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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 35  |  Issue : 3  |  Page : 413-418

A comparison study of proximal femoral nail and dynamic hip screw devices in unstable trochanteric fractures


1 Professor of Orthopedic Surgery Benha Faculty of Medicine, Benha University, Egypt
2 Assistant Professor of Orthopedic Surgery Benha Faculty of Medicine, Benha University, Egypt

Date of Submission22-Apr-2018
Date of Acceptance06-Sep-2018
Date of Web Publication07-Jan-2019

Correspondence Address:
Dr. Mohamed A Mostafa
Benha Faculty of Medicine, Benha, 13518
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_81_18

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  Abstract 


Background Trochanteric fracture of the femur is a common orthopedic injury in the geriatric population, and the use of extramedullary dynamic hip screw (DHS) is still more superior with fewer complication rates in stable trochanteric fractures. On the contrary, proximal femoral nail (PFN) may have some advantages in fractures at the level of lesser trochanter, reversed obliquity fractures and in subtrochanteric fracture, although the evidence is yet insufficient.
Aim The aim of this study was to compare the results of treatment of unstable trochanteric fracture of femur in 40 patients treated by either PFN or DHS regarding primary outcomes: early mobilization, pain improvement, radiological assessment for fracture reduction and fixation and secondary outcome.
Patients and methods This study was conducted on 40 patients with unstable pertrochanteric fractures treated surgically, where 20 patients were treated by DHS and 20 patients were treated by PFN.
All were planned for follow-up examination for a period of 8 months from the date of operation. Full workup including the age, sex, medical history, type of fracture, mechanism of injury, and plain radiographs was carried out on admission.
Results In this study, the duration of union in the whole study population ranged from 1.5 to 8 months, whereas in the group of patients with trochanteric fractures, it ranged from 2 to 8 months.
Conclusion We recommend to conduct larger studies to further evaluate the DHS and PFN in the management of unstable trochanteric fractures, with a longer follow-up duration.

Keywords: dynamic hip screw, proximal femoral nail, tip-apex distance, trochanteric fractures


How to cite this article:
Ahmed HH, Bassiooni HA, Mohamady EM, Mostafa MA. A comparison study of proximal femoral nail and dynamic hip screw devices in unstable trochanteric fractures. Benha Med J 2018;35:413-8

How to cite this URL:
Ahmed HH, Bassiooni HA, Mohamady EM, Mostafa MA. A comparison study of proximal femoral nail and dynamic hip screw devices in unstable trochanteric fractures. Benha Med J [serial online] 2018 [cited 2019 Dec 15];35:413-8. Available from: http://www.bmfj.eg.net/text.asp?2018/35/3/413/249431




  Introduction Top


Intertrochanteric fractures are defined as ‘fractures involving upper end of femur through and in between both trochanters with or without extension into upper femoral shaft’. An increasing incidence of intertrochanteric fractures with advancing age is well known [1].

Trochanteric fracture of the femur is a common orthopedic injury in the geriatric population and is often associated with generalized physical deterioration. Treatment options for such fractures are operative as well as nonoperative. Owing to the bulky musculature attachment in pertrochanteric region, with no control over the proximal fragment, nonoperative measures usually result in malunion [2].

Nonoperative treatment should only be considered in nonambulatory patients or patients with chronic dementia with pain that is controllable with analgesics and rest, terminal diseases with less than 6 weeks of life expectancy, active infectious disease that itself is a contraindication for insertion of a surgical implant and incomplete pertrochanteric fractures diagnosed by MRI [3].

Dynamic hip screw (DHS) has been the standard implant in treating trochanteric fractures. However, when compared with the intramedullary implants, it has a biomechanical disadvantage because of a wider distance between the weight bearing axis and the implants [4].

The use of extramedullary DHS is still more superior with fewer complication rates in stable trochanteric fractures. On the contrary, intramedullary nail proximal femoral nail (PFN) may have some advantages in fractures at the level of lesser trochanter, reversed obliquity fractures and in subtrochanteric fracture, although the evidence is yet insufficient [5].


  Aim Top


The aim of this study was to compare the results of treatment of unstable trochanteric fracture of femur in 40 patients treated by either intramedullary fixation by PFN or extramedullary fixation by DHS regarding primary outcomes such as early mobilization, pain improvement, and radiological assessment for fracture reduction and fixation and secondary outcomes such as duration of union and complication rate, for example, loss of fixation, malreduction, and nonunion.


  Patients and methods Top


This is a multicentric study conducted between August 2014 and November 2017. It was conducted on 40 patients with unstable pertrochanteric fractures treated surgically, where 20 patients were treated by DHS and 20 patients were treated by PFN. The study was approved by our institutional scientific ethical committee. All the 40 cases were planned follow-up examination for a period of 8 months from the date of operation. Full workup, including age, sex, medical history, type of fracture, mechanism of injury, and plain radiographs was performed on admission, and all fractures were categorized according to Evan’s ([Figure 1]) and Seinsheimer’s classification.
Figure 1 Evan classification of trochanteric fractures.

