Proximal Femoral Nailing for Unstable Trochanteric ... Femoral Nailing for Unstable Trochanteric...

Article ID: WMC002805 ISSN 2046-1690

Proximal Femoral Nailing for Unstable TrochantericFunctional Scores and Complications: AProspective StudyCorresponding Author:Dr. T Santhamoorthy,Senior Resident, Department of Orthopaedics, JIPMER, Pondicherry - India

Submitting Author:Dr. T Santhamoorthy,Senior Resident, Department of Orthopaedics, JIPMER, Pondicherry - India

Article ID: WMC002805

Article Type: Research articles

Submitted on:12-Dec-2012, 04:32:23 AM GMT Published on: 14-Feb-2013, 06:35:54 AM GMT

Article URL: http://www.webmedcentral.com/article_view/2805

Subject Categories:ORTHOPAEDICS

Keywords:Proximal Femoral Nail; Unstable Intertrochanteric Fractures

How to cite the article:Santhamoorthy T, Saseendar S, Patro DK, Menon J. Proximal Femoral Nailing forUnstable Trochanteric Functional Scores and Complications: A Prospective Study . WebmedCentralORTHOPAEDICS 2013;4(2):WMC002805

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Proximal Femoral Nailing for Unstable TrochantericFunctional Scores and Complications: AProspective StudyAuthor(s): Santhamoorthy T, Saseendar S, Patro DK, Menon J

Abstract

Purpose: The purpose of the study was to assess thefunctional outcome and complications pertaining tounstable trochanteric fractures treated by proximalfemoral nailMethods: 11 consecutive unstable type ofintertrochanteric and subtrochanteric fractures wereselected prospectively between 2007 to 2009 afterexcluding patients with Comminution at the entry pointin greater trochanter, Severe co morbidities precludinganesthesia and Open fractures. Parker and palmermobility score, Barthel index and Salvati-Wilson hipscoring system were used for functional assessment.Results: The mean Parker & Palmer score was8.1.The Barthel Index at 6 weeks and 3 months were70 and 90. All patients had excellent or goodfunctional hip scoring according to Salvati-Wilson hipscoring system. Implant related complicationsoccurred in 3 patients.Conclusion: Proximal Femoral Nail is a better implantfor unstable type of intertrochanteric andsubtrochanteric fractures as our study shows excellentand good functional results with acceptable implantrelated complications.

Introduction

Trochanteric fractures have been traditionallysubdivided into intertrochanteric and subtrochantericfractures. In 1949 Evans classified intertrochantericfractures into stable and unstable types.subtrochanteric fractures are inherently unstable.Before 1960s, treatment for trochanteric fractures wasof necessity nonoperative. In elderly patients, thisapproach was associated with high complicationrates1.Techniques of operative fixation have changeddramatically since the 1960s. Operative managementhas consequently become the treatment of choice forintertrochanteric fracture2.The sliding hip screw wasthe most widely used implant for stabilization of bothstable and unstable intertrochanteric fractures. Despitethis there has been dissatisfaction with use of this typeof dev ice to s tab i l i ze unstab le f rac ture

patterns3,4,5,6.This has led to the development ofintramedullary hip screw devices, which offers severalpotential theoretical advantages: a. More efficient load transfer,b. Shorter lever arm decreases tensile strain on theimplant c. Incorporates a sliding hip screw mechanism, whichallows controlled fracture impaction d. Theoretically requires shorter operative time andless soft-tissue dissection than a sliding hip screw2.

The various intramedullary devices avail were Endersnail (condylocephalic nail) and cephalomedullay nailslike gamma nail, intramedullary hip screw, trochantericantigrade nail, proximal femoral nail, trochantericf ixation nai l etc. Literature indicates bothintramedullary nailing and extramedullary devices hasbeen used in management of intertrochantericfractures, but with merits and demerits with either ofthe devices7,8. According to many authorscephalomedullary nail with strong fixation in theproximal femur is the treatment of choice forsubtrochanteric fractures9,10,11,12,13,14,15,16. Butfew authors believe that other devices equallyeffect ive or better than cephalomedul larynails17,18,19,20,21,22,23. Hence we proposed tostudy the functional outcome and complications ofproximal femoral nailing in unstable intertrochanteric &subtrochanteric fractures.

