Intertrochanteric fracture occur due to a simple self-fall. Chance of self-fall increases with increased age, which is further increased by muscle power, poor reflexes, decreased vision¹

These fractures involve from the extra capsular basilar neck region to the region along the lesser trochanter proximal to development of the medullary canal

Being a major weight bearing bone in lower limb, fracture intertrochanteric region leads to bed ridden for prolonged time leads to increased morbidity and mortality like urinary tract infections, bed sores, stiffness of joint. To avoid these complications, appropriate treatment of these fracture is needed^2-3

Nowadays operative treatment is preferred to prevent these complications. Fracture geometry and biomechanics leads to development of variety of implants to treat these fractures⁴

Proximal femoral nail ( PFN ) is an intramedullary load sharing device, it helps early post operative mobilization , weight bearing and early fracture union

It is a closed nailing procedure PFN preserve the fracture hematoma and associated with less blood loss and operating time⁵

Hence this study was conducted to evaluate the inter trochanteric fractures and their management by using Proximal femoral nail (PFN) and Proximal femoral nail second generation  (PFN A2) and To assess comparative performance of  PFN and PFN A2 in  management of intertrochantertic femur fractures.

This study was conducted in Chengalpattu Medical College and Hospital, Chengalpattu – 603001 Inclusion criteria: . 1). Diagnosis of intertrochanteric femur fracture 2). Age > 40 years and < 80 years 3). Singh’s index Grade 6 to Grade 3 4). Both Genders 5). Patients willing to give written informed consent Exclusion criteria: 1). Open fractures 2). Patients with pathological fractures 3). Singh’s grade 2 & grade 1 4). Age < 40 years and > 80 years 5). Patients with Bleeding diasthesis 6). History of previous surgery on proximal femur 7). Reverse oblique fractures and fractures with subtrochanteric extension 8). Polytrauma patients 9). Patients with Dementia using steroids and immunosuppressants Fifty consecutive patients with intertrochanteric fractures were treated with Proximal femoral nail ( PFN ) and Proximal femoral nail A2( 25 in each group ) at our institution between March 2019 to august 2020. Fifty patients were followed for at least nine months (mean 12 months, range 9 to 24 months) INVESTIGATIONS : • Radiological : Plain X-ray of the affected hip with femur in two standard Projections ( AP& cross table lateral view ) • Complete hemogram • Renal function tests • Bleeding time and Clotting time • Screening for infections – HIV , HbsAg , anti Hcv • Chest X ray and Electrocardiogram • If needed CT concerned Hip joint with 3D reconstruction - Post operative radiological outcome was assessed by Periodic X-rays of affected hip - Post operative functional outcome was assessed by using HARRIS HIP SCORE OPERATIVE PROCEDURE Position the patient supine on a radiolucent operating table. Abduct the unaffected leg as far as possible and place it on a leg support, so that it allows free fluoroscopic examinations. This should be tested preop-eratively. For unimpeded access to the medullary cavity, adduct the affected leg by 10 –15°) PREPARATION Perform closed reduction of the fracture under image intensifier control. If the result is not satisfactory, perform open reduction. Exact anatomical reduction and secure fixation of the patient to the operating table are essential for easy handling and a good surgical results Palpate the trochanter major Determine entry point Insert Guide Wire Insert reaming rod Insert the reaming rod into the medullary canal to the desired insertion depth. The tip must be correctly positioned in the medullary canal since it determines the final distal position of PFNA-II. Reaming Starting with the 8.5 mm diameter reaming head, ream to a diameter of 0.5 to 1.5 mm greater than the nail diameter. Ream in 0.5 mm increments and advance the reamer with steady, moderate pressure. Do not force the reamer. Partially retract the reamer repeatedly to clear debris from the medullary canal. Use the holding forceps to retain the reaming rod while reaming and to prevent it from rotating Guide the connecting screw through the insertion handle and secure the desired PFNA-II to the insertion handle using the hexagonal screwdriver with spherical head Use image intensifier control to insert the PFNA-II Carefully insert the PFNA-II manually using slight bidirectional turns of the insertion handle as far as possible into the femoral opening. If the PFNA-II cannot be inserted, select a smaller size PFNA-II diameter or ream the medullary cavity to a diameter that is at least 1 mm larger than that of the selected nail The correct PFNA-II insertion depth is reached as soon as the projected PFNA-II blade is positioned in the center of the femoral head. A too cranial or too caudal PFNA-II position should be avoided as it can lead to malposition of the PFNA-II blade. The anteversion can be determined by inserting a guide wire ventral to the femoral neck in the femoral head. In the mediolateral view, place the insertion handle parallel to the guide wire to align the correct rotation of the PFNA-II. Attach the connector on the insertion handle and use light hammer blows on the connector to insert the nail. Optionally, instead of the connector, the hammer guide can be threaded into the insertion handle and the hammer can be used as a slide hammer Insert the golden drill sleeve and the golden trocar through