A Prospective Observational Study of Clinical, Functional and Radiological Assessment of Unstable Intertrochanteric Fracture of Femur in Elderly Patients Treated with Proximal Femoral Nail Antirotation Using Harris Hip Score

Abstract

Background: The incidence of unstable intertrochanteric fracture in elderly is rising because of increased age and with low bone mineral density. The presence of osteoporosis in intertrochanteric fractures is important because fixation of the proximal fragment depends entirely on the quality of cancellous bone present. The surgical stabilization of unstable intertrochanteric fractures remains a persistent challenge. The purpose of this study is to study the effectiveness and drawbacks of one such newer intramedullary device, Proximal Femoral Nail Antirotation in management of intertrochanteric fractures. Patients and method: After obtaining clearance from hospital ethical board, patients who underwent PFNA for unstable intertrochanteric fractures at a tertiary care center, Mumbai, who have given written and informed consent. Patients fitting into inclusion criteria would form the study group. Sample size was calculated using Post-hoc analysis sample size calculator. Data collected by interviews, observation of clinical and radiological findings and assessment of function done using Harris hip score. Categorical data was analyzed by using Chi-square test and comparison of results done using Paired t test. Results: The study comprised of 40 patients, with a mean age of mean age 77± 8.93 years who suffered unstable fracture intertrochanteric femur, due to either trivial fall (82.50%) or RTA (17.50%) and managed by cephalomedullary nailing using Proximal Femoral Nai Antirotation at our centre. Majority of the patients had quality of reduction; Majority of patients took 14 weeks for union with mean union time of 14.2 weeks with standard deviation of ± 1.29. Patients were asked to follow up routinely, with post operative follow up ranging from minimum of 20 weeks to 9 months. At final follow up following results obtained according to Harris Hip Score, were-45% patients Excellent, 32.50% patients-Good, 20% patients-Fair, 2.50% patients-Poor. Conclusions: The intertrochanteric fracture in elderly patients treated with cephalomedullary nailing using proximal femoral nail-antirotation, which has biomechanical advantage of helical blade providing bone compaction, increasing surface area and better anchorage in femoral head, which showed favorable outcome by retarding rotation and varus collapse and prevents medialization by acting as a central pillar.

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International Journal of Research & Review (www.ijrrjournal.com) 81
Vol.5; Issue: 9; September 2018
International Journal of Research and Review
www.ijrrjournal.com E-ISSN: 2349-9788; P-ISSN: 2454-2237
Original Research Article
A Prospective Observational Study of Clinical, Functional and Radiological
Assessment of Unstable Intertrochanteric Fracture of Femur in Elderly
Patients Treated with Proximal Femoral Nail Antirotation Using Harris
Hip Score
Dr. Akshay Jain1, Dr. Lokesh Gudda Naik2, Dr. Pawal Gajendra Prabhakar1, Dr. Ankit Jain3
1Senior Registrar, Nanavati Super Specialty Hospital, Mumbai, India.
2Associate Consultant, Department of Orthopaedics, Sir HN Reliance Foundation Hospital, Mumbai, India,
3Resident, Gandhi Medical College, Bhopal, Madhya Pradesh, India.
Corresponding Author: Dr. Lokesh Gudda Naik
ABSTRACT
Background: The incidence of unstable intertrochanteric fracture in elderly is rising because of increased
age and with low bone mineral density. The presence of osteoporosis in intertrochanteric fractures is
important because fixation of the proximal fragment depends entirely on the quality of cancellous bone
present. The surgical stabilization of unstable intertrochanteric fractures remains a persistent challenge.
The purpose of this study is to study the effectiveness and drawbacks of one such newer intramedullary
device, Proximal Femoral Nail Antirotation in management of intertrochanteric fractures.
Patients and method: After obtaining clearance from hospital ethical board, patients who underwent
PFNA for unstable intertrochanteric fractures at a tertiary care center, Mumbai, who have given written
and informed consent. Patients fitting into inclusion criteria would form the study group. Sample size was
calculated using Post-hoc analysis sample size calculator. Data collected by interviews, observation of
clinical and radiological findings and assessment of function done using Harris hip score. Categorical data
was analyzed by using Chi-square test and comparison of results done using Paired t test.
Results: The study comprised of 40 patients, with a mean age of mean age 77± 8.93 years who suffered
unstable fracture intertrochanteric femur, due to either trivial fall (82.50%) or RTA (17.50%) and managed
by cephalomedullary nailing using Proximal Femoral Nai Antirotation at our centre. Majority of the
patients had quality of reduction; Majority of patients took 14 weeks for union with mean union time of
14.2 weeks with standard deviation of ± 1.29. Patients were asked to follow up routinely, with post
operative follow up ranging from minimum of 20 weeks to 9 months. At final follow up following results
obtained according to Harris Hip Score, were- 45% patients Excellent, 32.50% patients-Good, 20%
patients- Fair, 2.50% patients-Poor.
Conclusions: The intertrochanteric fracture in elderly patients treated with cephalomedullary nailing using
proximal femoral nail-antirotation, which has biomechanical advantage of helical blade providing bone
compaction, increasing surface area and better anchorage in femoral head, which showed favorable
outcome by retarding rotation and varus collapse and prevents medialization by acting as a central pillar.
Key Words: Intramedullary; Intertrochanteric fracture; AO & OTA classification; Singh’s index;
Cephalomedullary Femoral Nail; Proximal femoral nail antirotation; Helical blade; Harris hip score.
Abbreviations used: AP: Anteroposterior, AO: Arbeitsgemeinschaft fur Osteosynthesefragen, ASIF:
Association for the Study of Internal Fixation, OTA: Orthopaedic Trauma Association, PFNA: Proximal
Femoral Nail Antirotation, RTA: Road traffic accident, TAD: Tip Apex Distance, Wks: Weeks, Yrs: years.
INTRODUCTION
The incidence of intertrochanteric
fracture is rising because of the increase in
number of elderly population with
osteoporosis. These fractures are three to
four times more common in women and the

