Proximal femoral nail anti-rotation-2 in intertrochanteric fractures: Experience from the Kingdom of Saudi Arabia

Abdulmalik Baker Albaker

doi:10.4103/aihb.aihb_44_21

CASE REPORT

Year : 2021 | Volume : 11 | Issue : 4 | Page : 116-119

Proximal femoral nail anti-rotation-2 in intertrochanteric fractures: Experience from the Kingdom of Saudi Arabia

Abdulmalik Baker Albaker
Department of Orthopaedic Surgery, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia

Date of Submission	25-Mar-2021
Date of Decision	11-Jun-2021
Date of Acceptance	27-Aug-2021
Date of Web Publication	16-Oct-2021

Correspondence Address:
Abdulmalik Baker Albaker
Department of Orthopaedic Surgery, College of Medicine, Majmaah University, Al-Majmaah 11952
Saudi Arabia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/aihb.aihb_44_21

Abstract

Proximal femoral nail anti-rotation (PFNA)-2 is an intramedullary implant designed specifically for the Asian population for managing intertrochanteric (IT) fractures among the elderly. We presented this cases series with an objective to use and document the effectiveness of PFNA-2 for the management of unstable IT fracture among patients aged 60 years and above in the Kingdom of Saudi Arabia. Four females were treated above 65 years with severe pain in the hip region after a trivial fall on the ground over a period of 2 years (2018–2020), diagnosed with T3 and T4 unstable IT fracture. All the patients were hypertensive, with two having diabetes. It was decided to manage the fracture site by PFNA-II implant following baseline clinical and biochemical investigations. The duration of surgery took around 70–75 min with a blood loss of 100–150 ml, and there was no intraoperative complication. Early mobilisation and toe touch walking was achieved within 2 days postoperatively. Harris hip score was 'good' for all patients within 3 months, which became 'excellent' after 6 months for all except one. Union was achieved in all the cases with a full weight-bearing period ranging from 9 to 11 weeks. The usage of PFNA-2 for IT fractures among elderly having co-morbidities such diabetes and hypertension is perfectly promising good results for such reason we strongly recommend it. However, future prospective clinical trials using sufficient sample size, comparing PFNA-2 with PFN and dynamic hip screws are needed for better decision-making.

Keywords: Elderly, intertrochanteric fracture, proximal femoral nail anti-rotation-2, Saudi Arabia

How to cite this article:
Albaker AB. Proximal femoral nail anti-rotation-2 in intertrochanteric fractures: Experience from the Kingdom of Saudi Arabia. Adv Hum Biol 2021;11:116-9

How to cite this URL:
Albaker AB. Proximal femoral nail anti-rotation-2 in intertrochanteric fractures: Experience from the Kingdom of Saudi Arabia. Adv Hum Biol [serial online] 2021 [cited 2021 Dec 4];11:116-9. Available from: https://www.aihbonline.com/text.asp?2021/11/4/116/328398

Introduction

Injuries might be intentional or unintentional, and they are within the top ten leading causes of morbidity and mortality throughout the world. Especially among the elderly, unspecified falls, commonly referred to as trivial falls, have been recognised as the second major cause of morbidity and dysfunction.^[1] The rising incidence of hip fractures on one side, and life expectancy on the other side, have pushed orthopaedicians to develop effective fixation modalities to prevent the geriatric population from entering into the vicious cycle of immobility, bedsores, septicaemia and eventually death.^[2] Dynamic hip screws (DHS) have proven to be an effective and reliable fixation method for stable intertrochanteric (IT) fractures. For unstable IT fractures, intramedullary devices such as proximal femoral nails (PFNs) and gamma nails have become the treatment of choice. The latest implant in this category is proximal femoral nail anti-rotation (PFNA-II), which was designed specifically for the Asian population treating unstable proximal femur fractures.^[3] Although most of the studies have been documented from Asian countries as India,^[4],[5],[6] we could not find any study or even a case report documenting the clinical experience of using PFNA-II among the Saudi geriatric population.

PFNA-II consists of a femoral nail, helical blade, a locking bolt and an end cap. Due to its design, it offers advantages such as lesser operating time, fast healing and weight-bearing. However, it is associated with a few complications such as fracture of the femur at its distal tip and cut out of the helical blade.^[7] Looking at the advantages offered by PFNA-II over other available treatment options, we decided to use and document its effectiveness for the management of unstable IT fracture among patients aged 60 years and above.

Case Report

Patient information and clinical findings

Four elderly females aged above 65 years presented to the department of orthopaedics, multicentre on Riyadh region, KSA, with severe pain in the hip region after a trivial fall on the ground over a period of 2 years (2018–2020). The past medical history for the four patients consists of hypertension, with two having diabetes and coronary artery disease. After first aid treatment, plain radiography revealed unstable IT fracture Type T3 and T4 [Figure 1] (as per Jensen's modification of Evan's classification),^[8] on the left side among three patients, and on the right side of one female. It was decided to manage the fracture site by PFNA-II implant following baseline clinical and biochemical investigations.

Figure 1: Pre-operative X-ray of right side intertrochanteric fracture

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Surgical management

All surgeries were performed under spinal-epidural anaesthesia, written informed consent was take from the patient. Patients were given intravenous antibiotics, 1 h prior to surgery. The tip of the greater trochanter was chosen as the entry point for insertion of PFNA-II nail (11 cm × 230 cm) by using a guidewire. After insertion of a reamed nail, fluoroscopy was done to evaluate the fracture situation by placing guidewire in the central or slightly posteroinferior to the centre for anteroposterior lateral and lateral images. The nail was positioned to allow the proper insertion of a helical blade manually, then followed by gentle blows with a hammer. Closed reduction was made in all the cases.

