NATIONAL BOARD OF EXAMINATION-

THESIS PROTOCOL

‘’A COMPARATIVE PROSPECTIVE STUDY OF

THE SURGICAL OUTCOME BETWEEN
PROXIMAL FEMORAL NAIL AND BIPOLAR
HEMIARTHROPLASTY IN TREATMENT OF
INTERTROCHANTRIC FRACTURE OF FEMUR
IN ELDERLY PEOPLE’’

Candidate: DR MANINDRA SINGH SHEKHAWAT. (DNB orthopaedics

trainee).

Guide: DR B R BAGARIA (Head of departments in orthopaedics).

Co-guide: DR VIVEK PRADHAN (Asso.Consultant).

Place: Manipal hospital,jaipur.

 INDEX
 INTRODUCTION

 AIMS AND OBJECTIVES

 REVIEW OF LITERATURE

 STUDY DESIGN

 MATERIAL AND METHOD

 ETHICAL JUSTIFICATION

 INFORM CONSENT FORM

 PATIENT INFORMATION SHEET

 PREOPERATIVE WORK UP

 PROFORMA

 FOLLOW UP

 OBSERVATION AND SUMMARY

 CONCLUSION

 REFERENCESS
INTRODUCTION

Intertrochantric fractures are a major cause of morbidity and mortality

in elderly population. They are the most frequently operated fracture
type, have the highest post operative fatality rate of surgically treated
fractures, and have become a cause for concern because of the high
cost of care required after injury. The reason of the high cost of care is
primarily related to poor recovery of functional independence after
conventional fracture care in many patients.(13)

Intertrochantric fractures usually occur in patients over 60 years of

age commonly and are three times more frequent in females than in
males because women tend to be less active and develop
postmenopausal osteoporosis. (13)

The goal of treatment of any intertrochanteric fracture in elderly is to

restore mobility safely and efficiently while minimizing the risk of
medical complications and technical failure and to restore the patient
to the preoperative status. Restoration of mobility in patients with
intertrochanteric fracture ultimately depends on the strength of
surgical construct.(13)

Surgery in intertrocatric fractures is important in elderly patients for

prevention of complications associated with conservative treatment
like pressure sores, pulmonary infection, atelectesis, malunion etc,
and aimed at early rehabilitation and mobilization. internal fixation
does provide immediate fracture fixation.(13)
Intertrochanteric fractures can be treated with either PFN (Proximal
Femoral Nail) or Bipolar Hemiarthroplasty with equally good results.
PFN has a shorter operated time, less blood loss, lower mortality rate
and low cost compared to cement less Bipolar hemiarthroplasty.
Bipolar Hemiarthroplasty for unstable osteoporotic fratures in elderly
results in early ambulation and good functional results, (14)

Thus this study will help us to understand the management of

Intertrochanteric fractures in terms of surgical technique, possible
complications, and evaluate the functional outcomes after fixation
with PFN and Bipolar hemiarthroplasty(13)
 AIMS

To compare the clinical outcome and complications of

intertrochanteric fractures treated randomly with proximal
femoral nail (PFN) and Bipolar hemiarthroplasty.

OBJECTIVES

1. To evaluate the advantages and disadvantages associated with

fixation of intertrocanteric fractures with proximal femoral nail

(PFN) and bipolar hemiarthroplasty.

2. To compare the complications associated with fixation of

intertrocanteric fractures with proximal femoral nail (PFN) and

bipolar hemiarthroplasty.
 REVIEW OF LITERATURE
These fractures were managed by conservative methods before
1930s when the age of fixation began Conservative treatment
regimes included, simple support with pillows or splinting to the
opposite limb, Buck’s (skin) traction, Well-leg traction, plaster
spica immobilization, Russell’s balanced traction and skeletal
traction through the lower femur or upper tibia. non surgical
treatment usually not preffered due to high mortality rate due to
commonly due to cardiopulmonary complications,
thromboembolism, and sepsis.
EVALUATION OF SURGICAL METHOD:

A). Sliding Hip Screw: W. Schumpelick et al. revolutionized treatment

of IT fractures by presenting the results of the sliding neck screw of
the DHS in 1955(15).

B).Gamma nails:This was one of the earliest intra-medullary (IM)

implants to be designed in 1988(16).
C).Proximal Femoral Nail: In 1996, AO/ASIF developed the proximal
femoral nail (PFN) as an intramedullary device for the treatment of
unstable per, inter and subtrochanteric femoral fractures. Several
study reported that PFN had significantly less operative time, intra-
operative blood loss and length of incision than the DHS but there
was no difference in postoperative infection rate, lag screw cut-out
rate, or reoperation rate between the PFN and DHS. PFNA-II is the
modified PFN design meant to match the Asian proximal femoral
morphometry(17).

