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Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_2 | Pages 113 - 113
10 Feb 2023
Burrows K Lock A Smith Z McChesney S
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Failure of cephalomedullary fixation for proximal femur fractures is an uncommon event associated with significant morbidity to the patient and cost to the healthcare system. This institution changed nailing system from the PFNA (DePuy Synthes) to InterTan (Smith and Nephew) in February 2020. To assess for non-inferiority, a retrospective review was performed on 247 patients treated for unstable proximal femur fractures (AO 31 A2; A3). Patients were identified through manual review of fluoroscopic images. Stable fracture patterns were excluded (AO 31 A1). Pre/post operative imaging, demographic data, operative time and ASA scores assessed. Internal/external imaging and national joint registry data were reviewed for follow up. No significant difference was found in overall failure rate of PFNA vs InterTan (4.84% vs 3.23%; p = 0.748). Overall, short nails were more likely to fail by cut-out than long nails (7.5% vs 1.2%; p = 0.015). Nails which failed by varus cut-out had a higher tip/apex distance (TAD) (26.2mm vs 17.0mm; p < 0.001). Of concern, varus cut-out occurred in two InterTan nails with TAD of <25mm. The PFNA enjoyed a shorter operative time for both the short (59.1 vs 71.8 mins; p = 0.022) and long nails (98.8 vs 114.3 mins; p = 0.016) with no difference in 120-day survival rate. Overall failure rates of the PFNA and InterTan nailing systems were comparable. However, the failure rate of short nails in this study is concerning. Using long nails with a lag screw design for unstable intertrochanteric femoral fractures may reduce failure rates. Cumulative frequency analysis suggests stringent tip-apex distances of less than 21mm may reduce failure rates in lag-screw design cephulomedullary nails. This dataset suggests that unstable intertrochanteric fractures may be more reliably managed with a long cephalomedullary device


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_10 | Pages 12 - 12
1 Oct 2015
Kumar KHS Barbur S Twohig E Sandhu H
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Proximal Femoral Nail Antirotation (PFNA) I one of the implants commonly used to stabilise subtrochanteric fractures or communited inter/pertrochanteric fractures. The aim of this project was to assess the outcome of PFNA in a busy District General Hospital. Between November 2009 to November 2012, 76 patients underwent PFNA. These patients were identified from the local hip fracture database, which is prospectively collected. The mean age of the patients was 80.11 years (range of 26.83 to 98.53). 27 were male and 49 female. Right hip was involved in 36 cases and left hip in 40. 9 patients required revision surgery due to failure of the primary surgery. 2 patients died due to other causes. 5 out of the 9 patients who underwent revision surgery had their primary surgery performed by a trainee under consultant supervision and a consultant surgeon performed the other 4 cases. In our series failure rate was 11.8%. We conclude that although PFNA is an excellent device to fix subtrochanteric or communited intertrochanteric fractures of the proximal femur one needs to be cautious and follow the correct operative technique to avoid failures


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_II | Pages 136 - 136
1 May 2011
Mora A Marimon I Rius M Brill W Corral A Gaya S Corbi F
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Background: we compare the biomechanical behaviour of the proximal femoral nail (PFN) femoral neck screw with the proximal femoral nail (PFNa) helical blade, after operative treatment of trochanteric osteoporotic femoral fractures. Methods: 208 consecutive patients who had an acute trochanteric femoral fracture (AO/ASIF A1, A2 and A3) were evaluated in a prospective randomized trial. The patients were randomized to treatment with the PFN screw (n=105) or the PFNa blade (n=103), with follow up until fracture healing. We describe the intra and postoperative complications. Implant positioning in the femoral head was also analyzed. results were assessed on plain radiographic imaging (AP and axial view) and its biomechanical implication. Results: our review shows that PFN has a higher rate of biomechanical failure (4,8%) compared with PFNa (1.9%). Treatment success (avoiding cutout and cutin) of both devices depends on bone stock, stability of the fracture, correct reduction and implant positioning in the center-center of the femoral head. Conclusions: PFNa’s blade demonstrates a lower incidence of cutout in the treatment of trochanteric femoral fractures. The blade improves fixation stability decreasing bone loss of the remaining bone stock, increases the contact area between implant and the femoral head and compacts the cancellous bone. We recommend PFNa for the treatment of trochanteric femoral fractures in the elderly


