Long PFN in unstable subtrochantric fracture with absent lateral wall support in proximal fragment with delayed augmentation with encircalage wire and bone grafting.

In 1949 Boyd and Griffin Subtrochanteric fracture femur as a variant of peritrochanteric fracture with higher incidence of unsatisfactory result both in the elderly and young. Most of this fracture is with higher incidence of unsatisfactory result after operative treatment This single case study shows one of the unpredicted iotrogenic complications. Material and method: Patient is 78yr female patient with multiple co-morbid conditions with subtrochanetric fracture. Surgery was done with long PFN nail inserted with good purchase in head, reduction check under C-arm with in antero-posterior & lateral view shows little malreduction and nail is out of medulary cavity in proximal fragment. Revision in same sitting not possible due to some medical reasons. Revision surgery done after fitness and reduction held with encieclage wire and bone grafting done. Conclusion: Even without lateral wall support if there is good purchase of screws in head and shaft, there will be good union and good functional outcome.

Comparison of the Gamma Nail and the Dynamic Hip Screw for Peritrochanteric Fracture

PURPOSE: To retrospectively compare the clincal and radiological results between the gamma nail and dynamic hip screw (DHS) on the operative treatment of unstable peritrochanteric fractures. MATERIALS AND METHODS: From January 1999 to December 2006, we selected 215 patients who could be observed at least 1 year among 246 patients who received surgical treatment for unstable peritrochanteric fractures in our hospital. Eighty-six patients were males and 129 were females; the mean age was 72 years. Evans unstable fracture was included in our study. The gamma nail was applied in 133 cases, and the dynamic hip screw was applied in 82 cases. We evaluated union times, the collapse intensity of fractured sites after union, hospitalization duration, operation time, and post-operative complications. RESULTS: The mean union time was 15.7 weeks with the DHS and 13.7 weeks with the gamma nail. The collapse intensity of fracture sites were 3.5 mm and 1.9 mm, respectively. The mean hospital durations were 19.5 days for DHS surgery and 16.3 days for gamma nail surgery. The mean operation time was 85.5 minutes for DHS and 98.2 minutes for gamma nail. The post-operative complications were loosening of internal fixator (6 cases in DHS, 1 case in gamma nail), perforation of the femoral head (2 cases in DHS, 1 case in gamma nail), and non-union (7 cases in DHS, 2 cases in gamma nail). CONCLUSION: In unstable peritrochanteric fractures, biomechanically stable gamma nailing is thought to be one of the most effective treatments for reducing fracture site collapse and complications.

Complications of Femoral Peritrochanteric Fractures Treated with the Gamma Nail

PURPOSE: We analyzed the complications of femoral peritrochanteric fractures treated with the Gamma nail to reduce its complications. MATERIALS AND METHODS: We evaluated the complications among the 96 patients who were treated with the Gamma nail from January 2000 to May 2005. Mean follow-up period was 17.8 months and mean age was 75.2 years. We analysed the relationship between the complication and the fracture pattern, postoperative reduction status, position of the lag screw, bone density, displacement and tip-apex index (TAD). RESULTS: The complications were presented in 12 cases (12.5%). Cut-out of lag screw were in 5 cases, varus deformity with short lag screw in 2 cases, metal breakage of distal screw in 1 case, breakage of drill bit intraoperatively in 1 case, superficial infection in 2 cases and deep infection in 1 case. 5 cases (4.2%) were required reoperation. All of the cut-out of lag screw showed increased TAD (tip apex distance) above 25 mm. CONCLUSION: To reduce the complications of the Gamma nail, we need exact surgical technique, good positioning of the lag screw and choice of appropriate length for the lag screw.

