Intertrochanteric (IT) fractures of femur are one of the most frequently occurring fractures in the elderly. ^[1] This usually following trivial trauma due to increase in prevalence of osteoporosis. ^[2] Management of these fractures in elderly patients is a big task to many trauma surgeons, due to presence of osteoporosis and associated medical disorders that increases the risk associated with surgery and anaesthesia. ^[3]

Non-surgical mode of treatments have  associated with very high complications rate, like pneumonia, bedsore, joint contractures and thromboembolism which are due to prolonged immobilization and leads directly to the high mortality rate. It also associated with malunion in varus deformity and shortening. ^[4]

The goal of surgery is stable fixation of fracture and to mobilize the patient early, which allows early weight bearing and ambulation of the patient and rapid return to independent function. So, it is crucial to use an implant that is minimally invasive, allows early weight bearing, and has low complication rates. ^[5,6]

Presently, intertrochanteric fractures are treated by internal fixation, which is done by many trauma surgeons; however, due to poor bone quality and neck screw instability can adversely affect the results using the currently available fixation devices. ^[7] Many studies have been published on extramedullary Vs intramedullary implants. ^[8,9] Those Extramedullary devices have suffered a variety of complications like cut-out, screw back out, implant breakage, femoral shaft fractures and subsequent loss of reduction. ^[10-13]

Most of the literature recommends use of an intramedullary device, especially in an unstable fracture due to improved biomechanics of an intramedullary construct. ^[11-14]  Intramedullary devices such as proximal femoral nail (PFN), are more stable under loading with a shorter lever arm, so the distance between the hip joint and the nail is reduced compared with that for a plate, thus diminishing the deforming forces across the implant, thus more resistant to failure. PFN has some demerits like implant failure; screw cut out and screw migration which is also called z effect/ reverse Z effect. ^[15]

The helical blade in the PFN-A2 compacts cancellous bone in femoral head when it is driven inside. This compaction improves femoral head strength and increases stability in cervico-cephalic direction. A single helical blade PFN-A2 is technically better for small size femur in Asian population. Biomechanically, helical blade in PFN-A2 has better cut-out resistance levels than screws. ^[16] The compromised bone quality in the head and neck of the femur in the typical geriatric patient with osteoporotic bone changes requires an exact positioning of the head screw in the center-center or low-center position and, preferably, a small tip-apex distance (TAD). ^[17,18] Additionally, in relation to patient-related characteristics and the positioning of the lag screws, the design of the implants must be taken into account. Non-cylindrical and more blade-like head fixation devices have been developed to prevent, or at least reduce the failure rate in the latest implant generation. ^[19,20]

The quest is to find whether the PFN A2 is ideal and efficacious in IT fractures in elderly in presence of existing osteoporosis.

Objectives: To Evaluate clinico-radiological and functional outcome of intertrochanteric fractures of PFN-A2 in elderly.

After getting the institutional ethical committee approval a retrospective study of the 47 patients older than 60 years who underwent PFN-A2 fixation for non-pathological traumatic extra-capsular fracture of femur between January 2018 and December 2023 was taken.

Inclusion criteria: Age of above 60 years, Closed intertrochanteric fracture, Good cognitive function and Independent ambulatory status prior to injury. The patients were followed up to a minimum of 3-6 months or fracture union, whichever is earlier.

Exclusion criteria: Pathological fractures, Poly-trauma, severe osteoarthritis, fracture neck of femur and medically unfit patients.

All the data’s collected in four different categories. (1) Pre-injury - Age, gender, co-morbidities, blood parameters and grading of osteoporosis by Singh’s Index. (2) Surgical- Fracture classification (Evan’s), duration of surgery, fluoroscopy exposure, fall of Haemoglobin and duration of hospital stay. (3) Post operative- Medical and surgical complications. (4) Follow up - Data of Fracture union.

Written informed consents were obtained from all the participants.