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 213 - 213
1 Sep 2012
Knobe M Sellei R Kobbe P Lichte P Pfeifer R Mooij S Aliyev R Muenker R Pape HC
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Introduction. Unstable intertrochanteric hip fractures (AO 31A2) continue to be a challenge, as non-locking implants have shown a considerable rate of loss of reduction. Intramedullary fixation has been recommended, although screw cut-out has been identified as problematic. This study was performed to ascertain whether treatments with the established proximal femoral nail (PFN) and the newer PFNA with blade design (proximal femoral nail antirotation) have advantages over the use of the Percutaneous Compression Plate (PCCP, developed by Gotfried). Methods. Cohort study. Between March 2003 and March 2008, 134 patients with unstable fractures were treated with a PCCP, (n=44, 78.3 yrs, ASA 2.8), a PFN (n=50, 77.2 yrs, ASA 2.8), or a PFNA (n=40, 75.8 yrs, ASA 2.6). The patients (31 PCCP, 33 PFN, 30 PFNA) were then reexamined clinically and radiologically after approximately 21 months. Results. The PCCP was found to require less implantation time than the PFN and the PFNA (60 vs. 80 vs. 84 min, p<0.001) and less radiation exposition time (PCCP 139 vs. PFN 283 vs. PFNA 188 seconds, p<0.001). The rate of reoperations due to wound infections and hematomas amounted to 2% for the PCCP, 4% for the PFN, and 5% for the PFNA (p=0.799). Due to mechanical complications, 9% of patients implanted with a PCCP, 13% of those implanted with a PFN, and 5% of those implanted with a PFNA had to be reoperated (p=0.353). The cut-out rate was 2% after implantation of the PCCP, 4% after the PFN, and 5% after implantation of the PFNA (p=0.799). In one case, the shaft was fractured intraoperatively (PFNA). The tip-apex distance for the lower femoral neck screw (PCCP 22mm vs. PFN 30mm vs. PFNA 30mm, p<0.001), stress-related varisation of the collodiaphyseal (CCD) angle (4° for all implants), impaction (PCCP 5mm vs. PFN 5mm vs. PFNA 6mm, p=0.662) and femoral shortening (PCCP 3mm vs. PFN 3mm vs. PFNA 4mm, p=0.876) were not determinants of the postoperative function. On the basis of their scores according to Merle d'Aubigné and Harris, there was no variation in the results of the follow-up examinations. Conclusions. The use of the PCCP for the treatment of unstable trochanteric fractures presents a minimally invasive method of implantation, as well as a promising therapy option with regards to operation time, radiologic examination time, and rate of complications. Processes of impaction due to stress are seldom observed. No benefits could be established in an intramedullary treatment with the PFN or the PFNA; thus, it appears that the higher cost of these implants is avoidable


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 475 - 475
1 Dec 2013
Park SE Yeo DH
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The first case was that of an 89-year-old woman with advanced dementia. After falling onto the left hip, she was admitted to the emergency room. Standard x-rays revealed an unstable intertrochanteric fracture. Closed reduction and internal fixation was performed using the long PFNA with a 105-mm helical blade, the second patient treated with this implant in our series. The operation was performed by an attending surgeon who was experienced with treatment of trochanteric fractures with intramedullary devices. Six weeks later the patient presented again with severe pain after she had fallen onto her left hip for a second time. Follow-up x-rays showed a perforation of the helical blade through the cortex of the femoral head after a shortening of the femoral neck by 2 cm. CCD angle was still 129 degrees, and there were no radiological signs of rotational displacement. The acetabular cartilage appeared intact. At her second operation, a replacement of the blade was performed using a shorter 95-mm implant. Postoperatively the patient was again mobilized under full weight bearing, and at 12 weeks follow-up, we found cut through again, we replaced hip with biopolar hemiarthroplasty


