Comparitive Study between Proximal Femoral Nailing and Dynamic Hip Screw in Intertrochanteric Fracture of Femur

doi:10.4236/ojo.2013.37053

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Open Journal of Orthopedics, 2013, 3, 291-295

Published Online November 2013 (http://www.scirp.org/journal/ojo)

http://dx.doi.org/10.4236/ojo.2013.37053

Open Access OJO

291

Comparitive Study between Proximal Femoral Nailing and

Dynamic Hip Screw in Intertrochanteric Fracture of

Femur*

Ujjal Bhakat#, Ranadeb Bandyopadhayay

Bankura Sammilani Medical College, Bankura, India.

Email: #[email protected], ra[email protected]

Received September 11th, 2013; revised October 15th, 2013; accepted October 25th, 2013

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is

properly cited.

ABSTRACT

Background: Internal fixation is appropriate for most intertrochanteric fractures. Optimal fixation is based on the sta-

bility of fracture. The mainstay of treatment of intertrochanteric fracture is fixation with a screw slide plate device or

intramedullary device. So it is a matter of debate that which one is the best treatment, dynamic hip screw or proximal

femoral nailing. Method: A prospective randomized and comparative study of 2 years duration was conducted on 60

patients admitted in the Department of Orthopedics in our hospital with intertrochanteric femur fracture. They were

treated by a dynamic hip screw and proximal femoral nail. Patients were operated under image intensifier control. The

parameters studied were functional outcome of Harris hip score, total duration of operation, rate of union, amount of

collapse. These valu es were statistically evaluated and two tailed p-values were calculated and both groups were statis-

tically compared. Result: The average age of our patient is 67.8 years. Among the fracture, 31% were stable, 58% were

unstable, 11% were reverse oblique fracture. The average blood loss was 100 and 250 ml in PFN and DHS group, re-

spectively. In PFN there was more no. of radiation exposure intra-operatively. The average operating time for the pa-

tients treated with PFN was 45 min as compared to 70 min in patients treated with DHS. The patients treated with PFN

started early ambulation as they had better Harris Hip Score in the early period (at 1 and 3 months). In the long term

both the implants had almost similar functional outcomes. Conclusion: In our study we have found that the unstable

pattern was more common in old aged patients with higher grade of osteoporosis and PFN group has a better outcome

in this unstable and osteoporotic fracture. PFN group has less blood loss and less operating time compared to DHS

group. In PFN group patients have started early ambulation compared to DHS group.

Keywords: Intertrochanteric Fracture; Dynamic Hip Screw (DHS); Proximal Femoral Nail (PFN); P Value

1. Introduction

Extracapsular fractures (intertrochanteric and sub-tro-

chanteric fractures) primarily involve cortical and com-

pact cancellousbone. Because of the complex stress con-

figuration in this region and its nonhomogeneous osseous

structure and geometry, fractures occur along the path of

least resistance through the proximal femur [1].

Gulberg et al. has predicted that the total number of

hip fractures will reach 2.6 million by 2025 and 4.5 mil-

lion by 2050 [2]. In 1990 26% of all hip fractures oc-

curred in Asia whereas this figure could rise to 37% in

2025 and 45% in 2050 [3].

The various treatment options for intertrochanteric

fractures are operative and non-operative. The non-op-

erative method was used to be a treatment of choice in

early 19th century when the operative technique was not

evolved enough to do stable fixation. Non-operative

treatment should only be considered in non-ambulatory

or chronic dementia patients with pain that is controllable

with analgesics and rest, terminal diseases with less than

6 weeks of life expectancy, unresolved medical comor-

bidities that preclude surgical treatment, active infectious

disease that itself is a contraindication for insertion of a

surgical implant and in complete pertrochanteric fractures

diagnosed by MRI. Intertrochanteric fractures can be

*The authors declare that they have no conflict of interest related to the

ublication of this manuscript.

#Corresponding autho

Comparitive Study between Proximal Femoral Nailing and Dynamic Hip Screw in Intertrochanteric Fracture of Femur

292

treated by either DHS or PFN .The intramedullary de-

vices offer certain distinct advantages:

1. The implant itself serves as a buttress again st lateral

translation of the proximal fragment.

