|Year : 2023 | Volume
| Issue : 1 | Page : 71-77
Long PFNA-II versus dynamic hip screw for treatment of unstable intertrochanteric femur fracture: A prospective comparative study
Sanjiv Kumar, Punit Agarwal, Deepak Kumar, Ashish Kumar, Atul Kumar Saroj, Ashutosh Verma, Rishabh Agarwal
Department of Orthopaedics, K.G. Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||01-Mar-2023|
|Date of Acceptance||21-Mar-2023|
|Date of Web Publication||20-Apr-2023|
Atul Kumar Saroj
Room no. 203/F, Gautum buddha hostel, K.G. Medical University, Lucknow 226003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Intertrochanteric femur fractures are one amongst the most common hip fracture presenting to our centre. Clinical efficacy and safety of PFNA and DHS in the treatment of unstable intertrochanteric fractures in elderly patients and found that compared with the control group (DHS), the observation group (PFNA) experienced shorter operation time and fracture healing time and less intraoperative blood loss, and suffered a shorter incision. The purpose of this study was to compare the functional outcomes and related complications between DHS and PFNA in treatment of unstable intertrochanteric femur fracture. Methodology: Total of 60 patients having unstable intertrochanteric femur fracture were included in this study and was equally divided into two groups. Group-P included patients with unstable intertrochanteric femur fracture managed by PFN-A II while Group-D patients managed by DHS. The result was analysed using descriptive statistics and making comparisons among various groups. Categorial data were summarized as in proportions and percentage (%) while discrete as mean ± SD. Results: At final follow-up; it was found that 72.4% of the cases of PFNA have achieved excellent union as compared to 44.4% for DHS group, 24.1% cases of PFNA have good union as compared to 51.9% in DHS group and the difference of mean DHS was significantly higher for PFNA group (p=0.001). Conclusion: PFNA-II have benefits like minimally invasive procedure, less soft tissue dissection, less amount of blood loss and provides better result in terms of union. Therefore PFNA-II is recommended as a better choice as compared to DHS in management of unstable intertrochanteric fractures in terms of functional outcome.
Keywords: Dynamic hip screw, fracture intertrochanteric femur, Harris hip score, PFNA-II
|How to cite this article:|
Kumar S, Agarwal P, Kumar D, Kumar A, Saroj AK, Verma A, Agarwal R. Long PFNA-II versus dynamic hip screw for treatment of unstable intertrochanteric femur fracture: A prospective comparative study. J Bone Joint Dis 2023;38:71-7
|How to cite this URL:|
Kumar S, Agarwal P, Kumar D, Kumar A, Saroj AK, Verma A, Agarwal R. Long PFNA-II versus dynamic hip screw for treatment of unstable intertrochanteric femur fracture: A prospective comparative study. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:71-7. Available from: http://www.jbjd.in/text.asp?2023/38/1/71/374421
| Introduction|| |
Trochanteric fractures were first described by Cooper as a femur fracture that runs through the greater trochanter passes obliquely upward and outward from the lower part of the neck, but it only enters the base of the greater trochanter and does not entirely traverse the neck. The femur is fractured along a line that separates it into two pieces, one of which contains the head, neck, and trochanter major and the other of which contains the shaft and the remaining parts of the femur. Also, through the trochanteric level, he was the first to differentiate between intracapsular and extracapsular fractures of the neck of the proximal femur. Fracture of hip is the most heinous injury for any age group, with 90.0% of them occurs in old age. Due to the increase in life expectancy of population and Road traffic accidents, the incidence of proximal femur fracture has been tremendously increased.
In older individuals, these fractures are associated with significant morbidity and death, with 15.0%–20.0% mortality within a year following the fracture. Cortical and compact cancellous bones are largely involved in extracapsular fractures. Because of the complicated weight distribution in this area and the nonhomogeneous osseous structure, fractures occur via the proximal femur along the path of least resistance.
