A COMPARATIVE STUDY OF PROXIMAL FEMORAL NAILING VERSUS

DYNAMIC HIP SCREW DEVICE IN THE SURGICAL MANAGEMENT OF

INTERTROCHANTERIC FRACTURES

By
DR.PRADEEP KUMAR K

A Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

In partial fulfillment of the requirements for the degree of

MASTER OF SURGERY
In
ORTHOPAEDICS

Under the guidance of

DR. PROF. RAJASHEKAR.M

Professor and Unit Head
Department of ORTHOPAEDICS
Dr.B.R.Ambedkar Medical College,
Bangalore: 560045, Karnataka

2011-2013
i
 DECLARATION BY THE GUIDE

This is to certif y that the dissertation entitled, “A COMPARATIVE STUDY

OF PROXIMAL FEMORAL NAILING VERSUS DYNAMIC HIP SCREW

DEVICE IN THE SURGICAL MANAGEMENT OF INTERTROCHANTERIC

FRACTURES ” is a bonafide work done by Dr. PRADEEP KUMAR K. under

my Supervision and Guidance in the Department of Orthopaedic Surgery,

Dr.B.R.Ambedkar Medical College, Bangalore in partial fulfillment of the

regulations for the award of the degree of MS in Orthopaedics

Place: Bangalore Dr. RAJ ASHEKAR.M

Date : M . S. (O rtho)

Professor and unit head

Department of Orthopaedics
Dr.B.R.Ambedkar Medical College
KG halli, Bangalore
KARNATAKA

ii
 ENDORSEMENT BY THE HEAD OF THE DEPARTMENT

This is to certify that the dissertation entitled, “A COMPARATIVE STUDY OF

PROXIMAL FEMORAL NAILING VERSUS DYNAMIC HIP SCREW DEVICE IN

THE SURGICAL MANAGEMENT OF INTERTROCHANTERIC FRACTURES ” is

a bonafide work done by Dr. PRADEEP KUMAR K. under the guidance of Dr.

RAJASHEKAR Professor and Unit Head, Department of Orthopaedic surgery,

Dr.B.R.Ambedkar Medical College, Bangalore.

This dissertation is submitted to Rajiv Gandhi university of health science,

Karnataka, bangalore in partial fulfillment of the regulations for the award of the

degree of MS in Orthopaedics .

Place: Bangalore Dr. RAJEEV NAIK

Date : M .S. (O rtho) , D. O rtho , FR C S

Professor and Head

Department of Orthopaedics
Dr.B.R.Ambedkar Medical College
KG halli, Bangalore
KARNATAKA

iii
 ENDORSEMENT BY THE PRINCIPAL

This is to certify that the dissertation entitled, “A COMPARATIVE STUDY OF

PROXIMAL FEMORAL NAILING VERSUS DYNAMIC HIP SCREW DEVICE IN

THE SURGICAL MANAGEMENT OF INTERTROCHANTERIC FRACTURES ” is

a bonafide work done by Dr. PRADEEP KUMAR K. under the guidance of Dr.

RAJASHEKAR.M Professor and Unit Head, Department of Orthopaedic surgery,

Dr.B.R.Ambedkar Medical College, Bangalore.

This dissertation is submitted to Rajiv Gandhi university of health science,

Karnataka, bangalore in partial fulfillment of the regulations for the award of the

degree of MS in Orthopaedics .

Place : Bangalore Dr. STANLEY JOHN

Date : M .S . (E .N .T )

Principal
Dr.B.R. Ambedkar Medical College
Bangalore-560045

iv
 Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation titled “ A COMPARATIVE STUDY OF

PROXIMAL FEMORAL NAILING VERSUS DYNAMIC HIP SCREW DEVICE IN

THE SURGICAL MANAGEMENT OF INTERTROCHANTERIC FRACTURES ”

has been prepared by me under the guidance and supervision of Dr.

RAJASHEKAR.M, Professor And Unit head, Department of Orthopaedic

surgery, Dr.B.R.Ambedkar Medical College, Bangalore, in partial fulfillment

of the regulations for the award of the degree of MS in Orthopaedics.

I also declare that this dissertation has not been submitted for the

award of any degree of any other university.

Place : Bangalore Dr. PRADEEP KUMAR K.

Date : M . B. B . S. , D.O r th o (DN B)

v
 Rajiv Gandhi University of Health Sciences,
Bangalore, Karnataka

COPY RIGHT

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this
dissertation in print or electronic format for academic or research
purpose.

Date:
Place: Bangalore Dr. PRADEEP KUMAR K

© Rajiv Gandhi University of Health Sciences, Karnataka

vi
 Acknowledgement
It gives me immense pleasure to express my deep sense of gratitude

and sincere thanks to Dr. Rajashekar.M, Professor and unit head,

Department of Orthopaedics, whose guidance, moral support and friendly

approach has made this study possible.

It gives me immense pleasure to extend my sincere thanks to my

professors Dr. Rajeev naik, Dr. Purushotham.K, and Dr. Basavaraj.P.V

for their constant encouragement and help.

I also owe a great debt of gratitude to my Associate Professors

Dr.chandrashekar.M.R and Dr. Hashim.S.M for their constant guidance

and support throughout the study. I also express my s incere thanks to

Dr.Ramesh and Dr.Mahesh.M Senior resident for guidance and support.

I also express my sincere thanks to Dr. Stanley John, M.S., ENT,

Principal, Dr.B.R.Ambedkar Medical College, Bangalore, for permitting me to

carry out this study.

I thank my fellow post-graduates who have helped me in the

preparation of this dissertation.

I owe my gratitude to my mother, wife, son, friends and well wishers for

their constant help, encouragement and inspiration during my study.

I am grateful to all my patients who cheerfully co-operated with me.

Dr. PRADEEP KUMAR. K.

vii
 ABSTRACT

BACKGROUND AND OBJECTIVES:

The intertrochanteric fractures were found to be most common injuries
sustained predominantl y in patients over sixty years of age. They are three to
four times more common in women who are osteoporotic; trivial fall being the
most common mechanism of injury.
Little attention was paid to these fractures in the past, as they occur

through the cancellous bone with excellent blood suppl y and they healed without

any active treatment. However conservative treatment usuall y resulted in

malunion.

The goal of treatment of an in tertrochanteric fracture is the restoration of

the patient to his or her pre-injury status as earl y as possible. This led to

internal fixation of these fractures to increase patient comfort, facilitate nursing

care, decrease hospitalization and reduce complications of prolonged

recumbency.

The t ype of implant used has an important influence on complications of

fixation. Sliding devices like the dynamic hip s crew have been extensivel y used

for fixation.

Intramedullary devices like the proximal femoral nail have been reported

to have an advantage in such fractures as their placement allowed the implant to

lie closer to the mechanical axis of the extremit y, thereby decrease the lever arm

and bending moment on the implant.

viii
 The purpose of the present study is to verify the theoretical advantages of
the proximal femoral nail over the dynamic hip screw device and also whether it
actuall y alters the eventual functional outcome of the patient.
Fort y adult patients with intertrochanteric fracture who were avail able
for follow up of atleast 6months months post operativel y were in cluded in this
study. The patients were selected for Dynamic hip screw fixation or proximal
femoral Nailing randoml y. Th e study period was from june 2011 till august
2012.
The patients were evaluated as per the history, mode of injury. Necessar y
radiological investigations and hematology profile was done on admission. Type
of surgery and details were noted. The immediate Post -operative X-ray was
evaluated. All the cases were again evaluated at 3 months interval till 1 year and
then one in 6 months f or any morbidit y and mortalit y.
The assessment parameters included were the abilit y to bear weight, rate
of union both clinical and radiological, degree of deformit y and any limb length
discrepancy.
Data collected on a detailed proforma and anal ysis.
RESULTS:
The PFN required significantl y shorter incisions , less blood loss and
operative times. The DHS group required 16sec less fluoroscopy time. Post
operative complication in both group included malunion and infection, 5
malunion in DHS while 1 in PFN, 2 wound infections in DH S while 1 in PFN
and 1 screw back out in DHS . Patients treated with PFN had a significantl y
lower pain score at the sixth month of follow up. Patient treated with DH S
had more limb length shortening as compared to those treated with PFN. The
outcomes of the stable fractures treated with either DHS or PFN were
similar. Unstable intertrochanteric fractures, treated with PFN, had
significantl y better outcomes with all patients having good results.

ix
CONCLUSION:
Though both PFN and DHS have similar functional outcome in

stable fracture and PFN has better function outcome with unstable fractures,

PFN requires shorter operative time and a smaller incision, it has distinct

advantages over DHS even in stable intertroc hanteric fractures. Hence, in our

opinion, PFN may be the better fixation device for most intertrochanteric

fracture.

KEY WORDS:
Intertrochanteric fractures, DHS, P FN, Malunion, pain, wound infection,
post operative walking abilit y.

x
 TABLE OF CONTENTS

Sl.No Particulars Page

No.

1 INTRODUCTION 1

2 AIMS OF THE STUDY 3

3 REVIEW OF LITERATURE 4

4 REVIEW OF COMPARATIVE STUDIES 10

5 ANATOMY 15

6 MECHANISM OF INJURY 18

7 BIOMECHANICS 26

8 MATERIALS AND METHODS 33

9 RESULTS AND ANALYSIS 48

10 DISCUSSION 65

11 SUMMARY 73

12 CONCLUSION 75

13 BIBLIOGRAPHY 76

14 ANNEXURE

 MASTER CHART

 PROFORMA

 KEY TO MASTER CHART

xi
 LIST OF TABLES

Sl. No. Details of Tables Page No.

1. Age distribution 48

2. Sex distribution 48

3. Mode of injury 49

4. Side of injury 49

5. Type of fracture 50

6. Pre-injury walking abilit y 51

7. Length of incision 52

8. Duration of surgery 52

9. Fluoroscopy time 52

10. Blood loss 53

11. Post operative complications 53

12. Post operative pain 54

13. Post operative mobilit y score 54

14. Post operative shortening 55

15. Post operative range of movement 55

16. Time of fracture union 55

17. Functional outcome 56

18. Functional outcome V/s t ype of fracture with DHS 57

19. Functional outcome V/s t ype of fracture with PFN 58

20. Functional outcome V/s method of fixation (stable 59

fracture)

21. Functional outcome V/s method of fixation (Unstable 60

fracture)

xii
 INTRODUCTION

Trochanteric fractures are one of the most common injuries

sustained predominantl y in patients over sixty years of age. They are

three to four times more common in women who are osteoporotic; trivial

fall being the most common mechanism of injury 1 .

