Intramedullary Fixation of Intertrochanteric Fractures with the Proximal Femoral Nail (PFN)

Abstract

Objective: Minimally invasive internal fixation of interand subtrochanteric fractures allowing early weight bearing. Restoration of shape and early return to function of the lower limb. Indications: All inter-and subtrochanteric fractures of AO type 31.A. Femoral neck and intertrochanteric fractures; associated with proximal femoral fractures; in these instances, a longer nail is used. Contraindications: Marked ipsilateral coxofemoral osteoarthritis. Open physes. Surgical Technique: Reduction of fracture on fracture table. Stab incision. Unreamed intramedullary nailing. Insertion of femoral neck and antirotation screws over guide wires for dynamic fixation of femoral neck/head fragment ensuring stability in rotation. Possibility of dynamic or static locking at diaphyseal level. Results: Between January 1, 1996 and March 31, 1999, the described system was used in 231 patients (74.2% women, 25.8 men, average age 78.1 years). 2.1% intraoperative complications: three inadequate reductions, one antirotation screw implanted too deeply, one wrong placement of distal femoral drill hole. 9.5% postoperative complications related to surgery: three avulsions of implant, one femoral fracture, 14 hematomas or seromas, four deep infections. Followup after 12 months in 76.3% of patients: 63.4% personal postoperative assessment, 12.9% information supplied by family physician. Mortality: 17.5%. Impossible to reach: 6.2% of patients. Late complications in 6.2% of followed-up patients: nine migrating antirotation screws, two late infections. Bony consolidation in all patients, no nonunion. Merle d'Aubigné score: 34.2% excellent, 49.3% good, 13.7% satisfactory, 2.7% poor.

Proximal Femoral Fractures

“…Thus an initially solid reduction is mandatory for the successful outcome in all trochanteric fractures [21]. The use of one k-wire for stabilization in preference to a more voluminous screw is recommended to prevent dislocation with rotation during drilling activities inside the femoral neck as well as correction of rotational alignment prior to distal locking in screw-nail systems [40]. In particular, the latter are prone for iatrogenic retroversion and recurvation of the femural shaft [8].…”

“…In particular, the latter are prone for iatrogenic retroversion and recurvation of the femural shaft [8]. Here control of rotation is best assessed by alignment of the superior iliac spine and patella or by a flattened shape of the femoral head, the size of the minor trochanter in a.-p. roentgenograms as well as a posteriorly rotated spike at Adam's arch in the axial view [40]. If anatomic reduction is not possible in a closed manner, open reduction of the fragments, particularly at the site of Adam's arch, is recommended and performed in up to 12 %, although intramedullary devices were used [40,42,43].…”

“…Here control of rotation is best assessed by alignment of the superior iliac spine and patella or by a flattened shape of the femoral head, the size of the minor trochanter in a.-p. roentgenograms as well as a posteriorly rotated spike at Adam's arch in the axial view [40]. If anatomic reduction is not possible in a closed manner, open reduction of the fragments, particularly at the site of Adam's arch, is recommended and performed in up to 12 %, although intramedullary devices were used [40,42,43]. Particularly for the reduction of pertrochanteric fractures with subtrochanteric extension, cerclage wires aid in the accomplishment of reduction and its retention [40,43].…”

“…3 and 13) and wrong indication ( Fig. 8) [10,13,19,24,27,40] but seldom due to the wrong implant per se. Internal fixation of these fractures has advanced greatly in recent decades and the various concepts of fixation all provide good results [32] if applied correctly.…”

“…With a mean age about 80 years but still self-caring, women fear these fractures because often this event signifies the end of their independence, the way into nursing and old people's homes, and not rarely these patients die within a few months [30, 39 -41]. The early postoperative death rate is about 5-9 % [10,40] and during the initial 12-month-period 13-18 % die [5,23,40]. Therefore our aim is stabile fixation of these fractures enabling early and functional therapy with full weight-bearing and rehabilitation to regain independency.…”