Fixation of intertrochanteric fractures of the femur by proximal femoral nail versus dynamic hip screw: a comparative study of 30 cases.
Treatment options for such fractures are operative as well as non-operative. Due to the bulky musculature attachment in pertrochanteric region, with no control over the proximal fragment, nonoperative measures usually result in malunion. Non operative measures need prolonged immobilization and it has its own problems including hypostatic pneumonia, decubitus ulcers etc. It should be considered only in non-ambulatory patients or with chronic dementia with pain that is controllable with analgesics and rest, terminal diseases with less than 6 weeks of life expectancy, unresolved medical co-morbidities that preclude surgical treatment.
Surgical treatment should provide stable fixation and early mobilization and weight bearing. The development of dynamic hip screw in 1960s saw a revolution in the management of intertrochanteric fractures. This device allowed compression of the fracture site with very few complications. (3, 4) In the early 1990s intramedullary devices were developed which were considered to be biomechanically and biologically superior to conventional dynamic hip screw. (5,6,7)
Hence we conducted a study in our set up to compare the result of treatment of these fractures by either of these methods.
MATERIALS AND METHODS: The clinical material for the study of surgical management of intertrochanteric Fracture of Femur with Dynamic Hip Screws versus Proximal Femoral Nail consists of 30 cases of fresh Trochanteric Fracture of traumatic etiology meeting the inclusion and exclusion criteria, admitted to K. I. M. S. Hospital, between May 2007 and September 2009.
Period of Study: 2 years.
1. All patients with recent simple intertrochanteric fractures.
2. Age--Above 18 years of age.
3. Fractures that occurred within 3 weeks.
1. Patients with fractures more than 3 weeks old.
2. Medically unfit patients.
3. Subtrochanteric fractures.
4. Compound fractures.
5. Ipsilateral lower limb fractures, pelvic fractures and spine fractures are not included in the study.
As soon as the patient was admitted, a detailed history was taken and a meticulous examination of the patient was done. The required information was recorded in the proforma prepared. The patient's radiographs were taken in the Antero-Posterior view. The diagnosis was established by clinical and radiological examination.
In the study, Trochanteric fractures were classified according to the AO Classification The patients were randomly allocated into one of the groups--the PFN group or the DHS group, which would determine the surgery that particular patient, would undergo.
The patients were taken up for surgery after obtaining written & informed risk consent of the nature and complications of the surgery.
PFN group underwent closed reduction and internal fixation with PFN, while the DHS group underwent closed reduction and internal fixation with DHS.
Post operatively, patients were made to sit on second post op day and quadriceps drills were started. Non weight bearing mobilization was started depending on patient's acceptance and wound reaction. Sutures were removed after 2 weeks.
Patients were followed up at 6th, 12th, 18th and 24th weeks and were assessed clinically, and radiologically. Full weight bearing was started sequentially on the evidence of fracture union radiographically.
Table 1: Age incidence Age in Years Percentage (n=30) 18-40 10% (n=3) 41-65 40% (n=12) 66-80 33.33% (n=10) 81-89 16.67% (n=5) Table 2: Pre-operative demographic data DHS PFN TOTAL GENDER MALE 30%(n=9) 23.33% (n=7) 53.33% (n=16) FEMALE 20%(n=6) 26.66% (n=8) 46.66% (n=14) PRE-INJURY WALKING ABILITY WITHOUT AID 50% (n=15) 50%(n=15) 100% (n=30) WITH AID -- -- -- MODE OF INJURY TRIVIAL FALL 46.66% (n=14) 43.33% (n=13) 90% (n=27) RTA 3.33% (n=1) 6.66% (n=2) 10% (n=3) SIDE RIGHT 33.33% (n=10) 30% (n=9) 63.33% (n=19) LEFT 16.66% (n=5) 20% (n=6) 36.66% (n=11) TYPE OF FRACTURE A1.1 10%(n=3) 6.66% (n= 2) 16.66% (n=5) A1.2 0 10% (n=3) 10% (n=3) A1.3 0 0 0 A2.1 6.66% (n=2) 10% (n=3) 16.66% (n=5) A2.2 6.66% (n=2) 16.66% (n=5) 23.33% (n=7) A2.3 3.33% (n=1) 6.66% (n=2) 10% (n=3) A3.1 3.33% (n=1) 0 3.33% (n=1) A3.2 3.33% (n=1) 0 3.33% (n=1) A3.3 16.66% (n=5) 0 16.66% (n=5) Table 3: Intra operative comparison DHS PFN LENGTH OF INCISION (cm) MIN 14 4 MAX 20 8 AVERAGE 17.13 6.3 DURATION OF SURGERY(min) MIN 75 60 MAX 140 140 AVERAGE 113 104.3 FLUOROSCOPY TIME (s) MIN 10 19 MAX 25 52 AVERAGE 18 43.5 BLOOD LOSS (ml) MIN 80 40 MAX 256 210 AVERAGE 140.1 126
Intra-operative Complications: There were no intra-operative complications associated with DHS and PFN.
