Evaluation of the results of the proximal femoral nail surgery for intertrochanteric femur fractures
This study aimed to evaluate the clinical, functional, and radiological results of the patients who underwent proximal femoral nail (PFN) surgery due to intertrochanteric femur fractures (IFF). A total of 195 patients who underwent PFN surgery due to IFF in January 2014 and January 2018 in our institute and with at least six months follow-up periods were included in the study. Demographic data, comorbidities, Evans-Jensen fracture classification, anesthesia risk scores, hospitalization duration, time to surgery, duration of surgery, amount of blood loss, whether additional traumas exist, quality of reduction, complication rates, Harris hip scores (HHS), Fogagnolo Reduction Quality criteria and possible correlations between these variables were evaluated retrospectively. In our study, the majority of the patients were found to be between the ages of 70-90. Hypertension was found to be the most common comorbid disease in the patients (50.2%). The fracture type of the majority of the patients was determined as type 4. The majority of patients were identified as ASA III and ASA IV group patients (38.4% and 35.9%, respectively). Successful HHS was found at a rate of 77.5%. As the fracture type worsened, the HHS score worsened (p<0.05). Reoperation rates were significantly lower in those with good reduction quality than those with poor reduction (p<0.05). A significant association was found between the overall complication rate and reduction quality (p<0.05). A significant and negative correlation was found between HHS scores and total complication rates (p<0.05). Intertrochanteric femur fractures are frequently encountered by orthopedists. These fractures, which require surgical intervention in almost all of them, are important because the population is old and prone to complications, and accurate and rapid surgical intervention is required. Our results suggest that PFN surgery is an appropriate choice for IFF.
Keywords: Proximal femoral nail, Intertrochanteric femur fractures, Harris hip score, ASA score
Intertrochanteric femur fractures extend between the extracapsular basilar neck region and the trochanter minor. It is more common in patients over the age of 60 due to osteoporosis and is more common in women . Around 90% of intertrochanteric fractures in the elderly are caused by simple falls . As the age increases, the frequency of unstable and comminuted fractures increases. Among the reasons for this, women were shown to be more frequently exposed to metabolic bone diseases, wider pelvic structure, narrower femoral neck-shaft angle, and longer life expectancy . In intertrochanteric fractures with good blood supply, there is no union problem but the problem is instability.
Histologically, the absence of the cambium layer of the periosteum in the femoral neck results in the absence of periosteal callus after the fracture and negative impact on fracture healing.
It is not possible to have a good prognosis after conservative treatment and especially in elderly patients, complications and additional discomfort caused by staying in bed for a long time may increase mortality and morbidity. Surgical treatment aims to provide early mobilization, to provide lower morbidity, to increase the quality of life by preventing complications, and to return to the pre-fracture lifestyle as soon as possible. The surgical approach, bone quality, and the success of the surgery with anatomic reduction provided during the surgery vary . An intertrochanteric hip fracture, after stable reduction of fracture fragments with surgical treatment, early mobilization of the majority of elderly patients can be achieved by fixing them with a mechanically strong and well-placed implant.
Various treatment modalities have been tried in the treatment of intertrochanteric femur fractures. Among them, proximal femoral nails (PFN) that were manufactured in 1998 allow a second screw to be inserted into the femoral neck . PFN application is an effective surgical method that enables early mobilization by allowing early weight-bearing in intertrochanteric femur fractures. Despite the biomechanical advantage of the models with interlocking head screws in PFN, a fixation material deficiency called “Z-effect”, which is unique to this type of model, is observed especially in unstable fractures. Z-effect is the case when one of the interlocking head screws penetrates the joint by piercing the femoral head and the other screw slips back from the nail. This phenomenon occurs as a result of different effects of tension and compression forces on the interlocking screws. In the so-called “reverse Z-effect, it is seen when the anti-rotation screw slips excessively and maintains the position of the distal screw [5,6]. Moreover, various complications associated with the operation and postoperative complications have been reported [7,8].