For many, this fracture is often a terminal event resulting in death

due to cardiac, pulmonary or renal complications. Approximatel y 10 to

30% of patients die within one year of an intertrochanteric fractur e 2 .

Little attention was paid to these fractures in the past, as they

occur through the cancellous bone with excellent blood suppl y and they

healed without any active treatment. However conservative treatment

usuall y resulted in malunion with varus and e xternal rotation deformit y

resulting in a short limb gait and a high rate of mortalit y due to

complications of recumbence and immobilization.

The goal of treatment of an in tertrochanteric fracture is the

restoration of the patient to his or her pre-injury status as earl y as

possible. This led to internal fixation of these fractures to increase patient

comfort, facilitate nursing care, decrease hospitalization and reduce

complications of prolonged recumbency 3 .

The greatest problems for the orthopaedic surgeon treating this

fracture are instability and the complications of fixation that result from

1
instabilit y. Stabilit y refers to the capacity of the internall y fixed fracture

to resist muscle and gravitational forces around the hip that tend to force

the fracture into a varus position. Intrinsic factors like osteoporosis and

comminution of the fracture and extrinsic factors like choice of reduction,

choice of implant and technique of insertion, contribute to failure of

internal fixation.

The t ype of implant use d has an important influence on

complications of fixation. Sliding devices like the dynamic hip s crew

have been extensively used for fixation. However, if the patient bears

weight earl y, especiall y in comminuted fractures, these devices can

penetrate the head or neck, bend, break or separate from the shaft.

Intramedullary devices like the proximal femoral nail have been

reported to have an advantage in such fractures as their placement allowed

the implant to lie closer to the mechanical axis of the extremit y, thereby

decrease the lever arm and bending moment on the implant. They can also

be inserted faster, with less operative blood loss and allow earl y weight

bearing with less resultant shortening on long term follow up.

The purpose of the present study is to verify the theoretical

advantages of the proximal femoral nail over the dynamic hip screw

device and also whether it actuall y alters the eventual functional outcome

of the patient.

2
 AIMS OF THE STUDY

To compare the surgical treatment of intertrocha nteric fractures of

the femur with the proximal femoral nail and dynamic hip s crew device,

with respect to:

 Fluoroscopic time

 Duration of surgery

 Blood loss

 Fracture union and

 Functional outcome.

3
 REVIEW OF LITERATURE

HISTORICAL REVIEW

Until the 20 t h century, trochanteric fract ures were treated non

operativel y. The treatment however has advanced greatl y in the past few

decades. In the 1930's, Jewett 4 introduced the triflanged nail, which

allowed the surgeon to achieve immediate stabilit y of the fractu re and

earl y mobilization of the patient . However, use of the Jewett nail for the

fixation of unstable intertrochanteric fractures has been problematic and

loss of fixation has been common. Such a rigid implant does not allow the

impaction of comminuted f racture fragments to occur. As a result, there is

increased stress on the implant if union does not occur rapidl y; the

implant would ultimatel y fatigue and fail, or it would penetrate and cut

out of the femoral head 5 , 6 .

The shortcomings of fixed nail -plate devices were recognized in the

mid-1960's, and techniques were developed to recreate medial stabilit y in

patients who had an unstable intertrochanteric fracture. These techniques

combined the use of rigid devices with v arious t ypes of osteotomies.

Dimon and Hughston 7 advocated a procedure in which the lateral

trochanter was osteotomized and the shaft was displaced mediall y to force

the head and neck into the shaft . Sarmiento 8 and Williams 9 recommended

a valgus osteotom y in which a laterall y based wedge at the proximal end

4
of the fracture of the shaft was resected and the neck fragment placed on

the medial cortex in a valgus position to create a stable configuration .

During the same period, Clawson 1 0 , as well as Massie 1 1 , introduced

sliding devices that allowed impaction of the fracture fragments. After

several modifications, the dynamic hip screw (DHS) was introduced by

the AO/AS IF. This technique has produced results that are equal to or

better than those of osteotomies 1 2 and it remains the mainstay of treatment

today.

In 1980 Jenson and co -workers 1 3 showed that the telescoping of a

135° sliding hip screw by 10mm and 20mm improved implant strength by

28% and 80%, respectivel y, in part because of the shortening of the leve r

arm. Jacobs and co workers 1 4 demonstrated that the sliding hip screw acts

as a lateral tension band in stable fracture patterns, transmitting forces

through the medial cortex. Simpson and colleagues 1 5 , demonstrated that

loss of this sliding capabilit y lead to a functionall y rigid construct and

higher failure rates . In 1993 Rha 1 6 found that excessive sliding was the

major fact or causing failure of fixation. An association was made between

fracture settling and pain when Baixauli and associates 1 7 found sliding of

>15 mm to be associated with postoperative pa in. Müller-Farber and

associates 1 8 found increased sliding of the hip screw to be associated with

decreased postoperative mobilit y.

To overcome these complications, a trochanteric supporting p late

attached to a traditional sl iding hip screw device was used to increase the

5
stabilit y of intertrochanteric fracture fixation during revision surger y

after initial failure by superior lag screw cutout 1 9 . This t ype of side plate

provided a buttress effect for a comminuted greater trochanter during

compression hip plating of associated inter trochanteric fractures and

helped to reduce medial shaft displace ment during fracture impaction . In

osteoporosis, tightening of the lag screw lead to stripping of the screw

and loss of fixation within the femoral head. Hence a ugmentation of the

purchase strength of lag screws used with sl iding hip screw devices was

accomplished with the use of reversibl y deployable talons which increased

the purchase strength of the lag screw within the femoral head, resist

torque forces between the head and the lag screw, and increase the amou nt

of bone engaged by the screw, however ease of implant remo val in

clinical practice remained a concern 2 0 .

The Gotfried percutaneous c ompression plate (PCCP) was

developed to be easily applied using a minimall y invasive tec hnique. The

PCCP device included a chisel end for introduction through the vastus

lateralis muscle along the lateral cortex of the proximal femur. The other

unique feature of this device was the presence of 2 lag screws that could

be placed into the femora l head. The clinical benefit of percutaneous

insertion of this device however remained theoretical as cutout of lag

screws through the fem oral head with the PCCP occurred with similar

frequency as with compression hip screws 2 1 , 2 2 .

6
 The Medoff plate allowed compression in both the axis of the lag

screw and the long axis of the femur. The proximal portion of the plate

contains the barrel and lag screw. This po rtion of the implant telescopes

along the lateral femur within a separate side plate that is secur el y fixed

to the lateral femur . The biplane compression axes provide theoretical

advantages for more complex intert rochanteric femur fractures 2 0 . In a

large multicent eric trial, the Medoff plate was found to have higher

implant-related complications than the DHS 2 3 .

In the mid-to-late 1970's, flexible intramedullary devices for the

fixation of intertrochanteric fractures were introduced in the form of the

Ender nail and the condylocephalic nail. The advantage of these devices

was due to their intramedullary position, which places them closer to the

resultant force across the fracture and reduces the bending moment on the

device. In addition, the use of distal sites of insertion to decrease

operative time and loss of blood, compared with the use of proximal sites,

was reported 2 4 , 2 5 . This operative technique was made possible by the use

of image intensification and was promoted as a closed method for the

fixation of intertrochanteric fractures. However, a high prevalence of

varus deformit y, as well as pain in the knee cau sed by distal migration of

the pins, were reported in association with this procedure 2 6 , 2 7 . These

problems led to a high rate of re -operation for extraction of the pins and

correction of deformit y. A high rate of failure due to loss of reduction,

shortening, and external rotation resulted both from Ender nails and from

7
condylocephalic nails 2 4 . Accordingl y, most authors have recommended

that these devices not to be used for the fixation of intertrochanteric

fractures 2 8 .

The first -generation intramedullary n ails had a shorter lever arm,

to decrease tensile strain on the implant, the lack of requirement of an

intact lateral cortex, the improved load transfer (as a result of medial

location), the potential for closed fracture reduction, percutaneous

insertion, shorter operative time, and reduced blood loss are theoretical

advantages of intramedullary devices compared with compression hip

screw devices 2 0 . The first -generation nail for treatment of

intertrochanteric fractures, the Gamma nail, was associated with a

relativel y high incidence of peri -implant fracture of 2.2% to 17%

approximatel y 4 times greater than seen with compression hip screws 2 9 , 3 0 .

Nail geometry and size were contributing factors . A large (10°) valgus

bend, long (200 mm) length without an anterior bow, and relative stiffne ss

caused by large proximal (17mm) and distal (12 –16mm) diameters all

provided for increased stress concentration at the tip of the nail 2 0 . The

rate of cutout of these first-generation nails, 2% to 4.3% 2 9 , was no better

than that seen with compression hip screw devices, 2.5% 3 1 . Changes to

implant geometry, a reduced valgus bend to 4°, a decrease in the distal

diameter to 11 mm, and shortening of the length to 180 mm decreased the

stress concentration at the tip of second -generation Gamma nails 2 0 . The

8
rate of peri-implant fracture reduced with these second -generation devices

to between 0% and 4.5% 2 9 .

The third-generation n ails such as the proximal femoral nail (PFN ),

which incorporate multiple screws into the femoral head , have been

recentl y introduced. Multiple points of fixation theoreticall y provide

better rotational control of unstable fractures compared with a single lag

screw. The smaller-diameter screws of th ese multiple screw devices allow

a smaller diameter for the proximal section of the nail. The smaller nail

diameter is advantageous by reducing the amount of the gluteus medius

tendon that is injured on insertion and by improving bone integrit y in this

region. The theoretical concern about smaller diameter screws is screw

cutout directl y related to their decreased diameter that could be

exacerbated by screw bending. Such bending can prevent sliding of the

lag screw. Fracture of the smaller superior screws h as been seen,

especiall y when it is placed near the subchondral bone of the femoral

head. In this position, it encounters large varus stresses that are not

shared by the larger inferior screw 2 0 .

9
REVIEW OF COMPARATIVE STUDIES

Bridle and associates 3 2 prospectivel y compared fixation of 100

intertrochanteric fractures treated randoml y by either dynamic hip screw

or intra medullary device like the proximal femoral nail and found no

difference in operating time, blood loss, wound complications and final

mobilit y. In their study cut -out occurred in 3 cases with DHS and in 2

cases with intramedullary device. However 4 cases of fracture femur

occurred close to the tip of the intramedullary device.

