SHORT TERM ANALYSIS OF FUNCTIONAL OUTCOME OF

INTERTROCHANTERIC FEMUR FRACTURE TREATED BY

PROXIMAL FEMORAL NAIL ANTIROTATION II (PFNA-II) IN
TERTIARY CARE CENTRE OF EASTERN NEPAL

A THESIS
SUBMITTED TO
KATHMANDU UNIVERSITY
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF MASTER OF SURGERY IN ORTHOPAEDICS
(MS ORTHOPAEDICS)

DR. SURAJ SHAHI

MBBS (KU)

DEPARTMENT OF ORTHOPAEDICS
NOBEL MEDICAL COLLEGE TEACHING HOSPITAL

NOVEMBER, 2021
 DEDICATED TO

MY FAMILY

AND

MY PATIENTS WITH GRATITUDE

i
 DECLARATION

I hereby declare that I am the sole author of the work relating to this thesis entitled “SHORT

TERM ANALYSIS OF FUNCTIONAL OUTCOME OF INTERTROCHANTERIC

FEMUR FRACTURE TREATED BY PROXIMAL FEMORAL NAIL

ANTIROTATION II (PFNA-II) IN TERTIARY CARE CENTRE OF EASTERN

NEPAL” and that it has not been submitted for any degree previously.

I authorize the Kathmandu University to lend this thesis to other institutions or individuals

for the purpose of scholarly research.

I further authorize the Kathmandu University to reproduce this thesis by any means

electronic, mechanical, photocopying or otherwise, in total or in part, at the request of other

institutions or individuals for the purpose of scholarly research.

Dr. Suraj Shahi

November, 2021

ii
 ACKNOWLEDGEMENT

I take this opportunity to express my heartfelt thanks to all the people who have contributed

directly or indirectly to this thesis.

I am extremely grateful to my preceptor and guide Prof. Dr. Uday Chandra Chaudhary sir for

his valuable supervision, encouragement and invaluable guidance. My special thanks to Prof.

Dr. Dilip Majumdar sir for his immense support and motivation into the study of the subject.

I wish to thank to our in-charge, Associate Prof. Dr Prakash Sitoula sir, Associate Prof. Dr.

Ranjib Jha sir and Asst.Prof. Dr.santosh Thapa sir of our Department of Orthopaedics for

their continued advice and support. I also like to express my gratitude to our lecturers- Dr.

Sandip Adhikari, Dr. Dhiraj Singh, Dr. Suman Dhoj Kunwar, Dr. Bishamber Thapa, Dr.

Aashish Rajthala, Dr. Bikal Gautam and Dr. Lalit Kumar Bohra for their wonderful guidance.

I would also like to thank very helpful physiotherapist Dr. Pramod Kumar Mehta. I am also

very grateful to the Department of Radiology, Department of Anesthesiology, the ROT/EOT

staffs and staffs at the orthopaedic ward.My special thanks to Mr. D.D. Baral for lending me

a hand with statistical analysis.

I would like to thank my parents for making me able to serve the needy. I would also like to

thank my colleagues who assisted in various ways in completing the task.

Finally, I would like to thank all my patients who have contributed a lot for the completion of

this thesis.

Dr. Suraj Shahi

November, 2021

iii
 CERTIFICATE BY THE PRECEPTOR

This is to certify that this thesis entitled “SHORT TERM ANALYSIS OF FUNCTIONAL

OUTCOME OF INTERTROCHANTERIC FEMUR FRACTURE TREATED BY

PROXIMAL FEMORAL NAIL ANTIROTATION II (PFNA-II) IN TERTIARY CARE

CENTRE OF EASTERN NEPAL” is a good research work by Dr. Suraj Shahi under my

supervision and guidance in partial fulfillment of the requirement for the degree of Master of

Surgery in Orthopaedics granted by Kathmandu University.

I further affirm that this research project has been duly approved and ethically cleared by the

Institutional Review Committee of Nobel Medical College Teaching Hospital. The data

incorporated in this thesis is original and genuine.

────────────────

Dr. Uday Chandra Chaudhary

Professor

Department of Orthopaedics

Nobel Medical College and Teaching Hospital

November, 2021

iv
CERTIFICATE OF ETHICAL CLEARANCE

v
 GLOSSARY OF ABBREVIATION

AO Arbeitsgemeinschaftfür Osteosynthesefragen /Association  for Osteosynthesis

ASIF Association for the Study of Internal Fixation

AP Antero-Posterior

ANOVA Analysis Of Variance

IP In Patient

PFN Proximal femur nail

PFNA Proximal femur nail antirotation

PFNA-II Proximal femur nail antirotation II

DHS Dynamic hip screw

ORIF Open reduction internal fixation

CI Confidence Interval

IV/iv Intra Venous/intravenous

ROM Range of motion

ABSTRACT

Introduction: Peritrochanteric fracture are increasing in incidence worldwide.To prevent the

medical complications in these fractures, early mobilization is needed. There are many

methods of treatment but the ideal method should be less invasive with stable fixation of

vi
facture. Proximal Femoral Nail Antirotation (PFNA) is biomechanically considered one of

the most effective methods of treatment with promising results. Aims and objectives: To

evaluate the clinical and radiological outcomes in patient who were treated with PFNA in

unstable introchanteric fracture. Materials and Methods: Prospective study, include 30

samples, conducted in Nobel Medical College Teaching Hospital, Biratnagar Nepal from

January 2020 to June 2021. All the samples were clinically evaluated along with obtained

detail history and after the anesthesia clearance the sample were operated. During operative

procedure Duration of operative procedure, Fluoroscopic Shots, time of radiological union

and complication were noted and in the final follow up Harris Hip Score was used for

assessing functional outcome. Result: The mean age of the sample in this study was 72 years

(55-90 years) . The average time to complete the surgery was 62.6 minutes (minimum 32

minutes- maximum 97 minutes). Fracture union was seen at the average of 13.0 weeks (12-

116 weeks). the mean Harris Hip score at final follow up was 82.4 (70-90) with functional

status of 10% excellent result , 76.7% good and 13.3% fair. Conclusion: Proximal Femoral

Nail Antirotation in peritrochanteric fracture is an effective method of fixation as the

procedure reduces the operative time and radiation exposure .Since this is minimally invasive

procedure the blood loss is very less in compared to DHS or plate fixation. The patient can

also be mobilize early, reducing the complication arises from immobilization.

