Functional Outcome of Intertrochanteric Fractures Treated by Proximal Femoral Nailing Anti-Rotation-II

Abstract

INTRODUCTION: Intertrochanteric fracture is one of the most devastating injuries in the elderly. The incidence of these fractures increases with advancing age. These patients are more limited to home ambulation and are dependent in basic and instrumental activities of daily living. 50 % of fracture around hip patients in elderly is of trochanteric fracture and these 50 % of fracture are unstable type of trochanteric fractures. They are usually complicated with associated co-morbidities like .osteoporosis, diabetes, hypertension, renal failure. In such circumstances, nonoperative treatment is mainly reserved for poor medical candidates and non-ambulantatients with minimal discomfort after fracture. Today operative treatment has largely replaced conservative measures and the goal of treatment is to achieve accurate or acceptable. anatomical and stable reduction with rigid internal fixation. In order to achieve early mobilization of patients and prevent complications of prolonged recumbence. Despite marked improvements in implant design, surgical technique and patient care, intertrochanteric fractures continue to consume a substantial proportion of our health care resources and remain a challenge to date. Complications with intertrochanteric fractures arise primarily from fixation rather than union or delayed union. because the intertrochanteric area is made up of cancellous bones. AIM OF THE STUDY To Assess Functional outcome of Intertrochanteric fractures treated by Proximal Femoral Nailing Anti-rotation-II. MATERIALS AND METHODS At our institution we selected 20 cases (21 hips – one patient had bilateral trochanteric fracture) of unstable trochanteric fractures for this prospective study. There were 11 males and 9 females included. Study Centre: Department of orthopaedics, Govt. Kilpauk Medical College and Government Royapettah Hospital, Royapettah, Chennai. Study Period: All patients are followed up for period of atleast 6 months. Variables Studied: Functional outcome based on pain, function, absence of deformity and range of motion using HARRIS HIP SCORE. INCLUSION CRITERIA: • Patients > 18 years of age presenting to our causality with intertrochanteric femoral fractures with all Boyd and Griffin types (1-4). • Both displaced and Undisplaced fractures. • Fractures less than 1 week duration. • Without any other associated fractures. EXCLUSION CRITERIA: •Fractures with non union changes. •Old malunited intertrochanteric fracture. •Patients with arthritic changes in hip joint. •Pathological fractures. RESULTS: The results of the study are summarized as below: The time duration of surgery of the patients varied from 37 mins to 98 mins. The distribution of patients with Boyd and griffin types are charted below against time duration of surgery. The number of fluoroscopy shots used during surgery was also less. The data is charted below, less than ten shots in 3 patients, 10- 15 shots in 13 patients, more than 15 shots in 5 patients. The blood loss during surgery is also less in these patients with less than 50 ml in 1 patient, between 50-100 ml in 7 patients, between 100-150 ml in 12 patients, more than 150 ml in 1 patient. The HARRIS HIP SCORE grading was done and 5 patients were graded excellent, 11 as good, 4 as fair and none as poor. The patient with bilateral trochanteric fracture was graded good. Among excellent 3 were male and 2 female, among good cases 7 were male and 4 were female, among fair cases 1 was male and 3 were female. Patients were evaluated clinically and radiologically at 3 weeks interval for first 3 months and there after monthly for the next 3 months and bimonthly for next 12 months. During follow up the Harris Hip Score was evaluated at 3 months and 6 months post operatively. Various parameter like pain, limp, use of support, distance walked, stair climbing, sitting, absences of deformity, range of motion were evaluated using Harris Hip Score. CONCLUSION: Intramedullary nailing with the PFN A-II has distinct advantages over Conventional PFN or DHS like shorter operating time and lesser blood loss for elderly, osteoporotic unstable trochanteric fractures. Early mobilization and weight bearing is allowed in patients treated with PFN A-II thereby decreasing the incidence of bedsores, uraemia and hypostatic pneumonia. The operative time is much lower compared with other procedures which also contributes with lesser blood loss. The incidence of postoperative femoral shaft fractures, Non-union rates in PFN A-II can be reduced by good preoperative planning and correct surgical technique, adequate reaming of the femoral canal, insertion of implant and meticulous placement of distal locking screws. PFN A-II is a significant advancement in the treatment of trochanteric fractures which has the unique advantage of closed reduction, preservation of fracture hematoma, minimal soft tissue damage during surgery, early rehabilitation and early return to work