The Functional Outcome of Proximal Femoral Nail Antirotation-2 (PFNA-2) in Peritrochanteric Fractures of the Femur

Introduction Peritrochanteric fractures are defined as extra-articular fractures involving the trochanter and frequent extension into the subtrochanteric region. These fractures exhibit a bimodal distribution in terms of age. These fractures commonly happen in young individuals who experience high-energy trauma, often in combination with other injuries. In contrast, elderly individuals with osteopenia are more prone to fractures caused by low-energy trauma. Methods This study is a prospective investigation that was carried out over 30 months. The study focused on peritrochanteric fractures that were treated using proximal femoral nail antirotation-2 (PFNA-2) as a fixation device. A range of criteria were examined and documented, encompassing the mean duration of surgical procedures, blood loss, the duration of hospitalization, mobility, and any potential post-operative problems. Subsequent assessments were conducted at fixed intervals of two weeks, six weeks, three months, six months, and two years. The functional outcome analysis for all patients involved the utilization of the modified Harris hip score (HHS). Results The study involved 60 cases of peritrochanteric fractures. The average age was 56 years. The most common mode of trauma was trivial fall/slip (46.66%), followed by road traffic accidents (RTA) (31.66%) and falls from height (21.66%). The average operating time was 53.03±5.66 minutes. The average modified Harris hip score was 84.78 with 26.66% excellent, 70% good, and 3.33% fair results. Complications included superficial wound infection (5%), knee stiffness (11.66%), hip pain (8.33%), and shortening (1.66%). Conclusion PFNA-2 is a safe and easy implant option for treating peritrochanteric fractures as it preserves periosteal covering, minimizes blood loss, has a short operative time, and helps in early mobilization. PFNA-2 provides excellent outcomes in patients with peritrochanteric fractures with minimum complication rates compared to all other open methods and is highly recommendable.


Introduction
Peritrochanteric fractures are characterized as fractures that occur outside the joint and primarily affect the trochanter, often extending into the subtrochanteric region.Therefore, these fractures can be classified into two distinct categories: intertrochanteric fractures and subtrochanteric fractures.The fractures have a bimodal distribution in terms of age.These fractures occur in young individuals as a result of severe and forceful trauma.In individuals of advanced age suffering from osteoporosis, these fractures frequently occur as a result of a fall from a standing position with minimal force applied [1].Fractures in younger individuals often result from high-energy trauma, such as car accidents or falls from height [2].Fragility fractures in the trochanteric region in the elderly are often caused by low-energy traumas such as falls [3].In the preceding half-century, a diverse range of implants and fastening techniques have been employed for the purpose of surgical stabilization.Implementing enhanced sterilization methods and utilizing modular theatres with laminar flow have significantly decreased infection rates.Advancements in biology, reduction techniques, and biomechanically enhanced implants have significantly improved the treatment of peritrochanteric fractures.There exist multiple internal fixing alternatives for the management of these fractures, which can be broadly classified into two categories: intramedullary fixation and plating.The aim of this study was to assess the functional outcome of proximal femoral nail antirotation-2 (PFNA-2) (intramedullary implant) in peritrochanteric fracture fixation.

Materials And Methods
This study is a prospective investigation carried out between November 2019 and March 2022.All participants in the study provided written informed consent prior to their involvement.The study focused on peritrochanteric fractures that were treated using proximal femoral nail antirotation-2 (PFNA-2) as a fixation device.A range of criteria were examined and documented, encompassing the mean duration of surgical procedures, blood loss, the duration of hospitalization, and any potential post-operative problems.The study was approved by the Government Medical College, Jammu, Institutional Ethics Committee (approval number: IEC/GMC/2022/798).

Inclusion criteria
The study included individuals who were more than 18 years old, individuals who had radiological findings confirming peritrochanteric fracture, and patients who were medically fit and willing for surgery.

Exclusion criteria
The study excluded individuals who had compound fractures and patients who had pathological fractures.

Operative technique
The surgical procedure was performed using spinal or general anesthesia.Prior to surgery, the patient received a single intravenous dosage of broad-spectrum cephalosporin.In all instances, a fracture table and image intensifier were employed.A reduction was performed on the fracture using the C-arm.Under all aseptic precautions, the part was prepared and draped.Fracture reduction was checked under C-arm, and satisfactory reduction was achieved via closed or mini open method.In some cases, K-wires were used to hold the reduction in place.A skin incision was given, and entry was made with awl under the guidance of the C-arm; guide wire was inserted, followed by serial reaming of the medullary canal; the PFNA-2 was inserted.The guide wire was passed into the femoral neck in a manner that positioned the blade in the lower portion of the neck in the anteroposterior view and centrally in the lateral view.A hammer was used to introduce the helical blade, which was attached to a specific inserter over the guide wire.The distal locking of the PFNA-2 was achieved using either dynamic or static means.

