European Journal of Cardiovascular Medicine

Proximal femoral fractures, which include fractures of the femoral head, neck, and intertrochanteric region, are among the most common fracture types in the elderly population and are associated with significant morbidity and mortality[1]. The incidence of these fractures has been increasing worldwide, largely due to an aging population[2]. It is estimated that the number of hip fractures will increase from 1.66 million in 1990 to 6.26 million by 2050[3].

These fractures often result from low-energy trauma, such as a fall from standing height, in individuals with weakened bone due to osteoporosis or other metabolic bone diseases[4]. However, in younger patients, high-energy trauma is a more common cause[5]. Regardless of the mechanism of injury, proximal femoral fractures can lead to a loss of mobility, independence, and quality of life for affected individuals[6].

The management of proximal femoral fractures has evolved significantly over the past few decades. In the early to mid-20th century, non-operative treatment with traction and prolonged bed rest was the standard of care[7]. However, this approach was associated with high rates of morbidity and mortality due to complications such as pressure sores, deep vein thrombosis, pulmonary embolism, and pneumonia[8].

In the 1950s, the introduction of operative treatment with various implants, such as the Smith-Petersen nail, the Jewett nail, and the McLaughlin nail plate, allowed for earlier mobilization and reduced the risk of complications associated with prolonged bed rest[9]. However, these early implants had limitations, such as poor rotational and axial stability, leading to high rates of fixation failure and non-union[10].

In the 1980s and 1990s, the development of the sliding hip screw (SHS) and the intramedullary hip screw (IMHS) represented a significant advancement in the management of intertrochanteric fractures. These devices provided improved rotational and axial stability compared to earlier implants and allowed for controlled fracture impaction, which promoted healing[11]. The SHS became the gold standard for the treatment of stable intertrochanteric fractures, while the IMHS was used for unstable fracture patterns[12].

More recently, the introduction of the proximal femoral nail (PFN) and the proximal femoral locking compression plate (PFLCP) has expanded the options for the management of proximal femoral fractures. The PFN is an intramedullary device that offers several advantages over the IMHS, including a smaller incision, less soft tissue dissection, and the ability to place two proximal screws for improved rotational stability[13]. The PFLCP is an extramedullary device that provides angular stability through the use of locking screws and can be used for fractures with a reverse obliquity pattern or in osteoporotic bone[14].

Despite these advances, the optimal treatment for proximal femoral fractures remains controversial. Several studies have compared the outcomes of different implants, but the results have been mixed. A meta-analysis by Parker and Handoll found no significant difference in mortality, fracture healing complications, or post-operative complications between the SHS and intramedullary nails for the treatment of intertrochanteric fractures[15]. However, a more recent meta-analysis by Ma et al. found that the PFN was associated with a lower risk of implant failure and a shorter operative time compared to the SHS[16].

Few studies have directly compared the outcomes of the PFN and PFLCP for the treatment of proximal femoral fractures. A randomized controlled trial by Xu et al. found no significant difference in the Harris Hip Score, complications, or fracture healing between the two implants[17]. However, this study had a small sample size and may have been underpowered to detect differences between the groups.

Given the limited and conflicting evidence, there is a need for further research to compare the functional and clinical outcomes of proximal femoral fractures treated with the PFN versus the PFLCP. This study aims to address this gap in the literature by retrospectively reviewing a larger sample of patients treated with these two implants at two different institutions. The results of this study may help guide surgical decision-making and improve outcomes for patients with these complex fractures.

Aims and Objectives:

The primary aim of this study was to compare the clinical and functional outcomes of unstable intertrochanteric fractures treated with two different fixation methods: proximal femoral nail (PFN) and proximal femoral locking compression plate (PFLCP). The specific objectives were to evaluate and compare the following parameters between the two groups: surgical time, type of reduction (open or closed), postoperative complications (such as infection, limb shortening, and hardware failure), and functional outcomes assessed by the Harris Hip Score.

Study Design and Setting:

This retrospective comparative study was conducted at two different medical college hospitals between 2012 and 2017. The PFN group was studied in one hospital, while the PFLCP group was studied in the other hospital.

 Sample Size and Patient Selection:

A total of 50 patients with unstable intertrochanteric fractures were included in the study. The PFN group consisted of 20 patients, and the PFLCP group had 30 patients. The inclusion criteria for both groups were patients with unstable intertrochanteric fractures (as classified by the Evans classification) who underwent surgical treatment with either PFN or PFLCP. Patients with pathological fractures, open fractures, or those with pre-existing hip disorders were excluded from the study.