According to Rosenblum and his group 3 3 , intramedullary devic es

provided three point fixation , a more efficient load transfer due to its

medial location with a shorter lever arm and hence, less tensile strain on

the implant, reducing the risk of mechanical failure. However they also

found that the inherent stiffnes s of the intramedullary device imparted

non–physiological loads across the proximal part of the femur and

transmitted decreasing loads to the calcar with decreasing fracture

stabilit y hence bypassing the calcar and concentrating the compressive

loads on the distal tip of the nail leading to shaft fractures.

In successfull y treated intertrochanteric hip fractures , the average

tip apex diameter was found to be 24mm and no constructs with a tip apex

diameter of less than 25mm resulted i n cutout from the femoral head as

shown by Baumgaertner and colleagues 3 4 . Hence they concluded that the

tip apex diameter is the strongest predictor of cutout as seen in 84% of the

patients in their study.

10
 The rate of femoral shaft fractures as a compli cation of

intramedullar y device was found to be 5.3% in a study by Parker and

colleagues . 3 1 . They also found that the rate of cut out of intramedullary

device was 3.1% as compared to 2.5% in those intertrochanteric fractures

treated with dynamic hip screw .

Baumgaertner and associates 3 5 concluded that fractures stabilized

by an intramedullary hip screw required 10% less operative time and had

significantl y less blood loss (245cc V/s 340cc) than those stabilized with

the sliding hip screw.

A prospective randomized study of 100 intertrochanteric fractures

conducted by Hardy and associates 3 6 showed that the mean mobilit y score

was significantl y greater at one month and three months for the patients

who had an intramedullary nail and was had significantl y less sliding of

the lag screw and subsequent shortening of the limb as compared to those

treated with dynamic hip screw device. They also found a relationship

between thigh pain and use of two dis tal interlocking bolts. Kim and

colleagues 3 7 stated that the most important cause of dynamic hip screw

failure was fracture instabilit y.

Kukla and co-workers 3 8 recommended the use of intramedullar y

device onl y for unstable peritrochanteric fractures after studying 1000

consecutive patients treated with this device be tween 1992 – 1998.

No difference was found in the outcomes comparing stable and

unstable fracture patterns in a series by Adams et al. 3 9 and they reported

11
that onl y 21% of their 197 patients regained their pre -fracture

independence. Hence they stated th at the theoretical advant ages of

intramedullary devices have not been translated into an improvement in

the treatment of intertrochanteric fractures as more re -operations were

performed in the intramedullary hip screw groups (6%) as compared to 4%

in the d ynamic hip screw group, due to high number of lags screw cut

outs. In addition incidence of femoral shaft fractures were higher (2%) as

compared to none in dynamic hip screw group. Hence the y advocated that

the intramedullary hip screw should not be routin el y adopted for the

treatment of intertrochanteric fractures.

Saudan and associates 4 0 showed that there was no statist icall y

significant difference intraoperativel y, radiologicall y or clinicall y

between patients treated with dynamic hip screw or intramedullary hip

screw in their study of 206 patients.

According to Ahrengart and associates 4 1 , intramedullary device

more frequentl y preserved the fracture position obtained pre -operativel y.

They also concluded that in the less communited fractures the

compression hip screw method was the preferred method of treatment

whereas the intramedullary nail was an alternative treatment for more

communited fractures.

A study conducted by Bellab arba and colleagues 4 2 involving the

percutaneous treatment of peritrochanteric fractures using intramedullary

12
hip screw showed a union rate of 98% with no cases of varus malunion

exceeding 10  and onl y 3% had peri -operative femur fractures.

Kubiah and co-workers. 4 3 compared the outcomes of patients with

intertrochanteric fractures treated wit h either one large diameter or two

small diameter lag screws along with the intramedullary hip screw device

and concluded that there was no significant difference between the two in

static or cyclical loading with respect to screw sliding or inferior and

lateral head displacements.

Comparing the screw sliding ch aracteristics and stabilit y in four

part unstable intertrochanteric femur fractures , Bong and colleagues 4 4

found that a sliding hip screw attached with a lateral support plate

provided stabilit y and abilit y to resist medial displacement of the femoral

shaft similar to that seen with intramedullary hip screw.

O’Brien and group 4 5 concluded that no differen ce existed between

sliding hip screws and intramedullary hip screws in terms of technical

aspects (operating room time, screening time and blood loss), hospital

stay, malunion, nonunion, failure of fixation, general post operative

complications or final o utcome measures for the treatment of

intertrochanteric fractures. However intra medullary devices may be

superior to extramedullary devices for the treatment of reverse obliquit y

intertrochanteric fractures.

According to Magit and colleagues 4 6 , with union rates of greater

than 95% the dynamic hip screw device represented the standard of

13
treatment for trochanteric femur fractures, however, these implants had

their own problems such as high screw cutout from femoral head, excess

collapse at the fracture site , which in turn shortened the leg and reduced

the lever arm of the hip abductors, increased intraoperative blood loss and

extensive soft tissue dissection. They also stated that the less invasive

treatment of intertrochanteric femoral fractur es with intramedullary nail

offers several potential advantages over dynamic hip screw, such as

smaller incision, limited devascularisation and subsequentl y shorter

operative time, less blood loss and less wound complications.

The use of intramedullary hip screw in the treatment of pre

operativel y irreducible fractures was advocated by Garnavos and co -

workers 4 7 to avoid an open reduction and therefore reduced blood loss and

allows earl y mobilization of the patients.

Kregor and group 4 8 found that the failure rates of dynamic hip

screw device were too high to recommend its use and functional outcomes

were much better using intramedullary hip screw in the management of

unstable intertrochanteric hip fractures.

14
RELEVANT ANATOMY

The femur is the longest bone in the hu man body being a quarter of

the stature. The proximal end of the femur consists of the head, neck,

greater trochanter and lesser trochanter.

The head of femur forms two thirds of a sphere and is directed

mediall y and anterosuperiorl y. It is not a perfect sphere; hence the joint is

congruous onl y in the weight bearing positions . The neck is obliquel y

anteverted by 10 0 -15 0 with respect to the shaft . A broad, rough and

oblique line, the intertrochanteric line , gives attachment to the iliofemoral

ligament. The posterior aspect of the neck is separated from the shaft by a

prominent, rou gh ridge, the intertrochanteric crest. The lesser trochanter

is a cone shaped traction epiphysis of the iliopsoas muscle. The greater

trochanter is a traction epiphysis for the gluteus medius, which draws it

superomediall y and posteriorl y.

Most patients with intertrochanteric fractur es have considerable

osteopenia. The qualit y of bone for the purchase of fixation within the

femoral head and neck is less than desirable. It is important that the

internal fixation device be placed in that part of the head and neck where

the qualit y of bone is best. In 1838, Ward 4 9 described the internal

trabecular system of the femoral head . The orientation of the trabeculae

is along the lines of stress, with thicker trabeculae coming from the calcar

and passing superiorly into the weight -bearing dome of the femoral head.

Smaller trabeculae extend from the inferior region of the foveal area and

15
cross the head and th e superior portion of the femoral neck to the

trochanter and to the lateral cortex. In total there are five groups, namel y

the primary compressive, secondary compressive, primary tensile,

secondary tensile and the greater trochanter groups.

The calcar is a dense, vertical plate of bone extending from the

posteromedial portion of the femoral shaft under the lesser trochanter and

radiating laterall y to the greater trochanter, reinforcing the femoral neck

posteroinferiorl y. The calcar is thickest med iall y and gradually thins as it

passes laterall y. Therefore the qualit y of bone for purchase within the

head and neck varies from one quadrant to another. The bone of poorest

qualit y is in the anterosuperior aspect of the head and neck.

ROLE OF HIP MUSCLE S IN FRACTURES OF THE HIP:

The gluteus maximus covers the hip posteriorl y and inserts into the

iliotibial band and into the femur along the gluteal tuberosit y. This

muscle is responsible for the posterior displacement of the distal fragment

in some intertrochanteric fractures.

The gluteus medius, the principal abductor and internal rotator of

the hip, is relaxed by the displacemen t that occurs with intertrochanteric

fractures and thereby loses its effect. The external rotators produce

deformit y when the op posing internal rotators, primaril y the gluteus

medius, are inactivated by loss of the fulcrum normall y provided by the

fixation of the femur to the pelvis at the hip. This effect must be

considered during the reduction of the fractures.

16
 The vastus lateralis can be separated easil y at its origin from the

fascia lata and linea aspera posteriorl y to permit a bloodless and non -

traumatic appro ach to the femur.

The iliopsoas, which is attached to the lesser trochanter, contributes

to the upward displacement of the distal fra gment and to the external

rotation and flexion of the limb . After hip fracture, the adductors,

unopposed by the abductors, adduct and shorten the extremit y.

Evans 5 0 concluded that postero medial contact would prevent

fracture displacement into varus and retroversion when forces are applied

to the proximal femur and that the fractures with a reversed obliquit y of

fracture line has a marked tendency towards medial displacement of the

shaft secondary to adductor muscle pull, hence are unstable. Wolfgang et

al. 5 1 considered a trul y stable intertrochanteric fracture as one that, when

reduced, has cortical contact without a gap mediall y and posteriorl y.

VASCULAR SUPPLY OF THE PROXIMAL FEMUR

The blood suppl y of the proximal part of the femur stems pr imaril y

from the lateral and medial circumflex femoral arteries - branches of

Profunda Femoris artery. They form an extracapsular ring around the base

of the femoral neck.

The lateral circumflex artery divides into ascending, transverse and

descending branches at the medial edge of the rectus femoris. The

ascending and descending branches suppl y the adjacent muscles. The

17
transverse branch supplies portions of the tensor fascia and vastus

lateralis.

The medial circumflex artery gives two main branches, the superior

retinacular artery (also known as the lateral epiphyseal artery) to suppl y

the lateral one third of the femoral head and inferior retinacular artery 5 2

(medial metaphyseal artery according to Tru eta 5 3 ) which continues as the

inferior metaphyseal artery to suppl y the femoral head. The medial

circumflex artery ends by anastomosing with the terminal ramification of

the lateral circumflex branch.

The metaphysis of the femur is supplied copiousl y from the superior

and inferior metaphyseal vessels and lateral epiphyseal artery.

MECHANISM OF INJURY

Trochanteric fractures almost invariably occur as a result of a

trivial fall 1 , 2 9 , involving both direct and indirect forces. Direct forces act

along the axis of the femur or directl y over the greater trochanter to result

in trochanteric fractures. Indirect forces, including the pull of iliopsoas

muscle on the lesser trochanter and the abductors on the greater trochanter

have also been incriminated as a cause of the fracture. Other modes of

injury may be either road traffic accidents or a fall from height. In the

immediate post-traumatic stage of these fractures, the patient presents

with pain, inabilit y to bear weight, externall y rotated and shortened

extremit y 2 9 .

