IJCRR - 9(9), May, 2017
Pages: 14-19
Date of Publication: 15-May-2017
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Management of Subtrochanteric Fractures with Long PFN: Union Rates and Functional Results
Author: Shakeel Ahmad, Rajinder Singh, Abdul Ghani, Khalid Muzaffar, Omeshwar Singh
Category: Healthcare
Abstract:Introduction: The treatment of subtrochanteric fractures has evolved over a period of time, from conservative to extramedullary fixation to intramedullary fixation. The management of these fractures poses a significant challenge, the criteria for functional recovery becoming more and more exacting.
Aim of study: To assess union rates and functional status after long PFN in subtrochanteric fractures.
Material & Methods: A prospective study on adult patients with a follow up of 6 months was conducted at Orthopaedic department of Govt. Medical College Hospital, Jammu between June 2014 and May 2016. 40 patients above the age of 18 years with subtrochanteric fractures were included in the study. Patients were assessed clinically and radiologically on the 2nd postoperative day, at 4 weeks, 12 weeks and then between 6 months to 1 year depending upon the fracture union. At each follow up, functional evaluation of the patient was done.
Results: Majority of fractures(72.5%) united within 14 weeks.Full weight bearing was allowed by 12th week in majority (57.5%) of cases.Salwati & Wilson hip function score improved from 16 at discharge to 36 at 6 month follow up. As per Kyle's criteria, results achieved were Excellent/Good in 95% of cases.
Conclusion: Proximal femoral nail is an efficient device for the treatment of subtrochanteric fractures with high rate of bony union. The great majority of patients were provided with stable fixation, early mobilization, early rehabilitation and return to pre-fracture status.
Keywords: Subtrochanteric fractures, Long PFN, Union rates, Kyle’s criteria
Full Text:
INTRODUCTION
The treatment of subtrochanteric fractures has evolved over a period of time, from conservative to extramedullary fixation to intramedullary fixation. The high incidence of delayed union, malunion and nonunion of fractures in this region has left conservative treatment; as advocated by DeLee et al1 abolished in modern trauma care. This evolution in treatment modalities is due to unsatisfactory results achieved in these fracturesdue to medial comminution, high tensile forces active in this region2 and various muscular deforming forces acting on the fracture fragments3thus leading to high incidence of malunion and nonunion in these fractures and mechanical failure of the implant4,5. The appropriate implant for the internal fixation of subtrochanteric fractures remains debatable; and a multitude of different intra- and extramedullary devices for their surgical fixation have been advocated6- 10. The advantage of closed reduction over open reduction cannot be over emphasized. Open reduction increases the risk of infection, soft-tissue devitalisation, and non-union and thus, poor functional results. Up to one half of the patients with subtrochanteric fractures may not regain their pre-fracture walking capacity, and independent living may no longer be possible11. The management of these fractures poses a significant challenge, the criteria for functional recovery becoming more and more exacting. Subtrochanteric fractures are predisposed to complications from loss of position including coxa vara, rotational deformity or shortening, non-union due to implant breakage or failure of bone substance and migration of fixation components12.
We now report the results of clinical and radiographic follow-up of a series of subtrochanteric fractures treated with long proximal femoral nail (PFN – AO type design).
AIM OF STUDY
- To study union rates after long PFN in subtrochanteric fractures
- To assess functional status using Salwati & Wilson hip function scoring system after PFN in subtrochanteric fractures
MATERIAL AND METHODS
A prospective study on adult patients of both sexes with a follow up of 6 months was conducted at Orthopaedic department of Govt. Medical College Hospital, Jammu between June 2014 and May 2016.40 patients above the age of 18 years with subtrochanteric fractures were included in the study. After clinical assessment and haemodynamic stabilization, patients were subjected for radiographs of Pelvis with both hips-AP view and full length thigh-AP and lateral views. Patients selected for study include:
Age - above 18 years
Sex - both males and females.
Patients with Seinsheimer types I –IV subtrochanteric fractures
Patients excluded from study include:
Polytrauma
Old complicated fractures.
Pathological fractures.
Seinsheimer type V subtrochanteric fractures.
Subtrochanteric fractures with associated neck/intertrochanteric/shaft fractures.
Patients with any contraindication for anaesthesia or surgery
All the patients were operated on a fracture table in supine position under image intensifier control using standard techniques. Patients were assessed clinically and radiologically on the 2nd postoperative day, at 4 weeks, 12 weeks and then between 6 months to 1 year depending upon the fracture union.At each follow up, functional evaluation of the patient was done to note the range of movements at the hip and knee, ability to walk, any pain, limp, residual shortening, deformities, wound condition and any residual complaint. Healing was judged by both clinical (pain & motion at fracture site) and radiological (bridging callus filling the fracture site or trabeculations across the fracture site) criteria and functional outcome was reviewed according to the Salwati and Wilson hip function scoring system.