Bone & Joint Research
Vol. 2, Issue 5 | Pages 79 - 83
1 May 2013
Goffin JM Pankaj P Simpson AHRW Seil R Gerich TG

Objectives. Because of the contradictory body of evidence related to the potential benefits of helical blades in trochanteric fracture fixation, we studied the effect of bone compaction resulting from the insertion of a proximal femoral nail anti-rotation (PFNA). . Methods. We developed a subject-specific computational model of a trochanteric fracture (31-A2 in the AO classification) with lack of medial support and varied the bone density to account for variability in bone properties among hip fracture patients. Results. We show that for a bone density corresponding to 100% of the bone density of the cadaveric femur, there does not seem to be any advantage in using a PFNA with respect to the risk of blade cut-out. On the other hand, in a more osteoporotic femoral head characterised by a density corresponding to 75% of the initial bone density, local bone compaction around the helical blade provides additional bone purchase, thereby decreasing the risk of cut-out, as quantified by the volume of bone susceptible to yielding. Conclusions. Our findings indicate benefits of using a PFNA over an intramedullary nail with a conventional lag screw and suggest that any clinical trial reporting surgical outcomes regarding the use of helical blades should include a measure of the femoral head bone density as a covariable


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_18 | Pages 6 - 6
14 Nov 2024
Karjalainen L Lähdesmäki M Ylitalo A Eskelinen A Mattila VM Repo J
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Background. Cephalomedullary nails are widely used for fixation of unstable pertrochanteric fractures. In 2018, the Depuy Synthes Trochanteric Fixation Nail - Advanced (TFNA) implant was introduced at a level I academic trauma center. Thereafter, the TFNA swiftly replaced the older implant models used at the time. Subsequently, clinical concerns were raised about the use of the TFNA due to reports of nail breakage. The purpose of this study was to investigate whether the concerns raised about the performance of the TFNA were valid and to assess long-term outcomes. Methods. The data consisted of 2397 patients who had undergone a proximal femoral hip fracture procedure between 2014 and 2020. Data were handpicked from patient records. TFNA was compared with TFN, PFNA, Gamma3, and Intertan regarding nail breakage, breakage time and long-term outcomes. Results. After exclusion a total of 23/1667 (1.4%) nails broke during the follow-up period. The TFNA broke the most often with 15 cases (2.0%), followed by the Gamma3 with five cases (1.1 %) and the PFNA with three cases (1.3%). Overall, the mean (SD) nail breakage time was 233 (147.8) days. However, for the TFNA, PFNA, and Gamma3, the mean breakage times were 176.8 days (109.9), 419 days (108.6), and 291.8 (153.4), respectively. In cox regression analysis we observed significant reduction in nail breakage when using PFNA with adjusted hazard risk of 0.081 [95% Ci, 0.011-0.576, p=0.011]. Conclusions. In our data, the TFNA had a slightly higher risk for nail breakage when compared to the PFNA and the Gamma3, with a risk difference of 0.7% and 0.9%, respectively. On average, the TFNA broke nearly four months earlier than the Gamma3 and more than eight months earlier than the PFNA. It should be noted, however, that implant breakage is a relatively infrequent complication


