The importance of intramedullary hip nail positioning during implantation for stable pertrochanteric fractures: biomechanical analysis (original) (raw)
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International Journal of Orthopaedics Sciences
Trochanteric femoral fractures are among the most common injuries necessitating hospital admission. Regardless the type of fracture, trochanteric fractures can lead to substantial morbidity and mortality, especially in elderly patients [1, 2]. Surgery is the mainstay of the treatment for both displaced and non displaced trochanteric fractures, to allow early mobilization of the patient, depending on the stability of the reduction and fixation achieved [4]. Dynamic Hip Screw [DHS] as extramedullary and Proximal Femoral Nail [PFN] as intramedullary systems are established and standard in treatment of trochanteric femoral fractures [5, 6]. Aim: To compare the results of Dynamic Hip Screw and Proximal Femoral Nail in the treatment of intertrochanteric fractures. Materials & Methods: In our study we compared DHS with PFN in a group of 60 patients admitted in a tertiary care hospital between August 2013-December 2016. Patients with intertrochanteric fractures without having concomitant shaft femur or neck femur fractures were included. The preoperative morbidity was evaluated using Parker's mobility scale. Salvati and Wilson's scoring helped in measuring overall functional outcome at 16 & 24 weeks between the two study groups. Results: The preoperative Parker's mobility scale was comparable between two study groups. Salvati and Wilson's score at 16 & 24 weeks was significantly better with PFN group. The functional outcome based on SWS score was Fair in 39% of patients operated with DHS at 16 weeks while for PFN it was Fair to Good in 79% of patients. At 24 weeks it was Fair to Good in 84% patients operated with DHS while in case of PFN the score was Fair to Good in 59% of the patients & Excellent in 38% of the patients. Conclusion: Our conclusion from this study supported the use of PFN for both stable and unstable pertrochanteric fractures over DHS due to its lesser operation time, lesser blood loss, early weight bearing, limited open reduction & better functional outcome.
Background: Hip fracture in elderly patients is a very devastating complication of osteoporosis and has serious complications leading to serious threat to patient?s mobility & social life and sometimes causing death. Aims &Objectives:To report outcome of 50 consecutive patients having unstable intertrochanteric fracture hip treated with a proximal femoral nail (PFN), a recently introduced cephalomedullary nail by AO. Materials &Methods:Total 50 patients sustaining unstable intertrochanteric fractures due to any cause, as classified by AO underwent proximal femoral nailing with a lag screw, and an anti rotational hip Screw during the period of August 2013 to January 2016.The most common fracture type was A2.2 (n=25), followed by A2.3 (n=15) and A3.1 (n=3) and A3.3(n=7) The position of the tip of lag screw within the femoral head was measured from the center of the head in AP and lateral views, intra operatively, post operatively and in follow ups.. The lateral slide of the lag screw after fracture consolidation was measured by comparing the immediate postoperative and final anteroposterior radiographs. Results:90% of lag screws were placed in an optimal position(i.e, inferiorly on AP view and centrally in lateral view) . The length of lateral slide leading to telescoping effect of the lag screw in A2.2 fractures was significantly less than that in A3.3 fractures which are highly communited suggesting that free sliding of the lag screw facilitates direct impaction between fragments. Discussion: Compared to laterally placed slide plates, PFN decreases the bending forces upto 25-30% and in comparison with previous intramedullary devices e.g gamma nails, it showed significant less cutout rates due to an additional antirotational hip screw, with more suitable biomechanical properties. Conclusion.A PFN is optimum implant for the treatment of unstable inter trochanteric fracture hip.
