Indian Journal of Orthopaedics Surgery 2019;5(4):239–242
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Indian Journal of Orthopaedics Surgery
Journal homepage: www.innovativepublication.com
Original Research Article
Proximal femoral nailing in the management of subtrochanteric fractures of femur
in adults
D Rama Rao1 , C Siva Rama Krishna1, *, Karthik Thota1 , T Jaya Chandra2
1 Dept. of Orthopedics, GSL Medical College, Rajahmundry, Andhra Pradesh, India
2 Dept. of Microbiology, Scientist inchrage, GSL Medical College, Rajahmundry, Andhra Pradesh, India
ARTICLE INFO
ABSTRACT
Article history:
Received 07-11-2019
Accepted 12-10-2019
Available online 06-01-2020
Introduction: The proximal femoral nail (PFN) used as an intramedullary device for the treatment of
fractures.
Objectives: Study was taken to analyse the union of the subtrochanteric fracture, internally fixed with
PFN.
Materials and Methods: Study was conducted in the department of orthopaedics, GSL Medical College.
Individuals with acute subtrochanteric femur fractures >18 years were included in the study. The patient
was positioned supine on the fracture table under spinal or epidural or general anesthesia as the condition
of the patient permitted. Pre-operatively one dose of antibiotic was also administered. The fracture was
reduced by longitudinal traction on fracture table and the limb was placed in neutral or slight adduction to
facilitate nail insertion through the greater trochanter ; P <0.05 was considered statistically significant.
Results: At the end of five months, all except three patients could mobilise independently; statistically
there was significant difference (P<0.05). Based on Harris Hip score obtained 3 patients outcome was
excellent, 18 patients were good and 4 patients had fair outcome.
Conclusion: Minimal exposure, better stability and early mobilization are the advantages with PFN.
Fractures united in all cases and postoperative functional outcome was satisfactory. PFN could be a
preferred implant of choice in treating subtrochanteric fractures especially in elderly.
Keywords:
Fracture
Femur
Operative
Subtrochanteric
© 2019 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND
license (https://creativecommons.org/licenses/by/4.0/)
1. Introduction
ically distinct from other proximal femoral peritrochanteric
fractures and also from the femoral shaft fractures. As a
result, it must be treated with specially designed implants
which can withstand significant muscular forces for longer
periods of healing. These stronger muscular forces deform
the fracture fragments and make reduction difficult and
as comminution is common in subtrochanteric region the
implant must withstand significant early loading.
Subtrochanteric fracture femur has been variously defined,
many authors limit the term to fractures between the lesser
trochanter and the isthmus of the diaphysis. 1
In the last 50 years, the treatment of subtrochanteric
femur fractures have evolved with increased understanding
of both the fracture biology and biomechanics. Previously,
nonsurgical treatment of these fractures were associated
not only with significant malrotation and shortening, but
also with morbidity and mortality associated with prolonged
immobilization.
The difficult nature of treating subtrochanteric fracture
stems in part from the fact that this injury pattern is anatom-
The combination of tensile, compression and torsional
stresses in the region has challenged orthopaedicians
with problems of delayed union and nonunion, and
resulting in loss of fixation, implant failure, and iatrogenic
devascularization of the operative exposure.
Only recently has a better understanding of fracture biology, reduction techniques, and biomechanically
improved implants has allowed subtrochanteric fractures to
* Corresponding author.
E-mail address: gslcentralresearchlab@gmail.com (C. S. R.
Krishna).
https://doi.org/10.18231/j.ijos.2019.047
2395-1354/© 2019 Innovative Publication, All rights reserved.
239
240
Rao et al. / Indian Journal of Orthopaedics Surgery 2019;5(4):239–242
be addressed with some success.
In 1996, the proximal femoral nail (PFN) was
developed, 2,3 used as an intramedullary device for the
treatment of such fractures. In addition to all advantages
of an intramedullary nail, it has several other favourable
characteristics like it can be dynamically locked, allows
early mobilization, has high rotational stability and is done
with minimal soft tissue damage. With this a study was
taken to analyse the union of the subtrochanteric fracture,
internally fixed with PFN.
2. Materials and Methods
Study was conducted in the department of orthopaedics,
GSL Medical College. Study protocol was approved by
the institutional ethics committee; informed written consent
was taken from the study participants.
Individuals with acute subtrochanteric femur fractures
>18 years were included in the study. Fractures in
patients below the age of 18 years, open fractures and
pathological subtrochanteric femur fractures were not
considered. All patients were maintained on traction before
surgery. All surgeries were done under spinal or epidural
anaesthesia. Low molecular weight heparin prophylaxis
was given subcutaneously for the high risk patients during
the hospitalization. The length of hospital stay, any
blood transfusions or hospital acquired complications were
recorded.