18
Vascular supply of the proximal femur (Fig.1)

Muscle forces acting on the proximal femur (Fig.2)

19
RADIOGRAPHIC EVALUATION

An antero posterior and a lateral vie w of the hip are usuall y taken to

study the fracture geometry and to allow visualization of the trabecular

pattern of the proximal femur which is an important clue in estimating

bone qualit y.

Lorich and colleagues 2 9 noted that bone densit y is predictive of

intertrochanteric fractures with these fractures rarel y occurring in

individuals with bone densit y >1.0gm/cm , with the incidence increasing to

16.6 fractures / per 100 persons with bone densit y of <0.6 g/cm.

Singh and group 5 4 proposed An index for grading the degree of

osteoporosis present in the proximal femur based upon radiographic

appearance of the trabecular pattern.

Laros and Moore 5 5 found that patients with Singh grade 3 or lower

had an increased incidence of complications of f ixation.

Koot 5 6 , comparing dual energy x -ray absorptiometry to measure

bone mineral densit y with Singh index, found the latter to be inaccurate.

20
CLASSIFICATION

In a comparison of the results obtained with different methods of

internal fixation in intertrochanteric fractures it is essential to take into

consideration how the fractures have been assessed, as misleading

conclusions might otherwise be drawn.

Boyd and Griffin 4 9 classified intertrochanteric fractures based upon

the ease of obtaining and main taining reduction.

Evans 5 0 provided a simple classification based on the presence of

mechanical instability as related to detachments from the lesser or greater

trochanter. He recognized stable fractures as having and intact or

reducible posteromedial buttress which prevents varus collapse.

The Evans classification system was modified by Jensen and

Michaelsen 4 1 , 5 7 to improve the predictive value, to indicate which

fractures could be reduced anatomically and which were at risk for

secondary displacement after fixation.

Jensen 1 3 advocated that a classification system should contain valid

information concerning the possibilit y of obtaining a primary stable an d

anatomical fracture reduction and predict the risk of secondary fracture

displacement following internal fixation. He found the modified Evans

classification most accu rate in this regard.

21
Boyd and Griffin 4 9 Classification of Intertrochanteric Fractures:

Type 1: Fractures that extend along the intertrochanteric line from the

greater to the lesser trochanter.

Type 2: Comminuted fractures, the main fracture being along the

intertrochanteric line but with multiple fractures in the cortex.

Type 3: Fractures that are basicall y subtrochanteric with at least one

fractures passing across the proximal end of the shaft just dista l to

or at the lesser trochanter. The fracture line runs from

superomedial to inferolateral (the reverse obliquit y fracture).

Type 4: Fractures of the trochanteric region and proximal shaft with

fracture in at least two p lanes.

22
Evans 4 9 Classification of Intertrochanteric Fractures:

Evans was the first to classify trochanteric fractures based upon

their inherent stabilit y. His classification scheme recognized two basic

fracture t ypes.

23
Type I - in which the major fracture line parallels the intertrochanteric

line.

Type II - in which the fracture line has reversed obliquit y.

Type I fractures are further divided into four subt ypes based upon

their inherent stability.

The first two subt ypes are stable because postero medial cortical

opposition exists or can be restored by reduction.

The second two subtypes are inherentl y unstable and have a marked

tendency to collapse into varus owing to discontinuit y of the

posteromedial cortex.

Type II fractures include reverse obliquit y of the fracture line

which allows medial displacement of the shaft due to the unopposed pull

of adductors, hence are unstable.

24
Jensen and Michaelsen’s modification 4 1 , 5 7 of Evans Classification:

Type I: Two-fragment fracture without displacement, stable.

Type II: Two-fragment fracture with displacement, stable .

Type III: Three-fragment fracture with displacement of the greater

trochanter (lacks lateral support), unstable.

Type IV: Three-fragment fracture with displacement of the lesser

trochanter or the medial cortex (lacks medial support), unstable.

Type V: Four-fragment fracture including the greater and the lesser

trochanter or the medial cortex (lacking lateral and medial

support).

25
 BIOMECHANICS

The goal of reduction and fixation in any fracture is to achieve

union of the fracture with restoration of the normal anatom y and to

re-establish the normal force vector acting along the bone. In

intertrochanteric fractures , which usuall y occur in the eld erl y,

stabilization of the fracture and restoring the patient to his or her pre -

injury functional activit y at the earliest possible time is essential to

prevent complications of recumbency 2 9 .

The ball-and-socket configuration of the hip joint is inherentl y

stable and allows an excellent range of motion in all directions. The two

major forces acting on the hip joint are abductor muscle tension and body

weight, as defined by the joint -reaction force 5 8 . The mechanics of the hip

are such that implants designed for the fixation of fractures must

withstand extremel y high loads and bending moments. Even when the

structural integrit y of the hip has been restored, the major muscle forces

continue to test the stabilit y of the fracture fixa tion 5 8 .

The implant has to stabilize the fracture and carry loads without any

essential deformation, until osseous healing has taken place. In case of

stable fractures, the main task of the implant is fixation of the ends of the

fractured bone while the load is chiefl y carried by th e bone, however in

unstable fractures; load carrying capacity of the bone is lost. Normall y

during weight bearing the reacting force passes along the medial

26
trabaculations of the femoral neck. Any interruption of the structural

continuit y of the proximal end of the femur will alter the reacting force

exerted through the femoral shaft and the force between the pelvis and

greater trochanter exerted by the abductor muscles. If the bone fragments

are impacted so that the fracture surfaces are intermeshed firml y, the

normal force vectors about the hip may be restored.

A sliding device with a screw -plate angle closest to the combined

force vector allows optimum sliding and impaction. The closer the nail -

plate angle to the resultant vector of the forces across the hip, more is the

force available to assist impaction , as stated by Kyle and his colleagues 5 9

A device that is placed at a lower angle has less force working parallel to

the sliding axis and more force working perpendicular to the sliding axis.

This perpendicular force acts to jam or bend the device, preventing

impaction, hence, it is desirable to place the sliding device at as high an

angle as clinicall y possible 5 8 .

According to Jacobs and associates 1 4 , the sliding hip screw acts as a

lateral tension band in stable fracture patterns, transmitting forces

through the medial cortex. This allows impaction of the surfaces in

unstable fracture patterns, thereby shortening the lever arm, decreasing

the bending moment and avoiding cutout from the femoral head.

Loch and co-workers 6 0 showed that sliding hip screws require less

force to generate sliding than to intramedullary devices.

27
 Fixation of unstable intertrochanteric fractures with dynamic hip

screw is associated with excessive displacement of the fracture, leading to

medialization of the femoral shaft and lateralization of the grea ter

trochanter resulting in shortening of the limb and thus the lever arm of the

abductor mechanism of the hip, leading to abnormal hip biomechanics 6 1 .

Parker and co -workers 3 1 declared that m edialization of the femoral

shaft by greater than one -third of the diameter of the femur is associated

with a sevenfold increase in fixation failure .

According to Adams and colleagues 3 9 , the shorter lever arm of

intramedullary devices provided more load sharing and allowed less

collapse hence decreased the tensile strain on the implant and reduced the

risk of mechanical failure. Intramedullary devices provide three point

fixation and controlled impaction.

From a biomechanical standpoint, Kaufer and associates 1

concluded that intramedullary placement allowed the implant to lie closer

to the mechanical axis of the extremit y, thereby decreasing the lever arm

and bending moment on the implant. As the substrate for fixation in the

geriatric populati on generall y consists of weakened, osteoporotic bone,

intramedullary devices carry an advantage over other load -sharing devices

by not having to depend on plate fixation with bone screws purchasi ng a

compromised lateral cortex 3 6 , 6 2 .

28
COMPLICATIONS

1. Mortality

Fractures of the proximal part of the femur are an important cause of

morbidit y and mortalit y in all age -groups, especiall y the elderl y 5 8 .

Epidemiologic studies have consistently shown that a hip fracture is

associated with a significantl y increased risk of mortalit y for 6 to 12

months after the injury 6 3 . After the first year, the mortalit y ra te is similar

to that among age and sex-matched persons without hip fractures. An

increased risk of death after hip fracture is associated with advanced

age, 6 4 male sex, 6 5 poorl y controlled systemic disease, 6 4 operative

management before stabilization of coexisting medical conditions, 6 6 and

postoperative complications 6 7 .

Sernbo and associates 6 8 found one year mortalit y rates after internal

fixation of intertrochanteric fractures of 35% among men and 20% among

women.

Jensen and associates 1 3 reported a 10% in hospital mortality rate

associated with intertro chanteric fractures.

2. Wound Infection

With prophylactic use of antibiotics, the rate of infection is less

than one percent 5 8 . Different authors have reported wound infection rates

ranging from 1.7 to 16.9% following operative treatment of trochanteric

fractures 6 9 .

29
 According to Barr 7 0 , the factors associated with high rate of wound

infection are:

i) The patient population including patients in the seventh, eighth and

ninth decades with decubitus ulcers, bladder infections and

cardiovascular disease.

ii) A prolonged operating time.

iii) A disoriented patient, who may remove the bandage and

contaminate the wound.

iv) The proximit y of the wound to the perineum .

3. Pressure Sores

A 20% rate of pressure sore s in hip fractures was reported in a

series by Agarwal 7 1 .

Versluyjen 7 2 studied pressure sores in elderl y patients related to hip

operations and found mortalit y to be 27% in such patients. For this

reason, prevention is the cornerstone of treatment. The detection of earl y

stage pressure phenomena, such as localize d erythema, pain, or

discoloration, signals the need for a change in position and relief of

pressure on that area 6 9 .

4. Thromboembolism

A 40% incidence of thromboembolism is reported in patients with

fractures of the upper end of femur. Dextran h as been effective for

30
prophylaxis in hip fracture surgery but it presents associated problems,

including anaphylaxis, renal shut down and bleeding complications. Low

molecular weight heparin fractions have been found to be safe and

effective in patients wi th hip fractures to prevent thromboembolism.

Classic anticoagulation meth ods such as full dose warfarin or h eparin are

used in patients with prior thromboembolic disease 6 9 .

5. Technical and mechanical f ailures

The common mode of failure of fixation is the hip-screw cutting out

of osteoporotic bone and penetration of the head or neck of the femur by

the implant, allowing the fracture to collapse into varus angulation. If

little bone is left in the femoral head after this has occurred, a blade -plate

can be used to restore stabilit y. The plate provides more surface area to

resist cutting out through the femoral head 5 8 . If the acetabulum has been

injured by the protruding nail, a total hip replacement is the treatment of

choice 5 8 .