International Journal of Research in Orthopaedics, 2017
Trochanteric fractures are common in the elderly people. The frequency of these fractures has increased primarily due to the increasing life span and more sedentary life style brought on by urbanization. Trochanteric fractures occur in the younger population due to high velocity trauma, whereas in the elderly population it is most often due to trivial trauma. 1 Dynamic hip screws (DHS) have been considered as the standard fixation for extra-capsular femoral fracture and yielded good results in the patients with stable intertrochanteric fractures. 2,3 However, its value for ABSTRACT Background: Intertrochanteric fractures occur in people with poor bone quality, about half of the intertrochanteric fractures are comminuted and unstable. The purpose of the present study was to compare the outcome of surgical treatment of proximal femoral fracture by dynamic hip screw (DHS), proximal femoral nail (PFN) and proximal femoral locking compression plate (PFLCP). Methods: This prospective comparative observational study had included cases presented with intertrochanteric fractures of femur attended orthopedic OPD and emergency department were treated with dynamic hip screw (DHS), proximal femoral nailing (PFN) or proximal femoral locking compression plate. Post-operative x-rays were done to assess reduction and progress of union (non-union/mal-union), any post-operative complications e.g. operative wound infection, implant failure etc. Results: In our study, we found that PFNs prove to be more useful in difficult fractures with a subtrochanteric extension or reversed obliquity. The rotational stability was higher when proximal femoral nail is used in these fractures. The incidence of wound infection was found to be lower with intramedullary implants which resulted in early ambulation of the patients. Conclusions: In our study, we found that proximal femoral nails prove to be more useful in difficult fractures with a sub-trochanteric extension or reversed obliquity. The rotational stability was higher when PFN is used in these fractures. The incidence of wound infection was found to be lower with intramedullary implants which resulted in early ambulation of the patients. Non-union of trochanteric fracture although is a rare entity.
Indian Journal of Orthopaedics, 2015
Background: The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly people with osteoporosis. Although dynamic hip screw fixation is the gold standard for the treatment of stable intertrochanteric femur fractures, treatment of unstable intertrochanteric femur fractures still remains controversial. Intramedullary devices such as Gamma nail or proximal femoral nail and proximal anatomic femur plates are in use for the treatment of intertrochanteric femur fractures. There are still many investigations to find the optimal implant to treat these fractures with minimum complications. For this reason, we aimed to perform a biomechanical comparison of the proximal femoral nail and the locking proximal anatomic femoral plate in the treatment of unstable intertrochanteric fractures. Materials and Methods: Twenty synthetic, third generation human femur models, obtained for this purpose, were divided into two groups of 10 bones each. Femurs were provided as a standard representation of AO/Orthopedic Trauma Associationtype 31-A2 unstable fractures. Two types of implantations were inserted: the proximal femoral intramedullary nail in the first group and the locking anatomic femoral plate in the second group. Axial load was applied to the fracture models through the femoral head using a material testing machine, and the biomechanical properties of the implant types were compared. Result: Nail and plate models were locked distally at the same level. Axial steady load with a 5 mm/m velocity was applied through the mechanical axis of femur bone models. Axial loading in the proximal femoral intramedullary nail group was 1.78-fold greater compared to the plate group. All bones that had the plate applied were fractured in the portion containing the distal locking screw. Conclusion: The proximal femoral intramedullary nail provides more stability and allows for earlier weight bearing than the locking plate when used for the treatment of unstable intertrochanteric fractures of the femur. Clinicians should be cautious for early weight bearing with locking plate for unstable intertrochanteric femur fractures.
International Journal of Orthopaedics Sciences, 2017
Intertrochanteric fractures are those occurring in the region extending from the extra capsular basilar neck region to the region along the lesser trochanter. Due to an increasing life span and sedentary lifestyle the incidence of these fractures is on the rise. Also the geriatric age group has a higher incidence of osteoporosis, with low energy falls from standing height accounting for approximately 90% of the community hip fractures in patients more than 50 years of age, with a higher proportion in women. In intertrochanteric fracture, two types of implants are use for fixation. Extramedullary devices, example: Dynamic Hip Screw (DHS), Intramedullary devices, example: Proximal Femoral Nail (PFN).
