Analysis of clinical, radiological and functional outcome of proximal femoral nailing in unstable intertrochanteric fractures

INTRODUCTION: Intertrochanteric fracture is one of the most frequently operated injuries in the elderly. The incidence of these fractures increases with increasing in age. These patients are limited to home ambulation. Since most of them are elderly people quality of life will be poor if it is not stabilized and patients are mobilized early. Intramedullary position of the Proximal femoral nail prevents the excessive collapse of proximal fragment & medialisation of distal fragment. Being a intramedullary load sharing device, Proximal femoral nail helps in early post operative mobilization, weight bearing and ultimately the early fracture union. Being done as a closed nailing procedure most of the time Proximal femoral nail preserves the fracture haematoma and associated with less blood loss and short operating time. AIM: To assess the clinical radiological and functional outcome of proximal femoral nailing in unstable intertrochanteric fractures MATERIALS & METHODS: At our institution we have performed surgery for 22 cases of unstable inter trochanteric fractures with proximal femoral nailing. Out of which 20 cases came for regular follow up and they were included in the study. Cases were selected according to inclusion and exclusion criteria. Inclusion criteria - Unstable intertrochanteric fracture Boyd and griffin type 2 , 3 and 4 and Age > 18 years. Exclusion criteria - 1) Compound injury, 2. stable two part fracture, 3.Patients with severe comorbid conditions, 4.Age < 18 years, 5.Predominantly subtrochanteric fracture with intertrochanteric extension. Surgery was done in standard radiolucent fracture table with patient in supine position with adduction of affected limb by 10-15o. Closed reduction of fracture was done with gentle traction and rotation. The unaffected limb was placed in flexion and abduction so that it does not interfere with image intensifier. The C-arm was placed in a position to take anteroposterior and lateral views of hip. The patient was then painted and draped. In patients where reduction was not achieved by manipulation , a small 0.5 cm incision was made and fracture was reduced with the help of bone hook or curved artery forceps.The mobilization of hip fracture patients out of bed begin and ambulation training was initiated on postoperative day one. Furthermore, any patient who has been surgically treated for an intertrochanteric fracture was allowed to bear weight as tolerated.Functional outcome was studied with Harris hip score. RESULT: Operative time varied from 43 minutes to 90 minutes with average of 67.6 minutes Blood loss varied from 130 ml to 325 ml with mean loss of 187ml. The age group varied from a minimum of 33 years to a maximum of 80 years and average age was 54.8 years. Duration of the study was from March 2012 to August 2013.Maximum follow up is 18 months and minimum followup is 3 months. Mean follow up was 10 months. of the 20 patients 15 were male and five were female. Right side was involved in 12 cases and Left side in 8 patients. 16 patients were manual laborers, four were sedentary workers.The average interval from the injury to the time of surgery was 10.2 days.All the patients were managed initially with skeletal traction before taking up for surgery. Average union time in weeks is 14.6 weeks.(Range 12 to 18 weeks). In our series union was delayed in all type IV cases(17- 18 weeks). Harris hip Score at the end of 3 month is 73.8 and at end of 6 months is 84.3. Sixteen patients who were manual laborers went back to their original work.At the end of 6 months the result was Excellent in 5 cases .Good in 11 cases, fair in 3 cases and poor in 1 case. None of the patients developed thigh pain. CONCLUSION :Proximal femoral nail is an excellent device for unstable intertrochanteric fractures and it is technically demanding procedure. Proper reduction, correct entry point of nail , placement of neck screws of adequate length determines the outcome of surgery.The results are better if surgery is done earlier.Early mobilization and weight bearing is allowed in patients treated with Proximal femoral nail thereby decreasing the incidence of bedsores, uraemia and hypostatic pneumonia.Proximal femoral nail is a significant advancement in the treatment of unstable trochanteric fractures which has the unique advantage of closed reduction, preservation of fracture hematoma, less tissue damage during surgery, early rehabilitation and early return to work.When properly done Proximal femoral nail can give better results than other devices for unstable intertrochanteric fractures