Intertrochanteric fracture is a common condition seen by Orthopaedic surgeons. It accounts for 5-20% of all fractures and 45-50% of all hip fractures. More than half of these fractures are unstable in nature. ¹

The estimate by Gulberg et al indicates that total number of hip fractures will reach up to 2.6 million by 2025 and 4.5 million by 2050. Majority of the cases are above the age of 60 years and it is 2-3 times more common in females as compared to the males. ²

Hip fractures are very common among the elderly population, mainly because of increasing life span, sedentary lifestyle and increasing incidence of osteoporosis, especially in developing countries like India.

The goal of treatment of any intertrochanteric fracture is to restore mobility safely and efficiently while minimizing the risk of medical complications and technical failure and to restore the patient to preoperative status.

Conservative methods resulted in higher mortality rates and complications such as decubitus ulcer, urinary tract infections, pneumonia, thromboembolic complications³. Hence these methods have been abandoned now a days. Due to associated complexities with intertrochanteric fractures and increased mortality of 15-20%, surgical management is the treatment of choice now a days³.

Implants for the fixation of intertrochanteric fractures can broadly be divided into Extramedullary (eg. Dynamic hip screw) and Intramedullary (eg. Proximal Femoral Nail) devices⁴. AO/ASIF group introduced Proximal Femoral Nailing in 1997 which is intramedullary in nature. It is frequently being used now a days for the treatment of intertrochanteric fractures.⁵

Being a load sharing device, PFN gives more biomechanical strength and permits early mobilization. It preserves the vascularity and ensures better rotational stability even in osteoporosed bone of elderly. DHS is a load bearing device and needs extensive soft tissue stripping.

The mechanism of action of PFN is controlled collapse at the fracture site on weight bearing leading to compression at the fracture.  The distal screws lock the nail and help in control of rotation and telescoping of the fracture fragments. A PFN has a mechanical advantage of reducing the distance between the weight bearing axis and the implant. The lag screw withstands the bending movement which is transferred to the intramedullary nail and counterbalanced by its locking mechanism with the femoral cortex in the medullary canal. Almost the entire load is transferred to the nail and negligible portion to the femoral cortex.

In present study patients of intertrochanteric femur fractures were treated surgically with Proximal femoral nail at Department of Orthopaedics, R.K.Damani Medical College, Dr.Hedgewar Hospital, Chha.Sambhajinagar Maharashtra, India, between January 2019 to December 2021. A total of 30 patients were included in the study. Single senior Orthopaedic Surgeon operated all cases. Institutional Ethical Committee approval was taken. Inclusion Criteria 1. Age more than 60 yrs, 2. Recent traumatic history, 3. Isolated intertrochanteric fractures, 4. Stable and unstable fractures, 5. Patients willing to give consent for study. Exclusion Criteria 1. Patient with pathological fracture, 2. Patient with polytrauma, 3. Patient with old neglected fracture, 4. Fracture with neurovascular deficit, 5. Compound intertrochanteric fracture. The implant consists of a Proximal Femoral Nail. PFN is made up of either 316L stainless steel or titanium alloy. Length of PFN - 18 cm and 25 cm. Angles of nail - 130 0 and 1350 Proximal Diameter - 15mm This increases the stability of the implant. Proximal Nail Angulation - 6 0 which prevents varus collapse of fracture, even when there is medial comminution. Distal diameter - 9,10,11,12mm which also has groove to prevent stress concentration at the end of the nail and avoids fracture of the shaft distal to the nail. Lag screw diameter - 8 mm which acts as a sliding screw Derotation screw diameter - 6.2mm which helps to prevent the rotation Distal locking bolt - 4.9mm Jig for proximal and distal reamers and for locking Guide wire - 2 mm Cannulated step reamer guide wire sleeve and drill sleeve Detailed history, clinical examination, routine investigation, pre-anaesthetic check-up was done. Anteroposterior X-ray of pelvis with both hips and lateral view of the injured joint were taken. Distribution of the fractures were done using the Tronzo’s classification. The preoperative neck-shaft angle and the medullary canal diameter was calculated with the help of the radiographs of the normal opposite hip. Informed consent was obtained from patient for both the surgical procedure and participation in the study. Surgery was performed under suitable anaesthesia on standard radiolucent fracture table with patient in supine position with use of image intensifier. All the fractures were treated with initial closed reduction with alignment of the posteromedial cortex. In the cases where it was not possible, indirect reduction was done by percutaneous or mini-open techniques before making entry for the PFN. The approach for PFN is a 5 cm incision extending proximally from the tip of the greater trochanter followed by careful separation of the abductors. The point of entry was the tip of the greater trochanter at the midpoint in the anteroposterior diameter and is made with a curved awl under c- arm guidance. The guide wire was inserted using a tissue protector. The position of guide wire is checked in AP and lateral views. Entry point was reamed using 15mm entry point reamer and distal reaming of canal is done with graded cannulated reamers, whenever necessary. The nail with zig was inserted over the guide wire with hand. After removing guide wire, proximal and distal locking was done with zig under c arm image. Wound closed in layers over drain. Standard post-operative care was provided. DVT prophylaxis was given with low molecular weight heparin. Static exercise in bed for glutei, hamstrings, quadriceps and breathing exercises were started next day of surgery. Sitting was allowed on next day of surgery with passive exercises in bed. Drain was removed after 48 hours. ROM exercises were started actively. Sutures were removed after 15 days. Partial weight bearing started after 6 weeks and full weight bearing was started after 3 months approximately. Follow up was done post operatively at 3 months and 6 months. At each follow up visit patients were evaluated clinically. Functional outcome was evaluated by Harris Hip Score. FIGURE- 1 PREOP- AP AND LAT VIEW POSTOP- AP AND LAT VIEW FIGURE- 2 POSTOP CLINICAL PHOTOS FIGURE 3 PREOP –AP VIEW POSTOP-AP AND LAT FIGURE-4 PREOP-AP VIEW POSTOP- AP VIEW POSTOP- LAT VIEW FIGURE-5 PREOP -AP VIEW LAT VIEW POSTOP—AP AND LAT VIEW. XRAY SHOWING FRACTURE UNION