Key Words: Intertrochanteric fracture, PFNA-II

TABLE OF CONTENTS

DEDICATED TO................................................................................................i

DECLARATION................................................................................................ii

vii
ACKNOWLEDGEMENT................................................................................iii

CERTIFICATE BY THE PRECEPTOR........................................................iv

CERTIFICATE OF ETHICAL CLEARANCE..............................................v

GLOSSARY OF ABBREVIATIONS..............................................................vi

ABSTRACT......................................................................................................vii

TABLE OF CONTENTS................................................................................viii

LIST OF TABLES.............................................................................................ix

LIST OF FIGURES............................................................................................x

INTRODUCTION..............................................................................................1

REVIEW OF LITERATURE..........................................................................20

OBJECTIVES...................................................................................................26

METHODOLOGY...........................................................................................27

RESULT............................................................................................................32

DISCUSSION....................................................................................................40

CONCLUSION.................................................................................................43

REFERENCES.................................................................................................44

APPENDIX……………………………………………………………………55

LIST OF TABLES

Table 1: Sex distribution of patients…………………………….…………………………...32

Table 2: Distribution of patients according to mode of injury….…………………………...34

viii
Table 3: Distribution of patients according to side of injury ………………………………..35

Table 4: Distribution of patients according to type of fracture …………………………......36

Table 5: Functional outcome according to Harris Hip score……….…………………….….38

ix
 LIST OF FIGURES

Figure 1: Short external rotators of hip………………………………………………………..2

Figure 2: Gluteal muscles……………………………………………….…………….……….3

Figure 3: Trabeculae pattern ..........................................................................................…......4

Figure 4: Boyd & Griffin classification………………..………………………………….…10

Figure 5: Evan’s classification……………………………………………………………….11

Figure 6: AO classification…………………………………………………………………..13

Figure 7: Distribution of patients according to sex ……………………..…………………..33

Figure 8: Distribution of patients according to mode of injury……………………………..34

Figure 9: Distribution of patients according to side of injury……………………………....35

Figure 10: Distribution of patients according to AO classification………………………...36

Figure 11: Distribution of type of fracture according to gender …………………………...37

Figure 12: Functional outcome according to Harris Hip score…………….………………39

Figure 13: Instruments and implants………………………………..………………………61

Figure 14: Painting and draping ……………………………………………………………61

Figure 15: Intraop fluoroscopic image……………………………………………………...62

Figure 16: Preop xray……………………………………………………………………….62

Figure 17: Post op xray…………………………………........................................................63

Figure 18: Functional results…………………………………………………………………63

x
 INTRODUCTION

Background

In elderly, Intertrochanteric fracture is one of the most devastating injuries. The incidence of

these fractures increases with advancing age.[1] These patients are more limited to home

ambulation and are dependent in basic and instrumental activities of daily living. 50 % of

fracture around hip patients in elderly is of trochanteric fracture and these 50 % of fracture are

unstable type of trochanteric fractures. They are usually complicated with associated co-

morbidities like osteoporosis, diabetes, hypertension, renal failure. In such circumstances, non-

operative treatment is mainly reserved for poor medical candidates and non-ambulant patients

with minimal discomfort after fracture. Today operative treatment has largely replaced

conservative measures and the goal of treatment is to achieve accurate or acceptable. anatomical

and stable reduction with rigid internal fixation .in order to achieve early mobilization of

patients and prevent complications of prolonged recumbence. Despite marked improvements in

implant design, surgical technique and patient care, intertrochanteric fractures continue to

consume a substantial proportion of our health care resources and remain a challenge to

date[2,3,4].

The intertrochanteric region of the hip consisting of the area between the greater and

lesser trochanters represent a zone of transition from femoral neck to the femoral shaft. This

area is characterized primarily by dense trabecular bone that serves to transmit and distribute

stress similar to the cancellous bone of the femoral neck. The greater and lesser trochanters

are the sites of insertion of the major muscles of the gluteal region, the gluteus medius and

minimus, the iliopsoas and short external rotators. The Calcar femorale, a vertical wall of

1
dense bone extending from the posteromedial aspect of the femoral shaft to the posterior

portion of the femoral neck forms an internal trabecular strut within the inferior portion of

the femoral neck and intertrochanteric region which acts as a strong conduit for stress

transfer.5,6,7,8,9

Figure 1 : Short External Rotators of Hip

The musculature of the hip region can be grouped according to function and location.

The abductors of the gluteal region, gluteus medius and minimus which originate from the

outer table of the ilium and insert on to the greater trochanter function to control pelvic tilt in

the frontal plane. The gluteus medius and minimus along with tensor fascia latae are also the

internal rotators of the hip. The hip flexors are located in the anterior aspect of the thigh

include the sartorius, pectineus, iliopsoas and rectus femoris. Iliopsoas inserts on the lesser

trochanter. Gracilis and the adductor muscles(longus, brevis and magnus) are located in the

2
medial aspect of the thigh. The short external rotators, the piriformis, obturator internus.

Obturator externus, superior and inferior gemelli and quadratus femoris all insert to the

posterior aspect of the greater trochanter. The gluteus maximus originating from the ilium,

sacrum and coccyx inserts onto the gluteal tuberosity along the linea aspera in the

subtrochanteric region of the femur and the iliotibial tract.5,6,7,8,9

Figure 2 : Gluteus Muscles

INTERTROCHANTERIC LINE: It marks the junction of anterior surface of the neck with

shaft of femur. It begins above at the anterosuperior angle of the greater trochanter and is

continuous below with the spiral line in front of the lesser trochanter. 10 It provides attachment

to the capsular ligament of the hip joint, the upper band of illiofemoral ligament in the upper

part and the lower band of iliofemoral ligament in lower part; origin to the highest fibres of the

vastus lateralis from the upper end and the origin to the highest fibres of vastus medialis from

the lower end of the line.5-9

3
 INTERTROCHANTERIC CREST: This marks the junction of posterior part of neck with

shaft of femur. It begins above at the posterosuperior angle of greater trochanter and ends at

the lesser trochanter. The rounded elevation, a little above its middle is called the quadrate

tubercle, which provides insertion to quadratusfemoris extending to the area below it.10

TRABECULAR PATTERN: Ward first described the internal trabecular structure of proximal

femur in 1838. According to the wolf’s law, trabeculae are oriented along the line of stress and

thicker lines come from the calcar and raise superiorly into the weight bearing dome of the

femoral head. Upper end of femur is composed of cancellous bone which shows two different

types of trabeculae, namely the compression and tensile group.8,9The trabeculae6 have been

divided into following five groups: Primary compressive, Secondary compressive, Greater

trochanteric, Primary tensile and Secondary tensile.

Ward’s triangle is bounded by primary compressive, secondary compressive and primary tensile

group. Harty and Griffin described the calcar femorale a dense vertical plate of bone extending

from the posteromedial portion of the femoral shaft under the lesser trochanter and radiating

lateral to the greater trochanter, reinforcing the femoral neck posteroinferiorly.