There are many factors that affect the successful outcome in the surgical intervention of fractures. Besides examining these factors, it is also very important to name the successful outcome. Although many studies have been conducted on intertrochanteric femur fractures, the number of studies in the literature including a wide-ranging evaluation is limited, as in our study.In this study, we aimed to evaluate the results of our patients who were admitted to our hospital diagnosed with intertrochanteric femur fracture and underwent PFN surgery. The main purpose of our study was to contribute to the research conducted to select the most appropriate implant for PFN cases performed in our center and to contribute to the development of the algorithm according to the fracture type.
Materials and Methods
In our study, data were obtained by using the hospital information management system. This study was approved by the Institutional Scientific Research and Publication Ethics Committee (Ethical Approval Code 97132852/050.01.04). This study consisted of retrospective evaluation of 195 patients after PFN surgery for intertrochanteric femoral fracture between January 2014 and January 2018 at Firat University, Faculty of Medicine, Orthopedics and Traumatology Department, Elazig, Turkey. Evans-Jensen classification was used to classify fractures, and types I-III are considered stable and types IV, V, and R are considered unstable fractures. Patients who were treated with TRIGEN INTERTAN (Smith and Nephew), Cannulated PFN (Zimed Medikal), or PFN (Synthes) for intertrochanteric femur fracture with at least 6 months of the follow-up period were included in this study. Patients with missing or suspicious information in the patient file, patients who were found to have died in the first 6-month follow-up period, and patients who could not be reached by phone or who did not come for control were excluded from the study.
In our study, we recorded patients’ age, gender, fracture type, cause of the fracture, chronic diseases, post-operative anesthesia risk (the American Society of Anesthesiologists (ASA) physical status scores), the total length of hospital stay, time until the surgery, additional trauma, quality of the femoral reduction, the ratio of mechanical complications, Harris hip score (HHS) and evaluated the correlations between the data. In addition, we also noted the total time of the surgery and the volume of the blood loss during the surgery .
During the study, we called the patients or the relatives of the patients and kindly invited them to follow-up examinations. For the patients who could not come to the hospital, we requested pictures of the latest radiographic images and asked for items of the HHS to evaluate the function of the hip.
After the surgery, during the post-op follow-ups, patients were evaluated with radiologic imaging techniques for common complications like fixation failure, secondary varus deformities, rotation deformities, femoral neck shortness, acetabular penetration, screw or blade cut-out, implant breakage, peri-implant femoral fractures, avascular necrosis, lateral migration of PFN, Z-effect, malposition of the screws.
After a thorough physical and radiologic examinations of the patients who were admitted to the emergency department with hip pain transferred to the surgical ward for pre-operative preparations. Before the operation chest X-rays, ECG (electrocardiogram), and routine blood tests were ordered from all patients. We consulted the appropriate specialist if a patient had additional chronic diseases that can affect the operation. An anesthesiologist evaluated the patients with ASA physical status scores and decided to administer either general or spinal anesthesia. Patients are taken to the operation as early as their physical status is ready for surgery.
All patients were administered with prophylactic 4000 IU subcutaneous enoxaparin (40 mg/0.4 ml, Clexane®) injection daily to prevent deep venous thrombosis (DVT) from the first day they were admitted to the hospital. If a patient was over 80 kg, 6000 IU (60 mg/0.6ml) of subcutaneous enoxaparin was administered daily. Also, all patients were administered prophylactic intravenous 1st-generation cephalosporin (Cefazolin, 1 gr per 24 hours) for infections.
Before the operation, closed reduction of the fracture was applied with abduction, lateral rotation, adduction, and then medial rotation maneuvers. After inspecting the quality of reduction under the fluoroscopy, we decided to use either TRIGEN INTERTAN (Smith and Nephew), Cannulated PFN (Zimed Medikal), or PFN (Synthes). Intramedullary 2.8 mm Kirschner wire was inserted from the apex of the greater trochanter. Permanent fixation was done as described in the literature . Syntes PFN and TRIGER INTERTAN were fixed in place with one screw and cannulated PFN was fixed in place by two screws.