D).Hemiarthroplasty:. In patient with preexisting symptomatic

degenerative arthritis and in extremely comminuted osteoporotic
intertrochanteric fractures, hemiarthroplastymay is a better
option(17).

Classification of intratrochantric fracture :

1).EVANS Classifications:

Type I: Fracture line extends upwards and outwards from the

lesser trochanter (stable). Type I fractures can be further
subdivided as:
Type Ia: Undisplaced two-fragment fracture
Type Ib: Displaced two-fragment fracture
Type Ic: Three-fragment fracture without posterolateral
support, owing to displacement of greater trochanter fragment
Type Id: Three-fragment fracture without medial support, owing
to displaced lesser trochanter or femoral arch fragment
Type Ie: Four-fragment fracture without postero-lateral and
medial support (combination of Type III and Type IV)

Type II: Fracture line extends downwards and outwards from

the lesser trochanter (reversed obliquity/unstable). These
fractures are unstable and have a tendency to drift medially.
(18).

2).Boyd and Griffin Classification (1949):

Type 1: Fractures that extend along the intertrochanteric line.
Type 2: Comminuted fractures with the main fracture line along the
intertrochanteric line but with multiple secondary fracture lines (may
be in coronal plane).
Type 3: Fractures that extend to or are distal to the lesser trochanter.
Type 4: Fractures of the trochanteric region and proximal shaft with
fractures in at least two planes(19).
3).AO/OTA alphanumeric classification intertrochanteric
fractures (Type 31A):

Bone = femur = 3,Segment = proximal = 1,Type = A1, A2, A3

A1: simple (two-part) fractures, with the typical oblique fracture line
extending from the greater trochanter to the medial cortex; the lateral
cortex of the greater trochanter remains intact.
A2: fractures are comminuted with a posteromedial fragment; the
lateral cortex of the greater trochanter, however, remains intact.
Fractures in this group are generally unstable, depending on the size
of the medial fragment
A3: fractures are those in which the fracture line extends across both
the medial and lateral cortices; this group includes the reverse
obliquity pattern or subtrochanteric extensions.
31-A Femur, proximal trochanteric
31-A1 Peritrochanteric simple
31-A1.1 Along intertrochanteric line
31-A1.2 Through greater trochanter
31-A1.3 Below lesser trochanter
31-A2 Peritrochanteric multifragmentary
31-A2.1 With one intermediate fragment
31-A2.2 With several intermediate fragments
31-A2.3 Extending more than 1 cm below lesser trochanter
31-A3 Intertrochanteric
31-A3.1 Simple oblique
31-A3.2 Simple transverse
31-A3.3 Multifragmentary.(20)
.Dr. Rottela shiva kumar et s. All had done comparative study between
proximal femoral nail and bipolar prosthesis in IT fracture during
November 2013 to November 2015 and noted that 8 out of 10 patient
treated with PFN and 9 of the 10 patient treated with Bipolar regained
their pre injury walking ability at the fourth month of follow-up.
Patients treated with PFN had a significantly lower pain score at the
sixth month of follow up. The outcomes of the stable fractures treated
with either Bipolar or PFN were similar. Unstable comminuted
fractures treated with Bipolar showed significantly better outcomes
with all patients having good result(1).

Dr Wayan suryanto dusak et all had done Comparison between the

results of proximal femur nail anti-rotation and cemented bipolar
hemiarthroplasty in treatment of intertrochanteric fractures in Sanglah
Hospital during april 2016 to april 2017 in 40 patient (17 in PFN
group & 23 in Bipolar group) and noted that There were no
significant differences between the two group regarding to the Harris
Hip Score at 6 months follow up. Significant differences were found
between PFNA and BH group in comparison of intra-operative blood
loss (p < 0.001), length of stay (p = 0.006), surgical time (p < 0.001),
postoperative transfusion (p < 0.001), and decrease of hemoglobin
(p=0.001).(2)
.
Dr.Hrushikesh saraf and Dr Shreepal Munot had done comparative
study of PFN antirotation vs bipolar hemiarthroplasty in unstable
senile intertrochanteric fractures during January 2016 to January 2017
in 40 patients( 20 patient in each group) and noted that PFNA groups
had significantly less blood loss, less surgery time, less hospital stay
as compared to hemiarthroplasty group. Both groups had similar
medical and orthopaedic complications. PFNA patients can be
mobilised early as with hemiarthroplasty group. Hemiarthoplasty
groups have better harris hip score in initial 3 months but similar
score at the end of 1 year.(3).