Following sliding hip screw f ixation, Clawson 1 0 found failure rates

for 5.2 and 11.5 percent, respectivel y, in stable and unstable fractures.

Adams and associates. 3 9 stated that intramedullary hip screws have

been associated with an increased risk of intraoperative and postoperative

femur fractures co mpared with sliding hip screws. This increased fracture

incidence has been linked to stress co ncentration at the tip of the

intramedullary nail, stress concentration at the distal locking bolt, and the

31
reaming of the proximal femur to acc ommodate the increased proximal

diameter of the nail necessary to allow the large -diameter lag screw to

pass through the nail and maintain nail strength 3 2 , 3 3 .

Intramedullary nails that employ two small -diameter lag screws

placed into the femoral head , such as the proximal femoral nail, have been

developed. The two proximal screws , theoreticall y, provide greater

rotational control of the femoral head fragment than a single screw.

6. Other Complications

i) Non-union: This complication is found to be uncommon with

trochanteric fractur es and is reported to be 1 to 2 per cent . If non-

union does occur, the rate of success after simple removal of the

device, renailing in a more valgus position and insertion of a

cancellous bone graft has been reported to be 90 per cent 7 3 .

ii) Avascular necrosis: As intertrochanteric fractures are extracapsular,

aseptic necrosis is reported to be very low at around 0.8 per cent 2 .

iii) Stress fracture of femoral neck .

32
 MATERIALS AND METHODS

The study was conducted in Dr.B.R.Ambedkar me dical college

Hospital, Bangalore from June 2011 till October 2012 where 40 patients

with 40 intertrochanteric fractures were selected.

Adult patient with intertrochanteric fracture attending

Dr.B.R.Ambedkar Medical College Hospital was evaluated preoperativel y

and functional results were assessed post operativel y.

The patients were evaluated as per the history, mode of injury.

Necessary radiological investigations and hematology profile was done on

admission. Type of surgery and details were noted. The immediate post -

operative x-rays were evaluated. All the cases were again evaluated

through clinical and radiological methods at 6 weeks, 12 weeks, 6 mon ths

and 1 year for any morbidit y and mortality.

Descript ive and comparative study of functional outcome following

surgical management of intertrochanteric fractures with either proximal

femoral nailing or dynamic hip screw fixation.

A sample of size 40 was selected using purposive sampling

technique.

20 patients have undergone proximal femoral nailing.

20 patients have undergone dynamic hip screw fixation.

33
 All patients above 18 years of age with fresh intertrochanteric

fracture and who were able to walk prior to the fracture were included in

the study.

Patient with pathological fracture, active infection unstable medical

illness and non -traumatic disorder were excluded from the study.

The mode of injury were classified under 3 different categories

taking into consideration whether the injury was due to a ro ad traffic

accident, trivial fall or a fall from height. 30 out of 40 cases mode of

injury was due to road traffic accident.

The youngest patient in the series was aged 32 years and the oldest

was 86 years. 27 of our patient were older than 60 yrs.

The pre-injury walking abilit y was recorded as per the classifi cation

of Sahlstrand 7 4 . Anterioposterior and lateral radiographs of the affected

hip were taken. The patients were then put on skin traction over a Bohler –

Braun frame. All the patients were initial l y evaluated as to their general

condition; hydration and corrective measures were undertaken. The

fractures were classified as per Jensen and Michealsen’s modification of

Evans classification of intertrochanteric fractures. Type I and type II were

considered as stable fractures and t ype III, IV and V were considered as

unstable fractures. No open fractures were encountered in this series.

Patients were taken up for surgery on next elective OT day. Adequate

blood transfusion and other supportive measures we re given depending on

the preoperative condition of the patient and blood loss during surgery.

34
 The fractures were fixed with either dynamic hip screw fixation or

proximal femoral nailing. Allocation of the fractures to each treatment

group was done by ran dom selection. Of the 40 patients in the study, 20

were treated with dynamic hip screw fixation and 20 with proximal

femoral nailing. The length of the incision, duration of surgery, blood loss

and fluoroscopy time was recorded intraoperativel y.

Prophylactic medications:

All patients received injectable antibiotic (cephalosporins) given

one hour before surgery and continued post operativel y for 2 to 3 days.

Oral cephalosporins were continued for next 3 to 4 days. Aminogl ycosides

were added intraoperativel y if the procedure were prolonged. Analgesic

was initiall y given in IV or IM route for 2 to 3 post operative days and

then orall y for few days. We did use low molecular weight haperin as an

anti deep vein thrombosis prophylaxis only in few of our patients.

35
 DESCRIPTION OF PROCEDURES

All patients were positioned supine on a fracture table. The unaffected

lower limb was flexed and abducted to allow easy access for the image

intensifier.

Reduction :

The fracture was reduced by traction in neutral, slight internal or

external rotation depending on the nature of the fracture and checked b y

anteroposterior and lateral views on the image intensifier. All fractures

were reduced by the closed method. The objective of reduction is to

confer weight bearing st abilit y and correct varus and rotational

deformities. In stable fractures this is achieved by reduction of the calcar

femorale.

Method of fixation:

A. Dynamic hip s crew:

A straight lateral incision is made. T he vastus lateralis muscle is

then split . Using the angle guide, a point of entry at the trochant eric flare

is chosen under radiographic control. A 2.5mm tipped threaded guide wire

is inserted into the center of the neck and head of the femur midway

between anterior and post erior cortices to within 10mm from the joint

under image intensifier control. The length of the wire outside is

36
measured using an external measuring device to determine the length o f

the screw required.

The triple reamer is set to the length already measu red and reaming

is done over the guide wire under radiographic control. A tap is used to

prepare the bone after which the lag screw of appropriate length is

inserted. The position of the lag screw is again checked on image

intensifier. The barrel is then s lipped over the lag screw. The guide wire

is removed and the plate is fixed to the shaft of femur with screws.

Traction is then released and the fracture is compressed with the 19mm

compression screw. A suction drain is inserted and the wound is closed in

layers.

B. Proximal femoral nail .

A lateral skin incision is made extending from the hip of the

trochanter proximally for 3 -8cm depending on the size or obesit y of the

patient. The gluteus maximus aponeurosis is split in line with its fibers

from the hip of the trochanter proximally for 5cm s and then the gluteus

medius is split in line with its fibers.

An entry point is made just medial to the t ip of the greater

trochanter with a curved awl . A 3.2mm tip threaded guide pin is inserted

through the tissue protection guide pin centering sleeve beyond the

fracture site. The position of the pin is checked on image intensifier. The

proximal femoral reamer was then used to prepare the proximal portion of

37
the femur. In this study a 9 or 10mm nail was used dependi ng on the

diameter of the femoral canal with a fixed length of 250mm. The 6

mediolateral angle of the nail allows easy insertion. The proximal femoral

nail was then attached to the jig and passed over the guide wire into the

proximal femur and across the fracture site into the femoral shaft.

Once the proximal femoral nail is inserted , the head and neck of

femur are reamed for the cannulated hip screw, which is 8mm in diameter

and varying from 70 to 110mm in length. Under radiographic guidance the

hip screw is inserted into the lower half of the neck of femur within 5-

10mm from the subchondral bone of the femoral head . The stabilization

screw which is 6.4mm in diameter cannulated and varying from 60 -100mm

in length was then inserted into the proximal slot of the nail under

radiographic guidance after the drilling for the same. Then incisions were

made and distal locking bolt s were inserted using the jig from the lateral

cortex of femur through the slot in the nail. All the incisions were closed

and sterile dressings applied.

Postoperative care:

There was no defined postoperative patient protocol, but all patients

were given peri-operative antibiotics for 24 to 48 hours and deep venous

thrombosis prophylaxis. Patients were allowed to sit up in bed on the

second post -operative day. Static quadriceps exercises where started on

the second and third post-operative day. Sutures were removed after 10 to

38
14 days. Patients were mobilized non -weight bearing as soon as the pain

or general condition permitted. Weight bearing was commenced depending

upon the stabilit y of the fract ure and adequacy of fixation, de laying it for

patients with unstable or inadequate fixation.

All the patients were followed up at 6 weeks 3 months and 6 months

intervals for a period of 6 months and check x -rays were taken to assess

fracture union an d signs of failure of fixation. Walking abilit y of each

patient was recorded and compared with pre-injury walking abilit y using

the Sahlstrand 7 4 grading. Post operative pain was evaluated using the

four-point pain score as also used by Saudan 4 0 . The fracture union was

considered as malunion if varus angulation was greater than 10 degrees.

39
 Dynamic hip screw

Fig . No . 3 : I mp la nt s a nd I n str u me nts fo r dy n a mi c h i p scr ew fi xa tio n

F ig . N o . 4 : Pa t i en t po s itio n o n o pera t io n ta b le fo r D H S

Fig . No . 5 : S ki n i nc i sio n fo r DH S

40
Fig . No . 6 : I T ba n d o pe ne d a lo ng t he li ne o f s kin i nci s io n

Fig . No . 7 : B o ne e xpo se d a fte r dee p di s sect io n

Fig . No . 8 : G u id e w ire w ith 1 3 5 deg r ee a ng l e g ui de

41
 Fig . No . 9 : Rea mi ng w i th tr i ple rea me r

Fig . No . 1 0 : H i p s crew in se rtio n o v e r t he g ui d e w ire

Fig . No . 1 1 : P la te i ns er tio n

Fig .No .1 2 : Co mp re s sio n Scr ew a p pl ica tio n

42
 Proximal femoral nail

Fig . No . 1 3 : I mp la nt s a nd I n str u me nts fo r pr o xi ma l fe mo ra l na i li ng

F ig . N o . 1 4 : Pa ti en t po s itio n o n o pera t io n ta b le fo r PFN

Fig . No . 1 5 : S ki n i nc i sio n f o r PFN

43
 Fig . No . 1 6 : E ntry po rt a l w ith A W L

Fig . No . 1 7 : Na i l i n ser t io n w it h G ig o n g ui de w ire

Fig . No . 1 8 : P ro xi ma l g ui de w i re in se rtio n t hr o ug h th e g ig a n d sl eev e

44
Fig . No . 1 9 : C- a r m pi ct ure o f p ro xi ma l s crew dri ll i ng

Fig . No . 2 0 : Di sta l lo c king t hro ug h t he g ig

Fig . No . 2 1 : S ki n c lo s u re

45
 FUNCTIONAL ASSESSMENT

The functional outcome was assessed based on the

postoperative pain, walking abilit y, hip joint range of motion, and limb

length shortening as follows:

Excellent: An excellent result was when there was no postoperative

pain, shortening of up to 0.5cm, hip range of motion of more

than 80 percent of normal and abilit y to walk without support

Good : A good result was when there was mild postoperative pain not

affecting ambulation, hip range of motion of 60-80 per cent

of normal, shortening of 0.5 -1.5cm and abilit y to walk with a

cane or minimal support.

