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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 245-248

Difficulties encountered during fixation of trochanteric fractures with proximal femoral nailing: A prospective analysis of 200 cases at a tertiary care centre in North-West India


1 Department of Orthopaedics, Dr. R.P.G.M.C., Tanda, Himachal Pradesh, India
2 Department of Community Medicine, Dr. R.P.G.M.C., Tanda, Himachal Pradesh, India

Date of Submission29-Nov-2020
Date of Acceptance28-Jan-2022
Date of Web Publication15-Sep-2022

Correspondence Address:
Dr. Sunil Kumar Raina
Department of Community Medicine, Dr. R.P.G.M.C., Tanda, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aihb.aihb_139_20

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  Abstract 


Introduction: Proximal femoral nailing (PFN) compares favourably with dynamic hip screw in terms of surgical time, intra-operative blood loss and lag screw cut out in unstable inter-trochanteric fracture. However, data on difficulties faced during the fixation process are lacking. Therefore, the study was planned with the aim to identify difficulties encountered during fixation of trochanteric fractures with PFN in the patients. Materials and Methods: Two hundred patients with trochanteric fractures aimed for the operative procedure with PFN were included in the study. Patients with associated fracture of neck of femur, the shaft of the femur of the same side, with polytrauma, with multiple fractures, with pathological fractures and/or unwilling to participate in the study were excluded. Bone mineral density was evaluated using Singh's index. Fixation of trochanteric fractures was done using PFN. Results: More than 70% of the study participants were elderly, 53% of the participants were males, while 91% of the total participants belonged to a rural region. Hypertension was the most common comorbidity in 21% of the patients, followed by anaemia (14.5%) and diabetes (9%). 73% of the patients had grade 3 Singh's index. 53.5% of the patients had intra-trochanteric left femur while the remaining 46.5% of the patients had intra-trochanteric right femur. The reduction was the most common difficulty (26%) followed by entry point difficulty (21%) and guidewire passage (12.5%). No difficulty was observed in 29% of the patients. Conclusion: Achievement of good reduction between two main fragments without varus malalignment and placement of hip screw in a correct position are two important technical aspects that prevent most of the complications associated with these procedures.

Keywords: Proximal femoral nail, reduction, trochanteric fractures


How to cite this article:
Thakur L, Dua S, Raina SK, Awasthi B. Difficulties encountered during fixation of trochanteric fractures with proximal femoral nailing: A prospective analysis of 200 cases at a tertiary care centre in North-West India. Adv Hum Biol 2022;12:245-8

How to cite this URL:
Thakur L, Dua S, Raina SK, Awasthi B. Difficulties encountered during fixation of trochanteric fractures with proximal femoral nailing: A prospective analysis of 200 cases at a tertiary care centre in North-West India. Adv Hum Biol [serial online] 2022 [cited 2022 Dec 1];12:245-8. Available from: https://www.aihbonline.com/text.asp?2022/12/3/245/356104




  Introduction Top


Trochanteric fractures are one of the most common fractures seen in clinical practice among the elderly.[1],[2] The increase in the average life expectancy across the world has seen a further increase in these.[3] The cornerstone of managing such fractures included an early mobilisation of these patients. This makes surgical stabilisation of these fractures a preferred choice of intervention.[3],[4] Different modalities have been adopted in the past, with 'sliding hip screw device with a slide plate' remaining the gold standard for long.[3],[5] Despite this being a favourite, blood loss, increased time of surgery and anaesthetic procedures associated with this procedure often made clinicians look for alternatives. The reduction and healing are though acceptable, the results have not been favourable in unstable fractures. In addition, many of the patients continue to remain confined to the home and have significant shortening due to excessive collapse in unstable fractures. These adverse remarks “biomechanically more stable, the intramedullary device” made a popular option in trochanteric fractures.

The uses of intramedullary devices have also been realised to be associated with some difficulties. These difficulties may be related to the geometry of the fracture, technique of reduction, the nature of the implant itself or surgical procedures performed. Authors in the past have studied these difficulties.[6] The authors have found out that proximal femoral nailing (PFN) compares favourably with dynamic hip screw (DHS) in terms of surgical time, intra-operative blood loss and lag screw cut out in unstable inter-trochanteric fracture.

A study conducted by Janardhana and Rao in 2013 published an interesting report on this. It stated that reaming the proximal part of the femur adequately and observing the nail passage with the image are important in placing the nail correctly, while the placement of lag screw in the inferior part of the neck in anterior, posterior projection, and central in lateral projection is helpful in reducing the risk of implant failure.[7] An extensive search on PubMed reveals a paucity of data, indicating difficulties during fixation of trochanteric fractures with PFN. Hence, this study was thus aimed at understanding the difficulties encountered during fixation of trochanteric fractures with PFN in the patients attending a tertiary care centre in North-West India.