Dr Shenghu zhou et all had done a retrospective study, PFNA versus

cementless bipolar hemiarthroplasty for unstable femoral IT fracture
in the elderly .during march 2008 to December 2016 in 108 patient
and noted that Both PFNA and CPH are safe and effective treatments
for femoral intertrochanteric fracture in elderly patients. Nonetheless,
CPH allows faster mobilization and recovery(4).
Cheng-Guo Huang et all performed a comparative study .All
patients were followed-up from 6 months to 3 years (means 18.2
months). In surgical trauma: the results of length of incision,operation
time and blood loss was DHS>hemiarthroplasty>PFNA. PFNA group
had the most X-ray exposure, hemiarthroplasty group had the least. In
postoperative recovery: the results of in non-weight-bearing walking
time, hospitalization time and healing time was DHS> PFNA> hemi
arthroplasty. Harris scores at 12 weeks after operation in hemi
arthroplasty was higher than that of DHS and PFNA, but there was no
statistical difference between DHS and PFNA. The incidence of
postoperative complications in DHS group was more than that of
PFNA group, but there were not significant differences among three
groups.(11)
STUDY DESIGN

INTRATRACHANTRIC FRACTURE

DOES PATIENT FIT IN

INCLUSION CRITERIA?

YES NO EXCLUDE FROM STUDY

REFUSE TO
CONSENT GIVEN GIVE
CONSENT

RANDOMIZATION

ODD NUMBER EVEN NUMBER

PROXIMAL FEMORAL NAIL BIPOLAR HEMIARTHROPLASTY

CLINICAL FOLLOW UP AT 1 month ,6 month &

12 month

CONCLUSION
 METHOD
The objectives and importance of this study shall be explained to the patients
recruited in the study and informed consent will be taken from all the patients.
The study proposal and ethical procedures shall be approved by the Ethics
Committee of Manipal hospital,Jaipur.
1) Study area:-

All patients admitted in Department of Orthopaedics, Manipal

hospital,Jaipur.
2) Sample size:- :-. There will be total 30 patients. 15 patients in each group.
3) Study design:- Prospective –single blinded study, Observational
study

4) Study duration:- 1.5 year.

5) Study intervention:-
 Evaluation will be done by history and clinical examination..
6) DATA Collection:- After obtaining the Institutional Ethics Committee
permission for the study, patients satisfying the inclusion criteria will be
enrolled in the study. Detailed history of the patient will be elicited from the
patient or the relatives or those accompanying the patient at the time of
admission. The patient will be subjected to clinical examination and laboratory
investigations as mentioned in the visiting schedule format designed for the
study.

7) Visiting scheduled:- The patients will have to undergo follow-up visits

scheduled at 1 month , 3 month and 6 month following the procedure or earlier
if required. The patient will have to undergo a clinical & radiological evaluation
at every visit.

8) Period of follow up:- The patients are followed up for a period of 6 month at
1 month , 3 month and 6 month .
9) Criteria for selection of patients:-
INCLUSION CRITERIA

 a) AGE.>55 years

 b) Patient mobile before trauma.

 c) Medically fit for surgery

 d) Communited intertrochantric fracture of femur .

EXCLUSION CRITERIA

 a) AGE<55 years
b) Bedridden patient before trauma
c) Polytrauma patient
d) Medically unfit for surgery
e) Fracture due to tumor or any other pathological cause

Clinical Evaluation :-

Evaluated with pre injury activity and present functional

levels with Harris Hip Score (Harris hip assessment Tool)
 STATISTICAL ANALYSIS PLAN

Descriptive statistics of continuous variables will be presented as mean +/_

standard deviation and categorical variables will be presented as numbers,

percentages .Student t test and fishers exact test will be applied for

continuous and categorical variables appropriately..All the statistical

calculations will be done using statistical analysis software STATA 13

(STATA CORP, TEXAS USA). p value < 0.05 will be considered statistically

significant.
 ETHICAL JUSTIFICATION
 The study will be conducted after obtaining the Institutional Ethics
Committee permission for the study, patients reporting to department of
orthopedics, Manipal Hospital, Jaipur and satisfying the inclusion criteria.

 Informed verbal & written consent will be taken from the subject before
enrollment in the study and will be allowed to opt out any time without
constraints.

 There will not be any additional financial burden over patient.

 Patient’s identity will not be disclosed.

 [personal review: Both surgery have similar outcome and complications.]

INFORMED CONSENT FORM
Subject identification number for this study__________________________________________
Title of the Study: ______________________________________________________________

__________________________________________________________________________________
_____________________________________________________________________________

Name of the Investigator: Name of the Guide:

Tel / Mobile No.

1. I confirm that the researcher has explained the nature, purpose and duration of the study.

2. I consent to take part in the study and am aware that my participation is voluntary.

3. I have received the information sheet and was provided adequate time to read and understand it.

4. All my queries have been duly answered.

5. My consent is voluntary.

6. I can withdraw at any point without giving any reason and this would not affect my future care.

7. My information can be accessed and looked at by the research team and relevant authorities
(including Ethics Committee and audit authorities). I give permission for this.