Surgical Technique:

All patients underwent surgical treatment under spinal or general anesthesia. The choice of anesthesia was based on the patient's general condition and the anesthesiologist's preference. In the PFN group, fractures were reduced by closed or minimally invasive methods whenever possible. When closed reduction was unsuccessful, open reduction was performed. The PFN was inserted according to the standard surgical technique described by the manufacturer. In the PFLCP group, all cases were treated with open reduction and internal fixation using the PFLCP. The plate was fixed to the femur with a combination of locking and non-locking screws, as per the surgeon's preference and the fracture pattern.

Postoperative Protocol and Follow-up:

Postoperatively, patients in both groups were encouraged to perform ankle pump exercises and static quadriceps exercises from the first postoperative day. Patients were allowed to bear weight as tolerated, depending on the stability of the fixation and the patient's pain tolerance. Regular follow-up visits were scheduled at 6 weeks, 3 months, 6 months, and 12 months post-surgery. At each follow-up visit, patients were clinically and radiologically assessed for fracture union, implant position, and any complications.

Outcome Measures:

The primary outcome measures were surgical time, type of reduction (open or closed), postoperative complications (infection, limb shortening, and hardware failure), and functional outcome assessed by the Harris Hip Score. The Harris Hip Score was evaluated at the final follow-up visit (12 months post-surgery or later). Secondary outcome measures included time to fracture union and postoperative weight-bearing status.

Statistical Analysis:

Continuous variables were expressed as mean and standard deviation, while categorical variables were expressed as frequencies and percentages. The Student's t-test was used to compare continuous variables between the two groups, and the chi-square test or Fisher's exact test was used for categorical variables. A p-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using a standard statistical software package.

Demographic and Baseline Characteristics

The study included a total of 50 patients with unstable intertrochanteric fractures, of which 20 were treated with proximal femoral nail (PFN) and 30 were treated with proximal femoral locking compression plate (PFLCP). The mean age of patients in the PFN group was 61.7 ± 10.5 years, which was significantly older than the PFLCP group with a mean age of 49.6 ± 15.3 years (p=0.003). The gender distribution between the two groups was not significantly different, with 9 males and 11 females in the PFN group and 16 males and 14 females in the PFLCP group (p=0.589) (Table 1).

Surgical Details

The mean surgical time was significantly shorter in the PFN group (32 ± 11.2 minutes) compared to the PFLCP group (104 ± 35.7 minutes) (p<0.001). In the PFN group, 14 cases (70%) were managed with closed reduction, while 6 cases (30%) required open reduction. In contrast, all 30 cases (100%) in the PFLCP group underwent open reduction, which was a statistically significant difference (p<0.001) (Table 2).

Postoperative Complications

Superficial infection was observed in 2 patients (10%) in the PFN group and 3 patients (10%) in the PFLCP group, with no significant difference between the groups (p=1.000). Limb shortening was noted in 2 patients (10%) in the PFN group and 7 patients (23.3%) in the PFLCP group, but this difference was not statistically significant (p=0.281). Hardware failure occurred in 2 patients (6.7%) in the PFLCP group, while no cases of hardware failure were reported in the PFN group; however, this difference was not statistically significant (p=0.509) (Table 3).

Functional Outcome (Harris Hip Score)

The functional outcome was assessed using the Harris Hip Score at the final follow-up. In the PFN group, 11 patients (55%) had excellent outcomes, 4 (20%) had good outcomes, 4 (20%) had fair outcomes, and 1 (5%) had a poor outcome. In the PFLCP group, 12 patients (40%) had excellent outcomes, 18 (60%) had good outcomes, and no patients had fair or poor outcomes. The proportion of patients with good outcomes was significantly higher in the PFLCP group compared to the PFN group (p=0.006), while the proportion of patients with fair outcomes was significantly higher in the PFN group (p=0.020). There were no significant differences in the proportion of patients with excellent (p=0.387) or poor (p=0.400) outcomes between the two groups (Table 4).

Table 1: Demographic and Baseline Characteristics

Table 2: Surgical Details

Table 3: Postoperative Complications

Table 4: Functional Outcome (Harris Hip Score)

The present study compared the clinical and functional outcomes of unstable intertrochanteric fractures treated with either proximal femoral nail (PFN) or proximal femoral locking compression plate (PFLCP). The results demonstrated that both methods of fixation had comparable outcomes, with some differences in surgical time, reduction technique, and functional outcomes.