The final assessment was carried out at 24 weeks on the basis of radiological union and Salwati and Wilson hip scoring system.
Radiological assessment:-
All radiologically ununited fractures were graded as poor results.
Salwati and Wilson hip scoring system:-
The evaluation of results was based on following 4 parameters as Pain, Walking, Muscle power& motion, and Function. The results were classified as Excellent when the sum of scores was 32 or more, Good when it is 24 to 31, Fair when it is 16 to 23 and Poor when the score is 15 or less.
Pain
0 –Constant and unreliable, frequent strong analgesia
2 – Constant but bearable, occasional strong analgesia.
4 – Nil or little at rest, pain on activity.
6 – Little pain at rest, pain on activity.
8 – Occasional slight pain.
10 – No pain.
Walking
0 – Bed ridden
2 – Wheel chair
4 – Walking frame
6 – One stick, distance limited up to 400 yards
8 – One stick, long distance
10 – Unaided and unrestricted
Muscle power and Motion
0 – Ankylosing and deformity
2 – Ankylosing with good functional position
4 – Poor muscle power, flexion less than 60 degrees, abduction less than 10 degrees
6 – Fair muscle power, flexion 60 – 90 degrees, abduction 10 – 20 degrees.
8 – Good muscle power, flexion more than 90 degrees, abduction more than 20 degrees.
10 – Normal muscle power, full range motion
Function
0 – Bed ridden
2 – House bound
4 – Limited house work
6 – Most house work
8 – Very little restriction
10– Normal activity.
RESULTS
Total no. of patients in our study were 40; of which 25 were males and 15 females. Most of the patients belonged to age group of 41 – 50 years. The fractures were classified according to Seinsheimer classification13 (type II- 22 cases, type III – 14 cases, type IV – 4). In most of the cases(n = 23), the mechanism of trauma was a Road traffic accident, while as, in rest of cases(n = 17), Fall from height was responsible for trauma. 50% cases had associated injuries like fracture distal end radius, fracture calcaneum etc. Other characteristics noted are as mentioned below:
From the chart, it is clear that majority of cases were managed by closed reduction (87%). 8 % cases required mini-open reduction.
In 92% of cases, reduction achieved was anatomical to acceptable. Whereas, in 8% of cases, reduction was not acceptable
NEED FOR BONE GRAFTING
None of the cases required bone grafting in our series. All fractures united spontaneously.
Table 1 shows that majority of fractures united within 14 weeks(72.5%).
Table 2 shows that in 75% of cases, we started toe touch weight bearing within 4 days.
Table 3 shows that partial weight bearing was started at 4th week in majority of cases (40%).
Table 4 shows that we had allowed full weight bearing by 12th week in majority (57.5%) of cases.
Table 5 shows that excellent/good range of movement was achieved in majority (80%) of cases.
Table 6 shows that good range of movement was achieved in 85% of cases.
Table 7 shows that 80% of cases reported no pain at 24 week follow up.
Table 8 shows that 95% of patients attained good/normal muscle power by 6 months.
Table 9 shows that 90% of patients had attained normal walking ability.
Table 10 shows that we achieved Excellent/Good results in 95% of cases.
Pre-operative and Post-operative radiograph of40 year old patient. Patient is shown as sitting cross legged at 6 month follow up.
DISCUSSION
Subtrochanteric fractures of the femur have peculiar anatomic and mechanical characteristics which poses problems in their management. Extramedullary fixation with plating has the potential disadvantages of extensive surgical exposure, severe soft tissue damage and blood loss, thus leading to problems of fracture union and implant failure. In addition, the eccentric plating is prone to fatigue breakage due to their mechanical load-sharing effect14. Allowing a minimally open approach, intramedullary nailing is closely linked to “biological internal fixation”, in addition to its mechanical benefits over plate fixation15.
The result of the reduction was considered acceptable in 55% of the patients and anatomical in 37% of patients. Poor reduction was noted in 8% of patients and it was associated with poor outcome. In SCHIPPER et alstudy16, reduction was good to acceptable in 96.2% of their patients and poor reduction was seen only in 2.9% of their patients.
Most of the cases in our series were managed by close reduction. However, in 8% of cases, mini-open reduction was required. Here, a small incision was made over the fracture site without extensive soft tissue dissection and using bone levers or bone clamps, fragments were held in reduced position till nailing was done. This is comparable with the studies of Boldin et al17(90.90% Close Reduction) and other studies done elsewhere.
Varus malreduction was the most common complication noticed in our series. This can be attributed to initial malreduction in which proximal fragment remained abducted. It is important that fracture should be reduced first, even if open reduction is required, before intramedullary nailing.
