Scholarly article on topic 'Treatment options for unstable trochanteric fractures: Screw or helical proximal femoral nail'

Treatment options for unstable trochanteric fractures: Screw or helical proximal femoral nail Academic research paper on "Clinical medicine"

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Abstract of research paper on Clinical medicine, author of scientific article — Jeetendra Bajpai, Rajesh Maheshwari, Akansha Bajpai, Sumit Saini

Abstract Purpose To compare treatment outcome of screw proximal femoral nail (PFN) system with that of a helical PFN. Methods The study included 77 patients with closed unstable intertrochanteric fracture classified as AO 31A2 & 31A3, between June 2008 to August 2011. Inclusion criteria were: all mature skeletons above 50 years of age; closed unstable trochanteric fracture classified as AO 31A2 & A3. Exclusion criteria were: immature skeleton, pathological fracture of any cause other than osteoporosis, inability to walk independently prior to injury. Patients were randomized to 2 treatment groups based on admission sequence. Forty patients were treated with screw PFN and thirty seven were treated with helical PFN. Results Both groups were similar in respect of time of surgery, blood loss and functional assessment and duration of hospitalization. In screw PFN group 2 patients had superficial wound infection, 1 patient had persistent hip pain and 1 patient had shortening >1 cm but <2 cm, while in helical PFN group 1 patient had superficial wound infection. Conclusion Both screw and helical PFN are very effective implants in osteoporotic and unstable trochanteric fractures even in Indian patients where the bones are narrow and neck diameter is small. It is an implant of choice for osteoporotic and unstable trochanteric fractures.

Academic research paper on topic "Treatment options for unstable trochanteric fractures: Screw or helical proximal femoral nail"

Chinese Journal of Traumatology Lv î L

vkr&s)

ELSEVIER journal homepage: http://www.elsevier.com/locate/CJTEE

Original article

Treatment options for unstable trochanteric fractures: Screw or helical proximal femoral nail

Jeetendra Bajpai a *, Rajesh Maheshwari a, Akansha Bajpai b, Sumit Saini a

a Department of Orthopaedics, Himalayan Institute of Medical Sciences, HIHT University, Jollygrant, Dehradun 248140, India b Department of Radiology, Himalayan Institute of Medical Sciences, HIHT University, Jollygrant, Dehradun 248140, India

ARTICLE INFO ABSTRACT

Purpose: To compare treatment outcome of screw proximal femoral nail (PFN) system with that of a helical PFN.

Methods: The study included 77 patients with closed unstable intertrochanteric fracture classified as AO 31A2 & 31A3, between June 2008 to August 2011. Inclusion criteria were: all mature skeletons above 50 years of age; closed unstable trochanteric fracture classified as AO 31A2 & A3. Exclusion criteria were: immature skeleton, pathological fracture of any cause other than osteoporosis, inability to walk independently prior to injury. Patients were randomized to 2 treatment groups based on admission sequence. Forty patients were treated with screw PFN and thirty seven were treated with helical PFN. Results: Both groups were similar in respect of time of surgery, blood loss and functional assessment and duration of hospitalization. In screw PFN group 2 patients had superficial wound infection, 1 patient had persistent hip pain and 1 patient had shortening >1 cm but <2 cm, while in helical PFN group 1 patient had superficial wound infection.

Conclusion: Both screw and helical PFN are very effective implants in osteoporotic and unstable trochanteric fractures even in Indian patients where the bones are narrow and neck diameter is small. It is an implant of choice for osteoporotic and unstable trochanteric fractures.

© 2015 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents lists available at ScienceDirect

Chinese Journal of Traumatology

journal homepage: http://www.elsevier.com/locate/CJTEE

Article history:

Received 19 July 2014

Received in revised form

1 March 2015

Accepted 19 March 2015

Available online 28 November 2015

Keywords:

Intertrochanteric fracture

Screws

1. Introduction

Population of senior citizens is increasing as longevity increases day by day.1 Hip fracture is the second most common cause of hospitalization for elderly patients.2 Ninety percent of inter-trochanteric fracture in elderly patients result from a simple fall and are a considerable burden to the health care system through their association with increased mortality and morbidity.3 The high prevalence of these fractures in the elderly is related to numerous factors, including osteoporosis, malnutrition, decreased physical activity, impaired vision, neurological impairment, poor balance, altered reflexes and muscular weakness.4 Hip fractures continue to be a major cause of mortality and disability among the elderly. It also causes loss of mobility and can significantly reduce patients'

* Corresponding author. Tel.: +91 8601666666. E-mail address: dr.jbajpaii@gmail.com (J. Bajpai).