After the operation, all patients received prophylactic antibiotics for a day and low-molecular-weight heparin (LMWH) treatment for 15 days to prevent DVT. After 15 days of enoxaparin course patients were switched to 100 mg/day acetylsalicylic acid.
Weight-bearing mobilization with crutches as they could tolerate started the day after the surgery for the patients with adequate medial cortical continuity and proper reduction. Other patients were encouraged to use a walker and non-weight-bearing mobilization in the first four weeks. All patients started the quadriceps and knee strengthening exercises.
Patients were followed up at the first, second, fourth, sixth, and twelfth months. After the first year, patients were evaluated annually. HHS was used for functional evaluation and HHS scores were classified as; between 90-100 was Excellent, between 80-89 was Good, between 70-79 was Fair, and HHS scores less than 70 was Poor. Quality of the reduction was classified by the Fogagnolo reduction criteria as good, fair, or bad .
Spearman rank correlation coefficient for the ranked data and Crosstabs chi-square test for the categorical variables were used in SPSS for Windows (version 22.0). In the chi-square test of independence, if the expected frequency for each cell was less than 5, between 5 and 25, or more than 25, we used Fisher’s exact, Yates correction, or Pearson’s chi-square tests, respectively. If the frequencies of these cells were with great variability we utilized the Likelihood-ratio test. We used mean ± standard deviation (SD) for numerical data and numbers with percentages for the categorical data. P values less than 0.05 were considered statistically significant.
Of all cases, 88 (45%) were male, 107 (55%) were female and 110 (56%) had hip fractures on the right side, and 85 (44%) on the left side. Among them, the cause of the fractures in 165 was from simple falls (87.5%), three due to falling from a height (1.5%), three due to gunshot wounds (1.5%), 19 due to traffic accidents (9%), and five due to malignancy-related pathological fractures (3%).
Mean age of the male patient were 71±26 years, while in females, mean age was 77±20 years. Most of the patients were between the age group of 70 – 90 years (Figure 1). The most common comorbidity was hypertension (50%) followed by coronary artery disease (CAD) or heart failure (HF) (40%; Table 1).
Figure 1. Age group distribution of the patients
Most of the patients had Evans-Jensen type V fracture (59 (30.3%); patients without posteromedial and posterolateral support) and that was followed by Evans-Jensen type III (46 (23.6%); patients with trochanter major fracture; Figure 2A). In our study, 114 of 195 (58.5%) patients with intertrochanteric femur fractures were found to be stable and 81 (41.5%) were unstable. The mean time to surgery was 2.1 days. Most of our patients were in ASA-III intensive care unit (ICU) and ASA-IV ICU (n=75 (38.4%) and n=70 (35.9%), respectively, Figure 2B).
Figure 2. (A) Distribution of the fracture type of the patients according to Evans-Jensen classification. (B) Distribution of the ASA scores of the patients
Table 1. Comorbidities of the patients
During the preoperative preparation stage, 20 patients received a blood transfusion to increase their hemoglobin levels. Mean blood loss was 130 mL( min. 80 mL -max 400mL). Ten patients 10 patients received an intraoperative blood transfusion. The mean duration of surgery was between 40 minutes(min. 20 minutes-max 90 minutes). The total hospitalization period was determined as 7.2 days(min. 4 days max. 20 days). The average length of stay in the post-op period was 5.1 days(min.2 days max. 15 days), and the long duration of stay until discharge was more frequent in elderly patients and patients with comorbidities.
Functional evaluation of the patients was made according to HSS and 94 patients (48.2%) had excellent results, 70 patients (35.9%) had good results, 19 patients (9.7%) had fair results, and 12 patients (6.2%) had poor results. The quality of the reduction was classified by the Fogagnolo reduction criteria as good, fair, or bad . The quality of reduction in 159 patients (81.5%) was good, in 24 patients (12.3%) were acceptable and in 12 patients (6.2%) were poor. When the patients with Evans-Jensen type II, Evans-Jensen type III, and Evans-Jensen type IV fractures, which were the most common types of fractures, were examined 90% of 40 patients with Evans-Jensen type II fractures, 40% of 46 patients with Evans-Jensen type III fractures, and 66% of 59 patients with Evans-Jensen type IV fractures had good reduction quality.