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_13 | Pages 154 - 154
1 Nov 2021
Elbahi A Thomas O Dungey M Menon DK
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Introduction and Objective. When using radiation intraoperatively, a surgeon should aim to maintain the dose as low as reasonably achievable to obtain the diagnostic or therapeutic goal. The UK Health Protection Agency reported mean radiation dose-area-product (DAP) of 4 Gy cm2 for hip procedures. We aimed to investigate factors associated with increased radiation exposure in fixation of proximal femur fractures. Materials and Methods. We assessed 369 neck of femur fractures between April 2019 and April 2020 in one district general hospital. Fractures were classified as extracapsular or intracapsular and into subtypes as per AO classification. Data was collected on type of fractures, implants used, level of surgeon, duration of surgery and DAP. Types of fractures were subclassified as complex (multifragmentary, subtrochanteric and reverse oblique) or simple. Results. Patients with fractures fixed with DHS, short PFNA, long PFNA and cannulated screws were included. 50% of our patients were fixed with hemiarthroplasty or total hip replacement and were therefore excluded. 184 patients were included in the analysis. There was a significant association of higher DAP with fracture subtype (P=0.001), fracture complexity (P<0.001), if an additional implant was used (P=0.001), if fixation was satisfactory (P=0.002) and the operative time (P<0.001). DAP was higher in PFNA than DHS and greatest in Long PFNA. There was some evidence of association between the level of the surgeon and DAP, although this was not statistically significant (P=0.069) and remained not significant after adjusting for the variables (fracture complexity, fixation or implant used) (p=0.32). Conclusions. Increased radiation in proximal femur fractures is seen in fixation of complex fractures, certain subtypes, the type of implant used and if an additional implant was required. Seniority of surgeon did not result in less radiation exposure even when adjusting for other factors, which is in contrast to other published studies


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 4 - 4
1 Jan 2011
McCarthy MJH Long R Weston R Gheduzzi S Keenan J Miles A
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Objectives: To compare the biomechanical properties of lag screw insertion in a laboratory model. Two blades, the Synthes Dynamic Helical Hip Screw (DHHS) and Proximal Femoral Nail Antirotation (PFNA), and two screws, the Synthes Dynamic Hip Screw (DHS) and Stryker Gamma 3 lag screw, were compared. Setting: Orthopaedic biomechanics laboratory. Design: Insertion testing was carried out in high and low density polyurethane foam mounted and attached to a Zwick Roell Amsler Hydrowin. Outcome Measures: The axial load and torque during insertion of the implants was measured. Results: The force required to insert the DHHS and PFNA blades was greater than the DHS and Gamma 3 screws into both low and high density foam. The force required to insert the DHHS and PFNA blades into high density foam was greater than low density foam. The torque required to insert the DHHS and PFNA blades into high density foam was less than that to insert the DHS and Gamma 3 screws. The torque required to insert the DHS and Gamma 3 screws into low density foam was less than the DHHS and PFNA blades. The torque during insertion of the DHHS and PFNA blades seemed to be independent of foam density. Conclusions: The insertional properties of blades are significantly different to screws and this may have clinical importance


