From: Date:

DR VENKATESH K
POST GRADUATE STUDENT IN M.S. (ORTHOPAEDICS)
DEPARTMENT OF ORTHOPAEDICS,
VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BELLARY.
To

THE PRINCIPAL,
VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES,
BELLARY.

THROUGH PROPER CHANNEL

Respected Sir,

Subject : Acceptance of registration and forwarding of my dissertation topic.

With reference to the above subject, I, the undersigned studying post graduate course
in M.S. Orthopaedics has been allotted the dissertation topic ‘A STUDY OF UNSTABLE
IMTERTROICHANTERIC FEMORAL FRACTURES TREATED BY
TROCHANTERIC FEMORAL NAIL, under the guidance of DR D PRABHANJAN
KUMAR Professor and head of department, Department of Orthopaedics, VIMS, Bellary.

I request you to kindly forward the dissertation topic in the prescribed form to the
University for approval.

Thanking you,

Yours sincerely,

Signature of the guide

(DR VENKATESH K)

(DR. D.PRABHANJAN KUMAR)

Professor and HOD
Department of Orthopaedics,
VIMS, Bellary
From : Date:
The Professor and Head of the Department,
Department of Orthopaedics,
Vijayanagar Institute of Medical Sciences, Bellary.
To
The Registrar,
Rajiv Gandhi University of Health Sciences,
Bangalore.

THROUGH PROPER CHANNEL

Respected Sir,
As per the regulations of the University for registration of Dissertation topic, the
following Post Graduate Student in MS Orthopaedics has been alloted the dissertation topic
as follows by the Official Registration Committee of all qualified and eligible guides of the
Department of orthopaedics.

NAME TOPIC GUIDE

DR VENKATESH K ‘A STUDY OF UNSTABLE DR. D PRABHANJAN
INTERTROICHANTERIC
Post Graduate Student KUMAR
FEMORAL FRACTURES
M.S. Orthopaedics,
TREATED BY Professor & HOD,
VIMS, Bellary.
TROCHANTERIC Department of
FEMORAL NAIL Orthopaedics, VIMS,
Bellary.

Therefore, I kindly request you to communicate the acceptance of the dissertation topic
allotted to the postgraduate student at an early date.
Thanking you,
Signature of the guide: Yours faithfully,

DR.D PRABHANJAN KUMAR DR D PRABHANJAN KUMAR

Professor and HOD Professor and HOD
Department of Orthopaedics Department of Orthopaedics
VIMS, Bellary VIMS, Bellary

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.
 ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1 Name of the candidate and Dr VENKATESH K
address POST GRADUATE STUDENT IN
MS ORTHOPAEDICS
VIJAYANAGAR INSTITUTE OF MEDICAL
SCIENCES
BELLARY -583104

2 Name of the Institution VIJAYANAGAR INSTITUTE OF MEDICAL

SCIENCES
BELLARY -583104

3 Course of the study and subject M.S ORTHOPAEDICS.

4 Date of admission to the course 29.05.2013

5 Title of the topic “A STUDY OF UNSTABLE

INTERTROCHANTERIC FEMORAL
FRACTURES TREATED BY TROCHANTERIC
FEMORAL NAIL.”
6 BRIEF RESUME OF INTENDED WORK

6.1.Need for study

Intertrochanteric fracture is one of the most common fractures of the hip especially in the
elderly. The incidence of intertrochanteric fracture is rising because of the increase in
number of elderly population superadded with osteoporosis. These fractures are 3 to 4
times more common in women and the mechanism of injury is usually due to low energy
trauma like a simple fall. By 2040 the incidence is estimated to be doubled. In India the
figures may be much more.1

More than 50% of intertrochanteric fractures are unstable. Unstable patterns occur more
2
commonly with increased age and with low bone mineral density .The presence of
osteoporosis in intertrochanteric fractures is important because fixation of the proximal
fragment depends entirely on the quality of cancellous bone present
The surgical stabilization of unstable intertrochanteric fractures remains a persistent
challenge. The higher incidence of failure rates in unstable intertrochanteric fractures that
may reach up to 23% with the use of extramedullary implant like dynamic hip screw has
led to the evolution of intramedullary devices. 3, 4.
The purpose of this study is to evaluate the effectiveness and safety of trochanteric femoral
nail in unstable intertrochanteric fractures of femur in our set up .