Post-operative Complications: There were no post-operative complications like infection, fracture shaft distal to femur and malunion at the end of 24 weeks follow-up in 28 cases treated with DHS or PFN. 1 patient with DHS and 1 patient with PFN expired due to natural causes at 12 weeks.
Table 4: Post-operative comparison DHS PFN AVERAGE LIMB SHORTENING (cm) 0.7 0.7 MOVEMENT AT 24 WEEKS * M 1 33.33% (n=10) 16.66% (n=5) M 2 10% (n=3) 23.33% (n=7) M 3 3.33% (n=1) 6.66% (n=2) M4 0 0 PAIN SCORE AT 24 WEEKS (sudan's) ** GRADE I 40% (n=12) 43.33% (n=13) GRADE II 3.33% (n=1) 0 GRADE III 3.33% (n=1) 3.33% (n=1) GRADE IV 0 0 WALKING ABILITY AT 24 WEEKS (#) GRADE O 40% (n=12) 43.33% (n=13) GRADE I 3.33% (n=1) 0 GRADE II 0 0 GRADE III 3.33 % (n=1) 3.33% (n=1) GRADE IV 0 0
1 patient in DHS and 1 in PFN group expired at 12 weeks
* Movements--Of the hip is assessed and divided into four grades. It is noted as M I, M II, M III and M IV
Table 5 M I M II Flexion 140[degrees]-100[degrees] 80[degrees]-100[degrees] Extension 0[degrees]-10[degrees] 5[degrees] Abduction 30[degrees]-40[degrees] 20[degrees]-30[degrees] Adduction 25[degrees]-30[degrees] 15[degrees]-20[degrees] External Rotation 30[degrees]-40[degrees] 25[degrees]-30[degrees] Internal Rotation 25[degrees]-30[degrees] 15[degrees]-20[degrees] M III M IV Flexion 60[degrees]-80[degrees] Less than 60[degrees] Extension Nil Nil Abduction 10[degrees]-20[degrees] Less than 10[degrees] Adduction 10[degrees]-15[degrees] Less than 10[degrees] External Rotation 20[degrees]-25[degrees] Less than 20[degrees] Internal Rotation 10[degrees]-15[degrees] Less than 10[degrees] ** sudan's pain score
Grade 1--No pain
Grade 2--Mild pain not affecting ambulation
Grade 3--Moderate pain affecting ambulation & requiring analgesia.
Grade 4--Severe pain even at rest requiring strong analgesia
# POSTOPERATIVE WALKING ABILITY AS PER SAHLSTRAND:
Grade 0--Walks normally
Grade I--Walk with support
Grade II--Walk with a cane or minimal support.
Grade III--Walk with crutches, Walker, 2 canes or living support.
Grade IV--Confined to bed or wheel chair
Table 6 Results Excellent Good Fair Poor DHS 8 (53.33%) 5 (33.33%) 0 1 (6.67%) PFN 10 (66.67%) 3 (20%) 0 1(6.67%) * 1 patient in DHS and 1 in PFN group expired at 12 weeks Table 7: Results are based on sudan's table Excellent Good Fair No pain 1 Mild pain 2 Moderate pain 3 Range of motion > 80% 60-80% 40-60% Limb length shortening 0.5 to 1.5cms 1.5 to 2.5cms up to 0.5cms Return to pre fracture With cane With crutches walking ability or 2 canes Excellent Poor No pain 1 Severe pain even at rest 4 Range of motion > 80% < 40 % Limb length shortening > 2.5cms up to 0.5cms Return to pre fracture Confined to bed walking ability
DISCUSSION: Intertrochanteric fractures of the femur are relatively common injuries among the elderly individuals. Some- times the associated geriatric problems make it a terminal event in the lives of elderly individuals. In order to reduce the morbidity and mortality associated with conservative management of intertrochanteric fractures, surgical management is advocated as the best modality of management of these fractures.