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XVIII | Pages 62 - 62
1 May 2012
Chan K Wong J Thompson N
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INTRODUCTION. Intramedullary nail fixation has been used for successful treatment of long bone fracture such as humerus, tibia and femur. We look at the experience of our trauma unit in treating long bone fracture using the AO approved Expert femoral/tibial nail and proximal femoral nail antirotation (PFNA). We look at the union and complication rates in patients treated with AO approved nailing system for pertrochanteric, femoral and tibial shaft fracture. METHODS. We carried out retrospective case notes review of patients that underwent femoral and tibial nailing during the period of study- October 2007 to August 2009. All patients were treated using the AO approved nailing system. We identified all trauma patients that underwent femoral and tibial nailing through the trauma register. Further information was then obtained by going through medical notes and reviewing all followed-up X-rays stored within the online radiology system. RESULTS. 149 patients, 85 male and 64 female were included into the study. 150 procedures were carried out during period of study as 1 patient underwent conversion of lateral entry femoral nail to PFNA due to refracture. Patients' age ranged from 14-96 with mean of 55. 140 patients had isolated long bone fracture (either femur or tibia) compared to 9 patients with multiple bone fractures. Our unit performed 64 Expert tibial nail, 36 PFNA, 31 Expert lateral entry femoral nail and 19 Expert retrograde femoral nail during period of study. 13 patients treated with intramedullary nail sustained open fracture, 9 of them were compound tibial fracture compared to 4 compound femoral fractures. All patients were followed-up between 2 to 24 months or until death. 9 out of 17 patients that died in this study had diagnosis of tumour. Complication rates were 17% for Expert tibial nail (1 patient with valgus deformity, peroneal nerve palsy and delayed union, 3 with delayed union, 4 with broken locking screw, 2 with wound infection and 1 with abscess over wound site), 4% for lateral/retrograde femoral nail (1 each for pulmonary embolism and broken locking screw) and 4% for PFNA (1 each for delayed union and deep vein thrombosis). The overall complication rates were 10% from this study. DISCUSSION & CONCLUSIONS. We conclude that the AO approved nailing system used for treating pertrochanteric, femoral and tibial fractures were effective with high union rate. The overall complication rates were 10% from this study. Complication rates for tibial nail were as high as 17% compared to 4% for femoral nail or PFNA. The complication rates for PFNA in our study were lower compared to 29% in PFN that was reported in one literature


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_II | Pages 299 - 299
1 May 2010
Guyver P Mccarthy M Neil J Keenan J
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Introduction: The PFNA device was developed to address problems of rotational instability in proximal femoral fractures whilst simultaneously employing a single femoral neck element. The PFNA makes use of a helical blade that compresses rather than destroys osteopaenic cancellous bone. It is hammered into place over the guide wire and then locked laterally to prevent rotation. Study Design: Prospective cohort. Methods: All subtrochanteric fractures (AO 31A3) admitted to the department were treated with the PFNA. Demographic and clinical data during admission was recorded and formal post-operative X-Rays performed. Outcome Measures: 4 month follow-up appointment with clinical and radiological assessments, VAS, SF36, Jensen Social Function Score and Parker Mobility Score. Results: From April 2006 to June 2007, 62 patients were included in the study. 4 month follow up has been completed in 30 patients (77% of those available). 11 are awaiting follow up, 12 died and 9 were unable to attend follow up for various reasons. The mean age was 79.9 years. 13 short and 17 long nails were inserted. 6 patients required open reduction and internal fixation. There were no significant intra-operative or immediate postoperative complications. 1 patient with a short PFNA nail sustained a fracture of the femur through the site of the distal locking bolt during the follow up period and required revision. At follow up, 9 patients had tenderness over the greater trochanter and 1 had leg length discrepancy. None had malrotation. Only 7 patients regained their pre-operative mobility status. The mobility and social function scores were significantly reduced at follow up compared to preoperative status (p=0.001). All domains of SF36 were low compared to normative data. The mean VAS was 3/10. All 30 fractures united and there was no migration, lysis around or cut out of the helical blade. In total, 46 distal locking bolts were utilised. 4 of these had migrated or become loose. Conclusions: Subtrochanteric fractures in the elderly are a devastating injury. Patients do not return to pre-fracture function at 4 months post injury. Early results suggest that the PFNA appears to work well as evident by the fact that all of the fractures united. We recommend adding 4 to 6mm to the measured length of the distal locking bolts to prevent migration