When the subtrochanteric fractures occurred because of
high energy trauma, polytrauma management dominates the
initial fracture treatment. The life-threatening conditions
must be adequately handled before managing the definitive
treatment of the subtrochanteric fracture. In severely
injured patients, the concept of damage control in the
acute management must be considered and practiced. Nonoperative treatment is only indicated in the paediatric age
group or in patients who are not fit for surgery under
anesthesia. With the advancement of anesthesia technology
and intraoperative monitoring, most of the patients can
undergo surgery with predictable outcomes. The closed
method follows the principle of anatomical realignment in
which deformities in length and rotation are corrected to
achieve a result that is as normal as possible. This procedure
is applied with closed reduction and internal fixation. 4 The
PFN was developed by AO/ASIF. The Indian versions are
available and have been used in our study. 2,3
The patient was positioned supine on the fracture table
under spinal or epidural or general anesthesia as the
condition of the patient permitted. Pre-operatively one
dose of antibiotic was also administered. The fracture was
reduced by longitudinal traction on fracture table and the
limb was placed in neutral or slight adduction to facilitate
nail insertion through the greater trochanter (Figure 2).
Prior to positioning and draping, the opposite extremity
measurements of rotation and length of this extremity were
determined. Post operative results were assessed by Harris
Hip score.
Statistical analyses were done by using SPSS software
version 21.0. Chi-square test was used to assess the
association between different categorical variables; P<0.05
was considered statistically significant.
3. Results
Total 25 patients were included in this study ; patients were
distributed across all age groups, one patient above the age
of seventy years (Table 1); 17 were male patients and 8
female patients (Figure 2).
The average duration of hospital stay was 17.64 days,
ranged 14 to 23 days. At the end of five months, except
three patients remaining could mobilize independently. One
patient with a contralateral intertrochanteric fracture was
using a Zimmer frame to mobilise. Two patients were
using crutches to mobilize up to six months postoperatively
(Table 2). statistically there was significant difference
(P<0.05). Based on Harris Hip score obtained 3 patients
outcome was excellent, 18 patients were good and 4 patients
had fair outcome (Table 3).
Fig. 1: Passing the screws
Table 1: Age distribution of the study participants; n (%)
Age
18 – 30
31 – 50
51 – 70
> 70
Total
Participants
7(28)
9(36)
8(32)
1(4)
25(100)
4. Discussion
In modern trauma care, there is no role of the conservative
treatment, as advocated by Delee et al. 5 The treatment
choices for femoral subtrochanteric fractures can be divided
into cepholomeduallary hip nails and lateral plate-screw
systems.
Rao et al. / Indian Journal of Orthopaedics Surgery 2019;5(4):239–242
Fig. 2: Gender distribution among the study participants
Table 2: Postoperative independence of ambulation; n (%)
Task
Walk
Independently
Crutch
Zimmer Frame
12
weeks
3(12)
20 weeks
24 weeks
22(88)
25(100)
12(48)
10(40)
2(8)
1(4)
Nil
Nil
P =0.000; statistically there was significant difference.
Table 3: Harris hip score results among the study participants; n
(%)
Results
Excellent
Fair
Good
Total
Participants
3(12)
4(16)
18(72)
25(100)
Fig. 3:
The dynamic compression hip screw has been a popular
method of internal fixation for subtrochanteric fractures of
the femur. 6,7 It provides compression along the femoral
neck, and if the fracture reduction is stable, load-sharing
occurs between the bone and implant. 8 But, if stable
reduction with postero medial continuity and compression is
not achieved, there will be progressive medial displacement
of the femoral shaft, which results in loss of bony contact
and fixation failure and nonunion. If medialization of more
than one-third of the femoral diameter at the fracture site
occurs there is sevenfold increase of failure rate. 9 The use
of intramedullary nail in peritrochanteric fractures has been
241
increasing, and more scholars choose it because it is easy
and fast to apply and can give stability even in inherently
unstable fractures. 10,11
The average length of Hospital stay was 17.6 days. At
the end of five months, all except three patients could
mobilise independently without any aid. One patient with
a contralateral Intertrochanteric fracture femur was using a
Zimmer frame to mobilise. Other two patients was using
a crutch to mobilise up to six months postoperatively. One
patient had a superficial infection at the surgical wound site
which subsided with parenteral antibiotics. None of the
cases needed a reoperation.