2. The intramedullary location of the junction between

the nail and lag screw makes the implant stronger at re-

sisting the binding force.

3. The intramedullary device has a reduced distance

between the weight b earing axis and the implant th at is a

shorter lever arm.

4. An intramedullary device bears the bending load

which is transferred to the intramedullary nail and is re-

sisted by its contact against the medullary canal (load

sharing device).

5. The intramedullary hip screw is a more biological

method o f fi xation.

Hence we conducted a study in our rural set up to

compare the result of treatment of these fractures by ei-

ther of those two methods that is proximal femoral nail-

ing and dynamic hip screw.

2. Materials and Methods

A prospective randomized and comparative study was

conducted on the patients admitted in the Department of

Orthopedics of BSMC&H. Our study population mainly

consisted 60 patients (30 in each group) with more than

50 years of age. The study per iod was about 2 year from

July 2011 to June 2013. Eligibility criteria for the pa-

tients included in the study were as follows: 1) Patients

who were in the age group of more than 50 years of ei-

ther sex, 2) Intertrochanteric fracture type 31-A2, 31-A3

(OTA classification) without any systemic or psychiatric

illness, 3) patients fit for anaesthesia.

The exclusion criteria were 1) Patients unfit for the

surgery, 2) with compound or pathological fractures, 3)

admitted for re-operation 4) those who have not given

written consent for surgery.

The present study was undertaken in patients more

than 50 years of age with the following objectives

1. To compare the Dynamic Hip Screw and the Proxi-

mal Femoral Nail method of fixation in intertrochanteric

fracture of femur in the adults with respect to intra opera-

tive parameters (total duration of surgery, intraoperative

blood loss and intraope rative complication).

2. To compare the functional outcome with respect to

union of the fracture, functional return, and complica-

tions in the two groups.

3. To determine which implant would be ideal for

which fracture type so as to provide the best results with

the least complications.

4. To study the long-term follow up of the two groups

with respect to any residual impairment of function,

chronic infection and overall tolerability of implant.

The important parameters assessed were:

 Clinical:

1. Wound condition

2. Shorte ning

3. Harris hip sc ore

 Radiological:

1. Union

2. Amount of c ol l a pse

3. Complication like screw cut out

After obtaining ethical clearance from the institutional

Ethics committee, study was conducted among the study

populations after obtaining written informed consent in

accordance with the Ethical standards of the 1964 Dec-

laration of Helsinki as revised in 2000. The relevant in-

formation collected from all patients including history,

general and systemic examination findings. Initial radio-

graph of the hip joint was conducted besides routine pre

anesthetic investigations. The 60 patients were divided in

to two groups, 30 in each. The patients under group A

were treated by proximal femoral nailing (Figures 1 and

2) and patient under group B were treated by Dynamic

hip screw ( Figures 3 and 4).

Figure 1. Pre-operative x ray of group A (P.F.N).

Figure 2. Post-operative x ray of group A (P.F.N).

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Comparitive Study between Proximal Femoral Nailing and Dynamic Hip Screw in Intertrochanteric Fracture of Femur 293

Figure 3. Pre-operative x ray of group B (D.H.S).

Figure 4. Post-operative x ray of group B (D.H.S).

Implant either DHS or PFN was randomly selected by

operating surgeon. All the cases included in our study

were operated as soon as possible. The average delay of

surgery in our st udy was 3 days.

For PFN Nail diameter was determined by measuring

diameter of the femur at the level of isthmus on an AP

X-ray, Neck shaft angle was measured in unaffected side

in AP X-ray using goniometer and a standard length PFN

(250 mm) was used in all our cases.

For DHS Length of compression screw was measured

from tip of the head to the base of greater tronchanter on

AP view X-ray subtracting magnification. Neck shaft

angle was determined using goniometer on X-ray AP

view on unaffected side and length of side plate length of

the side plate was determined to allow purchase of at

least 8 cortices to the sh aft distal to the fracture.