According to Gulberg et al., hip fracture would double to 2.6 million by 2050 and 4.5 by 2050. Men will acquire a higher proportion increase (310.0%) than women (240.0%). Hagino et al. estimated that males over 50 have a lifetime risk of hip fracture of 5.6% and women over 50 have a lifetime risk of hip fracture of 20.0%. The majority of the management was conservative before the development of adequate fixation devices; however, this strategy has since lost fame due to the high incidence of complications. Operative surgery is the primary course of treatment because varus deformity and shortening are more common and cause poor function. Since then, numerous therapeutic options including extramedullary, intramedullary, and arthroplasty have emerged. The current concept of management is surgical fixation followed by early mobilization. Surgical fixation involved usage of various intramedullary and extramedullary implants such as dynamic hip screw (DHS), proximal femoral locking plate, proximal femoral nail (PFN), and PFN antirotation Asia (PFNA2).
The DHS implant is frequently used to treat intertrochanteric fractures because it enables fracture site collapse and fracture union. However, it is an open surgery with a longer operating duration, wider incision, and more soft tissue dissection.
In 2003, AO presented PFN antirotation (PFNA), a technique in which helical blades were used in place of screws. When the helical blade is inserted in, it strikes the cancellous bone nearby, increasing the femoral head’s strength and fixation stability. In particular in osteoporotic fractures, it can be implanted without reaming away bone from the head and neck regions, providing better anchoring. Asians have somewhat smaller femurs than other populations; hence, PFNA2 was developed for them.
Fixation issues are significantly influenced by the type of implant used. Sliding devices, such as the DHS, are frequently used. However, early weight bearing by the patient after comminuted fractures increases the risk of implant failure. The placement of intramedullary devices such as the PFNA allowed the implant to lie close to the mechanical axis of bone, reducing the lever arm and bending moment on the implant. This has been observed to be advantageous in unstable fractures. Because they are implanted more swiftly and with less operational blood loss, they permit early weight bearing and decreased limb shortening throughout the course of a lengthy follow-up. This study compared the effects and side effects of DHS and PFNA for treating unstable intertrochanteric femur fractures.
| Materials and Methods|| |
The study was conducted in the Department of Orthopaedics, King Georges Medical University. This was a prospective interventional study of 2 years duration from December 2020 to December 2022. Written informed consent was taken and the study was approved from the Institutional Ethical committee. A total of 60 patients with unstable intertrochanteric femur fracture were enrolled in the present study and were divided into two equal groups of 30 each, group A (managed by PFNA) and group B (managed by DHS). We included patients more than 18 years old with Unstable Intertrochanteric Femur Fracture of types IC, ID, IE, and II; Evans Jansen Classification, types II, III, and IV; Boyd and Griffin Classification; and all patients who were able to walk before the fracture. We excluded the patients not giving consent, patients with pathological fractures or metastatic disease, polytrauma, severe osteoarthritis of hip joint, an American Society of Anesthesiologists physical status of V (unfit for surgery), cognitive dysfunction, mental illness, and refusal to participate, stable intertrochanteric fractures and open fractures. Preoperatively, detailed history and clinical examination of every patient were done to rule out any neurovascular injury and injury to any other joints. Postoperatively, both groups of patients were evaluated in terms of surgical time, blood loss, union time, and functional outcome in terms of “Harris Hip Score” at 6, 12, 24, and 48 weeks. The results were analyzed using descriptive statistics and making comparisons between two treatment procedures, with respect to various parameters. Discrete (categorical) data were summarized as in proportions and percentages and mean ± standard deviation (SD).
| Results|| |
The mean age of the PFNA group was 54.7 ± 18.0 years, whereas that of DHS group was 60.7 ± 17.5 years. The males were higher in number than females in our study. Intraoperative blood loss was significantly lower in PFNA-II than DHS group (P < 0.05). In the follow-up at the 12th, 24th, and 48th weeks, the mean Harris hip score for PFNA-II group was significantly higher than that for DHS group. The majority of the patients were male (65.0%) followed by females (35.0%), and the association was statistically nonsignificant (P > 0.05). The majority of patients had trochanteric fractures of 68.3% followed by road traffic accident (RTA) (31.7%), and the association was statistically insignificant (P = 0.640).