In this study, clinical union was achieved within 14 weeks in 72.5% of cases which is comparable to Smith et al series, who reported clinical union in 10.5 weeks and to Domingo et al series who reported union in 12 weeks. In our study, one patient had iatrogenic femoral shaft fracture which took24 weeks to unite. In other series, the rate of fixation failure, femoral shaft fracture, and re-operation rate is high18 (12 %).
The mobilization strategy followed; touch down weight bearing was allowed within 4 days in 75 % of cases in whom there was little or no cortical comminution pre-operatively and in whom solid fixation was achieved, whereas it was allowed on 5th or 6th day in 20% of cases and after 6th day in 5% of cases where the fixation was not solid or there was gross comminution or due to iatrogenic fracture. This is consistent with the study of Smith et al, who allowed touch down weight bearing on 2nd postoperative day in 71.5% of cases and delayed in 28% of cases.
In our series, average time to full weight bearing was 14 weeks in 87.5% of cases which is late as compared to the series by Smith et al who started full weight bearing by 6.7 weeks.Walking and squatting ability was completely restored in each case at follow-up examination 6 months postoperatively.
References:
- DeLee JC, Clanton TO, Rockwood CA Jr. Closed treatment of subtrochanteric fractures of the femur in a modified cast-brace. J Bone Joint Surg Am 1981;63:773-9.
- Koch JC. The laws of Bone architecture. Am j anat 1917; 2:177.
- Campbell’s operative orthopaedics. 12th edition, Vol 3, 2751 – 2752, 2013.
- Haidukewych GJ, Berry DJ. Non-union of fractures of the Subtrochanteric region of the femur. Clin Orthop Relat Res 2004;419:185-8
- Broos PL, Reynders P. The use of the unreamed AO femoral intramedullary nail with spiral blade in nonpathologic fractures of the femur: experiences with eighty consecutive cases. J Orthop Trauma 2002;16:150-4.
- Blatter G, Janssen M. Treatment of subtrochanteric fractures of the femur: reduction on the traction table and fixation with dynamic condylar screw. Arch Orthop Trauma Surg 1994;113:138-41.
- Hotz TK, Zelweger R, Kach KP. Minimal invasive treatment of proximal femur fractures with the long gamma nail: indication, technique, results. J Trauma 1999;47:942-5
- Tornetta P III. Subtrochanteric femur fracture. J Orthop Trauma 2002;16:280-3
- Siebenrock KA, Muller U, Ganz R. Indirect reduction with a condylar blade plate for osteosynthesis of subtrochanteric fractures. Injury 1998;29Suppl 3:C7-C15.
- Ruff ME, Lubbers LM. Treatment of subtrochanteric fractures with a sliding screw-plate device. J Trauma 1986;26:75-80.
- Koval KJ, Skovron ML, Aharonoff GB, Zuckerman JD. Ambulatory ability after hip fracture. A prospective study on geriatric patients. Clin OrthopRelat Res.1995;310:150-9
- Roberto U, Velasco, MD; and Thomas H. Comfort, MD. Analysis of treatment problems in sub-trochanteric fracturesof the femur: The Journal of Trauma, Vol. 18, No. 7, 513 – 523, 1978.
- Seinsheimer, F., III: Subtrochanteric fractures of the femur. J.Bone Jt. Surg., 60-A: 300-306, 1978.
- Lunsjo K, Ceder L, Thorngren KG, Skytting B, Tidermark J, Burntson PO. Extramedullary fixation of 569 unstable intertrochanteric fractures. Acta Orthop Scand 2001;72:133-40.
- Brien WW, Weiss DA, Becker V Jr, Lehman T. Subtrochanteric femur fractures: a comparison of the Zickel nail, 95-degree blade plate, and interlocking nail. J Orthop Trauma 1991;5:458-64
- Schipper I B et al Treatment of Unstable trochanteric fractures :JBJS 2004; 86 B : 86 – 94
- Christian Boldin, Franz J Seibert, Florian Fankhauser: "The proximal femoral nail (PFN)—-a minimal invasive treatment of unstable proximal femoral fractures. Acta Orthop Scand 2003; 74(1): 53 - 58.
- Menezes DF, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop Relat Res 2005; 439:221–7.
- Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br 1972;54:61-76
- Strömberg L, Lindgren U, Nordin C, Ohlen G, Svensson O. The appearance and disappearance of cognitive impairment in elderly patientsduring treatment for hip fracture. Scand J Caring Sci 1997;11:167-75.
- Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. Bmj 2000;321:1107-11.
- Svensson O, Strömberg L, Ohlen G, Lindgren U. Prediction of the outcome after hip fracture in elderly patients. J Bone Joint Surg Br 1996;78:115-8.
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