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 34 - 34
1 Sep 2012
Singisetti K Mereddy P Cooke N
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Introduction. Internal fixation of pertrochanteric fractures is evolving as newer implants are being developed. Proximal Femoral Nail Antirotation (PFNA) is a recently introduced implant from AO/ASIF designed to compact the cancellous bone and may be particularly useful in unstable and osteoporotic hip fractures. This study is a single and independent centre experience of this implant used in management of acute hip fractures. Methods. 68 patients involving 68 PFNA nailing procedures done over a period of 2 years (2007–09) were included in the study. Average follow-up period of patients was 1 year. AO classification for trochanteric fractures was used to classify all the fractures. Radiological parameters including tip-apex distance and neck shaft angle measurement were assessed. Results. Average age of patients included in the study was 80 years. 18 patients died during the follow up period due to non-procedure related causes. Average tip-apex distance was 12.7 mm and radiological fracture union time was 5 months. Revision of short to a long PFNA was needed for periprosthetic fracture of shaft of femur in two patients. Two patients needed a complex total hip replacement eventually and further two patients had removal of the implant due to PFNA blade penetration through the femoral head. Discussion. PFNA is a technically demanding procedure and has a learning curve. Our experience shows that it is a useful implant in unstable pertrochanteric fracture fixation. A close radiological and clinical follow up is recommended due to the risk of late fracture and implant related complications


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLI | Pages 115 - 115
1 Sep 2012
Garg B Kumar V Malhotra R Kotwal P
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A prospective, randomized, controlled trial was performed to compare the outcome of treatment of unstable fractures of the proximal part of the femur with either a sliding hip screw or a short proximal femoral nail antirotation (PFNA-XS, Synthes). Eighty one patients (April 2007 – May 2008) presenting with unstable fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a short proximal femoral nail antirotation (n=42) or a sliding hip screw (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Follow-up was undertaken at 3, 6, and 12 postoperative months and yearly thereafter. Plain AP and lateral radiographs were obtained at all visits. All changes in the position of the implant, complications, or fixation failure were recorded. Hip range of motion, pain about the hip and the thigh, walking ability score and return to work status were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. Mean Operative time was significantly less in PFNA group (Mean 25 min, range 19 – 56 min) than DHS group (Mean 38 min, range 28 – 70 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. 6 patients in DHS group had implant failure as compared to none in PFNA group. The functional outcome was also better in PFNA group. When compared to DHS, PFNA-XS provides better functional outcome for unstable trochanteric fractures with less operative time, less blood loss and less complications, however one year mortality rate remains the same


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 357 - 357
1 May 2009
Guyver PM McCarthy M Jain N Keenan J
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Introduction: The PFNA device was developed to address problems of rotational instability in proximal femoral fractures whilst simultaneously employing a single femoral neck element. Study Design: Prospective cohort. Methods: All subtrochanteric fractures(AO31A3) admitted to the department were treated with the PFNA and specified data was recorded. Results: From April 2006 to June 2007, 62 patients were included in the study.4 month follow up has been completed in 30 patients(77% of those available).11 are awaiting follow up and 12 died.The mean age was 79.9 years. 1 patient with a short PFNA nail sustained a fracture of the femur through the site of the distal locking bolt during the follow up period and required revision. The mobility and social function scores were significantly reduced at follow up compared to pre-operative status(p=0.001).All domains of SF36 were low compared to normative data. All 30 fractures united and there was no migration, lysis around or cut out of the helical blade.In total, 46 distal locking bolts were utilised.4 of these had migrated or become loose. Conclusions: Subtrochanteric fractures in the elderly are a devastating injury. Patients do not return to pre-fracture function at 4 months post injury. Early results suggest that the PFNA appears to work well