8. I will receive a Xerox copy of the signed consent form.

9.I understand that no financial compensation shall be paid to me for being a

part of this study.
10. There will be no added financial burden for participating in this study.

_______________________ ________________________

Signature of impartial witness Signature/thumb impression of the

patient/legal guardian (if special
category)

Date: Time: Date: Time:

Name: Name:

_____________________
Signature of the person conducting the informed consent

Date: Name:

lwfpr lgefr i=
bl v/;;u ds fy, igpku la[;k
----------------------------------------------------------------------------------------------------------------
-----------------

v/;;u dk ’kh"kZd
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------

’kks/kdrkZ dk uke----------------------------------------------------------------------xkbZM dk
uke-------------------------------------------------------------------

eksckbZy uacj -----------------------------------------------------------------------------

1 eSa iqf"V djrk gw¡ @ djrh g¡w fd ’kks/kdrkZ ds )kjk v/;;u dh izd`fr] m}s’; vkSj vof/k dh
tkudkjh ns nh x;h gSA

2 eSa v/;;u esa Hkkx ysus dh lgefr nsrk @ nsrh g¡w vkSj eq>s irk gS fd esjh Hkkxhnkjh
LoSfPNd gSA

3 eq>s lwpuk i= izkIr gqvk gS vkSj bls i<us vkSj le>us ds fy, i;kZIr le; iznku fd;k x;k gSA

4 esjs lHkh iz’uksa dk mfpr mRrj fn;k x;k gSA

5 esjh lgefr LoSfPNd gSA

6 eSa fcuk fdlh dkj.k fdlh Hkh le; viuh Lohd`fr okfil ys ldrk g¡w @ ldrh g¡w vkSj blls esjh
Hkfo"; dh ns[kHkky izHkkfor ugha gksxhA

7 vuqla/kku ny vkSj izklafxd izkf/kdj.kksa ¼,fFkDl desVh vkSj ys[kk ijh{kk vf/kdkfj;ksa
lfgr½ }kjk esjh tkudkjh ns[kh tk ldrh gSA eSa blds fy, vuqefr nsrk @ nsrh g¡wA

8 eq>s gLrk{kfjr lgefr i= dh ,d QksVks dkih ns nh x;h gSA

9 मैं समझता हूं कि इस अध्ययन का हिस्सा बनने के लिए मझ

ु े कोई वित्तीय मआ
ु वजा नहीं दिया जाएगा।

10 bl v/;;u esa Hkkx ysus ds fy, dksbZ vfrfjDr foRrh; cks> ugha gksxkA
  fu"i{k xokg ds gLrk{kj jksxh @ dkuwuh vfHkHkkod ds
gLrk{kkj@ vaxwBs
dh Nki ¼ fo’ks"k Js.kh½

rkjh[k le; rkjh[k le;

uke uke

 lwfpr lgefr vk;ksftr djus okys O;fDr dk gLrk{kj

rkjh[k uke

मरीज सच
ू ना पत्र

1.अध्ययन शीर्षक: ‘इंट्राट्रोकैं ट्रिक फ्रैक्चर के उपचार के लिए दो शल्य क्रिया पो्क्षिमल

फीमोरल नैल एवं बाइपोलर हे मी आथो्प्लास्टी का तुलनात्मक अध्ययन

मैं डॉ. मनिंद्र सिंह शेखावत, डीएनबी प्रशिक्षु (हड्डी रोग विशेषज्ञ) मणिपाल

अस्पताल, जयपरु में , मख्

ु य शोधकर्ता के रूप में , डॉ. बी आर बगडिया (मेरे मार्गदर्शक) विभाग
के अध्यक्ष और वरिष्ठ सलाहकार, हड्डी रोग विभाग, मणिपाल अस्पताल, जयपरु , के साथ
उपरोक्त शोध अध्ययन का आयोजन करूँगा|

मैं आपको यहां आमंत्रित करता हूं और उसी में अपनी स्वैच्छिक भागीदारी का अनुरोध करता
हूं।
2.निमंत्रण अनुच्छे द: आपको एक शोध अध्ययन में भाग लेने के लिए आमंत्रित किया जा
रहा है । इससे पहले कि आप तय करें कि यह आपके लिए महत्वपूर्ण है ? यह समझने के
लिए कि अनुसंधान क्यों किया जा रहा है ? और इसमें क्या शामिल होगा? कृपया पढ़ने के
लिए समय निकालें,निम्नलिखित जानकारी को ध्यान से पढ़ें ,अगर वहाँ कुछ भी अस्पष्ट है
तो हमसे संपर्क करें तथा तय करें कि आप हिस्सा लेना चाहते हैं या नहीं।