There are two main types of fixations for trochanteric fractures, which are plate fixation and intramedullary implants. (89) The Dynamic Hip Screw with Barrel Side Plate assembly and the Proximal Femoral nail are theoretically, practically and biomechanically more advantageous than other implants.
The dynamic hip screw allowed compression of the fracture site without complications of screw cut-out and implant breakage associated with a nail plate. (3,4) Dynamic hip screw (DHS) has been the standard implant in treating trochanteric fractures. (10-15) However, when compared with the intramedullary implants, it has a biomechanical disadvantage because of a wider distance between the weight bearing axis and the implants. (16)
However, the extensive surgical dissection, blood loss and surgical time required for this procedure often made it a contraindication in the elderly with co-morbidities. The implant also failed to give good results in extremely unstable and the reverse oblique fracture.
The intramedullary devices offer certain distinct advantages (5-7):
1. The implant itself serves as a buttress against lateral translation of the proximal fragment.
2. The intramedullary location of the junction between the nail and lag screw makes the implant stronger at resisting the binding force.
3. The intramedullary device has a reduced distance between the weight bearing axis and the implant that is a shorter lever arm.
4. An intramedullary device bears the bending load which is transferred to the intramedullary nail and is resisted by its contact against the medullary canal (load sharing device).
5. The intramedullary hip screw is a more biological method of fixation.
The proximal femoral nail (PFN) introduced by the AO/ASIF group in 1998 has become prevalent in treating trochanteric fractures in recent years. (17-20) Although there were several reports showing benefits of proximal femoral nail (21-23), it was still associated with technical failures. (24,25)
Age incidence: In the present study, the average age for intertrochanteric fractures was 62.8 years ranging from 18-89 years. 40% were in the age group of 41-65 years. Viewed separately, the average age of patients undergoing DHS and PFN were 65 years and 61.4 years respectively. Intertrochanteric fractures are common in elderly. G.S.Kulkarni (26) in 1984 concluded average age of 62 years. Other studies done by T.S.Sethi (27) in 1993 and another by Panagopoulos et. Al (28) in 2004 also suggested average age in similar range.
Sex incidence: 53.3% (n=16) were males and 46.6% (n=14) were females in our study. Sex incidence in various studies have had varied picture, with few studies suggesting males (29, 30) are more prone to this particular fracture while others suggesting otherwise. (23,31)
Mode of injury: In our study, 90% (n=27) were due to trivial fall such as slipping in the bathroom or missing a step. Rest 10% was due to Road traffic accident. This is similar to other series, Hornby et al (32) (80%), pajarinen et al (23) (89.8%).
This supports the view that bone stock plays an important role in causation of fractures in elderly, which occurs after trivial trauma. No attempt was made to measure the degree of osteoporosis by Singh's index as it involves greater inter observer variability, in addition the accuracy of Singh's index have been questioned by authors such as Koot et.al. (33)
Side involved: Our study had 63.33% (n=19) fractures on the right side. This right side fracture preponderance is also seen in studies done by wade P.A et al (34) and R.C.Gupta. (35)
Type of fracture: In the study majority 50% (n=15) were AO type A2 fractures, while A1 and A3 comprised respectively 26.67% (n=8) and 23.33% (n=7).
Schipper et al. (18) in 2004 concluded 73.9% of type A2 fractures. Kish et.al. (36) in 2005 concluded 59.4% type A2 fractures and 31.6% of type A3 fractures. Menzes et.al. (37) in 2005 concluded 60% of type A2 fractures
Length of incision: PFN needed shorter (6.3 cm) length of incision as compared to DHS (17.3 cm). PFN requires smaller approach to enter the medullary cavity, hence the smaller incision. moreover, PFN uses less number of locking screws which are placed through percutaneous incisions compared to DHS where number of screws are more and open procedure is used.
Duration of surgery: Procedure for PFN needed 104.3 minutes on an average and was shorter than DHS (113 minutes).
It requires smaller incision, less number of locking screws as compared to DHS. However there is a steep learning curve in case of PFN in which an inexperienced surgeon may take much more time initially.
