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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 1  |  Page : 208-214

Fixation of subtrochanteric fracture femur using a proximal femoral nail


Orthopedic Department, Faculty of Medicine, Menofiya University, Menofya, Egypt

Date of Submission20-Aug-2013
Date of Acceptance02-Dec-2013
Date of Web Publication20-May-2014

Correspondence Address:
Soliman H. Zalalo
El-batanon, Shebin El-Kom, Menofya 32721
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.132811

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  Abstract 

Objectives
The aim of this work was to evaluate the results of management of 20 adult patients with subtrochanteric femoral fractures using a proximal femoral nail (PFN).
Background
Fractures of the proximal femur are a big challenge in traumatology. Rapid strides in implant and instrumentations in quest of ideal fixation of subtrochanteric femoral fractures have made various options available. The present study aims to study the role of standard PFN in the management of these fractures.
Materials and methods
We reviewed the results of 20 consecutive patients who had undergone intramedullary fixation with PFN for traumatic subtrochanteric fractures in our hospital from May 2011 to June 2013, including the follow-up. The average age of the patients was 45 years. Clinical and radiographic analyses were performed during follow-up at 6, 12 weeks, 6 months, and 1 year.
Results
All patients were clinically assessed according to the Merle d'Aubigné hip scoring system. Our final results were excellent in 25%, good in 40%, fair in 20%, and poor in 15% of patients. Poor results were seen in three cases. Radiologic assessment included union, malunion, failure of fixation, and implant failure. There was only one case of delayed union and two nonunited cases, with a union rate of 85% at final follow-up. Shortening and varus deformity occurred in two cases but had no effect on the clinical and functional outcome. Failure of fixation occurred in only one case but there were no implant failures. Also there were no intraoperative or postoperative shaft fractures.
Conclusion
The current study shows that PFN is an evolving safe and successful approach in the treatment of subtrochanteric femoral fractures and can be carried out in a minimally invasive manner.

Keywords: Proximal femoral nail, subtrochanteric fractures, trochanteric fractures


How to cite this article:
El-Mowafi HM, Eid TA, El-Sayed AS, Zalalo SH. Fixation of subtrochanteric fracture femur using a proximal femoral nail. Menoufia Med J 2014;27:208-14

How to cite this URL:
El-Mowafi HM, Eid TA, El-Sayed AS, Zalalo SH. Fixation of subtrochanteric fracture femur using a proximal femoral nail. Menoufia Med J [serial online] 2014 [cited 2017 Dec 14];27:208-14. Available from: http://www.mmj.eg.net/text.asp?2014/27/1/208/132811


  Introduction Top


Subtrochanteric fracture of the femur occurs in the area that is 5 cm below the lesser trochanter [1],[2].

The incidence of fractures of the proximal femur is markedly increasing because of increasing life expectancy and motor vehicle accidents. Subtrochantric fractures of the femur pose a great problem because of the diversity of fracture patterns and difficulty in attaining anatomical reduction. In eldery individuals, low-energy trauma usually results in multifragmentary fractures, sometimes with an unstable configuration [3].

The subtrochanteric region of the femur is subjected to many stresses resulting from bending movements and compressive forces generated by body weight and hip muscles, thus leading to the malunion and nonunion of fractures and mechanical failure of the implants [4].

The most appropriate implant for the internal fixation of subtrochanteric fractures remains a subject of debate, and a multitude of different intramedullary and extramedullary devices for their surgical fixation have been advocated [4].

For a long time, the solution for such fractures was open reduction and internal fixation. The technique of open reduction has changed substantially over the past decades. Originally, anatomical reduction with rigid internal fixation was desired, entailing too much soft-tissue dissection, leaving the fragment avascular. Intramedullary nailing has many advantages, including easy insertion using a closed technique, retaining the fracture hematoma, and a lower infection rate due to less surgical dissection. Closed nailing constitutes a form of biological fixation of the femur, which may be credited for a shorter time to union [3].