Post-operative protocol
The patients' limb was raised on a pillow, and they were closely monitored in the recovery room until they were stable, after which they were sent to the ward.Intravenous antibiotics were administered for the initial 48 hours, followed by a transition to oral administration for a duration of three days.A post-operative elastic capillary bandage was employed to prevent deep vein thrombosis (DVT) in elderly individuals (above 60 years).The initiation of static quadriceps exercises was done on the first day following the surgical procedure.On the following day of the surgical procedure, active quadriceps and hip flexion exercises were initiated.The post-operative dressing was done on the second and fifth days.The sutures were removed on the 14th day after the surgery.Partial weight-bearing walking was initiated between three days and six weeks after surgery, depending on the specific fracture pattern.Following the evaluation of the radiological and clinical union, complete weight-bearing walking was permitted.All patients started full weight-bearing by eight weeks post-operatively.The participants were called for periodic follow-up appointments at intervals of two weeks, six weeks, three months, six months, and two years.The functional outcome analysis for all patients was done using the modified Harris hip score (HHS).

Results
The research encompassed a total of 67 verified cases of peritrochanteric fractures, regardless of gender.Among the total of 67 patients, six cases were lost to follow-up, while one case expired owing to causes that were not related to the surgical procedure.The subsequent study pertains to the data of the remaining 60 patients, encompassing both intraoperative data and post-operative outcomes.Various parameters studied are detailed in Table 1.The age range of the participants spanned from 20 to 102 years.The mean age of the participants was 56.56±19.34years.The majority of the patients, comprising 11 individuals (18.33%), were within the age range of 60-69 years.In our study, 37 patients (61.66%) had left-sided fractures, and 23 patients (38.33%) had right-sided fractures.Our study had 41 male (68.88%) and 19 female (31.66%) patients.Males (68.88%) had a relatively higher percentage of fractures as compared to females (31.66%), with a male-to-female ratio of 2.15:1.The primary causes of injury were minor falls or slips below a height of 6 ft, falls from heights greater than 6 ft, and road traffic accidents (RTA).The majority of the patients who experienced a minor fall were of advanced age and had osteoporosis.Eleven patients (18.66%) had diabetes, while nine (15%) had hypertension.One (1.66%) was hepatitis C virus (HCV)-positive, one (1.66%) was hepatitis B surface antigen (HBsAg)-positive, and one (1.66%) was suffering from hypothyroidism.Fracture patterns were divided into various types according to Boyd and Griffin's classification of intertrochanteric fractures and according to Seinsheimer's classification of subtrochanteric fractures.The most common intertrochanteric fracture was Boyd and Griffin's type 2 (24 patients, 40%), while the most common subtrochanteric fracture was Seinsheimer's type IIB (seven patients, 11.66%).In 52 patients (86.66%), closed reduction was achieved, while in the remaining eight patients (13.33%), fracture was opened to achieve the reduction, followed by fixation with PFNA-2.The intraoperative blood loss was quantified by the number of mops employed during the surgical procedure.Approximately 50 mL of blood loss is equivalent to one mop.The mean blood loss was 1.85 mop, resulting in a quantity of 92.66±15.27mL.Out of the total number of patients, six (10%) needed to undergo an intraoperative blood transfusion due to their low preoperative hemoglobin levels.Two patients (3.32%) had associated shaft of femur fractures on the same side, one patient (1.66%) had medial femoral condyle fracture of the opposite side, one (1.66%) had L4 fracture without neurodeficit, and one (1.66%) had L1 and D12 fractures without neurodeficit.Both spinal fractures were managed conservatively, and weight-bearing in both of these cases was delayed.Figure 1 and Figure 2 show preoperative X-rays, and Figure 3 and Figure 4 show post-operative X-rays, along with clinical pictures of one patient who was included in the present study (Figures 5-7).

Conclusions
Based on our analysis, it can be inferred that PFNA-2, when well-executed, is a secure and straightforward alternative implant for treating peritrochanteric fractures, because it preserves periosteal covering and provides short operative time and early mobilization.PFNA-2 provides very good outcomes in most patients with peritrochanteric fractures with minimum complication rates as compared to all other open methods and is highly recommendable.

FIGURE 5 :FIGURE 6 :
FIGURE 5: Clinical picture showing the patient sitting in a cross-legged position

FIGURE 7 :
FIGURE 7: Clinical picture showing the patient in a squatting position

Table 2 .
The range of motion is determined by using the modified Harris hip scoring system; 43 patients (71.66%) had a score of 5 indicating a good range of motion, while 17 patients (28.33%) had a score of 4. The modified Harris hip score had an average value of 84.78±4.31.The results were as follows: 26.66% (16 patients) were excellent, 70% (42 patients) were good, and 3.33% (two patients) were fair.