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_3 | Pages 85 - 85
1 Jan 2016
Suh Y Nho J Park J Lee Y Ha Y Koo K
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Introduction. In comminuted intertrochanteric fractures, various operative options have been introduced. The purpose of this study was to determine whether there were differences in clinical and radiologic outcomes among bipolar hemiarthroplasty(BH), compression hip screw(CHS) and proximal femur nail antirotatory(PFNA) in treating comminuted intertrochanteric fractures(AO type, A2(21, 22, 23)). Materials and Methods. We retrospectively evaluated total 150 patients(BH:50, CHS:50, PFNA: 50) who were operated due to intertrochanteric fractures from March 2010 to Dec 2012 and were older than 65 years at the time of surgery. We compared these three groups for radiologic and clinical outcomes at 12 months postoperatively, including Harris hip score, ability of ambulation(Koval stage), visual analogue scale and radiologic limb length discrepancy(shortening). Landmark and radiologic length was checked. –A: postoperative length. –A’: POD 1year. –B: immediate posteopative contralateral length(from hip center to distal tip of lesser trochanter). –B’: POD 1year contralateral length(from hip center to distal tip of lesser trochanter). –. Limb length(shortening) was adjusted considering difference of magnification. = {A × (B’/B)}− A’. Results. There was no statistical significance among three groups in clinical outcomes including Harris hip score, ability of ambulation(Koval stage), visual analogue scale. However, there was significant differences in radiologic limb discrepancy in plain radiographs at 12 months postoperatively.(radiologic shortening- BH: 2.3mm, PFNA: 3.0mm, CHS:5.1mm, p=0.000). Conclusions. There were no clinical differences among BH, PFNA and CHS in this study. However, notable differences were observed in limb length discrepancy according to selection of operative methods


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 209 - 209
1 May 2009
Guyver P McCarthy M Jain N Keenan J
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The PFNA device was developed to address problems of rotational instability in proximal femoral fractures whilst simultaneously employing a single femoral neck element. The PFNA makes use of a helical blade that compresses rather than destroys osteopaenic cancellous bone. All subtrochanteric fractures admitted to the department were treated with the PFNA (AO 31A3). Demographic and clinical data during admission was recorded and formal post-operative X-Rays performed. Outcome assessment consisted of a 4 month follow-up appointment with clinical and radiological assessments, VAS, SF36, Jensen Social Function Score and Parker Mobility Score. From April to December 2006, 46 patients were included in the study. 4 month follow up has been completed in 17 of 23 patients. The average age was 78. 11 short and 7 long nails were inserted. Four patients required open reduction and internal fixation. There were no significant intra-operative or immediate postoperative complications. 1 short nail fractured through the site of the distal locking bolt during the follow up period and required revision. At follow up, 5 patients had tenderness over the greater trochanter and 2 had leg length discrepancy. None had malrotation. Only 2 patients regained their pre-operative mobility status. The mobility and social function scores were significantly reduced at follow up compared to pre-operative status (p=0.003 and p=0.001 respectively). All domains of SF36 were low compared to normative data. The mean VAS was 3/10. All fractures united and there was no migration, lysis around or cut out of the helical blade. In total, 25 distal locking bolts were utilised. Four of these had migrated or become loose. Patients with subtrochanteric fractures do not return to pre-fracture function at 4 months post injury. The PFNA appears to work well although there may be concern about bone hold of the distal locking bolts. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_II | Pages 137 - 137
1 May 2011
Jayakumar P Tibrewal S Prime M Sriranganathan R Basu I Vemulapalli K Banan H
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Introduction: The proximal femoral nail antirotation (PFNA) system is a cephalomedullary device originally designed to contend with the challenge of unstable tro-chanteric femoral fractures with the novel helical blade component aimed at limiting femoral head limiting cutout. We demonstrate its use in a variety of cases. Methods: This is a prospective study of 370 consecutive patients treated with short and long PFNA systems at a single center with 1-year follow-up. The device was used for unstable trochanteric femoral fractures (AO-classification 31. A.2 and A.3), prophylactic and definitive fixation of pathological fractures and high energy femoral fractures for a wide age range (19–101 years). Clinical outcome involved assessment of general mobility & function, operative and post-operative parameters & complications. Radiological outcome involved assessment of blade tip-apex distance, nail tip-femoral scar distance and distal locking configurations. Results: 17% died within the follow-up period. 72% achieved their pre-trauma mobility status and nearly all fractures healed within 6 months including those in over 85 years. Of 18 problematic cases, serious complications included deep infection, loss of proximal reduction, ipsilateral femoral shaft fracture and periprosthetic supra-condylar fracture. There were no cases of acetabular penetration or blade cut-out. Short PFNA was associated with the majority of femoral shaft fractures and the only significant finding regarding instrumentation. Discussion: This study supports long PFNA design theory demonstrating adequate purchase in the femoral head-neck zone, shown by lack of cut-out. Positive results have been demonstrated in a variety of cases making it a useful option in fractures in all ages and indications alongside unstable trochanteric configurations