Mechanical complications according to the quality of the reduction are given in table 2.
Table 2. Mechanical complications according to quality of the reduction
With the advancing age, the risk taken for surgery increased. A statistically significant relationship was found between age and anesthesia risk (p < 0.05; Table 3). We have seen that the anesthesia risk increases as the patients get older. We have seen that comorbidities (CVE, DM, and HT) are an important reason for this increased risk. A statistically significant relationship was found between the time until the operation and the duration of the operation (p < 0.05). It was observed that the shorter the time until the operation, the shorter the operation time. In all fracture types, the number of patients with ASA-III ICU was higher, but no statistically significant relationship was found between fracture types and ASA scores (p>0.05; Table 3).
There was a weak negative correlation between the reduction quality and fracture type, but it was not statistically significant (p>0.05). A statistically significant relationship was found between the type of fracture and HHS (p<0.05; Table 3). As the fracture type worsened, the HHS score worsened.
A moderate negative and statistically significant correlation was found between age groups and HHS, which was statistically significant (p<0.05; Table 3). When the correlation between the quality of the reduction and HHS was evaluated, a significant positive correlation was found, it was statistically significant (p=0.000; Table 2). However, there was a negative but not significant correlation between anesthesia risk and HHS was observed (p> 0.05; Table 3).
When the reduction quality and the rates of each complication type were compared, a statistically significant relationship was found between quality of reduction, reoperation, and reduction loss. Reoperation rates were significantly lower in those with good reduction quality than those with poor reduction (p<0.05; Table 3). Reduction loss was present in both patients who underwent reoperation. There was no significant relationship between the reduction quality and other complications. No statistically significant relationship was found between the type of fracture and the occurrence of complications (p>0.05). However, the complication rate was seen in the patients with Evans-Jensen type III and type V fractures were higher.
When each complication was compared according to fracture type and HHS, no statistically significant associations were found between fracture type and complication occurrence (p>0.05). There was no statistically significant relationship between loss of reduction and fracture type (p>0.05), as well as between loss of reduction and HHS (p>0.05), screw/blade cut-off and fracture type (p>0.05), screw/blade cut-off and HHS (p>0.05), lateral deviation and fracture type (p>0.05), lateral deviation and HHS (p>0.05), secondary varus deformities and fracture type (p>0.05), secondary varus deformities and HHS (p>0.05), reoperation and fracture type (p>0.05), reoperation and HSS (p>0.05), AVN and fracture type (p>0.05), AVN and HHS (p>0.05), peri-implant fracture and type of fracture (p>0.05), and peri-implant fracture and HHS (p > 0.05).
When the patients were evaluated in terms of quality of reduction, age groups, and HHS according to the incidence of at least one complication, it was seen that the overall complication rate was 25% in good reduction qualities, 31% in fair reduction qualities, and 44% in poor reduction qualities. Although there was no significant relationship between the reduction qualities and each complication, a statistically significant relationship was found between the overall complication rate and the reduction quality (p<0.05; Table 3).
There was no statistically significant relationship between age groups and complication rates (p>0.05). The complication rate was highest in the 70-80 years age group. A statistically significant and negative correlation was found between HHS scores and total complication incidence rates (p<0.05).
Hip fractures are usually caused by ground-level falls of elderly female patients who are more prone to osteopenia or osteoporosis. Tuzun et al. showed that the incidence of hip fracture is 3.5% at men and 14.6% at women who are older than 50 years . Other studies revealed that 90% of hip fracture patients are older than 65 . Femoral neck fractures usually occur in the younger population, but especially estimated that the mean age of intertrochanteric fractures is 72 years . Also, decreased bone mass in older patients leads to comminuted and unstable fractures with even low-impact trauma . In our study, the mean age of intertrochanteric fractures was 74 (females=77 and males=71). We had more female patients, possibly due to the weakness of the bones and osteoporosis .