the protection sleeve. Advance the entire sleeve assembly for PFNA blade through the aiming arm to the skin until it clicks into the aiming arm. Adjust the position of the buttress nut if necessary Make a stab incision in the area of the trocar tip. Advance the sleeve assembly through the soft tissues in direction of the lateral cortex. Insert the sleeve assembly as far as the lateral cortex. Advance the protection sleeve to the lateral cortex using slight clockwise turns of the buttress nut. Prepare the passage of the protection sleeve by turning the internal golden drill sleeve Remove the trocar. Insert a new guide wire through the golden drill sleeve into the bone. Verify both direction and position under image intensifier control in both AP and lateral view In the AP and lateral view, the optimal position of the guide wire is the exact center of the femoral head. Insert the guide wire subchondrally into the femoral head at a distance of 10 mm below the joint level. Minimal distance to the joint is 5 mm. The tip of the guide wire is positioned at the intended blade tip position Use monitoring during insertion of the PFNA-II blade. Insert the PFNA-II blade to the stop by applying gentle blows with the hammer Insert the three-part trocar combination (protection sleeve, drill sleeve and trocar) through the hole in the aiming arm that corresponds with the nail length, make a stab incision and insert the trocar to the bone. Remove the trocar Just after drilling both cortices, confirm the drill bit position. Ensure that the drill sleeve is pressed firmly to the near cortex and read the measurement from the calibrated drill bit at the back of the drill sleeve. This measurement corresponds to the appropriate length of the locking bolt. Remove the drill bit and the drill sleeve Insert a locking bolt of the measured length with the hexag¬onal screwdriver through the protection sleeve until the locking bolt head lies against the near cortex. The tip of the locking bolt should not project more than 1–2 mm beyond the far cortex Insertion of Standard PFN Carefully insert the nail manually as far as possible into the femoral opening. Slight twisting hand movements help inser¬tion. If the nail cannot be inserted, select a smaller size nail diameter. Insertion of femoral neck screw and hip pin Insert these screws using drill sleeve systems consisting of protection sleeve, drill sleeve and trocar. Tightly secure the appropriate Aiming Arm The position of the nail can be verified by placing a guide wire on the surface of the insertion handle. The position of the end of the nail can be checked by inserting a wire through the insertion handle. To ensure the correct anteversion of the implant, an addi-tional guide wire can be inserted ventral to the femoral neck into the femoral head. Insertion of guide wire for femoral neck screw Make a stab incision and insert the Drill Sleeve System through the aiming arm to the bone. Mark the femur and remove the trocar. Insert a 2.8 mm Guide wire through the drill sleeve, check direction and position under image intensifier in AP and lateral views. Choose a position in the caudal area of the femoral head so that both proximal screws can be in¬serted. Insert the guide wire 5 mm deeper into the femoral head than the planned femoral head screw. The nail posi¬tion of the guide wire should be in the lower half of the femoral neck. In lateral view, the wire should be positioned in the centre of the femoral neck. Insertion of guide wire for hip pin Insert the Drill Sleeve System through the blue drill hole on the aiming arm to the bone. Then remove the trocar and insert a second, 2.8 mm guide wire through the drill sleeve into the bone. The tip of the guide wire should be positioned at least 20 mm medial of the fracture line and 5 mm deeper than the planned hip pin, but approximately 15–20 mm less deep than the planned femoral neck screw. Insertion of hip pin Use the cannulated Hexagonal Screwdriver to in¬sert the selected hip pin over the guide wire to the stop. Remove and discard the 2.8 mm guide wire of the hip pin. Drill hole for femoral neck screw Advance the 11.0 mm reamer over the 2.8 mm guide wire. Drill to the stop. The sleeve prevents further drilling. Tapping is not required due to the self-tapping tip of the femoral neck screw. Insert the femoral neck screw over the 2.8 mm guide wire to the stop. Remove and discard the 2.8 mm guide wire of the femoral neck screw. Finally, remove both protection sleeves from the aiming arm. Check under image intensification that the femoral neck screw protrudes slightly over the lateral cortex. Distal locking is usually performed with a single locking bolt. For static interlocking Use the cranial locking hole only for static interlocking, and the caudal locking hole for dynamic interlocking. POST-OPERATIVE PROTOCOL • IV antibiotics and analgesic given for first two days • From 3rd day onwards oral antibiotics and analgesic given for another 1 week • Drain removed on 2ndpost-operative day • Dressing changed on 2nd,6thand 8thpost-operative day • Sutures removed on 12thpost-operative day • Non weight bearing mobilizationstarted under guidance of physiotherapist from 3rdpost op day • Chest physiotherapy started from 2ndpost-operative day • Weight bearing started as soon as possible on the basis of patient’s pain tolerance, bone quality, fracture reduction and biomechanical stability of the construct • Patients were followed up once in a month for at least 9 months with appropriate radiographs for assessing union and complications