Fair : A fair result was when there was moderate postoperative pain

affecting ambulation requiring regular analgesics, a hip range

of motion of 40-60 per cent of normal, shortening of 1.5 -

2.5cm and abilit y to walk with two canes, crutches or any

other living support

Poor : A poor result was when there was severe postoperative pain

even at rest requiring stronger analgesic s, a hip range of

motion of less than 40 per cent of normal, shortening of more

than 2.5cm and confined to bed or a wheel chair.

46
STATISTICAL ANALYSIS:

The collective data anal ysed by the Z -test, Student t -test, Chi-

square test ( 2 ), Wilcoxon signed rank sum test and the Mann Whitney U

test using SPSS software to evaluate the results.

47
 RESULTS AND ANALYSIS

PRE OPERATIVE VARIABLES

Table – 1

Age Distribution

Method of Fixation
Age (Yrs) Total
DHS PFN

21-40 3 (15%) 3 (15.0%) 6 (15.0%)

41-60 4 (20.0%) 3 (15.0%) 7 (17.5%)

61-80 9 (45.0%) 12 (60.0%) 21 (52.5%)

81-100 4 (20.0%) 2 (10.0%) 6 (15.0%)

Total 20 (100.0%) 20 (100.0% 40 (100.0%)

p=0.935 NS
Mean±SD 62.40±16.34 62.80±14.28
The most common age group was in the range of 61 -80, with a mean

of 62.6 yrs.

Table – 2

Sex Distribution

Method of Fixation
Total
DHS PFN

Female 12 (60.0%) 13 (65.0%) 25 (62.5%)

Male 8 (40.0%) 7 (35.0%) 15 (37.5%)

Total 20 (100.0%) 20 (100.0%) 40 (100.0%)

 2 = 0.417, p=0.519 NS

62.5% of the total patient was female in this series.

48
 Table – 3

Mode of Injury

Method of Fixation
Total
DHS PFN

Fall from height 2 (10.0%) 2 (10.0%) 4 (10.0%)

RTA 3 (15.0%) 3 (15.0%) 6 (15.0%)

Trivial fall 15 (75.0%) 15 (75.0%) 30 (75.0%)

Total 20 (100.0%) 20 (100.0%) 40 (100.0%)

 2 = 0, p=1 NS

The most common mode of injury was trivial fall.

Table – 4
Side of Injury

Method of Fixation
Total
DHS PFN
Left 9 (45.0%) 13 (65.0%) 22 (55.0%)
Right 11 (55.0%) 7 (35.0%) 18 (45.0%)
Total 20 (100.0%) 20 (100.0%) 40 (100.0%)
p=0.519 NS

Left side is involved in 55% of the patient.

49
 Table – 5
Type of Fracture

Type of Method of Fixation

Total
Fracture DHS PFN
T1 1 (5.0%) 0 (0.0%) 1 (2.5%)
T2 9 (45.0%) 12 (60.0%) 21 (52.5%)
T3 7 (35.0%) 4 (20.0%) 11 (27.5%)
T4 3 (15.0%) 4 (20.0%) 7 (17.5%)
T5 0 (0.0%) 0 (00.0%) 0 (0.0%)
T6 0 (0.0%) 0 (0.0%) 0 (0.0%)
Total 20 (100.0%) 20 (100.0%) 40 (100.0%)
p=0.574 NS

All fractures were classified as per Jensen and Michealsen’s 4 1 , 5 7

modification of Evans classification.

T1 : t ype I fracture

T2 : t ype II fracture

T3 : t ype III fracture

T4 : t ype IV fracture

T5 : t ype V fracture

There were 22 stable fractures and 18 unstable fractures.

50
 Table – 6
Pre-injury Walking Ability

Method of Fixation
Total
DHS PFN
Grade I 16 (80.0%) 15 (75.0%) 31 (77.5%)
Grade II 4 (20.0%) 5 (25.0%) 9 (22.5%)
Total 20 (100.0%) 20 (100.0%) 40 (100.0%)
Fisher’s p = 0.677 NS

The pre-injury walking abilit y of the patients was classified as per

grades described by Sahlstrand 7 4 :

Grade 1 – Walk without support

Grade 2 – Walk with a cane or minimal support

Grade 3 – Walk with 2 canes, crutches or living support

Grade 4 – Confined to bed or wheel chair

Pre-injury walking abilit y was similar in both the groups.

51
INTRA-OPERATIVE VARIABLES

Table – 7
Length of Incision

Method N Mean (cm) Std. Deviation (t)

DHS 20 16.15 16.15±1.34 22.569

PFN 20 8.1 8.10±0.85 P = 0.0001

HS
Patient treated with PFN required a significantl y smaller skin

incision.

Table – 8
Duration of Surgery

Method N Mean (cm) Std. Deviation (t)

DHS 20 87.25 87.25±9.66 8.225
PFN 20 69.5 69.50±9.58 P = 0.0001
HS

Proximal Femoral Nailing required mean 18 minutes less operative

time compared the Dynamic Hip Screw fixation.

Table – 9
Fluoroscopy Time

Method N Mean (sec) Std. Deviation Z

DHS 20 57.5 57.50±3.80 24.59
PFN 20 73.75 73.75±9.98 P = 0.0001 HS

Dynamic hip screw fixation required significantl y less fluoroscopic

time as compared to proximal femoral nailing.

52
 Table – 10
Blood loss (intra operative)

Method N Mean (ml ) Std. Deviation Z

DHS 20 375 375.00±63.86 HS
PFN 20 140 140.00±34.79 P = 0.0001

Dynamic hip screw fixation had significantl y less intra operative blood

loss as compared to proximal femoral nailing.

POST OPERATIVE VARIABLES

Table – 11
Post Operative Complication

Method of Fixation
Total
DHS PFN
Malunion 5 (25.0%) 1 (5.0%) 6 (15.0%)
Wound infection 2 (10.0%) 1 (5.0%) 3 (7.5%)
Screw cutout/ 1 (5.0%) 0 (0.0%) 1 (2.5%)
Screw back out
Fisher’s p = 0.605 NS

Malunion was seen in 25% of the patient in DHS group while there

was 5% malunion in the PFN group.

Wound infection was seen in 2 patients in the DHS group and in 1

patient in the PFN group.

One screw back out was seen in DHS.

53
 Table – 12

Post Operative Pain

Method of Fixation
Pain Score Total
DHS PFN
1 3 (15.0%) 8 (40.0%) 11 (27.5%)
2 7 (35.0%) 11 (55.0%) 18 (45.0%)
3 7 (35.0%) 1 (5.0%) 8 (20.0%)
4 3 (15.0%) 0 (0.0%) 3 (7.5%)
Total 20 (100.0%) 20 (100.0%) 40 (100.0%)
p=0.012 S

1 – No pain
2 – Mild pain not affecting ambulation
3 – Moderate pain affecting ambulation requiring regular analgesics.
4 – Severe pain, even at rest, requiring stronger analgesics.

In PFN group 40% of the patients were pain free while 50% of DHS

patient had moderate to severe pain.

Table – 13
Post Operative Mobility Score

Std.
Method N Mean Z p
Deviation

Pre operative mobility score 20 1.20 0.4577 0.004

DHS 2.879
Post operati ve mobility score 20 2.25 0.5936 S

Pre operative mobility score 20 1.15 0.4140 0.011

PFN 2.530
Post operati ve mobility score 20 1.45 0.5936 S

Fourteen patients in the PFN group regained their pre -injury

walking abilit y at third month follow up as compared to five in the DHS

group.

54
 Table – 14

Post Operative Shortening

Method N Mean (cm) Std. Deviation Z

DHS 20 1.25 0.75 2.597
PFN 20 0.575 0.56 P = 0.003 S

Significantl y less limb length shortening was seen in the PFN group as

compared to the DHS group with a mean of 1.25cms in the DHS group and

0.575cms in the PFN group.

Table – 15

Post Operative Range of Movement

Mean Std.
Method N T
(degree) Deviation
Range of DHS 20 84.25 20.53 2.12
motion
PFN 20 98.75 10.11 p= 0.07 S

There were significantl y better mean post operative range of

movement in PFN than DHS with 84.25 degree mean in DHS group and

98.75 degree mean in PFN group.

Table – 16
Time of Fracture Union

Mean
Method N Std. Deviation T
(weeks)
DHS 20 12 1.71 0.4865
PFN 20 12.15 1.42 P = 0.765 NS

All the fracture united at a mean of 12.075 weeks

55
 Table – 17

Functional Outcome

Method of Fixation
Total
DHS PFN

Excellent 3 (15.0%) 4 (20.0%) 7 (17.5%)

Good 7 (35.0%) 15 (75.0%) 22 (55.0%)

Fair 6 (30.0%) 1 (5.0%) 7 (17.5%)

Poor 4 (20.0%) 0 (0.0%) 4 (10.0%)

Total 20 (100.0%) 20 (100.0%) 40 (100.0%)

p=0.012 S

120.00%
Functional Outcome
100.00% Method of Fixation
80.00% PFN
60.00% Functional Outcome
Method of Fixation
40.00%
DHS
20.00%

0.00%
Excellent Good Fair Poor

Fig. No. 22: Functional Outcome

Excellent to good results were seen in 95% of patient in PFN group

and 50% of patients in DHS group.

56
 Table – 18

Functional Outcome V/s Type of Fracture with DHS

Type of fracture
T1 T2 T3 T4 T0TAL
Excellent 1 2 0 0 3
Good 0 6 1 0 7
Fair 0 0 5 1 6
Poor 0 1 1 2 4
Total 1 9 7 3 20
p=0.016 S

10 Poor
8 Fair

6 Good

4 Excellent

2
0
T1 T2 T3 T4

Fig no.23

Functional Outcome V/s Type of Fracture with DHS

Of the stable fractures 90 percent had excellent to good outcome,

while 40% of the unstable fracture had a poor outcome in the DHS group.

57
 Table – 19

Functional Outcome V/s Type of Fracture with PFN

Type of fracture
T1 T2 T3 T4 TOTAL
Excellent 0 3 1 0 4
Good 0 9 2 4 15
Fair 0 0 1 0 1
Poor 0 0 0 0 0
Total 0 12 4 4 20
p=0.002 S.