3. अध्ययन का उद्देश्य क्या है ? अध्ययन का उद्देश्य इंट्राट्रोकैं ट्रिक फ्रैक्चर

के 2 शल्य उपचार पो्क्षिमल फीमोरल नैल एवं बाइपोलर हे मी आथो्प्लास्टी के परीणामो एवं
जटिलता का मल्
ु यांकन करना है
4. जोखिम: दर्द, इस अध्ययन की भागीदारी इससे अलग कुछ

अतिरिक्त जोखिम नहीं है

5. लागत: रोगी पर कोई अतिरिक्त वित्तीय बोझ नहीं पड़ेगा।

6. व्यक्तिगत डेटा: एकत्रित डेटा का उपयोग सांख्यिकीय विश्लेषण के अधीन है । प्रतिभागी

की पहचान कभी भी प्रकट नहीं की जाएगी। सांख्यिकीय विश्लेषण के परिणाम को जर्नल में
शोध लेख के रूप में प्रकाशित किया जा सकता है ।

7.अध्ययन से पीछे हटने का अधिकार: आपको अध्ययन के दौरान कभी भी अपनी भागीदारी
वापस लेने का अधिकार है । किसी भी स्तर पर अध्ययन में भाग लेने का विकल्प चुनने या
बाहर निकलने का आपका निर्णय इस संस्था में आपके द्वारा प्राप्त उपचार को प्रभावित नहीं
करे गा।

8.संपर्क विवरण: आपसे अनुरोध है कि इस अध्ययन या इसमें आपकी भागीदारी के बारे में
किसी भी प्रश्न के लिए मझ
ु से मेरे फोन नंबर (9509894557) पर संपर्क करें । मझ
ु े आपकी
बात सुनकर खुशी होगी। इसमें आपकी भागीदारी, इस अध्ययन में एक प्रतिभागी के रूप में
आपके अधिकार और आपकी शिकायतों का निवारण, यदि इस समय किसी भी अध्ययन में
आपकी भागीदारी से कोई समस्या उत्पन्न होती है ।

9. प्रक्रिया: इस अध्ययन में हम इंट्राट्रोकैं ट्रिक फ्रैक्चर के उपचार के लिए दो शल्य क्रिया पो्क्षिमल

फीमोरल नैल एवं बाइपोलर हे मी आथो्प्लास्टी अलग अलग समह

ू में करें गे एवं उनके परीणाम

और जटिलता का मल्
ु यांकन करें गे
10. गोपनीयता : मैं यहां घोषित करता हूं कि आपकी पहचान और चिकित्सा रिकॉर्ड परू ी
तरह से गोपनीय रखा जाएगा। मैं आपसे अनरु ोध करता हूं कि आप स्वेच्छा से इस अध्ययन
में भाग लें और मझ
ु े नीचे उपयक्
ु त स्थानों पर हस्ताक्षर करके अपने मेडिकल रिकॉर्ड तक
पहुंचने की अनम
ु ति दें |
 PATIENT INFORMATION SHEET

NAME OF THE STUDY- ‘’A COMPARATIVE PROSPECTIVE

STUDY OF THE SURGICAL OUTCOME BETWEEN PFN AND
BIPOLAR HEMIARTHROPLASTY IN TREATMENT OF
INTERTROCHANTRIC FRACTURE IN ELDERLY PEOPLE’’
I ,Dr MANINDRA SINGH SHEKHAWAT, DNB Trainee
(Orthopaedics) in MANIPAL HOSPITAL,JAIPUR, shall be
conducting the above mentioned research study as the principal
 investigator, with Dr B R BAGARIA, HOD and Senior
consultant, Department of Orthopaedics, manipal
hospital,jaipur,as my guide I hereby invite you and request your
voluntary participation in the same.

Purpose of the study

The purpose of study is to To compare the clinical outcome and
complications of intertrochanteric fractures treated randomly with
proximal femoral nail (PFN) and Bipolar hemiarthroplasty in elderly
people
Study Population
Patients diagnosed with INTERTROCHANTRIC FRACTURE OF
FEMUR undergoing surgical treatment
Data collection & involvement of participant Data will be collected
from such individuals who will participate voluntarily and will sign
this informed consent form. During the course of the study, his/her
relevant medical records will be accessed once (post admission). The
patients will be evaluated at 1 month ,3 month and 6 month
following PFN/ BIPOLAR Hemi arthroplasty by harris hip score.

Study Type Prospective,single blinded, observational study. 

Risk There is no additional risk in participation of this study.

Use of Personal DataCollected data are subjected to statistical

analysis. Identity of the participant will never be revealed. Outcome
of statistical analysis can be published as research article in journal.
Cost All the investigations required for this study are routinely done
as a part of treatment. There will not be any additional financial
burden over patient.
Right to withdraw from the study You have the right to withdraw
your participation at anytime during the course of the study. Your
decision to opt in or opt out of participation in the study at any stage
will not affect the treatment you receive in this institution.