Surgical Procedure: The patients were taken up for surgery under regional anaesthesia within 48-72 hours of admission (except for patient on anticoagulants) after obtaining the fitness. All fractures were treated on fracture table in supine position by closed reduction under C-arm fluoroscopy control. Temporary transfixation of fracture done with percutaneous long K-wire with operating limb in abduction so as to make valgus angle at fracture site (Figure.1 a, b, c, d). Then, the limb is adducted and standard manufacturer’s instructions of the PFN-A2 were followed. Patients received a standard 200x10mm, 130⁰ with appropriate length of helical blade and locking bolt in static mode.

Post operative protocol and follow up: Isometric quadriceps and ankle pump exercises was started on post-operative day 1. Patients were mobilised on post-operative day 3 with the help of walker on partial weight bearing or as they tolerate. Simultaneously active hip and knee strengthening exercises were also started.  Post-operative thromboprophylaxis was used for 15 days in all patients. Radiography was done immediate post operatively, then at follow-ups at 6 weeks, 3 months and 6 months post discharge. With each follow up clinical and radiological evaluation was done. If union is found satisfactory and progressive, partial weight bearing is converted full weight bearing as tolerated at the earliest. Anti-osteoporosis therapy (combination of calcium and an agent that promoted calcium absorption was orally weekly) was initiated selectively, depending on severity of osteoporosis for a period of 3 months.

All cases are evaluated according to modified Harris hip score on residual effects on clinical grounds at final examination.

Statistical analysis

Statistical analysis was done using SPSS Software (IBM Version-20). The statistical calculation of the mean and standard deviation of parameters was done using the MS excel chart sheet (version-7).

In our study a total of 47 patients were underwent surgery for intertrochanteric fracture, which includes 18 (18%) males and 29 (63%) females, with ages ranging from 62 to 90 years (mean age: 76.5 years). 23 (49%) patients had left-sided fractures and 24 (51%) cases had right-sided fractures. Most common mode of injury was trivial fall noted in 27 (57.5%) patients, 12 (25.5%) patients met with accident and 8 (17%) patients had history of fall from height. All the fractures were classified by the Evans classification; there were 2 cases of type I fractures, 27 cases of type II, 13 cases of type III, and 5 cases of type IV fractures. X-rays showed that all patients presented with different degrees of osteoporosis, majority 42(88%) of patients had grade of IV to I. 39 (83%) patients had one or more associated medical co-morbidities (Table.1).

Table. 1 Patient demographics

Table. 2 Operative and follow-up results

Table.3 Complications

All patients operated under spinal anaesthesia with closed reduction and PFN-A2, under fluoroscopy.  Mean duration of surgery [from incision to closure] was 57 minutes (range 40-76mins). Mean number of fluoroscopy exposure were 27. Post-operative drop in Haemoglobin level was less than 1gm/dl in 35 (74%) patients and more than 1 gm/dl in remaining 12 (25%) patients (mean = 0.96gm/dl). All patients were monitored in ICU for 1 day, the reason being their fragile condition due to old age and multiple co-morbidities. 3 patients had a prolonged ICU stay for 3 days as they developed post-operative metabolic abnormalities, but recovered and discharged in medically fit condition. Mean duration of stay in hospital was 6.7 days, with 17 (36%) patients being discharged on post-operative day 5. Local complication occurred in 3 patients in the form of superficial infection which managed with oral antibiotics. Systemic complication in the form of electrolyte imbalance occurred in 3 patients, respiratory infection in 2 patients. All the systemic complications were managed medically.

Average time taken for fracture union was 11 ± 3 weeks. Bridging of three cortices in AP and lateral views was considered as union.  35 (74%) patients achieved pre trauma mobility by the end of 6 months. Majority of the patients retained their functions as shown by Harris Hip score. Late complication in the form of gait abnormality was found in 10 patients, anterior hip or thigh pain occurred in 4 patients. 2 cases had partial backing out of spiral blade. Backing out of blade was seen radiologically but no patient had symptoms of impingement.  One patient exhibited postoperative non-union with perforation of hip blade through the joint (Figure 3).

After the last follow-up, the mean Harris hip score was 85.4 (range, 65–95); the score was excellent in 15 patients (32%), good in 25 (53%), fair in 6 (13%), and poor in 1 (2%) for a positive outcome rate of 85 %. (Tables 2 and 3)

The present study evaluated the outcomes of patients with intertrochanteric fractures managed using the Short Proximal Femoral Nail Anti-rotation (PFNA-2). This discussion highlights the demographic findings, perioperative outcomes, and complications observed in the study cohort.