12
Poor
10
Fair
8
Good
6 Excellent
4

0
T1 T2 T3 T4

Fig no.24

The entire patient with stable fracture had excellent to good

functional outcome in PFN group while even 87.5% of unstable fracture

had good functional outcome.

58
 Table – 20

Functional Outcome V/s Method of Fixation

(Stable Fracture)

Method of Fixation
Total
DHS PFN
Excellent 3 (30.0%) 3 (25.0%) 6 (27.272%)
Good 6 (60.0%) 9 (75.0%) 15 (68.181%)
Fair 0 (0.0%) 0 (0.0%) 0 (0.0%)
Poor 1 (10.0%) 0 (0.0%) 1 (4.545%)
Total 10 (100.0%) 12 (100.0%) 22 (100.0%)
 = 3.773, p=0.152 ns
2

80.00%
70.00%
60.00% PFN
50.00%
40.00% DHS
30.00%
20.00%
10.00%
0.00%
Excellent Good Poor

Fig. No. 25: Functional Outcome V/s Method of Fixation

(Stable Fracture)
The functional outcome of stable fracture is non significantl y better

with PFN compared to DHS.

59
 Table – 21

Functional Outcome V/s Method of Fixation

(Unstable Fracture)

Method of Fixation
Total
DHS PFN
Excellent 0 (0.0%) 1 (12.5%) 1 (5.55%)
Good 1 (10.0%) 6 (75.0%) 7 (38.88%)
Fair 6 (60.0%) 1 (12.5%) 7 (38.88%)
Poor 3 (30.0%) 0 (0.0%) 3 (16.66%)
Total 10 (100.0%) 8 (100.0%) 18 (100.0%)
p=0.04 S

80.00%
70.00%
60.00%
50.00%
PFN
40.00% DHS
30.00%
20.00%
10.00%
0.00%
Excellent Good Fair Poor

Fig. No. 26: Functional Outcome V/s Method of Fixation

(Unstable Fracture)

Unstable fractures treated with PFN had a significantl y better

outcome with all the patients having good outcomes as compared to those

treated with DHS.

60
 Fig u re No . 2 7 : H ea l ed s ki n i nc i sio n

Fig u r e No . 2 8 : Pa t i ent s st a nd i ng Fig ure No . 2 9 : C h ec k X - ra y a fter 6 w ee k s

DYNAMIC HIP SCREW FIXATION

61
 Fig u re No . 3 0 : H i p f le xio n

Fig u re No . 3 1 : H i p fl e x io n w it h K ne e f le xio n

Fig u re No . 3 2 : C hec k X - ra y
a fter 6 w ee ks

DYNAMIC HIP SCREW FIXATION

62
 Fig u re No . 3 3 : DH S X - ra y a fter 3 mo nt hs

Fig u re No . 3 4 : DH S X - ra y a fter 6 mo nt h s

Fig u re No . 3 5 : Co mp li c a tio n – w o un d i nfect io n

DYNAMIC HIP SCREW FIXATION

63
Fig No . 3 6 Pa t ie nt s st a n di ng f ro m f ro n t Fig No . 3 7 : Pa t ie nt s sta nd i ng fro m si de

Fig u re No . 3 8 : Pre o pe ra t iv e X- ra y Fig u re No . 3 9 : P F N x ra y da y 1

Fig u re No . 4 0 : P FN 6 w ee ks X- ra y Fig ure No . 4 1 : P F N 3 mo n th s X- ra y

PROXIMAL FEMORAL NAILING

64
 DISCUSSION

The goal of the study was to compare the functional outcome of

patient with intertrochanteric fractures treated by two different fixation

devices, the extramedullary dynamic hip screw fixation and the

intermedullary proximal femoral nail. Our study consist s of 40 patient

with 40 intertrochanteric fractures out of which 20 was treated with DHS

and 20 with PFN.

Age Distribution:

The age of the patient ranged from 32 to 86 years with an average

of 62.6 years. In case of Dynamic hip Screw fixation it was 62.4 years and

in cases of proximal femoral nailing it was 62.8 years.

All the fractures that occurred in patients younger than 58 years

were either due to a fall from height or a road traffic accident. This

supports the view that bone stock plays an i mportant role in the causation

of fractures in the elderl y, which occur after a trivial fall. No attempt was

made to measure the degree of osteoporosis by the Singh index, as it

involves a great inter -observer variability and depends on good qualit y

x-rays. In addition, the accuracy of the Singh index has been questioned

by authors such as Koot et al. 5 6

White and colleagues 6 4 did a study of rate of mortalit y for elderl y

patients after fracture of the hip in the 1980's and they concluded that t he

average age for trochanteric fractures is 75.4years.

65
 The average age in our study nearl y correlates to that of White and

his colleagues 6 4 .

Sex Distribution:

In our study there were 15 males and 25 females showing female

preponderance.

Dahl and colleagues 6 5 , in their study 65% of patients were females,

explained by the fact that female are more prone for the osteoporosis after

menopause.

Sex distribution in our study correlates with that of other studies.

Mode of Injury:

Commonest mode of injury is trivial fall which was noted in 30

(75%). History of fall from height was in 12 (30%) patients.

All the fractures that occurred in patients younger than 58 years

were either due to a fall from height or a road traffic accident . This

supports the view that bone stock plays an important role in the causation

of fractures in the elderl y, which occur after a trivial fall.

Fracture Classification:

Our series consisted of 22 stable and 18 unstable intertrochanteric

fractures as classified according to Jensen and Michealsen’s modification

of Evans classification. The distribution of stable and unstable fractures

in both groups was similar. Out of the 22 stable fractures, 10 were in the

DHS group and 12 in the PFN group. Out of the 18 unstable fractures, 10

were in the DHS group and 8 in the PFN group.

66
Preinjury Walking Ability:

The preinjury walking abilit y was similar in both groups of patient

with DHS or PFN. 80 percent of patients in the DHS group and 75 percent

of the patient in t he PFN group were walking without support prior to the

injury. 22.5% of patients in the study had grade 2 walking abilit y prior to

fall. This is explained in the fact that intertrochanteric fracture occurs in

elderl y patient.

Length of Incision:

The length of the incision in the DHS group ranged from 14 cms to

18cm with a mean of 16.15 cm as compared to mean of onl y 8.1cm in the

PFN group. The smaller incision in the PFN group meant that there was

less intra operative blood loss. This was comparable to the study

conducted by Baumgaertner et al. 3 5 .

Duration of Surgery:

The duration of surgery in the DHS group ranged from 85 minutes

to 105 minutes with a mean of 87.25 minutes. The duration of surgery in

the PFN group ranged from 60 minutes to 90 minutes with a mean of 69.5

minutes. The difference in the operative times in both groups was found

to be highl y significant and we attributed this difference to the smaller

incisions in the PFN group. Baumgaertner et al. 3 5 also found that the

surgical times were 10 per cent higher in the DHS group in their series.

Saudan and colleagues 4 0 found that there was no significant difference

between the operative times in the two groups in their series.

67
Fluroscopy time:

The fluoroscopy time in the PFN group (average 73.75 sec)

was significantl y higher as compared to that of the DHS group (average

57.5 sec). This was similar to the series by Baumgaertner and associates 3 5

who also found a significant difference in the fluoroscopic times in their

series, with 10 per cent higher times for the PFN group. However in their

study Saudan et al. 4 0 found no difference between the fluoroscopy times

in both the groups.

Blood loss:

The DHS patients had significantl y more blood loss intra-operative

compared to PFN group (average 235ml). This is similar to the series by

Baumgaertner and associates 3 5 who also found a significant difference in

the intra operative blood loss in their series, with 150ml higher for the

DHS group.

Complication:

Results of treatment of stable and unstable fracture have usuall y

been reported together in the literature, and it is generall y accepted that

with increasing securit y of fracture pattern (stable to unstable), there is a

higher risk of complication and poor outcome.

The occurrence of femoral shaft fractures does not seem to

be a major problem with the PFN due to a narrower distal diameter as

compared to other intramedullary nails 7 5 . Also, rotational control is

inherent in the nail design and is not dependent on multiple parts that are

68
likel y to increase the risk of mechanical failure. Due to the smaller

diameter lag screws in these intramedullary nails, the proximal aspects of

the nail do not need to be flared to prevent mechanical failure of the nail

and hence requires less reaming of the proximal femur, thereby reducing

the risk of iatrogenic proximal femo ral fracture 4 3 . This was similar to the

findings of Saudan et al. 4 0 in their study. Other studies have also reported

femoral shaft fracture rates of 0 -2.1 per cent 7 6 , 7 7 . We did not encounter

any intraoperative complication in this study.

The onl y complications we encountered in this series were

malunion, screw back out and wound infection. There was no significant

difference between the two groups with regards to time of fracture union

as all fracture united at 12 weeks in case of DHS and 12.15 we eks in case

of PFN. 5 patients (25 percent) in the DHS group had malunion whereas 1

patient (5%) in the PFN group had malunion. There was statisticall y

significant difference between the two groups regarding malunion.

In our series 2 patients of the DHS g roup had wound

infections as compared to single patient in the PFN group, which was not

statisticall y significant. We attributed the higher number of wound

infections in the DHS group to the longer incisions and subsequentl y more

soft tissue handling in th is group as compared to the PFN group. However

all were onl y superficial wound infections and healed without any further

surgical intervention. Saudan and associates 4 0 also did not find an y

69
significant difference between the infection rates in the two grou ps in

their series.

In this study the average limb length shortening of patient in DHS

group was 1.25cm as compared to 0.575cm in PFN group which was

significant. This could be due to sliding of the lag screw in the DHS

group, allowing greater fracture im paction, as compared to the PFN 7 8 .

Four of the ten patients in DHS with fair or poor results had 2 cm or more

shortening, while 1 patient in PFN with fair result had 2cm or more

shortening.

One patient (5 percent) in our study had a hip screw back out.

This was seen in the DHS group involving an unstable intertrochanteric

fracture. However these patients were relativel y mobile and hence re -

operation was not necessary. There was no implant cut out in the PFN

group which was similar to the serie s by Menezes and co -workers 7 5 (0.7

per cent)

Post Operative Pain:

In our study we found there was significant difference in the post

operative pain in the two groups. Even though 17 of DHS and onl y 12 of

the PFN patient had post operative pain. 3 out of 17 patients in DHS had

severe pain compared to none in PFN patients. It was noted that in PFN

patient who had moderate pain had wound infection post operativel y.

70
 Saudan and colleagues 4 0 found that the amount of persistent pain

was similar in both groups in their series.