  Patients and Methods Top


This prospective study was conducted over a period of 1 year from November 2017 through October 2018 in the department of orthopaedics in a tertiary care setup in North-West India. The study was approved by the institutional ethics committee vide registration no: ECR/866/Rajendra/Inst/HP/2013-Re-Registration-2016 dated 12 November 2018.

Patients with trochanteric fractures aimed for the operative procedure with PFN were included. Patients with associated fracture of neck of femur, the shaft of the femur of the same side, with polytrauma, with multiple fractures, with pathological fractures and/or unwilling to participate in the study were excluded.

Each participant was examined clinic-radiologically. The bone mineral density of the participants was evaluated using Singh's index. The Singh's index is based on the radiological appearance of the trabecular bone structure of the proximal femur on a plain radiograph (grade 6: all the normal trabecular groups are visible, and the upper end of the femur seems completely occupied by cancellous bone; grade 5: the structure of principal tensile and principal compressive trabeculae is accentuated. Ward's triangle appears prominent; grade 4: principal tensile trabeculae are markedly reduced in number but can still be traced from the lateral cortex to the upper part of the femoral neck; grade 3: there is a break in the continuity of the principal tensile trabeculae; grade 2: only the principal compressive trabeculae stands out prominently, the others have been more or less completely resorbed and grade 1: even the principal compressive trabeculae are markedly reduced in number and are no longer prominent).

The surgery was conducted by a single consultant, with the senior resident/junior residents being the assistants. The patient was placed on the fracture table after the anaesthesia (regional/general anaesthesia). Then, the fracture was reduced and confirmed with C-arm, the entry point made with an awl and confirmed with C-arm and the guidewire was passed under C-arm guidance. Then, sequential reaming was done under C-arm guidance. Then, nail was inserted, fixation was done with a lag screw and de-rotational screw and distal screw were passed under C-arm guidance.

Data were presented as frequency, percentages, mean, and standard deviation. Student's t-test was used to compare quantitative variables between two groups. Categorical variables were compared using the Chi-square test. P < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS v21 (IBM, Armonk, New York).


  Results Top


Two hundred patients with trochanteric fractures were included in the study. More than 70% of the patients were elderly, and 53% of the participants were males. The majority (91%) of the participants belonged to a rural region. Among urban, 50% were from the upper-middle class, and among rural patients, 58% were from the middle class [Table 1]. Among the study subjects, hypertension was the most common comorbidity in 21% of patients, followed by anaemia (14.5%) and diabetes (9%). Sixty-nine patients had no comorbidity. Fractures were classified using AO classification. Forty-two per cent of fractures were type 31A2.2, followed by 31A3.1. Seventy-three patients had grade 3 Singh's index, followed by 23.5% patients with grade 2 fracture. In this study, 97.5% of the patients were mobile without support pre-operatively, while 2% of patients were mobile with support. One patient was not mobile. In our study, 53.5% of the patients had intra-trochanteric left femur, while the remaining 46.5% of the patients had intra-trochanteric right femur. The reduction was the most common difficulty (26%) followed by entry point (21) and guidewire passage (12.5). No difficulty was observed in 29% of the patients [Table 2]. [Table 3] gives the distribution of socio-demographic characteristics on the basis of difficulty encountered (n = 200). Socio-demography does not seem to play a significant role in the difficulties encountered during surgery. [Table 4] shows a comparison of pre-operative mobility status of the patients in which difficulties encountered and patients in which no difficulties encountered. Our study observed that pre-operative mobility status was not found to be statistically significant (P = 0.351). Hypertension was the most common comorbidity in 22 patients (with no difficulty) and anaemia in the patients with difficulty [Table 5]. In our study, out of 142 patients in whom intra-operative difficulties were encountered, 88 patients had severe osteoporosis. However, the severity of osteoporosis was not associated with intra-operative difficulty [Table 6].
Table 1: Socio-demographic characteristics of the study participants (n=200)

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Table 2: Intra-operative difficulty encountered (n=200)

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Table 3: Distribution of socio-demographic characterstics on the basis of difficulty encountered (n=200)

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Table 4: Pre-operative mobility status as cause of difficulty encountered (n=200)

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Table 5: Comorbidity as cause of difficulty encountered (n=200)

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Table 6: Association between osteoporosis (Singh's Index) and Intra-operative Difficulty Encountered

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  Discussion Top


PFN is a surgical procedure involving an intramedullary device. The procedure has been realised to have advantages such as decreasing the moment arm. In addition, the procedure can be performed by closed technique. This is known to preserve the fracture hematoma. This is an important consideration for fracture healing. It is also known to decrease blood loss, decrease infection risk, minimise soft tissue dissection and minimise wound-related complications.[8] The PFN system offers major biomechanical innovations.[9] The advantage of this procedure is that due to its position close to the weight-bearing axis, the stress generated on the intramedullary implants is negligible. The PFN implant also acts as a buttress in preventing the medialisation of the shaft. Probably, an important aspect of this procedure gaining more acceptance among surgeons is that the entry portal of the PFN through the trochanter limits the surgical insult to the tendinous hip abductor musculature, only, unlike those nails which require entry through the pyriformis fossa.[10]