According to harris hip score and our assessment criteria
3 patients had excellent outcome, 18 patients had good
outcome and 4 patients had fair outcome. We feel that
the PFN is a better implant in treating subtrochanteric
fracture of femur. However, a comparative study with
the other implants would be appropriate to make definitive
conclusions.
Open reduction in irreducible fractures is described in
many papers. 80% of our cases reduction was possible
with closed method and only 20% cases we needed to
open to achieve length, rotation and satisfactory angulation.
While study conducted by Kanthimathi et al., has reported
that 78% are reduced by closed method and 22% by open
method. 12 May be this disparity is because of the sample
character differing in between the two studies.
Short PFN were used for the type 1a and 1b, 2a fractures
following B.F. Ongkiehong A et al., stating that minimum
distance between distal screw and fracture site should be
4 to 5 cm. 13 Rest of fracture types where comminution is
present and the fracture is at lower level long PFN used as
implant of choice.
Baumgaertner et al., described that the tip-to-apex
distance to be useful intraoperative indicator of deep and
central placement of the lag screw in the femoral head, to
fix the fracture. This is most important measurement of
accurate placement and has been shown in multiple studies
to be predictive of success. 14 In our study the lag screw
of the PFN placed in the lower part of the femoral neck,
close to the femoral calcar, with the screw tip reaching the
subchondral bone, 10 mm below the articular cartilage in
the AP view and In the lateral view placed in the centre
of the femoral neck keeping the tip apex distance within
acceptable limit of less than 25 mm. The derotation screw
10 mm shorter than lag screw was preferred in most studies.
In one case we could not pass the second screw because
of the small neck similar to the experience of Kamboi et al
this patient had progressed to radiological union but with
the development of screw back out and cut through almost
to the superior cortex. 15 One case derotation screw had
become longer and it has shown a z effect, cut through near
to superior cortex but ultimately progressed to union with
varus and shortening this patient had to be kept non weight
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Rao et al. / Indian Journal of Orthopaedics Surgery 2019;5(4):239–242
bearing for a prolonged time. In this case we followed the
regular recommendation of 10 mm lesser screw than lag
screw. Post operative radiograph showed that the derotation
screw is higher than the lag screw, when a horizontal line
drawn from the tip of lag screw. This indicates that not only
one should consider 10 mm shorter screw while selecting a
derotation screw but also that it should not be placed higher
than the lag screw when we draw a horizontal, which places
the derotation screw in weight bearing position instead of
lag screw.
The reduced fractures are fixed with stable internal
fixation to allow early mobilization. To facilitate fracture
healing, the technique of internal fixation must follow the
guidelines of minimizing the trauma to the soft tissues
and the osseous fragments. Plating of subtrochanteric
region through lateral a pproach of the proximal femur,
the vastus lateralis muscle must be split or elevated off the
intermuscular septum close to large perforating branches of
the profunda femoris artery. Division of these vessels causes
copious bleeding, making surgical exposure difficult. With
proximal femoral nail exposure of lateral aspect of femur is
minimal thus avoiding unnecessary blood loss and fracture
hematoma remains undisturbed in 80 % of cases which can
be reduced in closed manner which helps in hastening the
union of bone.
Average time for radiological union in our study is 19
weeks (4.8 months). Radiological union in other studies
was 19 weeks, 18 weeks and 12.6 weeks respectively by
Ashish et al., Prasad M.Gowda et al., and B Kanthimathi et
al., 12,16,17 Our results of achieving union in 19 weeks are
at par with the rest of the studies. Patients are encouraged
to sit and start quadriceps exercises, on the first post
operative day. On second post operative day, patients with
no comminution, transverse and short oblique fractures are
allowed to start partial weight bearing with walker support
and gradually converted to weight bearing as tolerated.
5. Conclusion
PFN is a good implant for subtrochanteric fracture of the
femur. Minimal exposure (closed technique), better stability
and early mobilization are the advantages. Fractures united
in all cases and postoperative functional outcome was
satisfactory. PFN could be a preferred implant of choice in
treating subtrochanteric fractures especially in elderly since
it allows early and stable mobilization. However, a larger
study may be desirable.
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Author biography
D Rama Rao Associate Professor
C Siva Rama Krishna Associate Professor
Karthik Thota Resident
6. Source of Funding
T Jaya Chandra Associate Professor
None.
7. Conflict of Interest
None.
Cite this article: Rao DR, Krishna CSR, Thota K, Chandra TJ.
Proximal femoral nailing in the management of subtrochanteric
fractures of femur in adults. Indian J Orthop Surg 2019;5(4):239-242.