J Korean Orthop Assoc.  2017 Feb;52(1):25-32. 10.4055/jkoa.2017.52.1.25.

The Difference between Short and Long Intramedullary Nailing as the Treatment for Unstable Intertrochanteric Femoral Fracture (AO/OTA 31-A2) in Elderly Patients

• Shin WC
• Lee ES
• Suh KT

• KMID: 2369568
• DOI: http://doi.org/10.4055/jkoa.2017.52.1.25

Abstract

PURPOSE
The purpose of this study was to analyze the radiological and clinical outcomes in elderly patients with unstable intertrochanteric femur fractures in accordance with the length of intramedullary nail.
MATERIALS AND METHODS
Between August 2009 and December 2014, a total of 139 patients-older than 65 years of age with AO/OTA classification of 31-A2 unstable intertrochanteric femur fracture-who has been followed-up for at least 1 year after the treatment with internal fixation by using an intramedullary nail were enrolled for this retrospective control study. The subjects were classified into two groups according to the length of intramedullary nail: 106 patients in the short group (group I) and 33 patients in the long group (group II). For radiological assessments, the reduction state, time to union, and implant related complications were examined. The clinical outcomes were assessed by preoperative hemoglobin, operating time, intraoperative bleeding amount, blood transfusion rate, hospitalization period, and Charnley hip pain scoring system at the final follow-up.
RESULTS
The postoperative radiographs showed good or acceptable reduction in all cases. The mean time of radiologic bone union was 4.8 months, and there was no difference between the two groups. With respect to surgical time, the group II was found to take longer (57.87 minutes) than the group I (45.65 minutes) (p=0.003). The bleeding amount during surgery of the group II was greater (288.78 ml) than that of the group I (209.90 ml) (p=0.046). The clinical results at the final follow-up were found to be satisfactory in both groups.
CONCLUSION
In cases of good reduction of the fracture from the treatment of unstable intertrochanteric femur fracture accompanying the posteromedial fragment in elderly patients, both groups-long and short intramedullary nails-showed satisfactory radiological and clinical outcomes.

Keyword

femur; intertrochanteric fractures; intramedullary nailing

MeSH Terms

Aged*
Blood Transfusion
Classification
Femoral Fractures*
Femur
Follow-Up Studies
Fracture Fixation, Intramedullary*
Hemorrhage
Hip
Hip Fractures
Hospitalization
Humans
Operative Time
Retrospective Studies

Figure

• 

  Figure 1 Short proximal femoral nail antirotation (PFNA) II (A) and long PFNA II (B) were placed and postoperative radiographs show good reduction and optimal blade position in the femoral head.

• 

  Figure 2 The helical blade was placed in the ideal position. Group I: Internal fixation using proximal femoral nail antirotation (PFNA) II of 170, 200 mm length, Group II: Internal fixation using PFNA II of 300, 340 mm length.

Reference

1. Kim DS, Shon HC, Kim YM, Choi ES, Park KJ, Im SH. Postoperative mortality and the associated factors for senile hip fracture patients. J Korean Orthop Assoc. 2008; 43:488–494.

2. Lee KJ. Fixation failure of proximal femoral nail anti-rotation in femoral intertrochanteric fracture. Hip Pelvis. 2012; 24:302–308.

3. Radcliff TA, Regan E, Cowper Ripley DC, Hutt E. Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study. J Bone Joint Surg Am. 2012; 94:833–840.

4. Chung YK, Hwang JH, Kim HK. The treatment of peritrochanteric fracture of femur with proximal femoral nailcomparative study with dynamic hip screw. J Korean Hip Soc. 2007; 19:167–175.

5. Lv C, Fang Y, Liu L, et al. The new proximal femoral nail antirotation-Asia: early results. Orthopedics. 2011; 34:351.

6. Strauss E, Frank J, Lee J, Kummer FJ, Tejwani N. Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures: a biomechanical evaluation. Injury. 2006; 37:984–989.