Results of Treating Senile Osteoporotic Peritrochanteric Fracture with Proximal Femoral Nail Antirotation (PFNA)

PURPOSE: The purpose of this study was to evaluate the results of treating senile osteoporotic peritrochanteric fracture with proximal femoral nail antirotation (PFNA). MATERIALS AND METHODS: Between November 2006 and December 2007, 21 patients older than 65 years of age with intertrochanteric and subtrochanteric fractures were treated with PFNA. The mean duration of follow-up was 12.9 months and the mean age was 74.5 years. RESULTS: The mean operation time was 48.8 minutes (range: 25-90 minutes). The time to ambulation averaged 7.9 days. Eighty point nine percent (17 cases) of the patients returned to their previous walking status at 6 months after operation. The average T-score was -3.3. Eighteen cases (85.7%) achieved acceptable reduction and the mean time to radiologic bony union was 17.4 weeks. The average amount of PFNA blade sliding was 4 mm and the neck-shaft angle was changed to 1.3 degrees varus displacement at the final follow-up. The complications included pulmonary edema in 1 case and protrusion of the PFNA blade into the hip joint in 1 case. CONCLUSION: Because of the reduced operation time, favorable walking ability and low rate of complications, PFNA is an acceptable alternative for fixation of senile osteoporotic peritrochanteric fracture.

The Results of Proximal Femoral Nail Antirotation: A Comparative Study with Proximal Femoral Nail

PURPOSE: This study was performed to compare the results between PFNA (Proximal Femoral Nail Antirotation) and PFN (Proximal Femoral Nail) in the treatment of peritrochanteric fracture. MATERIALS AND METHODS: The patient group with PFNA (n=24, group I) was taken from operations between February, 2007, and March, 2008, whereas the PFN patient group (n=24, group II) were taken from January, 2005, to January, 2007. Both groups were carefully compared with regard to operation time, estimated blood loss, amount of transfusion, ICU care, amount of drainage, average duration of admission, intra- and postoperative complications, radiologic union, Tip Apex Distance (TAD), the change of neck shaft angle, the sliding length of lag screw, Jensen's functional score, and Paker and Palmer's mobility score. RESULTS: The results of our study showed statistical (P0.05). CONCLUSION: PFNA appears to be more effective than PFN for the treatment of peritrochanteric fractures of the proximal femur.

The Treatment of Peritrochanteric Fracture of Femur with Proximal Femoral Nail: Comparative Study with Dynamic Hip Screw

PURPOSE: This study compared the results between PFN (Proximal Femoral Nail) and DHS (Dynamic Hip Screw)in the treatment of a peritrochanteric fracture of the proximal femur. MATERIALS AND METHODS: 33 patients with peritrochanteric fractures treated with PFN for a minimum follow-up of at least 12 months were analyzed retrospectively. The patients with PFN group (n=33, group I) were taken from operations between Jan. 2003 and Dec. 2004, and the DHS group (n=34, group II) were used as the control group. Both groups were compared with regard to the operation time, blood loss, transfusion, ICU care, drain amount, duration of admission, complications, the neck shaft angle, the sliding length of lag screws, radiological union, and the functional recovery grade using Jensen and Palmar and Parker's method. RESULTS: The mean operative times were 105 (group I) and 157 minutes (group II), blood losses were 540 and 840cc, transfusion volumes were 1.5 and 2.2 pints, ICU care was 6 and 30%, drain amounts were 36 and 203 cc, admission duration was 25 and 33 days, complications were 15 and 17%, reoperations by the failure of the reduction were 2 cases(6%) (group I) and 0 (group II), difference in the neck shaft angles were 3.70 and 3.87degrees, sliding length of the lag screws were 1.9 and 6.9 mm, radiological union was achieved in 17.5 and 18.9 weeks, function scores were 1.81 and 1.94, and the mobility scores were 6.51 and 6.16, respectively. These results show that there were advantages of PFN in terms of the operative times, blood loss, transfusion, ICU care, drain amounts, admission duration, sliding length of the lag screws and radiological union with statistical significance (p<0.05). CONCLUSION: Good clinical results can be achieved with PFN compared with the DHS for the treatment of peritrochanteric fractures of the proximal femur.

