Trochanteric fixation nail in inter trochanteric fractures of femur in adult population
Rajeev Shukla, Daksh Sharma, Ravi Kant Jain
Depatment of Orthopaedics, Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
|Date of Web Publication||20-Mar-2019|
Dr. Ravi Kant Jain
Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Intertrochanteric fractures in the elderly are common fractures with high morbidity and mortality. Moreover, its surgical stabilization with early rehabilitation remains a persistent challenge. These patients have poor bone quality and conventional osteosynthetic procedures frequently lead to nonunion and metal failure. The primary goals of treatment are stable fixation and early rehabilitation. The aim of this study was to evaluate the functional outcome, complications of intertrochanteric fractures treated with trochanteric fixation nail (TFN).
Materials and Methods: This retrospective study was conducted on the total of 50 patients with fracture intertrochanteric femur and treated with TFN from July 2011 to August 2016. The patients evaluated at 6 months, 1–4 years postoperatively and assessed using the Modified Harris hip score.
Results: The mean age of patients was 59.78 ± 16.58 years. There were 37 males and 13 females. The mean duration of surgery was 40.40 ± 20.86 min. The mean union time was 2.20 ± 0.50 months. One (2%) patient developed deep venous thrombosis, whereas 1 (2%) patient had back out of stabilizing screw and 1 (2%) patient had implant failure. The Harris hip score at 1-year and 4-year follow-up was 92.12 and 97.92, respectively, which is slightly better than scores from other implants used for similar fracture.
Conclusion: For intertrochanteric fracture fixation, trochanteric femur nail offers good functional outcome with early ambulation and weight bearing with a high rate of union and minimal complications.
Keywords: Intertrochanteric fracture, trochanteric fixation nail, ultrashort proximal femoral nailing
A retrospective cross-sectional study of patients with trochanteric fractures of the femur that were treated with TFN at a tertiary care center in Indore (India) from July 2011 to August 2016 was conducted after clearance from the Institutional Ethical Committee.
Fifty-three out of 70 patients were eligible for this study, and 3 patients were lost to follow-up 1-year postoperatively. Hence, a total of 50 patients were analyzed in this study.
Age more than 21 years, closed fractures, and isolated intertrochanteric fracture of ipsilateral limb were included.
Fracture in pediatric age group, open fracture, pathological fracture, old-neglected fracture of more than 3 weeks, associated fracture of the ipsilateral limb.
Standard preoperative planning was done. Radiographs of the pelvis with both hips anteroposterior view and traction-internal rotation view were obtained to confirm the diagnosis.
All patients underwent surgery by one orthopedic specialist (the first author of the paper) with the patient in the supine position on a fracture table with fluoroscopic-guided imaging.
After the patient had been anesthetized, closed reduction to a near anatomical position was performed. As a standard protocol, intravenous cephalosporin was administered intravenously before the skin incision [Figure 1]. Patients were prepared for the fracture fixation with TFN [Figure 2] through a lateral approach. Femur was reamed by hand and guidewires used in all procedures. Distal interlocking screws were placed through the nail guide for all nails.
The classification used was the Evan's classification and all the fractures which were classified unstable were treated with TFN.
All patients in our study underwent a similar rehabilitation protocol involving intravenous antibiotics (cephalosporin) were given for 3 days followed by oral antibiotics for another 5 days. All drains were removed by 48 h. Active and passive physiotherapy of hip, knee, and ankle started according to pain tolerance of patients.
The wounds were inspected on the 2nd postoperative day. Stitches were removed between 10th and 14th postoperative day. Non-weight-bearing was started on the 2nd postoperative day with walker support, whereas partial weight-bearing was started at 2 weeks and full-weight-bearing walking was started after 6 weeks.
The patients evaluated at 6 months, 1–4 years postoperatively and assessed using the Modified Harris hip score.
All patients were followed up for a minimum period of 4 years.