4
Figure 3 : Trabecular Pattern

5
Calcar femorale is a vertical plate of bone that extends from the posteromedial cortex of femur

deep to the lesser trochanter and blends with the posterior cortex of the femoral neck. The calcar

femorale is thickest medially and gradually thins as it passes laterally.10

Epidemiology

Hip fractures are an important health-care concern in the elderly population. Currently, hip

fractures affect 18% of women and 6% of men globally with intertrochantertic fracture in ratio

female : male = 2:1 to 8:1.11,12According to Yang et.al, half of the hip fractures are

intertrochanteric.13 Epidemiological studies have demon- strated that the incidence of hip

fractures has been increasing.14

It is also important to recognize that hip fractures confer significant social and personal

economic burden. Although hip fractures represent only 14% of all fragility fractures, these

injuries represent a significant expense globally.15,16 Moreover, an economic analysis

demonstrated that apart from initial hospitalization, the cost increases much more due to

increasing need for additional care and super- vision following surgical treatment with a

proportion of patients with hip requiring long-term care.17-19 Thus, the management of hip

fractures will remain a significant aspect of geriatric health care.

MECHANISM OF INJURY

Intertrochanteric fractures in young adults are the results of high energy trauma like road traffic

accidents or fall from height. In contrast, 90 % of fractures occurring in the elderly are due to a

simple fall. The tendency to fall increases with age and is exacerbated by several factors like

poor vision, altered blood pressure, poor reflexes, decreased muscle power, vascular disease and

6
coexisting musculoskeletal pathology.20 Cummings and Nevitt identified four factors that

determine whether a particular fall results in a fracture of the hip.

a. The fall must be oriented that the person lands on or near the hip

b. Inadequate protective reflexes that do not reduce the energy of fall

c. Deficient local shock absorbers (muscle and bone around the hip)

d. Insufficient bone strength at the hip – Osteoporosis

BIOMECHANICS OF HIP JOINT

The forces acting on the hip joint may be static or dynamic. Static force means application of

external loads or forces in such a way that they are. balanced out each other and the joint is not

subjected to acceleration.22 Dynamic forces on the other hand refer to unbalanced loads or forces

associated with acceleration / deceleration. The forces include both gravity as well as forces

generated by muscle activity. The forces acting on the hip joint result from stabilizing the body’s

centre of gravity during stance and locomotion. The centre of gravity of the body is located just

anterior to the second sacral vertebra. The horizontal distance from the centre of gravity of the

body to the centre of hip joint is 8.5 to 10 cm. vertically the centre of gravity is about 3cm above

the hip joint axis and during stance the centre of gravity is the same frontal plane as the common

hip joint axis. The force acting on the hip joint is the sum of the supported body weight and

tension developed in the abductors. The forces acting on the hip joint are normally quite large

and much more than body weight. Loss of one pound of body weight relieves three pounds of

pressure. A long femoral neck is an advantage to hip motion. The ratio of the two lever arms is

important in the generation of total force acting on the hip joint. The shorter the horizontal

distance from the centre of gravity of the body to the hip joint, less muscle force is required of

7
abductors to balance it. Medial displacement of femoral head upon the pelvis may cause a

greater decrease in joint pressure. If the individual leans the trunk directly over the weight

bearing hip, the medial lever arm is reduced to zero so that no muscle force is necessary in the

abductor tensor muscles (as in trendelenberg’s gait) joint reaction force is reduced to body

weight. If the centre of gravity is moved away from the weight bearing hip abductor force is

more and hence the joint reaction force is increased.7-9,22-23

BIOMECHANICS OF TROCHANTERIC FRACTURES

Operative treatment of intertrochanteric hip fractures with internal fixation creates a fracture

fragment – implant assembly intended to withstand the forces acting on the fracture site. Since

avoiding recumbency is often the goal of internal fixation and since many patients with

trochanteric hip fractures lack the balance, coordination and ability to avoid weight bearing upon

the fractured femur, it is often necessary that the fracture fragment implant assembly be strong

enough to withstand the body weight and the very considerable muscle forces which act on the

trochanteric region of femur. These forces have been shown to be equivalent to as much as three

times the body weight acting upon the femoral head. Creating a fracture fragment implant

assembly capable of withstanding loads of this magnitude is the bio mechanical goal of the

surgeon who elects upon the operative treatments of intertrochanteric fractures.24,25

FRAGMENT GEOMETRY: Much clinical attention is focussed upon the number, location

and displacement of trochanteric fracture fragment. Comminution, especially if it involves size,

fragment the posterior and medial portion of the trochanteric region is recognized as a major

factor contributing to the complications of fixation. Multiple fragment with comminution

extending into the medial and posterior femoral cortex is far more therefore likely to displace

into considered unstable, while two parts varus and retroversion. Fractures with posterior and

8
medial cortical comminution are trochanteric fractures are far more likely to be stable.

Although reduction and inter. fragmentary fixation of the lesser fragment of a comminuted

unstable intertrochanteric .fractures can contribute to the stability of the post fixation assembly,

in practice, interfragmentary fixation is time consuming, frequently disappointing and may

contribute to infection and other biological complications of operative treatment. It is therefore

generally agreed that one should ignore the lesser fragments and concentrate on gaining stable

fixation of the major proximal fragment to the major distal fragment attaining posteromedial

cortical contact.25

SIGNS AND SYMPTOMS

Fractures may be undisplaced or impacted and, such patients may present with minimal pain at

the hip or may present with thigh pain. They may be ambulant. Whereas patients with displaced

fractures are clearly symptomatic usually cannot stand and are non ambulant.The pain is

localized to the proximal thigh and is exacerbated by passive or active attempts of hip flexion or

rotation.Pain with motion or crepitance testing is not performed unless there are no physical

signs of deformity,and radiological studies are negative for an obvious fracture.Pain with axial

load on the hip has a high correlation with occult fracture. Because of the pain and instability,

patients are unable to perform an active straight leg raise.

Patients with undisplaced fracture may present with virtual absence of clinical deformity

whereas those with displaced fracture exhibit the classical presentation of shortened and

externally rotated extremity. There may be tenderness on palpation in the area of the greater

trochanter. Ecchymoses may be present and should be noted.26

9
RADIOGRAPHIC AND OTHER IMAGING STUDIES

Standard radiographic examination includes AP view of the Pelvis, Intra-op AP and cross table

lateral view of the proximal femur. The lateral radiograph can help to assess the posterior

comminution of the proximal femur .in needed cases. An internal rotation view of the injured

hip may be helpful to identify undisplaced fractures. Internally rotating the involved femur 10 to

15 deg offsets the anteversion of the femoral neck and provides a true AP view of the proximal

femur a second AP view of the contra lateral side can be useful for preoperative planning.