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_5 | Pages 8 - 8
1 Mar 2014
Barbur S Robinson P Kumar S Twohig E Sandhu H
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The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure. Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure. The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision. A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_16 | Pages 39 - 39
1 Apr 2013
Sawaguchi T Sakagoshi D Shima Y Goldhahn S
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Introduction. When translating the principle of intramedullary nailing for trochanteric femoral fractures to Asian patients, design modifications made to adjust for anatomic differences resulted in an PFNA Asia. The primary endpoint of this study was the rate of complications attributable to fracture fixation. Material and methods. A prospective multicenter case series was performed; 176 patients with a median age of 84 with unstable trochanteric fractures treated with a PFNA Asia were included and followed for one year postoperatively. Complications were reviewed by a complication review board (CRB). Intra- and postoperative fracture fixation complications are presented according to type and incidence proportions (risk). Results. The CRB identified a total of three intraoperative (1.7%) and 14 postoperative fracture fixation complications (8%). Intraoperative complications included a problem with distal locking (1) and poor intraoperative reduction (2). Postoperative fracture fixation problems included significant neck shortening (8), implant breakage (3), cut-outs (2), and one severe loss of reduction. Outcome for most complications was adequate and none were classified as definitely related to the implant design but rather to surgical technique. Discussion & Conclusion. The adaptation of size and geometry to Asian patients leads to a low incidence of intra- and postoperative fracture fixation complications comparable to other studies


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_19 | Pages 1 - 1
1 Apr 2013
Kotwal R Moideen AN Jones S
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Introduction. The reverse obliquity fractures of the proximal femur are anatomically and mechanically different from most intertrochanteric fractures. These fractures are complex and very difficult to treat. To evaluate the results of the treatment of reverse obliquity intertrochanteric fractures with cephalomedullary nails. Materials and Methods. Between 2005 and 2009, 1179 extracapsular fractures of the proximal femur were treated at our institution. Retrospective review of these x-rays identified 59 patients with reverse obliquity fracture pattern. We analysed our results of cephalomedullary nailing of these complex fractures and evaluated factors responsible for failure of fixation. Results. Of the 59 patients with reverse oblique fracture pattern, one patient was treated with DHS, and two other patients didn't have post-operative x-rays and therefore were excluded from the study. Of the remaining 56 patients treated with cephalomedullary nails, forty eight were treated with gamma nails, five with PFNA and three with ATN. There were 40 females and 16 males with median age of 81.3 years (17–103 years). Six of the fifty six (10.7%) failed to heal or had failure of fixation. The failure rate was four of forty eight for the gamma nails, one of five of the PFNA and one of three of ATN. One of thirty seven (2.7%) of anatomically reduced fractures and five of nineteen (26.3%) of non-anatomically reduced fractures had failure of treatment (p = 0.01). Three of thirteen (23.1%) with femoral medialisation and three of forty three (6.9%) without femoral medialisation had failure of treatment (p = 0.13). Four of forty four (9.1%) with avulsed lesser trochanter and two of twelve (16.6%) without avulsion had failure of treatment (p = 0.59). Three of thirty seven (8.1%) with tip apex distance (TAD) of less than twenty and three of nineteen (15.7%) with TAD more than twenty had failure of treatment (p = 0.65). Conclusion. Inspite of the recent advances in the methods of internal fixation available to surgeons, reverse obliquity intertrochanteric fractures continue to be a challenge for orthopaedic surgeons. In our study, although poor fracture reduction was observed to be the only significant factor associated with a high failure rate, femoral medialisation and tip apex distance of more than 20 had a high association with poor outcome