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All Patients included are with recent unstable pertrochanteric fractures, ambulatory and fit for surgery. Other patients with the following were excluded from the study: pathological fracture of any other cause than osteoporosis, contralateral hip fracture, ipsilateral lower limb fracture, previous surgery on the ipsilateral femur, open fracture, fracture more than 3 weeks old, non-ambulatory or medically unfit for surgery.

The intraoperative variables included type of reduction, anesthesia, time of surgery, and complications. Anteroposterior and lateral radiographs of the hip were used to evaluate accuracy of the reduction and position of the lag screw within the head of the femur and tip-apex distance ([Figure 2]).
Figure 2 Tip-apex distance.

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On the postoperative radiographs, the quality of fracture reduction was graded as good (<5° varus/valgus), acceptable (5–10° varus/valgus) or poor (>10° varus/valgus). Postoperative assessment included recording of general and local complications as well as the duration of hospital stay. Harris hip score ([Table 1]) was assessed. Pain improvement, shortening of the femur, and Lurch were also evaluated. Radiographic evaluation included the position of the lag screw and union of the fracture, which means painless full weight bearing on the affected limb with the presence of radiographic consolidation. Delayed union is failure to achieve radiological evidence of complete union of the fracture by 3 months, whereas nonunion is defined as failure to achieve radiological evidence of complete union by 6 months. Patients were then kept under follow-up every 2 weeks for the first 2 months, then monthly for the next 6 months.
Table 1 Assessment by Harris hip score

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  Results Top


The current study included 17 (42.5%) male patients and 23 (57.5%) female patients with a mean age of 63.35 years (±6.9 SD). Of the 40 patients included, only 13 (32.5%) had no associated medical illnesses whereas the rest of the patients gave history of one or more associated medical illness (including diabetes mellitus, hypertension, anemia, cardiac disease, and asthma) ([Table 2],[Table 3],[Table 4]).
Table 2 Mean age and standard deviation of both groups

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Table 3 Sex distribution of both groups

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Table 4 Associated medical illness of both groups

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As for the mechanism of injury, 26 (65%) of the patients gave history of fall to the ground, whereas the rest of the patients (14, 35%) gave history of different mechanisms of injury including fall from a height and road traffic accident. Of the whole patient population, 27 (67.5%) patients had unstable intertrochanteric fractures, whereas 13 (32.5%) had subtrochanteric fractures (Tables 5 and 6).
Table 5 Mechanism of injury of both groups

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Table 6 Fracture type of both groups

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Closed reduction was used in most patients (35, 87.5%), whereas only five (12.5%) patients had open reduction. All patients treated with PFN were operated in the lateral position, whereas others with DHS were operated in supine position using traction table. Spinal anesthesia was used in most patients (33, 82.5%), whereas seven (17.5%) patients were given general anesthesia. Most of the patients did not require blood transfusion; however, seven (17.5%) patients received 1–3 units of blood transfusion. Of the 40 patients included, no intraoperative difficulties were encountered in 87.5% of them, whereas in 5 patients, some sort of intraoperative difficulty was encountered.

The duration of patients’ hospital stay ranged from 1 to 5 days. Of the 40 patients involved, 11 (27.5%) patients required 1–2 days of postoperative ICU admission. Postoperative general and local complications experienced by patients were also recorded. For the general complications, only one (2.5%) patient developed DVT and two (5%) patients developed postoperative infection, whereas none of the patients developed respiratory infections, urinary tract infections, gastrointestinal tract disturbances, or bed sores.

As for local complications, femoral shaft fracture was encountered in one (2.5%) patient whereas acetabular penetration (cut-out) was encountered in two (5%) patients, with no other local complications encountered in the rest of the study population.

Radiological assessment of implant position was done, where ideal implant position was achieved in 36 (90%) patients of the recruited 40 patients in the study. As for the quality of fracture reduction, 30 (75%) patients had good reduction, seven (17.5%) patients had acceptable reduction, and in three (7.5%) patients, fracture reduction was considered of poor quality ([Table 7]).
Table 7 Quality of fracture reduction of both groups

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Radiological assessment was also used to measure tip-apex distance, where it was found to be greater than 20 mm in 19 (47.5%) of our patients, 10–20 mm in 18 (45%) patients, and less than 10 mm in three (7.5%) patients. Sliding of the lag screw was not encountered in any of the patients.