Contact Details You are requested to contact me on my phone

number (9509894557) for any queries regarding this study or your
participation in it. I shall be happy to hear from you. Your
participation in it, your rights as a participant in this study and
redressal of your grievances, if any arising out of your participation in
this study at any point of time.
Confidentiality I hereby declare that your identity and medical
records will be kept entirely confidential. I Request you to voluntarily
participate in this study and permit me to access your medical records
by signing at appropriate places below.

PREOPERATIVE-WORK UP
Investigations
 Blood – CBC
 Urine – Routine and Micro.
 Blood grouping and Rh typing
 PT with INR , APTT
 HIV, HbsAg, HCV
 Blood Urea
 Serum Creatinine
 Blood sugar Level
  Liver function test
 Serum electrolytes
 ECG
 2 D Echocardiography(if required)
 Chest X –ray PA.
 Other if required

Physician opinion will be taken as to the fitness of patient before surgery and
when necessary.

Pre – operative Anesthetic check-up:

Detailed Pre – operative Anesthetic check-up of patient will be carried out by
respective anesthetist and any further investigation or modification in current
treatment will be carried out as per advice.

Pre – Operative preparation of patient:

Patients will be kept fasting for 6-8 hours before surgery.
Groin to toe parts will be prepared.
The patients will be taken up for surgery after obtaining written and informed
risk consent of the nature and complications of the surgery.

Operative procedure:-

PFN:
Anesthesia:
Spinal anesthesia
Pre Operative antibiotics:
Patients will be given injection Cefuroxime 1.5 gm intravenously 30 minutes
before incision.

Position:Supine position on radiolucent table.

Technique: After induction of anaesthesia patient put on supine position on
radiolucent table.Fracture reduction confirmed under image intensifier in
AP view and lateral view (20 degree oblique ). After closed reduction, an about
5 cm longitudinal incision was made approaching the greater trochanter. Entry
taken with awl through tip of GT. Guide pin passed through the tip into the
medullary canal. Nail passed over the guide pin without
reaming. Helical blade put centrally/inferiorly in
anteroposterior view and centrally in lateral view.
Distal static bolt put. wound closed in layers
without drain.
Post Operative Management
Patients kept nil orally for 4 to 6 hours post-operatively. Intravenous fluid will
given if needed.
Antibiotics will continue for 4 days. (first 1 days iv then next 3 days oral
antibiotics.)
Analgesics and tranquilizers will given according to the needs of the patient.
Post operatively Abduction pillow kept .Side turning and sitting will allow. All
patient will start non weight bearing walking with walker support from POD-1
and full weight bearing from 1 month.
The wound will inspect at 2ndpostoperative day.
Patient will discharge at around 2-3 days post-operatively. Suture/staple
removal will done on 15th postoperative day.
All patient will given DVT prophylaxis like aspirin/ Dvt exercises till 3 month.
Follow up
All patients will be followed up 1 month ,3 month and 6 month
At each follow up patients will be assessed clinically for pain ,complications.

post-op picture of An IT fracture femur operated with PFNA

BIPOLAR HEMIARTHROPLASTY:
Anesthesia: spinal anesthesia
Pre Operative antibiotics:
Patients will be given injection cefuroxime 1.5 gm intravenously 30 minutes
before incision.
Position: Lateral decubitus position
Technique: After induction of anaesthesia patient put on lateral decubitus
position.MooreS approach for all the cases.10 cm curved incision centering over
GT. Short external rotators ligated and cut. Removal of head in
intertrochanteric fracture is difficult. Head extractor is put and capsule is
released all around.Other option is to cut it subcapitally with saw as in neck
femur fracture and then remove remaining neck with piecemeal. Fracture
pattern is assessed. Usually LT is reconstructed first to get a anatomical
landmark using SS wire. Then Canal is reamed and serially broached. Trial stem
put. Final stem is put with/without cement. Final head put after trial reduction.
Greater trochanter then fixed with k wires /encirclage/tension band wiring
depending on fracture pattern. Wound closed over negative suction drain.
Post Operative Management
Patients kept nil orally for 4 to 6 hours post-operatively. Intravenous fluid will
given if needed.
Antibiotics will continue for 7 days. (first 2 days iv then next 5 days oral
antibiotics.)
Analgesics and tranquilizers will given according to the needs of the patient.
Drain removed at POD-1.
Post operatively Abduction pillow kept .Side turning and sitting will be
allowed. All patient started full weight bearing walking with walker support
from POD-1.
The wound will inspect at 2ndpostoperative day.
Patient will discharge at around 2-3 days post-operatively. Suture/staple
removal will done on 15th postoperative day.
All patient will given DVT prophylaxis like aspirin/ DVT exercises till 3
month.