The study cohort predominantly comprised elderly patients, with a mean age of 76.5 years, reflecting the vulnerability of this population to intertrochanteric fractures due to osteoporosis and reduced bone quality. The higher proportion of female patients (63%) aligns with the well-documented predisposition of postmenopausal women to osteoporosis. A majority of fractures (57.5%) resulted from trivial falls, a common mechanism in this age group due to reduced balance and frailty. The almost equal distribution of left- and right-sided fractures suggests no laterality preference. ^[21]

The classification of fractures demonstrated a wide variety, with Type II fractures being the most frequent. This is consistent with the typical presentation of intertrochanteric fractures. The degree of osteoporosis (Grade IV to I in 88% of patients) underscores the challenges in achieving stable fixation and highlights the importance of using implants like the PFNA-2, which are designed to provide robust stability in osteoporotic bone. ^[22]

The mean surgical time of 57 minutes and fluoroscopy exposure of 27 shots indicate a streamlined and efficient operative process. The minimal drop in hemoglobin levels in most patients (<1 gm/dl in 74%) suggests that PFNA-2 allows for minimally invasive surgery with reduced blood loss. This is particularly advantageous for elderly patients with multiple comorbidities, as evidenced by 83% of the cohort having associated medical conditions. ^[23]

Figure .1 Surgical Techniques

Figure . 2

Figure .3

The protocol of ICU monitoring for one day for all patients reflects the precautionary approach in managing elderly patients with comorbidities. Prolonged ICU stays in three patients due to metabolic abnormalities were managed effectively, indicating the importance of multidisciplinary postoperative care. ^[24]

Superficial infections in three patients were managed conservatively with antibiotics, indicating effective infection control protocols. Electrolyte imbalance and respiratory infections occurred in a small subset of patients, which were managed medically. Gait abnormalities (10 cases) and anterior hip/thigh pain (4 cases) highlight the need for ongoing physiotherapy and follow-up in this population. ^[25]

The occurrence of partial backing out of the spiral blade in two cases, while asymptomatic, emphasizes the importance of careful intraoperative technique and regular postoperative imaging. One case of non-union with perforation of the hip blade represents a rare but significant complication, underlining the challenges in managing severe osteoporosis and unstable fracture patterns. ^[26]

The Harris Hip Score (mean 85.4) demonstrates positive functional outcomes, with 85% of patients achieving excellent or good results. This is consistent with the literature on PFNA-2, which emphasizes early mobilization and weight-bearing as key factors for recovery. The restoration of pre-trauma mobility in 74% of patients by six months highlights the implant's efficacy in preserving function. ^[26]

The PFNA-2 demonstrates excellent functional outcomes and low complication rates in managing intertrochanteric fractures, particularly in osteoporotic elderly patients. Its minimally invasive nature, biomechanical stability, and ability to facilitate early mobilization make it a preferred choice for such fractures. However, careful patient selection, meticulous surgical technique, and close follow-up are critical to optimizing outcomes and managing complications. Further studies comparing PFNA-2 with other fixation methods could provide more comprehensive insights into its efficacy. ^[27]

Intertrochanteric fractures in elderly have a multiple challenges to operating surgeons to manage surgically. Due to the evolution of load sharing devices such as proximal femoral nail antirotation 2 (PFN-A2) was an ideal implant for intertrochanteric fractures. It has many advantages - such as little exposure of the fracture area, stable fixation, early weight bearing and ambulation, which allows for the benefit of improved rate of union, early return to independent function and quality of life.

However, it must be remembered that no implant design can compensate for poor reduction and inappropriate fracture selection or poor implant placement in these fractures. Level of osteoporosis has to be kept in mind while operating such fracture in elderly and has to keep the other option of fracture fixation like replacement, when expecting the chances of failures.

Limitations

The clinical samples observed in the treatment were relatively small; not compared to other internal fixation systems, the long-term complications remain unclear. Therefore large-sample, long term follow-up and multicenter studies are required.

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