Patients and Methods

The study was performed in accordance with theethical standards of the 1964 Declaration of Helsinkiand was approved by the Ethical Committee of ourInstitution. 11 patients presented to department oforthopedics between November 2007 to May 2009with Closed unstable intertrochanter ic &subtrochanteric fractures in adults were included. All11 patients underwent fixation using proximalfemoral nail after getting the informed consent.Intraop fracture reduction was assessed usingBaumgaertner 30 classification as good or acceptableor poor. Patients were made to do high situp, isometricquadriceps & deep breathing exercises from 1st post



operative day. Dangling of legs & ROM exercise forknee was taught from day 2. Non weight bearingwalking begun with crutches or walker as soon aspatients become confident (on an avg at 4-7 days postop). Follow up done from there on at 1st, 2nd, 3rd, 6thmonths & at 1 year. At each follow up patients wereassessed in terms of local wound status, pain, andambulation status, local part x ray to assess implantposition, fracture healing & TAD score. Each patient’sBarthel index at 6weeks & 3 months postoperativelywere assessed as an indicator of operative procedureon early functional recovery. Parker & Palmer mobilityscore 32 at 1 year were calculated. Functional hipscoring assessed using Salvati- Wilson 31 hip scoringsystem for all patients & results were expressed asexcellent, good, fair or poor.

Results

Among the 11 patients 6 were males and 5 werefemales and their mean age being 53.7 years. 6 ofthem due to simple fall, 4 were due to RTA & 1 wasspontaneous (pathological due to plasmacytoma). 6Patients had intertrochanteric & 5 patients hadsubtrochanteric fractures.4 of the intertrochantericfractures belonged to Evans type I-comminuted,unstable variety & 2 belonged to Evans typeII(reverse oblique ). 4 of the subtrochateric fracturesbelonged to type V Seinsheimers variety & 1 belongedto type IIB Seinsheimers variety as depicted in thechart below. Medical comorbidities requiring treatmentbefore surgery encountered in 3 patients. The meanPre-injury Parker & Palmer mobility score was 8.7.Three dimensional reconstructional CT-Scanevaluations done in 2 patients due to grosscomminut ion of the subtrochanter ic andintertrochanteric region( mainly to assess the entrypoint). Closed reduction achieved in 9 patients. Openreduction required in 2 patients. The reduction wasgood in 10 of the 11(91%) patients and acceptable in 1patient. The reduction was considered good,acceptable or poor –according to the modified criteria of Baumgaertner et al30 . Mean operative time was189 mins (range-120-220mins; including preparationtime). Average blood loss was 374.5 ml (100-1000ml).The mean fluoroscopy time was 96 secs (variedbetween 66 to 150 secs). In all patients both thecervical screws inserted except in one patient in whomdue to lack of space in the neck a Knowels pin wasused as the derotation screw. Both distal locking donein 9 of the 11 patients. In 2 patients only 1 distallocking done. All were static locking. In 1 patientcerclaging was done at distal locking site due

splintering of fracture. One patint developed stitchabscess,which was drained & treated with appropriate antibiotics. One patient had serous oozingfrom distal locking wound, but, C/S was negative & itsubsided over a period of week without anyintervention. One patient was immobilized in hip spicaprophylactically as there was intraoperative splinteringat distal locking site. 6 patients were able to walk nonweight bearing with crutches or walker during the 1st10 days of postoperative period.(patients withassociated distal radius fracture were mobilized onlyafter 4 weeks). Mean duration of hospital stay was43.5 days (21 to 120 days). Average follow up periodwas 11.1 months (3 months to 22 months). No woundrelated complication on follow up. All patients whocame for follow up complained of mild to moderatepain at trochanter region for 1st 3 months especiallyon doing physiotherapy. Among patients whocompleted 1 year follow up, 2 patients (28.5%) hadpersistent mild pain at the upper lateral thigh aspecton squatting. The average shortening of the operatedlimb after fracture healing was 1.1 cms (range 0.5-2.5cm).1 patient required shoe raise.Partial weightbearing started in 6 of 9 patients who turned up forfollow up at 6 weeks. All 11 were able to do full weightbearing at 6 months of postop. 8 of the 11 patients(72.7%) were able to squat and sit cross leg at theirfinal follow up. The mean Parker & Palmer mobilityscore at 1 year was 8.1 (6-9). Barthel index at 6 weeks& 3 months of postoperative period was 70 & 90respectively. 36.3% of our patients had excellent &66.7% of our patients had good functional resultsaccording to Salvati-Wilson scoring system(table-1).66.6 % (6/9) patients were able to climb the stairsunaided at 1 year of follow up. All 11 patients hadcomplete union at fracture site at 1 year followup.Average fracture healing time in these patients was3.7 months. Various malalignment of 1260 found in 1patient. TAD score in our study varied widely betweenpatients. The mean score was 26.3 in immediatepostoperative period and it has increased to 28.4 at 1year.1 patient had back out of lower cervical screw,which needed removal at 18 months, afterconsolidation of fracture(fig-1). Nail broken at upperdistal locking slot site at 10th month post op in 1 patient, when fracture healed completely(fig-2). 1patient died 2 years postop due to myocardialinfarction.

Discussion

The study is a prospective design, comprising of 11patients, of them 6 were males & 5 were females.