Follow up:
All patients will be followed up 1 month ,3 month and 6 month.
At each follow up patients will be assessed clinically for pain ,complications.
Post op picture of an IT fracture operated with Bipolar Hemiarthroplasty

PROFORMA

Name :
MRN No. :
Age/Sex :
Occupation :
Address :
Date of admission :
Date of surgery :
Date of discharge :
HISTORY :

Presenting complaints:

Side of injury: Right / Left Hip

Pain : right/left Hip
Onset
Duration
Swelling: Y/N
Deformity or Tenting into the skin : Y/N
Mechanism of injury:
H/O Fall
Road traffic accident
Assault
Miscellaneous injury
Associated soft tissue, neurovascular and skeletal injury:
History of presenting illness:-
Immediate treatment-

Duration between the injury and first visit-

FAMILY HISTORY:

PAST HISTORY:
Diabetes
Hypertension
Ischemic heart disease
Asthma
Fracture or same event
Others

DRUG HISTORY:
a) Steroids
b) Aromatase inhibitor and Androgen deprivation therapy
c) Depo-Provera (Medroxyprogesteron)
d) Proton pump inhibitor
e) Selective serotonin reuptake inhibitor
f) Thiazolidenediones
g) Antiepileptics
h) Steroids
i) Other
EXAMINATION:
1. Genera examination: Vitals
Pulse______ /min Temp______ 0F
SpO2 _______%
B.P. __________ mm of Hg R.R. ______ /min
2. Systemic examination:
Per Abdomen
Cardiovascular system
Respiratory system
Central nervous system

Local examination

Inspection :i) swelling

ii) Bruising

iii) Ecchymosis

iv) Abrasion

v) Tenting of skin

vi) Scar

vii) Sinus

viii)Attitude

viii) Active Toe movement

ix) sustained leg raise

x) Range of motion

Palpation:- i) Tenderness

ii)Swelling

iii) Crepitus

iv)limb shortening
 v) Deformity and Other findings

Neurovascular status

Investigation:

Blood:-CBC (Hb-______gm%, TC-_______, PC-___________)

Urine- Routine and Micro
Blood grouping and Rh typing _________
HIV ___________
HBV _________, HCV _________
LFT:- SGPT________; SGOT________
RFT:- Blood Urea ________ ; S.Creatinine __________
PT_______ and INR_______
APTT _______
RBS ________
OTHERS:-

X-RAY:

i. X-Ray- Plain x-ray of right/left Hip anteroposterior and

lateral views

ii. Traction and internal rotation x-rays if required

Associated injuries If any

 OT NOTES:-
Duration of Surgery
Type of Anesthesia
Blood loss
Blood transfusion:- Y/N
Intra-OP complication if any

POST OPERATIVE NOTES:-

Vitals- BP:- __________mm of Hg

PR:- _________/ min
SpO2 (Operated limb):- _______%

Antibiotics :

Wound healing :

Date of stitch removal:

Immobilization and support with:

Capillary refilling:
 COMPLICATIONS
a) Intra-operative

Neurovascular injury:

m/c vessel: profonda femoris

m/c nerve: femoral nerve(early)

 b) Post-operative:

Early

Pain

Infection : Superficial / Deep

Sepsis

Late

Sciatic nerve injury

Limb lengh shortening

Infection

Implant Failure/ Migration

Osteonecrosis of femoral head

Malrotation deformity
 FOLLOW UP
In follow up, we will assess patients clinically, at 1 month , 3 month
and 6 month

Clinical assessment:

Pain

Gait

Wound if any

Any discharge

SLR

ROM

Distal pulsation

Capillary refilling

Any neurological deficit

Other If any: Harris Hip Score

HARRIS HIP ASSESSMENT TOOL
Evaluation:-
Harris hip score at 1 month-
Harris hip score at 3 month-
Harris hip score at 6 month-
OBSERVATION AND SUMMARY
CONCLUSION
 REFERENCES