All patients in our study were treated with physical

methods such as early mobilization, manual compression

of the calf and elastic stockings. Patients were encour-

aged ankle and calf exercises from day one and mobi-

lized nonweight bearing from the second post-operative

day depending upon th e physical cond ition of the patien t.

All drains were removed by 24 h. The wounds were in-

spected on the 3rd and 6th post-operative day. Stitches

were removed on the 11th day. Patients were followed up

at one monthly interval till fracture union and then at 6

monthly interval for 1 year and then at yearly interval.

3. Results

The study involved 60 confirmed cases of intertro-

chanteric femurfracture of either sex from July 2011 to

June 2013. Out of 60 cases, 30 were treated by proximal

femoral nailing (group A) (Figures 1 and 2) and 30 were

treated by dynamic hip screw (group B) (Figures 3 and

4).

In our study maximum age was 79 years and minimum

was 51 years. The average age was 67.8 years. In both

groups A and B 13 were male and 17 were female pa-

tients.

In either group, 17 were OTA 31-A2 and 13 were 31-

A3. The results were statistically analyzed and the two

tailed p values were evaluated.

The Singh’s index for osteoporosis showed that there

were 26 patients with grade 4 and above (43.33%) (Ta-

ble 1 and Chart 1).

4. Intraoperative Details

4.1. Duration of Surgery

Duration of surgery was more for DHS compared to PFN.

The duration of surgery as calculated from the time of

Table 1. Singh’s index.

Grade No of Patient

I 8(13.33%)

II 14(23.33%)

III 12(20%)

IV 12(20%)

V 8(13.33%)

VI 6(10%)

Chart 1. Singh’s index for osteoporosis.

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Comparitive Study between Proximal Femoral Nailing and Dynamic Hip Screw in Intertrochanteric Fracture of Femur

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294

incision to skin closure was counted in each case. The

average duration of surgery for the PFN (Avg. time 48.73

min) was significantly shorter then DHS (Avg. time

69.03 min), p v al ue < 0.00 0 1 ( Table 2).

4.2. Blood Loss during Surgery

Blood loss was measured by mop count and collection in

suction drain. The average blood loss in the P.F.N group

was 116 ml and in the DHS group was 213 ml. blood loss

is less in PFN which is statistically significan t, p value <

0.0001 (Table 2).

4.3. Intraoperative Complications PFN

There was no failure to achieve close reduction among

all 30 patients. There was no iatrogenic fracture of lateral

cortex among all 30 patients.

In 3 of 30 cases, we failed to put anti-rotation screw. It

could not be accommodated in the neck after putting

neck screw. We had no difficulties in distal locking.

There were no instances of drill bit breakage or jamming

of nail (Table 3).

4.4. Intraoperative Complications DHS

In 2 of 30 cases there was improper placement of Rich-

ard’s screw. Difficulties were encountered in reverse

oblique fractures as the fracture site extended to entry

point. There was varus angulation in 2 of 30 patients. On

table surgeon had to switch to PFN in 2 cases in reverse

oblique fracture. These cases were considered with PFN

group (Table 4).

4.5. Infection

There were 2 cases of infection seen in the D.H.S group.

They were seen within 13 days of surgery and were

treated by local debridement and antibiotic and did not

require implant removal (Table 2).

4.6. Sliding

The sliding of both groups was compared at the end of 1

year on the X-rays as descr ibed by Hardy et al. [3], ther e

was an average of 5.53 mm of sliding in the P.F.N grou p

as compared to 8.10 mm in the D.H.S group (p < 0.0001).

[Table 2]

4.7. Shortening

The average shortening in the P.F.N group was 5.35 mm

as compared to 9.62 mm in the D.H.S group. So, short-

ening is less in PFN group which is statistically signifi-

cant. p value < 0.000 1 ( Table 2).

4.8. Implant Failure

There was 1 of 30 case of implan t failure in P.F.N group

and revision surgery was required for it. The usual ‘Z’

pattern of implant failure was the reason.