Additionally, a physician-assisted AP traction view of the injured hip can be helpful in further

characterizing fracture morphology and feasibility of closed reduction or need for open

reduction techniques.27-29

CLASSIFICATION

Few classifications have focussed on stability and anatomical pattern (Evans; Ramadier;

Decoulx; & Lavarde) while others on maintaining reduction of various types (Jensen's

modification of Evan's, Ender; Tronzo, AO). The commonly used classification is the Boyd and

Griffin classification.30 His classification included all fractures from the extracapsular part of

neck to a point 5 cm distal to the lesser trochanter:

Type 1: Fractures that extend along the. intertrochanteric line from the greater to the lesser

trochanter. Reduction is usually simple and is maintained with little difficulty. Results are

generally satisfactory.

Type 2: Comminuted fractures, the main. fracture being along the Intertrochanteric line but with

multiple fractures in the cortex. Reduction of these fracture are more difficult because the

10
comminution can vary from slight to extreme. A particularly deceptive form of the fracture is

one wherein there is an anteroposterior linear Intertrochanteric fracture occurs as in type 1 but

with an additional fracture in the coronal plane.

Type 3: 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 are usually more difficult to reduce and result in

more complications, both during operation and during convalescence.

Type 4 : Fractures of the trochanteric region and the proximal shaft, with fracture in at least two

planes, one of which usually in the sagital plane and maybe difficult to see in the routine

anteroposterior roentgenograms. If open reduction and internal fixation are used two plane

fixation is required because of the spiral, oblique or butterfly fracture of the shaft.

11
Figure 4 : Boyd and Griffin Classification

Evans devised a widely used classification system based on the division of fractures into stable

and unstable groups. He divided the unstable fractures further into those in which stability could

be restored by anatomical or near anatomical reduction and those in which anatomical reduction

would not create stability.31 In Evans type 1 fracture, the fracture line extends upwards and

outwards from the lesser trochanter, in type 2, the reverse obliquity fracture, the major fracture

line extends outward and downward from the lesser trochanter. Type 2 fractures have a tendency

towards medial displacement of the femoral shaft because of the pull of adductor muscles.

Figure 5 : Evan’s Classification

12
In Orthopaedic Trauma Association. classification, Group 1 fractures are simple 2 part fractures,

group 2 fractures are comminuted with a posteromedial fragment the lateral cortex of the greater

trochanter however remains intact. Group Three fractures are those in which the fracture line

extends .across both the medial and lateral cortices. This group includes the reverse obliquity

pattern.32

31-A Femur, proximal trochanteric 31-A1 Peritrochanteric simple

31-A1.1Along 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

13
Figure 6: AO Classification

14
Treatment

There is a wide variety of treatment options for these fractures. The main goal of hip fracture

treatment is early mobilization as it decreases the risk of postoperative complications and

improves long-term mortality rate. In turn, surgical treatment is generally indicated unless the

patient has significant comor- bidities that present an unacceptable risk.33

The types of implant used in these fractures have been divided into extramedullary implants and

intramedullary nails. The choice of implant is mainly determined by the fracture pattern (stable

or unstable). Unstable intertrochanteric fractures are those with major disruption of the

posteromedial cortex because of comminution or are fractures with reverse oblique patterns or

fractures with subtrochanteric extension. Fractures without posteromedial cortex disruption or

subtrochanteric extension are considered stable.34

The sliding hip screw device has been used for more than a decade for the treatment of these

fractures which may not be an ideal implant in all cases.35,36

Compared to sliding hip screws, intramedullary devices offer greater biomechanical

stabilization that is especially important in the setting of unstable intertrochanteric frac- tures37.

In these situations, the lack of contact between the posteromedial osseous fragments would

result in transfer of greater medial compressive loads to the implant. 38 The intra- medullary

device is closer to the force vector line of action through the center of the femoral head and has

a shorter lever arm. Thus for the same force, the nail experiences less moment and can resist

greater loads to failure.38

A biomechanical study found that use of the cephalomedullary device resulted significantly less

15
fracture displacement and similar load to failure compared to sliding hip in the setting of stable

and unstable intertrochanteric fracture models.37 Results from prospective randomized controlled

trials also suggest that intra- medullary fixation was associated with superior radiographic

outcomes (limb shortening or femoral neck shortening) post- operatively and lower rates of

incomplete union compared to sliding hip screw fixation in unstable intertrochanteric

fractures.39,40

The presence of lateral wall fracture in reverse obliquity and transtrochanteric patterns may also

compromise the stability of an intertrochanteric fracture and thus may require intramedullary

fixation.41 Studies evaluating sliding hip screws and intra- medullary constructs found that the

presence of lateral cortical wall fracture was a significant independent predictor of implant and

treatment failure when using sliding hip screws.42,43 From a biomechanical perspective, the

lateral cortical wall acts as a lateral buttress, and thus in the presence of lateral wall fracture,

placement of a sliding hip screw can result in loss of reduction via medialization of the femoral

shaft and lateralization of the proximal femoral component.41,44 Moreover, for reverse obli- quity

fractures, the fracture plane is nearly parallel to the direction of the sliding lag screw, and thus

use of this implant will result in loss of reduction with significant collapse of the femoral

neck.38,44 Retrospective studies demonstrated that in reverse obliquity or transtrochanteric

fractures, sliding hip screws were associated with higher failure rates compared to the 95○ blade

plate. However, intramedullary fixation was asso- ciated with lower rate of failure rates

compared to the 95○ blade plate.44,45 In turn, intramedullary nails are superior to sliding hip

screws for the treatment of reverse obliquity and transtrochanteric fracture or any

intertrochanteric fracture with associ- ated lateral wall fracture. This is because the

intramedullary device acts as a substitute lateral wall that can prevent medialization of the

16
femoral shaft and lateralization of the proximal femoral component.38,44 The most common

mechanism of failure of the sliding hip screw fixation is varus collapse of the femoral neck,

leading to lag screw cutout.

PFN A (antirotation) was introduced in 2003 with modifications, helical blade.

PFNA-II : In 2008 PFNA2 was introduced mainly to avoid lateral cortex impingement during

nail insertion which was a common problem in asian population due to shorter and narrower

greater trochanter.

PFNA-II helps in early post operative mobilization, weight bearing and ultimately the early

fracture union. PFNA-II utilizes a helical blade instead of the conventionally used two screws.