Fluoroscopy time: Average exposure during procedure for DHS is very less (18 s) as compared to PFN (43.53 s).
The number of screws to the head of the femur in PFN is two as compared to one in DHS, while inserting the screws utmost precision is required which increases the radiation exposure. Also, the distal locking in PFN is done percutaneously, which would increase the fluoroscopy time.
Blood loss: Average blood loss in PFN (126 ml) was less than DHS (140ml) probably resulting from smaller incision, less soft tissue handling, smaller duration of surgery associated with PFN.
Weight bearing: Although Kish et al (37) and waldheer et al (39) have proposed immediate full weight bearing on PFN, we used a gradual weight bearing in both the groups. All our patients started full weight bearing walk in both the groups by 12 weeks.
There were no post-operative complications like infection, fracture shaft distal to femur and malunion at the end of 24 weeks follow-up in 28 cases treated with DHS or PFN.
1 patient with DHS and 1 patient with PFN expired due to natural causes at 12 weeks. Which is similar to a study by Marc Saudan et.al. (31) in 2001, Portakal et.al (29) in 2006.
Movement at the end of 24 weeks and Pain score: Patients operated with DHS showed better movements (66.67%) at the end of 24 weeks as compared to PFN (33.33). However Pain score was better in PFN (86.7%) as compared to pain score in DHS (80%).
Limb shortening: Average limb shortening were almost same in both the groups.
Post operative walking ability: Post operative walking ability was better in PFN (86%) with 14 patients having Grade 0 as compared with 12 patients of Grade 0 of DHS (80%). This is similar to the study by Pajarinen et.al. 23 in 2005.
Follow up X-rays at the end of 24 weeks: Follow up X-rays of all the patients showed complete union at the end of 24 weeks.
Similar study by Portakal et.al. (29) in 2005 resulted in complete union of the fracture within 4 months.
Final Outcome: Patients operated with PFN showed excellent results in 66.67% patients as compared to 53.33% of DHS. One patient in DHS and one patient in PFN showed poor result due to Grade 3 pain score and range of movements were M III at the 24 weeks follow up. The patient had poor compliance and was not cooperative in aspects of active exercises and crutch walking.
This is similar to the study by Pajarinen et.al (23) in 2005 and Portakal et.al. (29) in 2005. Waldherr et.al. (39) in 2001 quoted PFN as a valid method to stabilize pertrochanteric fractures. S.Nuber et.al. (21) in 2003 recommends use of PFN.
In 2005 Kish et.al. (37) Quoted: PFN may be used as a good salvage procedure for failed DHS. A randomized postoperaative rehabilitation study by Pajarinen et. al. (23) in 2005 comparing Pertrochanteric femoral fractures treated with a DHS or a PFN was done. Result suggested that the use of PFN may allow faster post-operative restoration of walking ability when compared to DHS.
Cruz et. al in his study done in 2005 quoted PFN as efficient means for treating extracapsular fractures of proximal femur.
CONCLUSION: We conclude that PFN as an implant for fixation of intertrochanteric fractures of femur offers certain advantages over the time tested DHS.
PFN required smaller incision, shorter duration of surgery, less blood loss and faster recovery-early return to pre injury walking ability.
But still PFN is technically demanding and has longer fluoroscopy exposure with a steep learning curve.
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[1.] Shivananda S.
[2.] Radhakrishna A. M.
[3.] Rajshekhar K.
[4.] Vivek Jha
PARTICULARS OF CONTRIBUTORS:
[1.] Professor and HOD, Department of Orthopaedics, KIMS, Bangalore.
[2.] Associate Professor, Department of Orthopaedics, KIMS, Bangalore.
[3.] Consultant Orthopaedician, Department of Orthopaedics, KIMS Care Hospital, Bilaspur.
[4.] Resident, Department of Orthopaedics, KIMS, Bangalore.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Vivek Jha, Room No. 318s, KIMS Resident Quarters, KIMS Hospital, K. R. Road, V. V. Puram, Bangalore-560004, Karnataka.
Date of Submission: 23/04/2014.
Date of Peer Review: 24/04/2014.
Date of Acceptance: 20/05/2014.
Date of Publishing: 14/07/2014.
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Shivananda, S.; Radhakrishna, A.M.; Rajshekhar, K.; Jha, Vivek|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jul 14, 2014|
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