After the operation, patients could start partial weight bearing after a period ranging from 4 to 6 weeks. Pain improvement was also recorded, and the period to pain improvement ranged from 2 to 6 weeks. In the study at hand, 35 (87.5%) patients developed Lurch, but fortunately none developed limb shortening. Of the 40 patients in our study, three (7.5%) patients experienced delayed union, whereas none of the patients experienced nonunion. The duration of union for the whole study population ranged from 1.5 to 8 months. Clinical assessment of mobility score after treatment of the fracture was done using Harris hip score.

In the current study, 27 patients had intertrochanteric fractures; of whom 25 (62.5%) patients had closed fracture reduction whereas only two (5%) had open fracture reduction. On the contrary, 13 of the recruited patients had subtrochanteric fractures; 10 (25%) of them had closed fracture reduction, whereas three (7.5%) patients had open reduction.

In this study, the duration of union in the whole study population ranged from 1.5 to 8 months, whereas in the group of patients with intertrochanteric fractures, it ranged from 2 to 7 months. As for patients with subtrochanteric fractures, the duration of union ranged from 1.5 to 8 months.


  Discussion Top


In the current study, almost two-thirds of the patients were females. This preponderance of females is similar to that noticed across several studies conducted among patients with proximal femoral fractures. On the contrary, the mean age of the patients in our study is lower than that noticed in other studies such as Mereddy and colleagues, who in their study of the PFN recorded a mean age of 78 years in their study population. Loubignac and colleagues also showed a mean age of 80.3 years among their patients with trochanteric hip fractures. In this study, the mean age of the patients was 63.35 years.

Nearly half of all hip fractures are intertrochanteric fractures. Even though fixation with the DHS device has been the gold standard treatment for stable intertrochanteric fractures, there are many complications reported for unstable intertrochanteric fractures [6].

Analyzing the mechanism of injury in the current study revealed that most of the patients fell at home (65%). This is in agreement with the mechanism of injury reported by many studies conducted on proximal femoral fractures, where it has been reported that the typical patient presenting with a proximal femoral fracture is a female in her 60–70 s with a history of fall complaining of pain and inability to weight bear [7] .

It was reported that patients treated with PFN had shorter operative times, fewer blood transfusions, and shorter hospital stays compared with those treated with a DHS. Moreover, it was noticed that seven of the 20 patients who had been treated with the DHS experienced implant failure and/or nonunion, but in comparison to this, only one fracture of 20 treated with PFN had nonunion [8].

Several authors reported on the complication of femoral shaft fracture with intramedullary nail and recommended against its use, but in our study, no such complication occurred. Complication rate is seen to be higher in DHS than PFN, but is not statistically significant. Considering the fact that additional surgical exposure can theoretically prolong the operative time and thus the blood loss in DHS than PFN, it can also be noted that in our study there was history of blood transfusion postoperatively in DHS group [9].

Studies comparing the DHS with the PFN also found that patients who received a nail were 50% more mobile than those with a DHS [10].

Our findings regarding mobility are in line with these studies. At present, we consider that the PFN is a good minimally invasive implant when closed reduction is possible. The modification of the PFN and careful surgical technique reduced the high complication rate in our study. Pervez and colleagues revealed that no significant difference was found in several parameters, such as length of surgery, pneumonia, thromboembolic complications and wound infection or hematoma, between PFN and DHS. However, regarding blood loss, the fracture fixation with DHS led to more blood loss than with nail, as reported in several meta-analysis [11].

Although the superior biomechanical property of PFN over DHS, many studies indicated that PFN can result in a higher risk of intra-operative and later fracture around or below the implant than DHS. In our study it can be explained by multiple stress concentration on the femur fixed by PFN, for example, the stress concentration occurred in the inner side of femoral cortex in contact with the distal end of PFN [12],[13].

The general postoperative complications reported in our study included DVT in one patient who was at high risk as a result of being markedly obese, cardiac and hypertensive. That patient was diagnosed with DVT on the fifth day postoperatively – after discharge from the hospital – despite receiving prophylactic Low Molecular Weight Heparin (LMWH) during her hospital stay and aspirin 150 mg/day after discharge. Infection or malunion, pulmonary embolism, cerebrovascular, pneumonia, fat embolism, or myocardial infarction was not seen in any case.

A study by Tank et al. [14] in 2016 showed complications in the PFN group, including implant failure (3%), Z-effect (5%), and nonunion (3%).

Mean time to bony union was also insignificantly more in PFN group as compared with DHS group. Fractures united in all patients without any exception. Patients with PFN appeared significantly well with less postoperative pain at 3-month follow-up and superior range of movements at the final follow-up than those with DHS. Functionally, in unstable fractures, patients with PFN outperformed those with DHS with higher Harris hip scores, whereas no significant difference could be perceived in those with stable fracture configuration. Taken altogether, the PFN group again excelled with a statistically significant difference. As per the Harris hip score, in the DHS group overall, three patients had excellent results, nine patients had good, six patients had fair results, and two had poor results. In the PFN group, six patients had excellent results, 12 patients had good, two patient had fair, and none had poor results.On the follow-up, fracture was united with good clinical outcome. A total of 10 patients had varus collapse of fracture on final follow-up, but they did not complain on routine day-to-day activity. Moreover, five patients had abductor weakness, which was corrected on successive follow-up by physiotherapy. The low rate of wound infection and short operative time in this PFN group are probably owing to the closed nailing technique used.

