Our experience of management of sub trochanteric fractures of femur by proximal femoral nail.

Background: Sub trochanteric fractures of the femur remain some of the most challenging fractures. Most of the fractures result from trivial fall in the elderly; while in the younger age group, it's mainly due to road traffic accidents. Operative management is the preferred treatment. This study is intended to assess the outcome of the intramedullary fixation of sub trochanteric fractures with Proximal Femoral Nail (PFN). Methods: This study is a prospective, uncontrolled study of 40 cases of sub trochanteric fracture of femur admitted to a tertiary level hospital between August 2011 and November 2013; and treated with proximal femoral nails. Adults with recent sub trochanteric fracture of femur were included in this study; while patients less than eighteen years of age, pathologic fractures, periprosthetic fractures, and old neglected fractures were excluded from the study. Results: In our study of 40 cases, there were 28 male and 12 female patients with mean age of 51.43 years (range 22-87 years). Based on Seinsheimer’s classification, type IIIA fractures accounted for majority (32.5%) of the cases. majority of patients, i.e. 35% (n=14) showed union at 20 weeks after surgery. Cases were followed up and assessed according to the Harris hip scoring system (Modified). The outcome was good to excellent in 82.9% cases. Conclusions: From our study we conclude that PFN is a reliable minimally invasive implant for sub trochanteric fractures, with good to excellent functional outcome in the majority of cases.

Biomechanical evaluation on dynamic hip screw versus proximal femoral nail fixation for unstable femoral intertrochanteric fractures / 医用生物力学

Objective To investigate the biomechanical stability of both DHS (dynamic hip screw) and PFN (proximal femoral nail) for treating unstable intertrochanteric fractures. Methods A standard 4-part osteotomy was performed in 8 pairs of fresh frozen human cadaver femurs, which were then randomly assigned to two groups: PFN group and DHS group for biomechanical testing. These specimens were applied to a cyclic load up to 200, 400, 600, 800, 1 000, 1 200, 1 400 N, respectively. Fracture displacement was measured during the loading to determine biomechanical stability of the implant. Each specimen was repeatedly loaded for 5 times to calculate the average displacement and draw the load-displacement curve. For failure testing, the initial load and loading rate was set at 1 400 N and 10 N/s, respectively. The applied compressive load was increased by 600 N each time for five cycles. The pressure was gradually increased to its peak force, and sustained for 10 second before it was gradually decreased to 0 N. The highest force value sustained before failure was defined as the maximum strength of the implant. Results The biomechanical testing on all specimens was completed successfully. There was no damage to the internal fixation. The average displacement and stiffness in DHS group were (3.92±2.21) mm and (215.28±58) N/mm, while those in PFN group were (4.22±1.80) mm and (197.06±34.20) N/mm, so no significant difference was found between the DHS and the PFN group (P> 0.05). New fracture occurred at the distal end of nail in PFN group. The DHS was fractured at the distal cortical screw, but no nail was cut out of the femoral head. The average load required for failure was (4 312±560) N in PFN group and (3 954±520) N in DHS group, and no significant difference was found between the two groups(P＞0.05). Conclusions The test shows that the PFN does not appear to offer any distinct biomechanical advantage over the DHS in the treatment of unstable intertrochanteric fractures. The implant chosen for treating intertrochanteric fractures must depend on patient’s fracture geometry, and anatomic reduction should be conducted in clinical treatment. If the anatomic reduction is difficult, trying to recover continuity of the posterior cortical bone would be necessary.

The Proximal Femoral Nail - A Minimal Invasive Treatment for the Stabilization of Pertrochanteric and Subtrochanteric Femoral Fractures.

This study reports the outcome in pertrochanteric and subtrochanteric femoral fractures in 25 patients treated by using PFN. Salvati and Wilson hip function scoring system and Kyle's criteria were used for follow up evaluation. At the end of 24 weeks follow up the Salvati and Wilson hip function was 32 (out of 40) in 88% of patients, the Kyle's criteria described the outcome as good or very good in 92% of patients and the level of function was similar to pre-injury level in 90% of patients. Distal locking difficulty was encountered in 3 cases. Difficulty in placement of neck screw was encountered in 4 cases. Secondary varus was noted in 3 cases and in 1 patient antirotational screw cut through was seen.However all fractures united well in all the patients.PFN was designed by AO/ASIF in 1996 for the treatment of peritrochanteric fractures.It combines the intrinsic advantages of the intramedullary nail and those of sliding screw is a valid and an important option in the treatment of pertrochanteric and subtrochanteric femoral fractures. It is a relatively easy procedure, a bio mechanically stable construct and a minimally invasive device; especially ideal in compromised elderly patients who are the majority population suffering from these type of fractures.With incorporation of single helical blade in place of two proximal screws in PFN, AO/ASIF has further enhanced the treatment modalities by devising PFNA (Proximal Femoral Nail Antirotation).