Preoperative CT scan with 3D reconstructionevaluation was done in 2 patients with comminutedsubtrochanteric fracture. closed reduction obtained 9patients, among that 8 (88%) were in good positionand 1 was in acceptable position (according toBaumgaertner et al.). 2 patients required openreduction. In 1 patient due to guide wire break atfracture site, open reduction done to retrieve the guidewire. In other patient closed reduction was notacceptable & fracture line extended distally till distalscrew slot, in which case additional stabilization donewith a cerclage. After facing this difficulty we decidedto follow the rule of working distance of 5 cm from thedistal fracture site to distal locking screw slot assuggested by many authors8,9. In our study theaverage fluoroscopy time was 96.9 secs and averageblood loss was 374.5 ml, which were comparable toother studies using PFN. In our study none of thepatients required revision.1 patient requiredreoperation for proximal lateral thigh pain due to backout of lower cervical screw after f ractureconsolidation.Post operative wound complication ofour study was also similar to other studies 16,17,18.Many of the studies mention a fracture healing time of3 – 4 months..The longest healing time of 17 monthswas documented in the study by Si Yong Park et al332008 in treating trochanteric fractures [31-A3.1(6.5%),31-A3.2(34.8%), and 31-A3.3(58.7%)] using PFN in46 patients. In our study the fracture healing time was 3.4 months. None of the patients had non union. Manyof the studies mention that weight bearing beingallowed gradually around 6 weeks period when callusformation is adequate 16,24. In our study also wefollowed delayed controlled weight bearing at anaverage period of around 6 weeks when adequatecallus formation occured in all patients. We hadencountered few implant related complications. In 1patient back out of lower neck screw occurred at 1year of follow up. The patient underwent electiveremoval of the screw as fracture has consolidated well.Another patient had nail broken at the distal lockingscrew slot site at 10 months of follow up. Patient didnot had trauma & asymptomatic at device failure site.This patient found to have both the distal screws beingout of the slot on follow up radiography, as it wasmissed in initial few months.Both the patientsotherwise functionally not affected & returned to theirprevious profession.None had screw cut out, nail tipfracture or Z-effect. Similar and many other types of implant related complications been mentioned in theliterature14,25,26,27,28,29. The tip-apex distance wasused to describe the position of the screw. Thetip-apex distance (TAD), expressed in millimeters, isthe sum of the distances from the tip of the lag screw

to the apex of the femoral head on both the AP andlateral radiographic views. The utility of the TAD wasdemonstrated by MICHAEL R. BAUMGAERTNER etal30-1995 in a series of 198 intertrochantericfractures;. No lag screw cut-out occurred when theTAD was 27 mm or less.Conversely, lag screw cut-outrate increased to 60% when the TAD was more than45 mm. The mean TAD score in our study was26.3.none of the cases had screw cut out.

Functional parameters:

Independence of walking at 1 yr (using Parker &Palmer mobility scoring system) has been used as themost common mobility assessing system. Po-ChengLee et al18 2007(RTRN& DCS) - At the 2-yearfollow-up, the mean mobility score was 7.5 (Parker &Palmer mobility score). Mean mobility scoresignificantly differed according to the presence ofassociated injury (p - 0.05) and significantly correlatedwith the duration of hospital stay. In our study theaverage Parker & Palmer score at 1 year was 8.1.There are various scoring systems being used inliterature for assessing overall functional outcome inhip fracture patients (Harris hip scoring 34, charnleyscoring 35,. Merle d’Aubigné score system 36, BarthelADL Index 37, Salvati-Wilson scoring systems 31 etc)Among that Barthel index & Salvati-Wilson scoringsystems being used in our study. Barthel index takesinto account of the most of daily activities of life. Italso gives a feed back on the impact of treatment &rehabilitation in fastening the recovery as it is used at6 weeks & at 3rd month postop. The disadvantagewith Barthel index was scores are not being graded. Salvati-Wilson scoring systems consider pain, walkingability & hip movements, apart from functionalassessment. The merit of this system was, it alsogrades the scores as excellent, good, fair & poorwhich will be useful for understanding. In our study weused both the systems & the results are tabulatedabove. Using Barthel ADL index our study showsmean score of 70 at 6 weeks post op and 90 at 3rdmonth post op.8 patients(72.7%) recovered >90 % oftheir preinjury Barthel index values,which wascomparable to other studies which used the sameindex ,like Fogagnolo F et al 38(2004) using PFN-66.6%. To conclude Proximal Femoral Nail is asuitable implant for unstable type of intertrochantericand subtrochanteric fractures as our study showsexcellent and good functional results with acceptableimplant related complications.

References



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Illustrations

Illustration 1

Fig 1



Illustration 2

Fig 2



Illustration 3

Back out of Lag Screw( after fracture healing)



Illustration 4

1 Year Post op (implant failure; but fracture consolidated)



Illustration 5

showing Salvati-Wilson hip scoring for our patients



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