Title: Subtrochanteric Fracture of the Femur in the Elderly Osteoporotic Bone: Long Proximal Femoral Nail is the best Treatment Option: In Rural Population - Case Series

Authors: Neelakrishnan  R, Barathiselvan  V, Anush Rao P, Akilan C

 DOI: https://dx.doi.org/10.18535/jmscr/v6i10.174

Abstract

Sub-trochanteric fractures involve the upper part of femur between the lesser trochanter and the isthmic region. Fractures in this area are complex and treatment is bothersome to both the patient and the orthopaedic surgeon.  These fractures are common among elderly adults with coexisting low bone mineral density due to osteoporosis. Plates, dynamic hip screw, dynamic condylar screw, proximal femoral locking compression plate, intramedullary nail, cephalo medullary nail, proximal short and long femoral nail (PLFN) are the transformational procedures available in which the PLFN is being preferred due to stable fixation.1 10 patients were enrolled in the study.2 The patients were assessed using modified Harris hip scoring postoperatively at one, three, six month and one year from the date of surgery. Descriptive statistics was done in the MS office excel 2010. The encountered complications are non union (n=1), postoperative delirium (n=0) and a case of varus deformity (n=1). The biomechanical properties and minimally invasive fixation technique inspite of good of reduction the LPFN takes lower mean duration of surgery, lower rate of reoperation has the least complications among the other fixation techniques.

Background: Long proximal femoral nail has been the standard treatment for subtrochanteric fractures. However there are many fixation implants in the field of traumatology.1 Especially in elderly osteoporotic bone fractures long proximal femoral nail achieved good functional outcome with least complications compared to other implants which leaded to high failure rates.

Methods: A Series of eleven cases of osteoporotic subtrochanteric fractures are operated with long proximal femoral nail. One patient lost follow up. The patients are followed (at one, three, six month and one year) at regular intervals. Results were assessed using modified harris hip scoring system. 

Results: Total ten patients were taken for study were followed by minimum six months and maximum of one year. Clinical outcome was rated as per modified harris hip score.  Excellent – 60 %, Good – 20 %, Fair – 10%, Poor – 10%. 

Conclusion: The surgical management of subtrochanteric fracture with long proximal femoral nail provides stable fixation with moderate pain free early mobilization and good outcome in osteoporotic patients with limited complications.

Keywords: Long proximal femoral nail, osteoporosis, subtrochanteric fracture, modified harris hip scoring system.

References

  1. Boyd HB, Griffin (1949) Classification and treatment of trochanteric fractures. Arch surgery 58(6): 853-866.
  2. Fielding JW, Magliato HJ (1966) Subtrochanteric fractures. Surg Gynec Obstetric 122(3): 555-560.
  3. Simmermacher RKJ, Bosch AM, Van der Werken C (1999) The AO/ ASIF- Proximal femoral nail: a new device for the treatment of unstable proximal femoral fractures. Injury 30(5): 327-332.
  4. Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, et al. (2003) The proximal femoral nail (PFN)-a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand 74(1): 53-58.
  5. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hir-vensalo E (2005) Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A ran-domised study comparing post-operative rehabilitation. J Bone Joint Surg Br 87(1): 76-81.
  6. Lei-Sheng Jiang, Lei Shen, Li-Yang Dai (2007) Intra medullary Fixation of subtrochanteric fractures with Long proximal femoral nail or Long Gamma Nail; Technical Notes and Preliminary Results. Ann Acad Med Singapore 36(10): 821-826.
  7. Brian Aros B, Tosteson AN, Gottlieb DJ, Koval KJ (2008) Is a sliding hip screw or im nail the preferred implant for intertrochanteric fracture fixation. Clin orthrop Relat Res 466(11): 2827-2832.
  8. Calderon A, Ramos T, Vilchez F, Mendoza-Lemus O, Pena V, et al. (2013) Proximal femoral intramedullary nail versus DHS plate for the treatment of intertrochanteric fractures. A prospective analysis. Acta Ortop Mex 27(4): 236-239.
  9. Ekstrom W, Karlsson Thur C, Larsson S, Ragnarsson B, Alberts KA (2007) Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the Medoff sliding plate. J Orthop Trauma 21(1): 18-25.
  10. Fogagnolo F, Kfuri M, Paccola CA (2004) Intramedullary fixation of per trochanteric hip fractures with short AO ASIF PFN. J Arch Orthop Trauma Surg 124(1): 31-37.
  11. Simmermacher RKJ, Bosch AM, Van der Werken C (1999) The AO/ ASIF- Proximal femoral nail: a new device for the treatment of unstable proximal femoral fractures. Injury 30(5): 327-332.
  12. De Lee JC, Clanton TO, Rockwood CA Jr (1981) Closed treatment of subtrochanteric fractures of the femur in a modified cast-brace. J Bone Joint Surg Am 63(5): 773-779.
  13. Domingo LJ, Cecilia D, Herrera A, Resines C (2001) Trochanteric fractures treated with a proximal femoral nail. International Orthopaedics 25(5): 298-301.

Corresponding Author

Dr R. Neelakrishnan

Professor and Head, Department  of  orthopaedics, Rajah Muthaiah Medical college Hospitals,

Annamalai University, Chidambaram, Tamil Nadu, India

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.