Treatment of Intertrochanteric Fracture Using Proximal Femoral Nail for Patients over 90 Years Old

PURPOSE: This study examined the clinical and radiologic results of a proximal femoral nail (PFN) used to treat an intertrochanteric fracture of the femur in elderly people more than 90 years of age. MATERIALS AND METHODS: Between January 2005 and December 2008, 20 patients over 90 years old with an intertrochanteric fracture were treated with a PFN. Among them, 16 patients (mean age, 93.9 years; 13 females and 3 males) were followed up for a minimum of 6 months. Clinically, the modified Koval index was evaluated. Radiological bony union and complications were evaluated from the plain X-ray film. RESULTS: The average modified Koval index decreased from 3.1 before surgery to 1.8 after surgery. Only 5 cases could return to their pre-injury status. Radiologic bony union was achieved after an average of 8.2 weeks and there were no complications, such as non-union and femoral head perforations. CONCLUSION: Thirty one percent of patients older than 90 years and treated for an intertrochanteric fracture with a PFN had recovered to their pre-injury ambulatory status. However, all cases showed bony union and no complications. Overall, PFN might be a good treatment option for intertrochanteric fractures in elderly people older than 90 years.

Treatment of Intertrochanteric Fracture: Comparison of Proximal Femoral Nail and Proximal Femoral Nail A

PURPOSE: To evaluate the results of fracture fixation between using Proximal Femoral Nail and using Proximal Femoral Nail A and to analyze the effectiveness of proximal femoral nail A. MATERIALS AND METHODS: We reviewed 32 patients who suffered from intertrochanteric fracture in our hospital, which were 19 cases of PFN and 13 cases of PFNA. Retrospectively we evaluated mean operation time, amount of bleeding, beginning of ambulation, average union period, changes of neck shaft angle and complication on set of telephone interview and OPD. We also evaluated postoperative capability of function and mobility using 'Social function score' and 'Mobility score'. RESULTS: PFNA showed shorter mean operation time, less bleeding, shorter average union period, earlier ambulation and less change of neck shaft angle than PFN. Although they didn't show statistical difference, postoperative capability of function and mobility showed statistical and mathematical difference on each group. CONCLUSION: PFNA showed better results of postoperative function and mobility and less complications than PFN. So treatment using PFNA is better method than that of PFN.

Surgical Treatment with Proximal Femoral Nail for Intertrochanteric Fracture of the Femur in Elderly Patients

PURPOSE: To evaluate the clinical result of Proximal Femoral Nail (PFN) fixation for intertrochanteric fracture of the femur in elderly patients. MATERIALS AND METHODS: Between January 2004 and June 2006, 119 patients older than 65 years of age, with intertrochanteric fractures, were treated with PFN fixation. Ten patients who died within 4 weeks after operation were excluded from the analysis. Mean duration of follow-up was 13 months. There were 34 males and 75 females, and the mean age was 77.8 years. Operation time, amount of blood loss, transfusion requirement, time to ambulation, length of hospital stay, pre- and post-operative walking status, and post-operative complications were evaluated. Radiologic parameters such as amount of impaction, time to union, and neck-shaft angle were also evaluated. RESULTS: The mean operation time was 42 minutes, transfusion requirement averaged 340 ml, and amount of blood loss averaged 78 ml. The mean hospital stay was 20 days, and time to ambulation averaged 10.3 days. Eighty-five percent of patients returned to previous walking status. The average amount of fracture impaction was 3.8 mm, and mean time to radiologic bony union was 11.7 weeks. Neck-shaft angle was changed to 2.5 degrees varus displacement. Complications included intraoperative femur shaft fracture in 5 cases, protrusion of lag screw into the hip joint in 3 cases, backing out of lag screw in 2 cases, fixation failure in 2 cases, and proximal femur fracture in 1 case. Among these cases, 5 hips (2 cases of fixation failure and 3 cases of femoral head perforation by lag screw) were converted to total hip replacement. CONCLUSION: Because of reduction in operation time, low complication rate, and favorable outcome, PFN fixation is an acceptable alternative for fixation of intertrochanteric fractures in elderly patients.

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.

Clinical observation of PFN-A and DHS on the treatment of intertrochanteric fracture / 中国基层医药

Objective To compare the current trcmment of intertrochanteric fracture fixation commonly used in the two systems:proximal femoral nail(PFN-A)and the dynamic hip screw(DHS)of clinical efficacy and evaluate the treatment of the two intertroehanteric fracture of the gifted bad.Methods The clinical use on closed reduction and traction,respectively PFN-A with DHS and the treatment of intertrochanteric fracture patients with 106 cases and 115 cases,compared with its ease of operation,and the effect of surgery,postoperative complications.Results The clinical material demonstrated that in after PFN-A treatment thighbone thick pmsperom bone fracture technique,technique,the complication is short in DHS.Conclusion PFN-A well-designed,with simple anti-rotation indeed,surgical trauma,less bleeding,fewer complications,etc.,is the treatment of intertrochanteric fracture fixation one of the ideal.