In our study, we observed a greater number of cases in the age group of 60 – 70 years with mean age 63.28 of years. Male patients are outnumbered female in our study by 64 % in male group and 36 % in female group

• SIDE OF INJURY
• MODE OF INJURY

• CLASSIFICATION OF FRACTURES

• CO MORBID CONDITIONS

In our study 13  patients suffered from Type 2 Diabetes Mellitus, 11. Patients suffered from systolic hypertension, 2 patients suffered from coronary artery disease, 1 patient suffered from Chronic Kidney Disease, 2 patients suffered from bronchial asthma and 1 patient had completed treatment for Primary Pulmonary Tuberculosis.

 Operative details of intertrochanteric fractures treated by PFN

All 25 patients had a mean age group of  64.88 years. The mean duration of surgery was 52.16 ± 10.92 minutes. Mean blood loss during surgery  140 mL ± 22.91 mL. Mean number of C ARM shots taken – 21.76 ± 2.69. Mean no of weeks taken for fracture union – 14.44 ± 1.15. Mean Harris hip score at 3^rd month was 75.20 ± 3.40. Mean Harris hip score at 9^th month was 83.20 ± 4.25. Patient were allowed full weight bearing after an average duration of  14 weeks.

One patient had persistent pain in hip region hence weight bearing was delayed till radiological union occurred and symptoms subsided

Operative details of intertrochanteric fractures treated by PFNA2

All 25 patients had a mean age group of   63.28  years. The mean duration of surgery was  45.28 ± 9.25 minutes. Mean blood loss during surgery 138 ± 30.61 mL Mean number of C ARM shots taken  - 18.64  ± 2.46. Mean no of weeks taken for fracture union – 13.12 ± 0.92. Mean Harris hip score at 3^rd month was 74.76 ± 3.32. Mean Harris hip score at 9^th month was 82.80 ± 3.60. Patient were allowed full weight bearing after an average duration of  13 weeks.

The postoperative radiological outcome was assessed by taking serial X rays of affected hip in antero posterior and frog lateral view. All patients achieved radiological and clinical union.

17 patients underwent radiological union by 13 weeks, 12  patients underwent by 14 weeks, 10 patients underwent union by 15 weeks and 3 patients underwent union by 17 weeks.

Mean no of weeks taken for fracture union treated by PFN  14.44 ± 1.15. Mean no of weeks taken for fracture union treated by PFN A2 13.12 ± 0.92

One patients had varus malunion

FUNCTIONAL OUTCOME

The postoperative functional outcome was assessed by Harris Hip Score at 3^rd and 9^th month.

For patients with PFN

Mean Harris hip score at 3^rd month was 75.20 ± 3.40. Mean Harris hip score at 9^th month was 83.20 ± 4.25.

For patients with PFN A2

Mean Harris hip score at 3^rd month was 74.76 ± 3.32. Mean Harris hip score at 9^th month was 82.80 ± 3.60

The following complications were encountered in patients.

Wound complications

One PFN patient had a superficial wound infection. The patient was a male patient suffering from systolic hypertension and healed Tuberculosis. The infection subsided with prolonged antibiotics and one wound wash.

Two male patients had fever on 4th post operative day. One patient was diagnosed with urinary tract infection which settled with a course of antibiotics.