Akshay Jain et.al. A Prospective Observational Study of Clinical, Functional and Radiological Assessment of
Unstable Intertrochanteric Fracture of Femur in Elderly Patients Treated with Proximal Femoral Nail
Antirotation Using Harris Hip Score
International Journal of Research & Review (www.ijrrjournal.com) 82
Vol.5; Issue: 9; September 2018
mechanism of injury is usually due to a low-
energy trauma like a simple fall. By 2040,
the incidence is estimated to be doubled. In
India these figures may be much more. [1]
More than 50% of intertrochanteric
fractures are unstable. Unstable patterns
occur more commonly with increased age
and with low bone mineral density. The
presence of osteoporosis in intertrochanteric
fractures is important because fixation of the
proximal fragment depends entirely on the
quality of cancellous bone present. The
surgical stabilization of unstable
intertrochanteric fractures remains a
persistent challenge. Dissatisfaction with the
use of the extramedullary devices like the
Dynamic Hip Screw in unstable
intertrochanteric fracture patterns has
gradually led to the evolution of
intramedullary devices. The purpose of this
study is to study the effectiveness and
drawbacks of one such newer
intramedullary device, Proximal Femoral
Nail Antirotation in management of
intertrochanteric fractures that has
biomechanical advantage of helical blade
providing bone compaction and better
anchorage in femoral head. [2]
PATIENTS AND METHODS
After obtaining clearance from
hospital ethical board, patients who
underwent PFNA for unstable
intertrochanteric fractures at a tertiary care
center, Mumbai between April 2016 to May
2017, who have given written and informed
consent. Patients with AO type 31A2, 31A3,
age more than or equal to 60 years, fit for
surgery, willing to participate in study, visit
for follow up were included and would form
the study group. Patients with AO type
31A1, age below 60 years, unfit for surgery,
with associated fracture in the ipsilateral
lower limb, compound fractures,
pathological fractures, one who not
consented for surgery or study, existing
neurological deficits and with ongoing
chemo or radiotherapy were excluded.
Sample size was calculated using Post-hoc
analysis sample size calculator. Percentage
decrease and good to excellent results using
Harris hip score was taken to calculate the
sample size. As per Kumar GN et.al [3] it
was 78% and as per Sahin S et.al [4] it was
66.60%. We had to enroll 26 patients with
80% power and 95% significance. Hence a
sample size of 26 was chosen for the
purpose of study and also included
consecutive consented to a total of 40
patients. All patients were assessed as per
standard pre operative protocol by clinical
examination, necessary blood
investigations, X rays of pelvis with hips,
lateral view and also traction views
wherever necessary. All surgeries
performed by standard accepted method by
a single senior surgeon and standard post
operative protocol was followed for all the
patients. All patients were assessed
clinically, radiologically (According to
Baumgaertner criteria modified by
Fogagnolo et al [5]). Alignment
Anteroposterior plane: Normal
collodiaphysial angle or slight valgus and in
Lateral plane: Angulation less than 20º
degrees. 2). Displacement of main
fragments More than 80% overlapping in
both planes and shortening less than 5 mm.
Good meets both criteria, acceptable meets
only one criterion and Poor does not meet
both criteria) and functionally by Harris hip
score. Data collected by interviews,
observation of clinical and radiological
findings and assessment of function done
using Harris hip score. Categorical data was
analyzed by using Chi-square test and
comparison of results done using Paired t
test.
RESULTS
The mean age was 77 ± 8.93 years.
There was a female predominance. Majority
of the patients (pre-operative ambulatory
status) were walking without support, 36 out
of 40 patients, accounting for 90% of
patients. Majority of the patients had trivial
fall was the commonest mode of injury, 33
out of 40 patients, accounting for 82.50% of
patients. Majority of the patients had AO
and OTA classification- Type 31-A2.2