Analysis of pertrochanteric fractures managed by intramedullary or extramedullary fixation
International Journal of Orthopaedics Sciences, 2020
Fractures of the proximal femur are relatively common fractures seen in elderly with trivial trauma. These fractures are associated with substantial morbidity and mortality. There are various forms of internal fixation devices used for peritrochanteric Fractures. The most commonly used device is the Dynamic Hip Screw with Side Plate assemblies. This is a collapsible fixation device, which permits the proximal fragment to collapse or settle on the fixation device, seeking its own position of stability. The latest implant for management of trochanteric fractures is proximal femoral nail, which is also a Centromedullary and collapsible device with added rotational stability. In view of these considerations, the present study of Surgical Management of peritrochanteric fractures was taken up. This prospective comparative present study was carried out in People's College of Medical Sciences and Research Centre, Bhopal from September 2011 to September 2013. The study consisted a total of 61 patients with pertrochanteric fractures of femur satisfying the inclusion criteria, who are treated with Proximal Femoral nail (30 cases) and Dynamic Hip Screw (31 cases). The advantage with Proximal femoral nail is that a smaller exposure, lesser blood loss, shorter operating time, shorter screening time and less morbidity. (minimizes the jeopardy to the vascularity). It gives a biomechanically sound fixation. In osteoporotic bones Proximal femoral nail fixation carries definitive advantage over Dynamic Hip Screw fixation devices. The incidence of wound infection was found to be lower with PFN which resulted in early ambulation of the patients and lesser duration of antibiotics. The screening time with the help of image intensifier was much lesser in the cases operated by PFN. The implant related complications were much lesser in the patients treated with Dynamic Hip Screw (DHS). However, the rate of union was similar in two groups. (PFN & DHS). Both the implants in their own right are excellent modalities in the management of pertrochanteric fractures of the femur.
Revista Brasileira de Ortopedia (English Edition)
Objective: To evaluate and compare the clinical and radiological outcomes of patients with stable intertrochanteric fractures treated with proximal femoral nail vs. dynamic hip screw. Methods: Sixty patients with stable intertrochanteric fractures, aged over 18 years, were randomly divided into the proximal femoral nail and dynamic hip screw groups. Dynamic hip screw with a three-hole side-plate and an anti-rotation screw were used, as well as a modified ultra-short proximal femoral nail for the smaller Asian population. The intra-operative, early and late complications were recorded, and the functional outcome of each group was assessed using the Harris Hip Score. Results: In the dynamic hip screw group, the one-month mean Harris Hip Score was slightly lower than that of the proximal femoral nail group. However, at the three-and six-month monthly follow-ups, the dynamic hip screw group presented higher mean scores than the proximal femoral nail group; at the one-year follow-up, both the groups attained similar scores. Conclusion: Proximal femoral nail provides a significantly shorter surgery with a smaller incision that leads to less wound-related complications. However, the incidence of technical errors was significantly higher in proximal femoral nail when compared with dynamic hip screw as it is a technically more demanding surgery that leads to more implant failures and the consequent re-operations.
Zenodo (CERN European Organization for Nuclear Research), 2022
Introduction: Although the effects of PFN and DHS in treatment of intertrochanteric fractures have been reported, and many studies have been done to compare both implants but the results and conclusions are not consistent and there is still ongoing controversy whether PFN is a better choice than DHS. Therefore, with the goals of better stable surgical construct of intertrochanteric fractures and early mobilization of patients, this study was planned with rationale to compare the intraoperative complications and functional and radiological outcome of intertrochanteric fractures in patients treated with dynamic hip screw and proximal femoral nail. Materials and Methods: This study was carried out in GMERS Medical College and General Hospital Gotri Vadodara from September 2020 to December 2021, consisting of total 50 patients of intertrochanteric factures of femur. This was a Randomized control prospective study. All the patients were operated by surgeons experienced in handling both implants. For evaluation, personal data, mode of trauma, type of fracture, type of surgery, intra operative & post operative complications, follow up examination and duration of full weight bearing were recorded. Results: Fracture reduction in stable fractures was good and comparable in both DHS (81.25%) And PFN (80%) groups but fracture reduction in unstable fractures was better in PFN group (73%). Mean duration of hospital stay was more in DHS group(7.2 days).Union occurred in all fractures in our study but there were two cases of shortening and varus malunion in unstable type in each DHS and PFN group. Mean duration of fracture union was earlier in PFN group, [15.56 weeks] comparing to DHS group [20.64weeks]. The duration of fracture union was more in unstable type compared to stable type in DHS group but it is nearly same in both type in PFN group. Mean HARRIS hip score was more in PFN group at 6 weeks after surgery. But it became nearly equal in both groups at 20 weeks period. Conclusion: PFN group had advantage of lesser blood loss, incision length, operative time and lesser hospital stay, Early weight bearing and early functional rehabilitation. DHS group had advantage of lesser intraoperative radiation exposure and lesser implant related intraoperative complication. Varus collapse and shortening in unstable fractures were more in DHS than PFN group but statistically insignificant. In stable fractures Both PFN and DHS are equally performing implant. But in unstable fractures PFN had edge over DHS with better functional outcome.