Implant related complications

One PFN patient suffered from screw pull out

Intertrochanteric femur fractures are the most common hip fractures in elderly age groups especially more than 60 years which results in increased morbidity and mortality rate and decreased life expectancy Most common mode of injury is simple fall from height because of osteoporotic bone and poor muscle tone Various modalities of treatments are available like sliding hip screw, cephalon medullary nails, dynamic condylar screw, hemiarthroplasty and trochanteric stabilization plate. The goal of treatment being early mobilization of patients to prevent fracture disease complication In our study conducted in Chengalpattu Government Medical College and Hospital Chengalpattu,50 consecutive patients of various age groups with intertrochanteric fractures were treated with Proximal femoral Nail ( PFN ) for 25 patients and Proximal femoral Nail A2 ( PFN A2 ) for 25 patients All cases were followed up for a minimum of 9 months and were assessed for radiological and functional outcome. The results were analysed. The observations of our study are as follows: Most common age group affected with intertrochanteric fractures in our study was 60 – 70 year Male patients are outnumbered female in our study by males and females Mode of injury: Self fall from standing height is the most common mode of injury in our study Type of fracture: In our study we encountered type IV is more common Side of fracture: 33 patients suffered fracture on right side and 17patients suffered fracture on left side Comorbidities: 11 patients had systolic hypertension. 13 patients had type 2diabetes mellitus. 2 patient had coronary artery disease and type 2diabetes mellitus. 1 patient suffered from chronic kidney disease6 patients suffered from isolated systolic hypertension. 7 patients suffered from isolated diabetes mellitus. 1 patient was a known case of old healed pulmonary tuberculosis and completed Category 1 Anti TB treatment. All the patients had good preoperative mobility and were ambulating independently unassisted. Majority of patients were operated within 7 days, the average being 7.6 days. PFN All 25 patients had a mean age group of 64.88 years. The mean duration of surgery was 52.16 ± 10.92 minutes. Mean blood loss during surgery 140 mL ± 22.91 mL. Mean number of C ARM shots taken – 21.76 ± 2.69. Mean no of weeks taken for fracture union – 14.44 ± 1.15. Mean Harris hip score at 3rd month was 75.20 ± 3.40. Mean Harris hip score at 9th month was 83.20 ± 4.25. Patient were allowed full weight bearing after an average duration of 14 weeks6 PFN A2 All 25 patients had a mean age group of 63.28 years. The mean duration of surgery was 45.28 ± 9.25 minutes. Mean blood loss during surgery 138 ± 30.61 mL. Mean number of C ARM shots taken - 18.64 ± 2.46. Mean no of weeks taken for fracture union – 13.12 ± 0.92. Mean Harris hip score at 3rd month was 74.76 ± 3.32. Mean Harris hip score at 9th month was 82.80 ± 3.60. Patient were allowed full weight bearing after an average duration of 13 weeks Complications: One female patient a known case of Type 2 diabetes mellitus suffered from superficial wound infection. One patient suffered from urinary tract infection. One patients suffered varus collapse with limb shortening >2 cm. One patient suffered screw loosening. 7

 The study suggests that both PFN and PFNA II perform well, showing equally good functional outcomes following fixation of unstable trochanteric fractures. PFNAII offers no significant benefits over PFN in terms of post-operative complications. However as compared to PFN, use of PFNA2 significantly reduces the duration of surgery, the amount of operative blood loss and fluoroscopic imaging.

1. Rockwood and Green's Fracture in adults, Eighth edition - Section 4 - Lower extremity, Intertrochanteric fractures of the hip Page no 2075.
2. Anand J. Thakur - The elements of fracture fixation, Second edition - Chapter 6, Fixation of hip Page no 168, 170, 171, 172.
3. Kenneth A. Koval, Joseph Zuckerman - Handbook of fractures, sixth edition - part 5 Lower extremity fractures - Chapter 29 Femoral neck fractures page no 381.
4. WL Loo, SYJ Loh, HC Lee. Review of proximal nail antirotation PFNA and PFNA2. Malaysian orthopaedic journal 2011 Vol5 No 2.
5. Manoj R. Kashid, Tushar Gogia, Gopal Shinde, Comparative study between PFN and PFN A2 in management of unstable trochanteric fractures. International journal of research in orthopaedics. 2016 Dec ; 2(4); 354 – 358.
6. Anirudh Sharma, Anupam Mahajan, Bobby john, A Comparative study of PFN versus PNA in unstable trochanteric fractures, orthopaedic section 10.7680/ JCDR/ 2017.
7. Shasikant et al., and pramod et al., Comparative study of PFN vs PFN A2 in unstable intertrochanteric femur fractures; A randomized control study, international journal of orthopaedics sciences 2019; 5(3): 162-164.