European Journal of Cardiovascular Medicine

Intertrochanteric fractures are those that occur along the region proximal to the development of the medullary canal, spanning from the extracapsular basilar neck region to the region along the lesser trochanter. The intersecting cancellous compression and tensile lamellar networks, as well as the fragile cortical bone, are damaged in this proximal metaphyseal region of bone, resulting in a spectrum of fractures. The fracture fragments and connected muscle groups are displaced as a result of this. After surgical repair, these structures are subjected to multiplanar stresses. ^[1] Low-energy falls account for 90% of fractures in people over the age of 50, with females having a higher prevalence. Intertrochanteric fractures in children and teenagers are caused by high-energy trauma. The main goal of treating these fractures is to get a hip joint that is painless, stable and functioning. There are various treatment methods available, ranging from conservative to extramedullary and intramedullary internal fixation methods with their own pros and cons. Unstable fracture patterns are linked to higher surgical complexity and recovery. Posteromedial fragmentation, basicervical patterns, reverse obliquity patterns, displaced greater trochanteric (lateral wall) fractures, and inability to reduce the fracture prior to internal fixation are all examples of unstable characteristics. Post-surgical stability denotes the like- lihood of a successful union with no deformity or implant failure. Sliding implant devices, however, can cause considerable deformity. ^[2]

The present debate over implant selection is centred on how much deformity and fracture site motion is acceptable for a full functional recovery. Since the first reports of surgical treatment for pertrochanteric fractures, the literature has indicated that several fracture patterns, such as subtrochanteric fractures, reverse obliquity fractures, and fractures with lateral wall fracture extension, are not amenable to fixation with basic screw/nail side plate devices. Cephalomedullary nails (CMN) are being frequently used worldwide in the treatment of intertrochanteric fractures. In the United States and Europe, intramedullary repair of intertrochanteric fractures has increased significantly from 3% to 67%.

^[2] In the late twentieth century, the goal of surgical research on internal fixation was to reduce implant failure and cutout of the femoral head and neck fixing components while accepting the loss of fracture reduction. Fracture mal-union was not thought to be a factor in functional recovery. CMNs were originally all short, but because of concerns about stress risers and the resulting breakage at the nail tip, full length nails were produced. ^[3] With older nail designs, postoperative femoral shaft fracture rates ranged from 6 to 17 percent. ^[4]

Although there is a decrease in peri-prosthetic fracture rates with improved nail designs, there is still a risk of the same. Short and long CMNs are being employed to treat intertrochanteric fractures, each having its own set of benefits and drawbacks. ^[5] Meanwhile there has been some debate about the nail’s length. It has been observed that using a short PFN has its perks like a shorter operative time, less perioperative blood loss and a resultant lower rate of blood transfusion. However, there may be issues like peri prosthetic fractures, post operative anterior thigh pain and inadequacy of diaphyseal fixation in cases with subtrochanteric extension of fracture. On the other hand, proponents of long PFN argue that it has a lower rate of periprosthetic fractures and post operative thigh pain. Furthermore, it can be used to fix intertrochanteric fractures with subtrochanteric extension. While the cons of the latter being longer operative time, greater perioperative blood loss and greater transfusion rate. Another challenge to face is when a curve mismatch between the nail and femoral bow may perforate the anterior cortex. There is no apparent consensus in the literature on which is the better option for treating intertrochanteric fractures-A long or short PFN. The goal of this study is to come to a reliable conclusion about the usage of short vs. long PFN for the optimal management of intertrochanteric fractures.

STUDY DESIGN: A hospital-based prospective study

STUDY SHIFTING: This study will be conducted at Department of Orthopaedics and Anaesthesia.

STUDY PERIOD: 24 Months.

STUDY SIZE: Minimum of 30 Cases.

STUDY METHODOLOGY: This study aims to include a minimum of 30 patients’ adults both genders are taken to analyse, outcome with such fixation in adults.

INCLUSION CRITERIA: - Above 18 to 40 years of age regardless of body weight. - Confirmed diagnosis of unstable pertrochanteric fracture of femur. - Complete clinical and radiographic data.