Also, as the age of the patients increased, the HHS decreased. According to previous studies, 90% of the intertrochanteric fractures are caused by simple falls  followed by traffic accidents . In our study, 85% of the cases were caused by low-impact falls and 9% by traffic accidents.
After intertrochanteric fracture repair, it is vital to have early mobilization and restore the best functional outcomes of the hip joint because of the high age of the cases . Conservative approaches, compared to operative treatment following an intertrochanteric fracture, had a higher mortality rate during the hospital stay .
Thus, conservative treatment is reserved only for patients who are not eligible for surgery or have a poor medical condition.
Osteosynthesis and arthroplasty are the two main options in the surgical treatment of hip fractures. Arthroplasty is recommended for early mobilization in elderly patients with multiple systemic diseases and comminuted fractures. Authors reported 87% to 100% of the patients treated with prosthesis recovered to pre-fracture mobility state .
However, serious complications limit the use of prosthetics . Osteosynthesis with external fixators under local anesthesia is recommended to protect patients who cannot tolerate general anesthesia .
Kourtzis et al. reported that although the mechanical complications were less with external fixators, pin site infection is common . External fixation is not as stable as internal fixation and has disadvantages such as pin-track infection.
Currently, the typical treatment of intertrochanteric fractures is internal fixation . Kaufer defined five factors affecting the stability of the internal fixation for intertrochanteric fractures, including reduction of the fracture, implant shape, implant placement, bone quality, and fracture type . Saudan et al. could not find any significant difference between union time, functional outcome, and complication rates when they compared PFN and sliding plate screws in stable fractures . But the PFN is costly, therefore its use is less than sliding nails . Both Boldin et al. and Banan et al. reported higher success and lower complication rates for the PFN compared to other implant types in patients with unstable intertrochanteric fractures [21,22].
In our case series, we also applied PFN, especially in patients with unstable intertrochanteric fractures, due to high success and low complication rates. Kim et al. reported the mortality rate as 55% in the hemiarthroplasty group and 17% in the PFN group in the 3-year follow-up of unstable intertrochanteric fractures .
There is no consensus on the timing of the surgery to be performed. Kenzora et al. suggested that the detailed medical examination of the patient in the first 24 hours and the patient should be operated on immediately after optimal conditions are provided . Smektala et al. could not find a significant relationship between the mortality rate and the time of surgery, but they reported that the complication rates were higher in patients who underwent surgery after 36 hours .
Intertrochanteric femur fractures should be operated as soon as possible. It has positive effects on both mortality and shortening the duration of surgery. Zuckerman et al. found that the one-year mortality of the patients operated on after the second day of trauma increased two-fold . Some authors suggest that surgery should be delayed after the patient is stable medically, together with the authors who argue that the general medical condition of the patient should be corrected rapidly, and if possible operating them within the first 48 hours . Our meantime until surgery was 2.1 days (between 1-6 days) from their admission to the hospital. But the time until surgery and the HHS or age groups showed no significant correlations. There was a significant correlation between the time until surgery and the duration of the operation time. Patients with a short time until surgery had a faster and easier closed reduction in the operation room that also decreased the total operation time.
Temiz et al.reported mean surgical time as 36 minutes, and a mean blood loss of 185.9 mL and, D’Arrigo et al. reported as 45 minutes and a mean blood loss of 226 mL during the PFN surgery [6,14]. In our study, the surgery time was approximately 30-45 minutes, and intraoperative hemorrhage was 150-200 mL on average. Although our surgery time is comparable with previous reports, the changes in the operation time are related to the fracture type and experience of the surgeon. Also, the duration of surgery, in our study did not affect the HHS.
ASA scores help us predict postoperative mortality and morbidity rates. While the mortality rate was 23% in patients with ASA I and II scores, it was found that the mortality rate reached 39% in patients with ASA III and IV . In our series, 80% of all patients had the anesthesia risk of ASAIII-ICU and above. Anesthesia risk was not correlated to the type of fracture. When the fracture was fragmented and unstable, surgical risk and duration of surgery increased. Besides, we could not find a significant relationship between ASA scores and HHS or complication rates. But we observed as the ASA increased, the need for intensive care units increased too. The mean duration of hospital stay is reported between 6 and 10.5 days . In our study, it was found to be 7.2 days on average. It was seen that comorbidities were more common in patients with long-term hospitalization.