The helical blade is believed to provide stability, compression as well as rotational control of the

fracture. Theoretically it compacts the bone during insertion into the neck and hence has higher

cut out strength as compared to other devices. The differences are that mediolateral angle is

reduced from 6 degrees to 5 degrees. Lateral surface is flat and proximal nail diameter is

reduced from !7 to 16.5 mm. These changes avoided intra-operative fractures, post-operative hip

pain, allowed easier insertion, specifically for Asian population and there is less chance of

implant failure especially in elderly, osteoporotic bones. Thus, PFN Anti-rotation-II is a

modification of the conventional PFN which reduces even the minimal complications associated

with Conventional PFN , also providing additional advantages .46-49

PFN has some demerits like implant failure, screw cut out and screw migration which is also

called z effect. In this Z effect proximal screw (de-rotation screw) of PFN migrate medially and

distal screws (lag screw) migrate backward, while in reverse Z effect proximal screw (derotation

screw) migrate laterally and distal (lag screw) migrate medially. 50 Intramedullary nailing has

17
advantage of short incision, less operative time, rapid rehabilition and thus decreased medical

complications. PFNA II is newer intramedullary implant developed to obtain better fixation

strength in osteoporotic bones. Biomechanical studies has demonstrated that PFNA II blade has

a significance of higher cut out resistance than other commonly used screw systems.51

Several clinical and biomechanical studies have analysed the results of different implants such

as the dynamic hip screw (DHS)/Sliding / , the Gamma nail (GN) and the proximal femoral nail

(PFN). Those devices have suffered a varietyof complications like cut-out, screw back out,

implant breakage, femoral shaft fractures and subsequent loss of reduction.52-54

COMPLICATIONS

Complications with intertrochanteric fractures arise primarily from fixation rather than union or

delayed union. because the intertrochanteric area is made up of cancellous bones.41-55

LOSS OF FIXATION: Helical blade cutout from the femoral head generally occurs within 3

months of surgery and is usually due to

a) eccentric placement within the femoral head

b) improper reaming that creates a second channel;

c) inability to obtain a stable reduction;

d) unstable trochanteric fractures

Loss of fixation is minimized with PFN

 By intramedullary position of Nail

 Biomechanically shorter moment arm

18
 Prevent the excessive collapse of the Proximal fragment

 Prevent gross medialisation of the distal fragment

Failure management

a) Revision ORIF, which may require methylmethacrylate;

b) Conversion to prosthetic replacement

NONUNION : Nonunion following surgical treatmen.t of intertrochanteric fracture occurs in

less than 2% of patients; its rare occurrence is largely due to the fact that the fracture occurs

through well-vascularized cancellous bone. The incidence of nonunion is highest in unstable

fracture patterns. Most intertrochanteric nonunions follow unsuccessful operative

stabilization, with subsequent varus collapse, screw cutout through the femoral head. Another

possible etiology for intertrochanteric nonunion is an osseous gap secondary to inadequate

fracture impaction, but this is less with PFN A II. Intertrochanteric nonunion should be

suspected in patients with persistent hip pain that have radiographs revealing a persistent

radiolucency at the fracture site 4 to 7 months after fracture fixation. Progressive loss of

alignment strongly suggests nonunion, although union may occur after an initial change in

alignment, particularly if fragment contact improves. Abundant callus formation may be

present making the diagnosis of nonunion difficult to confirm. Tomography evaluation may

help to confirm the diagnosis; otherwise the diagnosis may not be possible until the time of

surgical exploration. As with any nonunion, the possibility of an occult infection must be

considered and excluded. In some cases, with good bone stock, repeat internal fixation

combined with a valgus osteotomy and bone grafting can be considered however, in most

elderly individuals, conversion to a Calcar replacement prosthesis is preferred.

MALROTATION DEFORMITY : The usual cause of malrotation deformity after

19
intertrochanteric fracture fixation is internal rotation of the distal fragment at surgery. In

unstable fracture patterns, the proximal and distal fragments may move independently; in such

cases, the distal fragment should be placed in neutral to slight external rotation during fixation of

the plate to the shaft. When malrotation is severe and interferes with ambulation, revision

surgery with plate removal and rotational osteotomy of the femoral shaft should be considered.

OTHER COMPLICATIONS

Osteonecrosis of the femoral. head is rare following intertrochanteric fracture. No association

has been established between location of the implant within the femoral head and the

development of osteonecrosis, although one should avoid the insertion of hip screw in the

postero-superior aspect of the femoral head because of the proximity of the lateral epiphyseal

artery system.

Laceration of the superficial femoral artery by a displaced lesser trochanter fragment has been

reported, as well as binding of the guide pin within the reamer, resulting in guide pin

advancement and subsequent intraarticular or intrapelvic penetration.

POST OPERATIVE FEMORAL SHAFT FRACTURE : Older generation cephalomedullary

Nails had very large distal locking screw near the tip of the Nail with associated risk of stress

riser near the Nail Tip causing post operative femoral shaft fracture near the Nail tip. In PFN A

II stress riser effect is decreased by the tapered distal end of the Nail and the distal locking

screws are placed more proximally on the Nail.

20
 REVIEW OF LITERATURE

Although fractures of hip were known since time of Hippocrates, Sir Astley Cooper (1822)

was the first to have given the accurate description of fracture occurring at proximal femur

and who has distinguished extra capsular from intra capsular fractures many decades before

the discovery of x-rays.36

Percival Pott at the end of 18th century was the first to stress the need of exerting traction in

fractures of upper end of femur. Steinmann in 1907 devised the metallic traction which

proved to be more effective way of applying traction.56

Invention of tri-flanged nail for internal fixation of fractures of femur by Smith Peterson

(1925) was the major breakthrough in field of internal fixation device for trochanteric

fractures.57

Thornton (1937) added an adjustable side plate to the S.P nail and thus made it possible to

use it for fractures of trochanter.58

[12] [13]
Boyd and Griffin (1949), Fielding and Magliato (1966), Zickel (1976), suggested

surgical management for pertrochanteric and subtochanteric fracture.30,59,60

Mervyn Evans (1951) classified fractures into stable and unstable group thus putting

emphasis on stability of the fracture which is very important for deciding line of management

and improving the ultimate outcome.31

Raymond and Tronzo described new classification of fracture, classifying it into 5 different

types keeping in mind the anatomy of fracture which is becoming more acceptable

internationally at present.61
Jewett (1952) recommended that all hip fractures be treated with 135 degree nail plate

device. He also developed the fixed-angled nail plate which was initially biflanged and

later on changed to triflanged. As they do not allow controlled collapse and impaction at the

fracture site, without penetration of the femoral head, a stable reduction (anatomical or non

anatomical) period to nail insertion is essential.62

Taylor G.M. (1955) was the first to talk of various deformities resulting from fractures. He

stated that varus deformity is symptomatic when the neck shaft angle is less than 120

degrees.63

Clawson DK in 1959 with help of Richards manufacturing company invented the sliding

compression screw device which is the second major breakthrough in the field of internal

fixation devices for fractures. In 1959, AO blade plates were developed by ASIF. They

advised the device to be effective, must function as tension band, with presence of prompt

reconstitution of an intact medial cortical buttress. Saramiento[19] (1963) introduced the

technique of valgus osteotomy to obtain stability in unstable fractures.64

Dimon and Hugston (1964) have suggested an easier way of achieving stability, the medial

displacement technique.65

Weismann et.al (1964) were fixing the lesser trochanter in order to achieve anatomical

reduction.66

Wardie (1967) has stated that reduction and fixation of displaced lesser trochanter fragment

to femoral shaft in order to provide a stable buttress for reduction to proximal fragment is