Clinical analysis of reconstruction interlocking nail in surgical treatment of femoral shaft fractures associated with ipsilateral peritrochanteric fractures of the femur / 中国矫形外科杂志

[Objective]To discuss the operative treatments and evaluate the effects of reconstruction interlocking nail(RIN)in treating femoral shaft fractures associated with ipsilateral peritrochanteric fractures of the femur.[Method]A retrospective study was done on 37 patients with femoral shaft fractures combined with ipsilateral peritrochanteric fractures treated by RIN from September 2002 to Janurary 2009.This study involved 32 males and 5 females,with an average age of 36 years (range,24 to 69 years).Thirty-three patients had high-energy injury (26 of road accident,7 of falling from height),and 4 low-energy injury.Among them,13 patients had fractures in the upper one-third of the femoral shaft,18 in the middle one-third and 6 in the lower one-third.Six patients had open fractures (Gustilo scale Ⅰ in 1,and Ⅱ in 5).According to Garden classification for femoral neck fractures,there were 19 cases of type Ⅱ,9 cases of type Ⅲ and 2 cases of typ Ⅳ.According to AO classification for femoral intertrochanteric fractures,there were 3 cases of type A1.1,1 case of type A2.1.According to Seinsheimer classification for femoral subtrochanteric fractures,there was 1 case of type Ⅰ,and 2 cases of type ⅡA.The mean duration from injury to surgery was 3.7 days (range,4 hours to 13 days).After operation step-by-step functional rehabilitation was encouraged.[Result]The follow-up periods ranged from 14 to 38 months (average,24 months).Bony union was achieved in all patients.The average bony union time was 13 weeks for fractures of femoral shaft,14 weeks for femoral neck,12.6 weeks for intertrochanteric and 15.5 weeks for subtrochanteric fractures.Femoral head necrosis occurred in one case.No such complications as infection,loosening of nails,coxa vara,or malunion was found.According to Harris Scoring system,32 cases (86.5%)were rated as good or excellent.[Conclusion]The treatment of femoral shaft fractures associated with ipsilateral peritrochanteric fractures of the femur with RIN is a good method because of its advantages of small trauma,stable fixation,high union rate,few complications and good results.It may have fewer internal fixators.Carefully choosing suitable patients,sophisticated operation skills and active functional exercise after operation are keys to success.

The Gamma Intramedullary Nailing for Peritrochanteric Fractures / 대한정형외과학회잡지

This study consisted of 66 peritrochanteric fractures which were treated by the modified Gamma nail (Asian Pacific nail) from August 1993 to October 1995. Sixty-one intertrochanteric fractures and five subtrochanteric fractures were treated in our institution. Average length of follow-up was 15.0 months. Four patients died during follow-up. The results were as follows; Lag screws were ideally introduced in 55 (83%) cases. The mean length in lag screw sliding was 4.3 mm in stable trochanteric fractures and 5.7 mm in unstable ones. Fifty-one out of 62 patients (82%) were returned to their previous ambulatory status. Intraoperative complications were as follows; distal crack (3 cases); rotation of femoral head (2 cases); entry point crack (I case); medialization of proximal fragment (7 cases); and missing of the interlocking screw (1 case). All of these complications did not affect the outcome. All medial cortical gaps were closed after sliding of lag screws. Three distal cracks did not propagate to the shaft. Postoperative complications were a case of superior cut-out, and two second fractures after falls. Callus formed more early in the stable trochanteric fractures (5+/-2.1 weeks) than unstable fractures (7.3+/-2.1 weeks). It was statistically significant. Union time between stable and unstable trochanteric fractures was not statistically significant. In conclusion, the Asian Pacific (AP) nail could appropriately fix the osteoporotic peritrochanteric fractures in elderly patient. It could offer early rehabilitation to these patients and decrease the mortality and morbidity.