1.Dr. Rottela Shiva Kumar, Dr. Guru Prasad Sultanpurkar, DR. K Harsha
Vikram and Dr. Harshavardhan Raorane ,Comparative study between
proximal femoral nail and bipolar prosthesis in intertrochanteric fracture femur,
International Journal of Orthopaedics Sciences 2018;4(1):708-713
2. Wayan Suryanto Dusak*, Herryanto Agustriadi Simanjuntak, I Gusti
Ngurah Paramartha Wijaya Putra , Comparison between the results of
proximal femur nail anti-rotation and cemented bipolar hemiarthroplasty in
treatment of intertrochanteric fractures in Sanglah Hospital in 2016,
Int j Res Med Sci.2019;sep 7(9):3475-3479
3. Saraf H, Munot S., Comparative study of PFN antirotation vs bipolar
hemiarthroplasty in unstable senile intertrochanteric fractures. Indian J Orthop
Surg. 2018;4(4):380-385.
4. Shenghu Zhou1,2†, Jun Liu2†, Ping Zhen2,Weiwei Shen2, Yanfeng
Chang2, Haoqiang Zhang2, QingshengZhu1* and Xusheng Li2*Proximal
femoral nail anti-rotation versus cementless bipolar hemiarthroplasty for
unstable femoral intertrochanteric fracture in the elderly: a retrospective
study,BMC Musculoskeletal Disorders (2019)20:500
5. Dr. Amandeep Singh Bakshi, Dr. Pardeep Kumar, Dr. BS Brar ,
Comparative study between DHS and PFN in intertrochanteric fractures of
femur , International Journal of Orthopaedics Sciences 2018; 4(1): 259-262
6. Swaroop Das D, Kalambe HV, Handralmath SP. Comparative
study of unstable intertrochanteric fracture treatment by trochanteric
femoral nail versus hip hemiarthroplasty.  Int J Orthop. 2017;3(4):548-52.
7. Suh Y-S, Nho J-H, Kim S-M, Hong S, Choi H-S, Park J-S. Clinical and
Radiologic Outcomes among Bipolar Hemiarthroplasty, Compression Hip
Screw and Proximal Femur Nail Antirotation in Treating Comminuted
Intertrochanteric Fractures , Hip Pelvis. 2015;27(1):30
8. Xu YZ, Geng DC, Mao HQ, Zhu XS, Yang HL. A comparison of the proximal
nail antirotation device and dynamic hip screw in the treatment of unstable, The
Journal of International Medical Research 2010; 38: 1266 – 1275
9. K-L Ma , X Wang , F-J Luan , H-T Xu , Y Fang , J Min , H-X
Luan , F Yang , H Zheng , S-J He Proximal femoral nails antirotation,
Gamma nails, and dynamic hip screws for fixation of intertrochanteric
fractures of femur: A meta-analysis , Orthop Traumatol Surg Res. 2014
Dec;100(8):859-66.
10.L Shen , Y Zhang, Y Shen, Z Cui ,Antirotation proximal femoral
nail versus dynamic hip screw for intertrochanteric fractures: a meta-
analysis of randomized controlled studies Orthop Traumatol Surg
Res2013 Jun;99(4):377-83.

11. Cheng-Guo Huang , Jun-Jian Ye ,Comparison of three methods

for the treatment of aged femoral intertrochanteric fracture, Zhongguo
Gu Shang 2012 Jul;25(7):549-53

12. Yong-Ming Jin , Jin-Ping Chen, Xiao-Lin Li, Ya-Zeng Huang, Di

Yang Retrospective study of comparing the different internal fixation
methods in treating intertrochanteric fracture of femur. Zhongguo Gu
Shang 2008 May;21(5):329-32.

13.. [Internet].
Rguhs.ac.in. 2020 [cited 22 December 2020]. Available
from: http://www.rguhs.ac.in/cdc/onlinecdc/uploads/01_M009_45215.doc

14. Osteosynthesis of intertrochanteric fractures by PFN and DHS – A

prospective randomized comparative study - Pulin Bihari Das, Anurag
Singh, Bhabani Shankar Lenka, Sunit Pani, 2020 [Internet]. SAGE
Journals. 2020 [cited 22 December 2020]. Available from:
https://journals.sagepub.com/doi/abs/10.1177/2210491720971832?
ai=2b4&mi=ehikzz&af=R

15. [Internet]. Scribd.com. 2020 [cited 22 December 2020]. Available

from: https://www.scribd.com/document/477987330/unstable-
trochanteric-fractures-issues-and-avoiding-pitfalls

16. Kempf I, Grosse A, Taglang G, Favreul E. Gamma nail in the treatment of

closed trochanteric fractures. Results and indications of 121 cases. 2020.

17. study comparing femoral: Topics by Science.gov [Internet].

Science.gov. 2020 [cited 22 December 2020]. Available from:
https://www.science.gov/topicpages/s/study+comparing+femoral.html

18. Intertrochanteric fractures - Evans classification - OrthopaedicsOne

Articles - OrthopaedicsOne [Internet]. Orthopaedicsone.com. 2020 [cited
22 December 2020]. Available from:
https://www.orthopaedicsone.com/display/Main/Intertrochanteric+fractur
es+-+Evans+classification

19. . [Internet]. 2020 [cited 22 December 2020]. Available from:

https://link.springer.com/article/10.1007/s00590-002-0033-6

20. [Internet]. 2020 [cited 22 December 2020]. Available from:

https://www.researchgate.net/publication/282356680_Classifications_of_Intertr
ochanteric_fractures_and_their_Clinical_Importance