22
difficult time consuming and often unsuccessful.67

Singh (1970) introduced the method of examining the degree of osteoporosis by x-ray

evaluation of trabecular pattern of proximal femur. This is important as fixation of proximal

fragment and fracture stability depends on bone quality.68

Ender (1970) introduced multiple flexible Condylocephalic nails.69

Green et al (1986) and Stern et al (1987) have presented a series of comminuted fractures

treated with Leinbach prosthesis and concluded that it is recommended for the elderly

patients with comminuted fractures.70

Russel Taylor (1990) introduced reconstructed intramedullary nail for pertrochanteric and

subtrochanteric fractures63

RJ Medoff in 1990 designed a device that allows axial compression through the neck

portion and through the metaphyseal subtrochanteric portion through a sliding device that is

incorporated onto the plate attachment to the shaft of femur. The compression slide acts as a

intermediate segment, capturing the lag screw proximally and .engaging the barreled side

plate distally in a sliding track. The barreled side plate is attached to the femoral shaft with

the bone screws directed into two planes. This is called “The axial compression screw plate

device”.71

Halder and Williams in 1992 introduced Gamma Nail and Parker described complications

23
of Gamma nail. S.C. Halder in 1992 published paper on the Gamma nail for peritrochanteric

fractures.2

In 1994, Gargan M F, Gundle R, Simpson A claimed that there is no benefit of osteotomy

and therefore recommended anatomical reduction and fixation by the sliding hip screw in

most cases.72

After invention of so much implants in history as mentioned above, studies based on

comparison to prove the best one started evolving.

In 1994, Blatter et al studied about treatment of the pertrochanteric and subtrochanteric

fractures of the femur with DCS. In 1994 an author studied about pertrochanteric and

subtrochanteric fractures of the femur treated with Zickel nail. Zickel nail is not been

recommended by them any more for treatment of pertrochanteric and subtrochanteric

fractures.73

In 1995, Butt M.S. Krikler S J, Nafie, Ali studied the comparisons of Gamma Nail and

DHS and found that clinical and radiological union results with both implants were the same

but the rate of complication with Gamma Nail was higher .74

In 1995, M R Baumgaertner, S L Curtin, D M Lindskog and J M Keggi had developed a

simple method to describe the position of the lag screw. The optimal placement of the lag

screw was in the centre/centre position.The correct placement of the lag screw and helical

blade at the centre of the femoral head and neck is important in both the antero-posterior and

axial views; in this the tip apex distance (TAD) In their study, to determine the value of this

24
measurement in prediction of the so called cut out of the lag screw the average tip apex

distance is 24 mm for successfully treated fractures.75

In 1996, the AO/ASIF developed the proximal femoral nail (PFN) as an intramedullary

device for the treatment of unstable per-, intra- and subtrochanteric femoral fractures in order

to overcome the deficiencies of the extramedullary fixation of these fractures. This nail has

the following advantages compared to extramedullary implant-such as decreasing the

moment arm, can be inserted by closed technique, which retains the fracture hematoma an

important consideration. in fracture healing, decreases blood loss, infection, minimizes the

soft tissue dissection and wound complications.

In 1998, Gotze et al compared the loadability of osteosynthesis of unstable per-and

subtrochanteric fractures and found that the PFN could bear the highest loads of all devices.

Takigami et al in 2008 found that the surgical time and operative blood loss were lower with

the use of PFNA as compared to PFN. They also found the cut out rates of 2% with PFNA2

which was lower as compared to PFN.76

Sahin et al in 2010  found cut out rates of4.7%  in their study. They reported successful

outcome and low complication rates in PFNA2 in unstable per trochanteric fractures when

compared with PFN .77

Geller et al.  in 2010 reported 44% of cut outs in intertrochanteric fractures fixation with TAD

of > 25 mm and did not cut out with TAD of < 25 mm.78

 Mora et al in 2011 recommend PFNA2 for treatment of trochanteric fractures in the elderly

as its blade demonstrated a lower incidence of cut out in their study.79

25
 Zeng et al in 2012 found that PFNA use was associated with a significant reduction in

duration of surgery, overall complication rate, post-operative fixation failure rate, and

intraoperative blood loss as compared to PFN. 80

Andruszkow H , et al in 2012 showed that Tip apex distance, hip screw placement, and neck

shaft angle as potential risk factors for cut-out failure of hipscrews after surgical treatment of

intertrochanteric fractures.81

 Boopalan et al.in 2012  reported 21% incidence of intra operative lateral wall fractures in 31

A1 and A2 pertrochanteric fracturefixation. The fracture union was not affected by the

presence of lateral wall fractures in their study.82

[35]
In 2012 Soucanye de landevoisin and E.Demortiere study showed PFNA was best in

treating intertrochanteric fractures.83

Aguado - Maestro et al in their study of 200 patients in 2013, treated with PFNA found that

helical blade device reduced the rate of cut out & accurate placement of helical blade was key

factor to prevent mechanical failures.84

Rubilo-Avila J, et al in 2013, in a systematic review found that Tip apex distance is one of the

most important predictive factors for the occurrence of a cut .85

AIMS AND OBJECTIVES

General Objective:

To analyse the short term functional outcome of PFNA-II used in the treatment of

intertrochantric femur fracture..

26
Specific Objective:

1.To analyse the radiological union by fracture gap in radiographs

2.To assess functional outcome of the treatment using Harris hip score

3.To assess other complications if any

27
 METHODOLOGY

Study design: This was a prospective observational study carried out in the department

of Orthopaedics, Nobel Medical College, Biratnagar. It was commenced after taking

approval from institutional review board. An informed consent was obtained from the

patients. All the data were collected from the patients during their stay in the

hospital, during follow up at regular intervals and from the medical records. The

patients were followed up for at least 6 months.

Study period: 18 months (January 2020 to June 2021 )

Sample size: Formula for sample size calculation is

n0 =Z2pq/d2(cocharan 1997)

where,

p is prevalence of previous study; q= 1-p; d = acceptable error(20%)

n is the desired sample size; N is the population size

Z is the confidence level set at 95% which is 1.96(Z =1.96 for 95% CI)

I could not find any exact literature on my study giving necessary informations on sample

size.The total cases presented to NMCTH last year was 30 so my sample size would be 30.

Setting: Department of Orthopaedics, Nobel Medical College Teaching Hospital,

Biratnagar – 5, Morang, Nepal (Tertiary health care center).

Inclusion criteria

28
- All unstable types of fracture pattern AO/OTA type 31A2.2 to 31A3.3 [4]

- Age between 18 - 90 years.

- Men and women both included in study.

- Patient undergoing Primary or Index surgery.

- Different mode of injuries i.e. fall from standing height, slippage, road traffic accident, -fall

from height are included.