The theoretical biomechanical advantages of such implants over screw and plate fixation are attributed to a reduced distance between the hip joint and the implant. This diminishes the bending movement across the implant and fracture construct and allows the load to be transferred directly to the femoral shaft, bypassing the calcar femorale. These characteristics offer theoretical advantages in the setting of unstable fractures. Despite these theoretical advantages, cephalocondylic nails have been associated with a number of complications including peri-implant fracture and thigh pain [5].


  Materials and methods Top


This study involved 20 consecutive patients with subtrochanteric fractures who had undergone intramedullary fixation with proximal femoral nail (PFN). All cases were performed in the Orthopedic department, Menoufia University Hospital, from May 2011 to June 2013, including the follow-up. The AO classification system was used to classify the fractures.

AO classification

The AO/ASIF group, in their Manual of Internal Fixation, recommend a three-part classification. This is a descriptive classification based on the fracture configuration. The subtrochanteric fracture belongs to the group of femoral diaphyseal fracture 32-(X-#)−1. (X) is the subclassification of the fracture patterns, and these patterns are subclassified into a, b, and c subgroups. Subgroup a represents simple fractures, group b represents wedge fractures, and c represents complex fractures. The numeric description # indicates the degree of comminution.

Only fresh cases with closed fractures were included in this study. Open fractures, pathological fractures, and a pre-existing femoral deformity preventing hip nail osteosynthesis were excluded from the study.

All patients at admission were subjected to initial management and resuscitation followed by a detailed history taking, clinical examination, radiograph of the pelvis showing both hips and the whole femur including the knee, and other relevant investigations.

Preoperative assessment of the neck shaft angle in the unaffected side on an anteroposterior radiograph using a goniometer, as well as assessment of the medullary canal size and any proximal femoral deformity, was made.

Proximal femoral nail implant details

The implant consists of a PFN, two proximal screws - an 8 mm and a 6.5 mm femoral neck screw - two 4.9 mm distal locking bolts, and an end cap. The nail has a proximal diameter measuring 14 mm. This increases the stability of the implant. The mediolateral valgus angle is 6°, which prevents varus collapse of the fracture even when there is medial comminution. Proximally, it has two holes: the distal one is for the insertion of an 8 mm neck screw, which acts as a sliding screw, and the proximal one is for a 6.5-mm hip pin, which helps prevent rotation. The distal diameter is tapered to 09-12 mm, which also has grooves to prevent stress concentration at the end of the nail and avoids fracture of the shaft distal to the nail. Distally, the nail has two holes for insertion of 4.9-mm locking screws, of which one is static and the other is dynamic, allowing a dynamization of 5 mm.

Operative technique

Prophylactic antibiotic was given to all patients 30 min before surgery. All patients in our study were operated upon under spinal anesthesia.

The patients were positioned supine on the fracture table in such a way as to visualize the proximal femur in lateral and anteroposterior planes. To overcome the difficulty in accessing the tip of the trochanter and for unimpeded access to the medullary cavity of the proximal femur, the trunk was abducted at the waist by 10-15° to the contralateral side or the affected limb was adducted to 10-15°. All patients were treated with a PFN under the C-Arm [Figure 1].
Figure 1:

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A skin incision measuring 3-5 cm is made 10 cm proximal to the tip of the greater trochanter on the proximal extension of the anatomical femoral bow. Then the subcutaneous tissue and deep fascia are incised and the gluteal muscle is split along its fiber.

The greater trochanter is palpated. Under image intensifier control, the bone awl was used to start the track on the tip of the greater trochanter (entry point) in anteroposterior view, and between the anterior one-third and posterior two-thirds in the lateral view, when there was difficulty in pushing the guidewire through the cortex of the greater trochanter. Then the cannulated drill bit was passed over the guidewire and through the protection sleeve to open the medullary canal [Figure 2]a-d.
Figure 2:

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The ball-tipped guidewire was advanced into the distal fragment.

After the tissue protector had been introduced, the reaming shaft, fitted with the first reamer head, was inserted over the guidewire. Usually, reaming begins with a 9 mm medullary reamer. Reaming was performed in sequential steps by increments of 0.5 mm each. Adequate reaming was performed to allow for smooth nail insertion.