Peer review under responsibility of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University.

quality of life. Factors that adversely affect mortality included advanced age, male sex, an intertrochanteric location of the fracture and the poor mobility before the fracture occurred.5 The goal of treating hip fracture is to return patient to their prefracture functional level, without long-term disability and avoiding medical complication.1 The introduction of sliding compression hip screw and side plate device till 1990 was considered the standard treatment for trochanteric fractures of femur for nearly 40 years and produced excellent results in stable fractures.6 The absence of medial support of lesser trochanter in the fracture area and dorsalmedial comminution in unstable fractures lead to implant failure, particularly cut-out and subsequent loss of reduction.7

Biomechanical studies have shown that intramedullary nail devices are more stable underload applied using a shorter lever arm and that excessive sliding is controllable.8

Thus, the goal of this study was to compare treatment outcomes achieved by a proximal femoral nail (PFN) screw system with those obtained using a PFN with a helical blade, and to determine the effectiveness of helical PFN in the treatment of intertrochanteric fractures.

http://dx.doi.org/10.1016/j.cjtee.2015.03.006

1008-1275/© 2015 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

2. Materials and methods

2.1. Patients

The prospective study include 77 patients with closed unstable intertrochanteric fracture classified as AO 31A2 & 31A3 was conducted in our institute, over a period of 24 months between June 2008 to August 2011 in patients having unstable trochanteric fractures of femur with minimum follow-up of 24 weeks and maximum follow-up of 2 year.

Inclusion criteria were: all mature skeleton above 50 years of age; new mobility score of 9 (palmer and parker 1993); closed unstable trochanteric fracture classified as AO 31A2 & A3.9 Exclusion criteria were: immature skeleton; pathological fracture of any cause other than osteoporosis, open fractures, inability to walk independently prior to injury event. Neurological and psychiatric disorders that would preclude assessment (eg, Parkinson disease, multiple sclerosis, severe depression).

Patients were included in the study after obtaining informed written consent. This study was approved by ethics committee at our hospital. Patients were randomized to 2 treatment groups based on admission sequence. Forty patients were treated with screw PFN (mean patients age, 69.1 years; men to female ratio, 1:2), and thirty seven were treated with helical PFN (mean patients age, 71.2 years; men to female ratio 9:28). There were 28 patients with 31A2 and 12 patients with 31A3 type in group treated with screw

PFN and 27 patients with 31A2 and 10 patients with 31A3 type in group treated with helical PFN.

2.2. Operation and postoperative management

Operation was performed on fracture table in supine position under general anesthesia. Closed reduction of fracture was confirmed by image intensifier. For both implants, the desired position of the lag screw was in the central femoral neck on the lateral view and in the central inferior femoral neck on the anteroposterior view, with the tip between 5 and 10 mm from the subchondral bone.10 Distal locking was performed with help of jig. Closure was done in layers. Blood loss was calculated with suction in drain substracting fluid used for irrigation and weight of sponge used.

Postoperatively patient was assessed for any postoperative complications. Crutch walking with partial weight bearing was allowed after 48 h/drain removal. Suture was removed on 12th day.

2.3. Follow-up

Patient was followed up at month 6, 12,18 and 24. They were assessed clinically and radiologically. Functional assessment was done after 18 months as per Harris Hip Score.11

Fig. 1. An unstable trochanteric case treated by helical PFN. A, B: Anteroposterior and lateral preoperative view; C, D: Anteroposterior and lateral films 6 weeks after operation; E, F: Anteroposterior and lateral films 24 weeks after operation showing union.

Fig. 2. An unstable trochanteric case treated by screw PFN. A, B: Anteroposterior and lateral preoperative view; C, D: Anteroposterior and lateral films 6 weeks after operation; E, F: Anteroposterior and lateral films 24 weeks after operation showing union.

2.4. Statistics

All continuous data are expressed as mean and ranges. Independent sample t test or Wilcoxon's rank sum test was used to analyze variables such as age, admission period, functional score, time to full weight bearing, time to union, and change in neck shaft angle. Categorical variables such as sex and AO classification were analyzed using Chi-square test or Fisher's exact test, as appropriate. SAS software (version 9.1.3, USA) was used for statistical analysis, and difference was considered to be statistical significant when p < 0.05.

3. Results

A total of 77 patients were included in this study. The operation time was defined from incision to skin closure and the two groups were similar in operation time (screw PFN, 85.91 min; helical blade PFN group 83.91 min; p = 0.43). The groups were also similar in amount of blood loss (415.12 ml in screw PFN group; 351.22 ml in helical proximal nail group; p = 0.21). The two groups were also similar in duration of hospitalization (17.12 days in screw PFN; 16.91 days in helical blade PFN group; p = 0.15) and time before operation (6.12 days in screw PFN; 5.90 days in helical blade PFN group; p = 0.04).

The functional assessment was done after fracture union which was statistically similar (helical PFN group 3.51 months, Fig. 1; screw PFN group 3.80 months, Figs. 2; p = 0.33) and functional assessment was done as per Harris Hip Score which was similar (screw PFN group 88.57; helical PFN group 88.73; p = 0.45, Table 1).