7. Yoo JH, Park JS, Noh KC, et al. The results of proximal femoral nail antirotation: a comparative study with proximal femoral nail. J Korean Hip Soc. 2008; 20:286–292.

8. Huang FT, Lin KC, Yang SW, Renn JH. Comparative study of the proximal femoral nail antirotation versus the reconstruction nail in the treatment of comminuted proximal femoral fracture. Orthopedics. 2012; 35:e41–e47.

9. Sung YB, Jo SI. Results of the proximal femoral nail antirotation (PFNA) in patients with an unstable pertrochanteric fracture. J Korean Hip Soc. 2011; 23:39–46.

10. Bellabarba C, Herscovici D Jr, Ricci WM. Percutaneous treatment of peritrochanteric fractures using the gamma nail. 2000. J Orthop Trauma. 2003; 17:S38–S50.

11. Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures. Int Orthop. 2006; 30:69–78.

12. Bojan AJ, Beimel C, Speitling A, Taglang G, Ekholm C, Jönsson A. 3066 consecutive gamma nails. 12 years experience at a single centre. BMC Musculoskelet Disord. 2010; 11:133.

13. Lavini F, Renzi-Brivio L, Aulisa R, et al. The treatment of stable and unstable proximal femoral fractures with a new trochanteric nail: results of a multicentre study with the Veronail. Strategies Trauma Limb Reconstr. 2008; 3:15–22.

14. Gadegone WM, Salphale YS. Short proximal femoral nail fixation for trochanteric fractures. J Orthop Surg (Hong Kong). 2010; 18:39–44.

15. Boone C, Carlberg KN, Koueiter DM, et al. Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (OTA 31-A1 and A2). J Orthop Trauma. 2014; 28:e96–e100.

16. Hou Z, Bowen TR, Irgit KS, et al. Treatment of pertrochanteric fractures (OTA 31-A1 and A2): long versus short cephalomedullary nailing. J Orthop Trauma. 2013; 27:318–324.

17. Raval P, Ramasamy A, Raza H, Khan K, Awan N. Comparison of short vs long anti-rotation in treating trochanteric fractures. Malays Orthop J. 2016; 10:22–28.

18. PFNA. Proximal femoral nail antirotation technical guide [Internet]. Oberdorf: SYNTHES;cited 2015 Fed 22. Available from: http://orto.hi.is/skrar/036490.pdf.

19. Park YS, Lim SJ, Lee TH. Prevention of venous thromboembolism in hip surgery patients. Hip Pelvis. 2014; 26:1–6.

20. Fogagnolo F, Kfuri M Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AOASIF proximal femoral nail. Arch Orthop Trauma Surg. 2004; 124:31–37.

21. Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1959; 41:1399–1408.

22. 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.

23. Brunner A, Jöckel JA, Babst R. The PFNA proximal femur nail in treatment of unstable proximal femur fractures--3 cases of postoperative perforation of the helical blade into the hip joint. J Orthop Trauma. 2008; 22:731–736.

24. Takigami I, Ohnishi K, Ito Y, et al. Acetabular perforation after medial migration of the helical blade through the femoral head after treatment of an unstable trochanteric fracture with proximal femoral nail antirotation (PFNA): a case report. J Orthop Trauma. 2011; 25:e86–e89.

25. Cheung JP, Chan CF. Cutout of proximal femoral nail antirotation resulting from blocking of the gliding mechanism during fracture collapse. J Orthop Trauma. 2011; 25:e51–e55.

26. Lorich DG, Geller DS, Nielson JH. Osteoporotic pertrochanteric hip fractures: management and current controversies. Instr Course Lect. 2004; 53:441–454.

27. Hesse B, Gächter A. Complications following the treatment of trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg. 2004; 124:692–698.

28. Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br. 1993; 75:789–793.

29. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991; 73:330–334.

30. Irgit K, Richard RD, Beebe MJ, Bowen TR, Kubiak E, Horwitz DS. Reverse oblique and transverse intertrochanteric femoral fractures treated with the long cephalomedullary nail. J Orthop Trauma. 2015; 29:e299–e304.