The duration of surgery took 70–75 min with a blood loss ranging from 100 to 150 ml, with no intraoperative complication. Early mobilisation was done the very next day of surgery, and toe touch walking was achieved after 2 days postoperatively. Static quadriceps, ankle pump exercises with hip and knee flexion and extension exercises were started on the 2^nd and 3^rd post-operative days. Sutures were removed after 10–14 days. However, one of the patients was 85 years had developed a superficial infection on the fracture site on the 4^th day after surgery. Therefore, her hospitalisation stays increased from 8 days to 13 days as compared to her counterparts. Rest the post-operative history and recovery of the patients were satisfactory.

Follow-up and outcomes

The follow-up was done after 6 weeks and on, 12 weeks, 6 months, 9 months and thereafter every 6 months for the evaluation of implant radiographically [Figure 2]. The timing of full weight-bearing ranged from 9 to 11 weeks. The functional outcome was assessed by using the Hip Harris score at three and 6 months.^[9] It ranged from 81 to 88 for all patients indicating good functional outcome at 3 months and increased to excellent level for three patients except one who has developed superficial infection postoperatively. All the patients have successfully achieved union at the end of treatment and were doing well with more than 1 year of follow-up in our hospital.

Figure 2: Post-operative X-ray of right side immediately after surgery, at 3 months and at 6 months

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Discussion

IT fractures of the femur account for serious morbidity owing to immobilisation leading to bedsores and other medical conditions. The remaining remains on achieving early mobilization and stress-free recovery. However, the optimal line of treatment for this fracture still remains unclear in lieu of conflicting evidence present in the literature. After reviewing the literature, we found that none of the case reports or case series has been reported from Middle East countries such as Saudi Arabia. Therefore, we attempted to present this case series for worth literature addition for the Saudi population.

Over time, intramedullary implants have evolved to counter the limitations of the existing ones. Initially, the gamma nail was introduced as an intramedullary implant for comminuted unstable IT fractures.^[10] However, it did not provide promising results due to its rotational instability, thus leading to a high risk of perforations. After this, PFN was introduced with an additional anti-rotational screw. However, lateral migration of the lag screw leading to varus collapse was reported as 'z effect' resulting in perforation of the femoral head.^[11],[12] Lateron, PFNA followed by PFNA-2 for the Asian population was introduced. ^[4],[5],[6] Studies have found PFNA-2 more effective as compared to PFNA in the management of IT fractures by reducing blood loss, early toe touch walking and better Harris Hip scores.

However, among the elderly, a few researchers have reported medial perforation as the most common complication of PFNA-2. This medial perforation is attributed to either trauma to the femoral head or due to failure of the lateralisation of the blade or imperfect blade locking.^{[3],[13],[14],[15]} Similarly, Nayak et al. recently reported medial perforation of the femoral head without loss of reduction due to loosening of the helical blade; the reason for this implant failure was not understood.^[16] Although most of the time, the failure of the implant is due to the inappropriate technique of insertion, as explained by researchers. Although we could not find any such observation among our cases whom we have been following for at least 1 year.

From our clinical experience, we observed a shorter duration of surgery, with lesser blood loss and better functional and radiographic outcomes by using PFNA-2. The early weight-bearing and toe touch walking that could be achieved within 2 days of surgery is highly motivating for a clinician and patient. The short term outcomes of our case series are similar to the ones reported by Kasha et al., Swaroop et al. and Gadhe et al.^[4],[5],[6] Interestingly, all these studies were reported from the Indian sub-continent. However, we found none of the studies from Middle East countries.

When we looked up other implants used to treat peritrochanteric fractures in the literature, we saw that the rate of screw cut-out, varus collapse, loss of reduction and implant breakage were higher than what we saw with PFNAII.^{[17],[18],[19]} Systemic complications were not encountered in our study lower although all of them were hypertensive and two were diabetics as well. This could be attributable to the patients' early mobilisation. More and more current literature is emerging that advocates for early ambulation, particularly in the elderly, to avoid systemic issues caused by recumbency.^[20],[21] This finding makes our case series even more unique because we could not find even a single case report which attempted to correlate the results with the past medical history of the patient. At the same time, it is evident that conditions such as hypertension and diabetes interfere with the normal healing process, which gets delayed or even lead to septicaemia at times. In this regard, the findings of this case series are very encouraging for recommending the usage of PFNA-2 among diabetic patients.

Long-term indicators further revealed the success of these implants, reflected by 100% union rates. The Harris hip score, indicative of functional assessment, indicated that at 3 months, the score was good for all patients, which turned to excellent after 3 months among three patients. Our findings are similar to the case series reported by Kasha et al.^[5]

Conclusion

To conclude, we strongly recommend the usage of PFNA-2 for IT fractures among the elderly. Ours is a case series with small sample size, so we suggest carrying out randomised controlled trials comparing the effectiveness of PFNA-2 with its counterparts like PFN and DHS for strong epidemiological and clinical evidence. Our study definitely builds evidence for orthopaedic surgeons to use these implants both from the surgeon's and patient's viewpoint.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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.

Acknowledgement

The author would like to thank Deanship of research at Majmaah University for generous support by funding this research with project No.R-2021-87. We would like to thank Dr Ohoud Abdulrehman Aloabid for helping me in data collection and the participants of the study for giving consent to participate in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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