6.2 Review of Literature

CLASSIFICATION OF INTERTROCHANTERIC FRACTURES

Boyd and Griffin (1949) classified fractures in the peritrochanteric area of the femur into
four types, which included fractures from the extracapsular part of the neck to a point 5 cm
distal to the lesser trochanter.
Type I: Fractures that extend along the intertrochanteric line from the greater to the
lesser trochanter. Reduction usually is simple and is maintained with little
difficulty. Results generally are satisfactory.
Type II: Comminuted fractures, the main fracture being along the intertrochanteric
line, but with multiple fractures in the cortex. Reduction of these fractures is more
difficult because the comminution can vary from slight to extreme.
Type III: Fractures that are basically subtrochanteric with at least one fracture
passing across the proximal end of the shaft just distal to or at the lesser trochanter.
Varying degrees of comminution are associated. These fractures usually are more
difficult to reduce and result in more complications at operation and during
convalescence.
Type IV: Fractures of the trochanteric region and the proximal shaft, with fracture
in at least two planes, one of which usually is the sagittal plane and may be difficult
to see on routine anteroposterior radiographs. If open reduction and internal
fixation are used, two-plane fixation is required because of the spiral, oblique, or
butterfly fracture of the shaft.

STABLE INTERTROCHANTERIC FRACTURES

A truly stable intertrochanteric fracture, is one when reduced has a cortical contact
without a gap medially and posteriorly. Medial cortices of proximal fragment and
distal fragment are not comminuted and there is no fracture or lesser trochanter is
not displaced. This contact prevents displacement in to varus or retroversion when
forces are applied.

UNSTABLE INTERTROCHANTERIC FRACTURES

Unstable intertrochanteric fractures are those in which comminution of

posteromedial buttress exceeds a simple lesser trochanteric fragment or those with
subtrochanteric extension. There is comminution of greater trochanter and there is
no contact between proximal and distal fragment because of displaced
posteromedial fragment. The importance of displaced lesser trochanter fragment,
its size and displacement is a key to decide the instability of intertrochanteric
fracture.

Similarly intertrochanteric fracture with reversed obliquity in which there is

inherent tendency of medial displacement of distal fragment secondary to pull by
adductor muscle are unstable injury.5

Another unstable fracture is described by Kyle where intertrochanteric fracture is

extended in to the fracture neck femur.6 The results of unstable fractures are less
reliable and have a high rate of failure 8%-25%.

MANAGEMENT OF UNSTABLE INTERTROCHANTERIC FRACTURES

The surgical stabilization of these fractures remains a persistent challenge.

The goal of treatment of any intertrochanteric fracture in the elderly is to restore
mobility safely and efficiently as early as possible while minimizing the risk of
medical complications and technical failure and to restore the patient to
preoperative status. Restoration of mobility in patients with unstable
intertrochanteric fracture ultimately depends on the strength of surgical construct.

There are multiple factors and variables, 7 which affect the biomechanical strength
of repair. Surgeon independent variables are bone quality, which is related to age
and osteoporosis and fracture pattern & fracture stability, whereas surgeon
dependent variables are quality of fracture reduction and choice & placement of
implant.

Unstable intertrochanteric fractures are technically much more challenging than

stable fractures; a stable reduction of an intertrochanteric fracture requires
providing medial and posterior cortical contact between the major proximal and
distal fragment to resist varus and posterior displacing forces. Hence Surgeons
must understand implant options available and should strive to achieve accurate
realignment and proper implant placement.

A. EXTRAMEDULLARY DEVICE SYSTEMS

Sliding devices like the Dynamic Hip Screw have been extensively used for
fixation. This open technique entailing the sliding hip screw may result in
deterioration of pre-existing co morbidities in elderly patients owing to increased
blood loss, soft-tissue damage, and longer rehabilitation. 8
Cutting out of the sliding hip screw, excessive medialisation of the distal fragment
(in unstable fractures), and collapse upon weight bearing are major concerns.9 10

Dissatisfaction with the use of the sliding hip devices in unstable intertrochanteric
fracture patterns led to the evolution of intramedullary devices.

B. INTRAMEDULLARY DEVICE SYSTEMS

There are various intramedullary device systems available such as the Gamma nail,
Intra Medullary Hip Screw (IMHS), Trochanteric Antegrade nail (TAN), Proximal
Femoral Nail (PFN), Proximal Femoral Nail Antirotation (PFNA),

Gamma nailing is a less invasive technique, but is associated with cutting out of the
screws, thigh pain, and femoral shaft fractures.11, l2
To overcome these
complications, intramedullary proximal femoral nailing with 2 proximal screws for
insertion into the head-neck fragment is developed for patients with unstable
trochanteric fractures.13 Nonetheless, the sizes of existing gamma nails and the
proximal femoral nails are excessively large for Asian femora. Modification of the
gamma nail by reducing its diameter and length has been performed in a Chinese
population.14
Intramedullary devices offer certain distinct advantages:
- More efficient load transfer than a dynamic hip screw, because of its
location.
- A shorter lever arm decrease tensile strain on the implant, thus decreasing
the risk of implant failure.