The [Table 1] shows the distribution of patients on the basis of B&G classification, and the distribution of majority of patients were in type-2 classification with 66.7% in PFN group, whereas 90.0% in DHS group. In type-3 classification; distribution were 13.3% in PFN group, whereas 6.7% in DHS group; and in type-4 classification, with 20.0% in PFN group, whereas 3.3% in DHS group.
|Table 1: Distribution of studied patients based on injury to surgery time in both groups|
Click here to view
The majority of patients were having right-side injury (56.7%) followed by left side (43.3%), and the association was insignificant (P > 0.05). The mean of injury to surgery time (in days) was lower in PFN group than in DHS, and it was found to be statistically nonsignificant (P > 0.05).
The [Table 2] shows the blood loss in PFN and DHS groups, and the association of blood loss was found to be statistically significant (P = 0.001) as the blood loss was significantly more in DHS group, whereas union weeks were also more in DHS group compared with PFN group. Also, the surgical time for DHS was significantly more than PFNA (P < 0.001). Time for union (weeks) was found to be statistically nonsignificant (P > 0.05) in both groups.
The [Table 3] show time of union weeks in PFN and DHS groups, and it was found to be time of union was lower in PFN group than in DHS.
|Table 3: Distribution of studied patients based on comparison of time of union in both groups|
Click here to view
The [Table 4] shows the distribution of patients in both the studied groups on the basis of complications, and PFN group showed no complications in 80.0% of patients, whereas 83.3% were having no complications in DHS group, and the association was insignificant (P > 0.05).
The [Table 5] shows the distribution of patients on the basis of union group, and the PFN group shows union in 93.2%, whereas that in DHS group union was 86.3%, and the association was nonsignificant (P = 0.584).
The [Table 6] shows the follow-up of the studied patients with Harris score at the 6th week, which was significantly nonsignificant (P = 0.149), Harris score at the 12th week was significantly high in PFN group (P = 0.044), and at the 24th week in PFN was highly significantly more than DHS group (P < 0.001), whereas at the 48th week (P < 0.001).
|Table 6: Distribution of studied patients based on functional outcome in terms of HHS at different follow-up intervals|
Click here to view
Clinical case 1
Clinical case 2
| Discussion|| |
In our study, we found that patients presented with unstable intertrochanteric fractures sustained due to RTA were younger than 57 years old, whereas patients aged more than 57 years sustained unstable intertrochanteric fractures following a trivial fall. Similar observations were made by Jonnes et al. where they found that 77% of the intertrochanteric fractures were due to trivial falls followed by road traffic accidents (23%). They also observed that patients with road traffic accidents were younger, whereas patients with trivial trauma were older, which is consistent with the findings of our study. The age ranges from 61 to 80 had the highest prevalence, with a mean of 67.13 years. Ahmed et al. reported the mean age of 63.35 years (±6.9 SD). This indicates that older patients, especially those in their 60s and 70s, are predominantly affected by these fractures. “In our study, the mean age group of patients suffering from unstable intertrochanteric fractures due to trivial fall is higher than that in the high-velocity trauma group.”
In our study, the number of male participants was 39 (65%), whereas 21 (35%) participants were females. Thus, the male-to-female ratio in our study was 1.8:1. However, among the females who presented to our side, 81% were older than 50 years of age. It is interesting to note that the higher incidence of unstable intertrochanteric. fracture was among postmenopausal women. Our results were in accordance with Sinha and Ishtiaque who reported 60.0% males and 40.0% females in their study.
Patients who suffered an RTA and sustained unstable intertrochanteric fractures were managed by PFNA-II (63.1%), whereas patients with unstable intertrochanteric fractures following trivial falls were managed by DHS (56.0%). The management was guided by the fact that following high-velocity trauma, such as that following RTA produces an intertrochanteric fracture that is highly unstable, and intramedullary nail fixation is the appropriate management of unstable IT fractures. The results of our study correlate with other studies on the management of intertrochanteric fractures.