In the D.H.S group ther e were 2 of 30 cases of implant

failure one was due to screw cut out and other was due to

plate breakage. In both the cases revision surgery was

required (Table 2).

4.9. Greater Trochanter Splintering

The greater trochanter splintering was seen in 2 (6.67%)

patients but it did not cause any complication later and

healed well. Greater Trochanter was either fixed with

Ethibond suture.

4.10. Harris Hip Score

In the D.H.S group the 1 month hip score (mean = 24.5)

Table 2. Comparison betwee n PFN and DHS.

PFN DHS p value

Surgery time (in minute) Mean = 48.73

SD = 2.99 Mean = 69.03

SD = 7.34 <0.0001

Blood loss (in ml) Mean = 116

SD = 19.9 Mean = 213

SD = 46.4 <0.0001

Infection 0 2(6.66%)

Sliding (in mm) Mean = 5.53

SD = 1.22 Mean = 8.1

SD = 0.84 <0.0001

Shortening (in mm) Mean = 5.35

SD = 1.4 Mean = 9.62

SD = 2.1 <0.0001

Harris hip score at 1 month Mean = 35.23

SD = 5.8 Mean = 24.5

SD = 3.99 <0.0001

Harris hip score at 6 month Mean = 82.8

SD = 5.13 Mean = 78.8

SD = 7.66 0.021

Harris hip score at 1 year Mean = 92.57

SD = 3.58 Mean = 92.1

SD = 3.12 0.467

Implant failure 1(3.33%) 2(6.66%)

Comparitive Study between Proximal Femoral Nailing and Dynamic Hip Screw in Intertrochanteric Fracture of Femur 295

Table 3. Intraoperative complication of PFN.

Complications No of Patient Percentage

Failure to achieve closed

reduction 0 0

Fracture of lateral cortex 0 0

Failure to put derotation screw 3 10%

Fracture displacement by nai l

insertion 1 3.33%

Table 4. Intraoperative complications DHS.

Intraoperative

complication No of patient Percentage

Improper ins ertion of

compression screw 2 6.66%

varus angulation 2 6.66%

was less than that of the P.F.N group (mean = 35.23), p <

0.0001, in 6 month hip score in DHS (mean = 78.8) was

also less than that of PFN (mean = 82.8) , p value = 0.021.

However this difference disappeared with the two group

after 1 year follow up being same (D.H.S-92.1 and

P.F.N-92.57). p value = 0.467 (Table 2 and Chart 2).

5. Discussion

The development of the dynamic hip screw in the 1960’s

saw a revolution in the management of unstable fractures.

The device allowed compression of the fracture site

without complications of screw cut-out and implant

breakage associated with a nail plate. However, the ex-

tensive surgical dissection, blood loss and surgical time

required for this procedure often made it a contraindica-

tion in the elderly with co-morbidities. The implant also

failed to give good results in extremely unstable and the

reverse obli que fracture.

In the early 90s intramedullary devices were developed

for fixation of Intertrochanteric fractures. These devices

100

at 1 monthat 6 monthat 1 year

P.F.N.

D.H.S.

Chart 2. Harris hip score.

had numerous biomechanical and biological advantages

over the conventional dynamic hip screw [4-6]. Long

term studies, however, revealed that the use of these de-

vices was associated with higher intra operative and late

complication often requiring revision surgery. This has

led to modifications in the device and technique of the

intramedullary devices.

In our study we found:

 Less operative time in PFN group

 Less operative b l o od loss in PFN gro up

 Early return to daily activities.

 Less complication in PFN group like less infection,

less sliding, less limb length discrepancy compared to

DHS group.

The plate and screw device will weaken the bone me-

chanically. The common causes of fixation failure are

instability of the fractures, osteoporosis, and the lack of

anatomical reduction, failure of fixation device and in-

correct placement of the screw.

We found the proximal femoral nail to be more useful

in unstable and reverse oblique patterns.

Hence PFN is much superior to DHS in management

of fracture intertrochanteric femur.

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[2] B. Gullberg, O. Johnell and J. A. Kanis, “World Wide

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