First results with the Trochanter Fixation Nail (TFN): A report on 120 cases
A complication rate between 4-18% for the conventional osteosynthesis of the proximal femur fracture continues to be unacceptable even if increasing age and co-morbidity of patients are taken into account. Therefore, new intramedullary techniques are under development, and we here report our results with the novel trochanteric fixation nail (TFN). During the study period (March 2003-February 2004) all patients with a trochanteric fracture Type A1-A3 (AO/ASIF classification) were eligible for the study, and 120 patients (mean age 81 years, range 47-100; male/female 1:4) subsequently enrolled. Most frequent was the (according to the AO classification) A.2.1. type of fracture (n=39) and the A.2.2. fracture (n= 39). Operation time from cut to stitch was 45 mins (minimal 21/maximal 194). Thirty-seven (31%) postoperative X-rays were classified as very good, 60 (50%) as good, 18 (15%) as satisfying and five (4%) as bad post-reposition results according to the Garden Alignment Index. The clinical results were documented by the time of hospital stay, postoperative mobilization and time of rehabilitation compared to the old social status. Time to hospital discharge was 17 days (9 /25). Overall complication rate was 7.5% (9 patients) with 5.8%  local wound infection; 1.6%  cutting out of the helical blade through the cortex of the femoral head. We had three (2.5%) hospital deaths in our patient group. We conclude that TFN is a safe and reliable technique. Compared with techniques like PFN and Gamma-nail, clinical results are excellent with less complications.
Available from: Rene Attal
- "However, these complications are comparatively rare relative to the total number of operations performed. A literature search identified 20 English-language publications listed on PubMed reporting a total of 47 cases of cutout/cut-through complications after treatment of 2458 trochanteric fractures[5,78910111314152324252627282930313233. This represents a complication rate of 1.9%, slightly higher than the 1.4% rate (57 of 4109) in the present study. "
[Show abstract] [Hide abstract]
To evaluate the outcome after different types of revision operations for blade 'cut-out' and 'cut-through' after fixation of trochanteric fractures with proximal femoral nail antirotation (PFNA) or a trochanter fixation nail (TFN).
Twenty hospitals participated in this multicentre study. A total of 4109 patients were retrospectively screened for cut-out or cut-through complications after nailing of trochanteric fractures using PFNA or TFN. Fifty-seven patients (28 with 'cut-through' and 29 with 'cut-out') were included in the study. In the 'cut-through' group, 16 patients underwent a blade exchange, six patients had a blade exchange with bone cement augmentation, and six received total hip arthroplasty (THA). In the 'cut-out' group, three patients had a blade exchange, one had a blade exchange with augmentation, three underwent re-nailing of the fracture with a new PFNA, one had a girdlestone procedure and 21 had THA procedures.
In the 'cut-through' group, eight patients who had a blade exchanges (50%) and two patients with blade exchange and augmentation (33%) required further revision operations. THA was the definite treatment in all 6 cases. In the 'cut-out' group, two patients (66%) who had blade exchanges and two (66%) who underwent re-nailing required additional revision operations during the subsequent course. One patient (4%) who had total hip arthroplasty needed revision surgery for acetabular replacement. Overall, a total of 81 revision procedures were performed.
Based on the data from this study, we recommend THA as the only valid salvage procedure for 'cut-out' and 'cut-through' of helical blades after fixation of trochanteric fractures with the PFNA and TFN.
- "The incidence of neck screw cutout has reduced considerably with improvements in the surgical technique but still remains the most common mode of fixation failure56 with IM implants. The proximal femur nail antirotation (PFNA) was developed aiming to reduce this complication and initial studies have shown promise.78 With this background, we analyzed our results with the PFNA in low velocity trochanteric fractures in the elderly. "
[Show abstract] [Hide abstract]
ABSTRACT: The proximal femur nail antirotation (PFNA) is the recent addition to the growing list of intramedullary implants for trochanteric fracture fixation. The initial results in biomechanical and clinical studies have shown promise. We report our results of low velocity trochanteric fractures internally fixed by proximal femur nail antirotation.
A prospective study was conducted to assess the results of 122 elderly patients with low velocity trochanteric fractures [39 - stable (AO; 31-A1) and 83 - unstable (AO; 31-A2 and A3)] treated with PFNA from December 2008 to April 2010. Followup functional and radiological assessments were done. Results obtained were compared between stable and unstable fracture patterns using statistical tools.
The mean followup was 21 months (12-28 months). 11 patients were lost in followup. Union was achieved in all but one patient. Varus collapse was seen in 14 patients and helical blade cut out in one patient. Stable and satisfactorily reduced fractures had a significantly better radiological outcome. Functional outcome measures were similar across fracture patterns. 65% of the patients returned to their preinjury status. The overall complication rate was also significantly higher in unstable fractures.
Good results with relatively low complication rates can be achieved by PFNA in trochanteric fractures in the elderly. Attention to implant positioning, fracture reduction and a good learning curve is mandatory for successful outcomes.
Available from: Amir Andreas Al-Munajjed
- "Clinical complications include the rotation of the femoral head and the cut-out phenomenon of the fracture fixation bolt (cutting out rate 3-18%). Previously we investigated the fixation of several proximal femur osteosyntheses using clinical and experimental studies indicating that a helical blade shows a better fixation of proximal femur fractures [5-7]. A recent study also concluded that a helical blade leads to a superior anchorage with a reduction in cut-out complications . "
[Show abstract] [Hide abstract]
ABSTRACT: Since cut-out still remains one of the major clinical challenges in the field of osteoporotic proximal femur fractures, remarkable developments have been made in improving treatment concepts. However, the mechanics of these complications have not been fully understood.We hypothesize using the experimental data and a theoretical model that a previous rotation of the femoral head due to de-central implant positioning can initiate a cut-out.
In this investigation we analysed our experimental data using two common screws (DHS/Gamma 3) and helical blades (PFN A/TFN) for the fixation of femur fractures in a simple theoretical model applying typical gait pattern on de-central positioned implants. In previous tests during a forced implant rotation by a biomechanical testing machine in a human femoral head the two screws showed failure symptoms (2-6Nm) at the same magnitude as torques acting in the hip during daily activities with de-central implant positioning, while the helical blades showed a better stability (10-20Nm).To calculate the torque of the head around the implant only the force and the leverarm is needed (N [Nm] = F [N] * × [m]). The force F is a product of the mass M [kg] multiplied by the acceleration g [m/s2]. The leverarm is the distance between the center of the head of femur and the implant center on a horizontal line.
Using 50% of 75 kg body weight a torque of 0.37Nm for the 1 mm decentralized position and 1.1Nm for the 3 mm decentralized position of the implant was calculated. At 250% BW, appropriate to a normal step, torques of 1.8Nm (1 mm) and 5.5Nm (3 mm) have been calculated.Comparing of the experimental and theoretical results shows that both screws fail in the same magnitude as torques occur in a more than 3 mm de-central positioned implant.
We conclude the center-center position in the head of femur of any kind of lag screw or blade is to be achieved to minimize rotation of the femoral head and to prevent further mechanical complications.
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.