An exchange tube was then passed over the guidewire and advanced into the medullary cavity until it entered the distal fragment. The ball-tipped guidewire was then removed and replaced with a plane-tipped guidewire and then the tube was removed after confirming the position of the plane-tipped guidewire in the distal fragment of the medullary cavity under an image intensifier.

A nail of appropriate size as determined preoperatively (according to the size of the medullary canal in the preoperative radiograph) was assembled into the insertion handle.

After confirming satisfactory fracture reduction, the nail was inserted manually as far as possible into the femoral opening. This step was performed carefully without hammering by slight twisting movements of the hand until the hole for the 8 mm screw was at the level of the inferior margin of the neck [Figure 3].

The guidewire for the neck screw and the hip pin were inserted with the help of the aiming device. The hip pin was inserted first to prevent possible rotation of the medial fragment when inserting the neck screw. The length of the hip pin was indicated on the measuring device and was calculated 5 mm before the tip of the guidewire. Then the neck screw was inserted using a cannulated screwdriver. The final position was confirmed with an image intensifier. Rotation of the distal fragment was then confirmed, followed by distal locking and closure of the wound in layers [Figure 4]a-d.
Figure 3:

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Figure 4:

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Postoperative care

Postoperatively, patients' vital signs were monitored. Antibiotics and analgesics were continued in the postoperative period. Forty units of fractionated heparin (Clexane) as an anticoagulant were given daily before the surgery and in the postoperative period until the patients were ambulatory. Suction drain if used was removed after 48 h. Sutures were removed between the 10th and 15th postoperative day.

Patients were encouraged to sit on the bed 24 h after surgery. Patients were taught quadriceps strengthening exercises and knee mobilization once the suction drain was removed. Only in very unstable fracture patterns was weight-bearing not advised. The patients were encouraged to weight-bear partially with axillary crutches or a walker depending on the pain tolerability of each patient.

All patients were followed up at the orthopedic clinic at 2 weeks for removal of sutures and then at an interval of 6 weeks until the fracture union was noted and then every 3 months for a minimum of 1 year.

At every visit the patient was assessed clinically and according to the Merle d'Aubigné hip scoring system [Table 1] for hip and knee function, walking ability, fracture union, deformity, and shortening. A radiograph of the involved hip with femur was taken to assess fracture union and implant bone interaction [Figure 5],[Figure 6] and [Figure 7] [5],[6].
Figure 5:

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Figure 6:

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Figure 7:

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Table 1: The Merle d'Aubigné scoring system

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The Merle d'Aubigné scoring system [1] used in this work depends on three 'core' factors: pain, mobility, and walking. Each factor is rated from 0 to 6 and the total score represents the summation of the points of three factors (18 points).

  1. Excellent: in this scoring system it is denoted by the highest score of 18.
  2. Good: ≥15 points.
  3. Fair: 12-14 points.
  4. Poor: ≤11 points. [Table 1].



  Results Top


This prospective study includes 20 subtrochanteric fractures in 20 patients. They were evaluated both clinically and radiologically. The clinical results were assessed according to the Merle d'Aubigné functional ability score (D'Aubigné; 1990). Radiological evaluation included assessment of union (delayed, nonunion), malunion, failure of fixation, and implant failure.

Ages of the patients in this study ranged from 20 to 70 years and 75% of them were above 40 years. The male {13} to female (seven) ratio was 1.2 : 1. The right side was affected in 11 patients (55%) and the left side in nine (45%). The mechanism of injury in this study was fall at home in most cases (14 patients, 70%), road traffic accidents (four patients, 20%), and fall from stairs (two patients, 10%).

Fracture type in this study according to the AO classification showed a predominance of type A (60%), followed by type B (30%) and type C (10%) [Table 2] and [Figure 8].
Figure 8:

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Table 2: Distribution of fracture type according to the AO system

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According to the The Merle d'Aubigné scoring system, five patients (25%) scored excellent, eight scored good (40%), four scored fair (20%), and three scored poor (15%).

Partial weight-bearing was begun by the 2nd to 4th day in six cases using crutches, whereas partial weight-bearing was begun between days 5 and 7 in 12 cases. Partial weight-bearing was delayed until after the first 2 weeks in two cases, because the patients were osteoporotic. Early weight-bearing resulted in no implant failures. The average time to partial weight-bearing ranged from 2 to 14 days with an average of 5.8 days. Eighteen patients (90%) were walking unaided by final follow-up.