Comparison of hemiarthroplasty and PFN fixation for the treatment of unstable intertrochanteric hip fractures in senile patients / 中国矫形外科杂志

[Objective]To discuss a reasonable treatment for unstable intertrochanteric hip fractures in senile patients by comparing the effects of PFN fixation and hemiarthroplasty.[Method]Totally 82 intertrochanteric hip fractures in senile patients with complete clinical data were retrospectively analyzed,who were treated with hemiarthroplasty or PFN fixation from April 2005 to April 2007.Forty-six were treated with hemiarthroplasty,36 were treated with PFN fixation.All of them had multiple medical co-morbidities.According to modified Evens-Jensen classification,all of them belonged to unstable fracture.Comparison was made between the two treated groups in terms of the length of incision,operative time,the blood lost,blood transfusion during or after surgery,time for bed rest postoperatively,postoperative complications and St.Michael hip score one year after surgery.[Result]The average duration of follow-up for PFN fixation and hemiarthroplasty were 16 and 18 months respectively.Compared with the group of hemiarthroplasty,the group of PFN fixation experienced longer operation time,longer time for bed rest postoperatively,less blood lost,less blood transfusion during or after surgery,shorter incision length,and the differences between two groups had statistical significance (P0.05).[Conclusion]Both of the two methods are reasonable treatment for unstable intertrochanteric hip fractures in senile patients.

Treatment of intertrochanteric and subtrochanteric fractuers of the femur with close reduction and the improved proximal femoral nail / 中国矫形外科杂志

[Objective]To investigate the clinical outcomes of treatment of intertrochanteric and subtrochanteric fractures of the femur with the improved proximal femoral nail(PFN).[Method]Between April,2002 to Mach 2005,a total of 81 cases of intertrochanteric and subtrocha nteric femoral fractures were treated with close reduction and the improved PFN.There are 45 males and 36 females,with an average age of 63.6(35 to 91).According to the Evans classification: there are 5 cases of type Ⅰ,10 cases of type Ⅱ,12 cases of type ⅢA,21 cases of type ⅢB,28 cases oftypel Ⅴ,5 cases of type against femoral peritrochanteric.[Result]Sixty-two cases were followed up for 12 to 47 months,averaged 28.6 months.Fracture union was obtained in all the patients.Of 62 cases,one case had according to Harris criterion 56 cases were excellent,(rate 90.3%) and 2 cases good(3.2%) excellent and good rate of the function of the hip joint was 93.5%.[Conclusion]The improved PFN is a useful device in the treatment of perit rochanteric fractures of the femur.It is relatively easy with less surgical trauma,it and also has the advantages of anti-rotation,stress-dispersing,rigid fixation and allowing early functional exercises.The complications can be avoided with improved operative technique.

A comparative study of Gamma nail and proximal femoral nail in treatment of intertrochanteric fractures of femur / 中华创伤骨科杂志

Objective To compare the clinical results of the intramedullary nails (Gamma nail and the proximal femoral nail) in treatment of intertrochanteric fractures of femur. Methods A review study was conducted on 116 intertrochanteric fractures of femur treated with the Gamma nail and 89 treated with PFN in our hospital between 2000 and 2003. Results In the Gamma nail group, the mean time for operation was 68.3(48 to 106)minutes,the mean blood loss during operation was 261(180 to 400)mL,the mean time for walking after operation was 5.0 (2.3 to 8.9)weeks and the mean time for bone union was 8.6(7.1 to 12.6)weeks. In the PFN group, the mean time for operation was 48.0(36 to 85)minutes, the mean blood loss during operation was 192(120 to 360)mL,the mean time for walking after operation was 5.3(2.5 to 8.1)weeks and the mean time for bone union was 8.8(6.9 to 12.1)weeks. There were significant differences in the mean time for operation and the mean blood loss between the 2 groups(P

Intertrochanteric fractures / 中华创伤骨科杂志

Intertrochanteric fractures occur mostly in the elderly population. Direction of fracture line, lesser trochanteric fracture, comminution and displacement are the chief concerns in radiological diagnosis of intertrochanteric fractures. Interchanteric fractures can be classified by Evansgrading, Jensens modification of Evansgrading, AO classification, and so on, which are to judge the stability of the fracture. Currently, the basic priciple of management is operation and fixation. The common implants of internal fixation consist of two basic kinds: gliding compression screws with lateral plate, such as dynamic hip screws (DHS), and intramedullary nail fixation, such as Gamma nails and proximal femoral nails. Exteranl fixators are only applied in cases of severe multiple trauma and elderly patients, and artificial joint replacements in those of serere comminuted fractures combined with high osteoporosis.