The majority of patients sustained injury on the right side (56.7%) but this was merely a coincidence, and the association was insignificant (P > 0.05). Injuries to the left hip and right hip are equal, as per Shivanna and Rudrappa. Sinha and Ishtiaque reported that the left side (60%) is more frequently involved than the right side (40.0%). There was no appreciable difference in the surgical time for both implant surgeries. The average time required for PFNA-II implantation in our setup was 85.1 ± 15.95 min, whereas that for DHS implantation was 87.5 ± 13.50 min, which is statistically insignificant. The average duration of surgery as calculated by Jonnes et al. from the time of incision to skin closure for PFNA-II was 90.6 min, which correlate closely with our study results.
The blood loss during DHS implant surgery was substantially more than it was during PFNA-II surgery in the our study, and this difference was shown to be statistically significant (P = 0.001). According to Hussain and Kamat, the DHS group had considerably greater intraoperative blood loss that required postoperative blood transfusions, which was correlated with a P value of less than 0.05. On average, less postoperative transfusion was required in patients operated with PFNA-II (mean: 0.4) than that operated with DHS (mean: 0.8).
In our study, the time of union of fracture managed by PFNA-II and DHS was approximately the same. We did not find any difference in time for fracture union among patients managed by the two modalities. However, these results did not meet the criteria for statistical significance defined in our study. Shivanna and Rudrappa reported a mean of 12 weeks in fracture union, which was more or less similar to our study. We observed a significant limb shortening in patients managed by DHS (1.51 cm) compared with those managed by PFNA-II (0.63 cm) (P <0.001). Boraiah and Kumar also reported the same results as our study, where there was significant clinical shortening in DHS (1–1.9 cm) compared with in PFNA-II group (0.5–0.9 cm).
In the present study, PFNA-II group showed no complications in the postoperative follow-up. Complications such as distal screws failure and anterior cortical pain were more commonly seen in the PFNA-II–managed patients, whereas 80.0% of patients did not have any troublesome complaints during the follow-up period. In the DHS group, we observed complications such as helical screw cut out and varus collapse during the 12-month follow-up period, whereas 83.3% had no such complications. Thus, the incidence of complications in the two groups is almost similar as per our study. However, this similarity was not found to be statistically significant. However, Kalaiah and Koshy reported that fewer complications occur in the PFNA-II group compared with the DHS group.
In our study, malunion was more in DHS group (10.3%) than PFNA-II group (3.4%). In their study, Shivanna and Rudrappa found that no patients in the PFNA-II group had fracture fragment malunion compared with three patients (20%) in the DHS group. They also observed that all the fractures united with less than 10° of varus angulation. The difference in the mean Harris Hip Score after the 24th-week groups were statistically significant (P < 0.001). At the third follow-up, the mean Harris Hip Score was 85.4 ± 3.9 in the PFN-II group and 81.6 ± 4.5 in DHS group.
At the 12th month of follow-up, the mean Harris Hip Score was 91.4 ± 3.3 in the PFN-II group and 88.6 ± 3.0 in the DHS group. This difference in mean Harris Hip Score at the third follow-up between the two groups was statistically significant (P < 0.001). PFN-II had a higher Harris hip score than in DHS group. Hussain and Kamat reported that the functional outcome was found to be more in PFNA-II group compared with DHS, which was statistically significant using Harris Hip Score (P < 0.05). Thus, our study demonstrates that patients managed with PFNA-II had better functional outcomes compared with those managed by DHS implant. During the course of follow-up, it was seen that the Harris hip score improved at each follow-up in both groups with 72.4% of PFNA-II group patients and 44.4% of DHS group patients attaining excellent outcomes at the 4th follow-up visit. Limitations of this study were small sample size and short-term follow-up period. A common problem in this kind of study was that many patients had associated comorbidities affecting their general health, making it difficult to participate in follow-up. We recommended a randomized study on the above subjects with larger study sample size and long-term follow-up to analyze properly the results of DHS/PFNA-II in unstable fractures in elderly patients.