As far as the difficulties encountered were concerned, reduction, entry point and guidewire passage were the most common difficulties observed in our study. As per our study, in 58 of our patients, we had difficulty in reduction, most of which were due to flexion of the proximal fragment (lateral view). In that cases, we used the lever to extend the proximal fragment and align the fragments and checked under C-arm in both anteroposterior and lateral views.

Generally, the standard entry point for PFN is the tip of the greater trochanter. However, it is not the thumb rule. In one of the patients in our study, there was comminution around the greater trochanter tip. We observed that when we made entry at the tip of the greater trochanter in this patient, bone awl straight away went into the fracture site. When we put guidewire through an entry point in the same patient, the guidewire went accurately on C-arm; however, when we started reaming, reamers and the nail got lateralised and fracture went into varus.

Another problem noticed by us in our study was related to loss of reduction. In this situation at the start, the reduction was found to be satisfactory. However, when the nail was put, the fracture got distracted. In two cases, we faced the problem of breakage of the guidewire of the lag screw. In one case, it was in the joint, which was confirmed by computed tomography scan after surgery, and a broken piece of the guide wire was removed by arthrotomy.

We also observed that instrumentations such as zig, sleeves, guide wires, reamers and screwdrivers should be available in adequate numbers. During our study faced a problem with one of our patients. While we were putting a lag screw, accidentally, the outer sleeve of the lag screw fell down. There was no second outer sleeve for the lag screw.

A review of the literature reveals that most PFN failures are associated with faulty techniques, such as failure to reduce properly and failure to anticipate nail touching anterior cortex while hammering. A study by Pajarinen et al.[4] comparing dynamic hip screw and proximal femoral nail found that the use of PFN has a positive effect on the speed of restoration of walking, mainly due to restoration of near-normal anatomy. Similar studies by Al-Yassari et al.[11] and Simmermacher et al.[12] also observed restoration of pre-operative mobility in approximately 40%–50% of the patients treated with PFN. The Pajarinen et al.'s study was of the view that early walking ability in PFN is due to better anatomical restoration in comparison to DHS, where there is greater impaction or fracture, leading to shortening of the femoral neck.[4]


  Conclusion Top


The authors believe that achieving a good reduction between two main fragments without varus malalignment and placement of hip screw in a correct position are two important technical aspects that will prevent most of the complications associated with these procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marks R. Hip fracture epidemiological trends, outcomes, and risk factors, 1970-2009. Int J Gen Med 2010;3:1-17.  Back to cited text no. 1
    
2.
Chang KP, Center JR, Nguyen TV, Eisman JA. Incidence of hip and other osteoporotic fractures in elderly men and women: Dubbo osteoporosis epidemiology study. J Bone Miner Res 2004;19:532-6.  Back to cited text no. 2
    
3.
Saudan M, Lübbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer P. Pertrochanteric fractures: Is there an advantage to an intramedullary nail?: A randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma 2002;16:386-93.  Back to cited text no. 3
    
4.
Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br 2005;87:76-81.  Back to cited text no. 4
    
5.
Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br 1949;31B: 190-203.  Back to cited text no. 5
    
6.
Gadegone WM, Salphale YS. Proximal femoral nail – An analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop 2007;31:403-8.  Back to cited text no. 6
    
7.
Janardhana AP, Rao S. Proximal femoral nailing: Technical difficulties and results in trochanteric fractures. Open J Orthop 2013;3:234-42.  Back to cited text no. 7
    
8.
Kalliguddi S, Jawali V, Reneesh UP. Proximal femoral nail in the mangement of peritrochanteric fractures femur and its functional outcome. Int J Res Pharm Biomed Sci 2013;4:1276-86.  Back to cited text no. 8
    
9.
Korkmaz MF, Erdem MN, Disli Z, Selcuk EB, Karakaplan M, Gogus A. Outcomes of trochanteric femoral fractures treated with proximal femoral nail: An analysis of 100 consecutive cases. Clin Interv Aging 2014;9:569-74.  Back to cited text no. 9
    
10.
Menezes DF, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop Relat Res 2005;439:221-7.  Back to cited text no. 10
    
11.
Al-yassari G, Langstaff RJ, Jones JW, Al-Lami M. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury 2002;33:395-9.  Back to cited text no. 11
    
12.
Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): A new device for the treatment of unstable proximal femoral fractures. Injury 1999;30:327-32.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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