Of the cases, 90% had united by final follow-up. The average time to radiological union was 6 months. Delayed union occurred in one case despite absence of pain and presence of normal function, and the patient refused further surgery. Two cases did not unite: in the first case, bone grafting was performed and the follow-up radiograph after 3 months showed union; in the second case, deep infection resulted in loosening of neck screws with backing out, which we had to remove, and a nail and external fixator were used. Twelve patients (60%) returned to their pretrauma environment or previous employment.

The neck-shaft angle varied from 107° to 130° with an average of 126.4°. Varus deformity was present when the neck-shaft angle was reduced by more than 10° compared with the contralateral hip. Varus malunion occurred in two cases (10%). In the first case, neck screws slightly backed out due to collapse at the fracure site, whereas in the second case the neck screws became loose secondary to infection and eventually backed out.

Intraoperative complication

There was only one case of broken medial cortex during insertion of the nail due to jamming of the nail against the medial cortex managed by reinsertion of the nail after over-reaming of the proximal part and gentle reinsertion.

Postoperative complication

There was backing out of neck screws in three cases. In the first case the two proximal screws backed out in 'reversed z effect'. In the second case the neck screws became loose due to deep infection, which resulted in screw backout after 4 months. In the third case, neck screws backed out after 6 months (relative finding as the proximal fragment had fallen into varus due to early weight-bearing), but with no effect on union.

We encountered only one case of deep infection. The patient was diabetic and there was loosening and backing out of neck screws. Surgical debridement was carried out in this patient and extraction of the nail was performed and an external fixator was used for fixation until the infection had subsided. There was one case of superficial infection, which responded to antibiotics.

Our study recorded time to operation, preopererative hemoglobin (HB), postoperative HB, amount of operative bleeding, operation time, screening time, partial weight-bearing, and hospital stay [Table 3].
Table 3: Statistical distribution of time to operation, preoperative hemoglobin, postoperative hemoglobin, amount of operative bleeding, operation time, screening time, partial weight-bearing, hospital stay

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  Discussion Top


In our work we encountered no femoral shaft fracture during nail insertion. Yoo and colleagues reported one case of femoral shaft fracture at the nail tip caused by a slip. Boriani et al. [6]reported having no intraoperative shaft fractures in 119 consecutive nailings [7].

Distal locking screws are indicated in subtrochanteric fractures but they have been recognized as the origin of complications, specifically diaphyseal fractures. Two distal locking screws were used in all fractures, and there was no postoperative femoral shaft fracture in any case. Alvarez et al. [8] mentioned that, as the distal part of the nail already produces a concentration of stress at that site, weakening of the bone by screws should be avoided.

The incidence of varus deformity was significantly less in patients treated with the PFN compared with those treated with side plates. Park and Alvarez reported in their study that six of their 43 patients (13.9%) experienced varus malunion. In this work, the neck shaft angle ranged from 107° to 130° with an average of 126.4°. We observed only two cases of varus collapse of the proximal fragment: mild varus 4° in case 15 and 13° of varus in case 16 [8],[9].

In this work there were no cases of open reduction. All fractures reduced in a closed manner and without the need of a cerclage wire. In a study by Hotz TK et al., [10] closed fracture reduction was not successful and open reduction with use of a cerclage wire was necessary in five patients with unstable peritrochanteric fractures (including subtrochanteric fractures). The latter procedure must, of course, be performed in some unstable proximal femoral fractures, although this is not the purpose of minimally invasive devices [10].

There were no proven cases of deep vein thrombosis in our work. Deep vein thrombosis has been reported in many studies, with an incidence of 8%. Hotz and colleagues reported one out of 37 cases developing deep vein thrombosis. There is no explanation in the literature for the occurrence of this complication. A possible explanation could be prolonged bed rest and pressure applied to the calf during traction on the orthopedic table. To avoid this complication, patients were given 40 units of fractionated heparin (Clexane) daily before the surgery and in the postoperative period until they were ambulatory [10].