The reduction qualities of the patients according to Fogagnolo’s criteria were compared with the fracture types. In this study, similar to previous papers, 72.5% of patients were rated good, 12.3% of patients were acceptable, and 6% of patients had poor reduction quality. There was a weak correlation between the reduction quality and fracture type, but it was not statistically significant. Likewise, unstable fractures tend to have low reduction scores but this was not at a significant level. But there was a significant, moderate, and positive correlation between the quality of reduction and HHS. Reduction quality is also significantly correlated to the complication rates. Poor reductions led to more complications. Complication rates were 25% in good, 31% is acceptable, and 44% in poor reductions.
Several complication rates were reported about the surgical treatment of intertrochanteric fractures in different studies. Bannister et al. found a 23% mechanical complication rate, while Lenich et al. reported only 1.6%, Stern et al.found 4.8%. D’Arrigo et al.had mechanical complication rates of 10.3%, and Georgiannos et al. found the mechanical complication rate to be 11.7%, while the most common complication was screw or blade cut-out with a frequency of 4.6% [6,16,30-32]. Simmermacher et al. reported that ten patients with poor reduction required a second surgery due to technical problems. Banan et al. reported that the rates of technical failure were 8.7%, cut-out in 6.7%, implant failure in one patient, femoral diaphyseal fracture in two patients, and 6.5% of the patients needed the second operation [22,33]. In our study, at least one mechanical complication was observed in 16 (8.2%) of 195 patients. Compared to other studies, our rates of mechanical complications were similar, but in our study, the most common complication was secondary varus deformity, and we did not observe any nonunion. Al-yassari et al. found a secondary operation rate of 7% in peritrochanteric fractures treated with PFN, but in our study, only two patients (1.02%) needed reoperation due to loss of reduction . The difference in second operation rates was thought to be due to the new implant technology. Statistically significant relationships were found between reduction quality and reoperation rates, and also between reduction quality and reduction loss.
The authors reported postoperative infection rates in intertrochanteric fractures between 0.15% and 15%. While deep infection was not observed in our study, superficial infection developed in 7 (3.5%) cases.
There are certain limitations of our study. Being retrospective and being single-centered are a few of its limitations. Due to the frequent occurrence of intertrochanteric fractures, prospective, multi-center studies with large patient groups are needed to determine the optimum conditions for minimizing mortality and morbidity.
Arthroplasty, intramedullary fixation, extramedullary systems, or conservative methods can be applied in the management of intertrochanteric fractures. We suggest that the general medical condition of the patient, comorbid diseases, functional state of the hip before the fracture, type of the fracture, bone density, the knowledge and experience of the surgeon, and the expectations of the patients should be considered in deciding PFN surgery for the intertrochanteric fracture. Technical problems and mechanical complications about the PFN application are frequently related to the type of fracture, surgical technique, and timing of the weight-bearing exercises rather than the implant itself. In the functional evaluation, taking the last data, not the follow-up process, and the lack of initial data were limiting factors of this study. Successful HHS scores at a rate of 77.5% show us that the PFN application is an appropriate choice in chosen cases when compared with other surgeries.
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Conflict of Interests: The authors declare that they have no competing interests.
Financial Disclosure: All authors declare no financial support.
Ethical Approval: This study was approved by the Institutional Scientific Research and Publication Ethics Committee (Ethical Approval Code 97132852/050.01.04).
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Ulusoy I, Kivrak A, Yilmaz E. Evaluation of the results of the proximal femoral nail surgery for
intertrochanteric femur fractures
. Med Science. 2022;11(2):750-6.
⇓ PlumX Meter
Corresponding Author: Ibrahim Ulusoy, Selahaddin Eyyubi State Hospital, Department of Orthopedics, Diyarbakir, Turkey