Complication rate in both groups were not serious: 2 patients in screw proximal group had superficial wound infection which was managed with antibiotics; 1 patient in screw proximal nail group had persistent hip pain and was managed with analgesics and 1 patient in screw proximal nail group had shortening >1 cm but <2 cm(1 cm—1.8 cm); 1 patient in helical PFN group had superficial wound infection which was managed with antibiotics after culture and sensitivity.

4. Discussion

Intertrochanteric fractures is one of the most common fractures of the hip especially in the elderly with porotic bone, usually due to low-energy trauma like simple falls. The incidence of inter-trochanteric fracture is rising because of increasing number of senior citizens with osteoporosis.3 The primary goal in the treatment in elderly patients with an intertrochanteric hip fracture is to return the patients to his prefracture activity level as soon as possible.12

Table 1

Comparison of clinical data.

Clinical data Screw PFN Helical blade PFN p value

Mean blood loss (ml) 415.12 (range 210-600) 351.22 (range 190-580) 0.21

Operation time (min) 85.91 (range 55-120) 83.91 (range 76-110 min) 0.43

Duration of hospitalization (d) 17.12 (range 10-32) 16.91 (range 11-28) 0.15

Time before operation (d) 6.12 (range 1-13) 5.90 (range 1-10) 0.04

Union (mon) 3.80 (range 3.0-4.5) 3.51 (range 3.2-4.0) 0.33

Harris hip score 88.57 88.73 0.45

Surgery is the treatment of choice for early mobilization and prompt return to prefracture functional level, as well as for reducing mortality and morbidity.13

Treatment of unstable trochanteric fracture with cepha-lomedullary implant or with extramedullary implant has been the topic of discussion for years together. Kim et al14 concluded in their study that unstable fractures with osteoporosis had a failure rate of more than 50% and in such cases dynamic hip screw should not be the first choice for treatment.

The rate of cut-out of the screw from the superior part of the femoral head and all those cases required revision surgery because of pain; the worst complication was 11% incidence of femoral shaft fractures which occurred with the Gamma nail.15

In 1996, the AO/ASIF developed the PFN as an intramedullary device. The PFN was designed to overcome some difficulties encountered with earlier design of intramedullary proximal nails. The main design difference PFN and other such devices are the introduction of an antirotation 6.5 mm neck screw, fluting of the nail tip which is said to decrease stress and finally the positioning of the distal locking screws more proximal than in some other devices hence avoiding abrupt changes in stiffness of the construct. It creates biomechanically stable construct allowing early weight

bearing.16

With cephomedullary implant it has advantage of shorter lever arm for the fixation device, and has less potential for the fracture collapse and limb shortening when used for unstable inter-trochanteric fracture.17

In the present study, postoperatively 2 (5%) patients had superficial wound infection in screw PFN group. Tyllianakis et al18 had similar finding, in their study they had 4.44% infection which is comparable to our study.

Gadegone and Salphale19 in their study had shortening in 10% of their patients which is comparable to our study. In cepha-lomedullary implant there was no telescoping reduction and less sliding because the proximal end of intramedullary nail was at the level of the of the greater trochanter. When telescoping of the lagscrew occurs the neck fragment abuts the intramedullary nail, thus preventing further collapse of the fracture, thus resulting in less subsequent shortening.20

Helical blade PFN has been introduced as an intramedullary option in recent years. Helical PFN is more suitable implant for unstable trochanteric fractures in elderly, osteoporotic patients population.21 The design of helical blade allows improve purchase in femoral head, which is accomplished by radial compaction of cancellous bone around the flanges of the blade during insertion. Biomechanically testing has demonstrated that the blade has significantly higher cut-out resistance than other commonly used screw system.22 Taken together, the helical blade showed higher rotation stability, but after a rotation its lower pull-out force demonstrates a higher degree of damage to femoral head.23 However, problems with helical PFN are being reported although it is an improvement of the screw PFN.24 Center—center position in head of femur of any kind of lag screw or blade is to be achieved to minimize rotation of the head of femur and to prevent further mechanical complication.25

In our study, complications like avascular necrosis, shaft fracture at tip of nail as mentioned by other authors were not found, as our follow-up was of short duration and it needs to be evaluated for longer duration but large enough to be statistically meaningful; despite 1 reported mild persistent hip pain and 1 reported superficial infection.

Our study indicates that both screw and helical blade PFN are very effective implants in osteoporotic and unstable trochanteric fractures even in Indian patients where the bones are narrow and neck diameter is small. Good reduction of the fracture, and optimal positioning and length of the hip pin and lag screw are crucial to avoid mechanical complication. Most important is to educate patients where patients are not enough educated in rural areas in developing countries. Results were same for both the groups and a long-term studies and a larger cohort are required to fully evaluate the performance of helical blade PFN, which is also costly as compared to screw PFN. It is an implant of choice for osteoporotic and unstable trochanteric fractures. Though this study is not big and it needs a longer and multicentre study to reach final conclusion, it is just an attempt to show how I experienced it in our set up.

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