In our study, it was found that there is improvement in functional outcome in terms of Harris hip score in both groups postoperatively. However, the difference in the 6th-week follow-up between both groups was statistically not significant. Hence, functional outcome was comparable in both groups at initial follow-up. While comparing the improvement in subsequent follow-up periods, the difference was statistically significant; hence, PFNA had beneficiary effect in improving Harris hip scores and, thus, functional outcome compared with DHS at long-term follow-up.
In the present study, significant limb shortening was found to be associated with DHS compared with those managed by PFNA-II. DHS works on the principle of controlled collapse, whereas PFNA-II helps in achieving biological reduction while achieving adequate stability without any excessive collapse, thus imparting overall good functional outcomes. The surgical technique may lead to the displacement of the proximal fragment into varus or may even explode the proximal femur during insertion, thus resulting in malunions. Many of the complications can be avoided by rigorous asepsis, adequate surgical indications, and rigorous surgical techniques. Good management of these complications can restore hip function.
PFNA-II is inserted by means of a minimally invasive procedure, allows minimal soft tissue dissection, thereby reducing surgical trauma and blood loss significantly. Therefore PFNA-II is recommended as a better choice compared with DHS in the management of unstable intertrochanteric fractures in terms of functional outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cooper A A Treatise on Dislocations and on Fractures of the Joints. London; 1822.
Bick EM Fractures of the Neck of the Thigh Bone. Classics of Orthopaedics. Philadelphia, Pa: Lippincott Williams; & Wilkins; 1976. p. 434-6.
Zuckerman JD Hip fracture. N Engl J Med 1996;334:1519-25.
Evans PJ, McGrory BJ Fractures of the proximal femur. Hosp Physician 2002;38:30-8.
Singh J, Selhi HS, Gupta R, Kaur G Functional outcomes of reverse distal femoral locking plate in the extra capsular fractures of proximal femur. Int J Res Orthop 2019;5:417.
Gullberg B, Johnell O, Kanis JA World-wide projections for hip fracture. Osteoporos Int 1997;7:407-13.
Hagino H, Furukawa K, Fujiwara S, Okano T, Katagiri H, Yamamoto K, et al
. Recent trends in the incidence and lifetime risk of hip fracture in Tottori, Japan. Osteoporos Int 2009;20:543-8.
Kyle RF, Cabanela ME, Russell TA, Swiontkowski MF, Winquist RA, Zuckerman JD, et al
. Fractures of the proximal part of the femur. Instr Course Lect 1995;44:227-53.
Chandy G, Saju S A comparative study on the functional outcome of intertrochanteric fractures treated by proximal femoral nailing or dynamic hip screw fixation. Int J Res Orthop 2021;7:51-5.
Raviraj A, Anand A, Chakravarthy M, Pai S Proximal femoral nail antirotation (PFNA) for treatment of osteoporotic proximal femoral fractures. Eur J Orthop Surg Traumatol 2012;22:301-5.
Jonnes C, Shishir SM, Najimudeen S Type II intertrochanteric fractures: Proximal femoral nailing (PFNA-II) versus dynamic hip screw (DHS). Arch Bone Jt Surg 2016;4:23-8.
Ahmed HH, Bassiooni HA, Mohamady EM, Mostafa MA A comparison study of proximal femoral nail and dynamic hip screw devices in unstable trochanteric fractures. Benha Med J 2018;35:413.
Sinha U, Ishtiaque S A randomized comparative study on functional outcome of pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. IOSR J Dent Med Sci 2016;15:05-21.
Shivanna UM, Rudrappa GH A comparative study of functional outcome between dynamic hip screw and proximal femoral nail in surgical management of per-trochanteric fractures. J Evol Med Dent Sci 2015;4:7489-98.
Hussain N, Kamat SG A comparative study of proximal femoral nail versus dynamic hip screw fixation for unstable and complex intertrochanteric fractures of the femur. J Cont Med A Dent 2017;5:46-50.
Boraiah V, Kumar SAS Intertrochanteric fracture PFNA-II vs DHS. Nat J Clin Orthop 2022;6:05-07.
Kalaiah K, Koshy JA Early functional outcome of proximal femoral nail vs dynamic hip screw in the management of intertrochanteric fractures. Int J Orthop Sci 2018;4:571-83.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]