The treatment of proximal femoral fracture / 中华创伤骨科杂志

Proximal femur consists of femoral head, femoral neck and trochanter. The neck and trochanteric parts of femur are easy to get fractured under conbolution forces. As the conservative treatment tends to cause high rates of complication and mortality, more and more surgeons vote for early internal fixation in recent years. The best treatment for femoral neck fracture is now internal fixation with cannulate screws, especially for the patients with good bone density, fundus and intertrochanteric fractures as well as the type I, type Ⅱand part of type Ⅲfractures in Gardon's classification. Although intertrochanteric fractures are relatively stable, but internal fixation is necessary for good results and prevention of complications. DHS(dynamic hip screw)are advisable for A1, part of A2 and A3 intertrochanteric fractures in AO classification, especially for A1 cases. PFN (proximal femoral nail) is designed for intertrochanteric fractures, inversion and elevation intertrochanteric fractures. In order to get better prognosis in patients older than 70 years and with serious osteoporosis and A2 3, A3 3 fractures, we designed a special kind of prosthesis for them and therefore get satisfactory results.

Treatment of intertrochanteric fractures with PFN introduction by minimally invasive percutaneous K-wire versus with conventional PFN introduction:a prospective randomized comparison / 中华创伤骨科杂志

Objective To compare proximal femoral nail(PFN)introduction by percutaneous K-wire through a small incision with conventional PFN introduction protocol in the treatment of intertrochanteric fractures. Methods From January 2004 to March 2005,51 patients with intertrochanteric fractures were randomly dis- tributed into a minimally invasive treatment group(group MI)and a conventional treatment group(group C).All the fractures were closely reduced.In group MI a K-wire was percutaneously inserted through the tip of the greater troehanter into the center of medullary canal of the pruximal femur before the PFN was inserted under the guidance of K-wire through a small incision made along the K-wire while in group C the PFN was introduced according to the conventional procedure.The operation time,intra-operative blood loss,length of incision,X-ray exposure,duration of in-patient stay and time of bone union in both groups were recorded and compared.Results The mean oper- ation time,mean intraoperative blood loss and mean length of incisions in group MI were 77.20 min,104.20 mL and 5.12 cm respectively and significantly lower than those in group C(P＜0.01).The X-ray exposure and the reduction time in group MI lasted longer than in group C(P＜0.01).The mean time of bone union and in-patient stay in both groups were nearly equal(P＞0.05).At the latest tollow-up,all the fractures united in both groups without nonuuion or delayed union.Conclusion Compared with the conventional protocol,introduction of PFN by a pereutaneuus K-wire inserted into the central medullary canal of the proximal femur is much more minimally in- vasive and effective.

Operative treatment of intertrochanteric fracture of femur in 106 cases / 中华创伤骨科杂志

Objective To analyze the therapeutic effects of different meth ods in operative treatment of intertrochanteric fractures of femur. Methods 106 cases were treated with operation and their average age was 72 year old. 39 case s of them were treated with external fixation, 3 cases with steeliness, 13 cases with Metanghin nail, 45 cases with DHS, and 6 cases with proximal femoral nail( PFN). Results The therapeutic effects of the dynamic hip screw(DHS) and PFN trea tment were the best among these methods. The excellent and good rates of DHS, PF N, external fixation, steeliness, and Metanghin were 100%, 87.2%, 33.3%, 69. 2%, respectively. Conclusion For the intertrochanteric fracture of lemur,DHS or PFN is recommendable to the patients who can tolerate an operation, whereas uni lateral external fixation is preferable to those who cannot or will not receive an operation.

Application of proximal femoral nail in the treatment of femoral intertr ochanteric fracture / 中华创伤骨科杂志

Objective To evaluate the clinical effects in t he treatment of femoral peritrochan teric frac-tures by PFN(proximal femoral nail).Methods A retrospective analysis was done in the treatment of femoral peritrochanteric fractures(72cases).38cases were male and 44cases female.Their age ranged 64～96years old with the average age being 78years old.70cases were intertrochanteric f ractures(EvensⅠtype 16,Ⅱtype 31,ⅢA type 14,ⅢB type 6,Ⅳtype 3),and 2cases subtrochanteric fractu res.Results65patients were followed up for over 6months.All fractures healed and all patients could take care of themselves and were satisfied with t he clinical curative effect except one patient who had the lag screw pulled o ut and coxa vara because of serious os-teoporosis.Conclusion PFNis a better way to cure femoral peritrochanteric fractures because of few complications and simple surgical procedure.Bein g a micro-trauma technique,it is worthy of wide application in clinic.[