- The intramedullary location limits the amount of sliding and therefore limb
shortening and the deformity is also less.
- Requires shorter operative time and less soft tissue dissection than a
dynamic hip screw, so decreasing the overall morbidity.
Short trochanteric femoral nail has a proximal diameter of 14mm. The narrow
proximal diameter enables easy insertion and reduces the risk of femoral fracture.
Distally it is available in 10, 11, 12, mm diameter . The nail has 6degree
mediolateral angle for easy insertion and a flexible distal tip to minimise stress
concentration. The nail is available in femoral neck angles of 130 and 135 degrees
It has 8 mm bolt(cannulated) compression screw and 6mm bolt(cannulated)
antirotation screw proximal to it. Distally it has 5 mm both static and dynamic
locking screws. The nail has longitudinal slot throughout, so as to accelerate
regeneration of endosteal bone. It is available in length of 180 mm and 200 mm
standard. 15
Various studies have been done to compare intramedullary fixation with
extramedullary fixation in intertrochanteric fractures:

16
Baumgaertner MR, Curtin SL, Lindskog DM (1998) did a study on
Intramedullary versus extramedullary fixation for the treatment of intertrochanteric
hip fractures. They concluded that in unstable proximal femoral fractures, control
of axial telescoping and rotational stability are essential. Intramedullary implants
inserted in a less-invasive manner are better tolerated by the elderly.

17
Schipper IB, Marti RK, van der Werken C.( 2004) did a review of 18
international papers that compared two different treatment methods for unstable
trochanteric fractures: extramedullary or intramedullary fixation. They concluded
for stable fractures, the sliding hip screw system is a safe and simple method. For
unstable fractures intramedullary implants are biomechanically superior.

18
Moein CM, Verhofstad MH, Bleys RL, van der Werken C. (2005) did a study on
the soft tissue injury related to choice of entry point in antegrade
femoral nailing: piriform fossa or greater trochanter tip. They concluded that
Cephalomedullary femoral reconstruction nails with a trochanteric entry point are
biomechanically stronger than extramedullary implants.
 19
Vidyadhara S, Rao SK (2007) evaluated the use of one and two femoral neck
screws with intramedullary nails for unstable trochanteric fractures of
femur in the elderly. They inferred that the two femoral neck screws: the stabilising
and the compression screws of the proximal femoral nail adequately compress the
fracture, leaving between them a bone block for further revision if necessary. It is a
biomechanically stable construct that enables early weight bearing.

6.3OBJECTIVES OF THE STUDY

1.To study the management of unstable intertrochanteric fractures of femur with

trochanteric femoral nail..
2. To study the radiological and functional (clinical) outcome of fractures treated with this
procedure.

MATERIALS AND METHODS

7.1 SOURCE OF DATA

All cases with the diagnosis of unstable intertrochanteric fracture of femur admitted to
Department of orthopaedics ,medical college hospital VIJAYANAGAR INSTITUTE OF
MEDICAL SCIENCES BELLARY from November 2013 to September 2014 and meeting
to the inclusion and exclusion criteria (mentioned below), will be subject of the study.

7.2 a) METHOD OF COLLECTION OF DATA

 The study will be conducted in the department of orthopaedics VIMS Bellary
by taking history of injury , by doing a detailed clinical examination and
relevant investigation .

INCLUSION CRITERIA
 More than 18 years
  Radiological findings confirming unstable intertrochanteric fractures
 Patients who are medically fit and willing for surgery

EXCLUSION CRITERIA
 Age: less than 18 years.
 Compound fractures.
 Patients with pathological fractures
 Patients medically unfit for surgery.
 Patients unwilling to consent for surgery.

Inpatients meeting the inclusion and exclusion criteria are selected for the study after
obtaining written and informed consent.Demographic data, History, Clinical examination
and details of investigations will be recorded in the study proforma. Routine pre operative
investigations will be done and radiographs to study the fracture anatomy will be taken.
Written informed consent and pre anaesthetic evaluation is done for the surgery. Under
anaesthesia, closed reduction and internal fixation with Trochanteric femoral nail will be
done using image intensifier. Post operatively, the patient will be made to sit on 2 nd post op
day, and active quadriceps drill started, partial weight bearing started as the wound reaction
and patient acceptance improves around one week. Full weight bearing depending on the
radiological evidence of union of the fracture and acceptance of the patient.Assessment at
regular intervals made at 6th, 12th, 24th post op week. At each follow up visit, patient will be
evaluated clinically and radiological evaluation of the fracture will be done. All patients
will be assessed by using the Kyle’s criteria20 at the follow-ups.

7.2 b) Sample Size And Duration of study

 Sample size:minimum of 30 cases.
 Duration of study: november 2013 to September 2014
 Study design: case series.