- Patients who survives minimum 6 months after operation are included

Exclusion criteria

- Age < 18 years.

- Pathological fractures.

- Previous surgery on proximal femur.

- Patients with intertrochanteric femur fracture treated with other modalities of internal

fixation.

- Old non-unions and mal-unions.

Management: A detailed history was taken. Mode and mechanism of injury was

elicited. Associated injuries were assessed. A detailed physical examination was done.

X – rays of the hip including thigh in AP and lateral views were taken.

Pre – operative protocol: Patients were admitted in the Orthopaedics ward.

Skin/skeletal traction was applied. Pain mangement was done with IV analgesics.

29
Preoperative investigations were done and the patients were assessed by

anesthesiologists department for the fitness for surgery. Medically unfit patients were

not enrolled in the study.

Intra - operative protocol: All patients were taken to the operation theatre only after

the informed consent of anesthesia and surgery. All patients were given IV cefuroxime

1.5 gm preoperatively as a routine antibiotic prophylaxis. Surgeries were done under

spinal with/ without epidural anesthesia over fracture table. C - arm image intensifier was

used in all cases.

Surgical technique: After anesthesia all the patients were kept in fracture table. Fracture was

reduced under image guidance. The affected limb was kept 10-15˚ of abduction for easy nail

insertion. Tip of greater trochanter was identified and skin incision was made 5 cm

proximally. Bone awl was used to make the entry point at the tip of trochanter and guide wire

was inserted. The position of wire was checked in image in both AP and lateral views. The

soft tissue was protected and intramedullary reaming was done using flexible reamers. The

appropriate diameter and length of nail was attached to the insertion handle and inserted into

the femur. The guide wire was removed. The 130˚ aiming arm was attached to the insertion

handle and guide wire for helical blade was inserted through small lateral incision. Central

position of blade guide wire in both AP and lateral view was checked. The length of helical

blade was measured and the cortex was drilled with 11 mm cannulated reamer. The

appropriate size helical blade was inserted over guide wire by gentle blow with hammer and

locked by turning the impactor clockwise. The distal locking of nail was done. Closure of the

wound was done by standard technique.

30
Post - operative protocol: Quadriceps exercise and knee ROM was started from first

postoperative day. First dressing was done on 3 rd postoperative day. Patient was mobilized

non weight bearing in walker or crutches.Sutures were removed on 14th postoperative day.

Weight bearing increased gradedly on the basis of degree of discomfort or apprehension that

such weight bearing causes(self protected weight bearing). Patient was followed up at the

interval of 6 weeks, 3 months and 6 months. Harris hip score (HHS) was used for functional

outcome at final follow up.

Statistical Analysis : The data was entered in Microsoft Excel and converted into

Statistical Package for Social Sciences (SPSS-21) for statistical analysis. For descriptive

data analysis percentage, mean, SD, minimum and maximum were calculated along

with tubular and graphical presentation . For inferential data analysis , one - way

ANOVA test was applied to find the significant differences between the scale

(numerical) variables and the nominal (categorical) variables ; Pearson Chi – square test

was used to find the statistical differences between two nominal ( categorical )

variables, and if could not be applied due to >20% of cells having expected counts

<5, Fischer exact test was used. And if Fischer exact test could not be used then

Likelihood ratio was used to find the significance of an association. CI was set at

95% and P < 0.05 meant the test was “significant”.

31
32
 RESULT
A prospective observational study was carried out to evaluate the results of short term

analysis of intertrochanteric femur fractur treated by proximal femur nail anti-rotation II

(PFNA-II) in a total of 30 patients those fulfilling the inclusion criteria and following

observations were made:

Age and sex distribution:

In this study mean age was aproximately 72.33±7.7years. As far as the sex ratio is concerned,

11 were males and 19 were females. There was no significant relation of sex with the

Table 1 : Sex distribution of the patients

Sex No. of patients Percent
Male 11 36.7
Female 19 63.3
Total 30 100.0
 functional outcome

Sex Distribution

37%

Male
Female

63%

Figure 7: Distribution of the patients according to sex

34
Mode of injury:

The fracture was highly associated with self fall accounting for 63.3 % of cases and the

remainder were associated with road traffic accident (RTA). There was no significant

association between the mode of injury and the functional outcome (p=0.4).

Table 2: Distribution of patients according to the mode of injury

Mode of injury No. of patients Percent
Self fall 19 63.3
RTA 11 36.7
Total 30 100.0

Figure 8: Distribution of Patients according to mode of injury

35
Side of injury:

In this study 63.3 % of the patients sustained injury in the left side and 36.7% on the right

side. There was no significant association between the side of injury and functional outcome

(p>0.05).

Table 3: Distribution of patients according to the side of injury

Side of injury No. of patients Percent
Left 19 63.3
Right 11 36.7
Total 30 100.0

Side of Injury

20
18
16
14 No of patients
12
10
8
6
4
2
0
Left Right

Figure 9: Distribution of the patients according to side of injury

36
Type of Fracutures (AO classification):

In this study, the majority of the fractures were found to be 31A2.3 (60%) followed by

31A3.3 (20%). There was no significant association between the AO type and functional

outcome (p=0.5).

Table 4: Distribution of patients according to the type of factures

AO Classification No. of Patients Percent
31A2.2 4 13
31A2.3 18 60
31A3.2 2 7

31A3.3 6 20
Total 30 100.0

AO Classification

13%
20%
A2.2
A2.3
A3.2
7%
A3.3

60%

Figure 10: Distribution of the patients according to AO classification

37
12

10

6 Male
Female

0
A2.2 A2.3 A3.2 A3.3

Figure 11: Distribution of type of fractures according to gender

38
Duration from time of injury to surgery:

In these 30 patients, surgery was performed within 2-9 days (average 5.30 days). There was

no significant association between the delay in fixation to functional outcome (p>0.05).

Average operative time was 62.60±15.18 minutes (Range 39-97 min.).

Average fluoroscopic shots used was 13.07±2.92 (Range 8-20).

Primary outcome: All fractures united within expected time at an average of 13±1.2 weeks

(range 12-16 weeks).

Secondary outcome: There was 1 case of scre back-out at 2 weeks for which revision

surgery was done.

Harris Hip Score:

The average Harris Hip score at final follow up was 82.40±5.50 (range 72-90). Out of 30,

10% patients had excellent, 76.7% had good and 13.3% had fair results

Table 5: Functional outcome according toHarris Hip Score

Outcome No. of patients Percent
Poor 0 0.0
Fair 4 13.3
Good 23 76.7
Excellent 3 10.0
Total 30 100.0

39
 Functional Outcome

Excellent

No of patients
Good

Fair

0 5 10 15 20 25

Figure 12: Functional outcome according to Harris Hip score

40
 DISCUSSION

The PFNA-IIis an effectively designed intramedullary load - sharing device; biomechanically

just like the conventional PFN, more stiff, having shorter moment arm i.e. from the tip of

helical blade to the center of femoral canal with lesser incidence of varus malunion

incorporating the principles and theoretical advantages over Dynamic hip screw and many

other implants with modifications for Asian population.