The incidence of postoperative infection with the cephalomedullary nailing is very low because of small wound and less surgical dissection. In our work, there was one case of superficial infection (5%) [case no. [2]] and one case of deep infection (5%) [case no. [12]], which started 3 months after surgery. Rethnam and colleagues reported infection in three out of 42 patients treated with a Russell-Taylor reconstruction nail: one was a superficial wound infection that settled with antibiotics and the other two patients required surgical debridement. Alvarez et al. [8] reported two out of 42 cases that developed infection [11].

The cephalomedullary nail has demonstrated superior strength, which is favorable in cases of unstable fractures at the subtrochanteric region. Boriani and colleagues reported only two nail breakages in 648 cases (0.3%). Alvarez et al. [8] reported no implant failure in 42 patients with unstable subtrochanteric fractures treated with a cephalomedullary nail. In this study there were no cases of nail breakage [6],[12].


  Conclusion Top


PFN is a reliable implant for subtrochanteric fractures, leading to high rate of bone union and minimal soft-tissue damage. Intramedullary fixation has biological and biomechanical advantages, but the operation is technically demanding. To make this method truly minimally invasive it must be learned gradually and with tremendous patience.

Subtrochanteric fractures are best stabilized with a PFN. The intramedullary location provides a buttress against lateral displacement and it decreases bending strain on the implant.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.D′Aubigne RMPostelM. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954; 35 :451-475.  Back to cited text no. 1
    
2.Chakraborty MK, Thapa P. Fixation of a subtrochanteric fracture of the femur. J Clin Diagn Res 2012; 5 :76-80.  Back to cited text no. 2
    
3.Bucholz, Robert W, Heckman, James D, Court-Brown, Charles M. Rockwood & Green′s Fractures in Adults, 6 th Edition. Lippincott Williams & Wilkins 2006; 2 :46.  Back to cited text no. 3
    
4.LS Jiang, Sheng L, Dai LY. Intramedullary fixation of subtrochanteric fractures with long proximal femoral nail or long gamma nail: technical notes and preliminary results. Ann Acad Med Singapore 2007; 36 :821-826.  Back to cited text no. 4
    
5.G Holt, P Nunag, K Duncan, A Gregori. Outcome after short intramedullary nail fixation of unstable proximal femoral fractures. Acta Orthop Belg 2010; 76 :347-355.  Back to cited text no. 5
    
6.Boriani S, De Iure F, Bettelli G, Specchia I, Bungaro P, Montanari G, et al. The results of a multicenter Italian study on the use of the Gamma nail for the treatment of pertrochanteric and subtrochanteric fractures: a review of 1181 cases. Chir Organi Mov 1994; 79 :193-203.  Back to cited text no. 6
    
7.Yoo JH, Yang KH, Park SY, Won JH, Yoon HK. The treatment of unstable reverse oblique intertrochanteric fractures with proximal femoral nail (PFN). J Korea Orthop Assoc 2005; 40 :733-740.  Back to cited text no. 7
    
8.Alvarez JR, Gonzolez RC, Aranda RL, et al. Indications for use of the long Gamma Nail. Clin Orthop 1998; 350 :62-66.  Back to cited text no. 8
    
9.Park S, Kang JS, Kim HS, Lee WH, Kim YH. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by the compression hip screw: a randomized prospective trial. Int Orthop 1998; 22 :157-160.  Back to cited text no. 9
    
10.1Hotz TK, Zellweger R, Kach KP. Minimal invasive treatment of proximal femur fractures with the long gamma nail: indication, technique and results. J Trauma 1999; 47 :942-945.  Back to cited text no. 10
    
11.1U Rethnam, Cordell-Smith J, Thirumoolanathan MK, Amit S. Complex proximal femoral fractures in the elderly managed by reconstruction nailing - complications & outcomes: a retrospective analysis. J Trauma Manag Outcomes 2007; 1 :1-7.  Back to cited text no. 11
    
12.1Lyddon DWJr The prevention of complications with the Gamma locking nail. Am J Orthop (Belle Mead NJ). 1996; :357-363.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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