Akshay Jain et.al. A Prospective Observational Study of Clinical, Functional and Radiological Assessment of
Unstable Intertrochanteric Fracture of Femur in Elderly Patients Treated with Proximal Femoral Nail
Antirotation Using Harris Hip Score
International Journal of Research & Review (www.ijrrjournal.com) 83
Vol.5; Issue: 9; September 2018
fracture, 12 out of 40 patients, accounting
for 30% of patients. Majority of the patients
had osteoporotic index (Singh’s index)
grade 3, 17 out of 40 patients, accounting
for 42.50 % of patients. Majority of
fractures were reduced by closed means
intraoperatively, 36 out of 40 accounting for
90% of cases. In majority of the patients, the
duration of surgery was less than 1 hour, 28
out of 40 patients, accounting for 70% of
patients. Majority of the patients we used
100 to 150 C-arm shoots, 33 out of 40
patients, accounting for 82.50 % of patients.
Majority of the patients had quality of
reduction, Good, 27 out of 40 patients,
accounting for 67.50% of patients. Majority
of the patients (post operative ambulatory
status) were, walking without support, 34
out of 40 patients, accounting for 85% of
patients. Majority of the patients were
walking with normal gait, 37 out of 40
patients, accounting for 92.50% of patients
and the rest 03 patients had abductor lurch.
Majority of the patients took 14 weeks for
union with mean union time of 14.2 weeks
with standard deviation of 1.29. Majority of
the patient’s final outcome according to
Harris hip score was excellent, 18 out of 40
patients, accounting for 45% of patients.
Only 3 patients had complications in the
form of anterior thigh pain and in the same
patients we had abductor lurch as well.
Harris Hip Score [15]
1. Pain (44 possible)
a) None or ignores it 44 points
b) Slight, occasional, no compromise in
activities 40 points
c) Mild pains, no effect on average
activities, rarely moderate Pain with unusual
activity, may take aspirin 30 points
d) Moderate pain, tolerable but makes
concessions to pain some limitation of
ordinary activity or work 20 points
e) Marked pain, serious limitation of
activities 10 points
f) Totally disabled, crippled, pain in bed,
bed ridden 0 points
2. Function (47 possible)
A) Gait (33 possible)
i) Limp
a) None 11 points
b) Slight 8 points
c) Moderate 5 points
d) Severe 0 points
ii) Support
a) None 11 points
b) Cane for long walk 7 points
c) Cane most of the time 5 points
d) One crutch 3 points
e) Two canes 2 point
f) Two crutches 0 point
g) Not able to walk (Specify reason)
0 point
iii) Distance walked
a) Unlimited 11 points
b) About 1000 meters 8 points
c) About 5000 meters 5 points
d) Indoors only 2 points
e) Bed and chair 0 point
B) Activities (14 possible points)
i) Stairs (4 maximum)
Foot over foot without use of banister
4 points
Foot over foot using banister 2 points
Stairs in any manner 1 points
Unable to do stairs 0 point
ii)Put on Shoes and socks (4 maximum)
With ease 4 points
With difficulty 2 points
Unable 0 points
iii) Sitting
Comfortably in ordinary chair for one hour
5 points
On a high chair for half an hour
3 points
Unable to sit comfortably in any chair
1 point
iv) Ability to enter public transportation
1 point
Absence of deformity (All yes=4;if less than
four yes=0)
-less than 300 flexion deformity
-less than 100 fixed adduction
-less than 100 fixed internal rotation in
extension
-limb length discrepancy<3.2cm

Akshay Jain et.al. A Prospective Observational Study of Clinical, Functional and Radiological Assessment of
Unstable Intertrochanteric Fracture of Femur in Elderly Patients Treated with Proximal Femoral Nail
Antirotation Using Harris Hip Score
International Journal of Research & Review (www.ijrrjournal.com) 84
Vol.5; Issue: 9; September 2018
Range of Motion
-Flexion 1400
-external rotation 400
-internal rotation 400
-Abduction 400
-Adduction 400
Range of Motion Score
2110-3000 5 points
1610-2100 4 points
1010-1600 3 points
610-1000 2 points
310-600 1 points
00-300 0 point
RESULT
SCORE
Excellent
91-100
Good
81-90
Fair
71-80
Poor
≤70
Case 1: Pre op AP view, Post op AP view and at final follow up AP and Lateral view.
Case 2: Pre op AP view, Post op AP view and at final follow up AP and Lateral view.