The mean age of patients was 59.78 ± 16.58 years. The eldest patients age was 87 years and the youngest patient was 43 years. There were 37 males and 13 females.
Out of 50 patients, 36 (72%) patients suffered fracture due to trivial trauma-like fall in the bathroom, whereas 14 (28%) suffered road traffic accident.
Three (6%) patients were diabetic, whereas 17 (34%) patients had hypertension. The mean duration of surgery was 40.40 ± 20.86 min. The mean perioperative blood loss during the surgery was 75.4 ± 26.4 ml.
Patient distribution according to fracture type was 40 (80%) patients had unstable fractures and 10 (20%) patients had stable fractures [Table 1].
Union time was evaluated radiologically by observing the callus formation at the fracture site in at least three planes. The mean union time was 2.20 ± 0.50 months.
Perioperative complications recorded include 1 (2%) case of deep venous thrombosis due to the long duration of bed rest, whereas 1 (2%) patient had back out of stabilizing screw due to unknown cause and 1 (2%) patient had implant breakage due to fall again.
The mean Modified Harris Hip Score at final follow was 97.92 ± 5.86 [Figure 3]. The patients were followed up for different intervals with a minimum follow-up of 4 years. Two patients were lost to the follow-up and 1 patient died during the study. The average follow up time was 4 years.
The mean age was 57.62 ± 15.78 years. However, some earlier studies done by Sonar et al. and Gill et al., shows relatively older age group in comparison to our study. The frequency of trochanteric fractures in a relatively younger age group in this series may be related to the shorter life expectancy of the population and high-velocity trauma causing the fracture in several younger patients in the study.
There was a male preponderance in comparison to the females. This finding in the present study is similar to a various published article such as in a study by Patil et al. which indicate a preponderance of male patients.
The reverse obliquity fracture and the intertrochanteric fracture with subtrochanteric extension are relative contraindications for dynamic hip screw (DHS) fixation due to their high rate of failure. Given all these limitations to DHS, nailing has shorter lever arm with reduction in bending stress and lower implant failure rate and makes no dissection at the fracture site. The nail occupies the medullary canal, preventing excessive sliding and medialization of the shaft. It also covers all the other fracture patterns-like reverse obliquity, and intertrochanteric fracture with subtrochanteric extension effectively.
Intertrochanteric nonunion should be suspected in patients with persistent hip pain that have x-rays revealing a persistent radiolucency at the fracture site 4–6 months after fracture fixation. Progressive loss of alignment strongly suggests nonunion, although union may occur after an initial change in alignment, particularly if fragment contact is improved. Average healing time in our study was 11 weeks whereas, in a study by Sanjay bhandari, the average time of union in all patients was about 16 weeks for the DHS and proximal femoral nailing (PFN).,
After TFN fixation, by the 2nd week, partial weight bearing was allowed in 70% of patients and full-weight bearing was allowed to 30% of patients by the 6th week, whereas in a study by Jonnes et al. partial weight bearing was started by 7.87 and 3.73 weeks and full weight bearing by 11.83 and 7.93 weeks for DHS and PFN, respectively.
Mean Harris hip Score at 1 year follow-up was 92.12, however in a comparative study by Jonnes et al. between PFN and DHS showed results of 89.08 and 90.33, respectively, which is slightly lesser than our study.
Complications were seen in 3 (6%) patients in our study, whereas study reported by Endigeri et al. in their study of 50 cases had complication in 11 (22%) patients treated by PFN and whereas a study reported by Mardani-Kivi et al. had complications in 6 (10%) patients treated with DHS. Bhakat and Bandyopadhayay and Nargesh et al. in their comparative study with DHS found that there is less shortening of the limb in TFN than DHS.,
The range of motions in flexion, abduction, and internal and external rotations was good to excellent in most of the cases operated. The fair and range of motion were attributed to the poor compliance of the patients for regular physiotherapy.
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