7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER
HUMANS OR ANIMALS?
Yes, the study requires routine preoperative investigations.
  Radiological investigation – X ray pelvis AnteroPosterior view, X ray of affected
Hip AnteroPosterior and crossed table Lateral view. A physician assisted internal
rotation view of affected Hip( to clarify the fracture pattern)
 No unnecessary investigations will be done in the study

7.4HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?
Yes, Ethical Clearance has been obtained from the Institutional Ethical Committee of
Vijayanagar institute of Medical Sciences.

LIST OF REFERENCES
1.GS Kulkarni, Rajiv Limaye, Milind Kulkarni, Sunil Kulkarni. Intertrochanteric fractures.
Indian journal of orthopaedics 2008,40:16-23
2.Koval KJ, Aharonoff GB, Rokito AS, Lyon T, Zuckerman JD. Patients with femoral neck
and intertrochanteric fractures: Are they the same? Clin Orthop.1996; 330:166-172
3.Gundle R, Gargan M.F, Simpson HRW (1995) how to minimize failure
of fixation of unstable intertrochanteric fractures. Injury 26:611-614.
4. Simpson AHRW, Varty K, Dodd CAF (1989) Sliding hip screws: modes of failure. Injury
20:227–231.
5.Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric
region of the femur J Bone Joint Surg (Am) 2001; 83:643-650
6.Kyle RF, Ellis TJ, Templeman DC. Surgical Treatment of Intertrochanteric Hip fractures
with associated femoral neck fractures using a sliding hip screw.
J Orthop Trauma. Jan 200

7 Kaufer H. Mechanics of the treatment of hip injuries.

Clin Orthop. 1980; 146:53-61
8 Morris AH, Zuckerman JD, American Academy of Orthopaedic Surgeons Council of
Health Policy and Practice. National Consensus Conference on Improving the Continuum
of Care for Patients with Hip Fracture. J Bone Joint Surg Am 2002;84:670–4
9Flores LA, Harrington IJ, Heller M. The stability of intertrochanteric fractures treated with
a sliding screw-plate. J Bone Joint Surg Br 1990;72:37–40.
10Simpson AH, Varty K, Dodd CA. Sliding hip screws: modes of failure. Injury
1989;20:227–31.
11Hesse B, Gachter A. Complications following the treatment of trochanteric fractures with
the gamma nail Arch Orthop Trauma Surg 2004;124:692–8.
12.Halder SC. The Gamma nail for peritrochanteric fractures.
J Bone Joint Surg Br 1992;74:340–4
13.Klinger HM, Baums MH, Eckert M, Neugebauer R. A comparative study of unstable
per- and intertrochanteric femoral fractures treated with dynamic hip screw (DHS) and
trochanteric butt-press plate vs. proximal femoral nail (PFN) [in German]. Zentralbl Chir
2005;130:301–6.

14.Leung KS, Chen CM, So WS, Sato K, Lai CH, Machaisavariya B, et al. Multicenter trial
of modified Gamma nail in East Asia. Clin Orthop Relat Res 1996;323:146–54.
15.use of trochanteric nail for proximal femoral extracapsular fractures hofer M et al,
orthopaedics. 2006 dec;29(12):1109-14
16.Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary
fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res
1998;348:87–94
17.Schipper IB, Marti RK, van der Werken C. Unstable trochantericfemoral fractures:
extramedullary or intramedullary fixation.Review of literature. Injury.2004;35(2):142-51.
18.Moein CM, Verhofstad MH, Bleys RL, van der Werken C. Soft tissue injury related to
 choice of entry point in antegrade femoral nailing: piriform fossa or greater trochanter tip.
Injury 2005; 36:1337–42.
19.Vidyadhara S, Rao SK. One and two femoral neck screws with intramedullary nails for
unstable trochanteric fractures of femur in the elderly: randomised clinical trial.
Injury 2007;38:806–14.
20. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two
intertrochanteric hip fractures. J Bone Joint Surg Am 1979;61:216–21.

9 Signature of the candidate

10 Remarks of the guide The intended study will help in the better understanding
of the management of unstable intertrochanteric fractures
of femur.
11 11.1. Name and designation of Dr. D PRABHANJAN KUMAR.
the guide. PROFESSOR AND
HEAD OF THE DEPARTMENT ,
DEPARTMENT OF ORTHOPAEDICS,
VIJAYANAGAR INSTITUTE OF MEDICAL
SCIENCES , BELLARY
11.2. Signature
 11.3. Head of the Department Dr. D PRABHANJAN KUMAR.
PROFESSOR AND
HEAD OF THE DEPARTMENT
DEPARTMENT OF ORTHOPAEDICS,
VIJAYANAGAR INSTITUTE OF MEDICAL
SCIENCES BELLARY.
11.4. Signature

12 12.1. Remarks of the Chairman

and Principal

12.2. Signature.