Pain improvement was also reported after a mean period of 3.229 weeks (±1.330 SD). Most reports have shown that the complication such as hip and thigh pain was common when treated with intramedullary fixation [15].


  Conclusion Top


We consider DHS and PFN as reliable fixation devices that offers the advantage of a closed procedure with a more stable biomechanical construct for pertrochanteric fractures. In the face of the good clinical and anatomical results as well as the low morbidity rate demonstrated throughout our study, we found that using PFN is of interest in primary surgery for both elder and young patients.

However, the present study had some limitations. First, the number of patients was small. Second, a common problem in this kind of study was that many patients had concomitant illnesses affecting their general health, making it difficult to participate in follow-up. Third, the follow-up period was relatively short where potential long-term problems may yet occur.

Therefore, it is our recommendation to conduct larger studies to further evaluate the DHS and PFN in the management of unstable trochanteric fractures, with a longer follow-up duration to better assess possible late complications that may be encountered.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar R, Singh RN, Singh BN. Comparative prospective study of proximal femoral nail and dynamic hip screw in treatment of intertrochanteric fracture of femur. J Clin Orthop Trauma 2012; 3:28–36.  Back to cited text no. 1
    
2.
Mayi SC, Shah S, Jidegar SR, Kullarni A. Randomized comparative study to evaluate the role pf proximal femoral nail and dynamic hip screw in unstable trochanteric fracture. I J Res Orthop 2016; 2:75–79.  Back to cited text no. 2
    
3.
Ujjal B, Bandyopadhayay R. Comparative study between proximal femoral nailing and dynamic hip screw in intertrochanteric fracture of femur. Open J Orthop 2013; 3:291–295.  Back to cited text no. 3
    
4.
Huang X, Leung F, Xiag Z, Tan PY, Yang T, Wei DQ, Yu X. Proximal femoral nail versus dynamic hip screw fixation for trochanteric fractures: met analysis of randomized controlled trials. Sci World J 2013; 10:355–361.  Back to cited text no. 4
    
5.
Hafez AR, Hosny H, Shaker AS, Hosny H. The use of screw versus proximal femoral nail in treatment of unstable pertrochanteric fracture. Int J Adv Res 2014; 2:581–591.  Back to cited text no. 5
    
6.
Yong C, Tan C, Penafort R, Singh DA, Varaprasad MV. Dynamic hip screw compared to condylar blade plate in the treatment of unstable fragility intertrochanteric fractures. Malays Orthopedics J 2009; 3:8–13.  Back to cited text no. 6
    
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Ahn J, Bernstein J. Fractures in brief; intertrochanteric hip fractures. Clin Orthop Relat Res 2010; 468:1450–1452.  Back to cited text no. 7
    
8.
Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P et al. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am 2002; 84-A:372–381.  Back to cited text no. 8
    
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Hussain N, Patel HB, Patil ND. Management of complex intertrochanteric fracture of femur in elderly patients – dynamic hip screw or proximal femoral nail. Int J Res Orthopedics 2017; 3:656–660.  Back to cited text no. 9
    
10.
Wasudeo M, Salphale Yogesh S. Short proximal femoral nail fixation for trochanteric fractures. J Orthop Surg 2010; 18:39–44.  Back to cited text no. 10
    
11.
Shen L, Zhang Y, Shen Y, Cui Z. Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: a meta-analysis of randomized controlled studies. Orthop Traumatol Surg Res 2013; 99:377–383.  Back to cited text no. 11
    
12.
Ekström W, Karlsson-Thur C, Larsson S, Ragnarsson B, Albert KA. Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the Medoff sliding plate. J Orthop Trauma 2007; 21:18–25.  Back to cited text no. 12
    
13.
Zhang H, Zhu XX, Pei G, Zeng XS, Zhang N, Xu P et al. A retrospective analysis of proximal femoral nail in treatment of unstable intertrochanteric femur in elderly. J Orthop Surg Res 2016; 301–332.  Back to cited text no. 13
    
14.
Tank PJ, Solanki RA, Patet HKA, Rathi NV, Misttry J, Bhabhor HB et al. Results of proximal femoral nail in intertrochanteric fracture femur. Int J Med Sci 2016; 1:17–24.  Back to cited text no. 14
    
15.
Utrilla AL, Reig JS, Muñoz FM, Tufanisco CB. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma 2005; 19:229–233.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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