Functional outcome of proximal femoral nail antirotation with helical blade fixation in extra capsular hip fractures in Himalayan region

Abstract

Background: Extra capsular Intertrochanteric hip fractures occur in older age person. These are pathological fracture mostly (osteoporosis). Currently, these hip fractures are generally fixed with intramedullary or extramedullary implants. Implants preference mainly determined by the fracture classification (stable or unstable). Most common complications in standard proximal femoral nail and extramedullary implants is neck screw cutout. Due to Research and improvement in surgical technique incidence of neck screw cutout has reduced considerably but still remains the most common fixation failure with intramedullary implants. With this question in mind we did study to find out functional outcome of proximal femoral nail antirotation with helical blade fixation in extra capsular hip fractures in Himalayan region. Methodology: This prospective study was done on 75 patients with extra capsular hip fractures, for fixation of fracture, implant of choice were used proximal femoral nail antirotation with helical blade. Study were done during the period from September 2015 to August 2016. Informed written consent were taken from all patients. The study was approved by institutional ethical committee. We included > 45 year cases. Fracture was classified according to Boyd and griffin classification. Exclusion criteria were age<45 years, open intertrochanteric hip fractures, pathological fracture other than osteoporosis and polytrauma patients. After discharged from hospital patients were called in OPD for clinical and radiological evaluation at regular intervals (6wks. 12wks, 24 wks, 36 wks. and 48 wks). Results: 75 cases of hip intertrochanteric fractures were included and operated with proximal femoral nail antirotation with helical plate. Mean age of patients was 65.67±10.60 yrs. (45-94 yrs.). Based on preoperative x-rays fracture pattern 8 cases in type1, 18 cases in type 2 and 3 in each group, 31 cases in type 4 were recorded. Assessment of osteoporosis were done according to Singh index. Type 1 (n=8), type 2 (n=18), type 3(n=18), type 4 (n=31) were had mean Singh's index 5.13, 4.59, 4.76, 4.70 respectively. Maximum number of patients (97.2%) showed sign of union between 18 to 24 weeks. The mean TAD was 24.69 mm±3.16 mm (Range 20-32mm). Union was achieved in all patients (n=66) at 48 weeks Harris Hip score was 38.47±13.14, 61.70+19.10, 83.44+12.24, 94.06+4.71, 98.18+4.27 and 98.68+1.84 respectively. At all the follow up intervals, Harris Hip score was improved (p<0.001). In our study overall outcome of patients (n=70) at 48 weeks who could complete the follow-up were good in 41 (58.5%), average in 25 (35.7%) and poor in 4 (5.7%) cases. Conclusion: Proximal femoral nail antirotation with helical blade gives better fixation even in osteoporotic intertrochanteric unstable femoral fractures. But preoperative assessment and planning, reduction and surgical technique should be followed. Intramedullary fixation has biological and biomechanical advantages over extra medullary fixation, helical blade has better bone hol...