures still favors the use of sliding hip screw over intramedullary implants.14,15 Also reviews of various other meta-analysis also were in favor of sliding hip screw.13,16,17 This was predominantly due to risk of femoral shaft fracture associated with earlier version of gamma nail9,10 and complications due to steep learning curve associated with the implant. But, with the advent of proximal femoral nail the complications associated with gamma nail have been reduced and results of proximal femoral nail in treatment of intertrochanteric fractures are comparable or even better than dynamic hip screw especially in unstable intertrochanteric fractures.18,19 Traditionally it was the posteromedial comminution which was considered the most important factor in determining the severity of fracture. The importance of the integrity of the lateral femoral wall has been documented recently.3,4,6 The lateral wall is the proximal extension of the femoral shaft. This lateral wall is extremely thin in unstable 31 A2 type fracture.3,4 The lateral wall in patients treated with dynamic hip screw provides a lateral buttress for the controlled fracture impaction and preventing collapse. Palm et al3 found that there was an eight times higher risk of re-operation due to technical failure with the gold standard technique of dynamic hip screw in patients with fracture of the lateral femoral wall. This has been attributed to the fact that when the lateral femoral wall is fractured, the fracture line is parallel to the sliding vector of the sliding hip screw, which, as in the reverse oblique intertrochanteric fracture, allows the trochanteric and femoral head and neck fragments to slide laterally and the shaft to slide medially. The fracture complex subsequently disintegrates, with a high risk of failure including cut-out of the screw into the hip joint. Another fact is that most of the fractures of the lateral femoral wall occur intra-operatively with the gold standard technique when the large diameter hole is drilled into the lateral femoral wall, thereby converting a 31 A2 type to 31 A3 type. Gotfried4 in JCOT Vol 1 No 2
D d
D>d
Figure 7 Decreased lever arm of intramedullary nail.
a retrospective analysis of 24 patients with documented postoperative fracture collapse and their findings showed unequivocally that in all patients, this complication followed fracture of the lateral wall and resulted in protracted period of disability until fracture healing. The importance of the integrity of the lateral wall for event-free fracture healing clearly is indicated, and fracture of the lateral wall should be avoided in any fixation procedure. Palm et al3 have recommended dividing the fractures into two categories: A1–A2.1 & A2.2–A3, and not just into A1, A2, and A3 fracture types as has been reported in most studies taking into account the integrity of lateral femoral wall. This has implication on treatment guideline that the dynamic hip screw is not a good implant in patients falling into the second category. In the series by Gotfried,4 lateral wall fracture occurred in one third of the hips with the most vulnerable lateral femoral wall i.e., in those with an AO/OTA A2.2 or A2.3 fracture, which lacks buttress support of the greater trochanter. Intramedullary nails are associated with less shortening and less sliding of the lag screw. This is due to the fact that intramedullary nail stops the telescoping displacement of the proximal aspect of the femur.20 In fact, the proximal part of the nail blocks 102
Results of proximal femoral nail in intertrochanteric fractures of the hip with compromised lateral femoral wall: a clinical outcome study
the head-and-neck fragment, preventing its complete impaction. Hardy et al,20 in a randomized study of 100 patients with an intertrochanteric fracture, found less limb shortening in the group treated with an intramedullary hip screw than in those treated with a dynamic hip-screw, especially in unstable intertrochanteric fracture. In unstable fractures with compromised femoral wall, a modification of dynamic hip screw with trochanteric stabilizing plate has been used in order to provide lateral buttress and limit excessive collapse of the trochanter and head and neck fragment but still achieving controlled impaction of the fragment. But the disadvantages are that it adds to surgical time, blood loss, and amount of dissection needed.21 Another implant which is used in intertrochanteric fractures is 95° dynamic condylar screw. Haidukewych et al5 in a retrospective analysis of 47 patients with reverse oblique type of intertrochanteric fractures concluded that 95° fixed-angle internal fixation devices performed significantly better than did dynamic hip screws. Dynamic condylar screw in intertrochanteric fractures doesn’t cause any sliding of the lag screw and it is used like a neutralization plate. But Sadowski et al22 in a randomized, prospective study comparing proximal femoral nail (PFN) with dynamic condylar screw (DCS) in treatment of the reverse oblique and transverse intertrochanteric fractures supported the use of an intramedullary nail rather than a 95° screw-plate for the fixation of reverse oblique and transverse intertrochanteric fractures in elderly patients. The results of our study regarding fixation of intertrochanteric fractures with lateral cortical breech (31 A3 type fracture) and those with extremely thin lateral cortex (31 A2.2 and A2.3) are highly encouraging with shortening of less than 1 cm in (approximately 75%) patients and close to 95% return of pre-injury mobility. The role of proximal femoral locking plate in intertrochanteric fractures is also coming up with fixation of fractures by minimally invasive techniques. We agree with Palm et al3 that while awaiting larger randomized studies of other implants, we recommend treating simple intertrochanteric fractures (A1–A2.1) with a sliding hip screw fixed to a side-plate and treating more complex intertrochanteric fractures (A2.2–A3) with a sliding hip screw fixed to an intramedullary nail. The results of fixation of intertrochanteric fractures with compromised lateral femoral wall with the gold standard dynamic hip screw are associated with high rates of complications. Newer implants such as proximal femoral nail, trochanteric stabilizing plate, and proximal femoral locking plates are being investigated with increasing frequency whether they can provide superior biomechanical stability and clinical outcome. Although a large randomly controlled trial with adequate statistical power is desirable to substantiate/negate the superiority of one implant over the other, our clinical series has validated the fact that proximal femoral nail is a suitable implant for these type of fractures where lateral femoral wall is compromised with good clinical outcome and an acceptable rate of technical complications. JCOT Vol 1 No 2
We affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript. There is no conflict of interest. ♦
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