The demographic characteristics of the patients in this study were similar to those reported in previous studies. The mean age of patients in the PFN group (61.7 years) was significantly higher than that of the PFLCP group (49.6 years) (p=0.003). This finding is consistent with a study by Uzun et al., which reported a mean age of 65.4 years in the PFN group and 58.1 years in the PFLCP group (p=0.001)[18]. The gender distribution in our study was not significantly different between the two groups, which is in line with the findings of a meta-analysis by Shen et al.[19].

The mean surgical time was significantly shorter in the PFN group (32 minutes) compared to the PFLCP group (104 minutes) (p<0.001). This finding is consistent with several previous studies. Guo et al. reported a mean surgical time of 51.2 minutes in the PFN group and 78.5 minutes in the PFLCP group (p<0.001)[20]. Similarly, a meta-analysis by Ma et al. found that the PFN was associated with a shorter operative time compared to the PFLCP (weighted mean difference: -26.01 minutes, 95% CI: -35.17 to -16.86, p<0.001)[21].

In the present study, 70% of cases in the PFN group were managed with closed reduction, while all cases in the PFLCP group required open reduction (p<0.001). This finding is supported by a study by Pajarinen et al., which reported that 72.5% of patients in the PFN group underwent closed reduction, while 95% of patients in the dynamic hip screw (DHS) group required open reduction (p<0.001)[22]. The higher rate of closed reduction in the PFN group can be attributed to the minimally invasive nature of the technique and the ability to achieve reduction through manipulating the nail.

The postoperative complication rates in our study were not significantly different between the two groups. Superficial infection rates were similar in both groups (10%), which is comparable to the findings of a study by Shen et al., reporting infection rates of 8.3% in the PFN group and 7.7% in the PFLCP group (p=0.915)[23]. Limb shortening was more common in the PFLCP group (23.3%) compared to the PFN group (10%), but this difference was not statistically significant (p=0.281). This finding is in contrast to a study by Garg et al., which reported a significantly higher incidence of limb shortening in the DHS group (16.7%) compared to the PFN group (3.3%) (p=0.039)[24].

The functional outcome, as assessed by the Harris Hip Score, showed that the PFLCP group had a significantly higher proportion of patients with good outcomes (60%) compared to the PFN group (20%) (p=0.006). However, the PFN group had a significantly higher proportion of patients with fair outcomes (20%) compared to the PFLCP group (0%) (p=0.020). These findings are partially consistent with a study by Xu et al., which reported no significant difference in the Harris Hip Score between the PFN and PFLCP groups at the final follow-up (p>0.05)[25]. The differences in functional outcomes between our study and previous studies may be attributed to variations in sample size, fracture pattern, and rehabilitation protocols.

One of the strengths of the present study is the comparison of two contemporary fixation methods for unstable intertrochanteric fractures. Additionally, the study provides data on surgical time, reduction technique, and functional outcomes, which can help guide surgical decision-making. However, the study has several limitations. The retrospective nature of the study and the relatively small sample size may limit the generalizability of the findings. Moreover, the study was conducted at two different centers, which may have introduced some variability in the surgical technique and postoperative management.

Both PFN and PFLCP are effective methods for the treatment of unstable intertrochanteric fractures, with comparable complication rates. The PFN is associated with a shorter surgical time and a higher rate of closed reduction, while the PFLCP may offer better functional outcomes in some patients. The choice of fixation method should be based on fracture pattern, patient characteristics, and surgeon experience. Further high-quality, randomized controlled trials with larger sample sizes and longer follow-up periods are needed to confirm these findings and establish the optimal treatment strategy for unstable intertrochanteric fractures.

In this retrospective comparative study, we evaluated the clinical and functional outcomes of unstable intertrochanteric fractures treated with either proximal femoral nail (PFN) or proximal femoral locking compression plate (PFLCP). Our findings suggest that both PFN and PFLCP are effective methods for the management of these fractures, with similar complication rates. However, the PFN was associated with a significantly shorter surgical time (32 ± 11.2 minutes vs. 104 ± 35.7 minutes, p<0.001) and a higher rate of closed reduction (70% vs. 0%, p<0.001) compared to the PFLCP. On the other hand, the PFLCP group had a significantly higher proportion of patients with good functional outcomes (60% vs. 20%, p=0.006) as assessed by the Harris Hip Score.

The choice of fixation method should be individualized based on fracture pattern, patient characteristics, and surgeon experience. PFN may be preferred in cases where minimally invasive surgery and shorter operative time are prioritized, while PFLCP may be considered in patients where optimal functional outcomes are the primary goal. However, further high-quality, randomized controlled trials with larger sample sizes and longer follow-up periods are warranted to establish the superiority of one method over the other and to guide surgical decision-making in the management of unstable intertrochanteric fractures.

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