EXCLUSION CRITERIA: - Patients younger than 18 years and older than 40 years - Stable pertrochanteric fractures - Osteoporotic pertrochanteric fractures - Fractures treated with techniques other than the one reported in this study. - Incomplete clinical and radiographic data. - Patient not giving informed consent for the study. For all participants, a clear history was taken followed by thorough clinical and radiological examinations. They were operated under spinal or epidural anaesthesia using a standard prescribed surgical technique of fixation using PFN (INOR Standard PFN (Wadia Group, Mumbai, India) with 8.0 mm lag screw and 6.4 mm antirotation screw with two distal locking screws)

A total of 30 patients who had intertrochanteric fractures were included in the present study, of whom 18 were managed with intramedullary nailing with intraoperative temporary K-wire stabilisation and 12 without intraoperative temporary K- wire’s stabilization. The average age of the patients was 69.65±14.73 years. In the study population, the average neck shaft angle was 130.61±4.31 degrees. There were 16 (53.3%) males and 14 (46.7%) females, with a male-to-female ratio of

1.11:1. The mean age of the patients in whom K wire was used was 71.71±14.26 years, and that of the patients without K wire was 68.04±15.20 years, the difference in the means was non-significant (p=0.2718).

Table 1: Descriptive statistics.

In 18 (60%) of all patients, the right side had a fracture, while the left side in 12 (40%).The patients were distributed according to Boyd and Griffin's classification, with more than half (20/30, (66.7%) of patients having type 2 fractures, followed by type 1 (6 (20%)) and type 4 (4 (13.3%)). Among 30 patients, in the majority, 24 (80%) patients’ reduction was maintained, and it was not maintained among 6 (20%) patients. The results are indicated in Table 1.

Among 30 patients in study, 15 patients operated with temporary K-wire, 14 patients’ reduction was maintained and loss of reduction was noted in 1 patients (4.2%) and 15 patients operated without K-wire, 10 patients reduction maintained and lost in 5 patients (20.8%).

Table 2: Association of status of reduction with gender, use of K wire, type of fracture.

IT fracture treatment is heavily influenced by fracture type and bone quality. DHS was the preferred treatment modality for IT fractures until the last few decades when PFN was introduced. Intramedullary devices, such as the PFN, were developed to address the shortcomings and complications associated with conventional extra-medullary devices, including non-union, re-operation rates, and malunion, particularly in unstable fractures. ^[6] Recent data show that intra-medullary devices can achieve union rates of up to 100% compared to extra-medullary devices. ^[7] Despite promising results with PFN, its overall efficacy in stable fractures remains contentious. ^[8]

We compared the functional and radiological outcomes in stable IT fractures treated surgically with either PFN or DHS. For all cases, we also compared intraoperative blood loss (mL), the time between the fracture and surgery (in days), the length of post-operative in-hospital stay (in days), and surgery duration (in minutes).

Compared to the literature, our study found that the PFN procedure's mean duration was roughly 20 to 40 minutes longer than the DHS procedure. Longer time for patient positioning and prepping could be a contributor. Although the senior consultant responsible for the cases was always scrubbed, some of the surgeries were done by senior-level trainees, and the learning curve can contribute to increased time. Studies contrasting the results of PFN and DHS have largely demonstrated that the PFN procedure was quicker than DHS. ^[9] Few studies indicated that the lengths of the two procedures were comparable. According to Das et al. analysis, PFN lasted longer when the nature of the fractures was more complicated. ^[10]

The mean time between fracture occurrence and surgery was similar for both procedures. On average, patients treated with DHS received correction within two days of injury, while PFN was performed between 2 - 3 days. This may be a reason for pretty promising results from each technique, where almost 50 percent of the cases achieved full weight-bearing capacity postoperatively. The proportion of post-PFN return to ambulation is greater than DHS, as available in the literature. While functional outcomes were better for PFN in the first three months, Myderrizi also noted in their work that there was no difference in recovery once the union was attained in six months. ^[11] As with our study, Zou et al. compared the two techniques and found no statistically significant differences in their functional outcomes. ^[12] In their prospective study of 135 patients, Baumgaertner et al. found similar functional recovery after either technique however, they did demonstrate the superiority of the intramedullary nailing technique, particularly in unstable fractures. ^[13] Klinger et al. and Xu et al. reported immediate weight bearing on the first postoperative day after PFN. ^[14]

In comparison to DHS, we observed greater intraoperative blood loss during PFN. This is contrary to what was previously reported in the literature, where greater blood loss during DHS has been observed. While eight patients from the DHS group required transfusions of up to 4 units in two cases, two patients who underwent PFN required blood transfusions of three units each. 

Despite the difference in the proportion of patients with the observable union on radiographs, neither the PFN nor the DHS group had any malunions. Malunion has been noted in DHS cases in the literature. ^[15]

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