Akshay Jain et.al. A Prospective Observational Study of Clinical, Functional and Radiological Assessment of
Unstable Intertrochanteric Fracture of Femur in Elderly Patients Treated with Proximal Femoral Nail
Antirotation Using Harris Hip Score
International Journal of Research & Review (www.ijrrjournal.com) 85
Vol.5; Issue: 9; September 2018
DISCUSSION
Stable intertrochanteric fractures are
those, in which posteromedial cortex
remains intact and calcar femorale is not
affected. Unstable intertrochanteric fractures
are those, in which comminution of
posteromedial buttress exceeds a simple
lesser trochanteric fragment, those with sub-
trochanteric extension or those with reverse
oblique fracture patterns.
Surgical management is the
preferred treatment for unstable fractures.
Successful treatment of intertrochanteric
fractures depends on surgeon independent
variables like bone quality (osteoporosis),
fracture pattern & fracture stability. Surgeon
dependent variables like quality of fracture
reduction, choice & placement of implant.
[6] In unstable proximal femoral
fractures, control of axial telescoping and
rotational stability are essential.
Intramedullary implants inserted in a less-
invasive manner are better tolerated by the
elderly. [7]
In the present study, the average age
for intertrochanteric fractures was 77 years.
P value of 0.001 on comparing with results
of other series, found to be statistically
significant. Which was higher when
compared to Kumar GN et.al (2015)3 with
mean age of 61years and lower when
compared to Soucanye E et.al (2012) [8] with
mean age of 85 years. Majority of the
patients were females and P value is 0.0001
on comparing with results of other series
found to be statistically significant. Which
was similar to Sadic S et.al (2014) [9] and
higher than Kumar GNet.al (2015. [3] Good
reduction was achieved in 27(67.50%)
patients. Acceptable reduction was achieved
in 12(30%) patients and poor reduction in 1
(2.50%) patient. With P value of 0.303 on
comparing with results of Sahin S et.al
(2010), [4] found to be statistically not
significant. Mean tip apex distance was
18.70 mm with standard deviation 3.90 with
a P value of 0.008 on comparing with
results of other series suggesting statistically
significant. It was similar to Sahin S et.al [4]
(2010). Mean duration of surgery was 55.8
minutes with standard deviation of 15.93
with a P value of 0.0001 on comparing with
results of other series found to be
statistically significant. It was similar to
LiM, WuL et.al [10] (2014). Mean duration
of radiological union was 14.2 weeks with
standard deviation of 1.29 with a P value of
0.04 on comparing with results of other
series found statistically significant. It was
similar to Lv C, Fang Y et.al [11] (2011).
In our study, we estimated the
patient functional outcomes following
Cephalomedullary nailing using proximal
femoral nail antirotation for unstable
intertrochanteric fractures in elderly patients
using Harris hip score and we found good
and excellent outcome in 31(77.50%). It
was similar to Kumar GN [3] et.al (2015).
We did not encounter any case of varus
collapse and blade cut-out, suggesting a
good purchase of helical blade. During
insertion of helical blade, it compacts the
trabecular bone around it and decreases its
susceptibility of yielding to strain. A study
done on cadaveric bones by Goffin et.al [12]
concludes that bone compaction caused
during insertion of helical blade is
significantly important in bones with lower
density and provides additional mechanical
anchorage to the blade and decreases
chances of cut outs. There have been other
biomechanical studies that conclude the
superiority of blade over screws with regard
to minimising chances of cut out. [13]
Though there have been a few cases
reported where cut out or joint perforation
has occurred, but most of these seem to
have occurred due to improper placement of
screw. [14] In our series, majority of the
patients had severe osteoporosis, but with
correct placement of blade we did not have
any case of implant failure. So, our
experience suggests that the helical blade,
when properly placed, is well suited for
osteoporotic patients.
CONCLUSION
The Intertrochanteric fractures in
elderly patients treated with

Akshay Jain et.al. A Prospective Observational Study of Clinical, Functional and Radiological Assessment of
Unstable Intertrochanteric Fracture of Femur in Elderly Patients Treated with Proximal Femoral Nail
Antirotation Using Harris Hip Score
International Journal of Research & Review (www.ijrrjournal.com) 86
Vol.5; Issue: 9; September 2018
cephalomedullary nailing with proximal
femoral nail antirotation that has
biomechanical advantage of helical blade
providing bone compaction and better
anchorage in femoral head, which retards
rotation, varus collapse and prevents
medialization by acting as a central pillar.
The proper selection of patients, good pre
operative planning and careful insertion of
PFNA helical blade in a patient with good
bone quality or osteoporotic, should be
mandatory.
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How to cite this article: Jain A, Naik LG, Prabhakar PG. A prospective observational study of clinical,
functional and radiological assessment of unstable intertrochanteric fracture of femur in elderly patients
treated with proximal femoral nail antirotation using Harris Hip Score. International Journal of Research
and Review. 2018; 5(9):81-86.