Table 1: Distribution of patients according to Gender

Table 2: Distribution of patients according to Mode of Injury

Table 3: Distribution of patients according to Tranzo’s classification

Table 4: Distribution of patients according to Complications of PFN

Table 5: Distribution of patients according to Modified Harris hip score

Hip fractures are associated with notable morbidity and mortality in elderly patients. Complexity of intertrochanteric fractures in elderly patients poses challenging problems, with an added risk of increased morbidity and mortality. Early ambulation following surgeries is important for preventing complications that can be caused by long term bed rest in elderly patients with poor general conditions. Internal fixation has drastically reduced the mortality associated with intertrochanteric fractures. Traditionally intertrochanteric fractures have been treated with internal fixation using Dynamic Hip Screw (DHS) or cephalo-medullary nailing (PFN) devices. Previously the sliding hip screw or D.H.S. was considered as the Gold standard for treating stable trochanteric fractures, but excessive collapse with shortening and high failure rates are concerns about their use in unstable trochanteric fractures 12. PFN acts as a buttress to prevent medialisation of the shaft and provides more efficient load transfer. It is designed to provide linear intraoperative compression of head neck segment to shaft along with rotational stability which minimizes neck mal-unions resulting in negligible complication rate. It also reduces stress concentration at the tip and the smaller distal diameter may prevent femoral shaft fractures. Union rates of close to 100% have been achieved in stable, well-fixed fractures in patients with good quality of bone. However, problems arise in unstable, osteoporotic fractures in medically challenged old patients, where a high incidence of complications has been observed. Complications include infection, non-union, screw breakage, dislocations , Z effect and screw cut outs6. Menezes DF et al 11 conducted a study on 155 cases of intertrochanteric fractures treated with P.F.N. and found 2% failure of fixation. In our study one patient had implant related complication which later required revision surgery and one patient had limb shortening which required shoe raise. Incidence of implant related complications can be reduced by good pre-operative planning, correct technique, adequate reaming of femoral canal and insertion of implant by hand, optimal screw positioning and avoid lateral screw prominence. Our study's functional outcomes compare favourably with other research in the domain. Prajapati et al studied 75 patients out of which 43(57.33%) patients showed excellent result, good in 19(25.33%) patients, fair in 3(4%) patients and poor in 10(13.33%) patients.10 Study of 20 patients by Yadav et al showed 10 patients (50%) achieved excellent results, 7 patients (35%) had good results, 2 patients (10%) had fair outcomes, and only 1 patient (5%) had poor result. In our study of 30 patients, good function was noted in 53% patients, excellent function was noted in 27% followed by fair function in 13% patients, and poor function was noted in 7% patients. Limitations of our study are small sample size, short term follow-up, and our study did not include a control group or comparison with other fixation methods which limits the ability to draw definitive conclusions about the relative efficacy of PFN.

The present study concludes that PFN is a significant advancement in the treatment of  intertrochanteric fractures in elderly patients which has the unique advantage of closed reduction, preservation of fracture hematoma, less tissue damage during surgery, early rehabilitation and early return to work thereby decreasing the incidence of bedsores, deep vein thrombosis, uraemia and hypostatic pneumonia.

Proximal Femoral Nail is a superior implant for stable and unstable intertrochanteric fractures in terms of operating time, surgical exposure, blood loss and complication rates.

CONFLICT OF INTEREST :  None.

SOURCE OF FUNDING   :  None

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