Post Operative Range of Hip Movement:

The average range of motion the hip joint was 84.25 degree in

the DHS group and 98.75 degree in the PFN group at 6 months of follo w

up. Hence, in our study the patients in the PFN group regained a

significantl y better range of motion as compared to those in the DHS

group (p=0.002). This is comparable to the results put forth by Saudan

and colleagues 4 0 .

Functional Outcome:

The overall functional outcome of patient treated PFN was

significantl y better compared to DHS (P=0.152). However when we

compared the stable and unstable fractures separatel y, we found that there

was no significant difference in the outcomes of the stable fracture s in the

two groups (p=0.198). While comparing the unstable fractures in the two

groups we found that the functional outcome of the patients in the PFN

group was significantl y better than the outcome of the patients in the DHS

group with good results for 8 7.5% of the unstable fractures treated with

PFN compared to onl y fair and poor results for 90% of the unstable

fractures treated with DHS. In our series, onl y 5 of the 20 patients (25 per

cent) in the DHS group regained their pre -injury mobility level as

71
compared to 14 of the 20 patients (70 per cent) in the PFN group at the

fourth month of follow up. Similar findings were seen in the series by

Pajarinen and group 7 8 . This suggests that the use of PFN may be favored

in stable fracture when compared to DHS . There is some amount of

shortening seen in the DHS group which can be explained as due to

significantl y greater impaction of the fracture in the DHS group.

The smaller incisions, shorter operative times, relativel y less

blood loss and less po stoperative pain with the PFN indicate that the PFN

has an advantage over the DHS even in the treatment of stable

intertrochanteric fractures where the functional outcomes are similar. In

addition, with unstable intertrochanteric the PFN has a definite adv antage

over the DHS in terms of less limb length shortening, earlier restoration

of pre-injury walking abilit y and a better overall functional outcome

72
 SUMMARY
 Majorit y of the patient in our study were between 61 -80 years with a

mean age of 62.6 years.

 Sixty percent of the patients were female.

 Trivial fall was the most common mode of injury.

 Left hip was involved in 55.0% of the patient.

 Stable fracture constituted 55% of the cases; unstable fractures 45

percent.

 Twent y patients treated with PFN and 20 treated with DHS fixation

were included in the study.

 The PFN required shorter incisions, less blood loss and operative

times.

 The DHS required 16.25sec less fluoroscopy time.

 Post operative complications in both group included malunion and

infection, 5 malunion in DHS while 1 in PFN, 2 wound infection in

DHS while 1 in PFN. One screw back out in DHS.

 Fourteen of the 20 patient treated with PFN and 5 of the 20 patient

treated with DHS regained their pre injury walking abilit y at the fourth

month of followup.

 Patients treated with PFN had a significantl y lower pain score at the

sixth month of follow up.

 Patients treated with DHS had more limb length shortening as

compared to those treated with PFN.

 The outcomes of the stable fractures treated with eith er DHS or PFN

were similar.

73
 Unstable intertrochanteric fractures, treated with PFN, had

significantl y better outcomes with all patients having good results

74
 CONCLUSION

We conclude that in stable intertrochanteric fractures, both the PFN

and DHS have similar outcomes. However, in unstable intertrochanteric

fractures the PFN has significantl y better outcomes in terms of earlier

restoration of walking abilit y. In addition, as the PFN requires shorter

operative time and a smaller incision, it has distinct advantages over DHS

even in stable intertrochanteric fractures. Hence, in our opinion , PFN may

be the better fixation device for most intertrochanteric fracture

75
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 MASTER CHART

DYNAMIC HIP SCREW FIXATION

Pre- Length Post Post

Method Duration Blood Post Range Time of
Mode of injury Type of of Fluorosc operativ Shorten- operativ
No. Name Age Sex Sides of of loss operativ of hip union Union Final
injury walking fracture incision opy time e compl- ing (cm) e
fixation surgery (ml ) e pain motion (weeks)
ability (cm) ication walking
ability
1 Shila N P 58 F L TF 1 T2 DHS 16 95 60 Wound 4 15-60 1.5 14 M 3 Poor
infection
2 Zubeda begum 65 F L TF 1 T3 DHS 14 80 300
350 50 - 3 10-80 1 14 U 3 Fair

3 Abdul jabbar 63 M R TF 1 T2 DHS 15 90 350 55 - 2 0-100 0.5 12 U 2 Good

4 Nayappa 55 M L TF 1 T3 DHS 18 100 500 60 - 3 0-80 1.5 12 U 3 Fair

5 Syed babu 45 F R FH 1 T2 DHS 16 85 450 55 - 2 0-100 0.5 12 U 2 Good

6 Nagamma 70 F L TF 1 T3 DHS 18 105 400 60 - 2 0-110 1.5 12 U 2 Good

7 Girish 35 M R RTA 1 T1 DHS 18 70 55 - 1 0-120 0 10 U 1 Excellen

t
8 Jayamma 66 F L TF 1 T2 DHS 15 90 350
300 50 - 2 0-100 0.5 10 U 2 Good

9 Jamruth jahan 72 F R TF 1 T4 DHS 15 100 400 55 - 4 10-80 2.5 14 M 3 Poor

10 Prahalad 32 M L RTA 1 T2 DHS 14 80 300 60 - 2 0-90 0.5 10 U 2 Good

11 Md sheriff 65 M R TF 1 T3 DHS 15 90 55 Wound 3 10-50 2 14 M 3 Poor

infection
12 Salma 44 F L FH 1 T2 DHS 16 70 350
300 60 - 1 0-100 0.5 10 U 1 Excellen
t
13 Jayaram 86 M R TF 2 T4 DHS 16 90 450 55 Screw 4 10-70 2.5 14 M 3 Poor
back out
14 Noorizia 69 F R TF 1 T2 DHS 18 85 400 65 - 2 10-90 1.5 10 U 2 Good

15 Subbamma 65 F L TF 1 T4 DHS 16 90 350 60 - 3 10-90 1.5 14 M 3 Fair

16 Mohammed 81 M L TF 2 T3 DHS 17 90 400 55 - 3 0-90 1.5 10 U 2 Fair

shafiulla
17 Rodrich 38 M R RTA 1 T2 DHS 15 70 300 60 - 1 5-100 0.5 12 U 1 Excellen
t
18 Victoriya 82 F L TF 2 T3 DHS 16 85 350 60 - 3 0-90 1.0 12 U 2 Fair

19 Sarojamma 73 F L TF 1 T2 DHS 17 90 400 60 - 2 5-100 1.5 10 U 2 Good

20 Bakshunisa 84 F R TF 2 T3 DHS 18 90 500 60 - 3 10-80 2.5 14 U 3 Fair

 PROXIMAL FEMORAL NAILING

Post
Preinjury Length of Post Range of Time of
Mode Type of Method of Duration of Post operative Short- operative
No. Name Age Sex Sides walking incision Fluoroscopy time operative hip union Union Final
of injury fracture fixation surgery compli-cation ening (cm) walking
ability (cm) Blood loss(ml) pain motion (weeks)
ability

1 Haseena 38 F R RTA 1 T2 PFN 8 60 150 70 - 1 0-100 0.5 10 U 1 Excellent

2 Ravi 66 F R TF 1 T2 PFN 7 65 100 75 - 1 0-110 0.5 10 U 1 Excellent

3 Hachi bai 45 F R FH 1 T2 PFN 8 80 200 70 - 1 5-100 0.5 14 U 2 Good

4 Abdul sattar 70 M L TF 1 T4 PFN 8 70 150 60 - 2 5-100 0.5 12 U 2 Good

5 Bandesh 33 M L RTA 1 T2 PFN 8 70 150 75 - 1 0-110 1.0 12 U 1 Good

6 Ramiza bai 78 F L TF 2 T2 PFN 8 65 100 75 - 2 0-100 0.5 12 U 2 Good

Wound
7 Sajjad 63 M R TF 1 T3 PFN 8 80 200 80 3 0-80 2.0 16 M 3 Fair
infection

8 Salma 66 F L TF 1 T2 PFN 7 60 150 75 - 2 10-100 1 12 U 2 Good

9 Noor jaan 65 F L TF 1 T4 PFN 7 60 100 95 - 2 10-90 0 12 U 1 Good

10 Ashraf 73 F L TF 1 T2 PFN 7 70 100 75 - 1 5-100 1.5 13 U 2 Good

11 Mastan baig 84 M R TF 1 T3 PFN 7 80 150 70 - 1 0-100 1 12 U 1 Excellent

12 Kamalamma 82 F L TF 2 T2 PFN 10 60 200 65 - 2 0-100 0 12 U 2 Good

13 Ravi pandey 39 M R FH 1 T4 PFN 9 65 150 95 - 2 0-90 0 12 U 1 Good

14 Parvathamma 66 F L TF 1 T2 PFN 9 65 150 65 - 1 0-110 0.5 14 U 1 Good

15 Celine taj 72 F R TF 2 T3 PFN 9 80 150 75 - 2 0-100 1 12 U 2 Good

16 Ramiza bi 70 F L TF 1 T2 PFN 8 65 100 60 - 1 0-110 1 12 U 1 Excellent

17 Rajeevi 55 F L RTA 1 T4 PFN 9 90 150 90 - 2 0-90 0 10 U 1 Good

18 Rohini 63 F L TF 1 T2 PFN 9 60 150 70 - 2 0-100 0 13 U 1 Good

19 Kuppuswamy 69 M L TF 1 T3 PFN 8 85 100 65 - 2 0-100 0 12 U 1 Good

20 Anand kumar 59 M L TF 1 T2 PFN 8 60 100 70 - 2 0-120 0 11 U 1 Good

 K E Y T O M A S TE R C H AR T

Se x : M – Male F – Female

Mode of Injury : R.T.A – Road traffic accident

FH – Fa l l f r o m h e i g h t

T F – T r i v i a l Fa l l

Side : L – Left R – Right

Pre-injury walking ability: 1 – Grade 1

2 – Grade 2

3 – Grade 3

4 – Grade 4

Type of fracture : T1 – type I fracture

T2 – type II fracture

T3 – type III fracture

T4 – type IV fracture

T5 – type V fracture

Method of fixation: DHS – Dynamic hip screw

PFN – Proximal femoral nail

Post-operative pain: 1 – P a i n Sc o r e 1

2 – P a i n Sc o r e 2

3 – P a i n Sc o r e 3

4 – P a i n Sc o r e 4

Union : M – Malunion

U – Sa t i s f a c t o r y u n i o n

Post-operative walking ability: 1 – Grade 1

2 – Grade 2

3 – Grade 3

4 – Grade 4