The larger proximal diameter (17 mm) of the PFNA-IIcompared with PFN (15 mm) gives

additional stiffness to the nail. Minimal blood loss, shorter operative time, early weight

bearing, less chances of implant failure, minimal fluoroscopy time, easier helical blade

insertion (compared with cumbersome lag screw and derotation screw), lesser chances of post

op hip pain, better performance than any other implant in elderly osteoporotic patients are all

advantages of PFN A-II.

In the current study the union rate was 100%. There were no cases of preoperative and

postoperative femoral fractures. There were no cases of varus malunion.

Average operating time in our series was 62.6 minutes. (Range 39 – 97 min) was comparable

to the series of Yu.W.Zhang et. al. and J Zou et.al.86,87

Leventkarapinar et al.88 -44.7min

Yu.W.Zhang et al.86 -55.6min

Average operating time Our series

J Zou, Y Xu et al.87- 68 min 62.6min

Li J et al.89 – 66.25 min

41
The use of image intensifier was 13.0 shots (Range: 8 to 20) in patients treated with the PFN,

which was comparable with the above mentioned studies.

The time to union was 13.0 weeks (Range: 12 to 16 weeks) in our study comparable to that

of Levent karapinar et.al. and Li J. et al and lesser than that of Yu. W. Zhang et al (14 weeks )

and J Zou, Y Xu et al (15.7 weeks).86-89

The average HARRIS HIP SCORE in our patients was 82.4 (at the end of 6 months) and

82.3. Most of them were graded as “good” as per HARRIS HIP SCORING.

88
Leventkarapinar et al -80.75

Yu.W.Zhang et al 86 -81.90
Average HARRIS HIP Our series - 82.3

SCORE Li J et al 89 - 86.19

One case of screw cut out (3.3%) was reported in our study. in few cases Two cases of helical

blade cut out (out of 42 patients, i e, 4.7%) was reported by Levent karapinar et al. 88 There

were no cases of non-union reported in our study comparable to that of Levent karapinar et

al.88

Peroperative and postoperative Femoral fractures have been documented in patients treated

with the PFN and PFN A-II. Multiple factors have been implicated like implant design and.

operative technique. Decreases in implant curvature, diameter, over reaming of femoral canal

by 1.5 to 2mm, insertion of the implant by hand and meticulous placement of the distal

locking. Screws without creating additional stress risers decreases the complication rate of

femoral shaft fracture (I.B. Schipper et al 2004)90. Patients with narrow femoral .canal and

abnormal curvature of the proximal femur are relative contra-indications to intramedullary

implants (Halder et al 1992).2 We have followed these recommendations in our series. Hence

42
in our series we don’t have encountered any preoperative and postoperative femoral. shaft

fractures. A larger cohort of patients is necessary to document the incidence of preoperative

and postoperative femoral shaft fractures, which is a limitation of our study.

43
 CONCLUS

ION

Intramedullary nailing with the PFNA-II has distinct advantages over Conventional PFN or

DHS like shorter operating time and lesser blood loss for elderly, osteoporotic unstable

trochanteric fractures.

Early mobilization and weight bearing is allowed in patients treated with PFNA-II thereby

decreasing the incidence of bedsores, uraemia and hypostatic pneumonia.

Good preoperative planning, correct surgical technique, adequate reaming of the femoral

canal, insertion of implant and meticulous placement of distal locking screws can further

reduce the incidence of postoperative femoral shaft fractures, non-union rates in PFNA-II.

PFNA-II is a significant advancement in the treatment of trochanteric fractures which has the

unique advantage of closed reduction, preservation of fracture hematoma, minimal soft tissue

damage during surgery, early rehabilitation and early return to work.

In short the PFNA-II is a better implant with specific design superior to conventional PFN

and with distinct advantages over other implants to treat intertrochanteric fractures. With

adequate surgical technique, the advantages of the PFNA-IIincreases and the complication

rate decreases.

44
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APPENDIX
NOBEL MEDICAL COLLEGE TEACHING HOSPITAL

Kanchanbari, Morang, Nepal.

(Affiliated to Kathmandu University and Recognized by Nepal Medical Council)

CONSENT

I,.…………………..………..................grandson/granddaughter

of........................... .................... son/daughter of ....................................., resident

56
of ............................. district...............................V.D.C/ municipality, have been well

informed about the illness. I am willing to get treated at NMCTH and have no objection for

relevant investigations and treatment. The information will be utilized for study purpose and I

undersign giving a valid written consent of no objection for investigation and treatment.

........................................

Signature

Name: .................................

I, Dr. Suraj Shahi, will keep the above mentioned information confidential and sole use for

research purpose.

.....................................

Dr. Suraj Shahi

PROFORMA

“Short term analysis of functional outcome of intertrochantric femur

fracture treated by PFNA-II”

Personal Data:

Name:

Age:

Sex:

Occupation:

57
Address:

IP Number:

Mechanism of injury:

Past history:

a) History of Diabetes mellitus , Hypertension , Epilepsy Tuberculosis , Asthma

b) Previous history of fractures

c) Smoking, Alcohol, tobacco.

General Physical Examination :

General Condition:

Pulse Rate

Blood Pressure

Respiratory Rate

Pallor, icterus, cyanosis , clubbing , lymphadenopathy , edema

Systemic Examination:

CVS/RS/CNS/PA:

Presence of associated injuries:

Local Examination:

Condition of skin

Presence of wound

Presence of infection

Simple or open fracture

58
Neurovascular deficits

Immediate post op
0-3mm(good) 3- >5mm(poor)
5mm(acceptable)
Fracture gap

present Absent
cut-out or lateral migration of helical
blade
Infection

At 6 weeks
0-3mm(good) 3- >5mm(poor)
5mm(acceptable)
Fracture gap

present Absent
cut-out or lateral migration of helical blade
Infection
Secondary varus development
Persistent limp
Heterotopic ossification

At 3 months
Fracture gap 0-3mm(good) 3- >5mm(poor)
5mm(acceptable)

present Absent
cut-out or lateral migration of helical blade
Infection
Secondary varus development
Persistent limp
Heterotopic ossification

At 6 months
Fracture gap 0-3mm(good) 3- >5mm(poor)
5mm(acceptable)

59
 present Absent
cut-out or lateral migration of helical blade
Infection
Secondary varus development
Persistent limp
Heterotopic ossification

60
Harris hip score at 6 months follow up

61
Figure 15 : Intraop fluoroscopic image

Figure 16 : Preop xray

63
Figure 17 : Post op xray

Figure 18 : Functional Results (cross legged sitting & squatting )

64